UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: Cognitive rest following concussion

Keywords: head injury, concussion, return to play, cognitive rest (PubMed Search)

Posted: 2/23/2013 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Just before you upgraded your old computer, recall what happened when you had Excel, Word and PowerPoint all open at the same time. In the concussed state, the brain is essenatially functioning like your old computer... and the more tasks it must perform, the slower it will work and slower it will recover. Hence the concept of cognitive rest. Below is taken from the AMSSM position statement of concussion in sport.

 

Return to school

There are no standardized guidelines for returning the injured athlete to school. If the athlete develops increased symptoms with cognitive stress, student athletes may require academic accommodations such as a reduced workload, extended test-taking time, days off or a shortened school day.

Some athletes have persistent neurocognitive deficits following a concussion, despite being symptom free. Consideration should be made to withhold an athlete from contact sports if they have not returned to their ‘academic baseline’ following their concussion (level of evidence C).

The CDC developed educational materials for educators and school administrators that are available at no cost and can be obtained via the CDC website. Additional resources for academic accommodations should be developed for both clinicians and educators (level of evidence C).

Adam Friedlander shared the practical application of this which I found amusing:

" I always recommend what Peds neuro called "a brain holiday" - my favorite part.  All of our nurses look at me like I'm nuts, but it is now on our official concussion/CHI DC instructions.  I always say to the kiddo: "You'll love this part.  No homework, no reading."  Then I turn to mom and dad and tell them they'll love the next part: "No TV, no video games."

Thank you for sharing Adam!!

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Category: Orthopedics

Title: Sports-related Concussion

Keywords: head injury, concussion, return to play (PubMed Search)

Posted: 2/9/2013 by Brian Corwell, MD (Updated: 3/29/2024)
Click here to contact Brian Corwell, MD

Estimated 3.8 million sport-related concussions per year (likely significantly higher due to underreporting)

Most patients recover within a 7-10 day period

** Children and teenagers require more time than college and professional athletes

This "accepted" time for recovery is not scientifically established and there is a large degree of variability based on multiple factors including age (as above), sex & history of prior concussions

 

Approximately 10% of athletes have persistent signs and symptoms beyond 2 weeks (which may represent a prolonged concussion or the development of post-concussion syndrome)

During this time the patient should have complete rest from all athletic activities, close follow-up with PCP and be educated re concussions.

If practical, "cognitive rest" should also be prescribed. This is one of the most frequently neglected aspects of post-concussion care and will be discussed in a future pearl.



Category: Orthopedics

Title: Hematoma Block

Keywords: Hematoma Block, anesthesia, fracture reduction (PubMed Search)

Posted: 12/27/2012 by Brian Corwell, MD (Emailed: 1/26/2013) (Updated: 3/29/2024)
Click here to contact Brian Corwell, MD

Hematoma Block

 

Provides good aesthesia for reduction of fractures. Onset in approximately 5 minutes

Benefits:  No need for NPO, simple and easy to perform & can be done without additional personnel (unlike w/ procedural sedation)

Contraindications: Open fractures, dirty or infected overlying skin

1) Identify fracture site with x-ray and palpation

2) Clean skin w/ Betadine

3) Insert needle into the hematoma. * Confirm placement by aspirating blood *

4)  Inject anesthetic (lidocaine 1 or 2%) into the fracture cavity and adjacent periosteum

 

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



Category: Orthopedics

Title: Concussion

Keywords: head injury, concussion, return to play (PubMed Search)

Posted: 1/12/2013 by Brian Corwell, MD (Updated: 3/29/2024)
Click here to contact Brian Corwell, MD

"When can my child get back out on the field doc?"

 

Return to play


▸ Concussion symptoms should be resolved before returning to exercise.
▸ A RTP progression involves a gradual, step-wise increase in physical
demands, sports-specific activities and the risk for contact.
▸ If symptoms occur with activity, the progression should be halted and
restarted at the preceding symptom-free step.
▸ RTP after concussion should occur only with medical clearance from a
licenced healthcare provider trained in the evaluation and management
of concussions.


Short-term risks of premature RTP


▸ The primary concern with early RTP is decreased reaction time leading
to an increased risk of a repeat concussion or other injury and
prolongation of symptoms.


Long-term effects
▸ There is an increasing concern that head impact exposure and
recurrent concussions contribute to long-term neurological sequelae.
▸ Some studies have suggested an association between prior concussions
and chronic cognitive dysfunction. Large-scale epidemiological studies are
needed to more clearly define risk factors and causation of any long-term
neurological impairment.

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Category: Orthopedics

Title: Boxer's (Metacarpal Neck) Fractures

Keywords: metacarpal, neck, fracture (PubMed Search)

Posted: 12/29/2012 by Michael Bond, MD
Click here to contact Michael Bond, MD

Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5th Metacarpal)

Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.

  • 2nd and 3rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
  • 4th Metacarpal fracture <20۫ angulation allowed
  • 5th Metacarpal fracture <30۫ angulation.
    • Studies have shown that even 30۫ angulation will decrease normal function by 20%.  
    • Normal excursion of the 5th MCP is 15۫ to 25۫.
  • No amount of rotation deformity should be allowed.

Wishing everybody a Happy and Healthy New Year.



Category: Orthopedics

Title: NSAIDs & Exercise

Keywords: Exercise, NSAIDs, bowel injury (PubMed Search)

Posted: 12/22/2012 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

NSAIDs are commonly used by professional and recreational athletes to both reduce existing and/or prevent anticipated exercise induced musculoskeletal pain

NSAIDs have potential hazardous effects on the gastrointestinal (GI) mucosa  during strenuous physical exercise

Potential effects include mucosal ulceration, bleeding, perforation. and short-term loss of gut barrier function in otherwise healthy individuals

Intense exercise by itself has previously been shown to induce small intestine injury

Human intestinal fatty acid binding protein (1-FABP) is a protein found in mature small bowel enterocytes which diffuses into the circulation upon injury

Ibuprofen and endurance exercise (cycling) independently result in increased 1-FABP levels

When occurring together, ibuprofen ingestion with subsequent exercise causes significantly increased small bowel injury and intestinal permeability

Small bowel injury was found to  be reversible in 2 hours

Taking empiric NSAIDs before endurance exercise may be an unhealthy practice and should be discouraged in the absence of a clear medical indication

 

 

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Category: Orthopedics

Title: Delayed pneumonia following blunt thoaraic trauma

Keywords: pneumonia, rib fracture, blunt chest trauma (PubMed Search)

Posted: 12/7/2012 by Brian Corwell, MD (Emailed: 12/8/2012)
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Are discharged patients who suffer minor thoracic injury at risk of developing delayed pneumonia?

 

Prospective study of 1,057 patients age 16 and older with minor thoracic injury who were discharged from the ED. 

32.8% had at least one rib fracture

8.2% had asthma

3.4% had COPD

Only 6 patients developed pneumonia!!

Sex, smoking, atelectasis on CXR, and alcohol intoxication were not significantly associated with delayed pneumonia.

However, for patients with preexistent pulmonary disease (asthma or COPD) AND rib fracture, the relative risk of delayed pneumonia was 8.6. Patients without either of these conditions are at extremely low risk of future development of pneumonia.  

 

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Category: Orthopedics

Title: Hematoma blocks

Keywords: hematoma blocks, fracture analgesia (PubMed Search)

Posted: 11/24/2012 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Hematoma blocks for distal radius fractures

 

Hematoma blocks provide safe, effective analgesia without an increased risk of post procedural infections when compared with other regional blocks

Provide equal reduction quality AND pain control as procedural sedation with Propofol.

However, mean time to reduction (0.9 vs. 2.6 hours) and time to discharge post procedure (0.74 vs. 1.17 hours) were reduced with hematoma blocks.

Consider this option next time the department is busy or the patient is not an ideal procedural sedation candidate.

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Category: Orthopedics

Title: Tarsal Tunnel Syndrome

Keywords: tarsal tunnel syndrome (PubMed Search)

Posted: 11/17/2012 by Michael Bond, MD (Updated: 3/29/2024)
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Tarsal Tunnel Syndrome (TTS)

Prior pearls have addressed Carpal Tunnel Syndrome and Cubital Tunnel Syndrome, which affect the median and ulnar nerves, respectively.  Tarsal tunnel syndrome, is a similar compression neuropathy of the tibial nerve as it transverses through the tarsal tunnel of the foot.

The tarsal tunnel is located behind the medial malleolus, and is where the posterior tibial artery, tibial nerve and several tendons transverse.  Patients will present complaining of numbness of the foot radiating into  Digits 1-4, pain, burning , and tingling of the base of the foot and heel.  TTS has many causes and is more common in athletes.

Consider the diagnosis in patients with foot pain and numbness.  If interested in more information about TTS please consider reading this eMedicine article, http://emedicine.medscape.com/article/1236852-overview



Injury is often caused by sudden dorsiflexion on a plantar flexed foot w/ the knee in extension or similarly sudden knee extension with the ankle in a dorsiflexed position.

Injury has a predilection for the poorly conditioned middle-aged athlete, with "thick calves" who are engaged in strenuous activity

Strains are treated with ice, analgesics, and compression (decreases hematoma size and facilitates healing)

Also, consider casting/splinting as dictated by injury severity, such as with a night splint or a CAM boot.

Severe strains and ruptures can be splinted in plantar flexion for 3 weeks.

 

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Category: Orthopedics

Title: To Reduce or Not to Reduce...That is the Question

Keywords: fracture reduction, distal radius (PubMed Search)

Posted: 10/27/2012 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Distal radius fractures are common in children

Traditional management includes closed reduction +/- procedural sedation

The downside of this approach includes: patient risks, cost, physician time, ED bed time and tying up resources.

Kids have excellent bone remodeling potential...displaced and angulated fractures heal well without reduction

Crawford et al - 51 children aged 3 to 10 (avg 6.9 yrs)  w/closed distal radius fractures.

Exclusions: open or growth plate fractures, metabolic bone disease or neurovascular injury.

No sedation, analgesia or fracture reduction was performed

Treatment: simple casting and gentle molding to correct angulation... i.e. fractures were left in a shortened, overriding position

Outcome: All patients had clinical and radiographic union and full range of motion of the wrist at one year w/ good patient (parent) satisfaction. This was associated w/ significant cost savings.

Consider this approach in consultation with orthopedist

Remember exclusions: open fractures, fracture dislocations, growth plate injuries and neurovascular injury.

Children w/ excessive angulation or rotational deformity should have standard care (closed reduction w/ sedation)

Multiple guidelines exist for "excessive angulation" but as a general rule

Age < 5 Up to 35 degrees

Age 5- 10 Up to 25 degrees

Age >10 Up to 20 degrees

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Category: Orthopedics

Title: Sudden cardiac death in Marathons

Keywords: Marathon, cardiac arrest, cardiac death (PubMed Search)

Posted: 10/13/2012 by Brian Corwell, MD (Updated: 3/29/2024)
Click here to contact Brian Corwell, MD

Congratulations to today's Baltimore marathoners and the medical race staff

In honor of them:

 

Marathons are becoming increasingly popular with participation rising from an estimated 143,000 US marathon finishers in 1980 to a record high of 507,000 during 2010.

Most victims of exercise-related sudden cardiac arrest have NO premonitory symptoms

Autopsy reports show that

1) 65 - 70% of all adult sudden cardiac deaths are attributable to coronary artery disease.

2) 10% due to other structural heart diseases (HOCM, congenital artery abnormalities)

3) 5 - 10% due to primary cardiac conduction disorders (prolonged QT, ion channel disorders)

4) Remainder are due to non cardiac etiologies

 

Overall risk of sudden cardiac arrest is approximately from 1 in 57,000 and the risk of sudden cardiac death is approximately 1 in 171,000. Mortality without intervention after sudden cardiac arrest  is greater than 95%. The majority occur in middle to late aged males.

V fib/V tach are the most common arrhythmias leading to sudden cardiac arrest. Most events occur in the last 4 miles of the racecourse.

Survival decreases by 7 - 10%  with each minute of delayed defibrillation. Defibrillation within 3 minutes can produce survival rates as high as 67 - 74%. After 8 minutes, there is a dramatic decrease in survival. Prompt CPR increases survival from 2.5% to greater than 8%.

 

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Fight Bites

  • Any abrasion or laceration over the knuckles should be presumed to be a fight bite.  Patients will often lie about the circumstances of the laceration.
  • Radiographs should be obtained on all of these patients to exclude
    • Retained foreign bodies (e.g., tooth fragments)
    • Fracture of the metacarpal head
  • Place patient on amoxicillin/clavulanic acid or clindamycin to cover mouth flora
  • Irrigate wound well, and explore through the fingers full range of motion to exclude joint or tendon injury.
  • Refrain from suturing the wound, as this will increase the risk of infection.
  • Splint in position of function and have them follow up in 2 days.


Category: Orthopedics

Title: SLAP lesions

Keywords: Shoulder, biceps, cartilage tear (PubMed Search)

Posted: 9/22/2012 by Brian Corwell, MD (Updated: 11/19/2013)
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SLAP tear/lesion – Superior labral tear anterior to posterior

Glenoid labrum – A rim of fibrocartilaginous tissue surrounding the glenoid rim, deepening the “socket” joint and is integral to shoulder stability

http://www.orthospecmd.com/images/shoulder_labral_tear_anat_02.jpg

Injury is most commonly seen in overhead throwing athletes

Or from a fall on the outstretched hand, a direct shoulder blow or a sudden pull to the shoulder

Sx’s:  A dull throbbing pain, a “catching” feeling w/ activity. Some describe clicking or locking of the shoulder. May also include nighttime symptoms. Pain is located to the anterior, superior portion of the shoulder.

Athletes may describe a significant decrease in throwing velocity

http://sitemaker.umich.edu/fm_musculoskeletal_shoulder/o_brien_s_test



Category: Orthopedics

Title: Apprehension test for patellar dislocation

Keywords: Apprehension test, patellar dislocation, (PubMed Search)

Posted: 9/8/2012 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Apprehension test for patellar dislocation

 

Test is used to access for the possibility of a patellar dislocation, prior to evaluation, now spontaneously reduced.                                                   

Similar to the shoulder apprehension test

Designed to place the patella in a position of imminent subluxation or dislocation

http://mulla.pri.ee/Kelley%27s%20Textbook%20of%20Rheumatology,%208th%20ed./HTML/f4-u1.0-B978-1-4160-3285-4..10042-7..gr16.jpg

http://www.youtube.com/watch?v=9AJxcbd9g8A

 

Place the knee in 20 - 30 degrees of flexion with the quadripces relaxed. Grasp the patella and attempt to place lateral directed stress.

If the patella is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion by contracting the quadriceps



Category: Orthopedics

Title: Apprehension test for shoulder dislocation

Keywords: shoulder dislocation, apprehension (PubMed Search)

Posted: 8/25/2012 by Brian Corwell, MD (Updated: 3/29/2024)
Click here to contact Brian Corwell, MD

Apprehension test for shoulder dislocation

 

Tests for chronic shoulder dislocation                                                       

Similar to the patellar apprehension test

Designed to place the humeral head in a position of imminent subluxation or dislocation

 

http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/112_kelly/kelly-fig11.jpg

 

ABduct and externally rotate arm to a position where the shoulder may dislocate

If the shoulder is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion.



Category: Orthopedics

Title: Synovial Fluid Analysis

Keywords: lactate, synovial fluid, (PubMed Search)

Posted: 8/18/2012 by Michael Bond, MD (Updated: 3/29/2024)
Click here to contact Michael Bond, MD

The Analysis of Synovial Fluid Analysis

When trying to diagnosis a septic joint, it is common to order the following labs on the synovial fluid:

  • Synovial WBC count
  • Glucose
  • Protein
  • Gram Stain
  • Culture

Unfortunately, there is no value of glucose or protein that has enough sensitivity and specificity to make the tests diagnostically helpful.  Gram stains are only postive in culture positive septic joints in approximately 50% of the cases.  Cultures take too long to be helpful in the ED.  The synovial WBC count can be helpful if very high, but a low value does not ensure that the patient does not have a septic joint.

The one test that has been shown to have a Positive Likelihood ratio of Infinity is a synovial lactate level >10.  A synovial lactate should be sent on all synovial fluid as a level of 10 and greater makes the diagnosis of septic arthritis, regardless of the gram stain or synovial WBC level.

 

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Category: Orthopedics

Title: Humerus Fractures

Keywords: Humerus Fractures (PubMed Search)

Posted: 7/21/2012 by Michael Bond, MD (Updated: 8/28/2014)
Click here to contact Michael Bond, MD

Humerus Fractures, Proximal

  • Proximal fractures of the humerus only account for about 5% of all fractures but account for 45% of all humeral fractures.
  • We should be familar with the Neer Classication System for Humeral fractures, which can also be seen at http://health-7.com/Handbook%20of%20Fractures/15%20-%20Proximal%20Humerus%20Fractures
     
  • The classification system classifies fractures based on
    • 1-part
    • 2-part
    • 3-part
    • 4-part
  • The bony segments that make up the parts are
    • Greater Tuberosity (GT)
    • Lesser Tuberosity (LT)
    • Humeral Head
    • Humeral Surgical Neck (SN)
  • A part is defined as displaced if >1 cm of fracture displacement or >45 degrees of angulation.
  • The greater the number of parts the more likely the patient will require surgery or have increased complications.
    • 3 and 4 part fractures are often fixed surgical due to the increased risk of vascualr compromise to the humeral head.

 



Category: Orthopedics

Title: Ulnar nerve compression neuropathy

Keywords: Ulnar nerve, compression, neuropathy, wrist (PubMed Search)

Posted: 7/14/2012 by Brian Corwell, MD (Updated: 3/29/2024)
Click here to contact Brian Corwell, MD

The median nerve is not the only compression neuropathy of the wrist

The ulnar nerve can become compressed at the level of the wrist as it 1) enters Guyon's canal or 2) or as the deep branch curves around the hook of the hamate

Compression can occur due to carpal bone fractures, local inflammation, ganglias, lipomas, anatomic abnormalities, etc

In sports medicine, the most common mechanism is injury is seen in cyclists (cyclist/handlebar palsy)

http://www.hughston.com/hha/b_15_3_2a.jpg

Also seen in those who participate in racquet sports, baseball, and golf

Symptoms can be isolated motor (claw hand = rare), sensory or both

http://en.academic.ru/pictures/enwiki/85/Ulnar_claw.jpg

Can be associated w/ median nerve compression

Tx: Activity modification such as wearing padded gloves, padding the object, or changing hand position on the handlebars

If above fails, surgical decompression is very effective.



Category: Orthopedics

Title: First Metacarpal Fractures

Keywords: Bennett, Rolando, fracture (PubMed Search)

Posted: 6/30/2012 by Michael Bond, MD (Updated: 3/29/2024)
Click here to contact Michael Bond, MD

First Metacarpal Fractures:

There are two types of fractures that commonly occur at the base of the 1st metacarpal.  They are:

Bennett Fracture:  This is an intraarticular fracture at the base of the 1st metacarpal that always involves some degree of subluxation or dislocation of the 1st carpometacarpal joint. 

Bennett Fracture

Image from Wikipedia Commons

  • This is the most common fracture of the thumb. 
  • This fracture is typically caused by axial loading the thumb while the metacarpal is partially flexed.  A common mechanism is when a person punches a wall or hard object with their thumb take the brunt of the force.
  • Most of these fractures will require surgical repair but can be treated in the ED with a Thumb Spica Splint.

Rolando Fracture:  This is a communited intraarticular fracture at the base of the first metacarpal that typically has a T or Y shaped configuration with 3 fragments.

Rolando Fx

Image courtesy of WikiPedia Commons

  • Less common then Bennett Fractures
  • Associated with a worse prognosis
  • Requires surgical repair but can be splinted in the ED with a thumb spica splint.