Sesamoid Injuries

Unlike other bones in the human body that are connected to each other at joints, sesamoid bones are only connected via tendons (or are imbedded in muscle).

The largest sesamoid bone is the patella.

2 small sesamoid bones lie on the plantar foot near the great toe

Sesamoid bones can fracture and the surrounding tendons can become inflamed (sesamoiditis)

Traumatic injury is usually due to hyperextension and axial loading

Sx: Pain located under the great toe on the ball of the foot (Gradual with sesamoiditis and acutely with a fracture).

There may be associated swelling and bruising. Pain with palpation, flexion and extension.

The medial/tibial sesamoid is larger, has great weight bearing status and is more commonly injured that its lateral counterpart.

In many people (10 - 25%) the medial sesamoid of the foot has two parts (bipartite). This finding is bilateral in 25% of people.

This may confuse some providers as it may appear to be a fracture

Look for a smooth contour to the bones and clinically correlate (bruising, soft tissue swelling, etc.) if it is an incidental finding.

Other radiographic clues include

1) The fractured sesamoid is usually slightly larger than the lateral sesamoid while the bipartite sesamoid has a much larger medial sesamoid than lateral sesamoid

2) The fractured sesamoid shows a sharp, radiolucent, uncorticated line between the two fragments while the bipartite sesamoid has two corticated components

3) The fractured sesamoid fragments often fit together like pieces of a puzzle while the bipartite sesamoid has two components that do not fit together snugly

4) Other means to differentiate the two involve MRI and bone scanning

Treatment involves a stiff-soled shoe or applying a cushioning pad or J-shaped pad around the area to relieve pressure.

It may take months for the pain to subside.

http://www.apfmj-archive.com/afm5_3/afm50.htm#F1

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Plain films are commonly used to screen children for pelvic fractures or dislocations following blunt torso trauma

The sensitivity of this common screening practice is unknown

A recent study looked at this question.

Of 451 patients with pelvic fractures or dislocations, 382 had AP radiographs. Injury was correctly identified in 297 patients (sensitivity 78%).

The sensitivity was greater in the sicker subgroups :92% for those requiring operative intervention and 82% for those with hypotension

Plain AP pelvic radiographs should have a limited role in the sole evaluation of children with blunt torso trauma.

They should be incorporated in the assessment of hemodynamically unstable children and those in whom the clinician is not planning on otherwise obtaining an abdominal/pelvis CT.

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Medication-overuse headache (MOH) is one of the most common chronic headache disorders

Worldwide prevalence of 1 2%

Characterized by chronic headache and overuse of different headache medications

Withdrawal of the overused medication is the treatment of choice

A 2014 study looked at adolescent patients treated in a headache clinic with chronic post traumatic headaches (concussion headaches)

77 had chronic post-traumatic headache of 3-12 months' duration

54 of 77 (70.1%) met criteria for probable medication-overuse headache.

After the OTC medicine was stopped 68.5% had resolution or improvement !!

Excessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents.

Sometimes the advise of "just keep taking the motrin and it'll get better" isnt the answer

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Radiographs of the sacrum and coccyx in the emergency department (ED) have no quantifiable clinical impact, according to a study published in the American Journal of Roentgenology.  

Researchers from Emory University Midtown Hospital and Morehouse School of Medicine in Atlanta, GA, sought to determine the yield and clinical impact of sacrum and coccyx radiographs performed in the ED.

Sacrum and coccyx X-rays performed on 687 consecutive patients over a six-year period in level-1 and level-2 trauma centers (4 total hospitals). The patients’ mean age was 48.1, 61.6% were women. The images were categorized as positive for acute fracture or dislocation, negative, or other.

The researchers then analyzed:

• Follow-up advanced imaging in the same ED visit

• Follow-up advanced imaging within 30 days

• New analgesic prescriptions

• Clinic follow-up

• Surgical intervention within 60 days

The researchers found positive results in 58 of the 687 patients, a positivity rate of 8.4%.

None of the 58 positive cases had surgical intervention.

There was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical follow-up among the patients evaluated at the level-1 trauma centers.

However at the level-2 trauma centers, 34 (97.1%) of 35 patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals. Negative cases were at 82.9%.

Of all cases, 39 patients (5.7%) underwent advanced imaging in the same ED visit and 29 patients (4.3%) underwent imaging within 30 days.

“Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit,” the authors wrote. “There was no significant difference in 30-day advanced imaging at the level-1 trauma centers, but there was at the level-2 trauma centers.”

The researchers concluded that routine sacrum and coccyx radiography should not be part of ED practice and that patients should be treated conservatively based on clinical parameters.

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https://www.youtube.com/watch?v=sCFOObsx_W4

What is their risk of MI???

Anger outbursts are bad for your heart. Out of 300 patients with an acute MI, just over 2% reported losing their temper within 2 hours of the event. A review of nine studies of rage and cardiovascular events all found an increase in cardiovascular events in the 2 hours preceding an anger outburst. Examples included arguments at home, at work or by road rage. Compared with their usual anger levels, the relative risk of heart attack from a fit of rage was 8.5.

What about those of us who are just fanatics, I mean fans....A recent study of World Cup soccer found that the intense strain and excitement of viewing a dramatic soccer match more than doubles the risk of acute heart attack, particularly in men with known coronary heart disease. This was regardless of the outcome of the match!

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Exercise and the heart

Exercise increases the risk of sudden cardiac death (SCD) acutely.

Exercise decreases the risk of SCD in the long term.

Regular physical activity (even as little as 15 mins/day) reduces the risk of cardiovascular disease (CVD). 

Up to 15% of MIs occur during or soon after vigorous physical exercise. This is typically in sedentary men with coronary risk factors.

In a 1993 study, in the first hour after heavy exertion, risk of heart attack rose more than 100-fold from baseline for habitually inactive persons. However, for frequent exercisers, this risk rose less than three-fold. Think of snow shoveling after a winter storm.

Both the Physicians’ Health Study and the Nurses’ Health Study show that the risk of SCD during exertion is reduced by habitual exercise.

If you are physically active, stay active. If you are not active, you should be because exercise has innumerable personal benefits. However, it is important to start gradually Some individuals at higher risk need to start under the guidance of a physician.

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Orthopedic documentation

1) Document location with specificity and laterality.

2) Document the location with as much specificity as possible

-Name of specific bone and specific site on bone (Shaft, head, neck, distal, proximal, styloid)

3) Document fractures as open/closed, displaced vs. non-displaced, routine or delayed healing,

-Orientation of fractures, such as transverse, oblique, spiral

- Document intra-articular or extra-articular involvement

4) For a particular injury, a complete note will include mention of the following

The joint above (e.g. for shoulder injuries this would be the neck, for hip injuries - the back)

The joint below

Motor (e.g. for arm injuries document the distal median, radial and ulnar motor innervation)

Sensory

Vascular

Skin (for all fractures document intact overlying skin esp. when covering with a splint)

Compartments (a simple mention of compartments are grossly soft/not tense will suffice)

*Especially relevant for forearm and tib/fib injuries

Metacarpal Fractures

* Localize fracture to head, neck or shaft (neck most common)

5th metacarpal most commonly fractured

* Note amount of angulation, shortening and the presence of malrotation

*Treatment is based on which metacarpal is fractured and the location of the fracture

*The amount of acceptable angulation varies by the digit involved

For example for index and long finger - acceptable angulation of the shaft is 10-20 degrees and neck is 10 to 15 degrees

Whereas for the 5th digit - acceptable angulation for the shaft is 40 degrees and neck is 50 degrees

Pearls

No degree of malrotation is acceptable (document the absence of this!)

Strongly suspect fight bite injury with abrasions/lacerations overlying metacarpal heads

Highly prone to infection given the proximity to the joint capsule

Consider lacerations over metacarpal fractures as open fractures (do not close/discuss management with hand surgery re timing of washout. Many prefer delayed fixation for suspected infections )

Document integrity of the extensor tendon (can be lacerated and retracted)

Femoral neck fracture

• The most commonly missed hip fracture

We typically think of the presentation of the displaced fracture severe pain, writhing in the bed, unable to ambulate, limited ROM

* However, patients with nondisplaced fractures (15 20%) may walk with a limp

* Occurs primarily in the elderly & osteoporotic population after a fall directly onto the hip

* Look for a cortical step-off in the femoral neck (w/ foreshortening)

* A patient with a minimally displaced fracture may only complain of hip, knee, or groin pain and may be able to walk (albeit with a limp)

* Almost 9% of hip fractures are radiographically normal (Nondisplaced or impacted fractures)

* Fractures which were initially nondisplaced, may become displaced upon re-presentation

* Remember the limitations of plain x-ray in the evaluation of femoral neck fractures!

* Because of the significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip

Achilles tendon rupture

More common in

men, ages 30 - 40yo, s/p steroid injections, fluoroquinolone use, and episodic athletes "weekend warriors

Mechanism: usually during an athletic endeavor, sudden forced planar flexion or violent dorsiflexion of a plantar flexed foot

Location: Usually occurs 4 to 6 cm ABOVE the Achilles calcaneal insertion (hypovascular region)

Patient will report a sudden pop, gunshot like sound

History: Will report heel and calf pain and weakness/inability to walk

Physical examination: Palpable gap, weakness with plantar flexion, + Thompsons test

https://www.netterimages.com/images/vpv/000/000/007/7714-0550x0475.jpg

Consult orthopedics and splint in resting equinus

http://img.medscape.com/fullsize/migrated/408/535/mos0216.01.fig5b.jpg

Spondylolysis

Prevalence 3-6% in the general population (Higher in athletes)

Location: L4 (5-15% of cases) & L5 (85-95% of cases)

Population: More likely in the skeletally immature athlete due to the vulnerability of the immature pars interarticularis to repeated stress

Symptoms: Lumbar pain worse with extension

Higher risk sports: Gymnastics, diving, weightlifting, wrestling

Treatment: Bracing and activity modification, physical therapy

- Good results in 80% with conservative management allowing return to play.

- Those who fail benefit from iliac crest bone grafting and posterolateral fusion.

-Return to play is controversial in this group

Please review th images below for anaomy and imaging appearence

http://orthoinfo.aaos.org/figures/A00053F01.jpg

http://www.sonsa.org/images/spondylolysis.jpg

http://www.physio-pedia.com/images/2/22/Spondylolysis_x_ray_.docx.jpg

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Recommended follow-up for common orthopedic injuries

Sever's disease also known as calcaneal apophysitis, is the most common cause of heel pain in the young adolescent (ages 8 to 12).

It can be thought of as the Achilles tendon equivalent of Osgood-Schlatter's disease (patellar tendon insertion pain).

It is a non inflammatory chronic repetitive injury.

Commonly seen bilaterally in up to two -thirds of cases.

Patients will complain of activity related pain to the heel.

There may be tenderness and local swelling at the Achilles tendon insertion.

Radiographs are not necessary for acute cases.

Treat with activity modification, heel raise, physical therapy.

Protracted Recovery from Concussion

Age and sex may influence concussion recovery time frame

Methods: 266 adolescent athletes presenting to a sports medicine concussion clinic

Female athletes had a longer recovery course (P=0.002) and required more treatment interventions (p<0.001).

Female athletes were more likely to require academic accommodations (p<0.001), vestibular therapy (P<0.001) and medications (P<0.001).

Be aware that not all concussion patient subgroups with concussions recover in the same manner. Further study is needed to support whether female adolescent athletes require unique management and treatment guidelines.

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Parental Knowledge of pediatric concussion

Sample: Parents of children brought to pediatric hospital or outpatient clinics for evaluation of orthopedic injuries.

Participants scored an average of 18.4 (0-25) on knowledge and 63.1 (15-75) on Attitudes toward concussions.

Safest attitudes were seen in white females. Knowledge increased with income and education levels.

Parents from low income or education levels may benefit from additional education in the ED prior to discharge in addition to providing paper information which may not be read or understood.

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Medial elbow pain is common among baseball pitchers and is also seen in other sports including football, javelin and gymnasts.

More than 97% of elbow pain in pitchers is located medially.

The ulnar collateral ligament of the elbow is an important structure in these patients.

http://www.aafp.org/afp/2014/0415/afp20140415p649-f3.jpg

While initially primarily seen in professional throwers, these injuries are now being seen in younger athletes.

Initially, patients may only note changes in stamina or strength of throws.

Later, they will note pain during the acceleration and follow through-phase of throwing

http://stlhealthandwellness.com/wp-content/uploads/2013/02/elbow03.jpg

The Valgus stress test for UCL deficiency is similar to the valgus test for the knee

https://www.youtube.com/watch?v=f6YvPSVk6G8

Treatment: splinting, ice, NSAIDs

Surgical indications: Failure of non-operative treatment with desire to return to same or higher level competition.

Hook of Hamate Fracture

Rare (2% of all carpal fractures)

Mechanism usually direct blow from a stick sport (golf, hockey, baseball)

Presents with hypothenar pain and pain with gripping activities

Physical examination - local swelling and tenderness to palpation over hook of hamate

Diagnostic test - Hook of hamate pull test

https://www.youtube.com/watch?v=A-mjRnC1yWQ

XR - standard wrist series but add carpal tunnel view

http://openi.nlm.nih.gov/imgs/512/60/2904904/2904904_256_2009_842_Fig1_HTML.png

http://www.cmcedmasters.com/uploads/1/0/1/6/10162094/7851913.png?359

A traditional ED practice has been to combine promethazine as an anxiolytic adjunct to morphine for patients with musculoskeletal pain (eg back pain).

However, when compared to morphine alone, this combination does not lead to greater analgesia or decrease anxiety. It does however prolong ED length of stay.

This use of this "pain cocktail" is not recommended

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Most common mass in popliteal fossa

Incidence 10 to 58%

Intra-articular pathology results in flow of synovial fluid from the joint into the bursa, forming a cyst

Association with concomitant intra-articular disorders 94%

Possible pathology - Meniscus, ligamentous, arthritis, other osteochondral defects

In children this is not a pathologic finding

Symptoms - Posterior knee bulging, posterior tightness/stiffness esp. with knee flexion

Ultrasound - 100% sensitive/specific

DDx: DVT

Tx: Refer for ultrasound guided aspiration, fenestration and steroid injection

http://www.caringmedical.com/wp-content/uploads/2013/11/Bakers-Cyst-treatment.jpg

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Sodium Supplementation and Exercise-Associated Hyponatremia (EAH) during Prolonged Exercise (ultramarathon running)

Weight loss of around 4% body weight (relative to pre race weight) can be anticipated to maintain euhydration in such a prolonged event

Those who become symptomatic with EAH have either gained weight or lost less that 3-4% body weight

Overhydration rather than inadequate supplemental sodium intake is a greater contributor to the development of EAH

There is a suggested link between EAH and rhabdomyolysis. The mechanism remains unknown and it is unclear which condition may augment the other. Further research is needed.

Take home: Avoid overhydration during prolonged exercise to prevent EAH.

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