UMEM Educational Pearls - Orthopedics

Transient brachial plexopathies aka Burners and Stingers

Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes.

49-65% of all college football players have experienced at least one burner with a 87% recurrence rate.

Injuries most commonly occur at C5-C6 but may involve any root level.

3 Mechanisms: Commonly due to

1) Traction caused by lateral flexion of the neck away from the involved side

2) Compression of the upper plexus between shoulder pads and scapula

3) Nerve compression caused by neck hyperextension and ipsilateral rotation.

CC: Burning or numbness in the neck, shoulder and/or arm

Symptoms are UNILATERAL and tend to usually  last seconds to minutes

Symptoms are reproduced by the Spurling maneuver.

Function gradually returns from the proximal muscle groups to the distal muscle groups.

Because most burners are self-limited, the most important goal is to rule out an unstable cervical injury.

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Iliopsoas tendonitis and Iliopsoas Syndrome

• Iliopsoas tendonitis is inflammation of the iliopsoas muscle which can also affect the bursa lying under the iliopsoas muscle tendon.  
• Iliopsoas syndrome is a stretch, tear or complete rupture of the iliopsoas muscle and/or iliopsoas tendon.
• The iliopsoas muscle and tendon are commonly injured from acute trauma and/or overuse resulting from repetitive hip flexion.
• The pain may radiate down the anterior thigh to the knee.
• One variant is the internal snapping hip syndrome which results in an audible snap or click in the hip or groin with hip flexion.
• Treatment consists of rest, stretching exercises, physical therapy and NSAIDs.

Meralgia Paresthetica - caused by entrapment of the lateral femoral cutaneous nerve (LFCN)

The LFCN is responsible for sensation of the anteriorlateral thigh.

http://www.chiropractic-help.com/images/Meralgia-Paresthetica.jpg

NOTE*  It has no motor component!

Associated with pregnancy, wearing tight pants, belts, girdles, and in diabetic and obese patients.

Symptoms include numbness, paresthesias and pain (not weakness). Worse w walking, standing. Better w sitting.

Diagnosis is clinical but may be confirmed with nerve conduction studies

Treatment includes, NSAIDs, injection and surgery for refractory cases.

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.
• Extensor tendon lacerations can be repaired by emergency providers.
  • 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 reasonable approach to all tendon lacerations is to close the wound and splint in 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.

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Tendon Lacerations:

Hand lacerations need to be carefully explored in order to determine whether there is an associated tendon laceration.  These can be be difficult to find unless a systematic approach is followed:

• The laceration should be explored to its base in a bloodless field while the fingers and wrist are moved through their full range of motion (ROM).  A tendon laceration can easily be missed if the hand is only visualized with the fingers extended. The area of the tendon that was lacerated can retract into the hand, or not be visible if the area was injured when the fingers were flexed. By extending the finger, the location of the injury may not line up with the wound making it impossible to see unless the fingers are moved through their full ROM.
• The fingers and wrist ROM should be tested actively and against resistance as the patient may only experience an increase in pain and have a completely normal ROM if there is only a partial tendon laceration.
• If there is a suspicion of a tendon laceration (decreased ROM, or increased pain with resistance when ROM is tested) the laceration may need to be extended in order to completely visualize the tendon if it can not be done through the wound that was created with the original injury.

Future pearls will cover techniques on how to repair tendon lacerations.  Stay tuned.

Gout treatment considerations

Treatment is directed to relieve pain and inflammation

NSAIDs, steroids and narcotics are the mainstays of treatment. All 3 should be used in combination.

Aspirin should be avoided as it may increase uric acid levels

     Note: not in prevention doses (81mg) in treatment doses (325-650mg q4h)

      NSAIDs and steroids take time to be effective.  Provide appropriate analgesia with oral narcotic medication for short term relief

     Don't forget the benefit of splinting a "hot" joint (the ankle or wrist for example)

NSAIDs: Use may be limited in the elderly and in those on coumadin or with peptic ulcer disease. 5-7 days of treatment is usually sufficient. Indomethacin is most commonly used (50 mg TID, which may be tapered to 25 mg TID after 3 days)

Steroids:  Likely more effective than NSAIDs. Oral prednisolone is more effective than naproxen (1). Use prednisone 30-50 mg for 3-5 days without tapering (as we use for asthma). May be useful to supplement with NSAIDs on the tail end to prevent a rebound flare. If tapping the joint consider intraarticular steroids. If there is concern for medical noncompliance with oral steroids consider IM steroids (triamcinolone 60mg or methylprednisolone).

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Gout Part 2

• Hyperuricemia can result from both uric acid overproduction (metabolic/myeloproliferative diseases) in addition to uric acid underexcretion (more common).
• Consider gout in any patient who complains of joint pain that reaches peak intensity over hours and may wake them from sleep. Septic joints tend to reach peak intensity of days.
• Patients may have multi joint involvement, low-grade fever and leukocytosis (factors that may lead one to consider an alternative diagnosis)
• Remember that gout is also a disease of the synovial tissue (tendonitis and bursitis).
• NSAIDs: Traditional preferred treatment for acute gout
• Colchicine: Less effective if the current attack is >24 hours. Use correct dosage for best effect/side effect ratio.
• Steroids: At least as effective as NSAIDs.

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Knee dislocations are uncommon, and prosthetic knee dislocations even rarer.  Some general facts about prosthetic knee dislocations are:

• Posterior dislocations typically occur in the post-operative period and are usually the result of trauma that disrupts the PCL ligament.
• Factors that predispose a person to posterior dislocations are valgus deformity of the knee, malposition or improper selection of prosthetic components, patellar instability, and extensor mechanism dysfunction.
• The mechanism for this dislocation is typically flexion and external rotation of the knee when the lateral side of the knee is too loose.
• Anterior dislocations more commonly occur months to years after surgery and usually are not associated with trauma.
• Many of these dislocations result from loss of integrity of the posterior cruciate ligament, which provides anteroposterior stability of the knee and assists in femoral rollback. This motion is essential for the extensor mechanism of the knee to function.
   

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GOUT part 1

Gout is an inflammatory arthritis that classically affects the first metatarsal phalangeal joint

Gout prefers cool ambient temperature hence gouty tophi prefer the great toe (one of the coldest parts of the body) and avoids "warmer" joints such as the hip and shoulder.

Remember that gout can affect other joints as well (elbow, wrist, knee and ankle) and  can cause painful bursitis and tendonitis

Multiple joints can be involved simultaneously (leading to confusing with RA and OA)

The involved joint will often be red, hot, swollen and very painful leading to easy confusion with cellulitis and or a septic arthritis

Diagnose gout by demonstrating monosodium urate crystals in the synovial fluid.

**Remember previous pearl by Dr. Bond regarding the coexistence of gout with septic joint**

Serum uric acid levels are commonly elevated but can be normal or even low

Use caution with this test because asymptomatic hyperuricemia is much more common than gout

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Talar Neck Fractures

Have a high rate of avascular necrosis (AVN), nonunion, and arthritis.  Almost all require ORIF

• Hawkins 1:
  • 0- 13% AVN rate
  • non-displaced fracture
• Hawkins 2:
  • 20- 50% AVN rate
  • Displaced fracture with subluxation or dislocation of the posterior facet of the subtler joint. Subtalar joint usually dislocated posteriory
• Hawkins 3:
  • 20-100% AVN rate
  • Displaced fracture of the talar neck with dislocation of the body of the talus from both the subtalar joint and the ankle joint

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Cubital Tunnel Syndrome aka Radial Tunnel Syndrome

• The most common neuropathy of the elbow
• Entrapment of the ulnar nerve as it passes posterior to the medial epicondyle of the elbow
• HX: medial elbow and forearm pain occasionally associated with ulnar digit paresthesias.
• May be due to trauma, degenerative changes or throwing sports.
• PE:  Pain with elbow flexion. Tenderness to palpation over the cubital tunnel. Positive Tinnel's sign.
• **Up to a quarter of normal asymptomatic patients will have a positive Tinnel's**
• DDx: Ulnar collateral ligament strain/tear and medial epicondylitis
• Tx: Ice, NSAIDs, activity modification, night splints with elbow in 45 degrees flexion and finally surgical decompression or nerve transposition    

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Sever's disease ,aka calcaneal apophysitis, is a common overuse injury in the pediatric and adolescent population.

Occurs secondary to traction of the calcaneus that most often occurs in young athletes (8-12 yo)

     -Avg. age of presentation is 11 years 10 months in boys & 8 years 8 months in girls

     -Repetitive traction to the weaker apophysis, induced by the pull of the Achilles on its insertion

Hx: Heel pain that increases with activity (running, jumping).

     -May involve one (40%) or both (60%) feet

PE: Tenderness of the posterior heel at the Achilles tendon insertion and ankle dorsiflexor weakness

Imaging:  Radiography is often normal.  When positive, show fragmentation and sclerosis of the calcaneal apophsis. NOTE:  These findings are nonspecific and also are observed in asymptomatic feet.

http://t0.gstatic.com/images?q=tbn:ANd9GcQ9R-fx1iyhbhNJpNL2W72bWdK72_mRBLNX5DUDtcMfnDli-x7Ong

DDx: Includes osteomyelitis and tarsal coalition.

Tx: Rest from aggravating activities, NSAIDs, ice (both pre and post sport).  When pain free a program of stretching (gastrocnemius-soleus), strengthening (dorsiflexors) and shoe inserts (heel cups, lifts, pads, or orthotics) can provide significant pain relief.

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Distal Radius Fractures

Typically distal radius fractures are treated with closed reduction and splinting in the ED, followed by operative repair. This is done because it is felt that patients will have the best functional outcomes if the bones are restored to their normal anatomic alignment.  However, two studies published in 2010 suggest differently.

The study by Neidenbach showed that after one year there was no difference in functional outcomes between patients that were just splinted in the ED in the position the fracture was found versus those that had closed reduction with splinting. 

The second study by Ego showed that there was no difference in outcomes between those that underwent conservative treatment with closed reduction and splinting versus those that underwent operative repair.

The take home point from these studies for the EM physician is that most distal radius fractures can be splinted in the position found with them following up with an orthopaedist.  There is probably little advantage to performing a closed reduction in the ED knowing that this procedure can use a lot of valuable time and resources.

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Iliotibial band syndrome (ITBS)

• Due to recurrent friction of the iliotibial band (ITB) sliding over the lateral femoral condyle.


http://footcarexpress.com/foot-orthotics/wp-content/uploads/2009/01/iliotibial-band-syndrome.jpg


Hx -

• Sharp or burning pain on the lateral aspect of the knee usually in runners.

• Rarely occurs at start of run, rather, occurs after reproducible time or distance
• (especially when running downhill)


PE-

• Typically negative other than local tenderness (approx. 2cm above lateral joint line) & occasional swelling over the distal ITB.
• 
Specialized tests: See also Ober's test and Noble's test

• 
http://www.youtube.com/watch?v=A0C0WBw4l4s

• http://www.youtube.com/watch?v=IIJVbf_t_2A


Tx

• Most patients respond to conservative treatment involving NSAIDs, stretching of the iliotibial band, strengthening of the gluteus medius, and altering training regimens.

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FARES Method for Reduction of Anterior Shoulder Dislocations.

This method that was recently highlighted in a publication had a ~78% success rate with the authors able to reduce the shoulder in an average of 2.36 ±1.24 minutes  without having to give the patients any analgesics or sedatives. The technique is done by:

• Placing the patient in the supine position.
• Hold the hand of the affected arm while the arm is at the patient’s side with the elbow extended and the forearm in neutral position.  
• Apply gentle longitudinal traction and slowly move the arm into abduction while oscillating the forearm with continuous, brief (two to three full cycles per second) and short range (approximately 5 cm above and beneath the horizontal plane) vertical  movements of the arm.  These oscillations should be done during all   all stages of the reduction as it helps that patient relax their muscles.
• Once the arm is abducted past 90º, gently externally rotate the arm while continuing to abduct it.  Continue the oscillations.
• Reduction is usually achieved at ~ 120º of abduction.  
• Once reduction is achieved, move the arm gently until it is internally rotated and resting on the patients chest.

Consider trying this with your next shoulder dislocation.  No single method of reduciton is 100% successful, but methods like this that only require a single provider and do not require analgesics are extremely helpful in improving patient flow as they do not utilize a lot of ED resources..

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                Involves an avulsion of the flexor digitorum profundus  (FDP) tendon from its insertion on the distal phalanx.

     Ring finger is most commonly involved.

                Usually occurs from a grabbing attempt (resulting in forced DIP extension during maximal FDP contraction) as would occur while attempting to grab someone’s jersey such as in football or rugby.

Clinically, there is normal passive DIP ROM with loss of active flexion. Examine this by asking the patient to flex the fingertip at the DIP while the PIP joint is held in extension.

*Remember that patients with a 90% full-thickness tendon laceration may still have normal (albeit painful) range of motion. The examiner must evaluation the strength of the tendon against resistance. This injury is commonly missed as it is diagnosed as a “jammed” finger.

Plain films may show a bony avulsion, but are often negative.

Treatment is primary repair especially with large bony fragments. Partial ruptures can be treated nonoperatively at the discretion of the hand surgeon.

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Peroneal Tendon Subluxation: The Other Ankle Sprain

• Peroneal tendon subluxation is an uncommon cause of lateral ankle pain that is often misdiagnosed as a simple ankle sprain.
• It is commonly associated with sports that require cutting such as skiing, basketball, soccer, and football.
• The subluxation occurs when there is a forceful contraction of the peroneal tendon while the foot is dorsiflexed and inverted.
• Patients will often complain of pain at the posterolateral ankle that started as a forceful pop.  They may also complain of snapping or popping around the lateral malleolus as it continues to sublux.
• On clinical exam, the patient will often have pain along the  retrofibular groove. The peroneal tendon can be tested by actively dorsiflexing and everting the ankle from a plantar-flexed and inverted position.  You should be able to see or feel the subluxation. Passive circumduction of the ankle may also recreate the subluxation.
• Conservative management (i.e.: ankle brace, cast or walking boot) is associated with a low success rate; therefore, these patients should be referred to sports medicine or orthopaedics for possible operative repair.

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Commotio Cordis

Emergency medicine & sports medicine physicians often cover sporting events where athletes are at risk of commotio cordis

• 2nd most common cause of sudden cardiac death in young athletes in the US (HCM #1)
• Young males between 4 and 18 years old are at greatest risk
• 50% of all cases occur during competitive sports (baseball #1)
• Nonpenetrating, blunt trauma to the chest resulting to cardiac arrhythmia and, often, sudden cardiac  death.
• Ventricular fibrillation (VF) is the most common arrhythmia.
• Thought to occur secondary to a precordial impact during an electrically vulnerable portion of ventricular repolarization (10-30 msec before the T-wave peak)
• Treatment:  Immediate chest compressions and early use of an automated external defibrillator (AED) ((effective in only 15% of cases))
• Survival is much improved if resuscitation administered within 3 minutes (25%) than after 3 minutes (3%)
• Differential diagnosis: other causes of sudden cardiac death including HCM, coronary artery anomalies, long QT syndrome, Brugada syndrome, WPW, CAD, myocarditis, arrhythmogenic right ventricular dysplasia

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Septic Arthritis

It is generally taught that if the synovial fluid white blood count (WBC) is less than 50,000 it is not septic, however, there is growing evidence that a clear delineation in the WBC between septic arthritis and inflammatory arthritis is not possible.  In fact, inflammatory arthritis (rheumatoid and gout) actually increases your risk for septic arthritis and the two can coexist.  Gram stains of the fluid  only show organisms in 50% of those with septic arthritis so you also can not rely on them either.  Inflammatory markers (CRP, ESR) can be elevated with inflammatory or septic arthritis so they too can not differentiate between the two.

In the end, because of the risk of permanent joint dysfunction, it is important to make the diagnosis on clinical grounds and treat empirically if you are unsure.  Err on the sound of treatment.  Serial joint aspirations to drain synovial fluid have the same outcomes as operative washout.

A recent article that discusses the concerns with making the diagnosis of septic arthritis is:

Mathews et al. Bacterial septic arthritis in adults. Lancet (2010) vol. 375 (9717) pp. 846-55

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Cervical Radiculopathy

The most commonly affected level is C7 (31-81%), followed by C6 (19-25%), C8 (4-12%) and C5 (2-14%)

Anterior compression can selectively affect motor fibers

Posterior compression can selectively affect sensory fibers

         -More common due to posterior lateral disc herniation or facet degeneration

Signs and symptoms: Sensory complaints (findings are in a root distribution) and possible weakness and reflex changes.

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