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.
Keywords: DeQuervain, Intersection, Tenosynovitis (PubMed Search)
DeQuervain and Intersection Syndromes:
Keywords: Sternoclavicular, Dislocation, Posterior (PubMed Search)
Sorry this is being delivered to you late.
Keywords: Metacarpal, Fracture, Boxer's Fracture (PubMed Search)
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.
Keywords: Knee Injury, ACL, dislocation (PubMed Search)
Some quick facts about Knee Injuries:
Keywords: Salter Harris, Fracture, Strain, pediatric (PubMed Search)
Pediatric Strain versus Fracture
Review of Salter Harris Fractures
Keywords: Back Pain, Guideline, Treatment (PubMed Search)
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:
Links to the Clinical Guidelines are listed below:
Keywords: Supracondylar, Fracture, Pediatric, Ossification (PubMed Search)
Keywords: Sports Hernia, groin pain (PubMed Search)
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.
Sports Hernia/Athletic Pubalgia: Evaluation and Management. Christopher Larson. Sports Health.
Keywords: tendon, antibiotics, tendonitis (PubMed Search)
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.
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.
Ross RK, Kinlaw AC, Herzog MM, Jonsson Funk M, Gerber JS. Fluoroquinolone Antibiotics and Tendon Injury in Adolescents. Pediatrics. 2021 May 14:e2020033316.