UMEM Educational Pearls - Orthopedics

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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Category: Orthopedics

Title: Sesamoid Injuries

Keywords: Foot pain, stress fractures (PubMed Search)

Posted: 2/28/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

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: 3/28/2024)
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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: 3/28/2024)
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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: 3/28/2024)
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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.



Category: Orthopedics

Title: "I have sciatica, I want a MRI and I want it now"

Keywords: Sciatica, radiculopathy, imaging (PubMed Search)

Posted: 9/19/2014 by Brian Corwell, MD (Emailed: 9/27/2014) (Updated: 9/27/2014)
Click here to contact Brian Corwell, MD

Back pain with radiculopathy can be very distressing to a patient and they have heard from their medically savvy neighbor that a MRI is the way to go. Now, armed with this knowledge, they are in your ED with earplugs in hand...

A few minutes of reassurance and education can save in both cost and ED throughput.

In one study researchers performed MRIs on asymtomatic adult patients.

               Almost two-thirds (64%) had abnormal discs

               Just over half (52%) had bulging discs

               Almost a third (31%) had disc protrusions

Further, finding a bulging disc already suggested by your history and physical examination does not change management. The majority of these patients improve with conservative treatment within four to to six weeks.

Restrict ED MRI use for the evaluation of suspected cauda equina, epidural abscess and spinal cord compression.



Category: Orthopedics

Title: Should we repair Tendon Lacerations

Keywords: Tendon, Laceration, Repair (PubMed Search)

Posted: 9/19/2014 by Michael Bond, MD (Emailed: 9/20/2014) (Updated: 9/20/2014)
Click here to contact Michael Bond, MD

Tendon Lacerations:

  • Flexor tendon lacerations have historically not been repaired by emergency providers due to the extensive pulley systems involved and possibility of loss of mobility from scarring.
    • However, if both ends of the tendon can be visualized in the ED it is not unreasonable to place 1 or 2 horizontal mattress sutures between the two ends to prevent retraction of the proximal portion which can make a formal repair more difficult.
    • These injuries have a very high complication rate so most will defer to a hand surgeon for definitive treatment.
  • Extensor tendon lacerations can be repaired by emergency providers.
    • Most often these repairs are limited to 6-8. See image at http://www.boneandjoint.org.uk/content/focus/extensor-tendon-injury
    • One technique is to use a running horizontal mattress suture with non-absorbable nylon sutures. 
    • The ultimate strength of the repair is dependent on the number and size of the sutures placed.
    • Careful placement of the sutures can prevent gap formation between the ends when the tendon is stressed.
    • A good discussion on tendon repairs can be found at http://www.boneandjoint.org.uk/content/focus/extensor-tendon-injury

A reasonable approach to all tendon lacerations is to loosly reapproximate the wound and splint the hand in the position of function until the patient can be seen by a hand surgeon in the next 1-3 days.  These injuries do not require immediate surgical repair, and with the high rate of complications it is probably best to discuss with your hand surgeon before attempting a repair.

 

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Category: Orthopedics

Title: Back Pain

Keywords: back pain, x-ray (PubMed Search)

Posted: 9/13/2014 by Brian Corwell, MD (Updated: 3/28/2024)
Click here to contact Brian Corwell, MD

Back pain accounts for more than 2.6 million visits

30% of ED patients receive X-rays as part of their evaluation

Imaging can be avoided in a majority of these patients by focusing on high risk (red flags)  findings in the history and physical exam.

Patients who can identify a an acute inciting event without direct trauma likely have a MSK source of pain.

Imaging rarely alters management

Attempt to avoid imaging in patients with nonspecific lower back pain of less than 6 weeks duration, with a normal neurologic exam and without high risk findings (fever, cancer, IVDA, bowel or bladder incontinence, age greater than 70, saddle anesthesia, etc)

Patients with radiculopathy (sciatica) and are otherwise similar to the above also do not require emergent imaging



Category: Orthopedics

Title: Radiology Ankle Fracture Pearls

Keywords: radiology, ankle, fracture (PubMed Search)

Posted: 8/30/2014 by Michael Bond, MD
Click here to contact Michael Bond, MD

Some radiology pearls concerning ankle pain and fractures courtesy of David Bostick and Michael Abraham

Maisonneuve fracture – fracture of the medial malleolus with disruption of the tibiofibular syndesmosis with associated fracture of the proximal fibular shaft (http://radiopaedia.org/articles/maisonneuve-fracture)

When to look for high fibular fracture

  • Isolated fracture of medial malleolus
  • Isolated fracture of malleolus tertius without fracture on the lateral side
  • Any painful swelling or hematoma on medial side without a fracture on x-ray

Always look for avulsion fracture of 5th metatarsal styloid in patients with ankle pain and
no obvious fractures

Dans-Weber Classification – for lateral malleolar fractures (http://radiopaedia.org/articles/ankle-fracture-classification-weber)

  • Type A – fracture below ankle joint
  • Type B – at level of joint with tibifibular joint intact
  • Type C – fracture above joint with tears syndesmotic joint


Category: Orthopedics

Title: Patellar tendonitis

Keywords: Jumpers knee, knee pain (PubMed Search)

Posted: 8/24/2014 by Brian Corwell, MD (Updated: 3/28/2024)
Click here to contact Brian Corwell, MD

Patellar tendonitis aka jumpers knee

Activity related knee pain due to degenerative, micro injury rather than an inflammatory process

Up to 20% in jumping athletes

Anterior knee pain during or after activity

Bassett Sign:
       a)  Tenderness to palpation with knee in full extension (patellar tendon relaxed)
       b) No tenderness with knee in flexion  (patellar tendon tight)