Keywords: cervical, neck, radiculopathy (PubMed Search)
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.
Wilbourn & Aminoff, 1998.
Keywords: Bursitis, heel pain (PubMed Search)
Chief complaint: “Posterior heel pain”
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.
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.
Keywords: Transverse Myelitis, spinal cord, MS (PubMed Search)
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.
Transverse Myelitis. Frohman EM, Wingerchuk DM. NEJM 2010 Aug 5;363(6):564-72.
Keywords: EPIDURAL SPINAL CORD COMPRESSION, CAUDA EQUINA SYNDROME (PubMed Search)
Epidural compression syndrome encompasses spinal cord compression, cauda equina syndrome, & conus medullaris syndrome.
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.
1. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760–5.
2. Gregory D, Seto C, Wortley G, et al. Acute lumbar disk pain: navigating evaluation and treatment choices. Am Fam Physician 2008;78:835–42.
3. Loblaw DA, Laperriere NJ. Emergency treatment of malignant extradural spinal cord compression: an evidence-based guideline. J Clin Oncol 1998;16:1613–24.
Keywords: joint, documentation, physical examination (PubMed Search)
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
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.
Keywords: Thumb, Gamekeeper's thumb, Skier's thumb (PubMed Search)
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.
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.
Consider imaging before stress testing (to avoid further displacing a fracture)
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)
Keywords: Shoulder, Rotator cuff (PubMed Search)
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.
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.
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.
Keywords: Elbow, radiographs (PubMed Search)
Radiologic evaluation of the elbow (Part 2)
Helpful clues in the evaluation of elbow trauma:
Keywords: Elbow, fat pad, fracture (PubMed Search)
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
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
Intravenous drug users, immunocompromised
Minor trauma in the elder
| Fever |
Writhing in pain
Bowel or bladder incontinence
Decreased or absent anal sphincter tone
erianal or perineal sensory loss
Severe or progressive neurologic defect
Major motor weakness
Keywords: Spondylolysis (PubMed Search)
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.
Keywords: Sports Hernia, groin pain (PubMed Search)
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.
Sports Hernia/Athletic Pubalgia: Evaluation and Management. Christopher Larson. Sports Health.
Keywords: tendon, antibiotics, tendonitis (PubMed Search)
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.
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.
Ross RK, Kinlaw AC, Herzog MM, Jonsson Funk M, Gerber JS. Fluoroquinolone Antibiotics and Tendon Injury in Adolescents. Pediatrics. 2021 May 14:e2020033316.