Grand Rounds: don’t RUSH ortho

In this week’s edition of Grand Rounds Zack performed a quick review of the RUSH exam for undifferentiated shock and Theresa outlined some easy to miss orthopaedic injuries. Below are a few resources on both below! 

The RUSH Exam

In the patient with undifferentiated shock you can use the power of the ultrasound to evaluate the “Pump, Tank and Pipes” or the HI-MAP. See the EMCrit post from the original creators.


For a super primer on the RUSH/HI-MAP exam check out this video from 5 minute soon here or this post from ALiEM.

Happy scanning with our new high frequency probe!!!

Easy to Miss Ortho Injuries

There is far too much to cover from Theresa’s awesome review on this topic. I’ve decided to highlight a couple of the injuries that she mentioned with links to the resources about those injuries for some quick reading.

There is a spectrum of scapholunate injuries that are easy to miss. These range from scapholunate dissociation (widening of the scapholunate joint) to peri-lunate dislocation to lunate dislocation.

The posterior shoulder dislocation can be easy to miss. Keep your eye for the lightbulb sign. Maybe we can consider using ultrasound for catching the diagnosis?

The lateral elbow x-ray is your friend. Keep your eye out for signs of occult fracture in this view.

I really appreciated Theresa’s discussion of the Ottawa Ankle rule. She reminded us that these rules can help assess the need for imaging but the components do not make up a complete or thorough ankle exam. Remember to check the proximal fibular head and examine the whole ankle and foot.

Theresa’s 10 Commandments for Ortho Injuries

  1. Know what you are looking for
  2. Obtain proper, perpendicular views, multiple views and specific views
  3. Be aware of specific, occult and dislocation radiographic signs
  4. Know what “normal looks like”
  5. Avoid being distracted
  6. Develop a systematic approach to xrays
  7. Use cognitive forcing strategies – (i.e. always document snuffbox tenderness and DRUJ findings in wrist exams)
  8. ALWAYS obtain post reduction films
  9. Examine the joint above and below
  10. History and physical trump ALL. Examine, image, re-examine.



Author: Eve Purdy

PGY2 in Emergency Medicine with added interests in online learning environments, paediatrics and anthropology. Outside of the department she strums a guitar occasionally and dog sits as often as she can.

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