UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: Treatment of Back Pain

Keywords: Benzodiazepines, Back Pain, Sciatica (PubMed Search)

Posted: 5/8/2010 by Michael Bond, MD (Updated: 5/9/2010)
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Conservative Treatment of Back Pain:

Muscle relaxanats and benzodiazipnes are often used in the non-operative management of sciatica and non-specific low back pain.  In fact, a 2003 Cochrane review concluded that muslce relaxanats were effective in the management of non-specific low back pain. However, a recent analysis of randomized trials reported little efficacy or only  minor benefits with the use of benzodiazapines in treatment of low back pain.

A recent prospective, randomized, placebo-controlled, double-blinded trial conducted in Germany that enrolled a total of 60 patients found that the use of diazepam was equivilant to placebo in the reduction of distance of referred pain at day 7 of treatment.  Diazepam was also noted on average to increase the length of stay of those patients hospitalized by 2 days (median hospital days of 8 for placebo versus 10 for diazepam), and the probablility of pain reduction on a visual analog scale by more than 50% was twice as high in the placebo group (p< 0.0015).  Placebo reduced the patients pain more than diazepam.

Though the sample size was small; this study should really make one reevaluate the use of diazepam in the treatment of back pain.  Early movement and discouraging bed rest have been associated with decreased back pain, so one mechanism by which  benzodiazepines may make things work is by causing enough sedation to prevent early movement.

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Category: Orthopedics

Title: Carpal Tunnel Syndrome

Posted: 4/25/2010 by Michael Bond, MD (Updated: 3/28/2024)
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Carpal Tunnel Syndrome (CTS):

  • A compressive neuropathy of the median nerve at the wrist as it travels through the carpal tunnel. 
  • Median nerve is bound on three sides by carpal bones and anteriorly by the transverse carpal ligament.  Surgical repair typically consists of cutting this ligament to allow decompression of the nerve.
  • The neuropathy results in:
    • parasethesia of the thumb, index and middle fingers
    • weaknesss of the thumb and thenar muscles.
  • NO physical exam test has great senstivity or specificity for CTS. The two most common are:
    • Phalen's test: hyperflexion of the wrist. Need to hold for 60 seconds.  Sensitivity ~68% and Specificity ~73%
    • Tinel Sign: tapping over cubital tunnel to produce parasthesia along the median nerve. Sensitivity ~50% and Specificity ~77%.
  • Increased risk in those patients with:
    • Diabetes
    • Rheumatoid arthritis
    • hypothyroidism
    • amyloidosis


Category: Orthopedics

Title: Prosthetic Hip Dislocatoins

Keywords: Hip Dislocation, Treatment (PubMed Search)

Posted: 4/11/2010 by Michael Bond, MD (Updated: 3/28/2024)
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Prosthetic hip dislocations are a common occurance in the Emergency Department.  After you have gotten the hip back in place there are several ways to prevent the hip from coming out again.  An abductor pillow will work but it confines the patient to bed.  A better option to prevent further hip dislocations until the patient can get an appropriate brace made or reparative surgery is to place the patient in a straight leg knee immoblizer. It is nearly impossible to dislocate your hip if your knee is fully extended.

So after reduction of their simple hip dislocation (i.e: no fractures) place the patient in a straight leg knee immobolizer and they can followup with their orthopedist as an outpatient.



Category: Orthopedics

Title: Ossification Centers of the Elbow in Children

Keywords: Ossification Centers, Elbow (PubMed Search)

Posted: 3/27/2010 by Michael Bond, MD (Updated: 3/28/2024)
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Review of the Appearance of Ossification Centers in Children's Elbows

Determing if a child's elbow has a fracture or if you are looking at an ossification center is easier if you remember the mnemonic CRITOE.  This is the order that the ossification centers appear:

  • Capitellum 1 to 8 months
  • Radial Head 3 to 5 years
  • Internal (medial) Epicondyle 5 to 7 years
  • Trochlea 7 to 9 years
  • Olecranon 8 to 11 years
  • External (Lateral) Epicondyle 11 to 14 yeras


Category: Orthopedics

Title: Knee Dislocation

Keywords: Knee, Dislocation (PubMed Search)

Posted: 3/13/2010 by Michael Bond, MD (Updated: 3/28/2024)
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Knee Dislocation:

  • It is not uncommon for a patient to have dislocated their knee and it to spontanously reduce prior to presenting to the ED. 
  • Consider the possibility of a spontaneously reduced knee dislocation in any patient with bicruciate (ACL and PCL) ligament instability.  
  • Normal pulses and capillary refill does not exclude occult vascular injury to the popiteal artery.
  • At a minimum the patient should have Ankle Brachial Indexs performed and if <0.9 serial exams and Doppler ultrasound studies should be obtained.
  • Angiography is not absolutely required, and several studies have shown that a selective approach to angiography is acceptable.  As the studies below showed, most patients with findings requiring operative repair on angiography had abnormal physical exams.

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Category: Orthopedics

Title: Pelligrini-Stieda Lesion

Keywords: Pelligrini, Steida (PubMed Search)

Posted: 3/6/2010 by Michael Bond, MD
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Pelligrini-Stieda Lesion:

A Pelligrini-Stieda lesion is shown in the radiograph below.  This lesion was originally described in 1905, and is associated with a tear of the Medial Collateral Ligament.  Heterotrophic calcification forms causing chronic pain, which typically needs to be surgically excised.


So for the students out there, it is possible to diagnosis an MCL tear on plain radiographs.  Just not very often.



Category: Orthopedics

Title: Segond Fracture

Keywords: Segond Fracture (PubMed Search)

Posted: 2/27/2010 by Michael Bond, MD (Updated: 3/28/2024)
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The Segond Fracture:

An benign appearing avulsion fracture of the lateral tibeal plateau that is marker for more significant injuries such as:

  1. Anterior Cruciate Ligament (ACL) tear associated with this fracture 75-100% of the time
  2. Injury to the Medial Meniscus occurs with a Segond fracture 66-75% of the time.

If this avulsion fracture is seen consider immobilzing the patients knee until they can follow up with Orthopedics and/or get an MRI to determine if additional injuries are present.

 



Category: Orthopedics

Title: Spine CT Scans

Keywords: Spine, Fracture, Diagnosis (PubMed Search)

Posted: 2/20/2010 by Michael Bond, MD
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A recent study by Smith et al showed that the general abdomen/pelvic CT scan in trauma patients obtained with 5mm slices is a better screening test for spine fractures than plain films. They also showed that when compared to dedicated reconstructed thoracolumbar CT scan (2mm slices focused on the spine) it did not miss any clinically significant fractures.

The statistic for plain radiographs and the nonreconstructive CT scan are shown below.

 
Plain Radiographs
Nonreconstructive CT Scan
 
Lumbar
Thoracic
Lumbar
Thoracic
Sensitivity % [95% CI]
47 [33 to 62]
13 [3 to 32]
94 [83 to 99]
73 [50 to 89]
Specificity % [95%  CI]
91 [78 to 97]
71 [54 to 85]
95 [85 to 99]
94 [79 to 99]
Positive Predictive Value % [95% CI]
85 [66 to 96]
15 [2 to 45]
95 [86 to 99]
89 [67 to 99]
Negative Predictive Value % [95% CI]
61 [48 to 72]
56 [41 to 71]
93 [82 to 99]
83 [66 to 93]

The take home point is that dedicated Spine CT scans are probably not needed unless they are going to be used to guide surgical or non-surgical management, and plain films should probably be abandoned in patients that are undergoing CT scans of the chest/abdomen/pelvis.

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Impingement Syndrome and the Diagnostic Accuracy of 5 Common Tests

It is also reported that subacromial impingement syndrome (SAIS) is the more frequent cause of shoulder pain.

The authors of this study attempted to determine the diagnostic accuracy of the following 5 tests for SAIS:

  • Hawkins-Kennedy
  • Neer
  • Empty Can
  • Painful Arc
  • External Resistance

The study demonstrated that any 3 positive tests out of the 5 has a sensitivity of 0.75 (0.54-0.96) , specificity of 0.74 (0.61-0.88), positive likelihood ratio of 2.93 (1.60-5.36) and negative likelihood ratio of 0.34 (0.14-0.80).  See the table below for the individual test characteristics.  No single test was deemed accurate enough to make the diagnosis by itself.

 

 

 

 

 

 

 

 

 

So in the end you should be familiar with most of these tests in order to use a combination of them to make the diagnosis of impingement syndrome.  Future pearls will review how to perform these tests.

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Category: Orthopedics

Title: Scaphoid Fractures

Keywords: Scaphoid, Fracture (PubMed Search)

Posted: 2/6/2010 by Michael Bond, MD
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Scaphoid Fractures:

For suspected scaphoid fractures with negative radiographs it is common practice to put a person in a short arm thumb spica splint until followup up radiographs can be obtained in 10-14 days.

However, there is evidence that a short arm thumb spica splint is not enough for people that have a true scaphoid fracture.  Gellman et al demonstrated that long arm thumb-spica cast immobilization for six weeks followed by short arm thumb-spica cast immobilization decreased time to union by 25% when compared to short arm thumb-spica casting alone.

The theory is that the short arm splint still allows for forearm rotation that can cause shearing motion of the volar radiocarpal ligaments.  A long arm splint prevents this shearing action.  The disadvantage of a long arm splint though is potential elbow joint stiffness and muscle atrophy that can occur during the prolonged period of immobilization.

So for your next patient with a scaphoid fracture seen on radiographs place them in a long arm thumb spica splint.

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Category: Orthopedics

Title: Paronychia

Keywords: Paronychia (PubMed Search)

Posted: 1/9/2010 by Michael Bond, MD
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Acute paronychia

  • Usually result from minor trauma of the skin around the fingernail such as biting, manicures, picking a hangnail or finger sucking.
  • Staphylococcus aureus is the most common infecting organism. However other mouth flora such as Streptococcus and Pseudomonas species, gram-negative bacteria, and anaerobic bacteria can also be a cause.
  • Recommended treatement consists of incision and drainage and placing the patient on  amoxicillin /  clavulanic acid or clindamycin to cover all the organisms noted above.


Category: Orthopedics

Title: Scaphoid Fractures in Children

Keywords: Scaphoid, Children (PubMed Search)

Posted: 11/14/2009 by Michael Bond, MD (Updated: 3/28/2024)
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Scaphoid Fractures in Children:

  1. Rare before the age of 11.
  2. Make up less than 0.34% of all pediatric fractures
  3. Scaphoid fractures may be missed 12.5% - 37% on the initial presentation.
  4. 30% of patients will have an radiographically apparant fracture on repeat films done 2 weeks later.
  5. These physical exam findings are more specific for fracture:
    1. Volar tenderness over the scaphoid
    2. Pain with radial deviation
    3. Pain with active wrist range of motion.  
  6. Though snuff box tenderness was seen in 100% of patients eventually proven to have a fracture, it was also seen in 92% of the patients that did not have a fracture at follow-up making it non-specific but sensitive.
     

Because of the high (30%) fracture rate seen on followup films it is recommended that all children be placed into a thumb spica splint until followed up.

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Category: Orthopedics

Title: Slipped Capital Femoral Epiphysis

Keywords: Klein's line, slipped capital femoral epiphysis (PubMed Search)

Posted: 11/7/2009 by Michael Bond, MD (Updated: 8/31/2014)
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Slipped Capital Femoral Epiphysis (SCFE)

SCFE can present as hip, thigh or knee pain in the young adolescent. Risk factors include hypogonadism, hypothyroidism, hypopituiratism, and obesity. One way to make the diagnosis is to obtain a AP view of the pelvis and draw a line(Klein's line) along the superior border of the neck of the femur.  This line should intersect the femoral epiphysis. If it does not the diagnosis of SCFE can be made.

However, this is only about 40% sensitivity. Green et al recently published a study that demonstrated that if you measure the distance from Klein's line and the lateral edge of the femoral epiphysis on both sides, and the difference between the two is more than 2mm you can make the diagnosis of SCFE more accurately and sooner.

FIGURE 1. Measurement methods on an anterior-posterior radiograph of a right slipped capital femoral epiphysis. White lines indicate Klein        s line for each hip. A and B, indicate maximum epiphyseal width lateral to Klein        s line. As B is 2mm greater than A, the left hip qualifies as a slip using our modification but not Klein        s original definition.

FIGURE 1. Measurement methods on an anterior-posterior radiograph of a right slipped capital femoral epiphysis. White lines indicate Klein’s line for each hip. A and B, indicate maximum epiphyseal width lateral to Klein’s line. As A is 2mm narrower than B, the right (A) hip qualifies as a slip using our modification but not Klein’s original definition.

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Category: Orthopedics

Title: Wound Irrigation

Keywords: Wound, Irrigation, Fibroblast (PubMed Search)

Posted: 10/31/2009 by Michael Bond, MD (Updated: 3/28/2024)
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Wound Irrigation

A recent article by Thomas et al showed that any concentration of betadiene and hydrogen peroxide used to irrigate a wound was  more toxic to fibroblasts (required for wound healing) then it was to bacteria.  Low concentrations of chlorhexidine remained bactericidial while having minimal affects on fibroblasts. 

WIth the addition of this study the routine practice of soaking a wound in betadiene or hydrogen peroxide should be abandoned.  Good irrigation with normal saline or even tap water is all that is really needed to decontaminiate a wound.  If a bactericidal agent is needed then low concentrations of chlorhexidine should be used.

 

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Category: Orthopedics

Title: Winged Scapula

Keywords: winged scapula, trapezius, serratus anterior, long thoracic nerve (PubMed Search)

Posted: 10/18/2009 by Dan Lemkin, MD, MS (Emailed: 10/24/2009) (Updated: 3/28/2024)
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Winged scapula is caused by muscular injury or damage to corresponding muscular innervation. Mechanism can be due to blunt or penetating thoracic trauma.

  • Trapezius muscle
    • Long thoracic nerve
  • Serratus Anterior muscle
    • Spinal Accessory Nerve

Clinical findings include

  • Protruding medial edge of the scapula
  • Exacerbation by pushing against resistance
  • Difficulty lifting arm over head

Treatments

  • Initial splinting and orthopedic referral
  • Depending on mechanism - trial of physical therapy
  • Surgical treatments include fascial grafts or adjacent muscle attachment

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Category: Orthopedics

Title: Snuff Box Tenderness

Keywords: Scaphoid Fracture, CT (PubMed Search)

Posted: 10/17/2009 by Michael Bond, MD (Updated: 3/28/2024)
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Snuff Box Tenderness:

It has become the standard of care that individuals with snuff box tenderness, or pain with axial loading of the thumb, be placed in a thumb spica splint for 1-2 weeks until follow up x-rays can be done.  This is done to rule out an occult scaphoid fracture.  However, this practice can be hugely inconvenient to the patient and result in some atrophy of their forearm.

An alternative approach is to obtain a CT scan through the wrist to look specifically at the scaphoid bone.  If the CT scan is negative you can send them home with some pain control, RICE (Rest, Ice, Compression, Elevation) treatment and let them use thier thumb.  No splint is needed.  If it is positive then you can splint them and have them follow up with orthopedics or hand surgery.



Category: Orthopedics

Title: AC Joint Injuries

Keywords: AC Joint, Separation, Dislocation (PubMed Search)

Posted: 9/26/2009 by Michael Bond, MD (Updated: 3/28/2024)
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AC Joint Dislocations

The acromioclavicular (AC) Joint is commonly injured when a person falls onto their shoulder.

The AC Joint consists of three ligaments:

  • acromioclavicular ligament (AC)
  • coracoacromial ligament (CA)
  • coracoclavicular ligament (CC)

Injuries to this joint are classified as Type I – Type VI and involve sprain or tears of the AC or CC ligaments

  • Type I – Is a sprain of the joint without complete tear of either the AC or CC ligament
  • Type II – Does not show significant elevation of the lateral end of the clavicle but is due to a tear of the AC ligament.
  • Type III – Results from tears in the AC and CC ligament. Noted by > 5 mm elevation of the AC joint.
  • Types IV – VI : are associated with complications of a Type III injury.


Category: Orthopedics

Title: Monteggia's Fracture

Keywords: Monteggia's Fracture (PubMed Search)

Posted: 8/1/2009 by Michael Bond, MD
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Monteggia's Fracture

  • Fracture of the proximal 1/3 of the ulna with an associated radial head dislocation.
  • Mechanisms of injury include direct blow, hyperpronation and hyperextension.
  • Radial head is dislocated anteriorly in 60% of the cases.
  • can be associated with Posterior Interosseous Nerve (PIN) palsy. 
  • PIN is the deep motor branch of the radial nerve and supplies the wrist extensors except for Extensor Carpi radialis Longus.  The palsy can be delayed so be sure to document wrist extenson strength.
  • Most patients will require operative repair of the ulna fracture.
  • Splint the  forearm in neutral rotation with slight supination, keeping the elbow flexed at 90 degrees.

 

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Category: Orthopedics

Title: Jones Fracture Malunion

Keywords: jones fracture,foot fracture,malunion (PubMed Search)

Posted: 6/21/2009 by Dan Lemkin, MD, MS (Emailed: 7/18/2009) (Updated: 7/18/2009)
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Jones fracture

  • Fracture of proximal metaphyseal 5th metatarsal
    • located w/in 1.5 cm distal to tuberosity of 5th metatarsal
  • Prone to malunion
    • Watershed area (poor blood supply)
    • Under tension from multiple tendons
  • Treatment
    • Immobilize with posterior-mold splint
    • Non-weight bearing - crutches
    • Prompt orthopedic evaluation
      • Some cases are managed with non-weight bearing casts
      • Others are repaired operatively.
      • Delayed jones fractures with malunion will require operative repair.
  • Distinguish from pseudo-jones fracture (dancers fracture)
    • metatarsal styloid avulsion fracture, generally does not require operative repair
    • much more common than true Jones fracture.

Presented with persistant foot pain from
Jones fracture malunion.

jones fracture

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Category: Orthopedics

Title: Blast Injuries

Keywords: Blast, hand, injuries (PubMed Search)

Posted: 7/5/2009 by Michael Bond, MD
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Blast Injuries:

In honor of the 4th of July holiday, here is a quick pearl about blast injuries.

  • Blast injuries due to fireworks most often affect the hands. 
  • Other than the obvious superficial wounds that are seen on exam, the EP should be aware of significant cavitation and destruction of muscles that can occur in the forearm, thenar and hypothenar muscle groups which may be distal from the gross wound seen. 
  • The energy from the blast is often transmitted through the carpal tunnel leading to an acute carpal tunnel syndrome from contusion of the median nerve.
  • Patients should also be monitored for compartment syndrome.
  • These patients can have significant injruies that are not immediately apparent. Consider observing these patients for awhile, or have them seen by hand surgery in case complications develop later on.

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