The Romberg test is part of the standard neurologic examination. The patient is asked to stand with feet together, hand on hips/sides and the eyes are closed. Vestibular and proprioceptive input is being tested. 

This test is not very sensitive overall, but especially in concussed athletes.

Many concussed athletes are able to stand relatively stable despite their neurologic injury.

In order to better identify postural instability in concussion, we perform 3 separate balance tests (modified balance error scoring system, mBESS).

A) Romberg

B) Single leg stance

21. Standing on the non dominant foot, the hip is flexed to approximately 30° and the is knee flexed to approximately 45°.
21. NonDominant Leg: The nondominant leg is defined as the opposite leg of the preferred kicking leg

C) Tandem Stance

https://www.researchgate.net/profile/Boaz_Saffer/publication/309591285/figure/fig2/AS:669641529626644@1536666390860/Balance-Error-Scoring-System-BESS-performed-on-firm-surface-A-C_W640.jpg

Have patient stand quietly with hands on hips

Have patient close eyes and start 20 second trial

If error occurs tell patient to return to start as quickly as possible

Examples of errors: opening eyes, lifting hands, falling out of position

A 25 year old athlete presents to the ED with right anterior shoulder pain.

Pain radiates into proximal biceps.

It is worse with heavy lifting and especially “pulling” exercises at the gym.

How do we evaluate for biceps tendonitis?

1. Tenderness to palpation in the bicipital groove
2. Speed’s test
3. Yergason’s test

Pathology is often the long head of the biceps

https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg

Start by palpating this area and attempt to reproduce the discomfort

Speed’s test

• Arm is supinated and extended and elevated against examiner’s  downward resistance
• https://youtu.be/N00gA4Pvsbw

Yergason’s test

• Arm is placed to patient’s side, in pronation and flexed to 90 degrees at elbow
• Patient attempts to supinate and externally rotate arm against resistance
• https://youtu.be/rQ2Mp6aSi88

Ulnar Collateral ligament injuries of the elbow

Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow

This can lead to valgus instability similar to what can occur in the knee

Overhead throwing places a significant valgus stress on the elbow

Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports

In the acute setting may be seen after an elbow dislocation

History includes a “pop” and medial elbow pain following throwing activities

In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.

The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion

One classic test for UCL instability is the milking maneuver

Patient may be sitting or standing

Patient’s forearm is supinated and elbow flexed at 90 degrees

A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line. 

Instability, pain or apprehension at the UCL is considered a positive test

https://www.youtube.com/watch?v=gbn24X_qqn0

Carpal Tunnel Syndrome (CTS)

The hallmark of classic CTS:  pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit.

The symptoms of CTS are typically worse at night and often awaken patients from sleep.

Fixed sensory loss is usually a late finding

Involves the median-innervated fingers BUT spares the thenar eminence.

This pattern occurs because the palmar sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the carpal tunnel.

Consider a more proximal lesion in cases involving sensory loss in the thenar eminence

            Example: pronator syndrome

Physical injury patterns associated with physical elder abuse

Elder abuse is both common and underrecognized

Between 5 and 10% of US older adults are victims of elder abuse annually

For many older adults, contact with a health care provider may represent their only contact outside the home

Differentiating physical elder abuse from unintentional trauma can be very difficult

A recent study compared these two groups with a case-control design

Study cases: 100 successfully prosecuted physical elder abuse cases from a single urban ED

Physical abuse victims were more likely to have:

               Bruising (78% vs. 54%)

               Injuries to maxillofacial, dental or neck region (67% vs. 28%)

                              Particularly the LEFT side

                              Neck injuries 6x more common is assault

                              Ear injuries occurred in assault but not in falls

               Absence of fracture (8% vs. 22%)

               Less likely to have lower extremity injuries (9% vs. 41%)

22% of victims had no visible injuries

Most common mechanism assault with hands or fists and pushing or shoving causing a fall

Take home: Consider elder abuse especially in cases of the above red flags

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A recent study looked at thoracic spinal fractures in the era of the trauma panscan

NEXUS Chest CT Study from 2011 to 2014 at 9 Level I trauma centers.

Goal: To describe the identification rate and types of thoracic spine fractures.

Inclusion: age over 14 years, blunt trauma occurring within 6 hours of ED presentation, and chest CT imaging during ED evaluation.

11,477 subjects, 217 (1.9%) had a thoracic spine fracture

The majority of spine fractures in patients who had both chest x-ray and CT were observed on CT only (91%). 50% had more than 1 thoracic spinal level involved (mean 2.1). 22% had associated cervical fractures and 25% had associated lumbar fractures.

               64% had vertebral body fractures

               45% had posterior column fractures

               28% had compression fractures

               6% had burst fractures

Many patients (62%) had associated thoracic injuries such as

               Rib fractures (45%)

               PTX (36%)

               Clavicle fracture (18%)

               Scapular fracture (17%)

               Hemothorax (15%)

100 patients had clinically significant thoracic spine fractures.

Thoracic spine fractures are relatively uncommon in adult patients with blunt trauma.

If thoracic spine fracture is suspected clinically, radiography is not an effective screen and clinician should consider CT. If not suspected, guidelines discourage ordering CT to screen for this injury because of effective screening instruments, the diagnosis of clinically insignificant injuries and radiation exposure.

All clinically significant thoracic spine fractures would have been detected by the NEXUS Chest CT decision instrument.

https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

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Diagnostic performance of Ultrasonography for detection of pediatric elbow fracture

Elbow fractures account for approximately 15% of pediatric fractures

Fat pads are traditionally taught as a marker of fracture

In a cadaveric study:

Elbow effusions of 1-3 mL could be identified with ultrasound

Elbow effusions of 5-10 mL could be identified with plain film

Pediatric plain films are sometimes challenging to obtain and interpret compared to adults

              -More likely to be uncooperative in obtaining required views

              -Non-ossified epiphyses

Ultrasound may be used to detect

              -Cortical disruption and irregularity

              -Growth plate widening

              -Hematoma interposed between fracture fragments

              -Elevated posterior fat pad

Absence of elbow fracture was indicated by

              -Lack of cortical disruption

              -Absence of posterior fat pad sign

Meta-analysis of 10 articles totaling 519 patients using ultrasonography to detect elbow fractures

              Sensitivity 96%

              Specificity 89%

              False negative rate 3.7%             

For comparison, plain radiographs

Interpreted by peds EM physicians (87.5% sensitive and 100% specific)

Interpreted by radiology (96% sensitive, 100% specific)

Consider using ultrasound as a noninvasive, radiation-free modality for accurate diagnosis of pediatric elbow fractures.

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Pronator Teres Syndrome

A compressive neuropathy of the median nerve in the region of the elbow

The median nerve passes through the cubital fossa and passes between the superficial and deep heads of the pronator teres muscle.

Rare compared to other compressive neuropathies such as carpal tunnel syndrome.

More common in women and in fifth decade of life

May be seen with weight lifters, arm wrestlers, rowers, tennis, archery, professional cyclists, dentists, fiddlers, pianists, harpists

Also associated with well-developed forearm muscles  

History:

Forearm pain – unlike carpal tunnel

Paresthesias in median distribution

No night symptoms – unlike carpal tunnel

Physical exam:

Sensory loss in medial nerve distribution.

Involves the thenar eminence!

Unlike carpal tunnel syndrome which doesn’t involve sensory loss in thenar eminence.

Pain may be made worse with resisted forearm pronation

Compression/Tinel’s sign over pronator mass reproduces symptoms

Treatment:

Splinting which limits pronation and NSAIDs

Steroid injection

Surgical nerve decompression is non operative treatment fails after greater than 6 months (rare)

Treatment for carpal tunnel syndrome (CTS)

The management of CTS depends of the severity of the disease

If symptoms or on the mild to moderate range, a trial of conservative treatment is encouraged.

Possible therapeutic approaches can include splinting in wrist neutral position. Some even extend to keep the CMP joints extended. Extreme flexion and extension can increase pressure within the carpal tunnel. Usually for nighttime use only. May be used during day based on work and activity demands.

Has been shown to improve electrophysiologic findings after 12 weeks of use in moderate CTS.

Formal hand physical therapy (by an experienced therapist) may also be of some benefit including carpal bone mobilization, ultrasound and nerve glide exercises.   

There is small evidence for the benefit of prednisone (20mg/d) as it has been shown to be more effective than placebo with improvements lasting an average of 8 weeks.

There is no benefit to NSAIDs or diuretics.

There is poor evidence for therapeutic ultrasound and acupuncture.

While more invasive than the above modalities, steroid injections may decrease inflammation and pressure in the carpal tunnel.  Patients randomized to steroid injection may do better than those randomized to nighttime splinting.

Early referral in those with positive electrodiagnostic findings is encouraged as they do best with earlier surgical release and have better recovery.

If however the patient has severe, progressive or persistent symptoms or there is known evidence of nerve injury on diagnostic testing, referral for surgical decompression is warranted.

Sickle cell trait (SCT) is common and often overlooked clinically

               -7.3% African Americans

               -0.7% Hispanics

               -0.3% Caucasians

SCT is a leading cause of exertional death in athletes who play football

The exact mechanism is unknown but likely involves a combination of high intensity exercise, dehydration, heat strain and inadequate opportunity for cardiovascular recovery leading to microvascular erythrocyte sickling.

This leads to hypoxia, cell death, hyperkalemia, and death from arrhythmia.

Presentation often involves rhabdomyolysis and exertional collapse.

In August of 2010 the NCAA enacted legislation requiring documentation of SCT status of all Division 1 athletes (2012 for Division 2 and 2014 for Division 3)

They also mandated education, counseling and issued guidelines for proper conditioning

Sudden death in athletes with SCT was first observed in military recruits in 1970.

Death in African American military recruits was 28 times more likely in those with SCT than in those without.

A 2012 study of football athletes found the risk of exertional death to be 37 times higher in athletes with SCT than in those without.

Despite game/competition situations being more intense, deaths occur almost exclusively during practice and conditioning drills.

Following the 2010 legislation, there has been a 89% decrease in death from SCT in NCAA D1 football.

Workout plans need to account for heat/humidity, the athletes level of conditioning and allow for adequate rest, recovery, hydration. SCT screening is only part of the solution.

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Post concussion musculoskeletal injuries

Sport related concussion (SRC) impairs numerous functions of the CNS.

Traditional research has focused on risk of repeat concussion following clearance and return to sport

Several studies have shown a consistent elevated risk of lower extremity injuries from 90 days up to one year following SRC.

These include lateral ankle sprains and ACL injuries. Risk ranges, 1.3-3.4x.

This risk may be greater in those with multiple concussions.

This elevated rate has been seen in populations ranging from high school, college to professional athletes and has also been seen in the general population.

Persistent neurological deficits in cognitive and postural control, stability and gait deviations have been postulated as potential mechanisms.

These may be potential modifiable risk factors before return to play/activity. This may be a role best served by sport physical therapists to assist with sport specific rehabilitation post concussion.

MRI for Concussion Testing in the ED

The increased sensitivity of MRI may have a role in detecting more subtle intracranial injuries.

135 patients with mild TBI were prospectively evaluated for acute head injury in emergency departments of 3 LEVEL I trauma. 

27% of these patients with a normal initial head CT had an abnormal brain MRI including contusions and microhemorrhages. A greater number of these subtle findings was associated with neuropsychological defects on both short-term memory function and with poorer 3 month cognitive outcomes. Inherent difficulties of access, actionable results and reimbursement issues prevent application of MRI for concussion evaluation in the ED.

Note: Mild TBI defined as GCS 13-15 is not the same as sport or activity related concussion which I consider to be GCS 14-15.

Take home: There is currently no role for MRI in the acute evaluation of concussion in the ED.

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Comparison of Oral Ibuprofen at Three Single-dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial

Ibuprofen is one of the most commonly used medications in the ED for the acute treatment of pain. Analgesic ceiling doses are not well supported. Some adverse effects of NSAIDs are dose dependent (GI and cardiovascular).

A recent study looked to compare the analgesic effect of oral ibuprofen at 3 different doses 

Population:  Adult ED patients (aged 18 and older) with acute pain.

Methods: Randomized double-blind trial.

Goal: To examine the efficacy of ibuprofen at 400, 600 and 800mg.

Only 225 patients enrolled (75 per group). Outcome was difference in pain scores at 60 minutes.

Results:  Difference in mean pain scores at 60 minutes between 400 and 600mg (0.14), 400 and 800mg (0.14) and 600 and 800mg (0.00).

Conclusion:  Reduction in pain scores was similar between all 3 dosing groups. Consider lower dosing of ibuprofen in ED patients presenting with acute pain. 

This analgesic ceiling dose is lower than recommended by the FDA and most EM textbooks.

Consider using the 400mg ibuprofen dose for ED patients with acute pain

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Question

A recent study looked at analgesic prescribing patterns for patients with back pain in EDs in the United States.

Back pain is the most common pain complaint worldwide

-Accounted for about 9% of all ED visits.

Summary:  ED use of tramadol for back pain doubled from 2007 to 2016 despite an overall decrease in opioid use (in that period)

Tramadol -- either administered in the ED or prescribed -- was used in 8.4% of back pain visits in 2016, up from 4.1% in 2007 (P=0.001).

In 2007, overall opioid use was 53.5%; in 2016, it was 46.5% (P=0.001). The largest drop was in hydrocodone use.

A recent study in JAMA looked at the risk of death in 90,000 people one year after filling a Rx for tramadol vs. one of several other analgesics such as naproxen, diclofenac or codeine.

All patients were aged 50 years or older and has osteoarthritis.

Initial Rx for tramadol was associated with a higher rate of mortality than with NSAIDs (but not compared to codeine).

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Studying the demographics of all both sports and recreation related injuries is important for the development of effective preventive strategies.

Methods: National electronic injury surveillance system all injury program from 2005 to 2013 (367,300 sports and recreation related ED visits).  

18 common sports and recreational activities in the United States

Results:  A fracture occurred in 20.6% and a joint dislocation in 3.6% in ED visits for a sport related visit

Most of the fractures occurred in football (22.5%) and occurred in autumn and summer. Most fractures occurred in arm/hand (finger most common). Most fractures occurred in school or sporting venues.

The OR for fracture was greatest for inline skating (6.03), males (1.21) and those between 10 and 14 years of age and those older than 84 years (4.77).

Dislocations were highest in basketball (25.7%) and occurred in the autumn and on weekends. Most dislocations occurred in school or sporting venues.

The OR for dislocation was greatest in gymnastics (4.08), males (1.50) and those aged 20 to 24 years (9.04)

The most common fracture involved the finger and the most common dislocation involved the shoulder, followed by finger and knee.

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Taking an accurate history to diagnose Cauda Equina Syndrome (CES)

Classic teaching is to inquire specifically about bowel and bladder function, sexual dysfunction, and/or loss of sensation in the groin.

Rather than asking about urinary incontinence, clinicians should ask specifically about difficulty passing urine, new leakage and retention.

Discussing issues related to sexual dysfunction are difficult for both clinicians and patients.

Rather than asking if there are any issues with sexual function, a more direct and informative way would be to ask if the patient has a “change in ability to achieve an erection or ejaculate” or “loss of sensation in genitals during sexual intercourse.”

Saddle anesthesia has the highest predictive value in diagnosing MRI-proven CES. Loss of sensation may be incomplete and patchy. Ask about change in sensation with wiping after a bowel movement.

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Timeliness of Concussion Referral

Do patients with a self-limited diagnosis of “concussion” require specialty follow up?

If so, is there a benefit to earlier evaluation?

Recently published research from the University of Pittsburgh Sports Medicine Concussion Program suggests so.

Subjects: 162 concussed athletes between the ages of 12 and 22

Findings: Athletes treated in the first week after injury recovered faster than those who did not receive care until 8 to 21 days post injury.

Note: Once in care the length of time spent recovering was the same for both groups. This suggests that the amount of time prior to the initiation of care may explain the longer recovery time of the 2^nd group.

Earlier recovery can help minimize effects on mood, quality of life and lost time in school/work.

Take home:  Consiuder early follow up referral to a qualified provider for all concussed patients seen in the ED

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Slipped Capital Femoral Epiphysis (SCFE)

• Progressive, posterior medial displacement (slipping) of the proximal femoral epiphysis
  • Complicated by AVN and premature physis closure

http://www.raymondliumd.com/images/SCFE%20illustrated%20and%20cropped.jpg

Early Diagnosis:

• Allows best chance for intervention and good functional outcome

• Subtle and difficult with X-ray

• Classic teaching is Klein’s line

Klein’s Line on AP view

• A line drawn from the superior aspect of the femoral neck will not intersect the femoral head epiphysis

• Modified line
  • >2mm difference in width lateral to line between each side

https://pedemmorsels.com/wp-content/uploads/2018/01/Slipped-Capital-Femoral-Epiphysis-3.png

Another virtual line may assist in diagnosis

S-sign

• The S-sign is a curvilinear line drawn on the inferior margin of the proximal femoral head neck junction along the proximal femoral physis.
•  Discontinuity or an abrupt sharp turn are abnormal

https://images.squarespace-cdn.com/content/v1/562149a6e4b0bca6fa53cb35/1530197888065-AOF0LA079Y81Q6M89RJU/ke17ZwdGBToddI8pDm48kE2XMWnCJSZ3ROkmIxQ7DdsUqsxRUqqbr1mOJYKfIPR7LoDQ9mXPOjoJoqy81S2I8N_N4V1vUb5AoIIIbLZhVYxCRW4BPu10St3TBAUQYVKcIZH9X6Fb-UKi0lvZd9RVmtFt1P_lj4JzgsdTxe78uiejbzfgXQaCWxJNArJhpf7P/Screen+Shot+2018-06-26+at+10.09.17+AM.png?format=1500w

Klein's line and S-sign

• A group of 20 orthopedic surgeons, radiologists, and pediatricians viewed 35 radiographs of SCFE using Klein's line on the AP view and the S-sign on frog-leg lateral view to make the diagnosis. 

• Overall diagnostic accuracy was better with the S-sign than Klein's line, 92% vs 79%.
  • Sensitivity of the S-sign was 89%, specificity 95%. 
  • Sensitivity of Klein's line was 68%, specificity 89%. 

• Combined S-sign + Klein's line sensitivity was 96%, specificity 85%.

Consider adding both of these virtual lines/signs to your review of the pediatric hip plain film

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The role of skeletal muscle relaxants in the management of lower back pain in the ED

Patients with lower back pain (LBP) presenting to the ED are often treated with NSAIDs plus skeletal muscle relaxants.

A recent study in Annals of Emergency Medicine compared functional outcomes and pain in ED patients with acute non radicular LBP with 4 different treatment regimens.

1. Ibuprofen plus placebo
2. Ibuprofen plus baclofen
3. Ibuprofen plus metaxalone
4. Ibuprofen plus tizanidine

Conclusion: Adding a muscle relaxant to ibuprofen did not improve pain or improve function at 1 week following an ED visit for LBP.

Note: Prior studies have found no benefit to adding opioids or diazepam to NSAIDs  for ED patients with acute non radicular LBP

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1. Decreased hepatic function
2. Decreased renal function
3. Multiple comorbidities and polypharmacy that can affect pharmokinetics of pain medications.

Therefore, pain medications must be dosed carefully, which runs the risk of underdosing.  Pain medications can also contribute to delerium, and decreased functional status.

Recommendations:

1. Start with non-opioid medications in most cases. Consider combination acetaminophen and ibuprofen/naproxen.
2. Consider regional nerve blocks where applicable due to the decreased risk of systemic side effects and excellent analgesic properties.
3. If using opioids, start low and reassess and use the lowest dose possible. Remember half-lifes are often prolonged so patient may not need the standard dosing interview.