Turf Toe:
Increased recent attention due to injuries in high profile athletes
Sprain of the first MTP joint
Mechanism: Forced hyperextension of the great toe (most common)
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Causes injury to the MTP joint capsule and surrounding ligaments
Presents as pain, swelling, discoloration, tenderness to palpation, possible joint laxity
Pain with active and passive ROM (both flexion and extension)
Graded 1-3 (Sprain, partial rupture, significant/complete rupture)
Most commonly seen in athletes who compete on artificial turf.
More rigid than natural grass
Synthetic surfaces do not release cleats as easily as natural grass
Improved synthetic surfaces perform more similar to natural grass
Much higher incidence in games vs practices.
In football, quarterbacks and running backs at highest risk
Between 30 and 45% of professional football players claim that they have experienced a turf toe injury, with over 80% of those injuries occurring on artificial turf
The combination of more rigid synthetic surfaces and lighter, more flexible shoes, increase risk of hyperextension injuries
Treatment: usually non operative
Rest/ice/taping after acute swelling decreased/stiff sole shoe/crutches/NSAIDs.
Consider walking boot or short leg splint for severe injuries
Less than 2% of injuries require surgery
Chondrocalcinosis is a condition where calcium pyrophosphate crystals form in the joints (particularly the knee and wrist), leading to inflammation and pain.
Appears as a cloudlike radiopacity in the knee’s articular cartilage and meniscus on XR, reflecting abnormal calcium-based crystal deposition.
This can be distinguished from the radiolucent appearance of monosodium urate crystals of gout.
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These calcium crystals are common in end-stage knee osteoarthritis and have been associated with disease severity.
Due to this well-observed coexistence (chondrocalcinosis and knee osteoarthritis), chondrocalcinosis is commonly considered a manifestation of osteoarthritis pathology.
However, this does not explain the commonly encountered instances where chondrocalcinosis appears in radiographically normal knees. This raises questions of whether chondrocalcinosis is a cause or merely a consequence of end-stage osteoarthritis.
Population studies have identified that about 6.% of individuals have chondrocalcinosis in joints unaffected by osteoarthritis
In a recent analysis including more than 6400 middle-aged to older adults, individuals with knee chondrocalcinosis were 75% more likely to develop knee OA than those without the condition at baseline.
Chondrocalcinosis may contribute to the risk of osteoarthritis through inflammation. These deposited crystals could induce the production of inflammation markers, matrix-degrading enzymes and induce chondrocyte hypertrophy or chondrocyte death. These effects not only damage the joint but also form a positive feedback loop to produce more calcium crystals.
Individuals with chondrocalcinosis may represent a specific subgroup of patients, for which a treatment targeting chondrocalcinosis induced inflammation may present a viable strategy to prevent osteoarthritis in this patient subgroup.
This idea has some support from the 2023, LoDoCo2 trial, (approx. 5500 patients) which showed an association between the use of colchicine, 0.5 mg daily, with a lower incidence of total knee and total hip replacements.
Low-Dose Radiation Therapy for Osteoarthritis
Current options for osteoarthritis include NSAIDs, physical therapy, intraarticular steroid injections, and lifestyle modifications, such as weight loss and exercise. After these options have been exhausted, there is joint replacement.
Problems with these options in older patients are that about 25% of all patients will not respond to these therapies or lose their responsiveness over time. NSAIDs also may not be great options in those with renal impairment and increased risk of GI bleeding.
Conventional radiation therapy (RT) in the treatment of malignant disorders relies on its antiproliferative effects. Alternatively, at doses of less than 1 Gray, RT has been shown to have strong anti-inflammatory effects.
RT may be an appropriate option for those with OA who have failed other conservative measures but are not ready for joint replacement…ideally before the onset of bone-on-bone changes at which point RT is less likely to be effective.
Appropriate candidates are older than 50 years. Patients do not typically experience acute side effects. There may be slight redness, milder than a sunburn, on the skin of the area radiated. Malignancy induced by RT treatment remains a small theoretical risk and is mitigated by selection of non central joints (i.e. not for spine OA).
The most commonly treated joints include hands, feet, knees, and elbows.
Pain relief can last from several months to years, with studies reporting that 30%-60% of patients maintain significant pain reduction 1-2 years after treatment. In one study, patients reported 85% decreased use of analgesic medications.
Typical treatment regimens involve 6 sessions of 0.5 Gy each conducted 2-3 times per week.
RT may be an effective modality for patients who have failed conventional treatment and are either not ready for surgery or are poor surgical candidates.
Use of Muscle Relaxants in the Elderly
A recent pearl discussed the risks of skeletal muscle relaxants (SMR) in the elderly population.
Risks included sedation, confusion, disorientation, orthostatic hypotension and increased risk for falls and fractures.
The Beers Criteria is a list of medications that older adults should generally avoid due to potential adverse effects.
Two commonly used muscle relaxants, Baclofen and Tizanidine (Zanaflex) are not included in the Beers criterion.
A study published last month investigated the safety profile of these medicines as compared to cyclobenzaprine (Flexeril).
Retrospective cohort study of Kaiser Permanente Southern California patients aged 65 to 99 years between 2008 and 2018.
From a population of approximately 88,000 participants (mean age 71.4 years; 59.8% women), approximately 118,000 study medication episodes were identified: 54.8% participants were dispensed baclofen, 6.3% tizanidine, and 38.9% cyclobenzaprine
Outcomes included injury-related hospitalizations, emergency department visits, and urgent care visits documented in EMR and identified through diagnostic codes for fractures, falls leading to fractures, brain injuries, and dislocation injuries
Compared with cyclobenzaprine, Baclofen demonstrated a 69% greater risk (adjusted Hazard Ratio 1.69, [95% CI 1.51-1.88]) and tizanidine carried a 34% greater risk (adjusted Hazard Ratio 1.34, [95% CI 1.11-1.62]) for composite injury outcomes.
Conclusion: Older adult patients prescribed baclofen or tizanidine have an increased risk of injury when compared with Flexeril (currently included on the Beers Criteria)
Use of Muscle Relaxants in the Elderly
A 2023 Cochrane Database review found moderate-certainty evidence that muscle relaxants may increase the risk of adverse events.
Primary adverse events are due to CNS depressant effects (dizziness, sedation) and anticholinergic effects.
Geriatric patients already have baseline unsteady gait, decreased coordination and cognitive changes.
A 2015 study showed that geriatric patients who took muscle relaxants were 2.25 times more likely to visit the ED for a fall or fracture and 1.5 times more likely to be hospitalized for a fall or fracture than patients who did not take these medications.
Risk is greatest in patients >65 years of age. This population was 1.32 times more likely to have an injury compared to patients who did not take skeletal muscle relaxants.
Epidural abscess
Likely the most serious missed emergent condition in patients diagnosed with non-specific back pain.
Challenging diagnosis to make in the ED
Almost half of patients are initially misdiagnosed and average two ED visits before the diagnosis is made.
At the time of diagnosis, the most common symptom is diffuse spine pain and the most common exam finding is severe local spinal tenderness.
Fever is only present in 30% to 50% of patients at presentation.
In one study, over 65% of patients with spinal epidural abscesses were afebrile on presentation.
Also, consider that the neurological examination is normal in two-thirds of patients at their first ED visit.
Scaphoid fractures
Make up almost 2/3rds of all carpal fractures
Fractures tend to be localized to 3 anatomic locations
Waist fractures make up 2/3rds. This may be diagnosed with anatomic snuffbox tenderness
Proximal pole fractures make up approximately 25%. This may be diagnosed with bone tenderness about a fingerbreadth distal to Lister’s tubercle
Distal fractures make up the remaining 10%. This may be diagnosed with tenderness at the volar prominence of the distal wrist crease
Imaging:
In addition to standard views of the wrist (PA/lateral/oblique) consider adding a scaphoid view. This imaging view is a PA film taken with the wrist in full pronation and ulnar deviation. This allows full visualization of scaphoid in its longitudinal axis. Also, this allows visualization of the area in question without the annoying overlap of adjacent carpal shadows
A recent study investigated the impact of pain management education counseling on postoperative opioid consumption.
Patients were randomly assigned to receive opioid limiting perioperative pain management education and counseling (intervention group) with instructions to take opioids “only as a last resort if the pain became unbearable.”
The control group received instructions to take opioids as needed for “severe pain” to” stay ahead of the pain.”
The primary outcome was the total morphine equivalents (TME) consumed in the 3 months after surgery.
Secondary outcomes included pain measured with the Numeric Rating Scale, sleep quality, opioid prescription refills, and patient satisfaction.
121 patients with a mean age of 29 years.
Both groups were told about potential adverse effects of opioids and were advised of alternative methods to control pain such as over-the-counter acetaminophen and ibuprofen.
60 patients in the treatment group consumed a mean of 46 mg TME versus 63.6 mg TME in the control group ( p < 0.001). There was no difference in the average score on the numeric rating scale in the first 14 days between groups. There was no significant difference in refill prescriptions between the groups. Sleep quality and patient satisfaction was also similar between groups.
Over 1/3 of patients in the intervention group took no opioids at all after surgery. In contrast, 9 out of 10 patients in the control group used all prescribed opioids after surgery.
Conclusion: Opioid limiting pain management education and counseling reduces opioid consumption without a change in reported pain. There may be a role for pain management education and counseling in emergency department patients in whom opiates are prescribed…similar to this study in perioperative orthopedic patients.
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What do you see?
There is no clear fracture line
Much like ice floats on water, fat also floats on water/blood because it is less dense.
An intra-articular fracture may allow for blood and fat to exit the bone marrow and settle in the joint space.
This is called a lipohemarthrosis.
Best seen with a cross-table horizontal lateral view x-ray.
Go back to the image and examine the supra patellar pouch.
Most commonly seen in the knee in presence of a tibial plateau fracture.
Seen in approximately 1/3rd of tibial plateau fractures
If you see this without a clear fracture, consider CT of knee which can help detect the hidden fracture.
Remember the DDx of knee hemarthrosis with negative plain films:
Meniscal tear, ligament tear (usually ACL), patellar dislocation and osteochondral fracture.
Except for meniscal tearing (>6h) these other pathologies cause rapid onset swelling (<2h).
Haglund’s deformity
Calcaneal bony growth at the Achilles insertion
Also known as a “pump bump”
Risks: Tight & rigid shoes. Shoes with a hard heel counter. High arches. Tight Achilles tendon. Repetitive heel stress (jumping). Genetically prone bone structures.
Most common in woman between the ages of 15 and 35. Wearing heels. Runners.
Hx: Heel pain and tenderness with a noticeable bump at back of heel. Worse with walking and with certain footwear.
PE: Swelling and redness around bony prominence.
Pain and tenderness in the posterior heel, especially when pressure is applied.
Imaging: Excessive traction and abnormal biomechanics lead to insertional calcifications and bone spurs.
Over time, an exostosis may develop at posterior superior calcaneus as shown in the attached film.
Tx: Physical therapy and orthotics that alter heel height in shoe.
Surgery for chronic cases.
NSAIDs are first line analgesic medications for many pain related ED presentations
All NSAIDs are not created equal in their side effect profile
Ibuprofen and ketorolac are both commonly used NSAIDs in the ED
A 2010 review looked at relative risk estimates of individual NSAIDs and associated upper GI bleeding/perforation.
Definitions: Most of included studies included patients with NSAID use within prior week and daignosed upper GI bleed admitted to the hospital.
Daily use predicted increased risk.
In comparison between these two common medications Ibuprofen and Ketorolac: RR as follows
Ibuprofen (2.69 [95% CI 2.17-3.33]) vs ketorolac (14.54 [95% CI 5.87-36.04])
Ketorolac has approximately double the half life of ibuprofen
Other commonly used ED medications were also included:
RRs:
Naproxen 5.63 (95% CI 3.83-8.28)
Indomethacin 5.40 (95% CI 4.16-7.00)
Meloxicam 4.15 (95% CI 2.59-6.64)
Diclofenac 3.98 (95% CI 3.36-4.72)
Conclusion: The risk of upper GI bleeding varies between individual NSAIDs at the doses commonly used in the general population. When possible, consider the relative risk of a particular NSAID when making a selection.
Distal Radius Fractures
One of the most common fracture locations seen in EM (1/6th of all fractures)
Surgical rates are approximately 15-20%
Bimodal injury distribution:
Younger patients (10-14yo)
Usually involved in sport and usually high energy mechanism
Sport associated injury: Artificial turf increase risk by 5x.
Increased risk with skiing and rugby
Increased risk with novice and intermediate snowboarders who don’t wear protective equipment.
Older patients (>50yo)
Associated with osteoporotic bone from low energy fall
Risk factors among older patients: Hx of recurrent falls, prior fragility fracture, decreased bone density, corticosteroid use, and also dementia when patient reaches age 75.
Encourage your older patients who sustain this injury to discuss bone density testing with their PCP. Patients at higher risk of hip fractures (which carries high morbidity and mortality)
Check and document median nerve function in all patients esp. in high energy injuries
Median nerve involved in up to 21-30%.
Check “A-OK sign” against resistance
Iatrogenic median nerve injury can also occur if patient splinted in position of flexion
Metformin, most widely used for type 2 diabetes, has shown promising early results in several different health outcomes.
A recent study, published in JAMA, investigated whether metformin could reduce knee pain in patients with symptomatic knee OA who were overweight or obese.
This was a small double-blind, placebo-controlled clinical trial involving 107 participants.
Background: There is some evidence (both preclinical and preliminary human) that metformin can reduce cartilage degradation and increase chondrocyte viability.
Intervention: Participants received metformin 2000 mg/day (n=54), or identical placebo (n=53) for 6 months.
Mean age, 58.8 [SD, 9.5] years. 68% female.
Patients had symptomatic radiologic knee OA and a body mass index > 25.
Adverse effects: Diarrhea (8 [15%] in the metformin group and 4 [8%] in the placebo group) and abdominal discomfort (7 [13%] in the metformin group and 5 [9%] in the placebo group).
Despite this, there were high levels of medication adherence.
The study found significant differences in primary and secondary outcome measures: Knee pain, stiffness and function.
There was some weight loss in both groups (mean change, 4 lbs in the metformin group and 2.6 lbs in the placebo group). Unlikely to explain outcome differences.
Conclusion: In patients with symptomatic knee osteoarthritis who were overweight or obese, metformin, had a moderate and statistically significant reduction in knee pain compared with placebo. Because of the small sample size, confirmation in a larger clinical trial is warranted.
Non benzodiazepine muscle relaxants
Muscle relaxants were the most commonly (32%) prescribed medication upon discharge from the ED for lower back pain.
Muscle relaxants, such as cyclobenzaprine, provide short term pain-relief for patients with acute low back pain compared to placebo.
There is little difference in efficacy among the various muscle relaxants.
Evidence for muscle relaxants for back pain is weak compared to NSAIDs, so limit use to patients who have contraindications to NSAIDS.
There is no strong evidence that combination therapy with NSAIDs is more effective than NSAIDs alone.
If using during the day, consider using a lower dose (cyclobenzaprine 5mg) and a higher dose at night (10mg).
If treating with NSAIDs, consider using only at night to promote sleep.
Also, limit use to those patients who can tolerate the side effect profile of muscle relaxants, which include anticholinergic effects, dizziness, and sedation.
Risks of these agents increase with age, so should be used with caution in older adults.
Often given to this population due to fears of NSAID side effects.
A recent cohort study performed by the NCAA and US Department of Defense looked at NCAA athletes and military cadets who had suffered a concussion.
The study included 1661 NCAA athletes and military cadets, mean age was about 18 years, and 45% were women.
In these groupings, 813 people took over-the-counter pain relievers after their concussion and 848 people did not take any pain relievers.
Analgesics used included medications such as acetaminophen or NSAIDs such as ibuprofen.
Acetaminophen (n = 600), NSAIDs (n = 75), and those taking both (n = 78).
1) 50% recovery
Lidocaine transdermal patches
Frequently used for lower back pain.
A single 5% patch contains 700mg of lidocaine.
There is low systemic absorption.
Data supporting efficacy for lower back pain are limited.
Best benefit in other neuropathic conditions such as post herpetic neuralgia.
Topical capsicum
Underused, safe, non-sedating.
Potential treatment option for acute and subacute back pain (<3 months duration).
Can be OTC or via prescription.
Available in cream, lotion and patches.
Best used 3-4 times per day for maximal effectiveness.
Grade A recommendation from North American Spine Society.
A previous pearl discussed Spondylolysis. Once clinical concern is sufficient, the question of appropriate imaging arises.
Traditionally, the addition of oblique radiographs was recommended because they showed the pathognomonic “Scotty dog” sign. Recent studies have shown there is no significant increase in diagnosing spondylolysis with the addition of these oblique views. These additional views carry added cost and radiation exposure (approximately double).
AP and lateral radiographs offer similar diagnostic sensitivity to the old four view series.
If plain films are negative and symptoms persist despite 2-3 weeks of rest from offending activities, advanced imaging can be pursued on an outpatient basis. This is also strongly considered if the patient wishes to return to sport.
Despite being primarily osseous pathology, studies have shown that MRI can have similar diagnostic sensitivity to CT particularly in cases of acute injury. MRI may also show signs of stress reaction before complete fracture occurs.
Communicate with radiology and MRI technicians that you are looking for spondylolysis as this may affect the MRI sequences.
If a positive finding occurs on plain film, ordering CT imaging for the entire lumbar spine should be deferred due to added radiation concerns especially in cases where MRI would be available.
If MRI is not practical, consider limiting CT to one level above and one level below the region of concern. This would decrease the radiation exposure by approximately 50%
If advanced imaging is not practical or available and patient has a positive plain film, consider recommending repeat imaging in 4-6 weeks as an outpatient with rest from all offending activities.
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“Hey Doc, do I knee surgery?”
