UMEM Educational Pearls - By Brian Corwell

Category: Orthopedics

Title: Imaging of Lisfranc Injuries

Keywords: foot fracture, radiology (PubMed Search)

Posted: 9/14/2019 by Brian Corwell, MD (Updated: 8/17/2022)
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Imaging of Lisfranc Injuries

Tarsometatarsal fracture-dislocation

Anatomy

         3 Columns of the midfoot, divided by the tarsometatarsal joints

  1. Medial
    1. First TMT joint
  2. Middle
    1. 2nd and 3rd TMT joints
  3. Lateral
    1. 4th and 5th TMT joints

The Lisfranc ligament

     - Extends from the 2nd MT to the medial cuneiform

     - Critical to structure and stabilization of the 2nd MT and the midfoot arch

 

Imaging 

Plain films: AP/lateral/oblique

Consider weight bearing view with contralateral comparison if high suspicion

CT: Can be useful to confirm abnormal plain films

MRI: not done in ED but can be used to diagnose pure ligament injuries

Below is a review of the lines of the foot which will ensure not missing this diagnosis. May be helpful to review with sample imaging.

Plain films findings: https://prod-images.static.radiopaedia.org/images/49189279/86408d5bae08ab80ae9ef377337ab7_big_gallery.jpeg

 

On AP view:

  1. Discontinuity of a line drawn from the medial part of 2nd MT to the medial side of the 2nd cuneiform
  2. Widening of the interval between the 1st and 2nd ray
  3. Bony fragment in 1st MT space (fleck sign) – Lisfranc ligament avulsion

On Lateral view:

  1. Dorsal displacement of the proximal 1st or 2nd MT (may be subtle)

On the Oblique view:

  1. Discontinuity of a line drawn from the medial border of the 3rd cuneiform with the medial border of the 3rd MT
  2. Discontinuity of a line drawn from the medial side of the 4th MT with the medial side of the cuboid 

Remember that the lateral margin of the 5th MT can project lateral to the cuboid (up to 3 mm)

 

Lines drawn on 2 view foot for review

https://radiopaedia.org/cases/lisfranc-ligament-normal-alignment

 

 

 

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Category: Orthopedics

Title: Lisfranc injury

Keywords: Foot, instability, dislocation (PubMed Search)

Posted: 8/24/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Tarsometatarsal fracture-dislocation

The Lisfranc ligament is critical for stabilization of the midfoot arch and the 2nd MT

Injuries can range from mild (sprains) to severe (gross dislocation)

Injury may be purely ligamentous injuries or a fracture-dislocations

Difficult diagnosis to make

https://www.aafp.org/afp/1998/0701/afp19980701p118-f4.jpg

 

Mechanisms: MVAs, fall from height or athletic injuries

            Common athletic mechanism: Axial load to a hyperplantar flexed forefoot

https://thumbs.dreamstime.com/z/vector-illustration-healthy-human-foot-foot-lisfranc-injury-weight-bearing-mechanism-injury-100392176.jpg

Injury severity is often underestimated

Severe pain and inability to weight bear

Plantar bruising and bruising throughout midfoot

https://footeducation.com/wp-content/uploads/2019/02/Figure-3-Bruising-from-Lisfranc-Injury-600x781.png

No specific tests as exam is limited due to pain

Midfoot stress tests

-Often positive but unlikely to be allowed by patient due to pain

https://www.youtube.com/watch?v=v8SGVwz2RHs

Midfoot instability test

Grasp metatarsal heads and apply dorsal force to forefoot.

Other hand palpates the TMT joints and feels for dorsal subluxation

 


Category: Orthopedics

Title: Plica Syndrome

Keywords: Anterior knee pain (PubMed Search)

Posted: 8/10/2019 by Brian Corwell, MD
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Plica Syndrome

-A painful impairment of knee function resulting from thickened and inflamed synovial folds

Plicae are embryologic remnant inward folds of the synovial lining present in most knees

Most plica are asymptomatic

A pathological synovial plica can become inelastic, thickened and fibrotic. It may bowstring across the femoral trochlea at 70 to 100 degrees of knee flexion

Can be a cause of anterior knee pain/mechanical Sxs

Medial patellar plica most commonly involved

 

Hx: Snapping sensation, pain w/ sitting or repetitive activity

Anterior knee pain, clicking, clunking, and a popping sensation on knee loading activity such as squatting/stairs or with prolonged sitting

Many present with history of blunt trauma to the anterior knee

 

PE: A taut band of tissue that reproduces concordant pain with palpation

Tenderness in the medial parapatellar region

Painful, palpable medial parapatellar cord

-This can be rolled and popped beneath the examiners finger

 

The knee may be tender to the touch, swollen, and stiff 

Can be difficult to distinguish from other intra-articular conditions such as meniscal tears, articular cartilage injuries, or osteochondral lesions,

The examiner can then palpate for the plica by rolling one finger over the plica fold, which is located around the joint lines in anterior knee compartment

https://www.ortho.com.sg/wp-content/uploads/2018/04/medial-plica-syndrome-31-e1478966479644.jpg

 

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Category: Orthopedics

Title: Bone stress injury (BSI) in Adolescents

Keywords: Bone stress reaction, fracture, overuse injury (PubMed Search)

Posted: 7/27/2019 by Brian Corwell, MD
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Bone stress injury (BSI) in Adolescents

 

A BSI occurs along a pathology continuum that begins with a stress reaction and may progress all the way to a stress fracture.

Difficult to diagnose clinically.

Identifying risk factors as part of the history is very important.

Common sites for BSI are most frequently in the lower extremity and include the tibia, fibula, tarsals and metatarsals, calcaneus, and femur.

When considering this in an ED setting, image the involved area and if there is no fracture, advise discontinuing the activity until time of PCP/sports medicine follow up. For those with rest pain, pain with minimal weight bearing or in whom a fracture was suspected but not present, consider providing a walking boot or crutches.

BSIs occur more frequently in young athletes than in adults.         

          Almost 50% of BSIs occur in those younger than 20 years of age

Primary care and sports medicine providers are seeing more of these patients due to many factors.

Year-round training, sports specialization at younger ages and increase in training intensity/duration contribute to the increase incidence in adolescents.

Not surprisingly, participation in organized sports as an adolescent is a known risk factor.

Just as a change in sporting level from high school to college is a known risk factor for BSI, young “gifted” athletes who are promoted to competing with the varsity team may be at similar risk.

Shin pain lasting more than 4 weeks may represent a unique subset of MSK pain complaints increasing risk of BSI.

A prior history of BSI is a strong predictor of future BSI.

Inquire about night pain, pain with ambulation, and pain affecting performance.

Athletes with BSIs have a significantly lower BMI than controls (<21.0 kg/m2).

Athletes with BSIs sleep significantly less than controls.

Athletes with BSIs have significantly lower dairy intake than controls.

Inquire about components of the female athlete triad (low energy availability, menstrual dysfunction and low bone mineral density)

 

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Long head of biceps tendon (LHBT) Testing

 

Overhead activities can cause anterior shoulder pain due to LHBT instability. A review of 3 physical exam maneuvers for bedside evaluation.

 

Speed test

Shoulder at 90° of flexion with arm fully supinated and elbow extended

Patient attempts to fwd. elevate arm against a downward force

Positive test is pain localized to bicipital groove.

Sensitivity 54% and specificity 81% for biceps pathology

https://youtu.be/N00gA4Pvsbw

 

Yergason test

Elbow at 90° of flexion with arm fully pronated and held against thoracic wall. Examiner grips patient’s hand and resists attempts at supination.

Positive test is pain localized to bicipital groove or LHBT subluxation.

Sensitivity 41% and specificity 79% for biceps pathology

https://youtu.be/_ot2S75mZ3o

 

Upper Cut test

Shoulder neutral with Elbow at 90° of flexion, arm fully supinated and hand in a fist. Patient moves hand toward chin in an uppercut motion like a boxer. Examiner places hand over patient’s fist and resists upward movement.

Positive test is pain localized to bicipital groove or LHBT subluxation.

Sensitivity 73%, specificity 78%, +LR 3.38 for biceps pathology

https://youtu.be/EE-WhlWFZvk

 

 

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Category: Orthopedics

Title: Pediatric back pain

Keywords: Disc, infection, back pain (PubMed Search)

Posted: 6/22/2019 by Brian Corwell, MD (Updated: 8/17/2022)
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Children are prone to inflammation and infection of the intervertebral discs

-Mean age 3-5years at presentation.

 

Lumbar region frequently involved

 

Although disc biopsy is not necessary for diagnosis, as many as 60% of biopsied discs grow bacteria

-Usually Staphylococcus aureus.

 

Untreated - may spontaneously resolve or progress to vertebral osteomyelitis or abscess

 

Chief complaint: Back pain and irritability, often associated with a limp or refusal to crawl or walk.

Fever is absent or low grade. 

Physical examination findings are nonspecific and may include a tendency to lie still and percussion tenderness over the involved spine.

Blood culture is generally sterile,

WBC count can be normal early in the disease course

 

However, the ESR is elevated in >90% of patients.

 

Plain radiographs are normal at the start of the illness, and generally take 2-3 weeks to demonstrate narrowing of the intervertebral space.

 

Therefore imaging study of choice is MRI.

 

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Category: Orthopedics

Title: Acute transverse myelitis (ATM)

Keywords: Spine, Autonomic Dysfunction (PubMed Search)

Posted: 6/8/2019 by Brian Corwell, MD (Updated: 8/17/2022)
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Acute transverse myelitis (ATM) refers to inflammation of gray and white matter in one or more adjacent spinal cord segments leading to acute/subacute dysfunction of all cord functions (i.e., motor, sensory, and autonomic).

 

There is a bimodal peak between ages 10-19 years and ages 30-39 years.

Most cases are idiopathic

Some patients may have had a preceding viral infection or autoimmune disorder.

The thoracic cord is most commonly involved.

Onset is characterized by acute/subacute development of neurologic signs and symptoms consistent with motor weakness, sensory changes or autonomic dysfunction.

Pain in the head, neck, and/or back may occur.

Motor and sensory changes occur below the level of the lesion and are more likely to be bilateral.

Motor symptoms include a rapidly progressing paraparesis.

Autonomic dysfunction may include urinary urgency or difficulty voiding, bowel or bladder incontinence, tenesmus, constipation, and sexual dysfunction.

Despite its low incidence, consider in a patient presents with a classic constellation of symptoms,

Rapid identification, and early initiation of treatment predicts the best outcomes

Diagnosis: whole spine MRI with and without gadolinium

Management: goals include reducing cord inflammation (IV glucocorticoids), alleviating symptoms (pain management, bladder decompression), and treating underlying causes (e.g., infections, autoimmune) as appropriate.

 

 


Category: Orthopedics

Title: Bone tumors in children

Keywords: cancer, pediatrics (PubMed Search)

Posted: 5/25/2019 by Brian Corwell, MD (Updated: 8/17/2022)
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Bone tumors can present as MSK pain!

Pain may be activity related initially (can lead to misdiagnosis)

Over time will progress to rest pain and night pain

 

1) Primary osteosarcoma - most common primary malignant bone tumor

Adolescents, male > female

70% occur about the knee (also in hip/pelvis and upper arm)

pain, swelling, tenderness to palpation

Consider in the presentation of non traumatic knee pain!

 

2) Ewing's sarcoma

Peak incidence ages 10-20, male > female

pain, swelling, tendernes to palpation

Elevated temps and ESR

Consider in the differential of osteomyelitis!!

Variable location - lusually the extremities but also pelvis, scapula, ribs

 

 


Category: Orthopedics

Title: Treat hyperthermia with a TACO

Keywords: Hyperthermia, cold water immersion (PubMed Search)

Posted: 5/11/2019 by Brian Corwell, MD (Updated: 8/17/2022)
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The TACO method (tarp assisted cooling with oscillation)

Cold water immersion (CWI) remains the standard for cooling in exercise induced hyperthermia

A low cost alternative is modified cold water immersion.

Sometimes, monetary reasons and location venue prevent the feasibility of CWI

Benefits: fast, cheap, portable

Portable – Allows for on site location at area of collapse

Cheap: Equipment required – 3 providers, 1 tarp, 20 gallons of water and 10 gallons of ice

Fast: Average time to set up – 3.4 minutes

The TACO method – fast effective reduction in core temperatures

              May be up to 75% as effective as CWI

             

https://www.youtube.com/watch?v=RxjP0-_RIdc

 

 

 

 

 

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Category: Misc

Title: CT Radiation doses

Keywords: CT, head, radiation (PubMed Search)

Posted: 4/13/2019 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

 
  • A recent retrospective study examined CT radiation doses in different types of facilities

 

  • Mean patient age: 12 years
  • Authors reviewed radiation doses for nearly 240,000 CT scans in over 500 facilities
  •  
  • The facilities were categorized into 4 groups: 

 

  • 1) academic pediatric,
  • 2) non-academic pediatric,
  • 3) academic adult, 
  • 4) non-academic adult

 

Most (65%) scans were performed at nonacademic adult centers

 

  • Radiation doses were significantly higher at adult facilities vs. pediatric facilities
  • Also, radiation doses were higher at non-academic vs. academic facilities
  • For example, the largest children received twice the radiation dose for abdomen-pelvis CT scans performed at nonacademic adult facilities compared with academic pediatric facilities
    • 11.9 mGy vs. 5.8 mGy
  • Academic pediatric facilities use lower radiation doses than do nonacademic pediatric or adult facilities for all head CT examinations and for the majority of chest and abdomen-pelvis

 

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Laboratory testing for Spinal Epidural Abscess

CBC

The CBC is poorly sensitive/specific

The WBC count may be nml or elevated

Left shift and bandemia may or may not be present

ESR and CRP

Sensitive but not specific

Elevated in >80% with vertebral osteomyelitis.

  • Sensitive for spinal infection, but not extremely specific.

 

  • ESR
    • ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients
  • CRP
    • Less useful for acute diagnosis since CRP levels rise faster and return to baseline faster than ESR
      • Elevated CRP seen in 87% of patients with SEA as well as in 50% of patients with spine pain not due to a SEA
    • Better used as a marker of response to treatment.

 

 

 

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Category: Orthopedics

Title: Cauda Equina Syndrome (CES)

Keywords: back pain, back emergency (PubMed Search)

Posted: 3/9/2019 by Brian Corwell, MD (Updated: 8/17/2022)
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Cauda Equina Syndrome (CES)

 

A recent pearl discussed CES. This is a very challenging diagnosis to make, especially on initial presentation

The 5 “classic” characteristic features are

  •  Bilateral radiculopathy
  • Saddle anesthesia
  • Altered bladder function
  • Loss of anal tone
  • Sexual dysfunction

Not all symptoms will be present in a given patient and there is no sign/symptom combination that either reliably diagnoses or excludes CES.

To illustrate how difficult this diagnosis is to make, a study looked at the predictive abilities of Neurosurgical residents.

Positive MRI for CES was accurately predicted by senior neurosurgical residents in approximately 50% of patients suspected of CES based on history and physical findings. As clinical certainty only becomes apparent with the classic symptoms (which are generally late findings) waiting to initiate MRI will delay decompressive surgery and can lead to worsened functional outcomes. This leads to increased MRI demand with more negative MRIs. Not surprisingly, only ~20% of MRI scans for suspected CES are positive.

 

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Category: Orthopedics

Title: Muscle relaxants and back pain

Keywords: low back pain, analgesia (PubMed Search)

Posted: 2/23/2019 by Brian Corwell, MD (Updated: 8/17/2022)
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In patients with lower back pain, there is good evidence that muscle relaxants reduce pain as compared to placebo and that different types are equally effective. However, the high incidence of significant side effects such as dizziness and sedation limits their use. Muscle relaxants may be beneficial in an every bedtime capacity thereby limiting side effects.

If cyclobenzaprine is used during daytime hours, a lower dose schedule may work as well as a higher dose with somewhat less somnolence (5 mg three times a day vs 10 mg three times a day. In general, muscle relaxants should only be used when patients cannot tolerate NSAIDs but can tolerate the side effect profile.

We commonly add muscle relaxants to NSAIDs hoping for a larger analgesic effect. However, combination therapy does not appear to be better than monotherapy. 

Adding cyclobenzaprine to high-dose ibuprofen does not seem to provide additional pain relief in the first 48 hours in ED patients with acute myofascial strain. Among an ED population with acute non radicular low back pain, a randomized trial found that adding cyclobenzaprine/other muscle relaxants to Naproxen did not improve functional outcomes or pain at one week or 3 months compared to naproxen alone.

Take home: Consider the limited usefulness use of muscle relaxants in ED patients with back pain


 

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Spurling’s maneuver and modified Spurling’s maneuver aka neck compression test.

This maneuver is highly specific for the presence of cervical root compression

Can be used to reproduce radicular pain/symptoms.

Perform this maneuver with caution as it should not be performed in patients who have potential cervical spine instability.

Keeping the patient’s head in a neutral position pressing down on the top of the head. If this fails to reproduce the patient's pain, the test is repeated with the head extended, rotated and tilted to the affected side (the modified Spurling’s maneuver).

Reproduction of symptoms (limb pain or paresthesias) beyond the shoulder is considered positive. Neck pain alone is nonspecific and constitutes a negative test.

The test has a high specificity (0.89 to 1.00) but low sensitivity (0.38 to 0.97).

            Meaning a positive test is helpful but a negative test does not rule out radicular pain.

This test should be used in conjunction with a thorough history and physical examination (strength, sensation and reflex testing)

 

https://www.youtube.com/watch?v=17QWqbXjSpc

 

 

 

 

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Category: Airway Management

Title: Hook of hamate fracture

Keywords: had, wrist, carpal (PubMed Search)

Posted: 1/26/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Hook of hamate fracture

Often missed fracture despite classic history

A frequent athletic injury

Seen in stick sports (golf, baseball, hockey)

Typically caused by a direct blow (grounding a gold club)

https://upload.orthobullets.com/topic/6035/images/hamate_baseball.jpg

Patient presents with hypothenar pain and pain with tight gripping

https://upload.orthobullets.com/topic/6035/images/hamate_golf.jpg

Presentation may be subacute with longstanding wrist or palmer pain

Physical exam: Tender to palpation over hook of hamate

Specialized test: hook of hamate pull test

Supinated hand held in ulnar deviation. Ask patient to actively flex 4th and 5th digits against resistance at DIP.
 

https://www.youtube.com/watch?v=A-mjRnC1yWQ

 

Radiology: Consider adding carpal tunnel view to standard wrist series if diagnosis is suspected

CT sometimes needed to image the fracture

 

Tx: Immobilize in a short arm splint

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Category: Orthopedics

Title: Epidemiology of Alpine Skiing Injuries

Keywords: Skiing, gamekeeper (PubMed Search)

Posted: 1/12/2019 by Brian Corwell, MD (Updated: 8/17/2022)
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Epidemiology of Alpine Skiing Injuries

 

Mean age of injury 30.3 (range 24 to 35.4 years)

Populations at greatest risk are children and adolescents and possibly adults over 50 (increased risk of tibial plateau fractures)

Sex: Males> females

              Knee injuries, esp to ACL, are higher among females

              Fractures greater in males

Injury location greatest at lower extremity (primarily to knee)

              Primarily sprains to MCL and ACL (increasing incidence)

14% occur to upper extremity and primarily involve the thumb and shoulder

              Skiers thumb – FOOSH with thumb Abducted gripping pole

              Pole is implicated as this injury is rare among snowboarders

The pole acts as a lever to amplify the forced Abduction of the thumb as the outstretched hand hits the ground.

Let go before you hit the ground!!

13% occur to head and neck

The number of all type injuries has decreased over time with advances in equipment and helmet use

Proportion of skiers wearing a helmet exceeds 80%        

However, the number of traumatic fatalities has remained constant

              Accidents involving fatalities exceed the protective capacity of helmets

              Helmets likely decrease risk of mild and moderate head injury

 

 

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Category: Neurology

Title: Medication Overuse Headaches

Keywords: headache, post concussion syndrome (PubMed Search)

Posted: 12/16/2018 by Brian Corwell, MD (Emailed: 12/23/2018) (Updated: 12/23/2018)
Click here to contact Brian Corwell, MD


A previous pearl discussed medication-overuse headache (MOH).

MOH is also known as analgesic rebound headache, drug-induced headache or medication-misuse headache.

It is defined as headache… occurring on 15** or more days per month in a patient with a preexisting headache disorder who has been overusing one or more acute treatment drugs for headache with symptoms for three or more months.

The diagnosis is clinical, and requires a hx of chronic daily headache with analgesic use more than 2-3d per week.

The diagnosis of MOH is supported if headache frequency increases in response to increasing medication use, and/or improves when the overused medication is withdrawn.

The headache may improve transiently with analgesics and returns as the medication wears off. The clinical improvement after wash out is not rapid however, patients may undergo a period where their headaches will get worse. This period could last in the order of a few months in some cases.

The meds can be dc’d cold turkey or tapered depending on clinical scenario.

Greatest in middle aged persons. The prevalence rages from 1% to 2% with a 3:1 female to male ratio.

Migraine is the most common associated primary headache disorder.

** Each medication class has a specific threshold.

Triptans, ergot alkaloids, combination analgesics, or opioids on ten or more days per month constitute medication overuse.

Use of simple analgesics, including aspirin, acetaminophen and NSAIDS on 15 or more days per month constitutes medication overuse. 

Caffeine intake of more than 200mg per day increases the risk of MOH.

 

Consider MOH in patients in the appropriate clinical scenario as sometimes doing less is more!

 

 


Category: Orthopedics

Title: Concussion headaches

Keywords: head injury, medication (PubMed Search)

Posted: 12/8/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Retrospective chart review at a headache clinic seeing adolescent concussion patients

70.1% met criteria for probable medication-overuse headache

Once culprit over the counter medications (NSAIDs, acetaminophen) were discontinued,

68.5% of patients reported return to their preinjury headache status

 

Take home:  Excessive use of OTC analgesics post concussion may contribute to chronic post-traumatic headaches

If you suspect medication overuse, consider analgesic detoxification

 

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Category: Orthopedics

Title: Pediatric Concussion 2

Keywords: head injury, sports medicine (PubMed Search)

Posted: 11/10/2018 by Brian Corwell, MD (Updated: 8/17/2022)
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In which age groups should children with Sport Related Concussion be managed differently from adults?

  • Not adequately addressed in literature.
  • Consider 5-12 years old vs 13 and over for child vs. adult testing

 

Are there targeted subgroups who would benefit from closer outpatient and specialty follow-up?

 

Predictors of Prolonged Recovery in Children
 

  • Female sex
  • physician diagnosis of migraine
  • Prior concussion with symptoms lasting longer than 1 weeks
  • Multiple concussions
  • ADHD/LD/Mood disorders
  • Acute headache
  • Age 13 or older
    • Teenage and high school years represents the greatest age period for prolonged recovery
  • Prior
  • Dizziness
  • Sensitivity to noise
  • Fatigue
  • Answering questions slowly
  • 4 or more errors on BESS testing

 

 

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Category: Orthopedics

Title: Pediatric Concussion

Keywords: head injury (PubMed Search)

Posted: 10/27/2018 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Concussion Management in Children

What are the predictors of prolonged recovery of concussion in children?

Female sex, age greater than 13, prior physician diagnosis of migraine, prior concussion with symptoms lasting longer than 1 week, history of multiple concussions, headache, sensitivity to noise, dizziness, fatigue, answering questions slowly and four or more errors on tandem stance testing.

Age:  As compared to younger children, adolescents have a greater number of and more severe postconcussive symptoms. They take longer to recover and return to school and sport.

Subjects: Math tends to pose greater problems followed by reading/language, arts, sciences and social studies.

Computer testing:  The widespread use of computer neuropsychological testing is not recommended in children and adolescents. This is due to issues with reliability over time and insufficient evidence of both diagnostic and prognostic value. When used, reference to normative data should be done with caution. Testing should also NOT be used in isolation in concussion diagnosis and management.

 

 

 

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