CRITOE Makes me Cry Though


An 8-year-old girl presents to the Emergency Department after falling backward onto her left arm while trying to catch a ball.  She cannot describe the mechanism in detail, but presents with moderate pain in the left elbow and holds her elbow in flexion as a position of comfort. On physical examination, there is obvious swelling but no bony deformity. Plain films of the elbow reveal a type II supracondylar fracture:

Figure 1: Type II supracondylar fracture with minimal displacement evidenced by the anterior humeral line no longer intersecting the middle third of the capitellum. Courtesy of A. Prof Frank Gaillard,, rID 10445.

Figure 1: Type II supracondylar fracture with minimal displacement evidenced by the anterior humeral line no longer intersecting the middle third of the capitellum. Courtesy of A. Prof Frank Gaillard,, rID 10445.


Which physical examination test of nerve function is most likely to be abnormal with a supracondylar fracture?

A.  Thumbs up

B.  “OK” sign

C.   Crossing fingers


The most common associated injury with supracondylar fractures is a neuropraxia involving the anterior interosseus branch of the median nerve. This type of nerve palsy prevents the ability of the patient to adequately perform an “A-OK” sign but often resolves spontaneously. “Thumbs up” (extension) tests the posterior interosseus branch of the radial nerve, and crossed fingers tests the ulnar nerve, both of which should be intact in the vast majority of supracondylar fractures.

Brief Review of Supracondylar Fractures:

Most commonly occur in children aged 5-7 years, with equal distribution between males and females. FOOSH (fall on outstretched hand) is most common mechanism.

Anatomy of this 8-year-old patient is particularly important, especially when assessing ossification centers of the elbow. It’s time to reach back into the recesses of medical school musculoskeletal knowledge and remember “CRITOE,” the most common mnemonic used to recall elbow ossification centers.

Figure 2: Elbow ossification centers, AP and lateral views. Images courtesy of, Ujash Sheth and Chris Souder.

Figure 2: Elbow ossification centers, AP and lateral views. Images courtesy of, Ujash Sheth and Chris Souder.

Figure 3: Ages of ossification and fusion of elbow anatomy. Table courtesy of, Ujash Sheth and Chris Souder. +/- one year, varies between boys and girl.

Figure 3: Ages of ossification and fusion of elbow anatomy. Table courtesy of, Ujash Sheth and Chris Souder. +/- one year, varies between boys and girl.

Figure 4: Gartland classification for supracondylar fractures.  Courtesy of Benoudina Samir,, rID 39938.

Figure 4: Gartland classification for supracondylar fractures.  Courtesy of Benoudina Samir,, rID 39938.

Type I – nondisplaced: stable

Type II – displaced, posterior cortex intact

Type III – completely displaced


Nonoperative management with a long arm posterior splint, followed by casting for 3 weeks is indicated for type I fractures. Closed reduction is required for type II fractures which exhibit >20 degrees of angulation. Open reduction and fixation is required for fractures with inadequate closed reduction, largely encompassing type III fractures.

Case Outcome:

The patient underwent closed reduction under procedural sedation in the Emergency Department, and a long arm cast was placed by Orthopedics.

Take Home Points:

When interpreting radiographs, the anterior humeral line should intersect the middle third of the capitellum, as seen on the image below. The capitellum displaces posteriorly in an extension-type fracture.  

CRITOE is a useful mnemonic to remember the order of ossification centers for pediatric patients with elbow pain.

Figure 5: Normal alignment of the anterior humeral line and the middle third of the capitellum. Courtesy of A. Prof Frank Gaillard,, rID 10343.

Figure 5: Normal alignment of the anterior humeral line and the middle third of the capitellum. Courtesy of A. Prof Frank Gaillard,, rID 10343.

Faculty Reviewer: Dr. Jeff Feden


Abzug, JM, Herman, MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012; 20(2): 69-77.

Cicero M. Chapter 82: Musculoskeletal Disorders in Children. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. 2011: 386-393.

Kim TJ, Sponseller PD. Pediatric supracondylar humerus fractures. J Hand Surg Am. 2014; 39(11):2308-11.

Sheth U, Souder, C. ‘Supacondylar fracture – pediatric.’ Orthobullets. 13 May 2016. Web. Accessed 27 May 2016. 

CITW 19: Feeling Light Headed


HPI: 48-year-old female with a history of seizures who presents to ED with confusion. The patient was found lying outside in her yard by her neighbors, confused and talking to herself. The patient is a poor historian and a reliable history is unable to be obtained.

ROS: Unable to be obtained

Vital signs: T: 98.2, HR: 82, BP: 107/64, R: 16, SpO2: 97% on room air

Pertinent Physical Exam: Patient is lying in bed comfortably. She is confused, but following commands. GCS 13 (E3V4M6). There is bruising noted on her tongue. She has left periorbital swelling, and ecchymosis to the right side of her face. Her mid face is stable. Her pupils are equal and reactive. Her TM’s are clear. Her neck is non-tender and supple. She has no obvious focal neurological deficits with appropriate strength and sensation appreciated in all four extremities.

Given the patient’s altered mental status, CT imaging of the brain was obtained:

Figure 1: CT Brain Imaging 

Figure 1: CT Brain Imaging 

What’s the diagnosis?


Or in layman's terms, air on the brain! This patient had a pretty remarkable amount of air that extended all the way to her mid-brain. CT face of the patient was also obtained given her facial trauma. There appeared to be bony defects in the roof of the left anterior ethmoid cells, indicative of a possible source of her pneumocephalus.

Figure 2: Ethmoid Sinus Fracture

Figure 2: Ethmoid Sinus Fracture


  • Clinical suspicion for skull fracture should be heightened in the presence of depressed mental status, focal neurological deficits, scalp lacerations or contusions, bony step-offs on the skull, peri-orbital ecchymosis, headache, nausea and vomiting.
  • Linear skull fractures typically have little to no clinical significance if imaging does not reveal any underlying brain injury, including intracranial hemorrhage. If asymptomatic, these patients can often be discharged after a period of observation.
  • Depressed skull fractures place patients at risk for CNS infection, seizures, and death, with the vast majority of them being open fractures. They should receive prophylactic antibiotics (typically ceftriaxone and vancomycin), tetanus, seizure prophylaxis, and admitted to the hospital.
  • Basilar skull fractures most typically involve the temporal bones. Specific signs of this fracture include peri-orbital and/or mastoid ecchymosis, CSF leak, and hemotympanum.
  • CSF leak should be considered in the presence of clear ottorhea or rhinorrhea. If blood tinged, the “halo-sign”, a clear ring of fluid can be seen around a drop of blood. Laboratory testing for beta-2-transferrin (found exclusively in CSF fluid) can also be performed and are indicative of CSF leak.
  • Most CSF leaks are treated conservatively, resolving spontaneously after a week.
  • Traumatic pneumocephalus can be appreciated in the setting of a basilar or depressed skull fracture, or in any case in which the dura mater is compromised.
  • Pneumocephalus is typically treated conservatively barring any significant complications, such as tension pneumocephalus. In one case series, tension pneumocephalus was treated with intracranial aspiration of air and the patients were given 100% oxygen to hasten air resorption.
  • Another complication of pneumocephalus is meningitis, which was seen 68% of patients in one retrospective review of 284 cases of traumatic pneumocephalus. 
  • The standard of care is to provide antibiotics in cases of pneumocephalus, although interestingly, a prospective, single-institution, randomized controlled trial of 109 patients examining prophylactic antibiotics (ceftriaxone) in traumatic pneumocephalus found no significant difference in the rates of meningitis.
  • Outcome is generally favorable, with only a 10% mortality appreciated in one retrospective analysis of 21 patients, with “multiple air bubbles” being indicative of a worse prognosis.

Case Conclusion:

It was considered that the patient may have suffered from a seizure earlier on the day of presentation leading to the ethmoid sinus fracture and subsequently the pneumocephalus, or had developed pneumocephalus from prior head trauma, and then had a seizure as a result of this. ED treatment consisted of anti-epileptics, with a keppra load, prophylactic antibiotics for the ethmoid sinus fracture, and admission to the neurosurgical service where she was managed conservatively. No repair of the ethmoid sinus fracture was done due to the absence of CNS fluid leak.  Repeat imaging demonstrated improving pneumocephalus and her mental status eventually improved.

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.

Faculty Reviewer: Dr. Alyson McGregor

See you again soon!


1: Rathore, AS, et. al. Post-Traumatic Tension Pneumocephalus: Series of Four Patients and Review of the Literature. Turkish Neurosurgery. January 1, 2016. 26 (2); 302-5.

2: Markham, JW. The Clinical Features of Pneumocephalus Based Upon a Survery of 284 Cases. Acta Neurochir. March, 1967; 16 (1). 1-78.

3: Eftekhar B, et. al. Prophylactic Administration of Ceftriaxone for the Prevention of Meningitis After Traumatic Pneumocephalus: Results of a Clinical Trial. Journal of Neurosurgery. November 1, 2004. 101 (5); 757-61.

4: Semih Keskil, et. al. Clinical Significance of Acute Traumatic Intracranial Pneumocephalus. Neurosurgery Review. 1998. 21. 10-13.

5: Heegaard, William, et al. Skull Fractures in Adults. UptoDate. <>. 2016.

6: Tintinalli, et. al. Emergency Medicine. 8th Edition. 2016. 1701.


Humpty Dumpty had a Great Fall


A 54-year-old male presented to the ED after falling from a 10-foot ladder while painting his home. He complains of left foot pain, especially in the heel. Examination reveals edema of the left posterior foot, and he is unable to bear weight. 

Figure 1: Left foot physical examination findings.

Figure 1: Left foot physical examination findings.

Figure 2: Plain films of the left foot.

Figure 2: Plain films of the left foot.

A fracture of the calcaneus can be a painful and devastating injury. Although uncommon, calcaneal fractures can lead to long-term disability. Physical examination of the ankle can be misleading and radiographic evidence can be difficult to interpret making a high index of suspicion in the right clinical setting important. The most common mechanism for a calcaneal fracture is high-energy trauma to the foot. Seventy-two percent of these fractures result from falls,[i] but other high-energy mechanisms, such as motor vehicle crashes, can also cause calcaneal injury.  

Types of Calcaneal Fractures:

There are two broad categories of calcaneal fractures: extra-articular and intra-articular:

25-30% of fractures are extra-articular. All fractures that do not involve the posterior facet are included in this category. These include calcaneal tuberosity avulsion fractures and extra-articular Lover’s fracture. The name is derived from the fact that a suitor may jump from the bedroom window while trying to escape from the lover's spouse.    

Calcaneal fractures are more frequently intra-articular, involving the subtalar joint (the calcaneus and the talus form the subtalar joint). A lover fracture may be intra- or extra-articular.

Clinical Presentation:

Patients often present after a fall from a height with complaints of heel pain and swelling. Examination of the patient with a foot or ankle injury follows the standard approach; inspection, palpation, range of motion testing, etc.  The heel may appear short and wide when compared to the non-injured foot. A hematoma extending to the sole of the foot is called "Mondor Sign" and is highly suspicious for calcaneal fracture. Remember to closely examine the skin for lacerations, blisters, and tenting.


Fractures of the calcaneus can be very subtle, and these fractures often are missed on radiographs. When the mechanism of injury or exam is highly suggestive of calcaneus fracture, lateral radiographs should be evaluated by measuring Bohler's angle or the critical angle of Gissane. The axial (Harris) view of the foot may demonstrate widening of the heel or lateral wall displacement. This view should be obtained if the standard films are negative but strong clinical suspicion exists. Comparison views are helpful if the diagnosis remains in question.

It is also important to differentiate calcaneal fractures based on whether they are intra-articular or extra-articular, and displaced or nondisplaced, as these findings will dictate treatment. CT imaging is often necessary to better define the extent of the fracture. Multiple classification schemes have been used for calcaneus fractures, the most popular of which is the Sanders classification system used to describe intra-articular calcaneal fractures. This classification is based on the number of intra-articular fracture lines and their locations on CT imaging. Type I fractures are non-displaced. Type II have two articular fragments. Type III has three articular fragments. Type IV fractures have more than three articular fragments and are highly comminuted.[ii]  

MRI has a limited but potentially important role in select cases. If an occult non-displaced calcaneus fracture is suspected (e.g., persistent symptoms plus suggestive but indeterminate findings on CT), MRI may be used to confirm or rule-out a fracture. MRI is also sensitive for detecting stress fractures of the calcaneus.

Bohler's Angle:

On lateral radiograph, Bohler's angle is the angle between two tangent lines drawn across the anterior and posterior aspects of the superior calcaneus on the lateral view. A Bohler angle of less than 20° suggests calcaneal fracture[iii], though a normal Bohler angle does not exclude fracture.

Figure 3: Bohler's angle.

Figure 3: Bohler's angle.

Critical Angle of Gissane:

Measured on lateral radiograph, this “critical angle” is formed by the downward and upward slopes of the calcaneal superior surface. A normal angle of Gissane measures between 100 and 130 degrees, with a greater angle indicating fracture of the posterior subtalar articular surface.

Figure 4: Gissane's Angle.

Figure 4: Gissane's Angle.

In 2006, Knight et al. published a randomized case-control trial evaluating the use and aid of Bohler’s angle and critical angle of Gissane. Of emergency department physicians studied, 97.9% were able to make an accurate diagnosis of calcaneus fracture without the benefit of measuring either angle on lateral radiograph.[iv]

Case Continued:

Our patient is also complaining of low back pain in addition to his heel pain. Examination of the lower back reveals axial lumbar tenderness without neurologic deficits.

Consider Associated Injuries:

Patients with calcaneus fractures often have concurrent injuries, and it is important to consider this possibility in their evaluation. Following major trauma, an obvious deformity of the hindfoot or ankle injury may distract us from these other injuries.  In addition to bony injuries, the amount of force required to fracture the calcaneus can cause damage to the surrounding soft tissues. Patients can develop compartment syndrome in the “calcaneal compartment” which, if left untreated, can lead to claw toe deformity. Up to 10% of calcaneal fractures will develop compartment syndrome and half of these can develop foot deformities, including clawing of the toes.[v]

High-energy impact to the feet can be accompanied by other lower extremity fractures in 25% of patients, vertebral injuries in 10% of cases, and contralateral calcaneus injuries in 7%.[vi] The mechanism of injury often involves a substantial load to the axial skeleton, such as jumping from a second story window. Therefore, a careful and focused spine evaluation is warranted. A thorough and focused tertiary survey should aim to rule out other injuries in common areas, in particular the thoracolumbar spine.

Figure 5: L1 Burst Fracture.


Nondisplaced fractures (Sanders Type I) can be treated nonoperatively. In general, patients should be placed in a bulky compression dressing (Jones dressing) until the initial swelling subsides. The dressing can then be replaced by a removable splint or boot to begin range-of-motion exercises of the ankle and the subtalar joint. Non-weight-bearing for at least 6 weeks after injury is recommended.

Displaced intra-articular fractures require surgical intervention, and it is important to arrange for prompt orthopedic follow-up. Emergent orthopedic consultation is required for open fractures, fractures associated with neurovascular injury, fractures associated with dislocation (which must be reduced immediately), and suspicion or diagnosis of acute compartment syndrome.

Figure 6: Surgically repaired calcaneal fracture.

The Take Home:

  • Physical examination of the ankle can be misleading and radiographic evidence can be difficult to interpret. It is important to have a high index of suspicion for calcaneal fracture in the appropriate clinical setting.
  • Bohler’s angle can be used to identify subtle fractures. Less than 20 degrees is consistent with a calcaneus fracture.
  • CT is the imaging modality of choice in evaluating calcaneal fractures.
  • ED physicians should always consider the possibility that calcaneus fractures can be bilateral and associated with other lower extremity fractures and/or thoracolumbar spine fractures. 
  • An important early complication is acute compartment syndrome.
  • Emergent orthopedic surgery consultation is necessary for intra-articular, open, or displaced calcaneal fractures.

Reviewed by Dr Jeffrey Feden, Attending and Assistant Professor and Dr Neha Raukar, Attending, Assistant Professor and Director, Division of Sports Medicine, Department of Emergency Medicine, Alpert Medical School of Brown University.


[i] Mitchell MJ, McKinley JC, Robinson CM. The epidemiology of calcaneal fractures. Foot (Edinb). 2009 Dec;19(4):197-200. doi: 10.1016/j.foot.2009.05.001. PubMed PMID: 20307476.

[ii] Daftary A, Haims AH, Baumgaertner MR. Fractures of the calcaneus: a review with emphasis on CT. Radiographics. 2005 Sep-Oct;25(5):1215-26. Review. PubMed PMID: 16160107.

[iii] Isaacs JD, Baba M, Huang P, Symes M, et al. The diagnostic accuracy of Böhler's angle in fractures of the calcaneus. J Emerg Med. 2013 Dec;45(6):879-84. doi: 10.1016/j.jemermed.2013.04.055. Epub 2013 Sep 17. PubMed PMID: 24054885.

[iv] Knight JR et al. Boehler’s angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED. 2006. Am J Emerg Med, Jul; 24 (4): 423-427.

[v] Germann CA, Perron AD, Miller MD, Powell SM, Brady WJ. Orthopedic pitfalls in the ED: calcaneal fractures. Am J Emerg Med. 2004 Nov;22(7):607-11. Review. PubMed PMID: 15666272.

[vi] Weedier IS, Charted J: Emergency Department Evaluation and Treatment of Ankle and Foot Injuries. Emergency Medicine Clinics of North America 2000;18:85-113.