Category: Orthopedics
Keywords: X-ray, radiographs (PubMed Search)
Posted: 5/4/2016 by Brian Corwell, MD
(Updated: 5/28/2016)
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Radiographs of the sacrum and coccyx in the emergency department (ED) have no quantifiable clinical impact, according to a study published in the American Journal of Roentgenology.
Researchers from Emory University Midtown Hospital and Morehouse School of Medicine in Atlanta, GA, sought to determine the yield and clinical impact of sacrum and coccyx radiographs performed in the ED.
Sacrum and coccyx X-rays performed on 687 consecutive patients over a six-year period in level-1 and level-2 trauma centers (4 total hospitals). The patients’ mean age was 48.1, 61.6% were women. The images were categorized as positive for acute fracture or dislocation, negative, or other.
The researchers then analyzed:
• Follow-up advanced imaging in the same ED visit
• Follow-up advanced imaging within 30 days
• New analgesic prescriptions
• Clinic follow-up
• Surgical intervention within 60 days
The researchers found positive results in 58 of the 687 patients, a positivity rate of 8.4%.
None of the 58 positive cases had surgical intervention.
There was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical follow-up among the patients evaluated at the level-1 trauma centers.
However at the level-2 trauma centers, 34 (97.1%) of 35 patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals. Negative cases were at 82.9%.
Of all cases, 39 patients (5.7%) underwent advanced imaging in the same ED visit and 29 patients (4.3%) underwent imaging within 30 days.
“Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit,” the authors wrote. “There was no significant difference in 30-day advanced imaging at the level-1 trauma centers, but there was at the level-2 trauma centers.”
The researchers concluded that routine sacrum and coccyx radiography should not be part of ED practice and that patients should be treated conservatively based on clinical parameters.
Sacrum and Coccyx Radiographs Have Limited Clinical Impact in the Emergency Department.
Hanna et al. American Journal of Roentgenology Volume 206, Issue 4
Category: Orthopedics
Keywords: MI, Sport (PubMed Search)
Posted: 5/14/2016 by Brian Corwell, MD
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https://www.youtube.com/watch?v=sCFOObsx_W4
What is their risk of MI???
Anger outbursts are bad for your heart. Out of 300 patients with an acute MI, just over 2% reported losing their temper within 2 hours of the event. A review of nine studies of rage and cardiovascular events all found an increase in cardiovascular events in the 2 hours preceding an anger outburst. Examples included arguments at home, at work or by road rage. Compared with their usual anger levels, the relative risk of heart attack from a fit of rage was 8.5.
What about those of us who are just fanatics, I mean fans....A recent study of World Cup soccer found that the intense strain and excitement of viewing a dramatic soccer match more than doubles the risk of acute heart attack, particularly in men with known coronary heart disease. This was regardless of the outcome of the match!
Eichner, E. Randy. Current Sports Medicine Reports: March/April 2016
Category: Orthopedics
Keywords: Sudden cardiac death, physical activity (PubMed Search)
Posted: 4/23/2016 by Brian Corwell, MD
(Updated: 12/12/2024)
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Exercise and the heart
Exercise increases the risk of sudden cardiac death (SCD) acutely.
Exercise decreases the risk of SCD in the long term.
Regular physical activity (even as little as 15 mins/day) reduces the risk of cardiovascular disease (CVD).
Up to 15% of MIs occur during or soon after vigorous physical exercise. This is typically in sedentary men with coronary risk factors.
In a 1993 study, in the first hour after heavy exertion, risk of heart attack rose more than 100-fold from baseline for habitually inactive persons. However, for frequent exercisers, this risk rose less than three-fold. Think of snow shoveling after a winter storm.
Both the Physicians’ Health Study and the Nurses’ Health Study show that the risk of SCD during exertion is reduced by habitual exercise.
If you are physically active, stay active. If you are not active, you should be because exercise has innumerable personal benefits. However, it is important to start gradually Some individuals at higher risk need to start under the guidance of a physician.
Category: Orthopedics
Posted: 4/10/2016 by Brian Corwell, MD
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Orthopedic documentation
1) Document location with specificity and laterality.
2) Document the location with as much specificity as possible
-Name of specific bone and specific site on bone (Shaft, head, neck, distal, proximal, styloid)
3) Document fractures as open/closed, displaced vs. non-displaced, routine or delayed healing,
-Orientation of fractures, such as transverse, oblique, spiral
- Document intra-articular or extra-articular involvement
4) For a particular injury, a complete note will include mention of the following
The joint above (e.g. for shoulder injuries this would be the neck, for hip injuries - the back)
The joint below
Motor (e.g. for arm injuries document the distal median, radial and ulnar motor innervation)
Sensory
Vascular
Skin (for all fractures document intact overlying skin esp. when covering with a splint)
Compartments (a simple mention of compartments are grossly soft/not tense will suffice)
*Especially relevant for forearm and tib/fib injuries
Category: Orthopedics
Keywords: Metacarpal Fractures (PubMed Search)
Posted: 3/26/2016 by Brian Corwell, MD
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Metacarpal Fractures
* Localize fracture to head, neck or shaft (neck most common)
5th metacarpal most commonly fractured
* Note amount of angulation, shortening and the presence of malrotation
*Treatment is based on which metacarpal is fractured and the location of the fracture
*The amount of acceptable angulation varies by the digit involved
For example for index and long finger - acceptable angulation of the shaft is 10-20 degrees and neck is 10 to 15 degrees
Whereas for the 5th digit - acceptable angulation for the shaft is 40 degrees and neck is 50 degrees
Pearls
No degree of malrotation is acceptable (document the absence of this!)
Strongly suspect fight bite injury with abrasions/lacerations overlying metacarpal heads
Highly prone to infection given the proximity to the joint capsule
Consider lacerations over metacarpal fractures as open fractures (do not close/discuss management with hand surgery re timing of washout. Many prefer delayed fixation for suspected infections )
Document integrity of the extensor tendon (can be lacerated and retracted)
Category: Orthopedics
Keywords: osteoarthritis, nsaids (PubMed Search)
Posted: 3/20/2016 by Michael Bond, MD
(Updated: 12/12/2024)
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A meta-analysis of 74 randomized trials with a total of 58,556 patients was recently published in the Lancet that looked at the effectiveness of NSAIDs in the treatment of osteoarthritis (OA) pain.
Briefly, their conclusion was that:
You can find the article here http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2930002-2/abstract
Category: Orthopedics
Keywords: X-ray, Hip pain (PubMed Search)
Posted: 3/12/2016 by Brian Corwell, MD
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Femoral neck fracture
We typically think of the presentation of the displaced fracture severe pain, writhing in the bed, unable to ambulate, limited ROM
* However, patients with nondisplaced fractures (15 20%) may walk with a limp
* Occurs primarily in the elderly & osteoporotic population after a fall directly onto the hip
* Look for a cortical step-off in the femoral neck (w/ foreshortening)
* A patient with a minimally displaced fracture may only complain of hip, knee, or groin pain and may be able to walk (albeit with a limp)
* Almost 9% of hip fractures are radiographically normal (Nondisplaced or impacted fractures)
* Fractures which were initially nondisplaced, may become displaced upon re-presentation
* Remember the limitations of plain x-ray in the evaluation of femoral neck fractures!
* Because of the significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip
Category: Orthopedics
Keywords: Achilles tendon rupture (PubMed Search)
Posted: 2/27/2016 by Brian Corwell, MD
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Achilles tendon rupture
More common in
men, ages 30 - 40yo, s/p steroid injections, fluoroquinolone use, and episodic athletes "weekend warriors
Mechanism: usually during an athletic endeavor, sudden forced planar flexion or violent dorsiflexion of a plantar flexed foot
Location: Usually occurs 4 to 6 cm ABOVE the Achilles calcaneal insertion (hypovascular region)
Patient will report a sudden pop, gunshot like sound
History: Will report heel and calf pain and weakness/inability to walk
Physical examination: Palpable gap, weakness with plantar flexion, + Thompsons test
https://www.netterimages.com/images/vpv/000/000/007/7714-0550x0475.jpg
Consult orthopedics and splint in resting equinus
http://img.medscape.com/fullsize/migrated/408/535/mos0216.01.fig5b.jpg
Category: Orthopedics
Keywords: back pain, sports injury (PubMed Search)
Posted: 2/14/2016 by Brian Corwell, MD
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Spondylolysis
Prevalence 3-6% in the general population (Higher in athletes)
Location: L4 (5-15% of cases) & L5 (85-95% of cases)
Population: More likely in the skeletally immature athlete due to the vulnerability of the immature pars interarticularis to repeated stress
Symptoms: Lumbar pain worse with extension
Higher risk sports: Gymnastics, diving, weightlifting, wrestling
Treatment: Bracing and activity modification, physical therapy
- Good results in 80% with conservative management allowing return to play.
- Those who fail benefit from iliac crest bone grafting and posterolateral fusion.
-Return to play is controversial in this group
Please review th images below for anaomy and imaging appearence
http://orthoinfo.aaos.org/figures/A00053F01.jpg
http://www.sonsa.org/images/spondylolysis.jpg
http://www.physio-pedia.com/images/2/22/Spondylolysis_x_ray_.docx.jpg
Huang P.et al.Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries: A Comprehensive Review. Sports Health2016 Jan;8(1):19-25.
Category: Orthopedics
Keywords: fracture care (PubMed Search)
Posted: 1/24/2016 by Brian Corwell, MD
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Recommended follow-up for common orthopedic injuries
Category: Orthopedics
Keywords: Salter Harris, pediatric, fracture (PubMed Search)
Posted: 1/16/2016 by Michael Bond, MD
(Updated: 1/19/2016)
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The Salter Harris Classification System is used in pediatric epiphyseal fractures. The higher the type of fracture the greater the risk of complications and growth disturbance.
Some common exam facts about Salter Harris Fractures are:
The Classification system as listed by Type:
For Maite, a helpful mnemonic is SALTR , Slipped (Type I), Above (Type II), Lower (Type III), Through (Type IV), and Ruined or Rammed (Type V)
A image of the fractures can be found on FP Notebook at http://www.fpnotebook.com/ortho/fracture/ephyslfrctr.htm
Category: Orthopedics
Keywords: Heel pain (PubMed Search)
Posted: 1/9/2016 by Brian Corwell, MD
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Sever's disease also known as calcaneal apophysitis, is the most common cause of heel pain in the young adolescent (ages 8 to 12).
It can be thought of as the Achilles tendon equivalent of Osgood-Schlatter's disease (patellar tendon insertion pain).
It is a non inflammatory chronic repetitive injury.
Commonly seen bilaterally in up to two -thirds of cases.
Patients will complain of activity related pain to the heel.
There may be tenderness and local swelling at the Achilles tendon insertion.
Radiographs are not necessary for acute cases.
Treat with activity modification, heel raise, physical therapy.
Category: Orthopedics
Keywords: Adolescent, head injury (PubMed Search)
Posted: 12/26/2015 by Brian Corwell, MD
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Protracted Recovery from Concussion
Age and sex may influence concussion recovery time frame
Methods: 266 adolescent athletes presenting to a sports medicine concussion clinic
Female athletes had a longer recovery course (P=0.002) and required more treatment interventions (p<0.001).
Female athletes were more likely to require academic accommodations (p<0.001), vestibular therapy (P<0.001) and medications (P<0.001).
Be aware that not all concussion patient subgroups with concussions recover in the same manner. Further study is needed to support whether female adolescent athletes require unique management and treatment guidelines.
Category: Orthopedics
Posted: 12/19/2015 by Michael Bond, MD
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Quick pearl for those that are trying to complete their holiday shopping.
Mulder's sign is not a sign that there is an extra-terrestial in your ED, But rather a sign that your patient is suffering from a Morton's Neuroma (see pearl from 2012)
Patients will often complain of pain in 3rd and 4th intermetatarsal space and if you can reproduce the pain by compressing the metatarsal heads together then you have a Positive Mulder's sign. Check out the original pearl at https://umem.org/educational_pearls/1684/
Category: Orthopedics
Keywords: Concussion, knowledge, education (PubMed Search)
Posted: 12/12/2015 by Brian Corwell, MD
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Parental Knowledge of pediatric concussion
Sample: Parents of children brought to pediatric hospital or outpatient clinics for evaluation of orthopedic injuries.
Participants scored an average of 18.4 (0-25) on knowledge and 63.1 (15-75) on Attitudes toward concussions.
Safest attitudes were seen in white females. Knowledge increased with income and education levels.
Parents from low income or education levels may benefit from additional education in the ED prior to discharge in addition to providing paper information which may not be read or understood.
Assessment of Parental Knowledge and Attitudes toward Pediatric Sports Related Concussions.
Lin, Salzman et al., 2015. Sports Health Journal
Category: Orthopedics
Keywords: Elbow, ligament, throwing athlete (PubMed Search)
Posted: 11/28/2015 by Brian Corwell, MD
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Medial elbow pain is common among baseball pitchers and is also seen in other sports including football, javelin and gymnasts.
More than 97% of elbow pain in pitchers is located medially.
The ulnar collateral ligament of the elbow is an important structure in these patients.
http://www.aafp.org/afp/2014/0415/afp20140415p649-f3.jpg
While initially primarily seen in professional throwers, these injuries are now being seen in younger athletes.
Initially, patients may only note changes in stamina or strength of throws.
Later, they will note pain during the acceleration and follow through-phase of throwing
http://stlhealthandwellness.com/wp-content/uploads/2013/02/elbow03.jpg
The Valgus stress test for UCL deficiency is similar to the valgus test for the knee
https://www.youtube.com/watch?v=f6YvPSVk6G8
Treatment: splinting, ice, NSAIDs
Surgical indications: Failure of non-operative treatment with desire to return to same or higher level competition.
Category: Orthopedics
Keywords: Hand injury (PubMed Search)
Posted: 11/15/2015 by Brian Corwell, MD
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Hook of Hamate Fracture
Rare (2% of all carpal fractures)
Mechanism usually direct blow from a stick sport (golf, hockey, baseball)
Presents with hypothenar pain and pain with gripping activities
Physical examination - local swelling and tenderness to palpation over hook of hamate
Diagnostic test - Hook of hamate pull test
https://www.youtube.com/watch?v=A-mjRnC1yWQ
XR - standard wrist series but add carpal tunnel view
http://openi.nlm.nih.gov/imgs/512/60/2904904/2904904_256_2009_842_Fig1_HTML.png
http://www.cmcedmasters.com/uploads/1/0/1/6/10162094/7851913.png?359
Category: Orthopedics
Posted: 10/31/2015 by Michael Bond, MD
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Happy Halloween!!
I hope you have had a safe and fun Halloween. Thank you to all the people that are staffing the EDs on a Saturday Night Halloween.
Prostate-Selective Alpha Antagonists have been tied to Falls and increased risk of fractues in elderly men. These medications can lead to syncope and hypotension putting patients at increased risk of falls. A recent canadian study showed that at 90 days of use; individuals on alpha antagonists were at increased risk of hospital visits for falls (1.45% vs. 1.28%) or fractures (0.48% vs. 0.41%). There was also an increased risk of head trauma.
Please warn patients that are on these medications of the risks, so that injuries can be minimized. They should take specific care when changing postural positions, and report episodes of lightheadedness to their PCPs.
The article can be found at http://www.bmj.com/content/351/bmj.h5398
Category: Orthopedics
Keywords: back pain, analgesia (PubMed Search)
Posted: 10/24/2015 by Brian Corwell, MD
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A traditional ED practice has been to combine promethazine as an anxiolytic adjunct to morphine for patients with musculoskeletal pain (eg back pain).
However, when compared to morphine alone, this combination does not lead to greater analgesia or decrease anxiety. It does however prolong ED length of stay.
This use of this "pain cocktail" is not recommended
Behrbalk E, Halpern P, Boszczyk BM, et al. Anxiolytic medication as an adjunct to morphine analgesia for acute low back pain management in the emergency department: A prospective randomized trial. Spine (Phila Pa 1976). 2014;39(1):17-22.
Category: Orthopedics
Keywords: Popliteal cyst, knee swelling (PubMed Search)
Posted: 9/26/2015 by Brian Corwell, MD
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Most common mass in popliteal fossa
Incidence 10 to 58%
Intra-articular pathology results in flow of synovial fluid from the joint into the bursa, forming a cyst
Association with concomitant intra-articular disorders 94%
Possible pathology - Meniscus, ligamentous, arthritis, other osteochondral defects
In children this is not a pathologic finding
Symptoms - Posterior knee bulging, posterior tightness/stiffness esp. with knee flexion
Ultrasound - 100% sensitive/specific
DDx: DVT
Tx: Refer for ultrasound guided aspiration, fenestration and steroid injection
http://www.caringmedical.com/wp-content/uploads/2013/11/Bakers-Cyst-treatment.jpg
Smith, Lesniak et al. 2015 Treatment of popliteal cysts with ultrasound-guided aspiration, fenestration and injection: long term follw-up