UMEM Educational Pearls - By Michael Bond

Placing a foley catheter in a patient with BPH or acute urinary retention can be very difficult at times.  Here are some tips to increase your chance of a successful placement.

1. Use a Uroject lidocaine gel syringe to help anesthesize the urethra and lubricate the tract.  The lidocaine gel should be slowly expressed (injected) into the urethral meatus.  This helps to provide lubrication further down the urethra, as opposed to just wiping the catheter tip in the lubricant.
2. When using a Coude catheter, ensure that the curved tip points upward.
3. Apply gentle continuous pressure to help open the prostrate spincter.  This will be more successful than trying to ram it through which can increase spincter contracture.
4. Do not inflate the balloon until you have confirmed placement with urine return.
5. Don't forget the ultrasound.  You can calculate urinary volume (post void residual) prior to catheter placement and confirm placement with ultrasound.

If all else fails, a suprapubic catheter may need to be placed.  For a great review on evaluation and treatment please see Drs. Vilke, Ufberg, Harrigan, and Chan's article in the August edition of Journal of Emergnecy Medicine entitled Evaluation and treatment of acute urinary retention.

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When examining a knee for a meniscal injury the commonly described tests are the McMurray Test and Apley Test.  However, these tests have sensitivities of 48-68% and 41% respectfully, and specificities of 86-94% and 86-93% respectfully.  Depending on whether you are looking at the medical or lateral meniscus.

The Tessaly Test that was first described in 2005 can be performed with knee in either 5 or 20 degrees of flexion and has a senstivity of 89-92% and specificity of 96-97% when performed in 20 degrees flexion.  The test also tends to be easier to perform.

To perform the test:

1. Stand on affected leg only with the other leg held up in the air.  The examiner holds hands for balance.
2. Flex knee to be test to 20 degrees, while the other leg is held in the air
3. Internally and Externally Rotate Knee
4. Positive test is pain at medial or lateral joint line with possible locking/catching sensation

Essentially you and your patient will look like you are doing the twist as they rotate their knee with you holding their hands.

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Most people are now using Ultrasound to aid in cannulation of the femoral and internal jugular veins, but if you find yourself without the ultrasound machine you can increase your chance of successful cannulation of the femoral vein by positioning the leg properly.

Werner et al looked at the common femoral veins of 25 healthy volunteers and noted that the femoral vein was accessable more often when the hip was abducted and external rotated.  This simple position change increased the mean diameter of the vein, and prevented the vein from being directly posterior to the artery.

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Fracture Management:

In order to maximize billing when caring for patients with fractures two things should be done:

1. The physician does not need to place the splint, but the physican must document that they checked the splint for proper placement and alignment for it to be billed appropriately..
2. Emergency physicians also provide a lot of "definitive" care for fractures.  (i.e.: we provide the same care that the treating specialist would provide) and can bill for a higher level if this is documented properly. 
   1. For instance, if you are treating a impacted, stable distal radius fracture with a splint and pain medication this is the same definitive care the orthopedist would do as they are only going to exchange your splint for  a cast. 
   2. Another example is the treatment of rib fractures which may consist only of pain control, incentive spirometry and instructions to prevent pneumonia.
   3. In these patients, have the patients follow up more than 48 hours later.  If you document that the patient will followup in less than 48 hours, most auditors and billing companies will assume you are not providing definitive care and will not code for the higher earning RVU.

Finally,  you should obtain post-reduction x-rays on any fracture that you manipulate and document that the patient is neurovascularly intact prior to discharge.

SCAPHOID FRACTURE:

• One of the most frequently missed fractures in the ED
• Most common carpal fracture.
• 10-20% fractures are “occult”
• Significant long-term complications:
  
  • Non-union
  • Avascular necrosis
• Complications more common due to the fact the blood supply comes form from the distal end of the bone.
• The more distal the fracture, the greater risk of complications
• MR remains the best test for occult fx.

Joint Fluid Analysis:

This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain.  For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.

 To view a gout crystal click this link.

To view a pseudogout crystal. Click this link

Pearls: 

• A WBC Count >50,000 is septic arthritis until cultures are negative. 
• Due to the wide range of WBC for septic arthritis have a high index of suspicion and do not discount the diagnosis because the WBC count is only 10,000.

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Calcaneus Fractures

Normally occur due to axial loading mechanism such as:

•     Fall from height
•     Motor Vehicle collisions
•     Repetitive impacts on a hard surface such as seen with running or jumping.

Miscellanous Facts:

1. 70% of calcaneal fractures are intra-articular
2. 10-15% are associated with spinal compression fractures
3. Estimated that 7-10% will have a fracture of the contralateral foot
4. Monitor for compartment syndrome of the foot.  Deep central compartment is most commonly affected with calcaneus fractures

Pearls:

1. Strongly consider getting Lumbar Spine Films and x-rays of the opposite foot in anybody that has a calcaneus fracture.
2. Perform frequent reassessments, and do not hesitate to check compartment pressures if you suspect they might be elevated.

Hip Fractures:

Typically divided into four types:

1. Intracapsular,
   1. femoral head and neck fractures
2. Extracapsular
   1.  trochanteric,
   2. Intertrochanteric
   3. subtrochanteric fractures. 

• Non-displaced fractures, especially in osteoporotic elderly patients, may be missed on plain films. This is estimated to occur in 2-9% of cases. 
• It can take up to 72 hours for a fracture to be seen on bone scan. And it is estimated that only 80% of fractures will be seen at 24 hours.
• MRI is now the preferred imaging modality (100% sensitivity and specificity) to confirm a hip fracture when plain films are negative and equivocal. A MRI will have positive findings in as little as 4 hours after a fracture.
• Consider CT scan of the hip if MRI is not available at your center.

Here is a link to a picture with a good representation of the different types of fractures.

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Now that we have entered the session of cookouts, picnics, and family get togethers I thought I would review some of the more common causes of food poisoning and the typical foods that they are found in.

Treatment of Wernicke's Encephalopathy

Traditionally the treatment dose of thiamine in those that we suspect to have Wernicke's Encephalopathy is 100mg per day.  The problem is that this does was arbiarily picked by two physicians, Victor and Adams, in the 1950's.  They thought that 100mg a day would be a large dose. They also made their recommendation without fully understanding the pharmacokinetics of thiamine which has a half life of 96 minutes or less.  Compound this with case reports of individuals dying of Wernike's Encephalopathy despite being given 100mg of Thiamine daily.

Several authors are now advocating that patients with Wernicke's Encephalopathy be treated with 500mg of IV thiamine daily, but with the short half life some are advocating that the thiamine be given 2 to 3 times a day.  There are no good studies to refute or support the claims that higher doses are needed, but there are well documented cases of treatment failures at the lower dose.

PEARLs: 

• Consider high dose thiamine 500mg IV in patients that you are treating with Wernike's encephalopathy. 
• The 100mg dose is still appropriate for those that are just being suppliemented and in who Wernicke's encephalopathy is a consideation but not high up on the differential.

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  Lisfranc Fracture:

Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid.  Common current  mechanism is when a person steps into a hole and twists the foot.Originally described when a horseman would fall of their horse with their foot still trapped in a stirrup.

Diagnosis should be considered if patient has difficult weight bearing with pain on palpation over the 2^nd and 3^rd metacarpal head with an appropriate mechanism.

Pearls:

• Fracture findings on plain films may be subtle.
• Can obtain weight bearing AP views of the foot to demonstrate dislocation/fracture.
• If still suspicious consider a CT scan of the foot.

I remember being taught as a medical student that clavicle fractures could be treated conservatively.  A direct quote was "if both ends of the clavicle are in the same room it will heal".

Though conservative treatment with a sling for 6 weeks with early pendulum ROM exercises for the shoulder is appropriate for the vast majority of clavicle fractures surgery should be considered for those that have:

1. An open fracture
2. Significant angulation with tenting of the skin
3. Midshaft fractures that have overlap or displacement greater than 1 cm.
4. Displaced fractures of the distal clavicle [high rate of non-union]
5. Surgery can also be beneficial to those that do a lot of lifting or want to return to work as quick as possible.

Extensor Tendon Injuries [Mallet Finger]

• Due to jamming the finger or to use a Pittsburgh term "stoving it".
• Can result in a swan neck deformity or permanent flexion of the DIP joint.
• Due to stretching of the extensor tendon,or avulsion of the extensor tendon off the distal phalanx.
• Approximately 50% will develop a complication.
• Conservative treatment is splinting the DIP joint in full extension for 5-6 weeks. 
  • The DIP joint must not be flexed for the full treatment period.
  • If the patient does flex their DIP, the 5-6 week time frame needs to completely restart.
• Due to the high complication rate all of these patients should be referred to a hand specialist early.

Posterior Interosseous Nerve Compression Syndrome

As eluded to last week Posterior Interosseous Nerve (PIN) Compression Syndrome, a deep branch of the radial nerve, is felt to be radial tunnel syndrome with paralysis.

• Symptoms depend on whether the PIN is compressed before or after it divides into medial and lateral branches.
  • Before: Results in complete paralysis of the digital extensors, and extensor Capri ulnaris. Wrist will become dorsoradial deviated.
  • After-Medial Branch: Paralysis of extensor carpi ulnaris, extensor digiti quinti, and extensor digitorum communis
  • After-Lateral Branch: Paralysis of abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis proprius
• Common causes:
  • Synovitis and Joint Ganglions
  • Nerve compression following fracture repair
  • Idiopathic Compression can occur at these sites
    • Fibrous bands anterior to the radial head
    • Tendinous origin of Extensor Carpri Radialis Brevis
    • Arcade of Froshe –Most common, it is the tendinous proximal border of supinator
    • Distal Edge of Supinator –Least Common
• Exam:
  • Increased pain with resisted supination of the forearm
  • Supination with Wrist Flexion symptoms will likely be reproduced.
  • Pain with resisted extension of the middle finger
  • Unable to extend thumbs or fingers at MCP joints, but can extend at PIP and DIP joints

For those at the University of Maryland that got the chance to hear my lecture this week, you learned about Cubital tunnel syndrome [ulnar neuropathy], the second most common compressive neuropathy.  Carpal Tunnel syndrome remains the number one compressive neuropathy, and this pearl, for the sake of completeness, will address Radial tunnel syndrome.

Radial Tunnel Syndrome

• Believed to be due to overuse, frequently due to excessive elbow extension or forearm rotation.
• May actually just be an early stage of posterior interosseous nerve syndrome.
• Due to compression of the radial nerve as it passes a fibrous band that is attached to the radiocapitellar joint, and the tendinous origins of two muscles, extersor carpi radialis brevis and the supinator.
• Patients typically have l pain along the anteriolateral forearm.
• Pain is increased by extending the elbow and pronating the forearm.
• This syndrome is associated mostly with pain
• Weakness and numbness are not often seen.

Stay tuned for next week for Posterior Interosseous Nerve syndrome.

Turf Toe:

Most commonly seen in atheletes who compete on artificial turf.  Presents as pain over the 1st Metatarsalphalangeal  (MTP) joint. 

• Due to a tear of the Metatarsal phalangeal Joint Capsule
• Results in subluxation or dislocation of the MTP joint
• Occurs due to:
  • Hyperextension (most common)
  • Hyperflexion
  • Valgus stress
• Treatment:
  • NSAIDS
  • Rest
  • Orthosis -- Prevents dorsiflexion during athletic activities

Achilles Tendon Rupture

• Most commonly occurs in males age 30-50 years that participate in occasional high intensity sports that are associated with jumping or quick starts.  [i.e.: Basketball, racquetball, tennis, squash, etc].
  • Exact mechanism is a sudden eccentric force that is applied to a dorsiflexed foot.
• Rupture is also associated with fluoroquinolone and glucocorticoid use.
• Patient will often hear or feel a sudden snap in the back of the ankle or calf.
• Typically ruptures 2-6cm proximal to its insertion on to the calcaneous where its blood supply is the least.
• On physical exam:
  • the patient is unable to plantar flex the foot, raise up on toes, and may have calf swelling. 
  • You may be able to palpate a gap in the achilles tendon.
  • Two specific tests for achilles tendon rupture.
    • Thompson test:  with the leg extended and the foot in neutral position, squeeze the calf muscles.  A positive test is when the foot does not plantar flex when the muscles are squeezed.
    • O’Brien needle test:  Insert a small gauge needle perpendicular to the skin into the proximal (about 10 cm from the calcaneous) achilles tendon. Passively dorsiflex and plantar flex the ankle and foot. If the needle moves in the opposite direction of the movement then the achilles tendon is intact.
• Treatment
  • Refer to orthopedics
  •  Place the patient in a posterior splint with the foot and ankle in slight plantar flexion. 
    • Ideally this will bring the two tendon ends together and speed healing.

This addition was sent in my Dr. Andrew Milstein:

Thanks for the Orthopedics update.  A few pearls for Achilles Tendon Rupture --> often these patients may present like a typical ankle sprain patient and are placed in a hallway chair.  You can't do an adequate Thompson Test while someone is sitting in a chair.  If you're concerned, lay them down on a stretcher to do the test.

Some simple facts about Pancreatitis:

1. Causes (First two are the most common in the United States)
   1. Gallstones
   2. Alcohol
   3. Hyperlipidemia
   4. Medications [azathioprine, corticosteroids, sulfonamides, thiazides, furosemides, NSAIDs, mercaptopurine, methyldopa, and tetracyclines]
   5. Peptic Ulcer Disease
   6. Scorpion and Snake Bites
   7. Trauma
   8. Infections [ ascaris, mumps, coxsackie virus, cytomegalovirus, Epstein Barr Virus, mycoplasma]
2. Chronic Pancreatitis may not be associated with an elevation of lipase or amylase.
3. Lipase is more specific for pancreatitis
4. Amylase can be elevated in:
   1. pancreatitits
   2. salivary gland injury/disease
   3. ruptured ectopic pregnancy
   4. ovarian cysts
   5. salpingitis
   6. inflammation of the bowel [appendicitis, obstruction]
   7. end stage renal and liver disease [due to decreased clearance]
5. Treatment:  mild cases can be discharged home with clear liquid diet and pain medications, more severe cases needed to be admitted for IV fluids and pain control.  Maintain NPO status.
6. Complications:
   1. Pseudocyst
   2. Phlegmon
   3. Necrosis of the pancreas
   4. Hemorrhage
   5. Intestional obstruction
   6. fistula formation.

Bacterial Vaginosis

1. The most common vaginal infection in childbearing women. 
2. Associated with burning, itching, and malodorous discharge.
3. Cause is not fully understood but associated with
   
   1. douching
   2. multiple sexual partners.
4. Complications caused by BV
   
   1. Increased susceptibility to HIV, HSV, chlamydia and gonnorrhea
   2. Increased risk for preterm labor.
   3. Increases the chance of an HIV woman passing HIV to her sex partner.
5. Woman at high risk for preterm delivery should be tested for and treated for BV, however, the US Preventive Services Task Force just released a statement discouraging testing in woman at low risk for preterm delivery. 
6. Treatment options include metronidazole and clindamycin.

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DeQuervain and Intersection Syndromes:
 

• DeQuervain's Syndrome (Tenosynovitis of the Abductor Pollicus Longus and Extensor Pollicus Brevis tendons) is a common disorder that has received a lot of press lately as BlackBerry Thumb or Gamer's Thumb.
  • This condition can be diagnosised by the Finklestein test [Have the patient bend their thumb into the palm of their hand, and then make a fist.  They should then ulnar deviate their wrist.  Pain along the tendons secures the diagnosis.]
  • The pain of DeQuervain's syndrome is typically along the distal end of the radius at the base of the thumb.
• Intersection syndrome is a less common disorder though closely related to DeQuervain's Syndrome
  • The pain is usually felt on the top of the forearm about three inches proximal to the wrist. 
  • The pain from this condition is due to tenosynovitis of the Extensor carpi radialis longus and Extensor Carpi radialis brevis muscles/tendons caused by the intersection of them with the Extensor pollicus brevis and Abductor pollicus longus tendons.
  • Occurs due to excessive wrist movements.
  • Intersection syndrome can be seen in weight lifters, skiers, and can be seen in homeowners in the fall and winter when they rake a lot of leaves or shovel snow.
• Treatment is the similar for both conditions and consists of:
  • NSAIDS
  • Cortisone injections can be effective
  • Thumb and wrist immobilization with a Thumb Spica Splint or Cock Up Wrist Splint