Category: Orthopedics
Keywords: X-ray, Hip pain (PubMed Search)
Posted: 3/12/2016 by Brian Corwell, MD
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Femoral neck fracture
We typically think of the presentation of the displaced fracture severe pain, writhing in the bed, unable to ambulate, limited ROM
* However, patients with nondisplaced fractures (15 20%) may walk with a limp
* Occurs primarily in the elderly & osteoporotic population after a fall directly onto the hip
* Look for a cortical step-off in the femoral neck (w/ foreshortening)
* A patient with a minimally displaced fracture may only complain of hip, knee, or groin pain and may be able to walk (albeit with a limp)
* Almost 9% of hip fractures are radiographically normal (Nondisplaced or impacted fractures)
* Fractures which were initially nondisplaced, may become displaced upon re-presentation
* Remember the limitations of plain x-ray in the evaluation of femoral neck fractures!
* Because of the significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip
Category: Orthopedics
Keywords: Achilles tendon rupture (PubMed Search)
Posted: 2/27/2016 by Brian Corwell, MD
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Achilles tendon rupture
More common in
men, ages 30 - 40yo, s/p steroid injections, fluoroquinolone use, and episodic athletes "weekend warriors
Mechanism: usually during an athletic endeavor, sudden forced planar flexion or violent dorsiflexion of a plantar flexed foot
Location: Usually occurs 4 to 6 cm ABOVE the Achilles calcaneal insertion (hypovascular region)
Patient will report a sudden pop, gunshot like sound
History: Will report heel and calf pain and weakness/inability to walk
Physical examination: Palpable gap, weakness with plantar flexion, + Thompsons test
https://www.netterimages.com/images/vpv/000/000/007/7714-0550x0475.jpg
Consult orthopedics and splint in resting equinus
http://img.medscape.com/fullsize/migrated/408/535/mos0216.01.fig5b.jpg
Category: Orthopedics
Keywords: back pain, sports injury (PubMed Search)
Posted: 2/14/2016 by Brian Corwell, MD
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Spondylolysis
Prevalence 3-6% in the general population (Higher in athletes)
Location: L4 (5-15% of cases) & L5 (85-95% of cases)
Population: More likely in the skeletally immature athlete due to the vulnerability of the immature pars interarticularis to repeated stress
Symptoms: Lumbar pain worse with extension
Higher risk sports: Gymnastics, diving, weightlifting, wrestling
Treatment: Bracing and activity modification, physical therapy
- Good results in 80% with conservative management allowing return to play.
- Those who fail benefit from iliac crest bone grafting and posterolateral fusion.
-Return to play is controversial in this group
Please review th images below for anaomy and imaging appearence
http://orthoinfo.aaos.org/figures/A00053F01.jpg
http://www.sonsa.org/images/spondylolysis.jpg
http://www.physio-pedia.com/images/2/22/Spondylolysis_x_ray_.docx.jpg
Huang P.et al.Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries: A Comprehensive Review. Sports Health2016 Jan;8(1):19-25.
Category: Orthopedics
Keywords: fracture care (PubMed Search)
Posted: 1/24/2016 by Brian Corwell, MD
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Recommended follow-up for common orthopedic injuries
Category: Orthopedics
Keywords: Heel pain (PubMed Search)
Posted: 1/9/2016 by Brian Corwell, MD
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Sever's disease also known as calcaneal apophysitis, is the most common cause of heel pain in the young adolescent (ages 8 to 12).
It can be thought of as the Achilles tendon equivalent of Osgood-Schlatter's disease (patellar tendon insertion pain).
It is a non inflammatory chronic repetitive injury.
Commonly seen bilaterally in up to two -thirds of cases.
Patients will complain of activity related pain to the heel.
There may be tenderness and local swelling at the Achilles tendon insertion.
Radiographs are not necessary for acute cases.
Treat with activity modification, heel raise, physical therapy.
Category: Orthopedics
Keywords: Adolescent, head injury (PubMed Search)
Posted: 12/26/2015 by Brian Corwell, MD
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Protracted Recovery from Concussion
Age and sex may influence concussion recovery time frame
Methods: 266 adolescent athletes presenting to a sports medicine concussion clinic
Female athletes had a longer recovery course (P=0.002) and required more treatment interventions (p<0.001).
Female athletes were more likely to require academic accommodations (p<0.001), vestibular therapy (P<0.001) and medications (P<0.001).
Be aware that not all concussion patient subgroups with concussions recover in the same manner. Further study is needed to support whether female adolescent athletes require unique management and treatment guidelines.
Category: Orthopedics
Keywords: Concussion, knowledge, education (PubMed Search)
Posted: 12/12/2015 by Brian Corwell, MD
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Parental Knowledge of pediatric concussion
Sample: Parents of children brought to pediatric hospital or outpatient clinics for evaluation of orthopedic injuries.
Participants scored an average of 18.4 (0-25) on knowledge and 63.1 (15-75) on Attitudes toward concussions.
Safest attitudes were seen in white females. Knowledge increased with income and education levels.
Parents from low income or education levels may benefit from additional education in the ED prior to discharge in addition to providing paper information which may not be read or understood.
Assessment of Parental Knowledge and Attitudes toward Pediatric Sports Related Concussions.
Lin, Salzman et al., 2015. Sports Health Journal
Category: Orthopedics
Keywords: Elbow, ligament, throwing athlete (PubMed Search)
Posted: 11/28/2015 by Brian Corwell, MD
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Medial elbow pain is common among baseball pitchers and is also seen in other sports including football, javelin and gymnasts.
More than 97% of elbow pain in pitchers is located medially.
The ulnar collateral ligament of the elbow is an important structure in these patients.
http://www.aafp.org/afp/2014/0415/afp20140415p649-f3.jpg
While initially primarily seen in professional throwers, these injuries are now being seen in younger athletes.
Initially, patients may only note changes in stamina or strength of throws.
Later, they will note pain during the acceleration and follow through-phase of throwing
http://stlhealthandwellness.com/wp-content/uploads/2013/02/elbow03.jpg
The Valgus stress test for UCL deficiency is similar to the valgus test for the knee
https://www.youtube.com/watch?v=f6YvPSVk6G8
Treatment: splinting, ice, NSAIDs
Surgical indications: Failure of non-operative treatment with desire to return to same or higher level competition.
Category: Orthopedics
Keywords: Hand injury (PubMed Search)
Posted: 11/15/2015 by Brian Corwell, MD
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Hook of Hamate Fracture
Rare (2% of all carpal fractures)
Mechanism usually direct blow from a stick sport (golf, hockey, baseball)
Presents with hypothenar pain and pain with gripping activities
Physical examination - local swelling and tenderness to palpation over hook of hamate
Diagnostic test - Hook of hamate pull test
https://www.youtube.com/watch?v=A-mjRnC1yWQ
XR - standard wrist series but add carpal tunnel view
http://openi.nlm.nih.gov/imgs/512/60/2904904/2904904_256_2009_842_Fig1_HTML.png
http://www.cmcedmasters.com/uploads/1/0/1/6/10162094/7851913.png?359
Category: Orthopedics
Keywords: back pain, analgesia (PubMed Search)
Posted: 10/24/2015 by Brian Corwell, MD
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A traditional ED practice has been to combine promethazine as an anxiolytic adjunct to morphine for patients with musculoskeletal pain (eg back pain).
However, when compared to morphine alone, this combination does not lead to greater analgesia or decrease anxiety. It does however prolong ED length of stay.
This use of this "pain cocktail" is not recommended
Behrbalk E, Halpern P, Boszczyk BM, et al. Anxiolytic medication as an adjunct to morphine analgesia for acute low back pain management in the emergency department: A prospective randomized trial. Spine (Phila Pa 1976). 2014;39(1):17-22.
Category: Orthopedics
Keywords: Popliteal cyst, knee swelling (PubMed Search)
Posted: 9/26/2015 by Brian Corwell, MD
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Most common mass in popliteal fossa
Incidence 10 to 58%
Intra-articular pathology results in flow of synovial fluid from the joint into the bursa, forming a cyst
Association with concomitant intra-articular disorders 94%
Possible pathology - Meniscus, ligamentous, arthritis, other osteochondral defects
In children this is not a pathologic finding
Symptoms - Posterior knee bulging, posterior tightness/stiffness esp. with knee flexion
Ultrasound - 100% sensitive/specific
DDx: DVT
Tx: Refer for ultrasound guided aspiration, fenestration and steroid injection
http://www.caringmedical.com/wp-content/uploads/2013/11/Bakers-Cyst-treatment.jpg
Smith, Lesniak et al. 2015 Treatment of popliteal cysts with ultrasound-guided aspiration, fenestration and injection: long term follw-up
Category: Orthopedics
Keywords: Sodium Supplementation, Exercise-Associated Hyponatremia, Prolonged Exercise (PubMed Search)
Posted: 8/22/2015 by Brian Corwell, MD
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Sodium Supplementation and Exercise-Associated Hyponatremia (EAH) during Prolonged Exercise (ultramarathon running)
Weight loss of around 4% body weight (relative to pre race weight) can be anticipated to maintain euhydration in such a prolonged event
Those who become symptomatic with EAH have either gained weight or lost less that 3-4% body weight
Overhydration rather than inadequate supplemental sodium intake is a greater contributor to the development of EAH
There is a suggested link between EAH and rhabdomyolysis. The mechanism remains unknown and it is unclear which condition may augment the other. Further research is needed.
Take home: Avoid overhydration during prolonged exercise to prevent EAH.
Sodium Supplementation and Exercise-Associated Hyponatremia (EAH) during Prolonged Exercise (ultramarathon running) Hoffman and Stuempfle 2015.
Category: Orthopedics
Keywords: Nerve, wrist (PubMed Search)
Posted: 8/8/2015 by Brian Corwell, MD
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Handcuff Neuropathy
Compression of the superficial radial nerve against the radius.
Tends to occur with prisoners (too tight cuffs or person struggling)
Usually purely sensory lesion
Nerve regeneration can take 8 weeks (about an inch a month)
Document sensory exam to sharps or 2 point sensation.
DDx: De Quervain's, Carpal tunnel, Gamekeeper's thumb,
No need to splint
Category: Orthopedics
Keywords: x-ray, fracture, wrist (PubMed Search)
Posted: 7/26/2015 by Brian Corwell, MD
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Triquetral fractures are the 2nd most common carpal fractures (scaphoid).
Dorsal surface most commonly.
Usually occur from impingement from the ulnar styloid, shear injury or from ligamentous avulsion.
XR: best seen on the lateral projection
http://images.radiopaedia.org/images/902179/42b3487baf4fb66183c51cd982477d_big_gallery.jpg
Remember this injury/radiographic appearance the next time you see an avulsion fracture dorsal to the proximal row of carpal bones on the lateral film but are unsure of the donor site.
Category: Orthopedics
Keywords: Hernia, abdominal pain (PubMed Search)
Posted: 7/11/2015 by Brian Corwell, MD
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A sports hernia is a painful musculotendinous injury to the medial inguinal floor.
It is the result of repetitive eccentric overload to the abdominal wall stabilizers of the pelvis.
It is common in sports that require sudden changes of direction or intense twisting movements.
Despite the term "hernia" in the title, it is not a true hernia as there is no "herniation" of abdominal contents
http://www.ssorkc.com/wp-content/uploads/2014/09/publagia.gif
Figure description: The upward and oblique pull of the abdominal muscles on the pubis fights against the downward and lateral pull of the adductors on the inferior pubis. This imbalance of forces can lead to injury.
PE: Evaluation of other GU/GYN/other intra-abdominal pathology comes first.
Clinician may note tenderness of the pubic ramus and medial inguinal floor.
Pain is more severe with resisted hip adduction and with resisted sit-up.
Combining these maneuvers (resisted situp while adducting hips) recreates the pathophysiology described above and is a good exam maneuver.
Sports hernia: the experience of Baylor University Medical Center at Dallas
Proc (Bayl Univ Med Cent). 2011 Apr; 24(2): 89 91
Category: Orthopedics
Keywords: wrist injury, FOOSH, Distal radius fracture (PubMed Search)
Posted: 6/27/2015 by Brian Corwell, MD
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Colles fracture
Almost 90% of distal radius fractures
Mechanism: Fall on the outstretched, hyperextended, radially deviated wrist with the forearm in pronation
Often seen in older patients and in those with osteoporosis
Distal radius fracture with dorsal angulation/displacement and/or radial shortening. "Dinner fork deformity"
https://en.wikipedia.org/wiki/Colles'_fracture#/media/File:Colles_fracture.JPG
Smith fracture (aka reverse Colles fracture)
Mechanism: Fall on the outstretched, flexed, radially deviated wrist with the forearm in pronation
Usually younger patients with high energy mechanism
Distal radius fracture with volar angulation or volar displacement. "Garden spade" deformity
Often unstable requiring ORIF
http://www.radiologyassistant.nl/data/bin/w440/a50979780ec887_Smith'-tek.jpg
Radial styloid fracture aka Chauffeur fracture
Fall causing compression of scaphoid against the styloid with wrist in dorsiflexion and ulnar deviation
Often associated with intercarpal ligamentous injuries (i.e., scapholunate dissociation, perilunate dislocation)
Often requires ORIF
http://images.radiopaedia.org/images/611818/cc52cce7bcfd8c905bcc7b5d2b6a65.jpg
Category: Orthopedics
Keywords: Posterolateral Corner Injury, PCL, ACL, knee (PubMed Search)
Posted: 6/13/2015 by Brian Corwell, MD
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Hx: hyperextension injury (contact and non contact), varus directed blow to flexed knee, direct blow to anteriomedial knee. Report instability symptoms when knee is in full extension.
PE: Varus stress testing
Varus laxity at 0 indicate LCL and cruciate ligament (ACL/PCL) injury
Varus laxity at 30 indicates LCL injury
Dial test - inspects the external rotation at the knee joint/performed in both 30 and 90 knee flexion. The dial test inspects the external rotation at the knee joint
https://www.youtube.com/watch?v=pW4yv0zg4RY
Positive at 30 = > 10 external rotation asymmetry = isolated PCL injury
Positive at 30 & 90 = Posterior lateral corner injury and PCL injury
Category: Orthopedics
Keywords: shoulder pain, bursitis (PubMed Search)
Posted: 5/23/2015 by Brian Corwell, MD
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Sx: pain to lateral arm, worse with overhead activity and sleeping/lying on arm
Anatomy: Pain generating structures include the rotator cuff, subacromial bursa, labrum and biceps tendon.
http://www.ortho-md.com/images/proceduresImg/SHOULDER2.jpg
Testing: Neer and Hawking tests
https://www.youtube.com/watch?v=U8-yLHQ_JaM
https://www.youtube.com/watch?v=OYK5qL2om-c
Done indepedently, Hawkings is more sensitive, however best to combine both tests.
Imaging: not indicated
Tx: rest, ice, physical therapy (modalities), subacromial steroid injection
Category: Orthopedics
Keywords: Radiology, orthopedics, shoulder (PubMed Search)
Posted: 5/9/2015 by Brian Corwell, MD
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Posterior Shoulder Dislocations are uncommon (strong supporting structures vs. anterior)
But commonly missed by physicians
Mechanism: Direct blow anterior shoulder/FOOSH with shoulder internally rotated and ADDucted)
May also see with seizure/electric shock (tetanic contraction)
Clinical findings subtle
Shoulder held in ADDuction and internal rotation. Patient unable to externally rotate arm from this position. If habitus allows, anterior shoulder depression/posterior fullness.
Radiology: Decreased overlap between humeral head and glenoid fossa. Proximal humerus fixed in internal rotation looks like a light bulb on a stick.
Y view will show subtle posterior displacement of humeral head (not as dramatic as is in anterior dislocations!)
http://cdn.lifeinthefastlane.com/wp-content/uploads/2009/06/posterior_shoulder_dislocation_005.jpg
http://eorif.com/Shoulderarm/Images/Shoulder-dislocationP1.jpg
Category: Orthopedics
Keywords: back pain, ESR, CRP, malignancy (PubMed Search)
Posted: 4/25/2015 by Brian Corwell, MD
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In cases of suspected spinal infection, the sensitivity of an elevated WBC count (35-61%), ESR (76-95%) and CRP (82-98%) may help guide further evaluation or consideration of other entities.
Incorporation of ESR/CRP into an ED decision guideline may help differentiate those patients in whom MRI may be performed on a nonemergent basis.
An elevated ESR (>20 mm/hour) also has a role in the diagnostic evaluation of occult malignancy (sensitivity 78%, specificity 67%).
Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain: Clinical article. Journal of Neurosurgery: Spine. 2011;14(6):765-770.
Deyo RA, Diehl AK. Cancer as a cause of back pain. Journal of general internal medicine. 1988;3(3):230-238.