UMEM Educational Pearls - By Brian Corwell

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.

Show References



Category: Orthopedics

Title: Acute brachial plexus neuritis

Keywords: Brachial plexus neuritis, neck pain (PubMed Search)

Posted: 8/13/2011 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

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.

Show References



Category: Orthopedics

Title: Refractory Osteomyelitis

Keywords: Osteomyelitis, hyperbaric oxygen (PubMed Search)

Posted: 7/23/2011 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

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

Show References



Category: Orthopedics

Title: Electrolyte abnormalities in marathon runners

Keywords: Electrolyte abnormalities, marathon runners, troponin (PubMed Search)

Posted: 7/9/2011 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

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

Show References



Category: Orthopedics

Title: Pes Anserine Bursitis

Keywords: Pes Anserine, Bursitis, knee pain (PubMed Search)

Posted: 6/25/2011 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

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.

Show References



Category: Orthopedics

Title: Kienb ck's disease

Keywords: Kienb ck's disease, wrist, avascular necrosis (PubMed Search)

Posted: 6/11/2011 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Kienbock’s disease is a rare entity involving collapse of the lunate due to avascular necrosis and  vascular insufficiency.

Occurs most commonly in young adults aged 15 to 40 years.

Cause is unknown but believed to be due to remote trauma or repetitive microtrauma in at risk individuals.

Patients complain of wrist pain, stiffness and swelling

On exam, limited range of motion, decreased grip strength and passive dorsiflexion of the 3rd digit produces pain.

Dx: plain film in the ED and with MRI as an outpatient.

Tx:  Wrist immobilization with splint and refer to orthopedics. Ultimate treatment is individualized and there is no clear consensus.

Lunate sclerosis seen on plain film

http://orthoinfo.aaos.org/figures/A00017F02.jpg

AVN of the lunate seen on MRI

http://www.assh.org/Public/HandConditions/PublishingImages/KeinbocksMRI_figure3.JPG

Show References



Category: Orthopedics

Title: Brachial Plexus Injuries in Sports Medicine

Keywords: Brachial plexus, stinger, burner (PubMed Search)

Posted: 5/28/2011 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Transient brachial plexopathies aka Burners and Stingers

Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes.

49-65% of all college football players have experienced at least one burner with a 87% recurrence rate.

Injuries most commonly occur at C5-C6 but may involve any root level.

3 Mechanisms: Commonly due to

1) Traction caused by lateral flexion of the neck away from the involved side

2) Compression of the upper plexus between shoulder pads and scapula

3) Nerve compression caused by neck hyperextension and ipsilateral rotation.

CC: Burning or numbness in the neck, shoulder and/or arm

Symptoms are UNILATERAL and tend to usually  last seconds to minutes

Symptoms are reproduced by the Spurling maneuver.

Function gradually returns from the proximal muscle groups to the distal muscle groups.

Because most burners are self-limited, the most important goal is to rule out an unstable cervical injury.

Show References



Category: Orthopedics

Title: Meralgia Paresthetica

Keywords: Meralgia Paresthetica, lateral hip pain (PubMed Search)

Posted: 5/14/2011 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

Meralgia Paresthetica - caused by entrapment of the lateral femoral cutaneous nerve (LFCN)

The LFCN is responsible for sensation of the anteriorlateral thigh.

http://www.chiropractic-help.com/images/Meralgia-Paresthetica.jpg

NOTE*  It has no motor component!

Associated with pregnancy, wearing tight pants, belts, girdles, and in diabetic and obese patients.

Symptoms include numbness, paresthesias and pain (not weakness). Worse w walking, standing. Better w sitting.

Diagnosis is clinical but may be confirmed with nerve conduction studies

Treatment includes, NSAIDs, injection and surgery for refractory cases.

 



Category: Orthopedics

Title: Gout 3/3

Keywords: Gout, pseudogout, NSAIDS, Steroids (PubMed Search)

Posted: 4/23/2011 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

Gout treatment considerations

Treatment is directed to relieve pain and inflammation

NSAIDs, steroids and narcotics are the mainstays of treatment. All 3 should be used in combination.

Aspirin should be avoided as it may increase uric acid levels

     Note: not in prevention doses (81mg) in treatment doses (325-650mg q4h)

      NSAIDs and steroids take time to be effective.  Provide appropriate analgesia with oral narcotic medication for short term relief

     Don't forget the benefit of splinting a "hot" joint (the ankle or wrist for example)

NSAIDs: Use may be limited in the elderly and in those on coumadin or with peptic ulcer disease. 5-7 days of treatment is usually sufficient. Indomethacin is most commonly used (50 mg TID, which may be tapered to 25 mg TID after 3 days)

Steroids:  Likely more effective than NSAIDs. Oral prednisolone is more effective than naproxen (1). Use prednisone 30-50 mg for 3-5 days without tapering (as we use for asthma). May be useful to supplement with NSAIDs on the tail end to prevent a rebound flare. If tapping the joint consider intraarticular steroids. If there is concern for medical noncompliance with oral steroids consider IM steroids (triamcinolone 60mg or methylprednisolone).

Show References



Category: Orthopedics

Title: Gout Part 2

Keywords: Gout (PubMed Search)

Posted: 4/10/2011 by Brian Corwell, MD (Emailed: 4/16/2011) (Updated: 4/16/2011)
Click here to contact Brian Corwell, MD

Gout Part 2

  • Hyperuricemia can result from both uric acid overproduction (metabolic/myeloproliferative diseases) in addition to uric acid underexcretion (more common).
  • Consider gout in any patient who complains of joint pain that reaches peak intensity over hours and may wake them from sleep. Septic joints tend to reach peak intensity of days.
  • Patients may have multi joint involvement, low-grade fever and leukocytosis (factors that may lead one to consider an alternative diagnosis)
  • Remember that gout is also a disease of the synovial tissue (tendonitis and bursitis).
  • NSAIDs: Traditional preferred treatment for acute gout
  • Colchicine: Less effective if the current attack is >24 hours. Use correct dosage for best effect/side effect ratio.
  • Steroids: At least as effective as NSAIDs.

Show References



Category: Orthopedics

Title: Gout

Keywords: Gout, uric acid (PubMed Search)

Posted: 3/26/2011 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

GOUT part 1

 

Gout is an inflammatory arthritis that classically affects the first metatarsal phalangeal joint

Gout prefers cool ambient temperature hence gouty tophi prefer the great toe (one of the coldest parts of the body) and avoids "warmer" joints such as the hip and shoulder.

Remember that gout can affect other joints as well (elbow, wrist, knee and ankle) and  can cause painful bursitis and tendonitis

Multiple joints can be involved simultaneously (leading to confusing with RA and OA)

The involved joint will often be red, hot, swollen and very painful leading to easy confusion with cellulitis and or a septic arthritis

Diagnose gout by demonstrating monosodium urate crystals in the synovial fluid.

**Remember previous pearl by Dr. Bond regarding the coexistence of gout with septic joint**

Serum uric acid levels are commonly elevated but can be normal or even low

Use caution with this test because asymptomatic hyperuricemia is much more common than gout

 

Show References



Category: Orthopedics

Title: Cubital Tunnel Syndrome

Keywords: nerve entrapment, ulnar nerve, elbow (PubMed Search)

Posted: 3/12/2011 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

Cubital Tunnel Syndrome aka Radial Tunnel Syndrome

  • The most common neuropathy of the elbow
  • Entrapment of the ulnar nerve as it passes posterior to the medial epicondyle of the elbow
  • HX: medial elbow and forearm pain occasionally associated with ulnar digit paresthesias.
  • May be due to trauma, degenerative changes or throwing sports.
  • PE:  Pain with elbow flexion. Tenderness to palpation over the cubital tunnel. Positive Tinnel's sign.
  • **Up to a quarter of normal asymptomatic patients will have a positive Tinnel's**
  • DDx: Ulnar collateral ligament strain/tear and medial epicondylitis
  • Tx: Ice, NSAIDs, activity modification, night splints with elbow in 45 degrees flexion and finally surgical decompression or nerve transposition    

      

   

Show References



Category: Orthopedics

Title: Sever's disease

Keywords: apophysitis, overuse injuries, heel pain, achilles (PubMed Search)

Posted: 2/26/2011 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

Sever's disease ,aka calcaneal apophysitis, is a common overuse injury in the pediatric and adolescent population.

Occurs secondary to traction of the calcaneus that most often occurs in young athletes (8-12 yo)

     -Avg. age of presentation is 11 years 10 months in boys & 8 years 8 months in girls

     -Repetitive traction to the weaker apophysis, induced by the pull of the Achilles on its insertion

Hx: Heel pain that increases with activity (running, jumping).

     -May involve one (40%) or both (60%) feet

PE: Tenderness of the posterior heel at the Achilles tendon insertion and ankle dorsiflexor weakness

Imaging:  Radiography is often normal.  When positive, show fragmentation and sclerosis of the calcaneal apophsis. NOTE:  These findings are nonspecific and also are observed in asymptomatic feet.

http://t0.gstatic.com/images?q=tbn:ANd9GcQ9R-fx1iyhbhNJpNL2W72bWdK72_mRBLNX5DUDtcMfnDli-x7Ong

DDx: Includes osteomyelitis and tarsal coalition.

Tx: Rest from aggravating activities, NSAIDs, ice (both pre and post sport).  When pain free a program of stretching (gastrocnemius-soleus), strengthening (dorsiflexors) and shoe inserts (heel cups, lifts, pads, or orthotics) can provide significant pain relief.

Show References



Category: Orthopedics

Title: Iliotibial band syndrome

Keywords: iliotibial band, knee pain (PubMed Search)

Posted: 1/22/2011 by Brian Corwell, MD (Updated: 2/19/2011)
Click here to contact Brian Corwell, MD

Iliotibial band syndrome (ITBS)

  • Due to recurrent friction of the iliotibial band (ITB) sliding over the lateral femoral condyle.


http://footcarexpress.com/foot-orthotics/wp-content/uploads/2009/01/iliotibial-band-syndrome.jpg


Hx -

  • Sharp or burning pain on the lateral aspect of the knee usually in runners.

  • Rarely occurs at start of run, rather, occurs after reproducible time or distance
  • (especially when running downhill)


PE-

  • Typically negative other than local tenderness (approx. 2cm above lateral joint line) & occasional swelling over the distal ITB.
  • 
Specialized tests: See also Ober's test and Noble's test


Tx

  • Most patients respond to conservative treatment involving NSAIDs, stretching of the iliotibial band, strengthening of the gluteus medius, and altering training regimens.


 

Show References



Category: Orthopedics

Title: Jersey Finger

Posted: 1/8/2011 by Brian Corwell, MD (Updated: 2/19/2011)
Click here to contact Brian Corwell, MD

                Involves an avulsion of the flexor digitorum profundus  (FDP) tendon from its insertion on the distal phalanx.

     Ring finger is most commonly involved.

                Usually occurs from a grabbing attempt (resulting in forced DIP extension during maximal FDP contraction) as would occur while attempting to grab someone’s jersey such as in football or rugby.

Clinically, there is normal passive DIP ROM with loss of active flexion. Examine this by asking the patient to flex the fingertip at the DIP while the PIP joint is held in extension.

*Remember that patients with a 90% full-thickness tendon laceration may still have normal (albeit painful) range of motion. The examiner must evaluation the strength of the tendon against resistance. This injury is commonly missed as it is diagnosed as a “jammed” finger.

Plain films may show a bony avulsion, but are often negative.

Treatment is primary repair especially with large bony fragments. Partial ruptures can be treated nonoperatively at the discretion of the hand surgeon.

Show References



Category: Orthopedics

Title: Commotio Cordis

Keywords: Sports medicine, Sudden cardiac death, Commotio Cordis, Defibrillation (PubMed Search)

Posted: 12/25/2010 by Brian Corwell, MD (Updated: 2/19/2011)
Click here to contact Brian Corwell, MD

Commotio Cordis

Emergency medicine & sports medicine physicians often cover sporting events where athletes are at risk of commotio cordis

  • 2nd most common cause of sudden cardiac death in young athletes in the US (HCM #1)
  • Young males between 4 and 18 years old are at greatest risk
  • 50% of all cases occur during competitive sports (baseball #1)
  • Nonpenetrating, blunt trauma to the chest resulting to cardiac arrhythmia and, often, sudden cardiac  death.
  • Ventricular fibrillation (VF) is the most common arrhythmia.
  • Thought to occur secondary to a precordial impact during an electrically vulnerable portion of ventricular repolarization (10-30 msec before the T-wave peak)
  • Treatment:  Immediate chest compressions and early use of an automated external defibrillator (AED) ((effective in only 15% of cases))
  • Survival is much improved if resuscitation administered within 3 minutes (25%) than after 3 minutes (3%)
  • Differential diagnosis: other causes of sudden cardiac death including HCM, coronary artery anomalies, long QT syndrome, Brugada syndrome, WPW, CAD, myocarditis, arrhythmogenic right ventricular dysplasia

Show References



Category: Orthopedics

Title: Cervical Radiculopathy

Keywords: cervical, neck, radiculopathy (PubMed Search)

Posted: 12/10/2010 by Brian Corwell, MD (Emailed: 12/11/2010) (Updated: 12/18/2010)
Click here to contact Brian Corwell, MD

Cervical Radiculopathy

The most commonly affected level is C7 (31-81%), followed by C6 (19-25%), C8 (4-12%) and C5 (2-14%)

Anterior compression can selectively affect motor fibers

Posterior compression can selectively affect sensory fibers

         -More common due to posterior lateral disc herniation or facet degeneration

Signs and symptoms: Sensory complaints (findings are in a root distribution) and possible weakness and reflex changes.

Show References



Category: Orthopedics

Title: Posterior heel pain

Keywords: Bursitis, heel pain (PubMed Search)

Posted: 11/27/2010 by Brian Corwell, MD (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

Chief complaint: “Posterior heel pain”

 

http://www.aidmybursa.com/_img/ankle-retrocalcaneal-subcutaneous-bursitis.jpg

Retrocalcaneal bursitis

The retrocalcaneal bursa is located between the Achilles tendon and the posterior superior border of the calcaneus.

H&P: Inflammation and pain may follow repetitive dorsi/plantar flexion of the ankle (excessive running, jumping activities). Tenderness anterior and superior to the Achilles insertion on the heel.

Treatment: Minimize weight bearing. ½ inch elevation. NSAIDs.

 

Posterior calcaneal bursitis

This bursa is subcutaneous, just superficial to the insertion of the Achilles tendon.

H&P: Inflammation and pain may follow irritation from the upper border of the heel counter of a shoe. Posterior heel pain. Tender “bump” (the inflamed and swollen bursa) on the back of the heel.

http://podiatry.files.wordpress.com/2006/12/patient2.jpg

 

Treatment: Opened-heeled shoes, sandals, or placement of a “U-shaped” pad between the heel and the counter. NSAIDs. Advance to shoes with soft or less convex heel counters.

Show References



Category: Orthopedics

Title: Transverse Myelitis

Keywords: Transverse Myelitis, spinal cord, MS (PubMed Search)

Posted: 11/13/2010 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Transverse Myelitis

A group of inflammatory disorders characterized by acute or subacute motor weakness, sensory abnormalities and autonomic (bowel, bladder, sexual) cord dysfunction.

Symptoms are usually bilateral but both unilateral and asymmetric presentations can occur.

Look for a well-defined truncal sensory level

       -below which sensation of pain and temperature is altered or lost.

Causes: Autoimmune after infection or vaccination (60% of cases in children), direct infection, or a demyelinating disease such as MS.  No cause is found in 15 – 30% of cases.

Incidence: Bimodal peak at 10-19 years and at 30-39 years.

Diagnostic testing: MRI of the ENTIRE spine to both rule out structural lesions and rule in an intrinsic cord lesion. If MRI is normal reconsider the original diagnosis.

Treatment: Steroids are first-line therapy. Dosing is controversial but generally involves high IV doses for 3-5 days (1000 mg methylprednisolone). Plasma exchange is second line for those who don’t respond to steroids.

Show References



Category: Orthopedics

Title: EPIDURAL SPINAL CORD COMPRESSION

Keywords: EPIDURAL SPINAL CORD COMPRESSION, CAUDA EQUINA SYNDROME (PubMed Search)

Posted: 10/22/2010 by Brian Corwell, MD (Emailed: 10/23/2010) (Updated: 7/13/2024)
Click here to contact Brian Corwell, MD

Epidural compression syndrome encompasses spinal cord compression, cauda equina syndrome, & conus medullaris syndrome.

Causes include:

  1. massive midline disc herniation (most commonly), usually at the L4 to L5 level.
  2. tumor
  3. epidural abscess
  4. spinal canal hematoma.

Measurement of a post-void bladder residual volume tests for the presence of urinary retention with overflow incontinence (a common, though late finding) (sensitivity of 90%, specificity of 95%).  Large post-void residual volumes (>100 mL) indicate a denervated bladder with resultant overflow incontinence and suggest significant neurologic compromise. The probability of cauda equina syndrome in patients without urinary retention is approximately 1 in 10,000.

Use this in your daily practice!!

The administration of glucocorticoids can minimize ongoing neurologic damage from compression & edema until definitive therapy can be initiated. The optimal initial dose and duration of therapy is controversial, with a recommended dose range of dexamethasone anywhere from 10 to 100 mg intravenously. Consider traditional dosing (dexamethasone 10 mg)  for those with minimal neurologic dysfunction, & reserve the higher dose  (dexamethasone 100 mg) for patients with profound or rapidly progressive symptoms, such as paraparesis or paraplegia.

Show References