UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: triangular fibrocartilage complex injuries

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

Posted: 10/23/2011 by Brian Corwell, MD (Updated: 3/28/2024)
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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: 3/28/2024)
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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: 3/28/2024)
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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: 3/28/2024)
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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
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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: 3/28/2024)
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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: 3/28/2024)
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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: 3/28/2024)
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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: 3/28/2024)
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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
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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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Category: Orthopedics

Title: Brachial Plexus Injuries in Sports Medicine

Keywords: Brachial plexus, stinger, burner (PubMed Search)

Posted: 5/28/2011 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

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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Category: Orthopedics

Title: Iliopsoas tendonitis and Iliopsoas Syndrome

Keywords: Iliopsoas, tendonitis, syndrome (PubMed Search)

Posted: 5/21/2011 by Michael Bond, MD
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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.


Category: Orthopedics

Title: Meralgia Paresthetica

Keywords: Meralgia Paresthetica, lateral hip pain (PubMed Search)

Posted: 5/14/2011 by Brian Corwell, MD (Updated: 3/28/2024)
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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.

 



Category: Orthopedics

Title: Tendon Laceration

Keywords: Tendon, laceration (PubMed Search)

Posted: 5/7/2011 by Michael Bond, MD (Updated: 3/28/2024)
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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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Category: Orthopedics

Title: Tendon Laceration

Keywords: Tendon Laceration (PubMed Search)

Posted: 4/30/2011 by Michael Bond, MD
Click here to contact Michael Bond, MD

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.



Category: Orthopedics

Title: Gout 3/3

Keywords: Gout, pseudogout, NSAIDS, Steroids (PubMed Search)

Posted: 4/23/2011 by Brian Corwell, MD (Updated: 3/28/2024)
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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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