UMEM Educational Pearls - By Brian Corwell

Exertional leg pain in the athlete carries a wide range of possible etiologies. In a recent review article, etiologies included, stress fracture (25%), exertional compartment syndrome (33%), medial tibial stress syndrome (13%), nerve entrapment (10%), and popliteal artery entrapment syndrome.

Medial Tibial Stress Syndrome (MTSS) is also known as shin splints. It is a repetitive-stress overuse injury.

Risk factors include: hyperpronation, higher BMI, increased hip internal rotation, and hyperplantar flexion.

While MTSS may be on a stress reaction spectrum that includes fracture, the causes are likely to also include tendinopathy and muscle dysfunction (tibialis anterior, posterior and soleus).

Radiographs will be normal with this condition. MRI and bone scan may show signal abnormality along the posterior medial tibial surface.

Treatment: In most cases participation in sports may continue. Also consider, rest/activity modification, ice, NSAIDs, physical therapy for calf stretching and strengthening,  and rigid orthotics (to correct foot hyperpronation). Semi rigid and neoprene orthotics may be considered for prevention in those with a prior history.

A recent study looked at the risk of sudden cardiac death during a marathon.

Many isolated reports of sudden death make headlines in the national news.

However, of nearly 11 million runners, only 59 went into cardiac arrest during a race. This equates to an incidence rate of 0.54 per 100,000 participants,

This rate appears to be on par with sudden death from other athletic endeavors such as triathlons and college athletics.

Median age was 42. Men affected more than women (men also more likely to die from the event).

71% of events were fatal.

Further, risk is greater for both cardiac arrest and sudden death for full marathons than half marathons.

Interestingly, older patients fared better (increased survival in those >40yo), thought to be due to an increased incidence of hypertrophic cardiomyopathy in younger aged runners.

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The plantar fascia arises from the medial tuberosity of the calcaneous and extends to the proximal phalanges of the toes.

Pkantar Fasciitis is the most common cause of heel pain in adults.

Etiology is thought to be from a degenerative tear at the fascial origin followed by a tendinosis type reaction and .

Affects women 2x> men

More common in overweight patients.

Onset is insidious and not related to trauma.

Hx: Pain and tenderness directly over the medial calcaneal tuberosity and 1-2cm distally along the plantar fascia.

Pain is worse with prolonged standing/walking. Pain is most intense however when rising from a resting position such as first thing in the morning.

PE: Pain is increased with passive dorsiflexion of the toes. Tenderness to palaption over the medial calcaneal tuberosity and 1-2cm distally along the plantar fascia.(At times, one may have to apply increased pressure to approximate weight bearing type stress)

XR: Usually not necessary with a good history and exam. Heel spurs are seen in up to 50% with the disease (and in up to 20% without it!)

DDx: Tarsal tunnel syndrome. Calcaneal stress fracture. Fat pad atrophy. traumatic rupture of planter fascia.

Severs disease

- Perhaps the most common overuse injury

-Pain is due to inflammation of the calcaneal apophysis growth plate

- Caused by repetitive microtrauma from the pull of the Achilles tendon on the apophysis.

- Occurs in young athletes ages 7-14

Sx’s bilateral in >50%

Hx – Gradual onset of posterior heel pain, worse with activity, better with rest.

PE – Tenderness at the insertion of the Achilles tendon onto the calcaneous. Swelling is mild.

This is a self limited condition because as the adolescent ages, the physis closes

Tx – Rest (no running or jumping), ice, NSAIDs, heel lifts/arch supports. Outpatient physical therapy for stretching and strengthening exercises.

Common herbs and supplements used to treat pain

1) Turmeric root - used for arthritis pain. Little evidence to support its use. May slow blood clotting/enhance anticoagulant/antiplatelet effects.

2) Boswellia - used for OA and RA pain. Little evidence to support its use.May interfere with anticoagulant drugs and leukotreine inhibitors.

3) St. John's Wort - used for HA, migraine, neuralgia, muscle pain, sciatica, fibromyalgia. Little to no evidence to support its use.May interfere with numerous medications including anticoagulants, digoxin and SZ medications.

4) Glucosamine and Chondroitin - used for OA, knee pain, back pain. The glucosamine/chondroitin arthritis intervention trial found that "the dietary supplements Glucosamine and Chondroitin, taken alone or in combination are generally ineffective for OA pain of the knee." May increase the effect of Warfarin.

5) KavaKava - used for HA, muscle pain. Insufficient evidence demonstrating effectiveness for treatment of painful conditions. May cause severe liver damage and potentiate drowsiness side effects of other medications.

6) Echinacea - used for pain, migraines, arthritis. Little evidence to support its use. May exacerbate symptoms of autoimmune disorders.

7) Valerian root – used for joint and muscle pain. Insufficient evidence to support its use. May potentiate sedative side effects of barbiturates and benzos.

8) Chinese Thunder God Vine – used for arthritis. There is some evidence to suggest that this agent has anti-inflammatory properties. Long term this agent may decrease bone mineral density in women, decrease fertility in men, and may produce GI side effects.

9) Feverfew – used for muscle pain, arthritis. Some evidence to suggest that may reduce frequency of migraine headaches. No evidence for benefit in RA. May enhance effects of anticoagulants and some drugs that undergo hepatic metabolism.

10) Cat’s claw – used for herpes zoster, bone pain, arthritis. Possible benefit for OA and RA in small studies in humans but no large study has shown benefit. May interact with clotting agents, BP meds and cyclosporine.

11) Black Cohosh – used for muscle pain and arthritis. Insufficient evidence demonstrating benefit. May be associated with severe liver side effects.

12) Bromelain – used for muscle pain, arthritis, knee pain. The NIH reports that bromelain may be effective for arthritis when used in combination with trypsin and rutin. May interact with amoxicillin and other antibiotics, anticoagulants and antiplatelet drugs.

13) Devil’s claw – used for muscle pain, back pain, arthritis, migraine. The NIH reports that “taking devil’s claw alone or with NSAIDs seems to help decrease OA related pain.” May increase effects of warfarin.

Our old friend Captain Morgan (the rum pirate) may now be able to assist us during a shift, not just afterwards.

http://www.inquisitr.com/wp-content/2011/08/captain-morgans-pirate-ship-satisfaction-panama.jpg

In a small case series in last months Annals of Emergency Medicine, a new reduction maneuver was described as an alternative to the traditional Aliis's maneuver.

The maneuver is named after the pirate spokesperson for the similarities in body positioning.

The patient is placed supine on a stretcher. The pelvis is fixed to a backboard with a strap. The patient's hip and knee are flexed to 90 degrees. The physician places one foot on the back board with the same knee behind the patient's knee. By holding the patient's ankle down, the patient's knee is kept in flexion. The physician then lifts his/her calf, thereby applying an upward force to the hip while gently rotating the lower leg from side to side.

http://www.youtube.com/watch?v=l07K-mO2X84

with a slight variation

http://www.youtube.com/watch?v=sGQZaqB48rw

The success rate was 12 of 13 cases. The single failure occurred in a patient with an acetabular fracture with an intra-articular fragment requiring open reduction. There were no described neurovascular complications or injuries to the knee. The technique limits the physician's risk of back strain and of falling from the stretcher.

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Approximately 48% of shoulder dislocations occur during sports and recreation.

These are usually first managed in the clinic and sideline setting.

In 6 reviewed studies, 5 used 20mL of 1% lidocaine and 1 used 4 mg/kg of 1% lidocaine.

    Patients incurred significantly reduced cost compared to IV sedation

There were no infections, neurovascular damage or systemic effects of the lidocaine.

No significant differences were noted in pain control, success rate or ease of reduction between intra-articular lidocaine and systemic sedation.

The risk of chondrolysis increases with higher concentration and longer duration of exposure to local anesthetics.

There is scant research about the effects of a single exposure of cartilage to lidocaine.

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The long head of the biceps originates from the glenoid tubercle and superior labrum. 

Rupture of the proximal biceps tendon comprises 90-97% of all biceps ruptures

Often in men aged 40-60y

     - Almost exclusively involves the long head.

     - Aka "Popeye Arm" (distal contraction of the muscle belly)

-          May be acutely traumatic or microtears & age associated degeneration

-          Minimal loss of function because short head of biceps remains attached

-          Many patients can be treated non operatively

-          Most asymptomatic after 4-6 weeks

-          Place in sling, ice, analgesia

-          Refer to ortho for re-evaluation and determination of operative versus conservative management

http://imaging.birjournals.org/content/15/4/193/F7.large.jpg

Metaphyseal bucket handle and corner fractures are almost pathognomonic for child abuse

These injuries were originally identified by clinicians evaluating children with subdural hematomas

These injuries are typically seen in the ankles, knees, elbows and wrists

Violent twisting, shaking, or pulling across a joint creates shearing forces across the weak epiphyseal growth plate and metaphysis

This leads to

1)      A thin rim of mineralized metaphyseal bone aka  “bucket handle”  

http://rad.usuhs.mil/rad/home/peds/bucketarrow.jpg

OR

2)      Small flecks of bone from the metaphyseal corner adherent to periosteum

http://t2.gstatic.com/images?q=tbn:ANd9GcT0kZ3VR1f7MwRj7oIa6jaYVp_-f8kZ1NhSbw4kCTRGNLDJ1pKK9g

The Weber classification system

A commonly used, simple, easily remembered system used to describe ankle fractures. The system focuses on the integrity of the syndesmosis.

http://www.accessemergencymedicine.com/loadBinary.aspx?fileName=simo_c017f013t.gif

  - TYPE A:  fibula fracture below the ankle joint/syndesmosis (which is intact). Deltoid ligament intact. Medial malleolus can be fractured. Usually treated with closed reduction.

http://www.gentili.net/image1.asp?ID=-241442344&imgid=AnkleWeberAAP600.jpg&Fx=Weber+A+Fracture

  - TYPE B:  is a transsyndesmotic fracture with usually partial rupture of the syndesmosis (though may be intact). No gross widening to the tib/fib articulation.. Deltoid ligament intact. Medial malleolus often fractured.  Variable stability. Any clinical or radiographic injury to the medial joint complex make this an unstable fracture

http://www.gentili.net/image.asp?ID=145&imgid=AnkleWeberBmortise600.jpg&Fx=Weber+B+Fracture

  - TYPE C:  Fibular fracture above the level of the syndesmosis with usually a total rupture of the syndesmosis (seen as widening of the distal tib/fin articulation), resulting in instability of the ankle mortise. Associated with medial malleolus fracture or deltoid ligament injury. Unstable.

http://www.gentili.net/image1.asp?ID=146&imgid=anklewebcapoblx2600.jpg&Fx=Weber+C+Fracture

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Arthrocentesis of the Wrist

First locate and feel comfortable identifying two important landmarks:

1) Lister's tubercle is an elevation found in the center of the dorsal aspect of the distal end of the radius

http://www.aafp.org/afp/2004/0415/afp20040415p1941-f2.jpg

2) The extensor pollicis longus (EPL) tendon runs in a grove just radially to Lister's tubercle. Active extension of wrist and thumb aid with identification.

http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/upper-body/extensor-pollicis-longus/atlasImage

A) Positioning:  Place wrist in ulnar deviation and 20 - 30 degrees of flexion. Apply longitudinal traction to the fingers of the hand.

B) Technique:  Insert a small needle (22g) just distal to the tubercle and on the ulnar side of the EPL tendon.

http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-80032-1477044tn.jpg

http://www.youtube.com/watch?v=nlPdb_mymw4&feature=related

http://www.youtube.com/watch?v=UVG7fZvZD-s&feature=related

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The TFCC (triangular fibrocartilage complex)  is a ligamentous/cartilage like complex similar to the meniscus of the knee located on the ulnar side of the wrist.

http://yanyanxu.com/wp-content/uploads/2008/01/trifibcc.gif

Hx: ulnar sided wrist pain following trauma and associated with activity related mechanical symptoms such as clicking.

PE:  tenderness to palpation distal to ulnar head or at ulnar styloid . Tenderness against resisted radial deviation.

Plain film may show ulnar styloid avulsion or injury to carpal structures.

Refer to hand/wrist surgeon

Splint in ulnar gutter of long arm spica

MRI or arthrogram are studies of choice.

http://www.cobalthealth.co.uk/MImageGen.ashx?image=%2Fmedia%2F12951%2Fwrist-tfcc-tear-big.jpg&width=170&crop=true

      Anterolateral dislocation is most common (>85%)

As the tib/fib joint has its own synovial cavity, a knee effusion will not be seen

Mechanism: fall on the flexed knee with foot/ankle inversion

Hx: swelling, variable amount of lateral knee pain (anywhere from mild discomfort to inability to bear weight)

PE: Prominence of the fibular head, ankle motion exacerbates knee pain. no associated neurovascular issues

However with less common dislocations (posterior and superior) peroneal nerve injury may occur

Reduction: Place patient supine with knee flexed to 90 degrees. Ankle should be dorsiflexed and externally rotated.

REVERSE THE INJURY: Apply firm posteriorly directed pressure to the fibular head. May head an audible pop as fibular head reduces.  Reassess collateral ligament function.

Saturday night palsy - radial nerve mononeuropathy due to improper arm positioning associated with inebriated sleep.

Physical examination - Wrist and finger drop. 

Patients may have findings suggestive of ulnar nerve co-involvement (interossei testing)  which may falsely lead the examiner to consider a more proximal location for the lesion such as the brachial plexus.

The finger drop caused by the radial nerve lesion places the hand at a mechanical disadvantage.  Adjust for this by examining the hand on a flat surface (stretcher, counter top). With the fingers now supported in extension at the MCP joint  (no longer "dropped"), the interossei can now be tested in isolation and will be normal.

Evaluation of circulatory status is the most important aspect of post reduction care.

Look for hard findings such as cool/cold lower extremity, diminished or absent pulses, pale or dusky skin, paralysis, etc.

However, the absence of these findings should not lull the clinician into a false sense of security. The degree of initial joint deformity, presence of full bounding pulses and warm skin over the dorsum of the foot can all be present in the setting of vascular injury.

The next step will be to perform an ABI (ankle-brachial index).

In one small study, no patient with an ABI greater than or equal to 0.9 had a vascular injury.

Patients with a reassuring physical exam and ABIs should be admitted for vascular checks without further imaging.

Patients with a reassuring physical examination but with an abnormal ABI should have an imaging study obtained (arteriogram/CT angiogram).

Patients with hard findings of a vascular injury should have an emergent vascular surgery consultation.

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Stability from 4 major ligaments (ACL, PCL, MCL and LCL)

Knee dislocation causes injury to multiple ligaments (usually 3 of the above).

Many of these dislocation spontaneously reduce prior to medical evaluation.  Therefore, consider knee dislocation in a patient with multi ligament injury, significant hemarthrosis and bruising.

Vascular injury in up to 40% (popliteal artery)

Nerve injury in up to 23% (peroneal nerve) ((ankle dorsiflexion and sensation to the first web space of the foot))

After reduction, immobilize knee in 15-20 degrees flexion.

The degree of initial deformity, presence of strong pulses, or warm skin cannot be used to rule out popliteal injury.

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Acute brachial plexus neuritis is an uncommon disorder that is easily confused with cervical radiculopathy.

Patients present with a characteristic pattern of acute onset of burning pain.  Pain subsides in days to weeks and is then followed by profound weakness and muscle wasting changes affecting the shoulder  and upper extremity. Weakness is best identified in the deltoid, biceps and rotator cuff muscles. Strength gradually recovers over 3-4 months.

DDX:  The constellation of pain, weakness and sensory loss associated with cervical radiculopathy tend to occur simultaneously.  Also cervical radiculopathy tends to involve only a  single root.

ED treatment is with analgesics and physical therapy and PCP referral for outpatient MRI/EMG. Consider a sling in those with severe shoulder weakness.

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Refractory Osteomyelitis is defined as a chronic osteomyelitis that persists or recurs after appropriate interventions have been performed or where acute osteomyelitis has not responded to surgery and antibiotics.

Case series, animal data and non-randomized prospective trials suggest that the addition of Hyperbaric Oxygen therapy to routine surgical and antibiotic management of previously refractory osteomyelitis is safe and improves the rate of infection resolution.

In patients with osteomyelitis involving spine, skull, sternum,  HBOT  is recommended prior to surgical intervention.  

Typically patients require 20-40 daily dives for sustained therapeutic benefit. 

How does HBOT work in osteomyelitis?

1.       Restoration of normal to elevated O2 level in infected bone.

2.       Leukocyte mediated killing of aerobic bacteria is restored when low O2 tension intrinsic to osteomyolitic bone is restored to physiologic or supra-physiologic levels.

3.       HBOT is noted to exert direct suppressive effects on anaerobic infections.

4.       HBOT augment the transport of certain abx (aminoglycosides and cephalosporins) across bacterial cell wall.

5.       Enhance osteogenesis

6.       Enhance angiogenesis

thank you to Dr. Sethuraman for this pearl

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Emergency physicians are often called upon to provide event coverage for marathons.

Prolonged endurance racing is safe for the majority of participants.

Hyponatremia (8.2% - 13.5%)  - finishing times of greater than 4 hours is an independent risk factor

Hypokalemia – uncommon

Renal function – BUN > 30 or Cr > 1.4 mg/dL (23.6%). There is no data that this is of any clinical significance.

Cardiac Troponin - (11%) had significant increases (troponin T > or = 0.075 ng/mL or  troponin I > or = 0.5 ng/mL). Elevations were more commonly seen with weight loss and increased Cr levels and may be associated with running inexperience (< 5 previous marathons) and young age (< 30 years) though interestingly not with race duration or traditional cardiac risk factors.

Findings are similar for men and women

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Pes Anserine Bursitis is an inflammatory condition of the medial knee

Occurs at the bursa of the pes anserinus which overlies the attachment of the 1) Sartorius 2) gracilis and 3) semitendinosis tendons

Note the location is 2-3 inches below the knee joint on the medial side

http://kneespecialistsurgeon.com/images/uploaded/Pes%20anserinus%20bursitis%20image.jpg

http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/575-27_default.jpg

Patients complain of pain (especially with stair climbing)

PE: Tenderness to palpation of the bursa with mild swelling

DDx: MCL tear, medial meniscus injury, medial (knee) compartment arthritis

Treatment: Cessation/modification of offending activities, Icing and ice massage, NSAIDs, hamstring stretching and physical therapy. Failure of the above should prompt referral for bursal steroid injection.

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