Keywords: Bone stress reaction, fracture, overuse injury (PubMed Search)
Bone stress injury (BSI) in Adolescents
A BSI occurs along a pathology continuum that begins with a stress reaction and may progress all the way to a stress fracture.
Difficult to diagnose clinically.
Identifying risk factors as part of the history is very important.
Common sites for BSI are most frequently in the lower extremity and include the tibia, fibula, tarsals and metatarsals, calcaneus, and femur.
When considering this in an ED setting, image the involved area and if there is no fracture, advise discontinuing the activity until time of PCP/sports medicine follow up. For those with rest pain, pain with minimal weight bearing or in whom a fracture was suspected but not present, consider providing a walking boot or crutches.
BSIs occur more frequently in young athletes than in adults.
Almost 50% of BSIs occur in those younger than 20 years of age
Primary care and sports medicine providers are seeing more of these patients due to many factors.
Year-round training, sports specialization at younger ages and increase in training intensity/duration contribute to the increase incidence in adolescents.
Not surprisingly, participation in organized sports as an adolescent is a known risk factor.
Just as a change in sporting level from high school to college is a known risk factor for BSI, young “gifted” athletes who are promoted to competing with the varsity team may be at similar risk.
Shin pain lasting more than 4 weeks may represent a unique subset of MSK pain complaints increasing risk of BSI.
A prior history of BSI is a strong predictor of future BSI.
Inquire about night pain, pain with ambulation, and pain affecting performance.
Athletes with BSIs have a significantly lower BMI than controls (<21.0 kg/m2).
Athletes with BSIs sleep significantly less than controls.
Athletes with BSIs have significantly lower dairy intake than controls.
Inquire about components of the female athlete triad (low energy availability, menstrual dysfunction and low bone mineral density)
Nussbaum et al., 2019. Identifying Factors That Contribute to Adolescent Bony Stress Injury in Secondary School Athletes: A Comparative Analysis With a Healthy Athletic Control Group. Sports Health.
Keywords: shoulder, overhead athlete (PubMed Search)
Long head of biceps tendon (LHBT) Testing
Overhead activities can cause anterior shoulder pain due to LHBT instability. A review of 3 physical exam maneuvers for bedside evaluation.
Shoulder at 90° of flexion with arm fully supinated and elbow extended
Patient attempts to fwd. elevate arm against a downward force
Positive test is pain localized to bicipital groove.
Sensitivity 54% and specificity 81% for biceps pathology
Elbow at 90° of flexion with arm fully pronated and held against thoracic wall. Examiner grips patient’s hand and resists attempts at supination.
Positive test is pain localized to bicipital groove or LHBT subluxation.
Sensitivity 41% and specificity 79% for biceps pathology
Upper Cut test
Shoulder neutral with Elbow at 90° of flexion, arm fully supinated and hand in a fist. Patient moves hand toward chin in an uppercut motion like a boxer. Examiner places hand over patient’s fist and resists upward movement.
Positive test is pain localized to bicipital groove or LHBT subluxation.
Sensitivity 73%, specificity 78%, +LR 3.38 for biceps pathology
Comprehensive Examination of the Shoulder. Cotter et al., 2018. Sports Health
Keywords: Disc, infection, back pain (PubMed Search)
Children are prone to inflammation and infection of the intervertebral discs
-Mean age 3-5years at presentation.
Lumbar region frequently involved
Although disc biopsy is not necessary for diagnosis, as many as 60% of biopsied discs grow bacteria
-Usually Staphylococcus aureus.
Untreated - may spontaneously resolve or progress to vertebral osteomyelitis or abscess
Chief complaint: Back pain and irritability, often associated with a limp or refusal to crawl or walk.
Fever is absent or low grade.
Physical examination findings are nonspecific and may include a tendency to lie still and percussion tenderness over the involved spine.
Blood culture is generally sterile,
WBC count can be normal early in the disease course
However, the ESR is elevated in >90% of patients.
Plain radiographs are normal at the start of the illness, and generally take 2-3 weeks to demonstrate narrowing of the intervertebral space.
Therefore imaging study of choice is MRI.
Fernandez M, et al. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics 2000.
Keywords: Spine, Autonomic Dysfunction (PubMed Search)
Acute transverse myelitis (ATM) refers to inflammation of gray and white matter in one or more adjacent spinal cord segments leading to acute/subacute dysfunction of all cord functions (i.e., motor, sensory, and autonomic).
There is a bimodal peak between ages 10-19 years and ages 30-39 years.
Most cases are idiopathic
Some patients may have had a preceding viral infection or autoimmune disorder.
The thoracic cord is most commonly involved.
Onset is characterized by acute/subacute development of neurologic signs and symptoms consistent with motor weakness, sensory changes or autonomic dysfunction.
Pain in the head, neck, and/or back may occur.
Motor and sensory changes occur below the level of the lesion and are more likely to be bilateral.
Motor symptoms include a rapidly progressing paraparesis.
Autonomic dysfunction may include urinary urgency or difficulty voiding, bowel or bladder incontinence, tenesmus, constipation, and sexual dysfunction.
Despite its low incidence, consider in a patient presents with a classic constellation of symptoms,
Rapid identification, and early initiation of treatment predicts the best outcomes
Diagnosis: whole spine MRI with and without gadolinium
Management: goals include reducing cord inflammation (IV glucocorticoids), alleviating symptoms (pain management, bladder decompression), and treating underlying causes (e.g., infections, autoimmune) as appropriate.
Keywords: cancer, pediatrics (PubMed Search)
Bone tumors can present as MSK pain!
Pain may be activity related initially (can lead to misdiagnosis)
Over time will progress to rest pain and night pain
1) Primary osteosarcoma - most common primary malignant bone tumor
Adolescents, male > female
70% occur about the knee (also in hip/pelvis and upper arm)
pain, swelling, tenderness to palpation
Consider in the presentation of non traumatic knee pain!
2) Ewing's sarcoma
Peak incidence ages 10-20, male > female
pain, swelling, tendernes to palpation
Elevated temps and ESR
Consider in the differential of osteomyelitis!!
Variable location - lusually the extremities but also pelvis, scapula, ribs
Keywords: Rotation, Fracture, Phalanx (PubMed Search)
Remember to evaluate for any rotational deformity when evaluating patients with a phalanx fracture.
The easiest way to do this is to have the patient flex all their fingers. They should all point to the scaphoid. If a finger deviates or overlaps another finger there is a rotational deformity. One should also make sure that all the nailbeds align.
This video shows how to evaluate for rotation https://www.youtube.com/watch?v=Dhp25UVn7RQ
Even if the finger is reduced otherwise, persistent rotational deformities should be referred to a hand surgeon for consideration of corrective surgery.
Keywords: Hyperthermia, cold water immersion (PubMed Search)
The TACO method (tarp assisted cooling with oscillation)
Cold water immersion (CWI) remains the standard for cooling in exercise induced hyperthermia
A low cost alternative is modified cold water immersion.
Sometimes, monetary reasons and location venue prevent the feasibility of CWI
Benefits: fast, cheap, portable
Portable – Allows for on site location at area of collapse
Cheap: Equipment required – 3 providers, 1 tarp, 20 gallons of water and 10 gallons of ice
Fast: Average time to set up – 3.4 minutes
The TACO method – fast effective reduction in core temperatures
May be up to 75% as effective as CWI
Hosokawa, Yuri et al.
Annals of Emergency Medicine , Volume 69 , Issue 3 , 347 - 352
Keywords: Spine infection, back pain (PubMed Search)
Laboratory testing for Spinal Epidural Abscess
The CBC is poorly sensitive/specific
The WBC count may be nml or elevated
Left shift and bandemia may or may not be present
ESR and CRP
Sensitive but not specific
Elevated in >80% with vertebral osteomyelitis.
Reihsaus E, et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000.
Keywords: back pain, back emergency (PubMed Search)
Cauda Equina Syndrome (CES)
A recent pearl discussed CES. This is a very challenging diagnosis to make, especially on initial presentation
The 5 “classic” characteristic features are
Not all symptoms will be present in a given patient and there is no sign/symptom combination that either reliably diagnoses or excludes CES.
To illustrate how difficult this diagnosis is to make, a study looked at the predictive abilities of Neurosurgical residents.
Positive MRI for CES was accurately predicted by senior neurosurgical residents in approximately 50% of patients suspected of CES based on history and physical findings. As clinical certainty only becomes apparent with the classic symptoms (which are generally late findings) waiting to initiate MRI will delay decompressive surgery and can lead to worsened functional outcomes. This leads to increased MRI demand with more negative MRIs. Not surprisingly, only ~20% of MRI scans for suspected CES are positive.
Bell DA et al. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 2007;21:201-3.
Keywords: low back pain, analgesia (PubMed Search)
In patients with lower back pain, there is good evidence that muscle relaxants reduce pain as compared to placebo and that different types are equally effective. However, the high incidence of significant side effects such as dizziness and sedation limits their use. Muscle relaxants may be beneficial in an every bedtime capacity thereby limiting side effects.
If cyclobenzaprine is used during daytime hours, a lower dose schedule may work as well as a higher dose with somewhat less somnolence (5 mg three times a day vs 10 mg three times a day. In general, muscle relaxants should only be used when patients cannot tolerate NSAIDs but can tolerate the side effect profile.
We commonly add muscle relaxants to NSAIDs hoping for a larger analgesic effect. However, combination therapy does not appear to be better than monotherapy.
Adding cyclobenzaprine to high-dose ibuprofen does not seem to provide additional pain relief in the first 48 hours in ED patients with acute myofascial strain. Among an ED population with acute non radicular low back pain, a randomized trial found that adding cyclobenzaprine/other muscle relaxants to Naproxen did not improve functional outcomes or pain at one week or 3 months compared to naproxen alone.
Take home: Consider the limited usefulness use of muscle relaxants in ED patients with back pain
Friedman et al., 2015. JAMA.
Keywords: Neck pain, radiculopathy (PubMed Search)
Spurling’s maneuver and modified Spurling’s maneuver aka neck compression test.
This maneuver is highly specific for the presence of cervical root compression
Can be used to reproduce radicular pain/symptoms.
Perform this maneuver with caution as it should not be performed in patients who have potential cervical spine instability.
Keeping the patient’s head in a neutral position pressing down on the top of the head. If this fails to reproduce the patient's pain, the test is repeated with the head extended, rotated and tilted to the affected side (the modified Spurling’s maneuver).
Reproduction of symptoms (limb pain or paresthesias) beyond the shoulder is considered positive. Neck pain alone is nonspecific and constitutes a negative test.
The test has a high specificity (0.89 to 1.00) but low sensitivity (0.38 to 0.97).
Meaning a positive test is helpful but a negative test does not rule out radicular pain.
This test should be used in conjunction with a thorough history and physical examination (strength, sensation and reflex testing)
Thoomes, Spine J 2018 Value of physical tests in diagnosing cervical radiculopathy: a systematic review.
Keywords: anesthetic, orthopedics, wound (PubMed Search)
When caring for a patient with a laceration we often do lcoal infiltration prior to suturing but remember the benefits of regional nerve blocks
Benefits of Regional Nerve Blocks
Quick reminder of properities of common anesthetic
|Anesthetic||Onset of Action||Duration of Action|| Max Dose |
| Max Dose |
|Bupivicaine||Seconds +||> 6 hrs||2mg/kg||3mg/kg|
Final reminder: There is no evidence that epinephrine causes necrosis and it can be used safely in digital blocks. Duration of action is max 90 minutes. Even individuals that have injected themselves with EpiPens into their hands have not had any long term sequelue or necrosis seen. Vast majority required no treatment at all.
Keywords: Skiing, gamekeeper (PubMed Search)
Epidemiology of Alpine Skiing Injuries
Mean age of injury 30.3 (range 24 to 35.4 years)
Populations at greatest risk are children and adolescents and possibly adults over 50 (increased risk of tibial plateau fractures)
Sex: Males> females
Knee injuries, esp to ACL, are higher among females
Fractures greater in males
Injury location greatest at lower extremity (primarily to knee)
Primarily sprains to MCL and ACL (increasing incidence)
14% occur to upper extremity and primarily involve the thumb and shoulder
Skiers thumb – FOOSH with thumb Abducted gripping pole
Pole is implicated as this injury is rare among snowboarders
The pole acts as a lever to amplify the forced Abduction of the thumb as the outstretched hand hits the ground.
Let go before you hit the ground!!
13% occur to head and neck
The number of all type injuries has decreased over time with advances in equipment and helmet use
Proportion of skiers wearing a helmet exceeds 80%
However, the number of traumatic fatalities has remained constant
Accidents involving fatalities exceed the protective capacity of helmets
Helmets likely decrease risk of mild and moderate head injury
Ekeland et al., 2018. Epidemiology of Alpine Skiing Injuries. J Sci Med Sport
Davey et al., 2018. Alpine Skiing Injuries. Sports Health
Keywords: head injury, medication (PubMed Search)
Retrospective chart review at a headache clinic seeing adolescent concussion patients
70.1% met criteria for probable medication-overuse headache
Once culprit over the counter medications (NSAIDs, acetaminophen) were discontinued,
68.5% of patients reported return to their preinjury headache status
Take home: Excessive use of OTC analgesics post concussion may contribute to chronic post-traumatic headaches
If you suspect medication overuse, consider analgesic detoxification
Heyer and Idris., 2014. Pediatr Neurol. Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients?
Keywords: head injury, sports medicine (PubMed Search)
In which age groups should children with Sport Related Concussion be managed differently from adults?
Are there targeted subgroups who would benefit from closer outpatient and specialty follow-up?
Predictors of Prolonged Recovery in Children
Davis et al., 2017. What is the difference in concussion management in children as compared with adults? A systematic review.
Zemek et al., 2016. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.
Keywords: head injury (PubMed Search)
Concussion Management in Children
What are the predictors of prolonged recovery of concussion in children?
Female sex, age greater than 13, prior physician diagnosis of migraine, prior concussion with symptoms lasting longer than 1 week, history of multiple concussions, headache, sensitivity to noise, dizziness, fatigue, answering questions slowly and four or more errors on tandem stance testing.
Age: As compared to younger children, adolescents have a greater number of and more severe postconcussive symptoms. They take longer to recover and return to school and sport.
Subjects: Math tends to pose greater problems followed by reading/language, arts, sciences and social studies.
Computer testing: The widespread use of computer neuropsychological testing is not recommended in children and adolescents. This is due to issues with reliability over time and insufficient evidence of both diagnostic and prognostic value. When used, reference to normative data should be done with caution. Testing should also NOT be used in isolation in concussion diagnosis and management.
Davis et al., 2017. Br J Sports Med 2017.
Keywords: Concussion, return to play, school, head injury (PubMed Search)
You have successfully diagnosed a concussion, explained everything to the parents, closed the encounter, reached for the doorknob and….
“What about school?”
An athlete should not return to play until they have successfully returned to school
Several studies have demonstrated that intense cognitive stimulation and intense intellectual stimulation result in worsening symptoms
-school work, TV, videogames, texting
Attempt to limit cognitive activity to the point where it begins to reproduce or worsen symptoms!
Step 1: 24 to 48 hours of rest
Step 2: Daily at home activities that do not increase symptoms. Starting with 5 – 10 minutes and gradually build up to a goal of tolerating 30 minutes of cognitive activity without worsening symptoms.
Home work, reading assignments, other cognitive activities
Step 3: Attempt Return to school (will not be completely symptoms free!) with either part time, partial days, or with extended breaks. Goal of tolerating an entire school day without symptoms.
Most students recover fully within 4 weeks and adjustments can then be discontinued. Others with ongoing symptoms may require ongoing academic modifications (extra time for tests, papers, etc).
Suggested examples of adjustments: Shortened days, 15 minute break for every 30 minutes of instruction, providing class notes, tutoring, decreasing course expectations, decreasing exposure to classes which exacerbate symptoms, no computer work, untimed tests and quizzes, lunch in a quiet place.
Bass & Valasek Auguest 2018 Contemporary Pediatrics
Keywords: thrower, insability (PubMed Search)
25yo baseball pitcher presents with medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Mild paresethesias in 4th and 5th digits.
What physical examination maneuvers can you do at the bedside to assist in the diagnosis?
Exam opposite elbow first to establish baseline and to assist patient relaxation and understanding.
Flexing elbow to 20 to 30 degrees unlocks the olecranon
Keywords: Ulnar nerve (PubMed Search)
Tests for motor weakness of the Ulnar nerve
Patient asked to hold piece of paper in both hands, grasping with the thumb and radial side of index finger of both hands
Examiner then pulls on the paper
Test is positive if patient flexes the thumb IP join in an attempt to hold onto paper
Keywords: Heat illness (PubMed Search)
Exertional Heat Stroke (EHS)
With football preseason starting across the country, it is important to review this topic
EHS is a medical emergency resulting from progressive failure of normal thermoregulation
EHS has a high mortality
-2nd most common cause of death in football players
History and Exam
Hyperthermia/Core temperature greater than 40°C (104°F)
Initial profuse sweating with eventual cessation of sweating with hot, dry skin
CNS dysfunction – disorientation, confusion, dizziness, inappropriate behavior, difficulties maintaining balance, seizures, coma
Other: Tachycardia/hyperventilation, fatigue, vomiting, headache
Multi-organ involvement: CNS, cardiac damage, renal failure, hepatic necrosis, muscle (rhabdomyolysis), GI (ischemic colitis), heme (DIC), ARDS
The single most important thing you can do on the field is recognize this entity. Early recognition leads to earlier initiation of treatment which is life saving.
Rapid cooling is key. This is often stated but what this means is whole body immersion in ice water. This should be available and ready for all summer practices.
The temperature needs to be lowered to below 39°C (102°F)
Also consider a cooling blanket, fanning, ice to body
DO NOT put them on ambo without initiating cooling!!!
Sustaining heat injury predisposes to subsequent heat related injury