Keywords: Ottawa, Ankle, Knee, Foot (PubMed Search)
Most people are familiar with the Ottawa Ankle Rules, but there are also Ottawa Knee and Foot rules. The Ottawa rules help to limit the number of x-rays you may need in patients that present with ankle, foot or knee pain after an injury.
The Ottawa Ankle Rule
An ankle x-ray is only needed if there pain in the mallelolar area and any of the following:
The Ottawa Foot Rule
A foot x-ray is only needed if there is pain in the midfoot and any of the following:
The Ottawa Knee Rule
A knee x-ray is only needed for knee injury patients when they have any of the following:
Keywords: Ankle Sprain, Treatment (PubMed Search)
Ankle sprains are typically treated with a short period of immbolization and then functional exercises are prescribed to rehabilitate the ankle. A study published in the Lancet this week might just change that. Lamb et al looked at 584 people with severe ankle sprains (unable to weight bear 3 days out from injury) that were randomized to be treated with a 10 day below knee cast, Aircast, Bledshoe Shoe or Tubular Compression dressing (similar to Ace Wrap). Those that were treated with the Cast and Aircast had quicker return to function and less disability at 3 months. There was no increased risk of DVTs in the cast group.
A commentary in the same issue points out that severe ankle sprains are associated with:
Based on this article I think it is prudent to treat all patients with severe Ankle Sprains with a prolonged period of forced immobilzation (Posterior Splint, Short Leg Cast or Aircast). I would also recommend the Aircast be used to prevent recurrent sprains especially if the patient is involved in sports that require jumping (Basketball, Volleyball) where the risk of reinjury is higher.
Mechanical supports for acute, severe ankle sprain:a pragmatic, multicentre, randomised controlled trial
S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*. Lancet 2009; 373: 575–81
Immobilisation for acute severe ankle sprain [Commentary] Hertel J. Lancet 2009; 373: 524-526
Keywords: maisonneuve, tibia, fibula, fracture, ankle, orthopedic (PubMed Search)
A maisonneuve fracture is a fracture dislocation resulting from external rotational forces to ankle -- through interosseous ligament to fibula.
If stability is questionable, orthopedic evaluation under anesthesia is required. Additionally always consider compartment syndrome. Do not rely on Kanduval's signs (pain, paraesthesia, pallor, poikilothermia, pulselessness) - "... with the exception of pain and paraesthesia, these traditional signs are not reliable." Emergent orthopedic consultation and compartment pressure assessment should be performed. (see attached photos)
Keywords: felon, management, incision (PubMed Search)
Management of Felons
For good photos of the incision technique please visit the reference article listed.
Keywords: Mallet Finger, Extensor Tendon Injury (PubMed Search)
A common injury resulting in a tear or avulsion of the extensor digitorium tendon inserting into the base of the distal phalanx. Occurs due to hyperflexion of the finger usually as of a esult of it getting jammed on a ball while playing sports. Most can be treated non-surgically.
The distal phalanx must be kept in full extension for 6 to 8 weeks. This is one of the few times that the finger should not be splinted in the position of function.
Make sure that patient is informed that if they remove the splint and flex their finger the 6 to 8 week healing window will be reset to day 0. These patients should not be doing ROM exercises and must wear the splint full time.
Keywords: Splint, Basic, Position (PubMed Search)
Keywords: olecranon, bursitiis, septic, treatment (PubMed Search)
Olecranon Bursitis is inflammation and swelling of the bursa overlying the olecranon process of the ulna. Can result from trauma, overuse, or infection.
Treatment can consist of:
Remember aspiration has some major risks that need to be explained to the paitent:
They also need to know that the fluid will likely reaccumulate. So aspiration is not a guaranteed cure.
Keywords: Tessaly, Meniscal, Tear, Knee Exam (PubMed Search)
When examining a knee for a meniscal injury the commonly described tests are the McMurray Test and Apley Test. However, these tests have sensitivities of 48-68% and 41% respectfully, and specificities of 86-94% and 86-93% respectfully. Depending on whether you are looking at the medical or lateral meniscus.
The Tessaly Test that was first described in 2005 can be performed with knee in either 5 or 20 degrees of flexion and has a senstivity of 89-92% and specificity of 96-97% when performed in 20 degrees flexion. The test also tends to be easier to perform.
To perform the test:
Essentially you and your patient will look like you are doing the twist as they rotate their knee with you holding their hands.
The Journal of Bone and Joint Surgery (American). 2005;87:955-962.
Keywords: Fracture, Management, Billing (PubMed Search)
In order to maximize billing when caring for patients with fractures two things should be done:
Finally, you should obtain post-reduction x-rays on any fracture that you manipulate and document that the patient is neurovascularly intact prior to discharge.
Keywords: scaphoid, fracture (PubMed Search)
Keywords: Arthrocentesis, Joint, Fluid, Septic (PubMed Search)
Joint Fluid Analysis:
This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain. For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.
|Diagnosis||Appearance||WBC||PMNs||Glucose % of |
|Normal||Clear||<200||<25||95 - 100||None|
| Degenerative |
|Clear||<4000||<25||95 - 100||None|
| Traumatic |
|Straw colored||<4000||<25||95 - 100||None|
|Acute Gout||Turbid||2000 - 50,000||>75||80 - 100||Negative birefringence|
|PseudoGout||Turbid||2000 - 50,000||>75||80 - 100||Positive birefringence|
|Septic Arthritis||Purulent / turbid||5000 - > 50,000||>75||< 50||None|
| Rheumatoid |
|Turbid||2000 - 50,000||50-75||~75||None|
Benjamin GC. Arthrocentesis. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 3rd ed. Philadelphia: Saunders; 1998:919-932.
Keywords: calcaneus, fracture, compartment (PubMed Search)
Normally occur due to axial loading mechanism such as:
Keywords: hip, fracture, mri, plain films (PubMed Search)
Typically divided into four types:
Perron A.D., Miller M.D., Brady W.J. Orthopedic pitfalls in the ED: Radiographically occult hip fracture. Am J Emerg Med 2002;20:234-237.
Keywords: Lisfranc Fracture (PubMed Search)
Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid. Common current mechanism is when a person steps into a hole and twists the foot.Originally described when a horseman would fall of their horse with their foot still trapped in a stirrup.
Diagnosis should be considered if patient has difficult weight bearing with pain on palpation over the 2nd and 3rd metacarpal head with an appropriate mechanism.
Keywords: Clavicle, fracture, surgery (PubMed Search)
I remember being taught as a medical student that clavicle fractures could be treated conservatively. A direct quote was "if both ends of the clavicle are in the same room it will heal".
Though conservative treatment with a sling for 6 weeks with early pendulum ROM exercises for the shoulder is appropriate for the vast majority of clavicle fractures surgery should be considered for those that have:
Keywords: Mallet finger, Extensor Injury (PubMed Search)
Extensor Tendon Injuries [Mallet Finger]
Keywords: Posterior Interosseous Nerve, Compression, Radial Tunnel (PubMed Search)
Posterior Interosseous Nerve Compression Syndrome
As eluded to last week Posterior Interosseous Nerve (PIN) Compression Syndrome, a deep branch of the radial nerve, is felt to be radial tunnel syndrome with paralysis.
Keywords: Radial Tunnel Syndrome (PubMed Search)
For those at the University of Maryland that got the chance to hear my lecture this week, you learned about Cubital tunnel syndrome [ulnar neuropathy], the second most common compressive neuropathy. Carpal Tunnel syndrome remains the number one compressive neuropathy, and this pearl, for the sake of completeness, will address Radial tunnel syndrome.
Radial Tunnel Syndrome
Stay tuned for next week for Posterior Interosseous Nerve syndrome.
Keywords: Turf Toe (PubMed Search)
Most commonly seen in atheletes who compete on artificial turf. Presents as pain over the 1st Metatarsalphalangeal (MTP) joint.
Keywords: Achilles Tendon Rupture (PubMed Search)
Achilles Tendon Rupture
This addition was sent in my Dr. Andrew Milstein:
Thanks for the Orthopedics update. A few pearls for Achilles Tendon Rupture --> often these patients may present like a typical ankle sprain patient and are placed in a hallway chair. You can't do an adequate Thompson Test while someone is sitting in a chair. If you're concerned, lay them down on a stretcher to do the test.