UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: Lidocaine for shoulder discloations

Keywords: intra-articular lidocaine, shoulder dislocation (PubMed Search)

Posted: 1/15/2012 by Brian Corwell, MD
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Approximately 48% of shoulder dislocations occur during sports and recreation.

These are usually first managed in the clinic and sideline setting.

In 6 reviewed studies, 5 used 20mL of 1% lidocaine and 1 used 4 mg/kg of 1% lidocaine.

    Patients incurred significantly reduced cost compared to IV sedation

There were no infections, neurovascular damage or systemic effects of the lidocaine.

No significant differences were noted in pain control, success rate or ease of reduction between intra-articular lidocaine and systemic sedation.

The risk of chondrolysis increases with higher concentration and longer duration of exposure to local anesthetics.

There is scant research about the effects of a single exposure of cartilage to lidocaine.

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Category: Orthopedics

Title: Biceps rupture

Keywords: biceps, tendon, rupture (PubMed Search)

Posted: 12/24/2011 by Brian Corwell, MD
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The long head of the biceps originates from the glenoid tubercle and superior labrum. 

Rupture of the proximal biceps tendon comprises 90-97% of all biceps ruptures

Often in men aged 40-60y

     - Almost exclusively involves the long head.

     - Aka "Popeye Arm" (distal contraction of the muscle belly)

-          May be acutely traumatic or microtears & age associated degeneration

-          Minimal loss of function because short head of biceps remains attached

-          Many patients can be treated non operatively

-          Most asymptomatic after 4-6 weeks

-          Place in sling, ice, analgesia

-          Refer to ortho for re-evaluation and determination of operative versus conservative management

http://imaging.birjournals.org/content/15/4/193/F7.large.jpg


Category: Orthopedics

Title: Subtle radiographic signs of child abuse

Keywords: fractures, child abuse, radiology (PubMed Search)

Posted: 12/10/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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Metaphyseal bucket handle and corner fractures are almost pathognomonic for child abuse

These injuries were originally identified by clinicians evaluating children with subdural hematomas

These injuries are typically seen in the ankles, knees, elbows and wrists

Violent twisting, shaking, or pulling across a joint creates shearing forces across the weak epiphyseal growth plate and metaphysis

This leads to

1)      A thin rim of mineralized metaphyseal bone aka  “bucket handle”  

http://rad.usuhs.mil/rad/home/peds/bucketarrow.jpg

OR

2)      Small flecks of bone from the metaphyseal corner adherent to periosteum

http://t2.gstatic.com/images?q=tbn:ANd9GcT0kZ3VR1f7MwRj7oIa6jaYVp_-f8kZ1NhSbw4kCTRGNLDJ1pKK9g


Category: Orthopedics

Title: Ankle fracture classification

Keywords: Weber, ankle fracture, fibula (PubMed Search)

Posted: 11/26/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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The Weber classification system

A commonly used, simple, easily remembered system used to describe ankle fractures. The system focuses on the integrity of the syndesmosis.

http://www.accessemergencymedicine.com/loadBinary.aspx?fileName=simo_c017f013t.gif

  - TYPE A:  fibula fracture below the ankle joint/syndesmosis (which is intact). Deltoid ligament intact. Medial malleolus can be fractured. Usually treated with closed reduction.

http://www.gentili.net/image1.asp?ID=-241442344&imgid=AnkleWeberAAP600.jpg&Fx=Weber+A+Fracture

  - TYPE B:  is a transsyndesmotic fracture with usually partial rupture of the syndesmosis (though may be intact). No gross widening to the tib/fib articulation.. Deltoid ligament intact. Medial malleolus often fractured.  Variable stability. Any clinical or radiographic injury to the medial joint complex make this an unstable fracture

http://www.gentili.net/image.asp?ID=145&imgid=AnkleWeberBmortise600.jpg&Fx=Weber+B+Fracture

  - TYPE C:  Fibular fracture above the level of the syndesmosis with usually a total rupture of the syndesmosis (seen as widening of the distal tib/fin articulation), resulting in instability of the ankle mortise. Associated with medial malleolus fracture or deltoid ligament injury. Unstable.

http://www.gentili.net/image1.asp?ID=146&imgid=anklewebcapoblx2600.jpg&Fx=Weber+C+Fracture

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Category: Orthopedics

Title: Treatment of Back Pain

Keywords: Back Pain, Treatment, Guidlines (PubMed Search)

Posted: 11/19/2011 by Michael Bond, MD
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Low Back is one of the most common complaints that we see in the Emergency Department.  Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…).  However, most of the back pain that we will see is musculoskeletal in origin.

The American College of Physicians (ACP) and the American Pain Society (APS)  released  joint recommendations on the evaluation of treatment of individuals with back pain in 2007.

In summary their key recommendations were:

  1. Routine imaging is not required. However, diagnostic imaging and testing should be obtained for patients with low back pain when severe or progressive  neurologic deficits are present or when serious underlying conditions are suspected.
  2.  For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
  3. Medications that have good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain).

Links to the Clinical Guidelines are listed below:


Category: Orthopedics

Title: wrist arthrocentesis

Keywords: wrist arthrocentesis radiocarpal joint (PubMed Search)

Posted: 11/12/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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Arthrocentesis of the Wrist

 

First locate and feel comfortable identifying two important landmarks:

1) Lister's tubercle is an elevation found in the center of the dorsal aspect of the distal end of the radius

http://www.aafp.org/afp/2004/0415/afp20040415p1941-f2.jpg

2) The extensor pollicis longus (EPL) tendon runs in a grove just radially to Lister's tubercle. Active extension of wrist and thumb aid with identification.

http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/upper-body/extensor-pollicis-longus/atlasImage

 

A) Positioning:  Place wrist in ulnar deviation and 20 - 30 degrees of flexion. Apply longitudinal traction to the fingers of the hand.

B) Technique:  Insert a small needle (22g) just distal to the tubercle and on the ulnar side of the EPL tendon.

http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-80032-1477044tn.jpg

http://www.youtube.com/watch?v=nlPdb_mymw4&feature=related

http://www.youtube.com/watch?v=UVG7fZvZD-s&feature=related

 

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Category: Orthopedics

Title: triangular fibrocartilage complex injuries

Keywords: TFCC, triangular fibrocartilage complex, wrist (PubMed Search)

Posted: 10/23/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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The TFCC (triangular fibrocartilage complex)  is a ligamentous/cartilage like complex similar to the meniscus of the knee located on the ulnar side of the wrist.

http://yanyanxu.com/wp-content/uploads/2008/01/trifibcc.gif

 

Hx: ulnar sided wrist pain following trauma and associated with activity related mechanical symptoms such as clicking.

 

PE:  tenderness to palpation distal to ulnar head or at ulnar styloid . Tenderness against resisted radial deviation.

 

Plain film may show ulnar styloid avulsion or injury to carpal structures.

Refer to hand/wrist surgeon

Splint in ulnar gutter of long arm spica

MRI or arthrogram are studies of choice.

http://www.cobalthealth.co.uk/MImageGen.ashx?image=%2Fmedia%2F12951%2Fwrist-tfcc-tear-big.jpg&width=170&crop=true


Category: Orthopedics

Title: Sinus Tarsi Syndrome

Keywords: Sinus tarsi syndrome (PubMed Search)

Posted: 10/15/2011 by Michael Bond, MD (Updated: 9/24/2013)
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Sinus Tarsi Syndrome

  • A painful syndrome of the ankle normally due to an inversion injury.  Results in pain along the lateral side of the ankle.
  • Often misdiagnosed as an ankle sprain.
  • Will have pain localized to the sinus tarsi (inferior and anterior to the anterior border of the lateral malleolus.
  • Can be diagnosed by injecting lidocaine into the sinus tarsi, which should completely relieve the pain.
  • Treatment consists of
    • NSAIDs
    • Ankle immobilization
    • Physical therapy
    • Oral or injected steroids in resistant cases

 

 


Category: Orthopedics

Title: Fibular head dislocations

Keywords: dislocation, fibula, reduction (PubMed Search)

Posted: 10/8/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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      Anterolateral dislocation is most common (>85%)

As the tib/fib joint has its own synovial cavity, a knee effusion will not be seen

Mechanism: fall on the flexed knee with foot/ankle inversion

Hx: swelling, variable amount of lateral knee pain (anywhere from mild discomfort to inability to bear weight)

PE: Prominence of the fibular head, ankle motion exacerbates knee pain. no associated neurovascular issues

However with less common dislocations (posterior and superior) peroneal nerve injury may occur

Reduction: Place patient supine with knee flexed to 90 degrees. Ankle should be dorsiflexed and externally rotated.

REVERSE THE INJURY: Apply firm posteriorly directed pressure to the fibular head. May head an audible pop as fibular head reduces.  Reassess collateral ligament function.

 

 


Category: Orthopedics

Title: Saturday Night Palsy

Keywords: radial nerve, mononeuropathy (PubMed Search)

Posted: 9/24/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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Saturday night palsy - radial nerve mononeuropathy due to improper arm positioning associated with inebriated sleep.

Physical examination - Wrist and finger drop. 

Patients may have findings suggestive of ulnar nerve co-involvement (interossei testing)  which may falsely lead the examiner to consider a more proximal location for the lesion such as the brachial plexus.

The finger drop caused by the radial nerve lesion places the hand at a mechanical disadvantage.  Adjust for this by examining the hand on a flat surface (stretcher, counter top). With the fingers now supported in extension at the MCP joint  (no longer "dropped"), the interossei can now be tested in isolation and will be normal.


Category: Orthopedics

Title: Posterolateral Corner Injuries of the Knee

Keywords: Posterolateral Corner, knee (PubMed Search)

Posted: 9/17/2011 by Michael Bond, MD (Updated: 6/25/2022)
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Posterolateral Corner Injuries

The posterolateral corner “PLC” of the knee is becoming increasingly recognized as an extremely important structure to maintain the stability of the knee joint.

PLC injuries occur with hyperextension, varus load and tibial external rotation.  So the most common mechanism is a posterolaterally directed blow to the anteromedial tibia when the knee is hyperextended. PLC injuries are commonly associated with injury to other ligaments (ACL, PCL, LCL) and occur in isolation in <5% of cases.  If suspected make sure to check for other ligamentous injuries.

Since this injury can be missed and is associated with significant disability it is important to test for it.  This YouTube video, http://youtu.be/bnXaTdvZZ6o, demonstrates several examination techniques that can identify the injury. 

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Category: Orthopedics

Title: Knee Dislocation (part 2)

Keywords: knee dislocation, ABI, vascular (PubMed Search)

Posted: 9/10/2011 by Brian Corwell, MD
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Evaluation of circulatory status is the most important aspect of post reduction care.

Look for hard findings such as cool/cold lower extremity, diminished or absent pulses, pale or dusky skin, paralysis, etc.

However, the absence of these findings should not lull the clinician into a false sense of security. The degree of initial joint deformity, presence of full bounding pulses and warm skin over the dorsum of the foot can all be present in the setting of vascular injury.

The next step will be to perform an ABI (ankle-brachial index).

In one small study, no patient with an ABI greater than or equal to 0.9 had a vascular injury.

Patients with a reassuring physical exam and ABIs should be admitted for vascular checks without further imaging.

Patients with a reassuring physical examination but with an abnormal ABI should have an imaging study obtained (arteriogram/CT angiogram).

Patients with hard findings of a vascular injury should have an emergent vascular surgery consultation.

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Category: Orthopedics

Title: Sugar Tong Splint

Keywords: Sugar Tong Splint (PubMed Search)

Posted: 9/3/2011 by Michael Bond, MD
Click here to contact Michael Bond, MD

Sugar Tong Splint

The sugar tong splint is ideal for splinting fractures of the radius, ulna, or wrist.  It prevents flexion and extension at the wrist, limits flexion and extension at the elbow, and prevents supination and pronation.  A posterior long arm splint does not prevent supinaton and pronation, therefore, it is of limited use for radius and ulna fractures.

The traditional sugar tong can be difficult to put on a patient without an assistant as it is often hard to hold the splint in position as you begin to ace wrap it. A variation on the sugar tong, the reverse sugar tong, prevents this frustration.  The splinting material is cut so that a small piece suspends the splint from the web space between the thumb and index finger.  The open ends at the elbow are also easily folded under each other, preventing any bulky splint material from extending out.

The reverse sugar tong is on the left, the original sugar tong on the right.

Check out this video showing how to place a reverse sugar tong splint.

http://www.youtube.com/watch?v=r-RHdttOMf0


Stability from 4 major ligaments (ACL, PCL, MCL and LCL)

Knee dislocation causes injury to multiple ligaments (usually 3 of the above).

Many of these dislocation spontaneously reduce prior to medical evaluation.  Therefore, consider knee dislocation in a patient with multi ligament injury, significant hemarthrosis and bruising.

Vascular injury in up to 40% (popliteal artery)

Nerve injury in up to 23% (peroneal nerve) ((ankle dorsiflexion and sensation to the first web space of the foot))

After reduction, immobilize knee in 15-20 degrees flexion.

The degree of initial deformity, presence of strong pulses, or warm skin cannot be used to rule out popliteal injury.

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Category: Orthopedics

Title: Acute brachial plexus neuritis

Keywords: Brachial plexus neuritis, neck pain (PubMed Search)

Posted: 8/13/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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Acute brachial plexus neuritis is an uncommon disorder that is easily confused with cervical radiculopathy.

Patients present with a characteristic pattern of acute onset of burning pain.  Pain subsides in days to weeks and is then followed by profound weakness and muscle wasting changes affecting the shoulder  and upper extremity. Weakness is best identified in the deltoid, biceps and rotator cuff muscles. Strength gradually recovers over 3-4 months.

DDX:  The constellation of pain, weakness and sensory loss associated with cervical radiculopathy tend to occur simultaneously.  Also cervical radiculopathy tends to involve only a  single root.

ED treatment is with analgesics and physical therapy and PCP referral for outpatient MRI/EMG. Consider a sling in those with severe shoulder weakness.

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Category: Orthopedics

Title: Refractory Osteomyelitis

Keywords: Osteomyelitis, hyperbaric oxygen (PubMed Search)

Posted: 7/23/2011 by Brian Corwell, MD
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Refractory Osteomyelitis is defined as a chronic osteomyelitis that persists or recurs after appropriate interventions have been performed or where acute osteomyelitis has not responded to surgery and antibiotics.

Case series, animal data and non-randomized prospective trials suggest that the addition of Hyperbaric Oxygen therapy to routine surgical and antibiotic management of previously refractory osteomyelitis is safe and improves the rate of infection resolution.

In patients with osteomyelitis involving spine, skull, sternum,  HBOT  is recommended prior to surgical intervention.  

Typically patients require 20-40 daily dives for sustained therapeutic benefit. 

How does HBOT work in osteomyelitis?

1.       Restoration of normal to elevated O2 level in infected bone.

2.       Leukocyte mediated killing of aerobic bacteria is restored when low O2 tension intrinsic to osteomyolitic bone is restored to physiologic or supra-physiologic levels.

3.       HBOT is noted to exert direct suppressive effects on anaerobic infections.

4.       HBOT augment the transport of certain abx (aminoglycosides and cephalosporins) across bacterial cell wall.

5.       Enhance osteogenesis

6.       Enhance angiogenesis

 

thank you to Dr. Sethuraman for this pearl

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Category: Orthopedics

Title: Electrolyte abnormalities in marathon runners

Keywords: Electrolyte abnormalities, marathon runners, troponin (PubMed Search)

Posted: 7/9/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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Emergency physicians are often called upon to provide event coverage for marathons.

Prolonged endurance racing is safe for the majority of participants.

Hyponatremia (8.2% - 13.5%)  - finishing times of greater than 4 hours is an independent risk factor

Hypokalemia – uncommon

Renal function – BUN > 30 or Cr > 1.4 mg/dL (23.6%). There is no data that this is of any clinical significance.

Cardiac Troponin - (11%) had significant increases (troponin T > or = 0.075 ng/mL or  troponin I > or = 0.5 ng/mL). Elevations were more commonly seen with weight loss and increased Cr levels and may be associated with running inexperience (< 5 previous marathons) and young age (< 30 years) though interestingly not with race duration or traditional cardiac risk factors.

Findings are similar for men and women

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Category: Orthopedics

Title: Pes Anserine Bursitis

Keywords: Pes Anserine, Bursitis, knee pain (PubMed Search)

Posted: 6/25/2011 by Brian Corwell, MD (Updated: 6/25/2022)
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Pes Anserine Bursitis is an inflammatory condition of the medial knee

Occurs at the bursa of the pes anserinus which overlies the attachment of the 1) Sartorius 2) gracilis and 3) semitendinosis tendons

Note the location is 2-3 inches below the knee joint on the medial side

http://kneespecialistsurgeon.com/images/uploaded/Pes%20anserinus%20bursitis%20image.jpg

http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/575-27_default.jpg

 

Patients complain of pain (especially with stair climbing)

PE: Tenderness to palpation of the bursa with mild swelling

DDx: MCL tear, medial meniscus injury, medial (knee) compartment arthritis

Treatment: Cessation/modification of offending activities, Icing and ice massage, NSAIDs, hamstring stretching and physical therapy. Failure of the above should prompt referral for bursal steroid injection.

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Category: Orthopedics

Title: Kocher Criteria for Childhood Septic Joint

Keywords: kocher, septic arthri (PubMed Search)

Posted: 6/18/2011 by Michael Bond, MD (Updated: 6/25/2022)
Click here to contact Michael Bond, MD

Kocher Criteria for Septic Arthritis in Children:

Septic arthritis should be suspected in children that have a painful joint especially if they do not want to weight bear.  Orthopedics uses the Kocher Criteria to determine the probability of whether the joint is infected. 

Four elements make up the criteria:

  • Erythrocyte Sedimentation Rate >40
  • WBC > 12
  • Non weight-bearing on the affected joint
  • Fever.

If only one sign is present there is a 3% chance the child has a septic joint.

  • 2/4 criteria = 40%
  • 3/4 criteria = 93%
  • 4/4 criteria = 99%


 


Category: Orthopedics

Title: Kienb ck's disease

Keywords: Kienb ck's disease, wrist, avascular necrosis (PubMed Search)

Posted: 6/11/2011 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Kienbock’s disease is a rare entity involving collapse of the lunate due to avascular necrosis and  vascular insufficiency.

Occurs most commonly in young adults aged 15 to 40 years.

Cause is unknown but believed to be due to remote trauma or repetitive microtrauma in at risk individuals.

Patients complain of wrist pain, stiffness and swelling

On exam, limited range of motion, decreased grip strength and passive dorsiflexion of the 3rd digit produces pain.

Dx: plain film in the ED and with MRI as an outpatient.

Tx:  Wrist immobilization with splint and refer to orthopedics. Ultimate treatment is individualized and there is no clear consensus.

Lunate sclerosis seen on plain film

http://orthoinfo.aaos.org/figures/A00017F02.jpg

AVN of the lunate seen on MRI

http://www.assh.org/Public/HandConditions/PublishingImages/KeinbocksMRI_figure3.JPG

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