UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: Sternoclavicular Dislocation

Keywords: Sternoclavicular, Dislocation, Posterior (PubMed Search)

Posted: 3/24/2008 by Michael Bond, MD (Updated: 5/16/2022)
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Sternoclavicular Dislocation:

  • A rare cause of chest/shoulder pain following trauma, but one that can be associated with serious vascular injuries.
  • Anterior dislocations of the Sternoclavicular(SC) Joint are much more common  than posterior and  usually resulting from  blow to the anterior shoulder that rotates the shoulder backward and transmits the stress to the medial clavicle and SC joint.
  • A blow to the posteior shoulder that drives the shoulder forward or a direct blow to the medial clavicle can cause a posterior dislocation.
  • Anterior SC dislocations
    • Generally not associated with any underlying injury and can be safely reduced in the ED. 
    • Ligaments and joint capsule entrapment can make it difficult to reduce the joint, and often it is difficult to maintain the reduction. 
    • It is not uncommon for these to require open reducation and internal fixation.
    • Can be reducted by abducting, extending, and applying traction to the ipsilateral arm/shoulder while applying posterior and inferior pressure on the medial clavicle.
  • Posterior SC dislocations
    • Rare
    • Associated with injuries to the underlying vasculature,  dyspnea due to tracheal compression, and parasthesias.
    • Often missed on plain films (CXR, Shoulder Series or Clavicular Series)
    • Best visualized with enhanced CT Scan of the Chest.  IV enhancement recommended to ensure that their is no associated vascular injury.
    • Can be reducted by abducting, extending, and applying traction to the ipsilateral arm/shoulder while pulling the clavicle forward.  Several references recommend using a towel clip to grasp the clavicle if you are unable to grab it effectively with your fingers. 

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Category: Orthopedics

Title: Metacarpal Neck Fractures

Keywords: Metacarpal, Fracture, Boxer's Fracture (PubMed Search)

Posted: 2/2/2008 by Michael Bond, MD (Updated: 5/16/2022)
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Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5th Metacarpal)

Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.

  • 2nd and 3rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
  • 4th Metacarpal fracture <20۫ angulation allowed
  • 5th Metacarpal fracture <30۫ angulation. 
    • Studies have shown that even 30۫ angulation will decrease normal function by 20%.  
    • Normal excursion of the 5th MCP is 15۫ to 25۫.
  • No amount of rotation deformity should be allowed.

Category: Orthopedics

Title: Knee Injuries

Keywords: Knee Injury, ACL, dislocation (PubMed Search)

Posted: 1/5/2008 by Michael Bond, MD (Updated: 5/16/2022)
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Some quick facts about Knee Injuries:

 

  • The most common cause of acute traumatic hemarthrosis of the knee is an anterior cruciate ligament tear.
    • Most patients with an ACL injury will give a history of immediate pain, disability, knee swelling and audible pop.
  • The most common ligament injuried in the knee is the medial collateral ligament.
  • Patella dislocations
    • Usually lateral dislocations and often spontaneous reduce.
    • Hyperextend the knee to make the reduction easier.
  • Dislocation of the knee:
    • Anterior is the most common and usually secondary to hyperextension
    • Popliteal artery injury is commonly seen and must be looked for.  Easy bedside test is Ankle Brachial Indexs.

 


Category: Orthopedics

Title: Pediatric Strains versus Fractures

Keywords: Salter Harris, Fracture, Strain, pediatric (PubMed Search)

Posted: 10/13/2007 by Michael Bond, MD (Updated: 5/16/2022)
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Pediatric Strain versus Fracture

  • Due to the fact that tendons are much stronger than the physeal growth plate in pre-pubescent children, one should be extremely cautious when diagnosing a strain/sprain. 
  • Pre-pubescent pediatric patients should be treated as if they have a Salter Harris I fracture with an appropriate splint and close follow up.

Review of Salter Harris Fractures

  1. A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened.
  2. A fracture through the physeal growth plate and metaphysis.
  3. A fracture through the physeal growth plate and epiphysis.
  4. A fracture through the physis, physeal growth plate and metaphysis.
  5. A crush injury of the physeal growth plate.

Please click here for a pictorial of Salter Harris Fractures from FP Notebook.


Category: Orthopedics

Title: Treatment and Evaluation of Low Back Pain

Keywords: Back Pain, Guideline, Treatment (PubMed Search)

Posted: 10/7/2007 by Michael Bond, MD (Updated: 5/16/2022)
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Low Back is one of the most common complaints that we see in the Emergency Department.  Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…).  However, most of the back pain that we will see is musculoskeletal in origin.

The American College of Physicians (ACP) and the American Pain Society (APS) recently released some joint recommendations on the evaluation of treatment of individuals with back pain.

In summary their key recommendations are:

  1. Routine imaging is not required. However, diagnostic imaging and testing should be obtained for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.
  2.  For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
  3. Medications that have good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain).

Links to the Clinical Guidelines are listed below:


Category: Orthopedics

Title: Supracondylar Fractures

Keywords: Supracondylar, Fracture, Pediatric, Ossification (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 5/16/2022)
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Supracondylar fractures in children: To assess the likelihood of a supracondylar fracture in a child look at the anterior humeral line. This is a line drawn down the anterior portion of the humerus on the lateral view of the elbow. This line should pass through the center of the capitellum in the distal humerus. If the line does not pass through the center there is a very high likelihood of a supracondylar fracture. Review of the Appearance of Ossification Centers in Children's Elbows CRITOE Capitellum 1 to 8 months Radial Head 3 to 5 years Medial (Internal)Epicondyle 5 to 7 years Trochlea 7 to 9 years Olecranon 8 to 11 years Lateral ( External) Epicondyle 11 to 14 yeras

Category: Orthopedics

Title: The association between fluoroquinolone use and tendon injury in an adolescent population

Keywords: tendon, antibiotics, tendonitis (PubMed Search)

Posted: 5/22/2021 by Brian Corwell, MD (Emailed: 5/16/2022) (Updated: 5/16/2022)
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A recent article in Pediatrics attempted to estimate the association between fluoroquinolone use and tendon injury in an adolescent population.

Fluoroquinolones are thought to negatively impact tendons and cartilage in the load-bearing joints of the lower limbs through collagen degradation, necrosis, and disruption of the extracellular matrix.

Population: 4.4 million adolescents aged 12–18 years with filled outpatient fluoroquinolone prescription vs. an oral broad-spectrum antibiotic for comparison.

Fluoroquinolones included ciprofloxacin, levofloxacin, moxifloxacin, and gatifloxacin

Comparator antibiotics included amoxicillin-clavulanate, azithromycin, cefalexin, cefixime, cefdinir, nitrofurantoin, and bactrim.

Outcomes: Primary outcome was 90-day tendon rupture (Achilles, patellar, quadricep, patellar, tibial) identified by diagnosis and procedure codes. Secondary outcome was tendinitis.

Results: The weighted 90-day tendon rupture risk was 13.6 per 100 000 fluoroquinolone-treated adolescents and 11.6 per 100 000 comparator-treated adolescents.

Fluoroquinolone-associated excess risk: 1.9 per 100 000 adolescents; the corresponding number needed to treat to harm was 52 632.

The weighted 90-day tendinitis risk was 200.8 per 100 000 fluoroquinolone-treated adolescents and 178.1 per 100 000 comparator-treated adolescents

Fluoroquinolone-associated excess risk excess risk: 22.7 per 100 000 adolescents; the corresponding number needed to treat to harm was 4405.

Conclusion:

The excess risk of tendon rupture associated with fluoroquinolone treatment was extremely small, and these events were rare. On average, 50,000 adolescents would need to be treated with a fluoroquinolone for 1 additional tendon rupture to occur

The excess risk of tendinitis associated with fluoroquinolone treatment though larger was also small.

Besides tendon rupture, other more common potential adverse drug effects may be more important to consider for treatment decision-making, in adolescents without other risk factors for tendon injury.

 

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Category: Orthopedics

Title: Sports Hernia/Athletic pubalgia

Keywords: Sports Hernia, groin pain (PubMed Search)

Posted: 4/6/2014 by Brian Corwell, MD (Emailed: 5/16/2022)
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Sports Hernia/Athletic pubalgia

 

Hx: Gradually increasing lower abdominal/proximal adductor pain. Usually activity related, resolves with rest. Frequent return despite rest when sports activity resumes.

Most common in athletes who perform cutting/maneuvers in addition to frequent acceleration/deceleration. Think ice hockey and soccer.

Bilateral symptoms not uncommon.

PE:  Resisted sit up with palpation of the inferolateral edge of the distal rectus may recreate symptoms. Similarly, resisted hip adduction may elicit symptoms. 

If for no other reason than to make the diagnosis harder to make, valsalva induced pain may also occur.

Fluoroscopic guided injections can be helpful to isolate the site of pain generation.

First line therapy is rest, non-narcotic analgesia and physical therapy.

With surgery, >80% return to pre injury level of play.

 

http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2009/11/groin-injuries.jpg

 

Show References


Category: Orthopedics

Title: Fulcrum test

Posted: 10/1/2017 by Brian Corwell, MD (Emailed: 5/16/2022) (Updated: 5/16/2022)
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https://www.physio-pedia.com/Fulcrum_Test


Category: Orthopedics

Title: Morel-Lavall e lesion

Posted: 10/1/2017 by Brian Corwell, MD (Emailed: 5/16/2022) (Updated: 5/16/2022)
Click here to contact Brian Corwell, MD

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4126145/