Keywords: Pet ownership, cardiovascular health, risk reduction (PubMed Search)
Dog ownership has become more common especially during the pandemic.
Almost 70% of US households own a pet and almost half own ≥1 dogs.
There are many health benefits associated with dog ownership including: reduced risk of asthma and allergic rhinitis in children exposed to pets during early ages, improvement in symptoms of PTSD, overall wellbeing & alleviation of social isolation in elderly individuals and increased physical activity.
The main positive impact of dog ownership seems to be in relation to cardiovascular risk including an association with lower blood pressure levels, improved lipid profile, and diminished sympathetic responses to stress.
Study: A systematic review and meta-analysis (10 studies, over 3 million participants) to evaluate the association of dog ownership with all-cause mortality, with and without prior cardiovascular disease, and cardiovascular mortality. Mean follow up 10 years.
Results: Dog ownership was associated with a 24% risk reduction for all-cause mortality as compared to non-ownership (relative risk, 0.76; 95% CI, 0.67–0.86) with 6 studies demonstrating significant reduction in the risk of death.
In individuals with prior coronary events, dog ownership was associated with an even more pronounced risk reduction for all-cause mortality (relative risk, 0.35; 95% CI, 0.17–0.69). When authors restricted the analyses to studies evaluating cardiovascular mortality, dog ownership conferred a 31% risk reduction for cardiovascular death (relative risk, 0.69; 95% CI, 0.67–0.71).
The cause of this benefit is unclear. Though some activities such as the act of petting a dog has been observed to lower blood pressure levels, the mechanism for the longer survival is likely through enhanced physical activity provided by dog walking.
Conclusion: Dog ownership is associated with reduced all-cause mortality likely driven by a reduction in cardiovascular mortality. Dog ownership as a lifestyle intervention may offer significant health benefits, particularly in populations at high-risk for cardiovascular death.
Finally, meet Winston, a French bulldog who, last night, won the National Dog Show!
Keywords: musculoskeletal pain, analgesia, opioids (PubMed Search)
Opioids & NSAIDs for MSK pain in the ED: Effectiveness and Harms
Study selection: A recent systematic review in Annals of Internal Medicine attempted to evaluate the effectiveness and harms of opioids for musculoskeletal pain in the emergency department.
Included were RCTs of any opioid analgesic as compared with placebo or a nonopioid analgesic.
Conditions studied: bone injuries, soft tissue injuries, spinal pain, and mixed presentations.
Out of 2464 articles, they included 42 trials (n=6128).
Effectiveness data: Opioids were statistically but not clinically more effective in reducing pain in the short term (approximately 2 hours) versus placebo and Tylenol but were not clinically or statistically more effective than NSAIDs.
Take home: Opioids and NSAIDs may have about the same pain outcomes.
Harm data: The results on harms were very mixed. Overall, there were fewer harms with NSAIDs than opioids. However, many studies showed less of a difference. The benefit with NSAIDs due to fewer harms may be less in patients with mixed musculoskeletal conditions.
Opioids may carry higher risk for harms than placebo, Tylenol, or NSAIDs. Authors also found that an increased opioid dose may increase harms from opioids.
Limitations: Limited data on long-term outcomes and longer-term pain management
Jones CMP, Lin CC, et al. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain: A Systematic Review and Meta-analysis. Ann Intern Med. 2022 Oct 18.
Keywords: hip, dislocation, DDH (PubMed Search)
Developmental dysplasia of the hip (DDH)
Category: Airway Management
Keywords: leg pain, compartment syndrome (PubMed Search)
Popliteal artery entrapment syndrome (PAES)
CC: Exertional lower leg pain, however, compression of posterior neurovascular structures can lead to nonspecific vascular and neurogenic symptoms.
Challenging diagnosis to make because of close overlap with chronic exertional compartment syndrome (CECS).
Anatomic PAES has a prevalence of 0.62% to 3.5% in the general population. Patients are more likely to be older be older, male, and have lower levels of activity.
Functional popliteal artery entrapment (FPAE) however has no anatomic anomaly. Sx’s are thought to be because of bulky surrounding muscle crowding with repetitive dynamic injury. This is most commonly from the medial head of the gastrocnemius. Patients are younger and more likely to be involved in athletics. Most athletes were involved in sports that put high value on repetitive plantarflexion, such as track and field (45%), soccer (25%), water sports (8%), lacrosse (6%), basketball (6%),
Sx’s: bilateral (25-75% of cases) cramping in the region of the soleus and plantar paresthesias.
Common exacerbating mechanism: ascending stairs or climbing inclines because of leg/knee position of extension with plantarflexion
In one review, 31% of patients who underwent debulking surgery for FPAES had been previously treated and extensively worked up at outside institutions for CECS, and already undergone various compartment releases.
Patients in one study underwent a dynamic CTA protocol. A positive test demonstrated normal flow in neutral position and compression or complete occlusion of the popliteal artery by the medial head of the gastrocnemius muscle against the lateral femoral condyle with provocative foot plantarflexion. Images below.
Nearly three-fourths of athletes limited by FPAES demonstrated full return to prior competitive levels with four compartment fasciotomy AND surgical debulking of the anterolateral quadrant of the medial head of the gastrocnemius muscle.
Lawley RJ,et al., Concurrent Diagnosis of Functional Popliteal Artery Entrapment Syndrome and Chronic Exertional Compartment Syndrome in Athletes. Curr Sports Med Rep. 2022 Oct 1;21(10):366-370.
Category: Airway Management
Keywords: knee pain, running injury (PubMed Search)
Pes Anserinus pain syndrome (formerly pes anserine Bursitis)
Occurs at the bursa of the pes anserinus which overlies the attachment of the 1) Sartorius 2) gracilis and 3) semi-tendinosis tendons. Insertions resemble a Goose’s foot.
An inflammatory condition of the medial knee
Location is 2-3 inches below the knee joint on the medial side
1st layer of medial compartment
Patients complain of knee pain just below medial joint line (esp with stairs)
History may include sudden increase in running distance especially with hills (common)
Associated with obesity, tight hamstring muscles and with knee OA
PE: Tenderness to palpation of the bursa possibly with mild swelling
DDx: MCL tear, medial meniscus injury, medial (knee) compartment arthritis, tibial stress fracture
Treatment: Cessation/modification of offending activities, Icing and ice massage, NSAIDs, hamstring stretching and physical therapy. Failure of the above should prompt referral for bursal steroid injection.
Keywords: mortality, exercise, dementia, walking (PubMed Search)
Exericse as preventative medicine!
A recent cohort study of over 2,000 adults (mean age approx. 45) over approximately 11 years of follow-up investigated the association of step count with mortality.
This study found that those participants taking at least 7,000 steps per day compared to those taking fewer steps had a 50%-70% lower risk of mortality. They did not find an association with step intensity.
Another recent study investigated the dose-response association between daily step count and intensity and the incidence of all-cause dementia.
Uk based study of >78,000 adults aged 40 to 79 years with approximately 7 years of follow-up. Data from wrist accelerometer and registry-based dementia diagnoses.
Optimal step dose was 9826 steps. Minimal dose was 3826 steps (value at which the risk reduction was 50% of the observed max).
In this study, steps performed at higher intensity (112 steps/min) resulted in stronger associations.
Conclusions: A great exercise goal for middle aged and older adults is just under 10,000 steps per day to decrease risks of both overall mortality and dementia.
1) Paluch AE, et al. Steps per Day and All-Cause Mortality in Middle-aged Adults in the Coronary Artery Risk Development in Young Adults Study. JAMA Netw Open. 2021;4(9):e2124516.
2) del Pozo Cruz B, et al. Association of Daily Step Count and Intensity With Incident Dementia in 78?430 Adults Living in the UK. JAMA Neurol. Published online September 06, 2022.
Keywords: Concussion, head injury, recovery, cognitive rest (PubMed Search)
Limited data are available to guide recommendations re screen time after concussion.
A recent ED study looked at screen time effects on concussion recovery.
Population: 125 patients aged 12 to 25 years presenting to the ED <24h after injury. Mean age 17. Approximately 51% male.
Intervention: Patients were placed in a screen time allowed group and a screen time not allowed group for the first 48 hours. Total minutes reported after the study were 630 minutes vs 130 minutes.
Outcome: Time to symptom resolution. Patients took daily symptom scoring tests for 10 days.
Result: Screen time allowed group had a significantly longer time to recovery (8 days) vs screen time not allowed (3.5 days).
Strength: Good attempt at quantifying effects on early screen time exposure on symptom recovery in an ED population.
Weakness: This was a small study. Many patients (>25%) were lost to follow-up and it relies on symptom self-reporting.
Macnow T, et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. Nov 2021.
Keywords: Dislocation, reduction, AVN (PubMed Search)
The hip joint is a very strong and stable structure requiring great force to produce a dislocation
Most hip dislocations are posterior (80-90%)
Mechanism: MVC generating force onto an adducted flexed hip (most commonly)
Associated injuries occur both locally (acetabular fx) and distant (knee bone and ligamentous)
Significant associated injuries in >70%
The hip joint has a very precarious blood supply.
One of the risk factors for AVN is total dislocation time
<6 hours - 5% incidence
>6 hours – up to 53% incidence
Examine the sciatic nerve carefully with posterior dislocations (10% incidence)
Motor – EHL/ankle dorsiflexion
Sensory – sensation dorsum of foot
There are many reduction maneuvers including the East Baltimore Lift technique
Demonstrated at 30 seconds in above video
Place patient supine with affected leg flexed to 90 degrees at knee and hip. 2 providers position themselves on opposite sides of the patient and each places their arm under the patient’s calf/popliteal region and their hand on the opposite providers shoulder. A 3rd person is required to stabilize the pelvis. Axial traction is generated by the providers slowly standing up. Gentle internal and external rotation can facilitate successful reduction
Keywords: AVN, wrist pain, lunate (PubMed Search)
Kienbock’s disease: collapse of the lunate due to avascular necrosis and vascular insufficiency.
Occurs most commonly in young adults aged 20 to 40 years.
Cause is unknown but believed to be due to remote trauma or repetitive microtrauma in at risk individuals.
On exam, limited range of motion, decreased grip strength and passive dorsiflexion of the 3rd digit produces pain.
Dx: plain film in the ED and with MRI as an outpatient.
Tx: Wrist immobilization with splint and refer to orthopedics as treatment is individualized.
Keywords: Hand nodules, contractures (PubMed Search)
Dupuytren disease/contracture: nodular thickening and resultant contraction of the palmer fascia.
Increased in those of Northern European discent
Increased risk over age 50
Increased frequency in those with diabetes and cigarette smoking
One or more painful nodules located near the distal palmer crease.
Over a variable amount of time, the nodule progresses to form a taught fibrous cord
This extends from the palm to the digits, generally ulnar sided and typically the ring finger
Can cause flexion contracture of digit at MCP joint
Sensation is normal.
No imaging necessary
Tx: padded gloves and activity modification for mild disease, steroid injection for moderate disease and surgery when contracture present
Keywords: Radial nerve compression, peripheral nerve injury, wrist drop (PubMed Search)
The radial nerve is susceptible to compressive neuropathy against the spiral grove of the humerus which can lead to neuropraxia.
When the upper arm is compressed against a chair back or bar edge sometimes from a lost battle with alcohol: Saturday night palsy.
When another individual sleeps on someone’s arm overnight compressing the radial nerve: Honeymoon palsy
From nerve compression from improper technique with crutches: Crutch palsy
If diagnosis not clear from history, DDx includes other entities that can also present with isolated wrist, thumb/finger drop
Horses: Radial verve palsy, CVA, C7 compression
Zebras: Lead toxicity, acute porphyrias (often polyneuropathy but upper extremity before lower and frequently distal extensors
Careful history and exam important in differentiating
In cases of peripheral compression against the spital groove the triceps maintains strength.
The distal extensors lose strength (wrist and fingers)
Including the thumb abduction (abductor pollicis longus is radial-innervated)
AND so will the brachioradialis
The brachioradialis (despite being a forearm flexor) has dual innervation from the radial nerve in 80% of people.
Brachioradialis strength is often preserved in a central lesion.
Best tested with arm supported on a surface in mid pronation/supination (hammer curl position) and have patient flex against resistance and evaluate muscle strength and bulk.
Category: Airway Management
Keywords: Concussion, risk, head impact (PubMed Search)
Head Impact Exposure and Concussion Incidence
There has been a major focus on head impact biomechanics as a cause of single-impact concussion in football.
The role of repeated subclinical (without diagnosed concussion) head impact exposure (HIE)
during the preseason and regular season may also be contributory.
There may exist individualized concussion tolerance levels. This threshold may be reduced by the burden of sustained subconcussive impacts
NCAA Division 1 football athletes sustain a median of 426 impacts over the course of a football season
652 impacts/season in high school football
Total head impact exposure during the preseason occurred at 2x the rate of the regular season
This association was investigated over 1120 athlete seasons from 6 NCAA D1 football programs across 5 years
Head Impact Telemetry was used to record head impact exposure
Elevated preseason HIE was strongly associated with preseason and in season concussion incidence
Total season HIE was strongly associated with total season concussion incidence.
Conclusion: There is a prolonged effect of HIE on concussion risk starting with preseason football.
Athletes with higher preseason HIE may have higher risk of concussion for the entire fall season.
In 2016, the Ivy League eliminated full contact practices from the regular season in addition to their existing limits on the amount of full contact in practice during the spring and preseason.
Currently, the NCAA has the following limitations: Teams won’t be allowed to hold full-contact practices on more than two days in a row. Each practice session is limited to only 75 minutes of full contact, in addition to a limit of two preseason scrimmages.
Stemper BD, et al; CARE Consortium Investigators. Association between Preseason/Regular Season Head Impact Exposure and Concussion Incidence in NCAA Football. Med Sci Sports Exerc. 2022 Jun 1;54(6):912-922.
Keywords: Boxer, reduction (PubMed Search)
28-year-old male present with dorsal hand pain after “losing his temper”
On exam, you note dorsal swelling, tenderness, and deformity
AP, lateral and oblique views are obtained.
There is no rotational deformity but using the lateral view, you note that there is angulation
Measured as the shaft of the metacarpal as compared to the mid-point of the fracture fragment
Acceptable shaft angulation generally accepted to be less than 40°
Patient has greater that acceptable angulation so you have to perform closed reduction
After appropriate pain control consider the “90-90 method.”
Flex the MCP, DIP, and PIP joints to 90 degrees.
This positioning stretches the MCP collateral ligaments helping to optimize reduction
Next, apply volar pressure over the dorsal aspect of the fracture site while applying pressure axially to the flexed PIP joint.
Best demonstrated below
Keywords: Varus, knee (PubMed Search)
4-year-old patient comes to the ED for an unrelated complaint and you notice that his knees appear to be touching while his ankles remain apart.
Genu Varum or “knock knees” may be caused by Infantile Blount’s disease
-A progressive pathologic condition causing genu varum in children between ages 2 to 5
- Centered at the tibia
-Bilateral in up to 80%
-More common in boys
-Leg length discrepancy
- Articular incongruity
Risk factors: Early walkers (<1 year), overweight, large stature, Hispanic and African American
Results in disruption of normal cartilage growth at the MEDIAL aspect of the proximal tibia while LATERAL growth continues normally
May complain of knee soreness or subjective instability
On physical exam
Focal angulation of the proximal tibia
Lateral thrust during stance phase of walking (brief lateral shift of proximal fibula and tibia)
No tenderness or effusion
Imaging: Plain film shows varus deformity of the proximal tibia with medial beaking (beak like appears of bone) and downward slope of the proximal tibia metaphysis (increased metaphyseal-diaphyseal angle)
Treatment depends upon the age of the child and the severity
Successful in up to 80%
Note: In adolescent variant bracing is ineffective and surgery is only treatment
: Genu varum is normal in children <2 years old and becomes neutral at 14 months
DDX: Physiologic varus, Rickets
Keywords: Elbow, osteochondritis, capitellum (PubMed Search)
9-year-old male left hand dominant, presents with left elbow pain.
He is a future “star pitcher,” says his coach dad. “Doc, I bet you didn’t know that although only 10% of people throw with their left hand almost a 1/3rd of MLB pitchers are lefties. He is 3x more likely than a righty to pitch in MLB.” “Maybe I’m asking him to throw too much.”
Hx: Lateral elbow pain and “stiffness” worse with activity that is better with rest
PE: Lateral elbow tenderness (capitellum) with slight (approx. 20 degrees) decreased loss of extension. Minimal swelling noted.
Dx: Panner's disease refers to osteochondrosis of the capitellum (similar to Legg Calve Perthes). Likely due to AVN from repetitive trauma. May also be due to endocrine disturbances.
Affects the dominant elbow of boys between the ages of 5 and 10
Associated with the repetitive trauma of throwing or gymnastics.
Must be differentiated from osteochondrosis dissecans which occurs in the older child >13yo when the ossification of the capitellum is complete
The articular surface of the capitellum may appear irregular or flattened with areas of radiolucency (43%). Loose bodies not seen with Panners, much more likely with OCD lesions.
Treatment: Ice and NSAIDs. Avoid pitching/gymnastics etc. until full radiographic and clinical healing. If significant pain and/or swelling place patient in long arm posterior splint for 7-10 days. Resolution may take several months and up to one year.
Keywords: Concussion, psychiatric, hospitalization (PubMed Search)
A recent study investigated the association between concussion and subsequent mental health conditions in a pediatric population.
Retrospective cohort study. Pediatric patients aged 5 to 18 years who presented to an ED, PCP or mental health practitioner from April 2010, to March 2020, in Ontario, Canada.
Primary outcome: Time to first diagnosis with a mental health condition during follow-up
Secondary outcomes: 1) self-harm 2) psychiatric hospitalization 3) death by suicide.
Mental health conditions: anxiety and neurotic disorders, adjustment reactions, behavioral disorders, mood and eating disorders, schizophrenia, substance use disorder, suicidal ideation, and disorders of psychological development.
Study group, almost 450,000 patients. Age and sex matching between those with concussion and those who experienced an orthopedic injury.
A significant association (P < .001) was found between concussion and mental health conditions
A significant association emerged between concussion and self-harm and psychiatric hospitalization
No association with suicide
Conclusion: Concussion was significantly associated with risk of mental illness, psychiatric hospitalization and self-harm but not death by suicide.
Concussed patients had an almost 40% higher rate of mental health conditions compared to controls (adjusted hazard ratio 1.39)
Take home: Screen patients who return to the ED with post concussive symptoms for mental health symptoms/concerns and provide appropriate awareness for parents
Ledoux A, Webster RJ, Clarke AE, et al. Risk of Mental Health Problems in Children and Youths Following Concussion. JAMA Netw Open. 2022;5(3):e221235.
Category: Airway Management
Keywords: PRP, hematoma, muscle tear (PubMed Search)
Treatment of Hamstring Strains in Athletes
28 year old athlete presents to the ED and diagnosed with a hamstring strain
Localized swelling, moderate pain and a small limp. Incomplete tearing of the muscle
He is worried that he will miss the remainder of his season and when he returns will reinjure the same hamstring
Consider referral to sports medicine/orthopedics
A recent study looked at use of ultrasound guided hematoma aspiration followed by platelet-rich plasma (PRP) treatment on recovery in acute hamstring injuries
55 male athletes between ages 18 -32 weighing between 170 and 260lbs
27 with treatment protocol plus rehabilitation and 28 treated conservatively (rehabilitation)
All had Grade 2 hamstring injuries diagnosed on MRI
Partial muscle tear (<50% cross sectional area)
Note: Grade 2 hamstring injuries are often associated with INTERmuscle hematoma and subsequent scarring. This can lead to persistent pain/discomfort and reinjury
Average return to play time was 32.4 days in the standard of care group
Average return to play time was 23.5 days in the intervention group (P<0.001)
Recurrence rate of hamstring strain was 28.6% in the standard of care group
Recurrence rater of hamstring strain was <4% in the intervention group (P=0.025)
Athletes with grade 2 hamstring injuries treated with hematoma aspiration and PRP injection into the strain had significantly shorter return-to-play and much lower recurrence rate that athletes treated with rehabilitation alone
Trunz LM, et al. Effectiveness of Hematoma Aspiration and Platelet-rich Plasma Muscle Injections for the Treatment of Hamstring Strains in Athletes. Med Sci Sports Exerc. 2022 Jan 1;54(1):12-17.
Keywords: knee osteoarthritis, plain film (PubMed Search)
The knee is one of the most commonly affected joints from osteoarthritis (OA).
Patients will complain of knee pain, swelling and stiffness.
This leads to disability as it interferes with walking, using stairs at home and getting in and out of chairs and the bath without assistance.
Increasing incidence due to aging of the general population and rising rates of obesity.
Patients frequently present to the ED for knee pain and imaging is often obtained.
Diagnosis of knee OA can be made with an appropriate history and imaging that shows osteophytes and joint space narrowing.
The best views for knee OA include 1) PA weight-bearing & 2) 45 degree of knee flexion
Note: Weight-bearing radiographs will demonstrate greater joint space narrowing than non-weight-bearing radiographs
Of the 3 compartments of the knee, the medial tibiofemoral compartment is most commonly affected > patellofemoral compartment > lateral tibiofemoral compartment.
Examples of knee OA
Category: Visual Diagnosis
23 y/o otherwise healthy Male presents for approx. 3 month history of Right leg mass. It is painful with activity (deep and sharp) but not enlarging. Patient remembers a fall from a bicycle 6 months ago, with negative imaging for fracture.
What is the diagnosis?
Keywords: Quadriceps contusion, immobilization, hematoma (PubMed Search)
Mechanism: Blunt trauma from ball, helmet, stick
Usually to the central region
Damage to highly vascular area of the muscle and to local blood vessels can cause hematoma formation
Typical trauma history and pain worse with muscle activation (knee flexion)
Physical exam: Bruising, tenderness, palpable mass/hematoma
Goals of care: Minimize intramuscular bleeding
Treatment: NSAIDS, crutches, unique type of immobilization
Attempt to increase resting length of the quadriceps muscle to facilitate early healing and return to function
Note: Left untreated, large contusions may result in myositis ossificans