Sep 21

Episode 22 is a response to an article on KevinMD from April 2014, "Forget Ultrasound, Do a Proper History and Physical Instead."  In this article, written by a radiologist, Dr. Saurabh Jha (@roguerad - follow him.  I do, very interesting thoughts and perspective), the argument is made that POC US is being done indiscriminately, instead of a good H/P.  Amongst other things, the article concludes that POC US is bad for patients, costing taxpayer money and leading to over testing and over diagnosis.  POC US has been similarly accused recently in regards to leading to over testing (see this thought provoking post from EM Nerd).  Dr. Jha’s article was originally written in response to this article from NEJM, which sang praises for POC US, but did have some mischaracterizations.  

Admittedly, we may have overall overreacted a bit to this article as can be seen in the comments (the title alone is inflammatory, but frankly KevinMD often is recently).  Dr. Jha made the following clarification in the comment section:

"I’m advocating against indiscriminate use of ultrasound, as routine, as a substitute or extension of H & P (see NEJM article), not against selective use of imaging within clinical context."

We agree in some respects:

  1. We should all absolutely be doing a good H/P, and using US as a diagnostic test in the clinical context of our patients.  
  2. We should all be properly trained. 
  3. US is not a simple, learn this overnight kind of thing.  It takes dedicated training, and constant learning and practice - which we do well in the POC US community. 
  4. The US is not a stethoscope, nor is it an extension of your physical exam, and should not be used indiscriminately.

But, the physical exam is not so great:

  1. How good is a Rovsing’s sign?
  2. How about a Homan’s sign?  See here or here
  3. Murphy’s sign?

One thing we do know is that POC US does have a positive impact on patient care through faster door to diagnosis times, faster throughput, and improved patient satisfaction, based on previous POC US studies.  

Announcements:

  1. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  2. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Great discussion this week on ketamine for post intubation sedation. 
  3. Tumblr Users: I’m aware of the video issue and will do my best to get it to cross over.  Consider following the blog here at emrespodcast.org, or subscribe to the RSS feed.  Getting a bunch of new Tumblr followers recently, so want to make sure this is working out for you.  

Now, onto the Podcast:

Listen here or listen below:

Sep 07

In this mini-episode, I talk a bit about an incredibly interesting and important article published recently in the New York Times regarding resident suicide and depression.  The bottom line: If you feel like you need help, you’re not alone.  

Check this sobering article out here

Two quick announcements:

1.  Are you interested in helping write for or participate in the EM Res Podcast and blog?  I am looking to expand the blog and podcast, and I’d love for you to help.  Have an idea for a blog post?  A series?  Podcast ideas?  email me at bobstuntzmd@gmail.com, and let me know what you think.  Residents and educators welcome.  

2. Thanks to everyone who has joined the EM Res Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  It gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  Feel free to post items, comment, and share.  

Now, onto the episode:

Sep 01

Episode 20 is Part 2 of Dr. Kochert’s lecture on COPD.  In Part 2, Dr. Kochert discusses the tough question regarding antibiotics in COPD exacerbations, smoking cessation in the ED, and finishes with a Q/A discussing some of the finer points of the lecture and managing COPD patients.  Thanks again to Dr. Kochert for allowing me to post his lecture.  Making a great lecture like this takes a bunch of work, and he gives a great comprehensive review.  

Here is the final summary for the whole COPD talk:

  1. Titrate oxygen on patients with COPD exacerbations to achieve saturations of 88-92%.  Want a more detailed discussion with references?  Check this out
  2. Steroids should be given for all patients with COPD exacerbations.  Prednisone 40 mg PO x 5 days seems to be a reasonable dose.  
  3. Have a low threshold for non-invasive positive pressure ventilation (NIPPV).  It has been shown to reduce mortality and intubation rates.  jump on it early.  Again, as discussed in Episode 19, there has not been any great evidence to show CPAP or BiPAP is better.  Talk with your friendly neighborhood respiratory therapist and see what the standard is at your shop.  
  4. The evidence for antibiotics is not totally clear, but, based on available evidence, give antibiotics to:
    • Patients admitted for COPD exacerbation (especially intubated patients)
    • Outpatients with purulent sputum
  5. Discuss smoking cessation in the ED.  This is a teachable moment.  As Dr. Kochert said, peri-intubation may not be the best time, but otherwise this can definitely impact patients in a positive way.  

Two Reminders:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. Below you will find the III/Asynchronous Learning Quiz for Episodes 19/20.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  

Remember, if you have feedback, or questions for me or Dr. Kochert, I want to hear from you!

Email: bobstuntzmd@gmail.com

Twitter: @BobStuntz

Google+

References

  1. GOLD: http://www.goldcopd.org
  2. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD): http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764.pub2/abstract
  3. New, A.  Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient.  Emerg Med J. 2006 February; 23(2): 144–146.

  4. Austin MA et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. BMJ 2010 Oct 18; 341:c5462.

  5. Quon BS, Gan WQ and Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and meta-analysis. Chest. 2008; 133:756–66.

  6. Leuppi JD et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: The REDUCE randomized clinical trial. JAMA 2013;309:2223. [PMID: 23695200]

  7. Nouira S, Marghli S, Belghith M, Besbes L, Elatrous S, Abroug F.  Once daily oral ofloxacin in chronic obstructive pulmonary disease exacerbation requiring mechanical ventilation: a randomised placebo-controlled trial.  Lancet. 2001 Dec 15;358(9298):2020-5.

  8. Miravitlles M, Moragas A, Hernández S, Bayona C, Llor C.  Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment?  Chest. 2013 Nov;144(5):1571-7. doi: 10.1378/chest.13-0518.

  9. http://www.acep.org/Clinical—-Practice-Management/Smoking-Cessation/

  10. Prochazka A, Koziol-McLain J, Tomlinson D, Lowenstein SR.  Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs.  Acad Emerg Med. 1995 Mar;2(3):211-6.

  11. Katz DA, Vander Weg MW, Holman J, Nugent A, Baker L, Johnson S, Hillis SL, Titler M.  The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling.  Acad Emerg Med. 2012 Apr;19(4):409-20. doi: 10.1111/j.1553-2712.2012.01331.x.

Enjoy the podcast!


Get the OK from your PD?  Get Asynchronous Learning credit for listening!

Aug 27

It is that great time of year.  Sure the kids are going back to school, but more importantly, football is back.  And with that, your ED may soon be filled with folks on backboards wearing full football attire, taped down for c-spine protection.  How do you get their helmet and those pesky shoulder pads off while maintaining c-spine precautions?  Check out the video below, which does a great job demonstrating how to do just that.  The video is courtesy of Dr. A.J. Monseau.  Dr. Monseau is the Assistant Program Director at the West Virginia University Emergency Medicine Residency, and a sports medicine specialist.  A few of the WVUEM residents show us how it is done. Make sure you are following them on Twitter:

Dr. Monseau: @EMedSportsDoc

WVUEM: @WVUEmergencyMed

Definitely give Dr. Monseau’s YouTube page a view as well - he has some great splinting videos.  

Also, please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

Aug 19

In Episode 19, Dr. Erik Kochert returns to the podcast to give a great talk on COPD.  There was so much good stuff, I decided to split this into two podcast episodes.  In Part 1, Dr. Kochert talks about GOLD, oxygen titration, inhaled therapies, steroids and NIPPV.  

The full write up and show notes will be posted with episode 2 next week.  Also, if you are interested, our III/Asynchronous Learning quiz will be posted with Part 2 as well.  In the meantime, you can find the reference for the article regarding oxygen titration and my thoughts on that here.

Two announcements/reminders:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. I am going to be offering quizzes at the end of each podcast I do (For this COPD discussion, it will be posted along with Part 2 next week).  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  As usual, Academic life in Emergency Medicine has led the way with this (check it out here), and I hope this is something that catches on with other blogs and podcasts.

Enjoy the podcast!



Jul 31

In Episode 18, we take a look at the ingestions and insertions - both accidental and not - that make their way into the GI tracts of your patients.  This is by no means a comprehensive review of all things toxicology that can affect the GI system.  Rather, we focus on ingestions, foreign bodies, and whether or not GI decontamination actually helps.  

Two announcements:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. I am going to be offering quizzes at the end of each podcast I do.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  As usual, Academic life in Emergency Medicine has led the way with this (check it out here), and I hope this is something that catches on with other blogs and podcasts.  

Check out the podcast below, the show notes that follow, and if you can get credit, the quiz is at the bottom of the page!  


Download the show notes here

Case 1: Caustic ingestion - alkali or acidic ingestion (Images from Reference 3)

  1. Epidemiology
    • Kids: Usually accidental and smaller amounts, more upper injury
    • Adults: Usually intention, more severe
  2. Types
    • Acidic: Coagulation necrosis, usually limited superficial injury, pain limits ingestion
      • Studies suggest acid ingestion may have worse outcome overall
      • Tend to affect stomach more vs esophagus
    • Alkali: Liquefactive necrosis, delayed/continued injury, 
      • Usually more viscous preparations
      • More esophageal injury
    • If you can obtain the material ingested, look at contents or check pH 
  3. Management
    • Airway: Intubate early for signs of airway compromise
    • Skilled intubator
    • Have backups and surgical airway ready
    • Imaging: CXR/AXR to evaluate for pneumomedastinum or pneumoperitoneum
    • Give IV fluids if needed.  If delayed and high suspicion for perforation/mediastinitis, treat as sepsis (fluids, antibiotics)
    • Decontamination: DON’T
      • Never induce emesis
      • NG/OG tubes contraindicated initially
      • charcoal of no benefit, and risk aspiration
    • Steroids: Thought to decrease inflammation and thus stricture formation
      • Stricture formation largely depends on initial injury grading (more on that later)
      • Current research suggests likely no benefit
    • Proton pump inhibitors: Thought to decrease acid damage in stomach
      • Few studies with mixed results
      • Talk to your local GI specialist
    • Antibiotics
      • Yes if patient on steroids or immunocompromised and suspect significant injury/ingestion
      • Yes if suspect high grade injury/significant ingestion
      • Yes if toxic/septic, or evidence of perforation/mediastinitis/pneumoperitoneum/peritonitis
      • Otherwise, no
    • Endoscopy
      • Want done within 24 hours
      • Grading of injury
        • 0, 1, 2A: Good prognosis
        • 2B, 3A and 3B: Bad prognosis
    • Consultation
      • GI for endoscopy
      • May need CT surgery for esophagectomy or more intensive therapy if severe or evidence of perforation
      • May need general surgery is gastric perforation
      • Psychiatry if intentional
      • Consider child abuse/neglect



Case 2: Billy swallowed something

  1. Epidemiology
    • Kids: usually accidental
    • Adults: usually intentional
  2. Management
    • Airway: Look for signs of airway compromise (stridor, drooling, respiratory distress)
    • Imaging
      • AP/Lateral Plain films to start
        • Esophagus: Face on AP
        • Trachea: face on lateral
        • Kids: T6/cricopharyngeus
        • Adults: Lower esophageal sphincter
      • If respiratory concern in kids with a non radioopaque foreign body (hot dog), consider plain films in lateral position, look for hyperinflation (ball valve physiology) - but that’s another episode
      • If negative and concerning or unknown ingestion, consider CT
    • Removal, or let it pass?
      • Most things: Let it pass
      • Indications for urgent removal:
        • Sharp objects or very long objects (> 2 inches/5 cm)
        • Magnets
        • Disc battery in esophagus
        • Inability to swallow or handle secretions
        • Toxic
      • Button batteries
        • Remove if in the esophagus
        • If in the stomach or farther, re-image in the next 3-4 days


Case 3: Packers and stuffers

  1. Stuffers: Running from the police, and they ingest a substance to avoid detection
    • Treat the toxidrome
    • Expected management based on what they ingested
  2. Packers: Intentional and methodical concealment of smuggled substances
    • Most commonly opioids and cocaine
    • Evaluation: Sick or not sick
      • If not sick/asymptomatic, packing likely intact
      • Otherwise, look for toxidrome
    • Imaging
      • XR: initial imaging, especially if concern for perforation
      • CT: If high suspicion or to guide clearance/surgical management/approach
    • Management
      • Treat toxidrome if present
      • Whole bowel irrigation (WBI) with PEG
      • If obstruction/perforation or symptomatic, surgical consult
      • Disposition: admit for WBI

Check out this interesting article regarding suspected body packers and the role of the police in these patients



So what about Decontamination?

  1. Ipecac: NO
  2. Gastric levage: NO
  3. Cathartics: NO
  4. Single dose charcoal
    • Minimal evidence this works at all
    • If you do it, do it within an hour of ingestion
    • No definite evidence of outcome improvement
  5. Multi-dose activated charcoal (MDAC)
    • Consider if life threatening ingestion of carbamazepine, dapsone, phenobarbitol, quinine or theophylline
  6. Whole bowel irrigation:
    • If iron, lead, zinc, or body packing, may help
    • Consider for sustained release or enteric coated drugs
    • Avoid if perforation, obstruction, hemodynamic instability, or otherwise toxic
  7. Sodium polystyrene sulfonate (SPS - kayexalate)
    • Used in Lithium ingestion to prevent absorption and increase excretion
    • Side effects: hypokalemia, GI necrosis
    • No definite clinical outcome improvement

References

  1. Brent, J et. al.  Critical Care Toxicology.  2005.  Elsivier Mosby.  
  2. Up To Date: Caustic Esophageal Injury in Adults, updated 9/11/13.
  3. Lupa, M et. al.  Update on the diagnosis and treatment of caustic ingestion.  Ochsner J. 2009 Summer; 9(2): 54–59. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096249/)
  4. Contini, S. and Scarpignato, C.  Caustic injury of the upper gastrointestinal tract: A comprehensive review.  World J. Gatroenterol.  2013 July 7; 19(25): 3918-3930.  
  5. Abaskharoun, R et. al.  Nonsurgical management of severe esophageal and gastric injury following alkali ingestion.  Can J Gastroeneterol.  2007 November 11; 21(11): 757-760.  
  6. Up To Date: Foreign bodies of the esophagus and gastrointestinal tract in children, updated 12/30/13. 
  7. Albertson, TE et. al.  Gastrointestinal decontamination in the acutely poisoned patient.  Int J of Emergency Medicine.  2011, 4(65).  

Talk to your program director and if they approve, take the test below to help you count this podcast and blog post towards asynchronous learning!

Jul 11

In this episode of the EM Res Podcast, we welcome back Dan Kaminstein, MD.  Dr. Kaminstein is our director of the section of International Medicine in the Emergency Department at Wellspan York Hospital, and a guru of ultrasound.  Dan got in touch with an old residency pal, Dr. Emory Patterson from Athens, GA to talk about all things Emergency Ophthalmology.  Lots of great leaning points and practical tips to be had.  Some of the highlights from the discussion:

  • You must know three things when you call the ophthalmologist: visual acuity, pupils, and pressure.

  • If you can’t get a visual acuity, have them count fingers, then identify hand movement, and if all else fails, ask about light perception.

  • If the patient has a detached retina - whether mac on or off - call the ophthalmologist.
  • If you are going to dilate, use a shorter acting agent, such as 2.5% phenylephrine and 1% tropicamide,
  • There are few, if any, conditions you will diagnose in the ED that require acute topical steroids when it comes to eye complaints.  You don’t need to prescribe them in the ED for the most part, and if you need to, you should at least talk with an ophthalmologist
  • When it comes to retrobulbar hematoma - know the pressure.  Just because they have one does not mean it is causing elevated pressure, which is why you do the lateral canthotomy.  
  • Dilute proparicaine is probably not ready for primetime.  Make sure you are talking to your local ophthalmologist about stuff like this before jumping on a small amount of data.  
  • When it comes to ocular exposure to alkali or acid, anything you can flush with is better than acid or alkali.  Normal saline is fine.  So is tap water.  
Jul 08

There is a bunch out there in social media and FOAMed lately about “dogmalysis,” or the idea that some of the things we do have no evidence base, and should not be done.  I love it.  Being quite cynical and skeptical myself, I love to see us start to question our practice’s evidence base to try to come up with the best care for our patients.  But new EM residents and new EM attendings may want to take some of this content with a grain of salt.  

Here’s my take:

  • New EM Residents: Before you go quoting advanced topics and dogmalytic principles (the “I heard it on a podcast” phenomenon), make sure you are well read and understand the basic concepts first.  I think it is great people are questioning things like Kayexalate for hyperkalemia, but make sure you know how to diagnose and treat the condition otherwise.  Lay the foundation before you spend too much time on advanced topics.  
  • New EM attendings: Get the lay of the land for the first 6-8 months.  You are not going to change an entire hospital system in one day, and you may in fact hurt your chances of effecting change in the future by being known from day one as the guy who pitched a hissy fit about protonix for an upper GI bleed on your first shift out when that is the standard of care across all practices at your place.  Remember change takes time, and educating your colleagues, both within your specialty and without, takes time and trust.  


May 28

We have all answered that call from radiology or a radiology tech.  In this episode, we talk about the myths and truths behind the use of oral contrast in the ED, ED imaging in pregnancy, and contrast induced nephropathy.

1. Oral Contrast in the ED: With new generation scanners, most patient with non traumatic abdominal pain do not need oral contrast.  Multiple studies have shown that with new generation scanners, CT for appendicitis does not suffer when oral contrast is not administered. In high grade bowel obstruction, the American College of Radiology (ACR) actually says we should NOT be giving oral contrast as it is bad for the patient (potential aspiration), and may obscure radiologic evidence of bowel wall ischemia.  With motion artifact reduction in new generation scanners, it really isn’t adding much to diverticulitis, either.  







2. Imaging in pregnancy: Remember this is all about how we communicate risk.  We always want to follow the ALARA (as low as reasonably achievable) principle, but we must not punish the patient for being pregnant by not doing the appropriate study.  CT versus VQ is controversial, but I feel this guideline from the American Thoracic Society/Society of Thoracic Radiology is a reasonable approach:



Abdominal imaging can be tricky, but the answer should generally be US first in the pregnant patient, followed by MRI if possible.  Again, if they need the CT, discuss the risk/benefit ratio and educate your patients.  



3. Contrast Induced Nephropathy (CIN): The incidence of CIN is likely lower than we thought previously.  In general patients with a GFR < 30 are at highest risk, and those with a GFR between 30-45 may be at higher risk.  The majority of are patients, however, are at a minimal risk of CIN.  To prevent it in high risk patients, the best we can try is hydration with isotonic fluids and educate the patients.  But again, if you need the scan, you need the scan.   




Listen to the podcast, and let me know what you think!

May 21

A 62 year old man presents after he tripped and fell on his R shoulder.  His only complaint is of R shoulder pain, and on exam his pain is localized to the distal clavicle.  The R shoulder X Ray shows the following.  What is your interpretation?  What are the different types of this injury?  What is your treatment plan?



The above image shows an acromioclavicular (AC) joint separation.  This should be considered in anyone who falls onto the the shoulder, particularly the apex, or an outstretched hand.  If you watch (American) football, think about the running back you see who gets tackled with his arms holding onto the ball, and they land right on the shoulder pad while being driven down.  Patients may complain of generalized shoulder pain and limitation of their range of motion, but will have point tenderness over the AC joint.  As with any injury, make sure to do a full neurovascualr exam distal to the injury, palpate the entire clavicle, and evaluate the ribs for possible injury and consider pneumothorax if you suspect thoracic injury.  And, as with any upper extremity injury, determine the handedness of the patient.  

It is important to know that there are different grades for AC injury.  The common classification is known as the Rockwood classification, and describes six types of AC injury.  To understand them, we must understand the anatomy involved.  



The Rockwood classification system requires interpretation of a few things:

  1. The acromioclavicular ligament
  2. The coracoclavicular ligament
  3. The AC joint capsule
  4. The deltoid
  5. The trapezius
  6. The relation of the clavicle to the acromion

There are six types of AC injury (Type I -VI).  A great description of each of the above factors in each type can be found here.  If pictures are more your thing, this will help: 



It is important to know what type it is as it relates to treatment.  Types I-II are generally treated conservatively with a sling and no surgical intervention, although severe type II injuries may require surgical intervention depending on occupation, severity, and clinical course.  Management of Type III is controversial, but may require operative intervention as well.  Types IV-VI require operative correction, and probably warrant more urgent orthopedic evaluation and consultation at the time of injury.  If you suspect an AC injury, but your film does not show a clear unobstructed view of the AC joint that allows you to evaluate the relationship of the inferior border of the acromion and the clavicle, consider a Zanca view (the XR gets a bit of cephalic tilt to allow clear visualization of the AC joint).  

So what about our patient?  The image shows that the inferior border of the clavicle is elevated when compared to the inferior border of the acromion, but does not pass its superior border, so this is likely a type II AC Joint injury.  The patient should be placed in a sling, given analgesia, and referred for urgent orthopedic evaluation.  

References:

  1. http://emedicine.medscape.com/article/92337-overview
  2. http://radiopaedia.org/articles/acromioclavicular-joint-injury-classification-rockwood
  3. Macdonald PB, Lapointe P.  Acromioclavicular and sternoclavicular joint injuries.  Ortho Clin North Am.  2008 Oct; 39 (4): 535-545.  

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