Distal Radius Fractures

High energy mechanism in younger patients

Falls more common in older patients

Higher incidence in older women due to osteoporosis

     May indicate overall poor bone health

  Avoid splinting in positions of flexion (palmer) and ulnar deviation

    Palmer flexed positions may have a higher rate of displacement

Non operative treatment

Extra-articular fx, less than 5mm shortening of radius, Less than 5 degrees of dorsal angulation.

     Consider fractures than are only stable in extreme positions to be unstable

If fx involves the ulnar styloid or DRUG (distal radial ulnar joint) place in long area posterior splint with arm in mid supination (anatomic position of forearm)

Iliotibial band tendonitis

IT band is the continuation of the tensor fascia lata and inserts on the tibia at Gerdy's tubercle

Common cause of lateral knee pain seen in Primary care/Sports med clinics

Mechanism: May be due to excessive friction between the IT band and the lateral femoral condyle

Second most common overuse injury of the knee (PF syndrome). Not an acute event.

Affects up to15% of active individuals

Impingement zone is at 30 degrees of knee flexion

Most common in runners and cyclists

Pain localized over the lateral femoral condyle. Better w/ rest. Often occurs at a predictable distance into the run and not at onset.

Exacerbated with changes to mileage or running terrain.

Additional risks include poor shoes (best to change every 300 to 500 miles), excessive foot pronation (pes planus), quad versus hamstring strength asymmetry, weak hip ABductors, leg length discrepancy, tight IT band.

Septic Arthritis in Children

Classic presentation: Pain, fever (may not always be present)

Limited range of motion of joint or refusal to bear weight,

 Joint swelling (difficult to visualize in hip or shoulder),

Limb held in position that allows greatest capsular volume (elbow held in 30° flexion for example)

Diagnostic testing may include diagnostic markers (ESR, CRP) or imaging (US/MRI)

Most common organisms: Staph and Strep, Neisseria (adolescents), HACEK organisms, consider gram negatives in immunocompromised children

DDX: Transient synovitis, osteonercrosis or osteomyelitis, Psoas abscess, acute leukemia, Lyme disease

A common ED presentation is the child with the painful limp

               35% of all cases of septic arthritis

>50% of cases occur in children younger than 2yo

Hip held in flexion, Abduction, external rotation

Fever and inflammatory markers are more sensitive than WBC count and refusal to bear weight

Kocher criteria:

1)     Refusal to weight bear on affected side

2)     Sed rate greater than 40mm/hr

3)     Fever (>38.5°C

4)     WBC count of >12,000 mm3

IF
                 - 4/4 criteria are met, there is a 99.6% chance of septic arthritis; 
                 - when 3/4 criteria are met, there is a 93% chance of septic arthritis; 
                 - when 2/4 criteria are met, there is a 40% chance of septic arthritis; 
                 - when 1/4 criteria are met, there is a 3% chance of septic arthritis; 

CRP can also be incorporated into a diagnostic algorithm

CRP>2.0 (mg/dl) in a child who refuses to bear weight yields a 74% probability of septic arthritis

Show References

Most of our knowledge of the athlete’s EKG is based on white athletes.

African/Afro-Caribbean athletes are more likely to have an abnormal EKG than white athletes in multiple studies.

Different selective criteria have been developed to minimize classification of benign normal patterns as abnormal.

The 2010 ESC criteria classified 40.4% of black athletes as abnormal versus the Refined criteria which resulted in 11.5% of EKGs classified as abnormal.

This reduction was aided by the recognition that isolated anterior TWI in asymptomatic black athletes is considered a benign finding.

               Note this does NOT apply if the TWI extend to the lateral leads

For example, T-wave inversion (TWI) was present in 23% of African/Afro-Caribbean athletes vs. 3.7% of white athletes (usually in contiguous anterior leads).

Other changes included a higher prevalence of early repolarization, RV hypertrophy, and LA/RA enlargement.

Show References

Question

Physicians are often called upon to serve as a team physician for a local high school in an official or unofficial capacity.

To aid in preparedness for sport-related emergencies, multiple national organizations have defined institutional best practices.

Knowledge of the following 3 best practice recommendations is important before taking on the role of “Doc covering the game”

     1)The written Emergency Action Plan (EAP) – details the standard of emergency care at the particular venue.

     2)The availability of life saving equipment: AED – where is it, charged and working?

     3)Are the coaches trained in use of the AED and CPR. You can’t be everywhere and often multiple sporting events occur on campus simultaneously. It’s imperative that your first responder (coach or athletic trainer) can perform these tasks until you are able to respond

Please investigate these best practice recommendations before agreeing to serve as the physician for the local high school.

Show Answer

22yo college track athlete presents with 3 weeks of gradual onset groin and thigh pain, worse with running, better with rest.

Stress fractures are a common cause of groin pain in athletes, particularly in long distance runners

Fractures occur in the pubic rami and femoral neck 

Ask about a sudden change in training regimens

PE: check for tenderness to deep palpation over the pubic ramus. Ask athlete to stand and support full weight on affected leg or perform one legged hop on affected side. Pain out of proportion to physical examination findings. 

Imaging: XR usually negative. Bone scans can be positive as early as 4 to 8 days after symptom onset. MRI used to diagnose and rule out other causes of groin pain.

Treatment: Rest for 4 to 6 weeks. Consider making patient non weight bearing if walking causes pain especially with femoral neck fractures on the superior side. Inferior side neck fractures may benefit from prophylactic fixation.

Show References

The Essex-Lopresti injury pattern is the lesser known of the triad of forearm injuries (Monteggia & Galeazzi).

It follows the “rule of the ring” aka the life saver candy rule: You can’t break a life saver in just one place.

These injury patterns are frequently missed because our eyes are drawn to the fracture and miss the associated dislocation.

The Essex-Lopresti fracture pattern involves a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint (DRUG)

               -With associated interosseous membrane disruption

Think of it as the Maisonneuve fracture of the forearm.

Mechanism: fall from height/high energy forearm trauma.

PE: Suspect if patient has significant tenderness at the DRUG with a radial head fx.

Patients have worse outcomes if injury is missed on initial presentation due to radial migration and instability.

Take home point: Remember the rule of the ring. Remember to exam the elbow with wrist injuries and the wrist with all elbow injuries

https://image.slidesharecdn.com/tgc9gbsusz6yf9gnomzq-signature-b704f322087ef3e158e7aa08078573cfc5a04ec6f8a3a982d1fcb26597be3f6d-poli-150513093239-lva1-app6891/95/elbow-injury-13-638.jpg?cb=1431509645

Is that a fracture or a growth plate?

Pediatric elbow x-rays are complicated to interpret due to the large number of ossification centers.

Elbow trauma is common in pediatrics.

Ossification centers of the elbow appear in a reliable chronologic pattern which aids in distinguising fractures from growth plates.

Note the age ranges are an estimate with great variability. For example, girls can develop these up to 2 years earlier than boys.

The numbers 1/3/5/7/9/11 correspond to the average age of development of each ossification center

Years of fusion shown below in ()

Capitellum (12-14yo)

Radial head (14-16yo)

Medial epicondyle (16-18yo)

Trochlea (12-14yo)

Olecranon (15-17yo)

Lateral epicondyle (12-14yo)

Pneumonic: "Can't Resist My Team Of Lawyers"

Consider ordering films of both elbows to compare if in doubt.

How is this useful? If the trochlear center is present, but there is no medial epicondyle then you are most likely looking at a fx where the ossification center has been avulsed and displaced. 

During a busy ED shift, your 40yo charge nurse asked you to look at his hand. He is known avid mountain biker. He has pain in his right 4^th and 5^th digits. . He feels a lack of coordination and a feeling of “clumsiness” of the hand. Where is his possible nerve compression and what do you expect to find on exam?

Ulnar nerve entrapment is sometimes called “handlebar palsy.” 

Compression location is Guyon’s canal.

The ulnar nerve supplies the intrinsic muscles of the hand AND the extrinsic muscles for flexion of the 4^th and 5^th digits. This is what aids in a “power grip” and why he may have diminished grip strength on exam.

               Also innervates the ADDuctor pollicis and 1^st dorsal interosseous muscles (pinch)

Note the ulnar nerve also passes through the radial tunnel at the elbow. Entrapment here is called Radial tunnel syndrome or Cubital tunnel syndrome and causes forearm pain and paresthesias in the 4^th and 5^th digits with grossly normal motor and sensory function.

You are covering a sporting event or working an ED shift when a young adolescent athlete without significant PMH presents with SOB and wheezing associated with exercise.

You immediately think exercise-induced asthma, prescribe a short-acting bronchodilator and pat yourself on the back.

While you may be right, there is increasing recognition of an alternative diagnosis

Exercise-induced laryngeal obstruction (EILO)

During high intensity exercise, the larynx can partially close, thereby causing a reduction in normal airflow. This results in the reported symptoms of SOB and wheezing.

This diagnosis has previously been called exercise induced vocal cord dysfunction. As the narrowing most frequently occurs ABOVE the level of the vocal cord, EILO is a more correct term.

While exercise induced bronchoconstriction has a prevalence of 5-20%, EILO is less common with a prevalence of 5-6%.

Patients are typically adolescents, with exercise associated wheezing and SOB, frequently during competitive or very strenuous events. Wheezing is inspiratory and high-pitched. Symptoms are unlikely to be present at time of medical contact unless you are at the event as resolution occurs within 5 minutes though associated cough or throat discomfort can persist after exercise cessation. EIB symptoms typically last up to 30 minutes following exercise.

Inhaler therapy is unlikely to help though some athletes report subjective partial relief. This may be explained as approximately 10% of individuals have both EIB and EILO.

In athletes with respiratory symptoms referred to asthma clinic, EILO was found in 35%.

Consider EILO in athletes with unexplained respiratory symptoms especially in those with ongoing symptoms despite appropriate therapy for EIB.

Show References

Concussions are associated with an elevated risk of musculoskeletal injury

Significant associations were found between concussion and

Lateral ankle sprain (P = 0.012)

Knee injury (P = 0.002)

Lower extremity muscle injury (P = 0.031)

Keep in mind that 50 – 80% of concussions may go undiagnosed or unreported.

A discussion about risks of early return after concussion should include mention of risks beyond repeat head injury/2nd impact syndrome

Study limits: Retrospective design limits ability to establish causation/reporting bias

Show References

Incidence and Cost of Ankle Sprains US Emergency Departments

In a sample of 225,114 ED patients with ankle sprains:

Lateral ankle sprains represent the vast majority of all ankle sprains (91%).

Lateral ankle sprains incur greater ED charges than medial sprains ($1008 vs. $914).

Lateral ankle sprains were more likely to have associated pain in the limb, sprain of the foot and abrasions of the hip/leg than medial sprains.

Medial sprains were more likely to include imaging.

Hospitalizations were more likely with high ankle sprains than lateral sprains.

There is a higher incidence of ankle sprains in younger patients (≤25 years) and in female patients (57%).

Show References

Question

https://images.radiopaedia.org/images/3173801/1ee24da1a6fe907a27d2bf20481174.jpg

Young toddler presents with left lower leg pain. What is the diagnosis??

Show Answer

Many of us use exercise as a coping strategy when emotionally stressed or to blow off steam when angry. This may place your heart at risk.

A recent observational study in Circulation surveyed 12,000 first MI patients about potential triggers. The associations didn't depend on age, smoking status, hypertension, or baseline physical activity.

Anger or emotional upset in the hour before onset elevated odds of MI 2.44 fold

A similar 2.31 fold elevation was observed form heavy exertion

However, the combination of the two raised the odds to 3.05 fold (P<0.001 for interaction)

Show References

Recurrence depends on age and activity level

27% if >30yo and 72% if <23yo

Surgical Recommendations:

Large bony Bankart lesion, glenoid or humeral head defect >25%, recurrent instability, event near the end of season

Non surgical return to play:

If event occurs at beginning/early in season

Rehabilitation for 2 to 3 weeks (most return to play in this time frame)

Immobilization for 3 to 7 days in simple sling, gentle range of motion, cryotherapy

Physical therapy to strengthen dynamic stabilizers

Shoulder stabilization brace for non overhead throwing and contact sports

Show References

Retroperitoneal hemorrhage

The pathophysiology is unknown. Some hypothesize that occult vasculopathy and arteriosclerosis of the small vessels in the retroperitoneum may render them friable and therefore prone to rupture. This can be seen in minor trauma in sports and forceful vomiting or coughing. Spontaneous bleeding starts at the microvascular level, and large vessels become disrupted or stretched as the hematoma enlarges.

Retroperitoneal hemorrhage occurs in a variety of clinical circumstances, including spontaneous hemorrhage into a pre-existing benign adrenal cyst or bleeding from a left inferior phrenic artery, tumors of the adrenal gland and kidney, rupture of any blood vessel (most commonly infrarenal aorta); percutaneous interventions (such as cardiac catheterization), trauma, and polycythemia vera,

It is most commonly seen in association with patients with bleeding abnormalities, in HD patients and with anticoagulation therapy,. Risk is much greater with unfractionated heparin therapy than with warfarin. In most of the heparin patients studied, their coagulation parameters were in the therapeutic range.

Patients may present to the non acute area of the ED with back, lower abdominal or groin discomfort, Over time, this may progress to hemodynamic instability, and a fall in hemoglobin, Early identification is crucial to improving patient morbidity and mortality. Early symptoms depend on the location of the bleeding.

Hematoma near or within the iliopsoas muscle usually presents as femoral neuropathy (groin pain or leg weakness).

Femoral neuropathy caused by retroperitoneal hematoma can present with sudden onset severe pain in the affected groin and hip, with radiation to the anterior thigh and the lumbar region. This can easily be missed as the presentation is similar to a pulled msucle or strained hip/back. Iliopsoas muscle spasm often results in the characteristic flexion and external rotation of the hip, and any attempt to extend the hip will result in severe pain. Over time, pain and parasthesia in the antero-medial thigh and leg is seen.

Show References

Young athletes, especially around the age of puberty, are at higher risk for pelvic avulsion fractures

Often seen in sports that require sprinting, rapid changes in movement or jumping

Caused by sudden, forceful contraction of the muscles of the abdominal, the hip and thigh or the hamstring

Avulsion fractures can occur at many areas of the pelvis.

A mnemonic is: Alabama’s stoned rappers got ill hunting armadillos

·  Iliac crest: Abdominal muscles

·  Anterior superior iliac crest: Sartorius

·  Anterior inferior iliac crest: Rectus femoris

·  Greater trochanter: Gluteal muscles

·  Lesser trochanter: Iliopsoas **(rare in adults)

·  Ischial tuberosity: Hamstrings

·  Pubic symphysis: Adductor group

http://roentgenrayreader.blogspot.com/2010/07/pelvic-avulsion-fractures.html

** Isolated nontraumatic avulsion fractures of the lesser trochanter in adults is a pathognomonic sign of metastatic disease

This site has some good images of common injury patterns

http://radiopaedia.org/articles/apophyseal-avulsion-fractures-of-the-pelvis-and-hip

Show References

47yo M chef presents to your ED with 2 days of worsening left hand pain after sustaining a puncture wound to hand at work. The hand is red and swollen and he complains of pain. Interestingly, his index and middle digits are in an ABducted position at rest.

Collar Button Abscess

Web space infection of the palmer AND dorsal hand

The Palmer aponeurosis prevents volar extension (but promotes dorsal encroachment)

The pus spreads between the MC bones and erupts dorsally....creating a DORSAL abscess.

Loss of palmer concavity is seen.

ABduction of the adjacent digits, resulting in a "V" configuration with the apex pointing to the site of infection. This would not happen from simple pus in the dorsal space!

Can be missed if only focused on the dorsal hand. The palm will show the original injury (splinter, cut, foreign body)

Treatment is urgent surgical drainage.

http://www.eplasty.com/article_images/eplasty16ic06_fig1.gif

Show References

30yo male weight lifter who 10 days ago had a painful left shoulder injury after bench press. The next morning his left anterior chest wall and left upper arm were bruised and swollen. He went to see his PCP who diagnosed him with a muscle strain. 8 days later the bruising and swelling have resolved but he still cant move his shoulder and comes to the ED.

http://321gomd.com/wp-content/uploads/2015/01/pec-major-tears.jpg

The pec major attaches to the humerus and originates from the sternum and clavicle

Injury is usually due to tendon rupture off the humerus but can also occur at the muscle tendon junction or within the muscle belly itself.

Injury is becoming increasingly common due to the popularity in power lifting sports.

Mechanism: excessive tension on a maximally eccentrically contracted muscle.

Patients will complain of pain and weakness of the shoulder.

PE: Swelling and bruising to anterior medial arm. Palpable defect and deformity or anterior axially fold (may be hidden by swelling).

Weakness and pain with adduction and internal rotation and forward flexion

Chronic presentations can be challenging to diagnose. Consider ultrasound

Non operative treatment may be indicated for partial tears (sling, ice, NSAIDs)

Operative repair of tendon avulsions is very successful. Patients age, occupation/activity level and location of injury and condition of tear are considered.

Sesamoid Injuries

Unlike other bones in the human body that are connected to each other at joints, sesamoid bones are only connected via tendons (or are imbedded in muscle).

The largest sesamoid bone is the patella.

2 small sesamoid bones lie on the plantar foot near the great toe

Sesamoid bones can fracture and the surrounding tendons can become inflamed (sesamoiditis)

Traumatic injury is usually due to hyperextension and axial loading

Sx: Pain located under the great toe on the ball of the foot (Gradual with sesamoiditis and acutely with a fracture).

There may be associated swelling and bruising. Pain with palpation, flexion and extension.

The medial/tibial sesamoid is larger, has great weight bearing status and is more commonly injured that its lateral counterpart.

In many people (10 - 25%) the medial sesamoid of the foot has two parts (bipartite). This finding is bilateral in 25% of people.

This may confuse some providers as it may appear to be a fracture

Look for a smooth contour to the bones and clinically correlate (bruising, soft tissue swelling, etc.) if it is an incidental finding.

Other radiographic clues include

1) The fractured sesamoid is usually slightly larger than the lateral sesamoid while the bipartite sesamoid has a much larger medial sesamoid than lateral sesamoid

2) The fractured sesamoid shows a sharp, radiolucent, uncorticated line between the two fragments while the bipartite sesamoid has two corticated components

3) The fractured sesamoid fragments often fit together like pieces of a puzzle while the bipartite sesamoid has two components that do not fit together snugly

4) Other means to differentiate the two involve MRI and bone scanning

Treatment involves a stiff-soled shoe or applying a cushioning pad or J-shaped pad around the area to relieve pressure.

It may take months for the pain to subside.

http://www.apfmj-archive.com/afm5_3/afm50.htm#F1

Show References