Andrew D. Perron

Stress fractures are an increasingly common injury in primary care patient populations. Early diagnosis and prompt conservative therapy are effective for most of these injuries. Special attention to clues from history taking and physical examination in an at-risk patient population can lead physicians to the correct diagnosis. Most stress fractures resolve with rest and progressive reintroduction of stressors, but certain injuries, such as stress fractures of the femoral neck and fifth metatarsal, have a high risk of complications and require aggressive therapy.

As the patient population becomes more involved with athletics, informally or in an organized fashion, risk of stress fracture increases. Rapid and safe recovery is best ensured with early diagnosis and expedient conservative therapy. A history of progressive pain, initially with exertion and ultimately at rest, suggests the diagnosis. Plain radiographs often do not reveal fractures, and specialized studies, such as bone scanning, SPECT, or MRI, may be necessary to confirm the diagnosis. Simple rest with progressive reintroduction of activity is the treatment of choice for most stress fractures.

Immediate concussive convulsions are an unusual but dramatic sequela to head injuries. Previously believed to be an epileptic phenomenon, they are now thought to be a brief traumatic functional decerebration that results from loss of cortical inhibition. With concussive convulsions generally occurring within seconds of head impact and lasting up to several minutes, patients are initially in a tonic phase, followed by a clonic convulsion. A postictal phase is generally brief if it occurs at all with these episodes. Patients with isolated concussive convulsions have no evidence of structural brain injury as assessed with neuroimaging studies or physical examination. Neuropsychological testing often demonstrates transient cortical dysfunction consistent with the concussive episode. The long‐term outcome for patients with isolated concussive convulsion is universally good, with no long‐term neurologic sequelae and no increased incidence of early or late posttraumatic epilepsy. Emergency department management should focus on evaluation of the associated concussive injury. The concussive convulsion requires no specific therapy, and antiepileptic medication is not indicated.