UMEM Educational Pearls - Orthopedics

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.

We often think of Plantar Fascitis as the cause of heel pain but there are a lot of other causes. Some of those include:

• Heel bursitis-  inflammation on the back of the heel. Can be from jumping or poor fitting footwear.
• Heel bumps - from excessively rubbing resulting in too much bone formation.
• Tarsal tunnel syndrome
• Chance inflammation of the heel pad
• Stress fractures
• Severs disease
• Achilles tendonitis
• Retrocalcaneal bursitis
• Posterior calcaneal bursitis

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.

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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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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.

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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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,

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.

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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.

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.

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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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

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

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)
 

Is there any benefit to the use of prednisone in the treatment of lower back pain?  One study showed that about 5% of patients receive prednisone for the treatment of their low back pain, but does it work.

A recent study by Eskin et al published in the Journal of Emergency Medicine looked at this question.  They conducted a randomized controlled trial of 18-55 year olds with moderately severe low back. Patients were randomized to receive prednisone 50mg for 5 days or placebo.

The study enrolled a total of 79 patients, and 12 were lost to follow up. At followup there was no difference in their pain, or in them resuming normal activities, returning to work, or days lost from work.  To make matters worse more patients in the prednisone group sought additional medical treatment 40% versus 18%.

Conclusion:  With the results of this study we should continue the treatment of low back pain with non-steroidials, muscle relaxants and exercise.  There does not appear to be any role for steroids in the treatment of these patients.

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Return to Play After Infectious Mononucleosis (IM)

-Long incubation period make it difficult to determine source or onset

Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.

DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)

Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)

Symptoms then progress into the classic “triad” of IM

                Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)

May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)

Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)

                Most commonly seen in patients treated with PCN antibiotics

Splenomegaly is an important complication in the athletic population

Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)

                - Lymphocytic proliferation enlarges the spleen beyond protection from the ribs

                - Physical examination has been shown to be unreliable for determining splenomegaly

                - Highest risk is in the first 21 days (rare after 28 days)

Ultrasound is the modality of choice

                -Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks

Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.

Cervical Cord Neuropraxia (CCN)

A concussion of the spinal cord as a result of an on-field collision.

A transient motor and/or sensory disturbance, lasting less than 24 hours.

A distinct and separate entity from spinal cord injury resulting in quadriplegia

Incidence 7.3 per 10,000 athletes

Approx. 50% of players experiencing CCN who return to play, have a second episode

The risk of this second episode is inversely proportional to the size of the cervical bony canal

Athletes with narrow canal diameter are more likely to have a 2nd episode

               Those with normal canal diameter (14 mm on MRI) have a 5% risk

               Those with a narrow canal (9 mm or less)) have a greater than 50% risk.

Whether repeat episodes lead to permanent spinal cord injury is unknown

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Football helmets

A review of head and neck injuries from football from 1959 to 1963 found the rates of intracranial hemorrhage /intracranial death were 2-3X higher than the rates of cervical spine fracture/dislocation or cervical quadriplegia. In contrast, a study of football injuries from 1971 to 1975, revealed a dramatic reversal in rates. Cervical injuries now exceeded the rate of ICH by 2-4X.

                A 66% reduction in ICH

                A 42% reduction in craniocerebral deaths            

                A 204% increase in cervical spine fractures and dislocations

The shift was attributed to the modern football helmet, whose superior protection promoted “spearing” (headfirst tackling technique). Spearing involves hitting with the crown of the helmet leading to axial loading of the spine. Spearing accounted for 52% of the quadriplegia injuries from 1971 to 1975. Research by Joesph Torg, M.D., resulted in rule changes that led to an immediate 50% reduction in quadriplegia in NCAA football.

As a parent, coach or team physician, teach and enforce proper form and protect our young athletes.

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