UMEM Educational Pearls - Orthopedics

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

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Category: Orthopedics

Title: Baker Cyst

Keywords: Popliteal cyst, knee swelling (PubMed Search)

Posted: 9/26/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

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

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Shoulder Dislocation Reduction

Do you have a chronic dislocated that frequents your ED? Are you interested in teaching them a way to relocate their shoulder without looking like Mel Gibson from Lethal Weapon, https://youtu.be/Igrdi_lhhW4, then the newly described GONAIS method might be what you are looking for.

This technique has the patient grab the top of a chair with the hand on the affected side, and then slowly equating, effectively bringing the hand and arm above their head. Once in the full squat position the patient can step backwards which should reduce the shoulder. If not they can use the opposite hand to apply pressure to push the humerus backward and reduce the location.

The full article can be found at http://bit.ly/1iZ8a9z

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Category: Orthopedics

Title: Policeman's Heel

Keywords: policeman, heel, contusion (PubMed Search)

Posted: 8/29/2015 by Michael Bond, MD (Updated: 3/5/2024)
Click here to contact Michael Bond, MD

Policeman's Heel:

When patient's present complaining of heel pain we often think immediately of plantar fascititis,and heel spurs. If they jumped and landed on the heel with are concerned for calcaneal fracture.  However, a policeman's heel can occur from repetitive bounding of the heel or from landing on it as in a fall or jump.

Policeman's heel has been descirbed as a plantar calcaneal bursitis, inflammation of the sack of fluid (bursa) under the heel bone, or a contusion of the heel bone due to flattening and displacement of the heel fat pad, which leaves a thinner protective layer allowing the bone to get bruised.

Regardless of cause this responds well to NSAIDs, limiting weight bearing, or taping the foot. If the repetitive activity is not reduced this can easily become a chronic cause of heel pain.  A short video showing how to tape the foot can be found at https://youtu.be/nQtkwfJrhXo



Category: Orthopedics

Title: Exercise Associated hyponatremia

Keywords: Sodium Supplementation, Exercise-Associated Hyponatremia, Prolonged Exercise (PubMed Search)

Posted: 8/22/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Sodium Supplementation and Exercise-Associated Hyponatremia (EAH) during Prolonged Exercise (ultramarathon running)

Weight loss of around 4% body weight (relative to pre race weight) can be anticipated to maintain euhydration in such a prolonged event

Those who become symptomatic with EAH have either gained weight or lost less that 3-4% body weight

Overhydration rather than inadequate supplemental sodium intake is a greater contributor to the development of EAH

There is a suggested link between EAH and rhabdomyolysis. The mechanism remains unknown and it is unclear which condition may augment the other. Further research is needed.

Take home: Avoid overhydration during prolonged exercise to prevent EAH.

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Handcuff Neuropathy

Compression of the superficial radial nerve against the radius.

Tends to occur with prisoners (too tight cuffs or person struggling)

Usually purely sensory lesion

Nerve regeneration can take 8 weeks (about an inch a month)

Document sensory exam to sharps or 2 point sensation.

DDx: De Quervain's, Carpal tunnel, Gamekeeper's thumb,

No need to splint



Category: Orthopedics

Title: Triquetral fractures

Keywords: x-ray, fracture, wrist (PubMed Search)

Posted: 7/26/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Triquetral fractures are the 2nd most common carpal fractures (scaphoid).

Dorsal surface most commonly.

Usually occur from impingement from the ulnar styloid, shear injury or from ligamentous avulsion.

XR: best seen on the lateral projection

http://images.radiopaedia.org/images/902179/42b3487baf4fb66183c51cd982477d_big_gallery.jpg

Remember this injury/radiographic appearance the next time you see an avulsion fracture dorsal to the proximal row of carpal bones on the lateral film but are unsure of the donor site.



Category: Orthopedics

Title: Compartment Syndrome - Making the diagnosis

Keywords: compartment syndrome, diagnosis (PubMed Search)

Posted: 7/18/2015 by Michael Bond, MD
Click here to contact Michael Bond, MD

Compartment Syndrome

Compartment syndrome is a diagnosis that needs to be made quickly in order to prevent long term muscle, nerve, and vascular compromise.

Two pieces of information are needed to determine if the patient has compartment syndrome.

  1. The patient's diastolic blood pressure (DBP) value
  2. The pressure value obtained from the compartment of concern (Compartment pressure)

Diastolic Pressure - Compartment pressure < 30 makes the diagnosis of compartment syndrome

So if a diastolic blood pressure is 80 and the compartment pressure is 40 the difference is 40 mmHg and the patient likely does not need a fasciotomy.  The diagnosis can only be 100% onfirmed by a trip to the OR so these values should still be discussed with your local orthopaedist.  When calling them just make sure you know both the DBP and the compartment pressure so that it can be interpreted correctly.



Category: Orthopedics

Title: Sports hernia

Keywords: Hernia, abdominal pain (PubMed Search)

Posted: 7/11/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

A sports hernia is a painful musculotendinous injury to the medial inguinal floor.

It is the result of repetitive eccentric overload to the abdominal wall stabilizers of the pelvis.

It is common in sports that require sudden changes of direction or intense twisting movements.

Despite the term "hernia" in the title, it is not a true hernia as there is no "herniation" of abdominal contents

http://www.ssorkc.com/wp-content/uploads/2014/09/publagia.gif

Figure description: The upward and oblique pull of the abdominal muscles on the pubis fights against the downward and lateral pull of the adductors on the inferior pubis. This imbalance of forces can lead to injury.

PE: Evaluation of other GU/GYN/other intra-abdominal pathology comes first.

Clinician may note tenderness of the pubic ramus and medial inguinal floor.

Pain is more severe with resisted hip adduction and with resisted sit-up.

Combining these maneuvers (resisted situp while adducting hips) recreates the pathophysiology described above and is a good exam maneuver.

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Category: Orthopedics

Title: Fractures of the distal radius

Keywords: wrist injury, FOOSH, Distal radius fracture (PubMed Search)

Posted: 6/27/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Colles fracture

Almost 90% of distal radius fractures

Mechanism: Fall on the outstretched, hyperextended, radially deviated wrist with the forearm in pronation

Often seen in older patients and in those with osteoporosis

Distal radius fracture with dorsal angulation/displacement and/or radial shortening. "Dinner fork deformity"

https://en.wikipedia.org/wiki/Colles'_fracture#/media/File:Colles_fracture.JPG

Smith fracture (aka reverse Colles fracture)

Mechanism: Fall on the outstretched, flexed, radially deviated wrist with the forearm in pronation

Usually younger patients with high energy mechanism

Distal radius fracture with volar angulation or volar displacement. "Garden spade" deformity

Often unstable requiring ORIF

http://www.radiologyassistant.nl/data/bin/w440/a50979780ec887_Smith'-tek.jpg

Radial styloid fracture aka Chauffeur fracture

Fall causing compression of scaphoid against the styloid with wrist in dorsiflexion and ulnar deviation

Often associated with intercarpal ligamentous injuries (i.e., scapholunate dissociation, perilunate dislocation)

Often requires ORIF

http://images.radiopaedia.org/images/611818/cc52cce7bcfd8c905bcc7b5d2b6a65.jpg



Category: Orthopedics

Title: Steroids and Sciatica

Keywords: Steroids, Sciatica (PubMed Search)

Posted: 6/20/2015 by Michael Bond, MD
Click here to contact Michael Bond, MD

Steroid Use in the treatment of Acute Sciatica

Have you used oral steroids in the treatment of your patient with acute sciatica thought to be secondary to a herniated disk.

Well a recent randomizaed, double-blind, placebo-controlled trial from 2008 to 2013 in a large integrated health care system in Northern California enrolled 269 patients to look at whether steroids improved pain or function. The intervention arm (twice as large as placebo arm) received a tapering 15-day course of oral prednisone (5 days each of 60 mg, 40 mg, and 20 mg; total cumulative dose = 600 mg; n = 181).

In the end there were no differences in surgery rates at 52-week follow-up, and the steroid arm had a modest improvement in function but no improvement in pain. There were also more adverse events at 3-week follow-up in the prednisone group than in the placebo group.

Conclusion: Giving steroids for acute sciatica does not appear to improve the patients pain, only has a modest improvement in function, and was associated with more adverse events. Put another way there was minimal benefit and more harm.

You can check out the full article at http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.4468

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Category: Orthopedics

Title: Posterolateral Corner Injury

Keywords: Posterolateral Corner Injury, PCL, ACL, knee (PubMed Search)

Posted: 6/13/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Posterolateral Corner Injury

Hx: hyperextension injury (contact and non contact), varus directed blow to flexed knee, direct blow to anteriomedial knee. Report instability symptoms when knee is in full extension.

PE: Varus stress testing

Varus laxity at 0 indicate LCL and cruciate ligament (ACL/PCL) injury

Varus laxity at 30 indicates LCL injury

Dial test - inspects the external rotation at the knee joint/performed in both 30 and 90 knee flexion. The dial test inspects the external rotation at the knee joint

https://www.youtube.com/watch?v=pW4yv0zg4RY

Positive at 30 = > 10 external rotation asymmetry = isolated PCL injury

Positive at 30 & 90 = Posterior lateral corner injury and PCL injury



Category: Orthopedics

Title: Subacromial impingement

Keywords: shoulder pain, bursitis (PubMed Search)

Posted: 5/23/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Sx: pain to lateral arm, worse with overhead activity and sleeping/lying on arm

Anatomy: Pain generating structures include the rotator cuff, subacromial bursa, labrum and biceps tendon.

http://www.ortho-md.com/images/proceduresImg/SHOULDER2.jpg

Testing: Neer and Hawking tests

https://www.youtube.com/watch?v=U8-yLHQ_JaM

https://www.youtube.com/watch?v=OYK5qL2om-c

Done indepedently, Hawkings is more sensitive, however best to combine both tests.

Imaging: not indicated

Tx: rest, ice, physical therapy (modalities), subacromial steroid injection



Tensor Fascia Latae (Iliotibial Band) Pain Syndrome:

Some patients will complain of hip and back pain and can have multiple visits before somebody considers Tensor Fascia Latae Pain Syndrome AKA Iliotibial Band Syndrome.

The tensor fascia latae helps with thigh flexion at the hip, abduction, and medial rotation; and stabilizes the knee laterally

When this muscle/fascia gets tight and overcontracted it will lead to dysfunction of the gluteus and rectus femoralis muscles leading to increased hip pain due to abnormal movement of the joint.

Patients often complain of increased pain with running, especially downhill and exam is notable for local tenderness (approx. 2cm above lateral joint line) & occasional swelling over the distal lateral thigh.

Most patients respond to conservative treatment involving NSAIDs, stretching of the iliotibial band, physical therapy, strengthening of the gluteus medius, and altering their running regimens.




Category: Orthopedics

Title: Posterior Shoulder Dislocations

Keywords: Radiology, orthopedics, shoulder (PubMed Search)

Posted: 5/9/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Posterior Shoulder Dislocations are uncommon (strong supporting structures vs. anterior)

But commonly missed by physicians

Mechanism: Direct blow anterior shoulder/FOOSH with shoulder internally rotated and ADDucted)

May also see with seizure/electric shock (tetanic contraction)

Clinical findings subtle

Shoulder held in ADDuction and internal rotation. Patient unable to externally rotate arm from this position. If habitus allows, anterior shoulder depression/posterior fullness.

Radiology: Decreased overlap between humeral head and glenoid fossa. Proximal humerus fixed in internal rotation looks like a light bulb on a stick.

Y view will show subtle posterior displacement of humeral head (not as dramatic as is in anterior dislocations!)

http://cdn.lifeinthefastlane.com/wp-content/uploads/2009/06/posterior_shoulder_dislocation_005.jpg

http://eorif.com/Shoulderarm/Images/Shoulder-dislocationP1.jpg



Category: Orthopedics

Title: Laboratory testing in patients with back pain

Keywords: back pain, ESR, CRP, malignancy (PubMed Search)

Posted: 4/25/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

In cases of suspected spinal infection, the sensitivity of an elevated WBC count (35-61%), ESR (76-95%) and CRP (82-98%) may help guide further evaluation or consideration of other entities.

Incorporation of ESR/CRP into an ED decision guideline may help differentiate those patients in whom MRI may be performed on a nonemergent basis.

An elevated ESR (>20 mm/hour) also has a role in the diagnostic evaluation of occult malignancy (sensitivity 78%, specificity 67%).

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Category: Orthopedics

Title: Should Acetaminophen be first line therapy in patients with Hip, Knee or Back Pain

Keywords: knee, hip, back, pain, acetaminophen (PubMed Search)

Posted: 4/18/2015 by Michael Bond, MD (Updated: 3/5/2024)
Click here to contact Michael Bond, MD

Is acetaminophen good for pain control in patients with Osteoarthritic of the Knee or Hip or Low Back Pain?  Most of my patients request narcotics, but conventional teaching is that we should try to start with Acetaminophen or NSAIDs.

This recent study, http://www.bmj.com/content/350/bmj.h1225, published in the BMJ analyzed 13 studies looking at over 5400 patients.  In the end, they found that acetaminophen did not appear to improve pain, disability or the patient’s quality of life in patients with back pain. Also, there was a small improvement in pain and disability in those with hip and knee pain, but it was not deemed clinically significant.

Even worse, patients taking acetaminophen had a 4x greater chance of having abnormal liver function tests.

This meta-analysis really questions whether Acetaminophen should be first line therapy in patients with osteoarthritis of the knees or hips, or in those with low back pain.  For now I will stick with a course of a NSAID.  Especially with the risk of unintentional overdose if they are taking other over the counter medicaitons that might also contain acetaminophen.

 

 

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Category: Orthopedics

Title: Waddell's signs

Keywords: back pain, medication seeking (PubMed Search)

Posted: 3/28/2015 by Brian Corwell, MD (Updated: 3/5/2024)
Click here to contact Brian Corwell, MD

The ED clinician must  be able to distinguish between true pathologic back pain and nonorganic back pain.

Waddell’s signs are physical exam findings that can aid in making this important distinction and can be remembered by the acronym “DORST” (Distraction, Over-reaction, Regional disturbances, Simulation tests and Tenderness).

Superficial, non-anatomic, or variable tenderness during the physical exam suggests a non-organic cause.

The clinician may also simulate back pain through provocative maneuvers such as axial loading of the head or passive rotation of the shoulders and pelvis in the same plane. Neither maneuver should elicit low back pain.

There may be a discrepancy between the symptoms reported during the supine and sitting straight leg raise (SLR). The seated version of the test, sometimes termed the distracted SLR, can be performed while distracting the patient or appearing to focus on the knee. Further, radicular pain elicited at a leg elevation of less than 30° degrees is suspicious because the nerve root and surrounding dura do not move in the neural foramen until an elevation of more than 30° degrees is reached.

Sensory and motor findings suggestive of a nonorganic cause include stocking, glove or non-dermatomal sensory loss or weakness that can be characterized as “give-way,” jerky or cogwheel.

Finally, gross overreaction is suggested by the exaggerated, inconsistent painful responses to a stimulus.  

Waddell’s signs, especially if three or more are present, correlate with malingering and functional complaints (physical findings without anatomic cause). When combined with shoulder motion and neck motion producing lower back pain, Waddell’s signs predict a decreased probability of the individual returning to work.

That said, Waddell’s signs should never be used independently because they lack the sensitivity and specificity to rule out true organic pathology. Further, our focus should be on evaluating for medical emergencies. Malingering and psychosocial causes of pain are diagnosis of exclusion. 



Category: Orthopedics

Title: Back Pain in the Elderly

Keywords: Back Pain, Elderly (PubMed Search)

Posted: 3/21/2015 by Michael Bond, MD
Click here to contact Michael Bond, MD

It is commonly taught that radiographs are not needed in non-traumatic back pain unless the patient is <18 or > 65 years old.  Several studies have started to disprove this in the pediatric population, and a recent study in JAMA is giving some weight to not having to do this in the eldery.

The JAMA study was a prospective cohort of 5239 patients over age 65 who presented to a PCP or urgent care center in three different health systems from 2011-2013 with a complaint of back pain without radiculopathy.  Patients were determined to have early imaging if they had a plain films, CT, or MRI done within 6 weeks of their initial visit for back pain.  The primary outcome measure was back or leg-pain related disability at 12 months when comparing those that had early imaging versus late (> 6 weeks).  They excluded patients with prior surgery, prior back pain, or if they had a cancer visit in the prior year.

At one year they found that there was no statistical difference in the primary outcome of back or leg-pain related disability at one year.  The early imaging did pick up more fractures of the spine, but again no change in long term outcomes.  The serious diagnoses were summarized in this graph.

This study was not done in the Emergency Medicine setting, and our patients may not be equivilant, but it suggests that we do NOT have to get radiographs on all patients over 65 years old with non-traumatic back pain without radiculopathy.  If you are not going to get radiographs make sure your patient has clear discharge instructions on what to return for and that they should follow up with their primary care provider within a week.

 

A link to the full article is here http://jama.jamanetwork.com/article.aspx?articleid=2203801

 

 

 

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Category: Orthopedics

Title: Radiology of child abuse

Keywords: x-ray, child abuse, fracture dating (PubMed Search)

Posted: 3/14/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Imaging plays an important role in the evaluation of child abuse.

It aids in the identification, evaluation and in treatment.

Additionally, it is often the only objective evidence of abuse available to the courts.

It is often discovered through two means.

1) Injuries/fractures that are inconsistent with the alleged mechanism of injury.

2) Pathognomonic fracture patterns are found on routine radiographs

The ED physician should not attempt to precisely "date" the injury.

That said, soft tissue swelling resolves in 2-5 days. The periosteum becomes radiodense in 7 to 10 days. In subtle fractures this may be the only radiographic finding. If there is no evidence of bone healing (periosteal reaction), the fracture is less than 2 weeks old. Callus formation and resorption of the bone along the fracture line begins at 10 to 14 days. The callus is visible for up to 3 months. Bone remodeling continues for up to one year.

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