UMEM Educational Pearls - By Brian Corwell

Category: Orthopedics

Title: Knee dislocation

Keywords: knee dislocation, vascular and nerve injury (PubMed Search)

Posted: 11/22/2014 by Brian Corwell, MD (Updated: 12/26/2014)
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Knee dislocation 2

Most commonly occur after MVCs but also seen after falls, industrial accidents and sports related trauma.

Up to 50% of knee dislocations will have spontaneously reduced by time of presentation to the ED.

Strongly consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability (3 or more ligaments torn).

A thorough neurovascular examination is a must due to the risk of vascular (34%)(5-79%) and nerve (23%)(16-40%) injuries. There is a must higher incidence of these injuries in high force trauma such as from a MVC. The popliteal artery and common peroneal nerve are at the greatest risk

Though the absence of distal pulses suggests vascular injury, the presence of pulses cannot be used as evidence of the lack of a vascular injury.

After reduction, the knee should be immobilized in 15-20° of flexion in a knee immobilizer.



Category: Orthopedics

Title: knee dislocation

Keywords: trauma, knee, dislocation (PubMed Search)

Posted: 11/8/2014 by Brian Corwell, MD
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Beware of spontaneous reduction masking the true injury!

Knee dislocations are rare due to supporting ligaments (MVCs, falls, sports)

but can be seen after minor trauma in obese patients.

Named by the direction of the displacement of the tibia relative to the femur

- Anterior and posterior are most common

Dislocations involve disruption of at least 2 of the major knee ligaments (ACL/PCL most common)

Usually associated with large hemarthrosis however capsular tearing may allow dissipation of the blood into adjacent soft tissue.

Consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability,



Category: Orthopedics

Title: Iliocostal syndrome

Keywords: Osteoporosis, elderly, (PubMed Search)

Posted: 10/25/2014 by Brian Corwell, MD
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Iliocostal syndrome aka iliocostal friction syndrome

Consider this entity in an elderly patient with osteoporosis with unexplained abdomen/flank or back pain.

Osteoporosis and/or vertebral compression fractures can result in a narrowing of the distance between .

the lowest anterior rib and the top of the iliac crest producing pain where this rib contacts the pelvis.

This can be perceived as side or back pain. This pain can restrict walking leading to a possible misdiagnosis of spinal stenosis. Treatment is with physical therapy and therapeutic injection.

http://www.caringmedical.com/wp-content/uploads/2013/09/iliocostalis.syndrome.jpg



Category: Airway Management

Title: Concussion treatment

Keywords: Concussion, patient education (PubMed Search)

Posted: 10/11/2014 by Brian Corwell, MD
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There is no effective pharmacologic treatment known to hasten recovery from concussion. In future pearls we will examine possible interventions that may help.

The importance of educating our patients was demonstrated in two studies looking at concussion education. Patients were separated into 2 groups. The intervention group received a booklet of information discussing common symptoms of concussion, suggested coping strategies and the likely time course of recovery. At a 3 month follow-up evaluation, the intervention group reported fewer symptoms. This was repeated in pediatric patients with similar results.

Take Home: Consider taking the time to put such an information sheet together for concussed patients seen in the ED.

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Category: Orthopedics

Title: "I have sciatica, I want a MRI and I want it now"

Keywords: Sciatica, radiculopathy, imaging (PubMed Search)

Posted: 9/19/2014 by Brian Corwell, MD (Emailed: 9/27/2014) (Updated: 9/27/2014)
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Back pain with radiculopathy can be very distressing to a patient and they have heard from their medically savvy neighbor that a MRI is the way to go. Now, armed with this knowledge, they are in your ED with earplugs in hand...

A few minutes of reassurance and education can save in both cost and ED throughput.

In one study researchers performed MRIs on asymtomatic adult patients.

               Almost two-thirds (64%) had abnormal discs

               Just over half (52%) had bulging discs

               Almost a third (31%) had disc protrusions

Further, finding a bulging disc already suggested by your history and physical examination does not change management. The majority of these patients improve with conservative treatment within four to to six weeks.

Restrict ED MRI use for the evaluation of suspected cauda equina, epidural abscess and spinal cord compression.



Category: Orthopedics

Title: Back Pain

Keywords: back pain, x-ray (PubMed Search)

Posted: 9/13/2014 by Brian Corwell, MD (Updated: 3/29/2024)
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Back pain accounts for more than 2.6 million visits

30% of ED patients receive X-rays as part of their evaluation

Imaging can be avoided in a majority of these patients by focusing on high risk (red flags)  findings in the history and physical exam.

Patients who can identify a an acute inciting event without direct trauma likely have a MSK source of pain.

Imaging rarely alters management

Attempt to avoid imaging in patients with nonspecific lower back pain of less than 6 weeks duration, with a normal neurologic exam and without high risk findings (fever, cancer, IVDA, bowel or bladder incontinence, age greater than 70, saddle anesthesia, etc)

Patients with radiculopathy (sciatica) and are otherwise similar to the above also do not require emergent imaging



Category: Orthopedics

Title: Patellar tendonitis

Keywords: Jumpers knee, knee pain (PubMed Search)

Posted: 8/24/2014 by Brian Corwell, MD (Updated: 3/29/2024)
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Patellar tendonitis aka jumpers knee

Activity related knee pain due to degenerative, micro injury rather than an inflammatory process

Up to 20% in jumping athletes

Anterior knee pain during or after activity

Bassett Sign:
       a)  Tenderness to palpation with knee in full extension (patellar tendon relaxed)
       b) No tenderness with knee in flexion  (patellar tendon tight)
 



Return to Play After Infectious Mononucleosis (IM)

-Long incubation period make it difficult to determine source or onset

Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.

DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)

Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)

Symptoms then progress into the classic “triad” of IM

                Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)

May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)

Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)

                Most commonly seen in patients treated with PCN antibiotics

Splenomegaly is an important complication in the athletic population

Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)

                - Lymphocytic proliferation enlarges the spleen beyond protection from the ribs

                - Physical examination has been shown to be unreliable for determining splenomegaly

                - Highest risk is in the first 21 days (rare after 28 days)

Ultrasound is the modality of choice

                -Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks

Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.



Category: Orthopedics

Title: Cervical Cord Neuropraxia (CCN)

Keywords: Spinal Cord injury (PubMed Search)

Posted: 7/13/2014 by Brian Corwell, MD (Emailed: 7/26/2014) (Updated: 7/23/2014)
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Cervical Cord Neuropraxia (CCN)

A concussion of the spinal cord as a result of an on-field collision.

A transient motor and/or sensory disturbance, lasting less than 24 hours.

A distinct and separate entity from spinal cord injury resulting in quadriplegia

Incidence 7.3 per 10,000 athletes

Approx. 50% of players experiencing CCN who return to play, have a second episode

The risk of this second episode is inversely proportional to the size of the cervical bony canal

Athletes with narrow canal diameter are more likely to have a 2nd episode

               Those with normal canal diameter (14 mm on MRI) have a 5% risk

               Those with a narrow canal (9 mm or less)) have a greater than 50% risk.

Whether repeat episodes lead to permanent spinal cord injury is unknown

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Category: Orthopedics

Title: Football helmets

Keywords: cervical spine injuries, football (PubMed Search)

Posted: 7/12/2014 by Brian Corwell, MD (Updated: 3/29/2024)
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Football helmets

A review of head and neck injuries from football from 1959 to 1963 found the rates of intracranial hemorrhage /intracranial death were 2-3X higher than the rates of cervical spine fracture/dislocation or cervical quadriplegia. In contrast, a study of football injuries from 1971 to 1975, revealed a dramatic reversal in rates. Cervical injuries now exceeded the rate of ICH by 2-4X.

                A 66% reduction in ICH

                A 42% reduction in craniocerebral deaths            

                A 204% increase in cervical spine fractures and dislocations

The shift was attributed to the modern football helmet, whose superior protection promoted “spearing” (headfirst tackling technique). Spearing involves hitting with the crown of the helmet leading to axial loading of the spine. Spearing accounted for 52% of the quadriplegia injuries from 1971 to 1975. Research by Joesph Torg, M.D., resulted in rule changes that led to an immediate 50% reduction in quadriplegia in NCAA football.

As a parent, coach or team physician, teach and enforce proper form and protect our young athletes.



Category: Orthopedics

Title: Elbow trauma

Keywords: Elbow extension test (PubMed Search)

Posted: 5/27/2014 by Brian Corwell, MD (Emailed: 6/28/2014) (Updated: 6/28/2014)
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A 98% sensitivity is pretty good, and a test doesn't have to be perfect to be useful.
 
Prior studies found the elbow extension test to be sensitive for fracture after acute trauma. Lack of full extension and presence of bony point tenderness or bruising were found to be 96% to 100% sensitive for fracture in several studies.
 
A recent study evaluated the ability of full extension and absence of point tenderness to rule out fracture. All patients had elbow x-rays.
 
There were 587 participants (233 children and 354 adults), of whom 59% had a fracture. In both adults and children, 98% of fractures were detected by inability to extend the elbow fully or presence of point tenderness. Only one patient with full extension and no tenderness required surgery.
 
Comment
There are two ways of evaluating this study.
1) These results show that the elbow extension test is not 100% accurate. (And we seem to strive for 100% all the time)
OR
2) If a patient can extend the elbow fully, has no significant point tenderness on palpation, and has no sign of overlying trauma such as laceration or bruising, the worst-case scenario is a 4% chance of fracture.
 
 
Consider documenting these clinical features and adding them to your sound clinical judgment
 

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Category: Misc

Title: Drowning

Keywords: Drowning, rescue (PubMed Search)

Posted: 5/24/2014 by Brian Corwell, MD (Updated: 3/29/2024)
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Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article

 

The Instinctive Drowning Response—so named by Francesco A. Pia, Ph.D., is what people do to avoid actual or perceived suffocation in the water. And it does not look like most people expect. There is very little splashing, no waving, and no yelling or calls for help of any kind. To get an idea of just how quiet and undramatic from the surface drowning can be, consider this: It is the No. 2 cause of accidental death in children, ages 15 and under (just behind vehicle accidents)—of the approximately 750 children who will drown next year, about 375 of them will do so within 25 yards of a parent or other adult. In some of those drownings, the adult will actually watch the child do it, having no idea it is happening.* Drowning does not look like drowning—Dr. Pia, in an article in the Coast Guard’s On Scenemagazine, described the Instinctive Drowning Response like this:

  1. “Except in rare circumstances, drowning people are physiologically unable to call out for help. The respiratory system was designed for breathing. Speech is the secondary or overlaid function. Breathing must be fulfilled before speech occurs.
  2. Drowning people’s mouths alternately sink below and reappear above the surface of the water. The mouths of drowning people are not above the surface of the water long enough for them to exhale, inhale, and call out for help. When the drowning people’s mouths are above the surface, they exhale and inhale quickly as their mouths start to sink below the surface of the water.
  3. Drowning people cannot wave for help. Nature instinctively forces them to extend their arms laterally and press down on the water’s surface. Pressing down on the surface of the water permits drowning people to leverage their bodies so they can lift their mouths out of the water to breathe.
  4. Throughout the Instinctive Drowning Response, drowning people cannot voluntarily control their arm movements. Physiologically, drowning people who are struggling on the surface of the water cannot stop drowning and perform voluntary movements such as waving for help, moving toward a rescuer, or reaching out for a piece of rescue equipment.
  5. From beginning to end of the Instinctive Drowning Response people’s bodies remain upright in the water, with no evidence of a supporting kick. Unless rescued by a trained lifeguard, these drowning people can only struggle on the surface of the water from 20 to 60 seconds before submersion occurs.”

This doesn’t mean that a person that is yelling for help and thrashing isn’t in real trouble—they are experiencing aquatic distress. Not always present before the Instinctive Drowning Response, aquatic distress doesn’t last long—but unlike true drowning, these victims can still assist in their own rescue. They can grab lifelines, throw rings, etc.

Look for these other signs of drowning when persons are in the water:

  • Head low in the water, mouth at water level
  • Head tilted back with mouth open
  • Eyes glassy and empty, unable to focus
  • Eyes closed
  • Hair over forehead or eyes
  • Not using legs—vertical
  • Hyperventilating or gasping
  • Trying to swim in a particular direction but not making headway
  • Trying to roll over on the back
  • Appear to be climbing an invisible ladder

So if a crew member falls overboard and everything looks OK—don’t be too sure. Sometimes the most common indication that someone is drowning is that they don’t look like they’re drowning. They may just look like they are treading water and looking up at the deck. One way to be sure? Ask them, “Are you all right?” If they can answer at all—they probably are. If they return a blank stare, you may have less than 30 seconds to get to them. And parents—children playing in the water make noise. When they get quiet, you get to them and find out why.

 

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Category: Orthopedics

Title: Risk Modifiers for Concussion and Prolonged Recovery

Keywords: Concussion, recovery, head injury (PubMed Search)

Posted: 4/6/2014 by Brian Corwell, MD (Emailed: 5/10/2014) (Updated: 5/10/2014)
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Risk Modifiers for Concussion and Prolonged Recovery

 

A history of prior concussion is a risk factor for future concussion (>2x risk).

For individual sports, boxing has the highest risk.

For team sports, football, ice hockey and rugby have the highest risk.

Women’s soccer confers the highest risk for female athletes.

Younger age confers increased risk.

Female sex confers higher risk when comparing similar sports with similar rules.

Those with migraine headaches may be at increased risk.

Risk of prolonged concussion

Most athletes have symptom resolution within one week

Post traumatic amnesia (both retrograde and anterograde) predict increased number and longer duration of symptoms.

Younger age also predicts pronged recovery.

Other studies have found associations with headache lasting greater than 60 hours, fatigue, “fogginess,” or greater than 3 symptoms at initial presentation. Cognitive studies have identified deficits in visual memory and process speed as predictors of prolonged recovery. 

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Category: Pharmacology & Therapeutics

Title: Acetaminophen the villain of 2013

Keywords: Tylenol, liver faliure (PubMed Search)

Posted: 4/6/2014 by Brian Corwell, MD (Emailed: 4/27/2014) (Updated: 4/27/2014)
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Acetaminophen spent much of 2013 being chased by paparazzi and sharing magazine covers with Miley Cyrus. What a fall from stardom after becoming known as the pain reliever “hospitals use most,” and the one, “recommended by pediatricians.” Slogans we know well based on $100 million/year spent on advertising.

Approximately 150 patients a year die from unintentional acetaminophen poisoning averaged over the past 10 years. From 2001 to 2010, annual acetaminophen-related deaths amounted to about twice the number attributed to all other over-the-counter pain relievers combined, 

The FDA sets the maximum recommended daily dose of acetaminophen at 4 grams, or eight extra strength acetaminophen tablets.

Ingestion of 150 mg/kg or approximately 10g for a 70 mg individual reaches the toxic threshold for a single ingestion. The toxic threshold decreases in cases of chronic ingestion.

Patients who “unintentionally” overdose have been found to take just over 8g per day (almost double the recommended maximum).  This is unlikely due to taking one extra 325mg tablet once or twice.

Before we all go on a mad NSAID prescribing binge, let's all be aware of the dangers, educate our patients and allow Acetaminophen to walk the red carpet again.

 

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Ankle Syndesmosis Injuries are also called high ankle sprains as they involve trauma to the ligaments above the ankle joint

Most ankle sprains are lateral ankle sprains. High ankle sprains are relatively uncommon.

Usual mechanism: External rotation injuries

Exam: Tenderness at the syndesmosis and compression of the tib/fib at the mid calf level causing syndesmosis pain (squeeze test)

Median recovery time is almost 4 times as long as a lateral ankle sprain 62days vs. 15days

Emergency department care is similar tto that of other ankle sprains but the added benefit of patient education and advice may improve overall care and follow-up.

 

 

 



Category: Orthopedics

Title: Herpes Gladiatorum in Wrestlers

Keywords: Herpes Gladiatorum, skin rash, sports medicine (PubMed Search)

Posted: 3/9/2014 by Brian Corwell, MD (Updated: 3/29/2024)
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Herpes Gladiatorum in Wrestlers

HSV causes non genital cutaneous infections primarily in wrestlers, commonly called herpes gladiatorum (HG)

Annual incidence in NCAA wrestlers is 20% to 40%

Most common cutaneous infection leading to lost practice time (40.5% of all infections)

Transmission is skin to skin.

Incubation period is 4 to 7 days from exposure. Healing usually occurs within 10 days after the initial lesion (without scaring).

Appearance: Numerous grouped uncomfortable (painful) vesicles/pustules on an erythematous base…evolve into moist ulcerations, followed by crusted plaques.  Lesions typically get abraded during competition therefore may have an atypical appearance and may be mistaken for other infections such as staph. Distribution typically more diffuse than typical HSV infections. Occurs on body surfaces areas that typically come into contract with opponents (face, head, neck, ears, upper extremities).  Lesion location typically on side of patient’s handedness. Recurrences occur at location of initial outbreak, a useful diagnostic aid.

Perform a thorough examination as ocular involvement was seen in 8%  of high school wrestlers  in one HG outbreak.

Typical treatment for primary infection is Valacyclovir 1g PO b.i.d. for 7 days. This is best started within 24h of symptom onset.

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Category: Orthopedics

Title: Adult Septic arthritis

Keywords: MRSA, arthocentesis (PubMed Search)

Posted: 2/22/2014 by Brian Corwell, MD
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The clinical examination is often unreliable in ruling out septic arthritis in the ED.

 Diagnostic arthrocentesis is often performed.

Traditional teaching involved very high WBC count thresholds as part of diagnosis.

In one 2009 study, synovial leukocyte counts in cases of MRSA were often less than 25,000 cells/uL

Have a low threshold for empiric antibioitics even in the face of low WBC counts (and incredulous consultants)

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Category: Orthopedics

Title: Overtraining Syndrome

Keywords: Overtraining syndrome, exercise (PubMed Search)

Posted: 2/8/2014 by Brian Corwell, MD
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Overtraining syndrome

A maladaptive response to excessive exercise without adequate functional rest

-Results in disturbances of multiple body systems (neurologic, endocrinologic, immunologic and psychologic).

- May be caused by systemic inflammation and resultant neurohormonal changes
            - Multiple hypotheses exist

-Symptoms

Parasympathetic alterations: fatigue, depression, bradycardia

Sympathetic alterations: insomnia, irritability, agitation, tachycardia, hypertension, restlessness

Other: anorexia, weight loss, poor concentration, anxiety

 

Usual presentation is prolonged underperformance despite adequate rest and recovery (weeks to months).



Category: Orthopedics

Title: Pellegrini Stieda lesion

Keywords: MCL, knee, (PubMed Search)

Posted: 1/17/2014 by Brian Corwell, MD (Emailed: 1/25/2014) (Updated: 1/25/2014)
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Pelllegrini-Stieda lesion

Ossified post-traumatic lesions at the MCL adjacent to the femoral attachment site of the medial femoral condyle.

Mechanism is likely from an avulsion injury that subsequently calcifies after the initial trauma.

Often an incidental finding on plain films.

If symptomatic, refer to ortho as an outpatient

If not symptomatic, no treatment is indicated

 

http://images.radiopaedia.org/images/30076/b62e61e83241e30f2da693901edcdc_gallery.jpg

http://www.imageinterpretation.co.uk/images/knee/PELLEGRINI%20STIEDA2.jpg



Category: Orthopedics

Title: Osteoarthritis Part 2

Keywords: Osteoarthritis, treatment (PubMed Search)

Posted: 1/11/2014 by Brian Corwell, MD
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Treatment:
Topical agents: The most widely used preparations contain capsaicin, lidocaine and NSAIDs
These preparations have been shown to be efficacious in controlled double-blind studies of OA of the hand and knee (minimal overlying soft tissue).
Note: Some of the topical NSAIDs are as efficacious as oral NSAIDs (lower incidence GI side effects).
*Consider in older patient with OA of hand or knee*
Oral agents: Acetaminophen is still considered first line treatment for mild to moderate pain. It has a small but significant effect for pain but this did not carry over for stiffness or functional improvement.
NSAIDs: More efficacious than acetaminophen for pain. Consider first line for moderate to severe pain.
While all attempts should be made at avoiding NSAIDs in patients at risk of upper GI bleeding, the safest approach may be to use Celecoxib with a proton pump inhibitor.

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