UMEM Educational Pearls - Orthopedics

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
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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: 6/15/2024)
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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: 6/15/2024)
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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
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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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Category: Orthopedics

Title: Sesamoid Injuries

Keywords: Foot pain, stress fractures (PubMed Search)

Posted: 2/28/2015 by Brian Corwell, MD
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Sesamoid Injuries

The first MTP joint contains the 2 sesamoid bones. They play a significant part in the proper functioning of the great toe. 30% of individuals have a bipartite medial or lateral sesamoid.

http://www.coreconcepts.com.sg/mcr/wp-content/uploads/2008/05/sesamoid_foot.jpg

Injury can occur from trauma, stress fracture or sprain of the sesamoid articulation or of the sesamoid metatarsal articulation. Overuse injuries tend to occur in sports with a great deal of forefoot loading (basketball/tennis).

SXs: Pain with weight bearing, pain with movement of first MTP, ambulation on lateral part of foot.

PE: Tenderness and swelling over medial or lateral sesamoid. Resisted plantar flexion (flexor hallucis) reveals pain and weakness.

Imaging: plain film with sesamoid view to assess for a sesamoid fracture. Stress fractures may take 3-4 weeks to show on plain film.

http://www.agoodgroup.com/running/Fracture002.jpg

Treatment for fractures and suspected stress fractures involve 4 to 6 weeks of non weight bearing.



Category: Orthopedics

Title: Orthopedic Causes of Chest Pain

Keywords: Orthopaedic, Chest Pain (PubMed Search)

Posted: 2/28/2015 by Michael Bond, MD (Updated: 6/15/2024)
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Orthopedic Causes of Chest Pain

The first thing that pops into everybody’s mind when they hear a patient state they have chest pain radiating to the left arm is Acute Coronary Syndrome and specifically a Myocardial Infarction. However, there are a lot of orthopedic causes of chest pain that can also radiate to the left arm. It is estimate that up to 20% of patients with pectoral symptoms have an underlying orthopedic problem.

Some of them are:

  • Herniated Disc
  • Cervicothoracic tension syndrome
  • Blockage of intervertebral or rib joints
  • intercostal neuralgia


Some other less common causes are

  • Arthritis of the shoulder
  • Spondylocystitis
  • Osteoporotic fractures
  • Bone tumors


So instead of just ordering some troponin and admitting to medicine, consider that the cause can be orthopedic in origin.

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Category: Orthopedics

Title: Peroneal tendonitis

Keywords: LATERAL ANKLE TENDINOPATHY (PubMed Search)

Posted: 2/14/2015 by Brian Corwell, MD (Emailed: 2/15/2015) (Updated: 2/15/2015)
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LATERAL ANKLE TENDINOPATHY

Hx: subacute onset (weeks) of the pain seen in athletes esp. runners (banked or uneven surfaces).

PE: Tenderness to palpation posterior to the lateral malleolus or over the course of the tendon. Pain worse with resisted ankle eversion from a dorsiflexed postion. Examine for subluxation of tendon.

The diagnosis is made from the above and does not require imaging.

Tx: Rest, conservative care, physical therapy (eccentric exercise focus), ankle taping or lace up brace. Severe cases may even require a walking boot.

http://www.epainassist.com/images/Article-Images/Peroneal_Tendonitis.jpg



Category: Orthopedics

Title: Calcaneal stress fractures

Keywords: Heel pain, bone injury (PubMed Search)

Posted: 1/24/2015 by Brian Corwell, MD
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Overuse injury

Seen in runners, military recruits (marching), ballet dancers and in jumping sports (heavy landing).

Insidious onset of heel pain, that is worse with jumping then running then later with simple weight bearing.

Tenderness to palpation posteriorly (medially or laterally), and squeezing bilateral posterior calcaneus.

Testing:

XR: May not be positive for 2 to 4 weeks. Sclerotic appearance (vertically oriented) posterior calcaneus.

MRI: high signal T2 at fracture site.

DDx: plantar fasciitis.

Treatment: Reduction of activity if Sxs mild, for severe pain start a trial of non weight-bearing (boot or splint with crutches).

Stretching of calf, achilles, plantar fascia.



Category: Orthopedics

Title: Causes of Heel Pain

Keywords: heel, pain, causes (PubMed Search)

Posted: 1/17/2015 by Michael Bond, MD (Updated: 6/15/2024)
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We often think of Plantar Fascitis as the cause of heel pain but there are a lot of other causes. Some of those include:



Category: Orthopedics

Title: Quadriceps contusion

Keywords: Contusion, hematoma (PubMed Search)

Posted: 1/10/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Mechanism: Direct blow to anterior thigh (Football/basketball) or from a ball traveling at a high rate of speed (field hockey/lacrosse).

Exam: focal tenderness and edema. Pain may be severe and worse with active contraction and passive stretch. Hematoma may already be present. Amount of passive knee flexion at 24 hours can be a clue to the severity of the hematoma.

Treatment: Crutches if pain with weight-bearing. Ice. Immobilization in 120 degrees of flexion immediately after the injury for the first 24 hours may be beneficial.

-Bandage entire lower limb. Provide crutches and pain medication. Soft tissue therapy is contraindicated for the first 48 hours and when instituted must be gentle and cause no pain. Risk of re-bleeding is greatest in first 7 to 10 days.

http://fce-study.netdna-ssl.com/2/images/upload-flashcards/75/20/63/5752063_m.jpg



Category: Orthopedics

Title: Knee dislocation

Keywords: knee dislocation, vascular and nerve injury, vascular emergency (PubMed Search)

Posted: 12/26/2014 by Brian Corwell, MD (Emailed: 12/27/2014) (Updated: 12/27/2014)
Click here to contact Brian Corwell, MD

Knee Dislocation

Following reduction and immobilization, a thorough vascular assessment should follow. Any signs of vascular injury should prompt immediate vascular consultation (pallor, absent or diminished pulses)

1) Palpate popliteal and distal pulses

2) Measure ankle-brachial index (*ABI) (<0.9 = abnormal)

3) Duplex ultrasound (if available)

*ABI ratio of SBP in lower (DP/PT) and upper (brachial) extremities.

**Evaluation is often institutional specific. Discuss with your consultants.

A) If strong pulses normal ABI and normal u/s admit patient for observation with serial vascular examinations.

B) If the limb is still well perfused but the pulses are asymmetric or ABI is abnormal or US is abnormal then consult vascular surgery and obtain arteriogram (expanding role for CTA here).

C) If pulses are weak or absent or distal signs of ischemic limb then obtain emergent vascular consultation for surgical repair.



A recent meta-analysis of 14 studies looked at the typical red flags of back pain to see which ones actually truly increase the risk that the patient will have a fracture or malignancy.


The typical historical red flags that are taught are

  • Age under 18 or over 50
  • Pain lasting more than 6 weeks
  • History of cancer
  • Fever and chills
  • Night sweats, unexplained weight loss
  • Recent bacterial infection
  • Unremitting pain despite rest and analgesics
  • Night pain
  • Intravenous drug users
  • Immunocompromised
  • Major trauma
  • Minor trauma in the elderly


And physical exam red flags are

  • Fever
  • Writhing in pain
  • Bowel or bladder incontinence
  • Saddle anesthesia
  • Decreased or absent anal sphincter tone
  • Perianal or perineal sensory loss
  • Severe or progressive neurologic defect
  • Major motor weakness


However, this meta-analysis showed that the only red flags that actually increased the risk of fracture or malignancy were

  • Older Age  Post test Probability 9% (95% CI 3% to 25%)
  • Prolonged corticosteroid use Post test Probability 33% (95% CI 10% to 67%)
  • Severe trauma Post test Probability 11% (95% CI 8 % to 16%)
  • Presence of contusion or abrasion Post test Probability 62% (95% CI 49% to 74%)


So this study highlights that a lot of the red flags that we have learned do not actually increase the risk fracture or malignancy, although some like fever, IVDA, and immunocomproromised increase the risk of epidural abscesses, which was not addressed in this meta-analysis.

The take home point for me is that plain radiographs/CT scans are probably only needed in patients with older age, prolonged corticosteroid use, severe trauma or presence o contusion or abrasion. If you are really worried about others with back pain just proceed directly to MRI as the plain films/CT scans are not going to be very helpful.
 

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Category: Orthopedics

Title: Knee dislocation

Keywords: knee dislocation, vascular and nerve injury (PubMed Search)

Posted: 11/22/2014 by Brian Corwell, MD (Updated: 12/26/2014)
Click here to contact Brian Corwell, MD

Knee dislocation 2

Most commonly occur after MVCs but also seen after falls, industrial accidents and sports related trauma.

Up to 50% of knee dislocations will have spontaneously reduced by time of presentation to the ED.

Strongly consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability (3 or more ligaments torn).

A thorough neurovascular examination is a must due to the risk of vascular (34%)(5-79%) and nerve (23%)(16-40%) injuries. There is a must higher incidence of these injuries in high force trauma such as from a MVC. The popliteal artery and common peroneal nerve are at the greatest risk

Though the absence of distal pulses suggests vascular injury, the presence of pulses cannot be used as evidence of the lack of a vascular injury.

After reduction, the knee should be immobilized in 15-20° of flexion in a knee immobilizer.



Category: Orthopedics

Title: Management of Felons

Keywords: felon, management (PubMed Search)

Posted: 11/15/2014 by Michael Bond, MD (Updated: 6/15/2024)
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Management of Felons

  • An abscess of distal finger that involves the pulp. 
  • A difficult infection to treat due to the fibrous septa that divide the pulp into multiple small compartments. 
  • These septa run from the periosteum to the skin increasing the risk of osteomyelitis
  • Patients typically present with a lot of pain, redness, and swelling.
  • Typically triggered by a puncture wound (i.e.: splinter)
  • Incision and Drainage can result in a:
    • anesthetic finger tip
    • unstable finger pad
    • neuroma
  • If you are going to drain one it is recommended that you do a volar longitudinal incision down the middle of the finger pad or a high lateral incision. 
  • The high lateral incision should be at about 5 mm below the nail plate border. This distance is required to avoid the more volar neurovascular structures.

For good photos of the incision technique please visit the reference article listed.

 

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Category: Orthopedics

Title: knee dislocation

Keywords: trauma, knee, dislocation (PubMed Search)

Posted: 11/8/2014 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Beware of spontaneous reduction masking the true injury!

Knee dislocations are rare due to supporting ligaments (MVCs, falls, sports)

but can be seen after minor trauma in obese patients.

Named by the direction of the displacement of the tibia relative to the femur

- Anterior and posterior are most common

Dislocations involve disruption of at least 2 of the major knee ligaments (ACL/PCL most common)

Usually associated with large hemarthrosis however capsular tearing may allow dissipation of the blood into adjacent soft tissue.

Consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability,



Category: Orthopedics

Title: Iliocostal syndrome

Keywords: Osteoporosis, elderly, (PubMed Search)

Posted: 10/25/2014 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Iliocostal syndrome aka iliocostal friction syndrome

Consider this entity in an elderly patient with osteoporosis with unexplained abdomen/flank or back pain.

Osteoporosis and/or vertebral compression fractures can result in a narrowing of the distance between .

the lowest anterior rib and the top of the iliac crest producing pain where this rib contacts the pelvis.

This can be perceived as side or back pain. This pain can restrict walking leading to a possible misdiagnosis of spinal stenosis. Treatment is with physical therapy and therapeutic injection.

http://www.caringmedical.com/wp-content/uploads/2013/09/iliocostalis.syndrome.jpg



Category: Orthopedics

Title: Reverse Segond Fracture

Keywords: Segond, Reverse, Fracture (PubMed Search)

Posted: 10/19/2014 by Michael Bond, MD
Click here to contact Michael Bond, MD

The Reverse Segond Fracture

Most people have heard of a segond fracture (avulsion fracture of the lateral tibeal platuea) seen on knee xrays which is a marker for Anterior Cruciate Ligament and medial meniscus injuries. See Pearl https://umem.org/educational_pearls/1015/

However, there is also a Reverse Segond Fracture that is another benign appearing avulsion fracture of the medial tibeal plateau that is marker for significant injury to the Posterior Cruciate Ligament (PCL).

If a Segond or Reverse Segond Fracture is seen consider immobilzing the patients knee until they can follow up with Orthopedics and/or get an MRI to determine if additional injuries are present.