UMEM Educational Pearls - Orthopedics

When examining a knee for a meniscal injury the commonly described tests are the McMurray Test and Apley Test.  However, these tests have sensitivities of 48-68% and 41% respectfully, and specificities of 86-94% and 86-93% respectfully.  Depending on whether you are looking at the medical or lateral meniscus.

The Thessaly Test that was first described in 2005 can be performed with knee in either 5 or 20 degrees of flexion and has a senstivity of 89-92% and specificity of 96-97% when performed in 20 degrees flexion.  The test also tends to be easier to perform.

To perform the test:

  1. Stand on affected leg only with the other leg held up in the air.  The examiner holds hands for balance.
  2. Flex knee to be test to 20 degrees, while the other leg is held in the air
  3. Internally and Externally Rotate Knee
  4. Positive test is pain at medial or lateral joint line with possible locking/catching sensation

Essentially you and your patient will look like you are doing the twist as they rotate their knee with you holding their hands.

 

A video of the technique can be found at http://youtu.be/R3oXDvagnic

 

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Category: Orthopedics

Title: LisFranc Fractures

Keywords: lisfranc, fracture (PubMed Search)

Posted: 5/17/2014 by Michael Bond, MD (Updated: 11/2/2024)
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Lisfranc Fracture:

Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid.  Common current mechanism of injury is when a person steps into a hole and twists the foot.  The original mechanism of injury that was described was when a horseman would fall of their horse with their foot still trapped in a stirrup.

Diagnosis should be considered if patient has difficultly weight bearing with pain on palpation over the 2nd and 3rd metacarpal head with an appropriate mechanism.

Pearls:

  • Fracture findings on plain films may be subtle.
  • If in doubt obtain weight bearing AP views of the foot to demonstrate dislocation/fracture.
  • If weight bearing films are negative and you are still suspicious consider a CT scan of the foot.

 

 



Category: Orthopedics

Title: Risk Modifiers for Concussion and Prolonged Recovery

Keywords: Concussion, recovery, head injury (PubMed Search)

Posted: 4/6/2014 by Brian Corwell, MD (Emailed: 5/10/2014) (Updated: 5/10/2014)
Click here to contact Brian Corwell, MD

Risk Modifiers for Concussion and Prolonged Recovery

 

A history of prior concussion is a risk factor for future concussion (>2x risk).

For individual sports, boxing has the highest risk.

For team sports, football, ice hockey and rugby have the highest risk.

Women’s soccer confers the highest risk for female athletes.

Younger age confers increased risk.

Female sex confers higher risk when comparing similar sports with similar rules.

Those with migraine headaches may be at increased risk.

Risk of prolonged concussion

Most athletes have symptom resolution within one week

Post traumatic amnesia (both retrograde and anterograde) predict increased number and longer duration of symptoms.

Younger age also predicts pronged recovery.

Other studies have found associations with headache lasting greater than 60 hours, fatigue, “fogginess,” or greater than 3 symptoms at initial presentation. Cognitive studies have identified deficits in visual memory and process speed as predictors of prolonged recovery. 

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Category: Orthopedics

Title: DeQuervains versus Intersection Syndromes

Keywords: DeQuervain, Intersection, Syndrome, Tenosynovitis (PubMed Search)

Posted: 3/30/2014 by Michael Bond, MD (Updated: 11/2/2024)
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DeQuervain and Intersection Syndromes:
 

  • DeQuervain's Syndrome (Tenosynovitis of the Abductor Pollicus Longus and Extensor Pollicus Brevis tendons) is a common disorder that has received a lot of press lately as BlackBerry Thumb or Gamer's Thumb.
    • This condition can be diagnosised by the Finklestein test [Have the patient bend their thumb into the palm of their hand, and then make a fist.  They should then ulnar deviate their wrist.  Pain along the tendons secures the diagnosis.]
    • The pain of DeQuervain's syndrome is typically along the distal end of the radius at the base of the thumb.
  • Intersection syndrome is a less common disorder though closely related to DeQuervain's Syndrome
    • The pain is usually felt on the top of the forearm about three inches proximal to the wrist. 
    • The pain from this condition is due to tenosynovitis of the Extensor carpi radialis longus and Extensor Carpi radialis brevis muscles/tendons caused by the intersection of them with the Extensor pollicus brevis and Abductor pollicus longus tendons.
    • Occurs due to excessive wrist movements.
    • Intersection syndrome can be seen in weight lifters, skiers, and can be seen in homeowners in the fall and winter when they rake a lot of leaves or shovel snow.
  • Treatment is the similar for both conditions and consists of:
    • NSAIDS
    • Cortisone injections can be effective
    • Thumb and wrist immobilization with a Thumb Spica Splint or Cock Up Wrist Splint


Ankle Syndesmosis Injuries are also called high ankle sprains as they involve trauma to the ligaments above the ankle joint

Most ankle sprains are lateral ankle sprains. High ankle sprains are relatively uncommon.

Usual mechanism: External rotation injuries

Exam: Tenderness at the syndesmosis and compression of the tib/fib at the mid calf level causing syndesmosis pain (squeeze test)

Median recovery time is almost 4 times as long as a lateral ankle sprain 62days vs. 15days

Emergency department care is similar tto that of other ankle sprains but the added benefit of patient education and advice may improve overall care and follow-up.

 

 

 



Category: Orthopedics

Title: Herpes Gladiatorum in Wrestlers

Keywords: Herpes Gladiatorum, skin rash, sports medicine (PubMed Search)

Posted: 3/9/2014 by Brian Corwell, MD (Updated: 11/2/2024)
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Herpes Gladiatorum in Wrestlers

HSV causes non genital cutaneous infections primarily in wrestlers, commonly called herpes gladiatorum (HG)

Annual incidence in NCAA wrestlers is 20% to 40%

Most common cutaneous infection leading to lost practice time (40.5% of all infections)

Transmission is skin to skin.

Incubation period is 4 to 7 days from exposure. Healing usually occurs within 10 days after the initial lesion (without scaring).

Appearance: Numerous grouped uncomfortable (painful) vesicles/pustules on an erythematous base…evolve into moist ulcerations, followed by crusted plaques.  Lesions typically get abraded during competition therefore may have an atypical appearance and may be mistaken for other infections such as staph. Distribution typically more diffuse than typical HSV infections. Occurs on body surfaces areas that typically come into contract with opponents (face, head, neck, ears, upper extremities).  Lesion location typically on side of patient’s handedness. Recurrences occur at location of initial outbreak, a useful diagnostic aid.

Perform a thorough examination as ocular involvement was seen in 8%  of high school wrestlers  in one HG outbreak.

Typical treatment for primary infection is Valacyclovir 1g PO b.i.d. for 7 days. This is best started within 24h of symptom onset.

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Category: Orthopedics

Title: Adult Septic arthritis

Keywords: MRSA, arthocentesis (PubMed Search)

Posted: 2/22/2014 by Brian Corwell, MD
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The clinical examination is often unreliable in ruling out septic arthritis in the ED.

 Diagnostic arthrocentesis is often performed.

Traditional teaching involved very high WBC count thresholds as part of diagnosis.

In one 2009 study, synovial leukocyte counts in cases of MRSA were often less than 25,000 cells/uL

Have a low threshold for empiric antibioitics even in the face of low WBC counts (and incredulous consultants)

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Category: Orthopedics

Title: Overtraining Syndrome

Keywords: Overtraining syndrome, exercise (PubMed Search)

Posted: 2/8/2014 by Brian Corwell, MD
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Overtraining syndrome

A maladaptive response to excessive exercise without adequate functional rest

-Results in disturbances of multiple body systems (neurologic, endocrinologic, immunologic and psychologic).

- May be caused by systemic inflammation and resultant neurohormonal changes
            - Multiple hypotheses exist

-Symptoms

Parasympathetic alterations: fatigue, depression, bradycardia

Sympathetic alterations: insomnia, irritability, agitation, tachycardia, hypertension, restlessness

Other: anorexia, weight loss, poor concentration, anxiety

 

Usual presentation is prolonged underperformance despite adequate rest and recovery (weeks to months).



Category: Orthopedics

Title: Pellegrini Stieda lesion

Keywords: MCL, knee, (PubMed Search)

Posted: 1/17/2014 by Brian Corwell, MD (Emailed: 1/25/2014) (Updated: 1/25/2014)
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Pelllegrini-Stieda lesion

Ossified post-traumatic lesions at the MCL adjacent to the femoral attachment site of the medial femoral condyle.

Mechanism is likely from an avulsion injury that subsequently calcifies after the initial trauma.

Often an incidental finding on plain films.

If symptomatic, refer to ortho as an outpatient

If not symptomatic, no treatment is indicated

 

http://images.radiopaedia.org/images/30076/b62e61e83241e30f2da693901edcdc_gallery.jpg

http://www.imageinterpretation.co.uk/images/knee/PELLEGRINI%20STIEDA2.jpg



Category: Orthopedics

Title: Osteoarthritis Part 2

Keywords: Osteoarthritis, treatment (PubMed Search)

Posted: 1/11/2014 by Brian Corwell, MD
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Treatment:
Topical agents: The most widely used preparations contain capsaicin, lidocaine and NSAIDs
These preparations have been shown to be efficacious in controlled double-blind studies of OA of the hand and knee (minimal overlying soft tissue).
Note: Some of the topical NSAIDs are as efficacious as oral NSAIDs (lower incidence GI side effects).
*Consider in older patient with OA of hand or knee*
Oral agents: Acetaminophen is still considered first line treatment for mild to moderate pain. It has a small but significant effect for pain but this did not carry over for stiffness or functional improvement.
NSAIDs: More efficacious than acetaminophen for pain. Consider first line for moderate to severe pain.
While all attempts should be made at avoiding NSAIDs in patients at risk of upper GI bleeding, the safest approach may be to use Celecoxib with a proton pump inhibitor.

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No single feature of the history of physical examination reliably rules out ostemyelitis

 

 

Aids in making the diagnosis include:

An ulcer area larger than 2 cm2 (LR 7.2),

A positive probe to bone test (LR 6.4),

An ESR greater than 70 mm/h (LR 11)

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Category: Orthopedics

Title: Osteoarthritis - Part 1

Keywords: Osteoarthritis, treatment (PubMed Search)

Posted: 12/14/2013 by Brian Corwell, MD (Updated: 11/2/2024)
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Treating knee osteoarthritis - from the American College of Rheumatology 

Exercise whether it be aquatic, aerobic (land -based) or resistance can decrease pain and improve functional capacity. Exercise should be performed 3 to 5 times a week. Effects are usually noted after 3 to 6 months.

Weight loss of 5% or greater body weight is associated with a small improvement in pain and physical function. The main benefit of weight loss has more to do to effects on co-morbid conditions.

Walking aids: A single crutch or cane should be held on the side contralateral to the affected knee and should be advanced with the affected limb when walking to reduce the load on the affected joint. 

Cane sizing: The distance from the floor to the patient's greater trochanter (brings the elbow to 15º to 20º of flexion.

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Category: Orthopedics

Title: Posterior Shoulder Dislocation

Keywords: Posterior, Dislocation, Shoulder (PubMed Search)

Posted: 11/30/2013 by Michael Bond, MD (Updated: 11/2/2024)
Click here to contact Michael Bond, MD

Posterior Shoulder Dislocations

  • A rare type of shoulder dislocation
  • Accounts for 2-4% of all shoulder dislocations
  • Classic mechanism of injury is a seizure or electrocution
  • Reported to occur bilaterally in 15% of cases
  • Often missed on the initial visit.
  • Patient will complain of pain with movement of the shoulder and the arm is held in internal rotation.
  • Can be missed on the AP, lateral and Y-views of the shoulder.
  • Axillary or modified Axillary views are the best view to visualize a posterior shoulder dislocation. Shown below:

Axillary View of Shoulder

(A posterior shoulder dislocation will show the humeral head displayed superiorly in the image away from the clavicle which is the inferior most bone)

Some things to look for on the AP view that will suggest a posterior shoulder dislocation:

  • Lightbulb sign – The head of the humerus in the same axis as the shaft producing a lightbulb shape
  • The ‘rim sign’ – Widening of the glenohumeral space
  • The vacant glenoid sign – the anterior glenoid fossa appears empty

Life in the Fast Lane as a great discussion of posterior shoulder dislocations at http://lifeinthefastlane.com/posterior-shoulder-dislocation/

 Best way to make the diagnosis --- suspect it and get an axillary view.



Category: Orthopedics

Title: Exercise-induced laryngeal obstruction (EILO)

Keywords: bronchospasm, asthma, exercise-induced laryngeal obstruction (PubMed Search)

Posted: 11/23/2013 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Unexplained respiratory symptoms during exercise are often incorrectly considered secondary to exercise induced asthma/bronchospasm.

An important diagnosis on the differential should be exercise-induced laryngeal obstruction (EILO).

Of 91 athletes referred for asthma workup, 35% had EILO.

The presence of inspiratory symptoms did not differentiate athletes with and without EILO.

61% of athletes with EILO used regular asthma medication at referral.

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Category: Orthopedics

Title: Compartment Syndrome

Keywords: Compartment Syndrome (PubMed Search)

Posted: 11/16/2013 by Michael Bond, MD (Updated: 11/2/2024)
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Compartment Syndrome

Compartment syndrome is classically described as having the 6 Ps:

  • Pain out of proportion to what is expected
  • Pulselessness [Late finding that you hope to never see]
  • Paresthesia
  • Paralysis
  • Pallor
  • Pressure


The diagnosis of compartment syndrome can be difficult but ultimately it comes down to measuring the pressures in the area of concern.  Various recommendations of the allowed pressure can be found, but in general a fasciotomy is not needed if the compartment pressure is 30 mmHg less then the diastolic pressure (The Delta 30).  So if the patients diastolic pressure is 70, a fasciotomy is not need if the compartment pressure is less then 40.  

Finally, if you are suspecting compartment pressure do NOT elevate the limb.  Leave it in a dependent position to help improve blood flow into the limb.



Category: Orthopedics

Title: Cauda Equina

Keywords: back pain, cauda equina (PubMed Search)

Posted: 11/4/2013 by Brian Corwell, MD (Emailed: 11/9/2013) (Updated: 11/9/2013)
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Cauda equina syndrome results from compression of multiple lumbar and sacral nerve roots

Causes: Central disc herniation, spinal epidural abscess, malignancy, trauma, hematoma.

Consider this entity in those with back pain and radiculopathy at multiple spinal levels

Urinary retention occurs in >90% of patients

Saddle anesthesia occurs in 75%

Decreased rectal sphincter tone occurs in 60 to 80%

A post void residual volume <100 mL makes this entity very unlikely



Category: Orthopedics

Title: Lateral hip pain

Keywords: gluteus, trendelenberg test, hip pain (PubMed Search)

Posted: 10/26/2013 by Brian Corwell, MD (Updated: 11/2/2024)
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 Lateral hip pain

 

 

 Findings of weakness and/or pain while testing hip abduction may point to gluteus medius muscle dysfunction with associated with greater trochanteric pain syndrome.

 

The Trendelenburg test may help. The patient stands on the affected leg. A negative test result occurs when the pelvis rises on the opposite side. A positive test result occurs when the pelvis on the opposite side drops and indicates a weak or painful gluteus medius muscle.

 

http://www.youtube.com/watch?v=TY-G4ErruUA
 



Prior fracture represents the strongest predictor of stress fracture in both sexes

For girls:  Low body mass index, (<19), late menarche (age 15 or older), previous participation in gymnastics and dance.

For boys: increased number of seasons.

Participation in basketball appears protective in boys.

This may represent a modifiable risk factor for stress fractures.

 

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Category: Orthopedics

Title: Thumb MCP joint arthritis

Keywords: Basilar joint, thumb, arthritis, Basal joint grind test (PubMed Search)

Posted: 9/14/2013 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

The thumb MCP joint is subject to arthritric changes.

Sx's of arthritis will frequently present with pain in a similar region to deQuervain's disease.

The basal joint grind test

          Perform by stabilizing the triquetrum with your thumb and index finger and then dorsally subluxing the thumb metacarpal on the trapezium while providing compressive force with the opposite hand.

 

http://www.youtube.com/watch?v=oEJH7KFGx_Y



Category: Orthopedics

Title: Charcot Joints

Keywords: Charcot Joints (PubMed Search)

Posted: 8/17/2013 by Michael Bond, MD
Click here to contact Michael Bond, MD

Charcot Joint - Neuropathic arthropathy

A Charcot Joint is a progressive degeneration of a weight bearing joint that is normally seen in patients that have decreased peripheral sensation and proprioception.

Conditions associated with Charcot Joints are:
    •    Alcohol neuropathy
    •    Cerebral palsy
    •    Diabetes mellitus
    •    Spinal Cord Injury
    •    Strokes
    •    Syphilis (tabes dorsalis)

The foot is most commonly affected and radiographs can also show bony destruction, bone resorption, and gross deformity. The onset of pain and deformity is typically insidious.  Charcot joints are often associated with ulcerations, secondary osteomyelitis, and can lead to amputations.

Charcot Joint

It is important to recognize the presence of a Charcot Joint so that the patient can be referred to Orthopaedics and treated (often with cast immobilization) to prevent further destruction of the joint.