Diagnosed with a Fracture?


Fractures are classified into different types based on the location and type of cut made to the bone. The terminology is very important in these cases so play close attention to the wording of the fractures, words such as open, closed , compound etc all have special meanings in orthopedics and require different treatments. The way the fracture axis splits the bone helps further classify fractures. Types include linear, oblique, transverse, longitudinal, and spiral fractures.

Types of Fractures

Comminuted fracture – the bone is shattered into small pieces. This implies that the bone is cracked completely into two separate pieces .

Simple fracture – or ‘closed’ fracture. The broken bone hasn’t pierced the skin.

Compound fracture – or ‘open’ fracture. The broken bone juts through the skin, or a wound leads to the fracture site. The risk of infection is higher with this type of fracture.

Compression fracture – occurs when two bones are forced against each other. The bones of the spine, called vertebrae, are prone to this type of fracture. Elderly people, particularly those with osteoporosis, are at increased risk. THESE ARE SEEN IN PATINTS WITH OSTEOPOROSIS, The Vertebral bones get compressed and break due to the fact the the bone is so brittle it breaks on its own weight.

Pathological fracture – bones weakened by various diseases () tend to break with very little force. These are due to diseases of the bone such as osteogenesis imperfecta

Greenstick fracture Is a special type of fracture where only one side of the bone is broken and the other side remains intact. Kind of like breaking a wet stick. ONLY ONE SIDE CRACKS the other remains intact.

Avulsion fracture – muscles are anchored to bone with tendons, a type of connective tissue. Powerful muscle contractions can wrench the tendon free, and pull out pieces of bone. COMMON IN KNEE AND SHOULDER JOINTS.

Stress Fractures– These are due to Low impact constant pressure and predominantly involve the lower extremities. They are due to over usage, classic example is a parade band person who complains of pain in his foot and X-rays are negative. The X-RAYS will usually not SHOW ANYTHING.

Fractures identification

Linear fractures– have a break that runs parallel to the bone’s main axis or in the direction of the bone’s  shaft.

Oblique fracture– crosses a bone at approximately a 45° angle to the bone’s axis
transverse fracture- crosses a bone’s axis at a 90° angle.

longitudinal fracture – The fracture line extends along the shaft but is more irregular in shape and does not run parallel to the bone’s axis.

Spiral fractures– Are due to torsion or twisting forces which crossing a bone at an oblique angle, creating a spiral pattern. This break usually occurs in the long bones of the body such as the upper arm bone (humerus) or the thigh bone (femur).


X-Ray involves at least two views of the area to confirm the presence of the fracture because not all fractures are apparent on a single x ray. Some fractures are often difficult to see and may require several views at different angles to see clear fracture lines. In some cases, CT, MRI or other imaging tests are required to demonstrate fracture. Sometimes, especially with children, the initial x ray may not show any fractures but repeat seven to 14 days later may show changes in the bone(s) of the affected area. If a fracture is open and occurs in conjunction with soft tissue injury, further laboratory studies are often conducted to determine if blood loss has occurred.

Tuning Fork Test In the event EXERCISE RELATED STRESS FRACTURES (micro-fractures due to excessive stress) ., a tuning fork can provide a simple, inexpensive test. The tuning fork is a metal instrument with a stem and two prongs that vibrate when struck. If an individual has increased pain when the tuning fork is placed on a bone, such as the tibia or shinbone, the likelihood of a stress fracture is high. Bone scans also are helpful in detecting stress fractures.

Treatment of Fractures

Just as there are different types of fractures there are various ways to treat them. Casting, Figure 8 Device, ORIF ( open reduction internal fixation ) , Closed Reduction External Fixation, etc. So it is important to know what treatment is used for what injury .

If you have questions concerning your specific case, contact us to schedule a 2nd opinion consultation with our expert orthothopedic surgeon.

Emote Medical Services is currently accepting new patients, and has openings for consultation requests. Book your appointment today !

Emote Medical Services is proud to announce, Dr de Moura of New York Spine Institute as our Expert Orthopedist and Neurosurgery 2nd opinion consultant. Set up an appointment to address your concerns.

Emote Medical Services is proud to announce, Dr Amy H Fisch of as our Expert Anesthesiology 2nd opinion consultant. Set up an appointment to address your concerns

Making Sense of Birthmarks


Childrens FeetBirthmarks are a common finding in  children and require special attention since they are of great concern to  parents. These conditions can sometimes mimic more serious conditions and can even lead the clinician to suspect child abuse so a thorough understanding of the subtleties is warranted.

Erythma Toxicum – Don’t let the name fool you. This is not a serious condition. It is a rapidly transient skin lesion which presents with tiny erythemetous pustules and vesicles, which disappear and reappear in different parts of the body. Biopsy of the lesions will show the characteristic EOSINOPHLIA. They are present usually after 48 hrs from birth.

Capillary Hemangioma- Capillary hemangiomas are  proliferation’s of the vascular endothelial cells. They are usually not present during birth but appear within months of birth but can come on after 1 y/o. These lesions are bright red, raised usually appearing on the cheeks also known as “Strawberry” hemangiomas.

Mongolian Spot- These are black and blue lesions which have an indistinct border, they present usually within the first 2 weeks and can persist up to 4 years. They are often times confused with bruises,

Nevus Simplex- (Stork Bite, Angels Kiss) This is the remnant capillaries of the skin during neonatal development. The are the most common type of birth marks. They characteristically are present in the back of the neck (nape) and are called “Stork bite”. The lesions are flat and pink in color (also called salmon patch) They can also be found in the forehead and are also called “Angels Kiss”. They are present at birth and disappear within a year.

Nevus Flammeus (Port wine stain) – Is a permanent birth mark of vascular origin that most commonly appears on the face but can appear anywhere. The key is that this birth mark is permanent and will not disappear with time. It can be treated with lazer therapy if social and psychological stress persists. The occur due to venous malformations in the capillary beds. They present with irregularly shaped raised lesions which usually darken with age. They look as if “ Burgandy Port wine has been spilled on the persons face”.

Have a child with a unique type of birthmark? discuss your child’s health with our expert pediatric consultant. Make an appointment today.!


Understanding Heart Failure


Congestive Heart Failure  (CHF)

Congestive Heart failure is a condition in which the heats pumping mechanism becomes weak, and is unable to push out the Blood in its chambers adequately enough. This is a condition that has many underlying causes. So its important to realize that the cause of the heart failure can be due to some other underlying pathology. In many ways CHF is as much a  SYMPTOM as  a DIAGNOSIS. CHF can be subcategorized, possibly given the physician a clue regarding the underlying cause of the heart failure. The two catagories are

Systolic Heart Failure – Refers to a weakened heart, meaning the heart doesn’t contract well  enough, to  pump out blood. This can be due primary cardiomyopathy, it can also be due to hypertension, which means the muscles will be working fine its just that they are pushing out against High Resistance of the  arterial vessels.

Diastolic Heart Failure refers to in adequate FILLING PRESSURES – This means that the Heart is really Stiff and wont allow the chambers to fill properly . Or it can mean that there is a blockage of blood flow on the right side. Thus there is inadequate venous return. A traffic jam if you will of blood flow and this traffic jam can be anywhere in the system behind the Left ventricle. So it can be due to lets say a Mitral Stenosis. Or  Pulmonary Heart failure, or Cor Pulmonale, Or Liver disease. So its important as a patient to understand the type of Heart Failure you are diagnosed with.

Have concerns about your Congestive Heart Failure Diagnosis? Contact us to schedule a consultation with our expert cardiologist!

Nutrition and Lifestyle

Amy Heather Fisch's picture

Every person has nutrition concerns or questions. Some go to media “experts” or diets to attempt success. Every person is different and no one popular item will find the cure for what they need. Some people want to look better, some need to and seek to eliminate medical problems such as High Blood Pressure or Diabetes. Most commonly, people seek Nutritionists to help them LEARN how to FEEL better and do everything they want.

I am happy to bring personalized Nutrition Counseling to Emote Medical, not only to aid Patients reduce their medial problems but also to teach any individual to achieve their goals to lose weight, overcome an eating disorder, learn about super foods and live their best lives.

I am not only an Anesthesiologist, but a Nutritionist and fitness enthusiast. I am ready to meet new clients and provide each person the individual attention they need and deserve.

Dr. Amy H.

Pediatric Anesthesia

Does your baby or child need to undergo surgery?

It’s probably the most dreadful thought a parent could encounter; finding out that their child needs to undergo surgery.  Often times parents are left to make difficult decisions without having complete information about the anesthesia risks and the process of what to expect during surgery.


Question/Answer session

1) Do you know how to take care of children? This is my baby!

Your Anesthesiologist is an expert in their field; your child will be monitored and will  be in the hands of people who can handle emergencies

2) What can I expect when my child goes off to sleep?

The process of a child going to sleep involves several stages of Anesthesia, and it tends to be more traumatic for the parents than for the child.  Expect your child to cry, to appear to fight, and sometimes a child’s eyes roll back as they fall asleep.  This is routine and not of much concern. Be prepared to be strong and hold your child’s hand or trust that the Anesthesiologist has left everything but your child’s care behind and will be there 100% of the time

3) Will my child know what’s going on?

Not only are Anesthesiologists able to premedicate if needed depending  on your child’s personality and medical condition, but even without premedication, the induction  of  Anesthesia is fast and young children do not remember.  Most importantly, if the  Anesthesiologist knows about your child prior to the day of surgery, care can be individualized even more.

4) How do they wake up?

Children wake up in a state called “emergence delirium”.  They may fight, cry and not recognize their surroundings for several minutes after surgery.  Be prepared, its not pain, its confusion.  Until the child is fully awake remain calm and try not to stimulate your baby, they will wake up and begin to recognize you in minutes.  Talking extensively with an Anesthesiologist prior to the day of surgery will help you know what to expect and what medications can help, if any.

5) Will my child be in pain??

Every surgery can cause pain.  The goal of the Anesthesiologist is not only to minimize pain but to eliminate pain and nausea.  Discuss this not only with the Surgeon, but consider how much a consult preoperatively with an Anesthesiologist will relieve your anxiety.

If you wish to have your questions answered by a board certified Anesthesiologist, please feel free to make an appointment and they will sit one on one with you to answer any questions you may have. Surgery is a serious endeavor, and fortunately with the advances of modern medicine, the outcomes have improved. However it is best to stay informed and know what to expect, and be prepared so you can ask the right questions and be in control of the situation.


Getting Surgery? Have questions about anesthesia ?

Will I wake up in the middle of Surgery?

Waking up During Anesthesia is exceedingly rare and most reputatble reports are in severe trauma cases and Cardiac Bypass.  The most common misunderstanding is a Patient awakening during a sedation case and thinking they were under General Anesthesia…..Big difference.  We can monitor Brain wave activity to ensure depth of Anesthesia is appropriate

How Do You Make Sure I wake up?

Anesthesia is an Art developed by years of training and experience every patient is unique and we dose our medications to each patient as a unique Entitiy and dose all medications as you react to them, not weight based alone, but on how each patient reacts.  Every BODY is different and is treated as such

What Drugs are You Using??  I read that Michael Jackson died from anesthetic medications

Anesthesia involves a unique combination of medications to cause a hypnotic state where lack of recall takes place, pain medicine, anti-anxiety medications and anti-nausea medications.  Any celebrity that has been in the news is a unique situation most often tragedy results from misuse of medications outside the controlled setting of the operating room

Will you make sure I am not in Pain ?

I can never PROMISE no pain, I can promise to teach you how to not only stay ahead of severe pain, but I will use the best medication to suit your needs.

Promise You Will Be In the Room The Entire Time ?

It’s the Law that an Anesthesia Professional be in the room at all times, as long as you’re a patient in the Operating Room the Anesthesiologist has a moral and legal responsibility to take the best care of your life and keep you safe from harm.


These are the common questions that often lead to more, especially as surgery becomes more specialized and so does our management of our patients as Anesthesiologists.Are you undergoing surgery, feel free to contact use for an independent in-depth, preoperative consultation, our board certified anesthesiologist will sit one on one and answer any questions and address any concerns you might have..


Failure To Thrive


Failure to thrive is a generalized term used to describe a condition of poor growth in children; this can have multiple causes, and thus require a thorough evaluation. This condition takes into three important parameters, Height/ Length, weight and Head Circumference. There is no standard definition of failure to thrive. Nor is there a standard time frame for how long it should exist before taking action. General pediatric consensus states that generally patients who fall below 5%tile – 2%tile or those who fall of the growth curve by two curves. Numerous factors need to be considered, and can be subdivided into organic causes, or inorganic causes (psychosocial factors, eg poverty, or maternal inexperience, or neglect). Failure to thrive is a bit tricky because by itself it’s not a diagnosis but a symptom to warrant further evaluation to isolate the cause.

Causes of Failure to Thrive

The most common cause of failure to thrive, is insufficient nutritional/caloric intake, (inorganic cause) could be due to many causes, Mothers lack of knowledge, (seen in teenage pregnancy), poor socioeconomic status, abuse in the form of neglect.

Organic causes

Celiac disease, Pyloric stenosis, GI malformations, immune deficiencies, malignancy Thyroid disease,


Because failure to thrive is mostly a psychosocial issue,  and both the care provider and the patient need to be evaluated, to identify the cause, often time’s blood tests will not yield the cause of the problem and are generally not the next step in management. Getting more details of the family dynamic and Childs feeding habits are more important then lab tests.


Parental education, will be key to treatment in most cases, advice will be directed at the cause, for example.. cause is no money for food, suggest resources for free meals
If cause is parental depression, then psychotherapy and counseling services to treat parent.….If abuse/neglect is suspected, then hospitalization is warranted. If poor parental knowledge is the cause, provide nutritional support to educate parents on thickening meals.. ( cream sauces add gravy sauces, increase fat content) ..

In medicine doctors will come across patients of multiple backgrounds, some diets are plant and water based..ie south Indian diets,) so in patients who leave their country often times leave a support system and come to America with little knowledge of culture and dietary options.. People may not know about things like sour cream or, mayonnaise) so the doctor is the support system and should provide the proper nutritional counseling needed.If the condition is due to a a medical cause then treatment should be directed at the medical condition…

Was your child diagnosed failure to thrive? Do you feel your questions went unanswered?  Do you want to sit one on one with our pediatrian, and discuss your unique case? .. Contact us…

General Health and Wellness

Obesity is a MAJOR problem in the UNITED STATES.. In the United States approximately 1/3rd of the people are Obese. Obesity can have effects on both the physical and mental health of the effected individual, and should be considered as a serious problem demanding treatment. Obesity has a range which is based on BMI. BMI stands for Basal Metabolic Index and is calculated of (Weight in KG/ (Hight in Meters)2

Obesity Scale
Overweight – 25.0-29.0
Mild Obesity—30.0 -35
Moderate -35.0 -40

Obesity in child and Adolescents is defined as weight and height values >95%tile ..

Treatment should target the 3 principal mechanisms leading to obesity

1) Dietary management should consist of a LOW CALORIE DIET
2) Physical Exercise should be increased or added
3) Behavioral modification should also be a part of management as well

Weight loss goals should be 10% decrease from initial body weight within 6 months. The rate of weight loss should be 1 lbs /week.
Medications are indicated for BMI >30 or BMI >27 + Obesity related Risk factors ( CAD, DM,HTN)



Hypertension is one of the most common problems treated by family physicians. It effects up to 20 % of the population. It serves as a significant risk factor for other common conditions, such as CAD, and Stroke. Hypertension can occur in all ages and has many causes to its eitiology. It is very important to employ clinical guidelines and treating patients in a systematic way. Hypertension can be further divided into PRIMARY or SECONDARY ( meaning due to another disease process). Treatment of Hypertension is MULTIMODAL, IT involves Lifestyle modifications, medical management, and in some cases surgery.

Blood Pressure is a measure of two important factors : Cardiac Output and Total Peripheral Resistance.


Normal BP is 110/70
High BP is 140/90 (American Standards)
WHO defines it as 160/90

The mail cause of Hypertension is still unknown, however tertiary effects include,
Reno-Vascular Hypertension, (1-2%)
Neurological effects include Drugs-Oral Contraceptives, cocaine, Pre-eclempsia

The degree of hypertension is gauged primarily by the diastolic levels. Which represents the denominated number (bottom number).

Diagnosis of Hypertension is made by measuring the Blood pressure, and requires 3 SEPARATE READINGS usually done within 8 weeks.

Classifying Hypertension

Hypertension Class and associated treatment recomamdations

Pre- HTN 130/80-139/89 usually treated with  LIFE STYLE MODIFICATIONS SUCH AS WEIGHTLOSS  DASH Diet ( Hypertension low sodium diet), INCREASE PHYSICAL ACTIVITY Limit ETOH, X 6 MONTHS ( Weight loss is most important
modifiable risk factor in reducing bp)

CLASS -1 140/90-160/100 Try Life Style Modifications x 6 months if no reduction..TREAT WITH SINGLE AGENT ANTIHYPERTENSIV(Thiazide diuretic first line for most…)

CLASS-II 160/100-180/110 Life STYLE MOD + 2 DRUG TREATMENT (Will depend on clinical setting)

CLASS- III >180/110 Seek Emergent Care.

Non Pharmacological Interventions for lowering BP

1) WEIGHT LOSS!! ( this is the most significant modifiable risk factor for reducing BP)
2) DASH DIET( This is not just a low sodium diet but a Dietary Approach to Stop HTN)
3) Physical Exercise

Esential Hypertension has varying pathophysiology, statistically African Americans living in America the rate of HTN is greater then caucaisians.. But AA world wide have the same rate of HTN as caucasians!