UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: Muscle relaxants and back pain

Keywords: low back pain, analgesia (PubMed Search)

Posted: 2/23/2019 by Brian Corwell, MD (Updated: 6/19/2024)
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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


 

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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)

 

https://www.youtube.com/watch?v=17QWqbXjSpc

 

 

 

 

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Category: Orthopedics

Title: Anesthestic Pearls

Keywords: anesthetic, orthopedics, wound (PubMed Search)

Posted: 1/19/2019 by Michael Bond, MD
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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

  • Less Painful
  • Prevents distortion of the wound which can help with cosmetic closure
  • Allows for a greater area to be anesthesized with less anesthetic use (prevents toxic levels)
  • Can allow for longer anesthetic time

Quick reminder of properities of common anesthetic

Anesthetic Onset of Action Duration of Action Max Dose 
No Epi
Max Dose
With Epi
Lidocaine Seconds 1 hr  4mg/kg 7mg/kg
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.

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Category: Orthopedics

Title: Epidemiology of Alpine Skiing Injuries

Keywords: Skiing, gamekeeper (PubMed Search)

Posted: 1/12/2019 by Brian Corwell, MD (Updated: 6/19/2024)
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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

 

 

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Category: Orthopedics

Title: Concussion headaches

Keywords: head injury, medication (PubMed Search)

Posted: 12/8/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

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

 

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Category: Orthopedics

Title: Pediatric Concussion 2

Keywords: head injury, sports medicine (PubMed Search)

Posted: 11/10/2018 by Brian Corwell, MD (Updated: 6/19/2024)
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In which age groups should children with Sport Related Concussion be managed differently from adults?

  • Not adequately addressed in literature.
  • Consider 5-12 years old vs 13 and over for child vs. adult testing

 

Are there targeted subgroups who would benefit from closer outpatient and specialty follow-up?

 

Predictors of Prolonged Recovery in Children
 

  • Female sex
  • physician diagnosis of migraine
  • Prior concussion with symptoms lasting longer than 1 weeks
  • Multiple concussions
  • ADHD/LD/Mood disorders
  • Acute headache
  • Age 13 or older
    • Teenage and high school years represents the greatest age period for prolonged recovery
  • Prior
  • Dizziness
  • Sensitivity to noise
  • Fatigue
  • Answering questions slowly
  • 4 or more errors on BESS testing

 

 

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Category: Orthopedics

Title: Pediatric Concussion

Keywords: head injury (PubMed Search)

Posted: 10/27/2018 by Brian Corwell, MD (Updated: 6/19/2024)
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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.

 

 

 

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Category: Orthopedics

Title: Concussion question parents will ask you

Keywords: Concussion, return to play, school, head injury (PubMed Search)

Posted: 10/13/2018 by Brian Corwell, MD (Updated: 6/19/2024)
Click here to contact Brian Corwell, MD

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.

 

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Category: Orthopedics

Title: Medial Elbow Instability

Keywords: thrower, insability (PubMed Search)

Posted: 9/23/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

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

  1. Valgus stress test – flex elbow with forearm/hand supinated. Apply valgus stress test and note for laxity/firm endpoint.

https://www.youtube.com/watch?v=KXQxH0UTn-8

  1. Milking maneuver – Here the valgus stress is created by pulling on the patient’s thumb with the forearm supinated and elbow flexed to 90°. Note instability, pain, or apprehension.

https://www.youtube.com/watch?v=4sa9goJ4afs

or

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

  1. Moving valgus stress test – Similar to the milking maneuver, the valgus stress test is applied while the elbow is ranged through full flexion and extension. Note instability, pain, or apprehension in mid range (between 70 and 120 degrees)

https://www.youtube.com/watch?v=OnkkHpG3Dqg

 



Category: Orthopedics

Title: Froment's Sign

Keywords: Ulnar nerve (PubMed Search)

Posted: 9/9/2018 by Brian Corwell, MD (Updated: 6/19/2024)
Click here to contact Brian Corwell, MD

Froment’s Sign

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

 

https://handlab.com/resources/wp-content/uploads/2014/04/June-2013-No25.jpg

 



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

 



Category: Orthopedics

Title: Delayed Onset Muscle Soreness

Keywords: Muscle pain, exercise (PubMed Search)

Posted: 7/28/2018 by Brian Corwell, MD (Updated: 6/19/2024)
Click here to contact Brian Corwell, MD

Delayed Onset Muscle Soreness (DOMS), aka “muscle fever”

Muscle pain and weakness following unfamiliar exercise

Occurs after high force, novel (unaccustomed) eccentric muscle contractions

               Occasionally isometric in an extended position

Eccentric exercise – controlled elongation

Slowly lowering yourself to start position doing pullups for example

Time of onset

Begins 6 to 12 Hours after exercise, Peaks 2-3days post and resolves in 5-7 days

               Speed of onset and severity are often related

How do you know if you have it?

Much like the flu, you know it when you have it. The simple act of getting out of a car, sitting down or walking down stairs is excruciatingly painful.

Cause:

Exact cause is unknown. Thought to be due to sarcolemma damage leading to intra cellular calcium release and activation of proteolytic enzymes. Creatine kinase leaks from muscle cells into plasma attracting inflammatory cells.

Treatment:

Best treatment is prevention: Repeated bout effect – a bout of eccentric or isometric exercise can prevent DOMS from the same exercise for 4-12 weeks.

               Stretching before exercise has not been shown to be effective prevention

Other modalities: rest, ice, heat, massage, electrical stimulation

Take home:

Eccentric exercises or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of the sporting season or the start of a new, novel exercise routine. For example, not starting the Insanity day one workout without “pretraining.” This will reduce the level of physical impairment and/or training disruption and lead to gains with much less pain.

 



Category: Orthopedics

Title: Stingers and Burners

Keywords: Cervical spine, neuropraxia (PubMed Search)

Posted: 7/14/2018 by Brian Corwell, MD (Updated: 6/19/2024)
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Stingers and Burners

Also known as transient brachial plexus neuropraxia, “dead arm syndrome,” or brachial plexopathy. Symptoms such as pain, burning, and/or paresthesias in a single upper limb, lasting seconds to minutes.

Usually involves more than one dermatome

May be associated with weakness.

               -Common in collision sports that involve tackling, such as football.

               -Most common C-spine injury in American Football.  

               -More than 50% of college football players sustain a stinger each year

-Having 1 stinger increases the risk of having another 3 fold

Mechansims: C5, C6 (deltoid,biceps) most commonly involved

-Traction injury due to forcible lateral neck flexion away with downward displacement of arm

-Nerve root compression during combined neck extension and lateral neck flexion

-Direct trauma to the brachial plexus in the supraclavicular fossa

Physical Exam:

-Examine muscle strength in the deltoid, biceps, and infraspinatus muscles

-Check sensation and reflexes in upper extremities

-Check C-spine range of motion and perform Spurling’s Test

Imaging:

Consider MRI for symptoms lasting more than 24 hours, bilateral symptoms or for recurrent stingers

Return to play guidelines vary:

-No neurologic symptoms

-Can return to play in same game if symptoms resolve within 15 minutes and no prior stingers that season.

-If 2nd stinger in that season, do NOT return to play in the same game

-if 3rd stinger in a season, consider imaging before return to play and consider sitting out the remainder of the season.

 



ED visits for acute gout increased almost 27% between 2006 & 2014, a 26.8% increase

Presentation: Acute severe pain, swelling, redness, warmth.

Pain peaks between 12 to 24 hours and onset more likely at night

Quiet, calm period between flares vs other arthritic disorders

Signs of inflammation can extend beyond the joint

Normal to low serum urate values have been noted in 12 to 43% of patients with gout flares 

Accurate time for assessment of serum urate is greater than 2 weeks after flare subsides

Most hyperuricemic individuals never experience a clinical event resulting from urate crystal deposition.

Gout flares may occasionally coexist with another type of joint disease (septic joint, psedugout),

A clinical decision rule has shown to be more accurate than clinical diagnosis (17 versus 36%)

*Male sex (2 points)

*Previous patient-reported arthritis flare (2 points)

*Onset within one day (0.5 points)

*Joint redness (1 point)

*First metatarsal phalangeal joint involvement (2.5 points)

*Hypertension or at least one cardiovascular disease (1.5 points)

*Serum urate level greater than 5.88 mg/dL (3.5 points)

 Scoring for low (≤4 points), intermediate (>4 to <8 points), and high (≥8 points) probability of gout identified groups with a prevalence of gout of 2.2, 31.2, and 82.5 percent, respectively.

Consider supplementing your clinical decision with this in the future

 

 

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Category: Orthopedics

Title: Concussion Management

Posted: 6/2/2018 by Michael Bond, MD (Emailed: 6/17/2018) (Updated: 6/17/2018)
Click here to contact Michael Bond, MD

Bottom Line:

Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.

In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.

Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571

 

 



Syndesmotic sprain aka a “high ankle sprain”

Ankle injuries make up almost 30% of the injuries in professional football

High ankle injuries make up between 16 and 25% of these injuries in the NFL (lateral most common)

               10% in general population

In comparison to lateral ankle sprains, high ankle sprains result in significantly more missed games, missed practices and required a longer duration of treatment

Anatomy: The syndesmosis comprises several ligaments and the interosseous membrane

Mechanism: External foot rotation with simultaneous rotation of the tibia and fibula.

               Can lead to a Maisonneuve fracture

Injuries 4x more likely in game setting than practice

A positive proximal squeeze test significantly predicts missed games and practices compared to those without.

 

https://www.youtube.com/watch?v=ThiW_9m7cFM

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Category: Orthopedics

Title: Exertional rhabdomyolysis (ER)

Keywords: Heat, exertion, muscle (PubMed Search)

Posted: 5/26/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Exertional rhabdomyolysis (ER)

The warm weather is here and with it comes an increased risk of ER

Risks include the intensity, duration and types of exercises performed

One of the biggest risks is the exercise experience of the participants, both in those with little to no experience and in those experienced athletes less trained than their counterparts.

Multiple case reports find that intense novel exercises early in the preseason before getting acclimatized and “in shape” carry great risk to the participant. These can be summarized as “too much, too soon, too fast.”

Coaches need to be educated about this and be prepared to detect and effectively handle ER through an emergency action plan.

               -Conditioning workouts need to be phased in rather than start at maximum intensity on day one.

Eccentric exercises appear worse than concentric exercises.

Has been seen in almost all sports, ranging from swimming to golf.

               It’s not just preseason football!

High humidity and high temperature environments increase the likelihood of ER

Males are more vulnerable to ER than females

Increased risk with sickle cell trait and glycogen storage diseases

Multiple drugs may increase individual risk including alcohol, cocaine, amphetamines, MDMA and caffeine.

Implicated medicines include, salicylates, neuroleptics, quinine, corticosteroids, statins, theophylline, cyclic antidepressants and SSRIs

 

 

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Category: Orthopedics

Title: Concussion and dementia

Keywords: Mild traumatic brain injury, concussion (PubMed Search)

Posted: 5/12/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Does mild traumatic brain injury increase risk of dementia?

Background: Most studies of moderate to severe TBI have found an association with increased risk of dementia and earlier onset of Alzheimer’s. There is growing concern that repeated TBIs, even if more mild, can lead to neurodegenerative conditions such as chronic traumatic encephalopathy (CTE). However, the link between mild TBI and dementia risk has not fully been elucidated, especially in the case of mild TBI without loss of consciousness (LOC).

Recent Data: A recent JAMA study evaluated the association between TBI severity, LOC, and dementia diagnosis in 350,000 veterans between 2001-2013. After adjusting for demographics as well as medical and psych comorbidities, veterans with even mild TBI without LOC had more than a 2-fold increase in risk of dementia diagnosis than those with no TBI. The risk increased only slightly if there was LOC (from a hazard ratio of 2.4 to 2.5). Risk was >3-fold for those with moderate-severe TBI.

Take home: TBI of any severity, even without LOC, appears to be associated with long term neurodegenerative consequences. Avoidance of TBI is of the utmost importance, and if TBI occurs, close neurocognitive follow up should occur.  

 

 

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Category: Orthopedics

Title: Exercise talking points for the pregnant patient

Keywords: Pregnancy, sports medicine (PubMed Search)

Posted: 4/28/2018 by Brian Corwell, MD (Updated: 6/19/2024)
Click here to contact Brian Corwell, MD

Exercise talking points for the pregnant patient

(from ACSM 2017 Consesnsus statement)

 

Exercise throughout pregnancy is generally safe but should be monitored

No evidence of higher rates of preterm or prolonged labor, or deliveries that require induction or episiotomy

No evidence of negative effect on APGAR scores

Other benefits:

Avoidance of excessive weight gain, improved balance, and decreased back pain

Improved well-being, energy levels, and sleep patterns

Improved labor symptoms and facilitation of post-partum recovery

Lower risk of C-section

Reduced risk of having a large for gestational age (LGA) or small for gestational age (SGA) infant

Risks include environmental exposure, dehydration, hypoxia, and uterine trauma:

High impact or high-strain physical activity during the fetal implantation phase may lead to slightly higher risk of miscarriage

Sports with high risk of trauma last in pregnancy could result in placental abruption

Scuba diving is contraindicated because the fetus is not protected from decompression problems

Limit use of sauna or hot tub to fewer than ten minutes or omit altogether

 

 

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Category: Orthopedics

Title: Female Athlete Triad

Keywords: Stress fracture, amenorrhea (PubMed Search)

Posted: 4/14/2018 by Brian Corwell, MD (Updated: 6/19/2024)
Click here to contact Brian Corwell, MD

Female Athlete Triad

  1. Low energy availability
    1. With or without eating disorders
  2. Menstrual dysfunction
  3. Low bone mineral density (BMD)

 

Energy availability considers the amount of remaining energy for metabolic processes based on calories takin in with eating and calories burned through exercise or both.

 

Menstrual dysfunction occurs as a result of low energy availability causing decreased GnRH inhibition and ovarian suppression and decreased estrogen.

 

Low bone mineral density occurs due to amenorrhea and decreased energy availability. Estrogen limits bone resorption (stimulates calcitonin and renal calcium retention).

This is very important for young girls as by age 12 they have 83% of their total BMD & 95% two years after menarche.

 

If you see an athlete in the ED with one component of the triad, inquire about the other two. A 15yo athlete with a stress fracture may not realize that her disordered eating, excessive exercise or amenorrhea may by contributing factors and may benefit from follow up with PCP, dietitian, Gyn, etc.