UMEM Educational Pearls - By Brian Corwell

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)
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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.

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Category: Orthopedics

Title: Posterior heel pain

Keywords: Bursitis, heel pain (PubMed Search)

Posted: 11/27/2010 by Brian Corwell, MD (Updated: 9/29/2023)
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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.

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Category: Orthopedics

Title: Transverse Myelitis

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

Posted: 11/13/2010 by Brian Corwell, MD
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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.

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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: 9/29/2023)
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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.

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Category: Orthopedics

Title: Documenting joint injury

Keywords: joint, documentation, physical examination (PubMed Search)

Posted: 10/9/2010 by Brian Corwell, MD (Updated: 9/29/2023)
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Previous pearls have described tips for smart and safe documentation of typical ED complaints such as chest pain.  Properly assessing and documenting orthopedic complaints is likewise very important.  No evaluation or chart is complete if it does not include include the following 7 components:

 

The joint above

The joint below

Motor

Sensory

Vascular

Skin

Compartments

The joint above/below is important in cases of shoulder and hip pain actually being radicular pain (from the neck and back respectively).  Also, hip pain from trauma may be due to a femur fracture for example.

For motor and sensory evaluation, test the most distal isolated innervation of a particular nerve (L5 - great toe dorsiflexion for example).

Note distal pulses and check ABIs for injuries with potential subtle vascular  findings.

Note intact skin especially in cases where the joint will be covered by a splint.

Note "soft" compartments especially in cases of forearm and lower leg fractures.

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Category: Orthopedics

Title: Gamekeeper s/Skier s Thumb

Keywords: Thumb, Gamekeeper's thumb, Skier's thumb (PubMed Search)

Posted: 9/25/2010 by Brian Corwell, MD (Updated: 9/28/2010)
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Injury was originally described as an occupational hazard in Scottish gamekeepers (from breaking the necks of rabbits against the ground). Today, skiing is now the most common cause and injury is now the second most common orthopedic injury in skiers (MCL injury #1).

Injury to the ulnar collateral ligament (UCL) results from a sudden forced abduction (radial deviation) stress at the MCP joint of the thumb, commonly due to a fall against a ski pole or the ground.

http://blog.fitter1.com/wp-content/uploads/2010/04/b_14_1_2a.jpg

The most frequent site of rupture is the insertion into the proximal phalanx. The UCL may even avulse a small portion of the proximal phalanx at its insertion site.

http://img.medscape.com/pi/emed/ckb/sports_medicine/84611-97564-98460-1652013.jpg

Consider imaging before stress testing (to avoid further displacing a fracture)

http://img.medscape.com/pi/emed/ckb/sports_medicine/84611-97564-98460-1652060.jpg

Stabilize in a thumb spica splint and refer to hand surgery.

Calling this entity a “simple sprain” may result in chronic disability (chronic pain, instability, loss of pinch strength)

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Category: Orthopedics

Title: Physical examination of the rotator cuff

Keywords: Shoulder, Rotator cuff (PubMed Search)

Posted: 9/11/2010 by Brian Corwell, MD (Updated: 12/18/2010)
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Supraspinatus: “Empty can” test. Have the patient abduct the shoulders to 90 degrees in forward flexion with the thumbs pointing downward. The patient attempts to lift the arms against the examiner’s resistance.

http://bjsportmed.com/content/42/8/628/F2.large.jpg

Infraspinatus and teres minor: These muscles are responsible for external rotation of the shoulder. Have the patient flex both elbows to 90 degrees while the examiner provides resistance against external rotation.

http://www.physio-pedia.com/images/4/4b/Infraspinatus_test.jpg

Subscapularis: “Lift-off” test. The patient rests the dorsum of the hand on the lower back (palm out) and then attempts to move the arm and hand off the back.  Patients with tears may be unable to complete test due to pain.

http://www.aafp.org/afp/2008/0215/afp20080215p453-f4.jpg

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Radiologic evaluation of the elbow (Part 2)

Helpful clues in the evaluation of elbow trauma:

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Category: Orthopedics

Title: Radiologic evaluation of the elbow (Part 1)

Keywords: Elbow, fat pad, fracture (PubMed Search)

Posted: 8/14/2010 by Brian Corwell, MD (Updated: 9/18/2010)
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Helpful clues in the evaluation of elbow trauma

Fat pads The fat pad sign can be seen with any joint effusion (infection, inflammation) but in the setting of trauma, effusions are indicative of fractures about the elbow (even if no fracture line can be identified).

There are two fat pads within the elbow. Normally, on a true  lateral radiograph only the anterior fat pad is seen as a small triangular radiolucent shadow anterior to the distal humeral diaphysis. The posterior fat pad is ordinarily not visualized on a lateral radiograph because it is tucked away within  the olecranon fossa. 

Normal lateral view: http://nypemergency.org/images/ElbowNormal.jpg

With fractures, the joint becomes distended with blood.  The anterior fat pad becomes displaced superiorly and outward from the humerus giving the so called "sail sign."  Similarly, the posterior fat pad gets displaced out of the olecranon fossa and becomes visible on the lateral radiograph. 

Anterior (sail) and posterior fat signs: http://nypemergency.org/images/Elbowsfatpadarrow.jpg

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Category: Orthopedics

Title: Back Pain

Posted: 7/24/2010 by Brian Corwell, MD (Updated: 9/29/2023)
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  • Back pain is the most common musculoskeletal complaint that results in visits to the ED.
  • It has a benign course in more than 90% of patients, so we must be vigilant and comfortable looking for warning signs of a neurologically impairing or life-threatening cause.
  • We rely on the presence of so-called "red flags" or alarm symptoms to guide further diagnostic tests, specialty evaluation, and treatment. 
  • Additionally, always consider 2 important extra-spinal causes of back pain: aortic dissection (sudden onset back pain) and abdominal aortic aneurysm (patients >50, esp. those who you think have a kidney stone- isolated back and groin pain is a common presentation).

 

History and Physical Examination Red Flags

Historical Red Flags Physcial Red Flags
Age under 18 or over 50
Pain lasting more than 6 weeks
History of cancer
Fever and chills
Night sweats, unexplained weight loss
Recent bacterial infection
Unremitting pain despite rest and analgesics
Night pain
Intravenous drug users, immunocompromised
Major trauma
Minor trauma in the elder
Fever
Writhing in pain
Bowel or bladder incontinence
Saddle anesthesia
Decreased or absent anal sphincter tone
erianal or perineal sensory loss
Severe or progressive neurologic defect
Major motor weakness

Category: Orthopedics

Title: Spondylolysis

Keywords: Spondylolysis (PubMed Search)

Posted: 7/10/2010 by Brian Corwell, MD (Updated: 9/29/2023)
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  • Spondylolysis is a unilateral or bilateral defect in the pars interarticularis portion of the vertebrae.
  • It is a stress fracture mostly seen in the lumbar vertebrae, and most commonly L5.
  • Pain is relieved with rest and worsened by lateral bending or extension (NOTE: most back pain is worsened by flexion).
  • If neurologic symptoms and/or radiculopathy are present, an alternative diagnosis should be considered, because they are rarely associated with spondylolysis.
  • Diagnostic imaging should start with plain radiographs with added oblique views.
  • Classically, oblique views show the Scotty dog sign with a crack on the dog’s neck/collar, the pars.


http://www.gentili.net/signs/images/400/spinescottyparsdefectdrawing.JPG

The Scotty dog’s head (superior articular facet), nose (transverse process), eye (pedicle), neck (pars interarticularis), and body (lamina) should be easily identified on the oblique radiograph.
 

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Category: Orthopedics

Title: Sports Hernia/Athletic pubalgia

Keywords: Sports Hernia, groin pain (PubMed Search)

Posted: 4/6/2014 by Brian Corwell, MD (Emailed: 9/29/2023)
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Sports Hernia/Athletic pubalgia

 

Hx: Gradually increasing lower abdominal/proximal adductor pain. Usually activity related, resolves with rest. Frequent return despite rest when sports activity resumes.

Most common in athletes who perform cutting/maneuvers in addition to frequent acceleration/deceleration. Think ice hockey and soccer.

Bilateral symptoms not uncommon.

PE:  Resisted sit up with palpation of the inferolateral edge of the distal rectus may recreate symptoms. Similarly, resisted hip adduction may elicit symptoms. 

If for no other reason than to make the diagnosis harder to make, valsalva induced pain may also occur.

Fluoroscopic guided injections can be helpful to isolate the site of pain generation.

First line therapy is rest, non-narcotic analgesia and physical therapy.

With surgery, >80% return to pre injury level of play.

 

http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2009/11/groin-injuries.jpg

 

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Category: Orthopedics

Title: Fulcrum test

Posted: 10/1/2017 by Brian Corwell, MD (Emailed: 9/29/2023) (Updated: 9/29/2023)
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https://www.physio-pedia.com/Fulcrum_Test


Category: Orthopedics

Title: Morel-Lavall e lesion

Posted: 10/1/2017 by Brian Corwell, MD (Emailed: 9/29/2023) (Updated: 9/29/2023)
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4126145/


Category: Orthopedics

Title: The association between fluoroquinolone use and tendon injury in an adolescent population

Keywords: tendon, antibiotics, tendonitis (PubMed Search)

Posted: 5/22/2021 by Brian Corwell, MD (Emailed: 9/29/2023) (Updated: 9/29/2023)
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A recent article in Pediatrics attempted to estimate the association between fluoroquinolone use and tendon injury in an adolescent population.

Fluoroquinolones are thought to negatively impact tendons and cartilage in the load-bearing joints of the lower limbs through collagen degradation, necrosis, and disruption of the extracellular matrix.

Population: 4.4 million adolescents aged 12–18 years with filled outpatient fluoroquinolone prescription vs. an oral broad-spectrum antibiotic for comparison.

Fluoroquinolones included ciprofloxacin, levofloxacin, moxifloxacin, and gatifloxacin

Comparator antibiotics included amoxicillin-clavulanate, azithromycin, cefalexin, cefixime, cefdinir, nitrofurantoin, and bactrim.

Outcomes: Primary outcome was 90-day tendon rupture (Achilles, patellar, quadricep, patellar, tibial) identified by diagnosis and procedure codes. Secondary outcome was tendinitis.

Results: The weighted 90-day tendon rupture risk was 13.6 per 100 000 fluoroquinolone-treated adolescents and 11.6 per 100 000 comparator-treated adolescents.

Fluoroquinolone-associated excess risk: 1.9 per 100 000 adolescents; the corresponding number needed to treat to harm was 52 632.

The weighted 90-day tendinitis risk was 200.8 per 100 000 fluoroquinolone-treated adolescents and 178.1 per 100 000 comparator-treated adolescents

Fluoroquinolone-associated excess risk excess risk: 22.7 per 100 000 adolescents; the corresponding number needed to treat to harm was 4405.

Conclusion:

The excess risk of tendon rupture associated with fluoroquinolone treatment was extremely small, and these events were rare. On average, 50,000 adolescents would need to be treated with a fluoroquinolone for 1 additional tendon rupture to occur

The excess risk of tendinitis associated with fluoroquinolone treatment though larger was also small.

Besides tendon rupture, other more common potential adverse drug effects may be more important to consider for treatment decision-making, in adolescents without other risk factors for tendon injury.

 

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