UMEM Educational Pearls - By Brian Corwell

In cases of suspected spinal infection, the sensitivity of an elevated WBC count (35-61%), ESR (76-95%) and CRP (82-98%) may help guide further evaluation or consideration of other entities.

Incorporation of ESR/CRP into an ED decision guideline may help differentiate those patients in whom MRI may be performed on a nonemergent basis.

An elevated ESR (>20 mm/hour) also has a role in the diagnostic evaluation of occult malignancy (sensitivity 78%, specificity 67%).

Show References

The ED clinician must  be able to distinguish between true pathologic back pain and nonorganic back pain.

Waddell’s signs are physical exam findings that can aid in making this important distinction and can be remembered by the acronym “DORST” (Distraction, Over-reaction, Regional disturbances, Simulation tests and Tenderness).

Superficial, non-anatomic, or variable tenderness during the physical exam suggests a non-organic cause.

The clinician may also simulate back pain through provocative maneuvers such as axial loading of the head or passive rotation of the shoulders and pelvis in the same plane. Neither maneuver should elicit low back pain.

There may be a discrepancy between the symptoms reported during the supine and sitting straight leg raise (SLR). The seated version of the test, sometimes termed the distracted SLR, can be performed while distracting the patient or appearing to focus on the knee. Further, radicular pain elicited at a leg elevation of less than 30° degrees is suspicious because the nerve root and surrounding dura do not move in the neural foramen until an elevation of more than 30° degrees is reached.

Sensory and motor findings suggestive of a nonorganic cause include stocking, glove or non-dermatomal sensory loss or weakness that can be characterized as “give-way,” jerky or cogwheel.

Finally, gross overreaction is suggested by the exaggerated, inconsistent painful responses to a stimulus.  

Waddell’s signs, especially if three or more are present, correlate with malingering and functional complaints (physical findings without anatomic cause). When combined with shoulder motion and neck motion producing lower back pain, Waddell’s signs predict a decreased probability of the individual returning to work.

That said, Waddell’s signs should never be used independently because they lack the sensitivity and specificity to rule out true organic pathology. Further, our focus should be on evaluating for medical emergencies. Malingering and psychosocial causes of pain are diagnosis of exclusion. 

Imaging plays an important role in the evaluation of child abuse.

It aids in the identification, evaluation and in treatment.

Additionally, it is often the only objective evidence of abuse available to the courts.

It is often discovered through two means.

1) Injuries/fractures that are inconsistent with the alleged mechanism of injury.

2) Pathognomonic fracture patterns are found on routine radiographs

The ED physician should not attempt to precisely "date" the injury.

That said, soft tissue swelling resolves in 2-5 days. The periosteum becomes radiodense in 7 to 10 days. In subtle fractures this may be the only radiographic finding. If there is no evidence of bone healing (periosteal reaction), the fracture is less than 2 weeks old. Callus formation and resorption of the bone along the fracture line begins at 10 to 14 days. The callus is visible for up to 3 months. Bone remodeling continues for up to one year.

Show References

Sesamoid Injuries

The first MTP joint contains the 2 sesamoid bones. They play a significant part in the proper functioning of the great toe. 30% of individuals have a bipartite medial or lateral sesamoid.

http://www.coreconcepts.com.sg/mcr/wp-content/uploads/2008/05/sesamoid_foot.jpg

Injury can occur from trauma, stress fracture or sprain of the sesamoid articulation or of the sesamoid metatarsal articulation. Overuse injuries tend to occur in sports with a great deal of forefoot loading (basketball/tennis).

SXs: Pain with weight bearing, pain with movement of first MTP, ambulation on lateral part of foot.

PE: Tenderness and swelling over medial or lateral sesamoid. Resisted plantar flexion (flexor hallucis) reveals pain and weakness.

Imaging: plain film with sesamoid view to assess for a sesamoid fracture. Stress fractures may take 3-4 weeks to show on plain film.

http://www.agoodgroup.com/running/Fracture002.jpg

Treatment for fractures and suspected stress fractures involve 4 to 6 weeks of non weight bearing.

LATERAL ANKLE TENDINOPATHY

Hx: subacute onset (weeks) of the pain seen in athletes esp. runners (banked or uneven surfaces).

PE: Tenderness to palpation posterior to the lateral malleolus or over the course of the tendon. Pain worse with resisted ankle eversion from a dorsiflexed postion. Examine for subluxation of tendon.

The diagnosis is made from the above and does not require imaging.

Tx: Rest, conservative care, physical therapy (eccentric exercise focus), ankle taping or lace up brace. Severe cases may even require a walking boot.

http://www.epainassist.com/images/Article-Images/Peroneal_Tendonitis.jpg

Overuse injury

Seen in runners, military recruits (marching), ballet dancers and in jumping sports (heavy landing).

Insidious onset of heel pain, that is worse with jumping then running then later with simple weight bearing.

Tenderness to palpation posteriorly (medially or laterally), and squeezing bilateral posterior calcaneus.

Testing:

XR: May not be positive for 2 to 4 weeks. Sclerotic appearance (vertically oriented) posterior calcaneus.

MRI: high signal T2 at fracture site.

DDx: plantar fasciitis.

Treatment: Reduction of activity if Sxs mild, for severe pain start a trial of non weight-bearing (boot or splint with crutches).

Stretching of calf, achilles, plantar fascia.

Mechanism: Direct blow to anterior thigh (Football/basketball) or from a ball traveling at a high rate of speed (field hockey/lacrosse).

Exam: focal tenderness and edema. Pain may be severe and worse with active contraction and passive stretch. Hematoma may already be present. Amount of passive knee flexion at 24 hours can be a clue to the severity of the hematoma.

Treatment: Crutches if pain with weight-bearing. Ice. Immobilization in 120 degrees of flexion immediately after the injury for the first 24 hours may be beneficial.

-Bandage entire lower limb. Provide crutches and pain medication. Soft tissue therapy is contraindicated for the first 48 hours and when instituted must be gentle and cause no pain. Risk of re-bleeding is greatest in first 7 to 10 days.

http://fce-study.netdna-ssl.com/2/images/upload-flashcards/75/20/63/5752063_m.jpg

Knee Dislocation

Following reduction and immobilization, a thorough vascular assessment should follow. Any signs of vascular injury should prompt immediate vascular consultation (pallor, absent or diminished pulses)

1) Palpate popliteal and distal pulses

2) Measure ankle-brachial index (*ABI) (<0.9 = abnormal)

3) Duplex ultrasound (if available)

*ABI ratio of SBP in lower (DP/PT) and upper (brachial) extremities.

**Evaluation is often institutional specific. Discuss with your consultants.

A) If strong pulses normal ABI and normal u/s admit patient for observation with serial vascular examinations.

B) If the limb is still well perfused but the pulses are asymmetric or ABI is abnormal or US is abnormal then consult vascular surgery and obtain arteriogram (expanding role for CTA here).

C) If pulses are weak or absent or distal signs of ischemic limb then obtain emergent vascular consultation for surgical repair.

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.

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,

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

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.

Show References

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.

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

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.

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

Show References

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.

Show References

Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article

Show References