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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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).

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

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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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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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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:

(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.

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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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.

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

 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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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

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.

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.
 

The flexor tendons of the finger may become thickened and narrowed from chronic inflammation and irritation.

 - Causes limitation in range of motion and snapping or locking during flexion

 - Can involve any digit but usually the ring and the long finger

CC: pain, "catching" May awake to finger being "locked" with spontaneous resolution during the day

Stenosis occurs at the MCP level

PE: Distal flexor crease tender to palpation and may have a painful nodule 

Full finger flexion is sometimes not possible

Tx: NSAIDs and steroid injection in tendon sheath. If this fails - surgical release.

Dupuytren disease is a nodular thickening and resultant contraction of the palmer fascia.

Increased in those of Northern European dissent.

One or more painful nodules located near the distal palmer crease.

Over time may result in flexion at the MCP joint.

Most commonly affects the ring finger.

Sensation is normal.

Over time affects ADLs

Tx: night splints and surgery

Tests for distal ulnar nerve entrapment

Ask patient to hold a piece of paper between the thumb and the index finger

Normally this is a fairly simple task.

With an unlar nerve palsy, the patient will substitute with the FPL (flexor pollicis longus - median nerve innervation). This causes flexion of the thumb in order to maintain the grip since the adductor pollicis cannot be used. This causes thumb flexion rather than extension.

http://www.mims.com/resources/drugs/common/CP0042.gif

http://www.youtube.com/watch?v=yJTIhm1VfSI

Sternal fractures

• Initially thought to be associated with high mortality due to associated injuries though newer studies show the mortality rate is about 1%.
• Can be associated with
  • Rib fractures
  • Mediastinal injury
  • Cardiac Contusion
  • Pneumothorax
  • Aortic dissection
  • Pulmonary Contusion
• The diagnosis can be made with plain radiographs, but a fracture can be missed on a regular PA and Lateral Chest Xray.  Ask for dedicated sternal views to better define the fracture
  • CT Chest is only needed if you are concerned about associated injuries
• Obtain an ECG on arrival and at 6 hours to ensure there are no signs of a myocardial contusion
  • ST segment changes, arrhthymias
• Treatment is supportive. Provide adequate pain control and treat associated injuries

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Tennis Elbow

The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

 The ECRB  muscle helps stabilize the wrist when the elbow is straight.

Ask the patient to straighten the arm at the elbow and then perform resisted long finger extension. This will stress the ECRB and reproduce the pain. One can also ask the patient to lift the top of a chair in the air with the elbow extended.

Trapezium Fractures

• The trapezial body is often fractured due to an axial load through the thumb
• The trapezial ridge is often fractured during a fall on an outstretched hand
• Accounts for 1% to 5% of all carpal fractures.

Suspect the Diagnosis when you note

• Tenderness  over trapezium 
• Often have increased pain with axial loading of thumb.
• Point tenderness at the volar base of the thumb just distal to the scaphoid, at the base of the first metacarpal.
• Since the trapezium is obscured by superimposed bones in PA and lateral views, fractures are most easily identified on the oblique radiographs

If you are suspected the diagnosis oblique radiographs or a CT scan of the wrist will note the fracture the best.

Treatment consists of placing the patient in a thumb spica splint.