UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: POCUS for Knee Pain

Keywords: POCUS, Knee Pain, Tendon Rupture (PubMed Search)

Posted: 6/5/2023 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD

Question

Pt presents to the emergency department with knee pain.

You decide to ultrasound the proximal knee. You place your ultrasound probe in the midline of the knee with your probe marker towards the patient's head. 

What is the diagnosis?

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The answer is a quadriceps tendon rupture with femur fracture.

 

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Category: Orthopedics

Title: Dorsal wrist pain

Keywords: overuse injury, wrist (PubMed Search)

Posted: 5/25/2023 by Brian Corwell, MD (Emailed: 5/27/2023)
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Intersection syndrome

Intersection syndrome is an overuse injury of the forearm.

Pain is located approximately 2 finger breaths (4cm) proximal to the wrist joint.

  • Pathology occurs at the “intersection” of the 1st (APL and EPB) and 2nd (ECRL and ECRB) dorsal compartments.
  • Friction occurs at the muscle bellies of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB), where they cross over the extensor carpi radialis longus (ECRL) and brevis (ECRB)

https://www.sportsmedreview.com/wp-content/uploads/2020/11/intersectionsyndrome.png

Mechanism: friction is caused by repetitive wrist extension activities

Commonly: Rowing, skiing, tennis, canoeing and weightlifting 

Friction may cause crepitus with finger/wrist extension.

Tenderness, mild swelling may be present

  • Intersection syndrome is often confused with de Quervain’s tendinopathy. 

 

 

 



Category: Orthopedics

Title: Baker Baker Bake Me a Pie

Keywords: Baker's cyst, knee, effusion (PubMed Search)

Posted: 5/13/2023 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

A Baker's cyst is a common incidental finding on ultrasound reports and bedside physical exam.

Clinically, these cysts are commonly found in association with intra-articular knee disorders. Most commonly: osteoarthritis, RA and tears of the meniscus.

Sometimes Baker's cysts are a source of posterior knee pain.

In an orthopedic clinic setting, Baker’s cysts are frequently discovered on routine MRI in patients with symptomatic knee pain. They tend to occur in adults from ages 35 to 70.

Over 90% of Baker’s cysts are associated with an intraarticular knee disorder. While most frequently associated with OA and meniscal tears, other knee pathologies that have been associated include inflammatory arthritis and tears of the anterior cruciate ligament.

DDX:  DVT, cystic masses (synovial cyst), solid masses (sarcoma) and popliteal artery aneurysms.

Based on cadaveric studies, a valvular opening of the posterior capsule, proximal/medial and deep to the medial head of the gastrocnemius is present in approximately 50% of healthy adult knees.

Fluid flows in one way from knee joint to cyst and not in reverse. This valve allows flow only during knee flexion as it is compressed shut during extension due to muscle tension.

Most common patient complaint is that of the primary pathology, meniscal pain for example. At times, symptoms related to the cyst are likely due to increasing size as they may report fullness, achiness, stiffness.

In one small study, the most common symptoms were 1) popliteal swelling and 2) posterior aching. Patients may complain of loss of knee flexion from an enlarged cyst that can mechanically block full flexion.

If the Baker cyst is large enough the clinician will feel posterior medial fullness and mild tenderness to palpation. The cyst will be firm and full knee extension and softer during the flexion (Foucher’s sign).

This may help with differentiation from other popliteal masses (hematoma, soft tissue tumor, popliteal artery aneurysm).

With cyst rupture, severe pain can simulate thrombosis or calf muscle rupture, (warmth, tenderness, and erythema). A ruptured cyst can also produce bruising, which may involve the posterior calf starting from the popliteal fossa and extending distally towards the ankle.

 

Treatment: initial treatment for symptomatic Baker cysts is nonoperative unless vascular or neural compression is present (very unlikely)

Treatment involves physical therapy to maintain knee flexibility. A sports medicine physician may perform an intraarticular knee corticosteroid injection as this has been found to decrease size and symptoms of cysts in two-thirds of patients.

For patients that fail above, refer for surgical evaluation. Inform patients that they are not undergoing ED drainage of this symptomatic cyst due to the extremely high rate of recurrence which, as a result of the ongoing presence of the untreated intraarticular pathology, results in the recurrent effusion.

 



Category: Orthopedics

Title: Treatment of lower back pain without opioids

Keywords: lower back pain, analgesia, NSAIDs (PubMed Search)

Posted: 4/8/2023 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

 Acute lower back pain is a very common emergency department presenting complaint. Over the last several years there has been impetus to move away from opioids in the management of lower back pain.

A recent systematic review investigated the pharmacologic management of acute low back pain. This review looked at RCTs investigating the efficacy of muscle relaxants, NSAIDs, and acetaminophen for the treatment of acute nonspecific lower back pain of fewer than 12 weeks duration in patients > 18 years of age. Studies that investigated the use of opioids were not considered.

18 RCTs, totaling 3478 patients were included. 54% were women. The mean patient age was 42.5 ± 7.3 years. The mean length of follow-up was 8.0 ± 5.6 days. The mean duration of symptoms before treatment was 15.1 ± 10.3 days. 

Results:  Muscle relaxants and NSAIDs were effective in reducing pain and disability in acute LBP at approximately 1 week.

The combination of NSAIDs and acetaminophen was associated with a greater improvement than the sole administration of NSAIDs.

However, acetaminophen alone did not promote any significant improvement. Placebo administration was not effective.

Limitations: Most patients with acute LBP experience spontaneous recovery or at least reduction of symptoms, therefore, the real impact of most medications is uncertain. The present study wasn't able to distinguish among different classes of NSAIDs. A best practice treatment protocol cannot be extrapolated from this study.

Take home:  In my practice, patients are treated with NSAIDs and Acetaminophen first line. I also include Licocaine patches for all patients. If there is a contraindication to NSAIDs, I treat with muscle relaxants alone.

This study highlights the lack of benefit of acetaminophen as mono therapy (which has been noted in other studies).

 

 

 

 

 

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Category: Orthopedics

Title: Patellofemoral anatomy and disease

Keywords: knee pain, running injury (PubMed Search)

Posted: 3/25/2023 by Brian Corwell, MD
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Patellofemoral anatomy and disease (part 1)

During normal knee flexion, the patella slides within the trochlear grove. Both (patella and the trochlear groove) are lined with articular cartilage at the patellofemoral articulation.

https://www.stvincentsboneandjoint.com.au/images/patellofemoral-joint2.jpg

Multiple forces act on the patella which can affect proper tracking:  Proximately, by the quadriceps tendon, distally, by the patellar tendon, medially, by the medial retinaculum/vastus medialis and laterally by the lateral retinaculum and the vastus lateralis.

Patellofemoral OA can occur when this cartilage starts to wear and can be seen in skyline/sunrise/notch or equivalent views. OA here rarely occurs in isolation (<10%) and is usually part of medial or lateral knee OA.

 

https://www.stvincentsboneandjoint.com.au/images/patellofemoral-joint3.jpg

 

Patellofemoral pain is usually from overuse/training overload or malalignment.

Contributors to overuse involve total joint load which may have influence from training volume (total miles), intensity (competitive sports) in addition to BMI (>25) in addition to overall fitness level.

Malalignment aka abnormal patellar tracking involves both static (leg length discrepancy, hamstring tightness, etc.) and dynamic components (hip weakness, gluteus medius weakness, excessive foot pronation, etc.).

 

Patients with anterior knee pain should have activity modification, ice, NSAIDs (not steroids) and long-term engagement in physical therapy (>6 months) with a focus on flexibility and strengthening of lower extremity kinetic chain including the vastus medialis, gluteus medius, hip external rotators and core.

 

Also, consider looking for hyper supination or pronation. Foot orthotics can be of help with this.

 

 



Question

21-year-old college softball player presents for evaluation of Left hand/wrist pain following batting practice.

She states her pinky is “tingly”

On exam, there is tenderness over her volar ulnar wrist.

You obtain an X-ray.

https://prod-images-static.radiopaedia.org/images/52314027/a662d8f338ec08ba56178463638d25_jumbo.jpeg

What’s the diagnosis?

 

 

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Category: Orthopedics

Title: Prolonged recovery from concussion

Keywords: concussion recovery, head injury, post concussive syndrome (PubMed Search)

Posted: 2/11/2023 by Brian Corwell, MD (Updated: 5/25/2024)
Click here to contact Brian Corwell, MD

 

Prolonged post-concussion symptoms are loosely defined as those lasting more than three or four weeks versus typical recovery, typically between 10-14 days. 

Athletes who take longer than "typical” to recover have a challenging road of uncertainty. Medical providers are asked to make informed decisions about “normal” and expected return based on limited information. 

Evaluating both athlete and parental expectations is challenging, especially when navigating difficult conversations about medical disqualification and permanently discontinuing their sport. 

A 2016 study of approximately 50 patients with sports-associated concussion who had persistent symptoms lasting greater than one-month found that a collaborative multidisciplinary treatment approach was associated with significant reduction in post concussive symptoms at six months versus usual treatment. 

A recent 2023 study in Neurology provides additional good news for athletes who are slow to recover from sports associated concussion. Approximately 1750 concussed collegiate athletes (diagnosed by team physician) were enrolled. In this study, slow recovery was defined as taking more than 14 days for symptoms to resolve OR taking more than 24 days to return to sport.  

Approximately 400 athletes met the criteria for slow recovery (23%).  

Male athletes participated primarily in football, soccer, and basketball.  

Female athletes participated primarily in soccer, basketball, and volleyball. 

Of the athletes who took longer than 24 days to return to play: 

77.6% were able to return to play within 60 days of injury, 

83.4% returned to play within 90 days, and 

10.6% did not return to play at 6 months. 

 

Slow to recover athletes averaged 35 days after injury for return to play. 

This study provides valuable information for medical providers: There is an overall favorable prognosis for slow to recover concussed athletes for return to school and sport. 

 

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Category: Orthopedics

Title: Exercise intensity and cardiovascular mortality

Keywords: exercise, death, physical activity (PubMed Search)

Posted: 12/10/2022 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

"The Tortoise and the Hare" fable has been used as a metaphor for the epidemiological differences between slower, low-intensity exercise versus faster, high-intensity physical activity.

"Current physical activity recommendations are predicated on the idea that both the hare and the tortoise can win the race for better health, but the provocative studies give an edge to the hare's higher-intensity approach,"

Regular physical activity is associated with significant health benefits, including decreased risk of cardiovascular disease, cancer, and all-cause mortality.

Traditional research has focused on exercise volume (150 minutes/week) over intensity.

Two recent studies looked at the benefits of shorter bouts of vigorous activity at higher intensities. 

A recent large population-based cohort study of middle-aged adults used objective measurement of activity (wrist accelerometer) over self-reporting to investigate the role of exercise intensity and CV health.

Higher intensity physical activity is associated with lower rates of incident CVD.

This makes theoretical sense as greater stimulation will result in greater physiologic CV adaptations resulting in overall improved CV fitness.

For example. the authors extrapolate that an ambling 14-minute stroll has roughly the same cardiovascular benefits as an up-tempo 7-minute walk at a brisk pace.

Increasing the total amount of activity is not the only means of achieving health goals which can be met with raising overall intensity.

Vigorous physical activity is a time-efficient means to achieve overall health benefits of exercise.

A recent study (Ahmadi et al., 2022) involved 71,893 older adults with a mean age of 62.5. Authors found that quick bursts of vigorous physical activity throughout the day can lower older adults' risk of premature death by 16% to 27%, depending on daily frequency and weekly totals (from 15-20 min/week up to 50-57 min/week).

For example, doing one two-minute burst of high-intensity exercise every day for a total of 14 minutes per week was associated with an approximately 18% lower risk of all-cause mortality. The authors also found that doing as little as one to nine minutes per week of vigorous activity in quick bursts versus doing no vigorous activity was associated with significantly lower all-cause mortality risk over five years.

Exercise may not need to be a planned hour-long session at the gym for our middle-aged and older population. Accruing small amount sporadically over the day/week is an attractive option to reap the CV benefits of exercise. Existing exercise guidelines will need to be modified with future research to pinpoint the optimal exercise intensity and duration for adults in different stages of life.

 

 

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Category: Orthopedics

Title: Own a dog to live long & prosper

Keywords: Pet ownership, cardiovascular health, risk reduction (PubMed Search)

Posted: 11/25/2022 by Brian Corwell, MD (Emailed: 11/26/2022)
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Dog ownership has become more common especially during the pandemic.

Almost 70% of US households own a pet and almost half own ≥1 dogs.

There are many health benefits associated with dog ownership including: reduced risk of asthma and allergic rhinitis in children exposed to pets during early ages, improvement in symptoms of PTSD, overall wellbeing & alleviation of social isolation in elderly individuals and increased physical activity.

The main positive impact of dog ownership seems to be in relation to cardiovascular risk including an association with lower blood pressure levels, improved lipid profile, and diminished sympathetic responses to stress.

Study:  A systematic review and meta-analysis (10 studies, over 3 million participants) to evaluate the association of dog ownership with all-cause mortality, with and without prior cardiovascular disease, and cardiovascular mortality. Mean follow up 10 years.

Results: Dog ownership was associated with a 24% risk reduction for all-cause mortality as compared to non-ownership (relative risk, 0.76; 95% CI, 0.67–0.86) with 6 studies demonstrating significant reduction in the risk of death.

In individuals with prior coronary events, dog ownership was associated with an even more pronounced risk reduction for all-cause mortality (relative risk, 0.35; 95% CI, 0.17–0.69). When authors restricted the analyses to studies evaluating cardiovascular mortality, dog ownership conferred a 31% risk reduction for cardiovascular death (relative risk, 0.69; 95% CI, 0.67–0.71).

The cause of this benefit is unclear. Though some activities such as the act of petting a dog has been observed to lower blood pressure levels, the mechanism for the longer survival is likely through enhanced physical activity provided by dog walking.

Conclusion:  Dog ownership is associated with reduced all-cause mortality likely driven by a reduction in cardiovascular mortality. Dog ownership as a lifestyle intervention may offer significant health benefits, particularly in populations at high-risk for cardiovascular death.

Finally, meet Winston, a French bulldog who, last night, won the National Dog Show!

https://static.onecms.io/wp-content/uploads/sites/47/2022/11/22/national-dog-show-winner-french-bulldog-winston-2022-2000.jpg

 



Category: Orthopedics

Title: Opioids & NSAIDs for MSK pain in the ED: Effectiveness and Harms

Keywords: musculoskeletal pain, analgesia, opioids (PubMed Search)

Posted: 11/12/2022 by Brian Corwell, MD (Updated: 5/25/2024)
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Opioids & NSAIDs for MSK pain in the ED:  Effectiveness and Harms

 

Study selection:  A recent systematic review in Annals of Internal Medicine attempted to evaluate the effectiveness and harms of opioids for musculoskeletal pain in the emergency department.

Included were RCTs of any opioid analgesic as compared with placebo or a nonopioid analgesic.

Conditions studied:  bone injuries, soft tissue injuries, spinal pain, and mixed presentations.

Out of 2464 articles, they included 42 trials (n=6128).

Effectiveness data:  Opioids were statistically but not clinically more effective in reducing pain in the short term (approximately 2 hours) versus placebo and Tylenol but were not clinically or statistically more effective than NSAIDs.

 

Take home: Opioids and NSAIDs may have about the same pain outcomes.

 

Harm data:  The results on harms were very mixed. Overall, there were fewer harms with NSAIDs than opioids. However, many studies showed less of a difference. The benefit with NSAIDs due to fewer harms may be less in patients with mixed musculoskeletal conditions.

Opioids may carry higher risk for harms than placebo, Tylenol, or NSAIDs. Authors also found that an increased opioid dose may increase harms from opioids.

Limitations: Limited data on long-term outcomes and longer-term pain management

 

 

 

 

 

 

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Category: Orthopedics

Title: Developmental dysplasia of the hip & proper swaddling

Keywords: hip, dislocation, DDH (PubMed Search)

Posted: 10/22/2022 by Brian Corwell, MD (Updated: 5/25/2024)
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Developmental dysplasia of the hip (DDH) 

 

  • A spectrum of conditions related to hip development in infants & young children
  • Results from abnormal development of the acetabulum and proximal femur
  • Results in mechanical instability of the hip joint 
  • Left hip (3:1) vs Right
  • Female sex (5:1)
  • Breech presentation (20%)
  • Family history of DDH
  • Infants and young children with untreated hip dislocation rarely have pain or other limitations.
  • Most affected children begin to walk and reach developmental milestones at the appropriate time.
  • In cultures where tight swaddling with the lower limbs in extension is common, significantly higher rates of DDH have been reported.
  • In South Australia 79% of those with DDH were tightly swaddled
  • In Japan, when traditional swaddling was used, the incidence of DDH was 5%.
  • A public campaign to switch to wrapping techniques encouraging hip flexion and abduction led to DDH rates falling to less than 0.4%.
  • https://res.cloudinary.com/dbwozcf0d/images/f_auto,q_auto/v1589948650/10624649_794826423982877_5167788043433556178_n/10624649_794826423982877_5167788043433556178_n.jpg

 



Category: Orthopedics

Title: Walk don't run to the nearest exit

Keywords: mortality, exercise, dementia, walking (PubMed Search)

Posted: 9/10/2022 by Brian Corwell, MD (Updated: 5/25/2024)
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Exericse as preventative medicine!

A recent cohort study of over 2,000 adults (mean age approx. 45) over approximately 11 years of follow-up investigated the association of step count with mortality.

This study found that those participants taking at least 7,000 steps per day compared to those taking fewer steps had a 50%-70% lower risk of mortality. They did not find an association with step intensity.

 

Another recent study investigated the dose-response association between daily step count and intensity and the incidence of all-cause dementia.

 

Uk based study of >78,000 adults aged 40 to 79 years with approximately 7 years of follow-up. Data from wrist accelerometer and registry-based dementia diagnoses.

 

Optimal step dose was 9826 steps. Minimal dose was 3826 steps (value at which the risk reduction was 50% of the observed max).

In this study, steps performed at higher intensity (112 steps/min) resulted in stronger associations.

 

Conclusions:  A great exercise goal for middle aged and older adults is just under 10,000 steps per day to decrease risks of both overall mortality and dementia.

 

 

 

 

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Category: Orthopedics

Title: Concussion & Screen Time

Keywords: Concussion, head injury, recovery, cognitive rest (PubMed Search)

Posted: 8/27/2022 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Limited data are available to guide recommendations re screen time after concussion.

A recent ED study looked at screen time effects on concussion recovery.

Population:  125 patients aged 12 to 25 years presenting to the ED <24h after injury. Mean age 17. Approximately 51% male.

Intervention:  Patients were placed in a screen time allowed group and a screen time not allowed group for the first 48 hours. Total minutes reported after the study were 630 minutes vs 130 minutes.

Outcome:  Time to symptom resolution. Patients took daily symptom scoring tests for 10 days.

Result: Screen time allowed group had a significantly longer time to recovery (8 days) vs screen time not allowed (3.5 days).

Strength: Good attempt at quantifying effects on early screen time exposure on symptom recovery in an ED population.

Weakness:  This was a small study. Many patients (>25%) were lost to follow-up and it relies on symptom self-reporting.

 

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Category: Orthopedics

Title: Posterior Hip Dislocation

Keywords: Dislocation, reduction, AVN (PubMed Search)

Posted: 8/13/2022 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

The hip joint is a very strong and stable structure requiring great force to produce a dislocation

Most hip dislocations are posterior (80-90%)

Mechanism:  MVC generating force onto an adducted flexed hip (most commonly)

Associated injuries occur both locally (acetabular fx) and distant (knee bone and ligamentous)

                Significant associated injuries in >70%

The hip joint has a very precarious blood supply.

One of the risk factors for AVN is total dislocation time

                <6 hours - 5% incidence

                >6 hours – up to 53% incidence

Examine the sciatic nerve carefully with posterior dislocations (10% incidence)

                Motor – EHL/ankle dorsiflexion

                Sensory – sensation dorsum of foot

 

There are many reduction maneuvers including the East Baltimore Lift technique

https://www.youtube.com/watch?v=1zvelGbVn04

Demonstrated at 30 seconds in above video

Place patient supine with affected leg flexed to 90 degrees at knee and hip. 2 providers position themselves on opposite sides of the patient and each places their arm under the patient’s calf/popliteal region and their hand on the opposite providers shoulder. A 3rd person is required to stabilize the pelvis. Axial traction is generated by the providers slowly standing up. Gentle internal and external rotation can facilitate successful reduction

 



Category: Orthopedics

Title: 25yo with left wrist pain, stiffness and mild swelling

Keywords: AVN, wrist pain, lunate (PubMed Search)

Posted: 7/23/2022 by Brian Corwell, MD (Updated: 5/25/2024)
Click here to contact Brian Corwell, MD

Question

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Question

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Category: Orthopedics

Title: Wrist drop

Keywords: Radial nerve compression, peripheral nerve injury, wrist drop (PubMed Search)

Posted: 6/25/2022 by Brian Corwell, MD (Updated: 5/25/2024)
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The radial nerve is susceptible to compressive neuropathy against the spiral grove of the humerus which can lead to neuropraxia.

When the upper arm is compressed against a chair back or bar edge sometimes from a lost battle with alcohol:  Saturday night palsy.

When another individual sleeps on someone’s arm overnight compressing the radial nerve:  Honeymoon palsy

From nerve compression from improper technique with crutches:  Crutch palsy

If diagnosis not clear from history, DDx includes other entities that can also present with isolated wrist, thumb/finger drop

Horses:  Radial verve palsy, CVA, C7 compression

  • Most central disorders that cause arm weakness affect extensor muscles to a greater degree than the flexors.

Zebras:  Lead toxicity, acute porphyrias (often polyneuropathy but upper extremity before lower and frequently distal extensors

Careful history and exam important in differentiating

In cases of peripheral compression against the spital groove the triceps maintains strength.

The distal extensors lose strength (wrist and fingers)

Including the thumb abduction (abductor pollicis longus is radial-innervated)

AND so will the brachioradialis

The brachioradialis (despite being a forearm flexor) has dual innervation from the radial nerve in 80% of people.

Brachioradialis strength is often preserved in a central lesion.

            Best tested with arm supported on a surface in mid pronation/supination (hammer curl position) and have patient flex against resistance and evaluate muscle strength and bulk.

 

 



Category: Orthopedics

Title: Fifth Metacarpal Fracture

Keywords: Boxer, reduction (PubMed Search)

Posted: 5/28/2022 by Brian Corwell, MD (Updated: 5/25/2024)
Click here to contact Brian Corwell, MD

28-year-old male present with dorsal hand pain after “losing his temper”

On exam, you note dorsal swelling, tenderness, and deformity

AP, lateral and oblique views are obtained.

https://images.squarespace-cdn.com/content/v1/55d5e97fe4b0c4913b06a4dd/1440082762211-V6RW1TTWB1Q5C89TPIEC/boxers+2.jpg?format=500w

There is no rotational deformity but using the lateral view, you note that there is angulation

Measured as the shaft of the metacarpal as compared to the mid-point of the fracture fragment

Acceptable shaft angulation generally accepted to be less than 40°

Patient has greater that acceptable angulation so you have to perform closed reduction

After appropriate pain control consider the “90-90 method.” 

Flex the MCP, DIP, and PIP joints to 90 degrees.

This positioning stretches the MCP collateral ligaments helping to optimize reduction

Next, apply volar pressure over the dorsal aspect of the fracture site while applying pressure axially to the flexed PIP joint.

Best demonstrated below

https://www.youtube.com/watch?v=40irKoUJqsM

 

 



Category: Orthopedics

Title: Blount's disease

Keywords: Varus, knee (PubMed Search)

Posted: 5/15/2022 by Brian Corwell, MD (Updated: 5/25/2024)
Click here to contact Brian Corwell, MD

4-year-old patient comes to the ED for an unrelated complaint and you notice that his knees appear to be touching while his ankles remain apart.

 

Genu Varum or “knock knees” may be caused by Infantile Blount’s disease

          -A progressive pathologic condition causing genu varum in children between ages 2 to 5

          - Centered at the tibia

          -Bilateral in up to 80%

          -More common in boys

          -Leg length discrepancy

          - Articular incongruity

Risk factors:  Early walkers (<1 year), overweight, large stature, Hispanic and African American

Results in disruption of normal cartilage growth at the MEDIAL aspect of the proximal tibia while LATERAL growth continues normally

May complain of knee soreness or subjective instability

On physical exam

          Focal angulation of the proximal tibia

Lateral thrust during stance phase of walking (brief lateral shift of proximal fibula and tibia)

          No tenderness or effusion

Imaging:   Plain film shows varus deformity of the proximal tibia with medial beaking (beak like appears of bone) and downward slope of the proximal tibia metaphysis (increased metaphyseal-diaphyseal angle)

 

https://paleyinstitute.org/wp-content/uploads/blounts1.jpg

Treatment depends upon the age of the child and the severity

  1. Medial unloader braces (should be started by age 3)

Successful in up to 80%

  1. Surgical correction (tibial osteotomy or growth plate arrest surgery)

Note: In adolescent variant bracing is ineffective and surgery is only treatment

          : Genu varum is normal in children <2 years old and becomes neutral at 14 months

 

DDX: Physiologic varus, Rickets

 

 

 



Category: Orthopedics

Title: Panner's disease

Keywords: Elbow, osteochondritis, capitellum (PubMed Search)

Posted: 4/23/2022 by Brian Corwell, MD (Updated: 4/24/2022)
Click here to contact Brian Corwell, MD

9-year-old male left hand dominant, presents with left elbow pain.

 He is a future “star pitcher,” says his coach dad. “Doc, I bet you didn’t know that although only 10% of people throw with their left hand almost a 1/3rd of MLB pitchers are lefties. He is 3x more likely than a righty to pitch in MLB.” “Maybe I’m asking him to throw too much.”

Hx: Lateral elbow pain and “stiffness” worse with activity that is better with rest

PE:  Lateral elbow tenderness (capitellum) with slight (approx. 20 degrees) decreased loss of extension. Minimal swelling noted.

Dx: Panner's disease refers to osteochondrosis of the capitellum (similar to Legg Calve Perthes). Likely due to AVN from repetitive trauma. May also be due to endocrine disturbances.

Affects the dominant elbow of boys between the ages of 5 and 10

Associated with the repetitive trauma of throwing or gymnastics.

Must be differentiated from osteochondrosis dissecans which occurs in the older child >13yo when the ossification of the capitellum is complete

Radiology

The articular surface of the capitellum may appear irregular or flattened with areas of radiolucency (43%). Loose bodies not seen with Panners, much more likely with OCD lesions.

Treatment:  Ice and NSAIDs. Avoid pitching/gymnastics etc. until full radiographic and clinical healing. If significant pain and/or swelling place patient in long arm posterior splint for 7-10 days. Resolution may take several months and up to one year.