Letters to the editor.(Letter to the Editor)

Publication: American Family Physician

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COPYRIGHT 2003 American Academy of Family Physicians

Hypertension Should Be Confirmed Before Treatment

TO THE EDITOR: I would like to thank Dr. Niedfeldt and American Family Physician for the fine article, "Managing Hypertension in Athletes and Physically Active Patients." (1) However, I would like to add a point to this statement: "If (hypertension) is diagnosed, appropriate treatment should be started to reduce the risk of morbidity and mortality associated with cardiovascular disease." (1) I believe that it is important to be sure that the patient does indeed have hypertension. Some athletes have extra large or extra small upper arms and have been screened with an inappropriately sized cuff when taking their blood pressure. (2) Other athletes exhibit "white coat" hypertension. (3) Therefore, when diagnosing hypertension, physicians should use appropriately sized cuffs for those "extra" sized athletes. I have found that the use of ambulatory pressure monitors has saved many athletes with white coat hypertension from taking unnecessary medication.

JOHN PHILIP SHERROD, M.D. University of North Carolina at Chapel Hill Department of Family Medicine Manning Dr. Chapel Hill, NC 27514

REFERENCES

(1.) Niedfeldt MW. Managing hypertension in athletes and physically active patients. Am Fam Physician 2002;66:445-52.

(2.) Zitelli BJ, Davis HW (eds). Atlas of pediatric physical diagnosis. 3d ed. St. Louis: Mosby-Wolfe, 1997.

(3.) Noble J, Greene HL. Textbook of primary care medicine. 2d ed. St. Louis: Mosby, 1996.

Early Diagnosis and Treatment Vital in Cases of Foot Fractures

TO THE EDITOR: I read with great interest the article, "Foot Fractures Frequently Misdiagnosed as Ankle Sprains," (1) which provided a thorough discussion of the various types of talus fractures and how they can be missed initially on physical examination. This is of particular importance in children, because talus fractures in children are extremely rare (2-4) and may lead to lifelong morbidity unless they are diagnosed and treated appropriately. Furthermore, a large percentage of confirmed talus fractures are read as normal on initial radiographs. (1,3)

During a seven-year period, only 15 patients (average age: five years, five months) were identified at our institution who had either a talar head, neck, or body fracture (avulsion fractures and osteochondral fractures were excluded). (2) The most common mechanism of injury was a motor vehicle crash, and the second most common was a fall from a height. Additionally, in 12 of these patients, the talar fracture occurred in conjunction with other ipsilateral lower extremity fractures. The initial radiographic diagnosis of these fractures was missed in 33 percent of the cases in the emergency department, which is similar to results found by Drs. Judd...

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