Category: Orthopedics
Keywords: knee dislocation, vascular and nerve injury (PubMed Search)
Posted: 11/22/2014 by Brian Corwell, MD
(Updated: 12/26/2014)
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Knee dislocation 2
Most commonly occur after MVCs but also seen after falls, industrial accidents and sports related trauma.
Up to 50% of knee dislocations will have spontaneously reduced by time of presentation to the ED.
Strongly consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability (3 or more ligaments torn).
A thorough neurovascular examination is a must due to the risk of vascular (34%)(5-79%) and nerve (23%)(16-40%) injuries. There is a must higher incidence of these injuries in high force trauma such as from a MVC. The popliteal artery and common peroneal nerve are at the greatest risk
Though the absence of distal pulses suggests vascular injury, the presence of pulses cannot be used as evidence of the lack of a vascular injury.
After reduction, the knee should be immobilized in 15-20° of flexion in a knee immobilizer.
Category: Orthopedics
Keywords: trauma, knee, dislocation (PubMed Search)
Posted: 11/8/2014 by Brian Corwell, MD
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Beware of spontaneous reduction masking the true injury!
Knee dislocations are rare due to supporting ligaments (MVCs, falls, sports)
but can be seen after minor trauma in obese patients.
Named by the direction of the displacement of the tibia relative to the femur
- Anterior and posterior are most common
Dislocations involve disruption of at least 2 of the major knee ligaments (ACL/PCL most common)
Usually associated with large hemarthrosis however capsular tearing may allow dissipation of the blood into adjacent soft tissue.
Consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability,
Category: Orthopedics
Keywords: Osteoporosis, elderly, (PubMed Search)
Posted: 10/25/2014 by Brian Corwell, MD
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Iliocostal syndrome aka iliocostal friction syndrome
Consider this entity in an elderly patient with osteoporosis with unexplained abdomen/flank or back pain.
Osteoporosis and/or vertebral compression fractures can result in a narrowing of the distance between .
the lowest anterior rib and the top of the iliac crest producing pain where this rib contacts the pelvis.
This can be perceived as side or back pain. This pain can restrict walking leading to a possible misdiagnosis of spinal stenosis. Treatment is with physical therapy and therapeutic injection.
http://www.caringmedical.com/wp-content/uploads/2013/09/iliocostalis.syndrome.jpg
Category: Airway Management
Keywords: Concussion, patient education (PubMed Search)
Posted: 10/11/2014 by Brian Corwell, MD
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There is no effective pharmacologic treatment known to hasten recovery from concussion. In future pearls we will examine possible interventions that may help.
The importance of educating our patients was demonstrated in two studies looking at concussion education. Patients were separated into 2 groups. The intervention group received a booklet of information discussing common symptoms of concussion, suggested coping strategies and the likely time course of recovery. At a 3 month follow-up evaluation, the intervention group reported fewer symptoms. This was repeated in pediatric patients with similar results.
Take Home: Consider taking the time to put such an information sheet together for concussed patients seen in the ED.
Ronsford J, et al. Impact of early intervention on outcome after mild traumatic head in adults. 2002
Category: Orthopedics
Keywords: Sciatica, radiculopathy, imaging (PubMed Search)
Posted: 9/19/2014 by Brian Corwell, MD
(Emailed: 9/27/2014)
(Updated: 9/27/2014)
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Back pain with radiculopathy can be very distressing to a patient and they have heard from their medically savvy neighbor that a MRI is the way to go. Now, armed with this knowledge, they are in your ED with earplugs in hand...
A few minutes of reassurance and education can save in both cost and ED throughput.
In one study researchers performed MRIs on asymtomatic adult patients.
Almost two-thirds (64%) had abnormal discs
Just over half (52%) had bulging discs
Almost a third (31%) had disc protrusions
Further, finding a bulging disc already suggested by your history and physical examination does not change management. The majority of these patients improve with conservative treatment within four to to six weeks.
Restrict ED MRI use for the evaluation of suspected cauda equina, epidural abscess and spinal cord compression.
Category: Orthopedics
Keywords: back pain, x-ray (PubMed Search)
Posted: 9/13/2014 by Brian Corwell, MD
(Updated: 3/29/2024)
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Back pain accounts for more than 2.6 million visits
30% of ED patients receive X-rays as part of their evaluation
Imaging can be avoided in a majority of these patients by focusing on high risk (red flags) findings in the history and physical exam.
Patients who can identify a an acute inciting event without direct trauma likely have a MSK source of pain.
Imaging rarely alters management
Attempt to avoid imaging in patients with nonspecific lower back pain of less than 6 weeks duration, with a normal neurologic exam and without high risk findings (fever, cancer, IVDA, bowel or bladder incontinence, age greater than 70, saddle anesthesia, etc)
Patients with radiculopathy (sciatica) and are otherwise similar to the above also do not require emergent imaging
Category: Orthopedics
Keywords: Jumpers knee, knee pain (PubMed Search)
Posted: 8/24/2014 by Brian Corwell, MD
(Updated: 3/29/2024)
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Patellar tendonitis aka jumpers knee
Activity related knee pain due to degenerative, micro injury rather than an inflammatory process
Up to 20% in jumping athletes
Anterior knee pain during or after activity
Bassett Sign:
a) Tenderness to palpation with knee in full extension (patellar tendon relaxed)
b) No tenderness with knee in flexion (patellar tendon tight)
Category: Orthopedics
Keywords: mono, spleen (PubMed Search)
Posted: 8/9/2014 by Brian Corwell, MD
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Return to Play After Infectious Mononucleosis (IM)
-Long incubation period make it difficult to determine source or onset
Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.
DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)
Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)
Symptoms then progress into the classic “triad” of IM
Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)
May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)
Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)
Most commonly seen in patients treated with PCN antibiotics
Splenomegaly is an important complication in the athletic population
Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)
- Lymphocytic proliferation enlarges the spleen beyond protection from the ribs
- Physical examination has been shown to be unreliable for determining splenomegaly
- Highest risk is in the first 21 days (rare after 28 days)
Ultrasound is the modality of choice
-Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks
Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.
Category: Orthopedics
Keywords: Spinal Cord injury (PubMed Search)
Posted: 7/13/2014 by Brian Corwell, MD
(Emailed: 7/26/2014)
(Updated: 7/23/2014)
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Cervical Cord Neuropraxia (CCN)
A concussion of the spinal cord as a result of an on-field collision.
A transient motor and/or sensory disturbance, lasting less than 24 hours.
A distinct and separate entity from spinal cord injury resulting in quadriplegia
Incidence 7.3 per 10,000 athletes
Approx. 50% of players experiencing CCN who return to play, have a second episode
The risk of this second episode is inversely proportional to the size of the cervical bony canal
Athletes with narrow canal diameter are more likely to have a 2nd episode
Those with normal canal diameter (14 mm on MRI) have a 5% risk
Those with a narrow canal (9 mm or less)) have a greater than 50% risk.
Whether repeat episodes lead to permanent spinal cord injury is unknown
Bell, Gordon. Return to play after Cervical Cord Neuroplraxia.2014
Category: Orthopedics
Keywords: cervical spine injuries, football (PubMed Search)
Posted: 7/12/2014 by Brian Corwell, MD
(Updated: 3/29/2024)
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Football helmets
A review of head and neck injuries from football from 1959 to 1963 found the rates of intracranial hemorrhage /intracranial death were 2-3X higher than the rates of cervical spine fracture/dislocation or cervical quadriplegia. In contrast, a study of football injuries from 1971 to 1975, revealed a dramatic reversal in rates. Cervical injuries now exceeded the rate of ICH by 2-4X.
A 66% reduction in ICH
A 42% reduction in craniocerebral deaths
A 204% increase in cervical spine fractures and dislocations
The shift was attributed to the modern football helmet, whose superior protection promoted “spearing” (headfirst tackling technique). Spearing involves hitting with the crown of the helmet leading to axial loading of the spine. Spearing accounted for 52% of the quadriplegia injuries from 1971 to 1975. Research by Joesph Torg, M.D., resulted in rule changes that led to an immediate 50% reduction in quadriplegia in NCAA football.
As a parent, coach or team physician, teach and enforce proper form and protect our young athletes.
Category: Orthopedics
Keywords: Elbow extension test (PubMed Search)
Posted: 5/27/2014 by Brian Corwell, MD
(Emailed: 6/28/2014)
(Updated: 6/28/2014)
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Jie KE et al. Extension test and ossal point tenderness cannot accurately exclude significant injury in acute elbow trauma. Ann Emerg Med 2014
Category: Misc
Keywords: Drowning, rescue (PubMed Search)
Posted: 5/24/2014 by Brian Corwell, MD
(Updated: 3/29/2024)
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Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article
The Instinctive Drowning Response—so named by Francesco A. Pia, Ph.D., is what people do to avoid actual or perceived suffocation in the water. And it does not look like most people expect. There is very little splashing, no waving, and no yelling or calls for help of any kind. To get an idea of just how quiet and undramatic from the surface drowning can be, consider this: It is the No. 2 cause of accidental death in children, ages 15 and under (just behind vehicle accidents)—of the approximately 750 children who will drown next year, about 375 of them will do so within 25 yards of a parent or other adult. In some of those drownings, the adult will actually watch the child do it, having no idea it is happening.* Drowning does not look like drowning—Dr. Pia, in an article in the Coast Guard’s On Scenemagazine, described the Instinctive Drowning Response like this:
This doesn’t mean that a person that is yelling for help and thrashing isn’t in real trouble—they are experiencing aquatic distress. Not always present before the Instinctive Drowning Response, aquatic distress doesn’t last long—but unlike true drowning, these victims can still assist in their own rescue. They can grab lifelines, throw rings, etc.
Look for these other signs of drowning when persons are in the water:
So if a crew member falls overboard and everything looks OK—don’t be too sure. Sometimes the most common indication that someone is drowning is that they don’t look like they’re drowning. They may just look like they are treading water and looking up at the deck. One way to be sure? Ask them, “Are you all right?” If they can answer at all—they probably are. If they return a blank stare, you may have less than 30 seconds to get to them. And parents—children playing in the water make noise. When they get quiet, you get to them and find out why.
http://www.slate.com/articles/health_and_science/family/2013/06/rescuing_drowning_children_how_to_know_when_someone_is_in_trouble_in_the.html
Category: Orthopedics
Keywords: Concussion, recovery, head injury (PubMed Search)
Posted: 4/6/2014 by Brian Corwell, MD
(Emailed: 5/10/2014)
(Updated: 5/10/2014)
Click here to contact Brian Corwell, MD
Risk Modifiers for Concussion and Prolonged Recovery
A history of prior concussion is a risk factor for future concussion (>2x risk).
For individual sports, boxing has the highest risk.
For team sports, football, ice hockey and rugby have the highest risk.
Women’s soccer confers the highest risk for female athletes.
Younger age confers increased risk.
Female sex confers higher risk when comparing similar sports with similar rules.
Those with migraine headaches may be at increased risk.
Risk of prolonged concussion
Most athletes have symptom resolution within one week
Post traumatic amnesia (both retrograde and anterograde) predict increased number and longer duration of symptoms.
Younger age also predicts pronged recovery.
Other studies have found associations with headache lasting greater than 60 hours, fatigue, “fogginess,” or greater than 3 symptoms at initial presentation. Cognitive studies have identified deficits in visual memory and process speed as predictors of prolonged recovery.
Risk modifiers for concussion and prolonged recovery.
Sports Health. 2013 Nov;5(6):537-41
Category: Pharmacology & Therapeutics
Keywords: Tylenol, liver faliure (PubMed Search)
Posted: 4/6/2014 by Brian Corwell, MD
(Emailed: 4/27/2014)
(Updated: 4/27/2014)
Click here to contact Brian Corwell, MD
Acetaminophen spent much of 2013 being chased by paparazzi and sharing magazine covers with Miley Cyrus. What a fall from stardom after becoming known as the pain reliever “hospitals use most,” and the one, “recommended by pediatricians.” Slogans we know well based on $100 million/year spent on advertising.
Approximately 150 patients a year die from unintentional acetaminophen poisoning averaged over the past 10 years. From 2001 to 2010, annual acetaminophen-related deaths amounted to about twice the number attributed to all other over-the-counter pain relievers combined,
The FDA sets the maximum recommended daily dose of acetaminophen at 4 grams, or eight extra strength acetaminophen tablets.
Ingestion of 150 mg/kg or approximately 10g for a 70 mg individual reaches the toxic threshold for a single ingestion. The toxic threshold decreases in cases of chronic ingestion.
Patients who “unintentionally” overdose have been found to take just over 8g per day (almost double the recommended maximum). This is unlikely due to taking one extra 325mg tablet once or twice.
Before we all go on a mad NSAID prescribing binge, let's all be aware of the dangers, educate our patients and allow Acetaminophen to walk the red carpet again.
http://www.propublica.org/article/tylenol-mcneil-fda-use-only-as-directed
Category: Orthopedics
Keywords: ankle sprain (PubMed Search)
Posted: 3/22/2014 by Brian Corwell, MD
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Ankle Syndesmosis Injuries are also called high ankle sprains as they involve trauma to the ligaments above the ankle joint
Most ankle sprains are lateral ankle sprains. High ankle sprains are relatively uncommon.
Usual mechanism: External rotation injuries
Exam: Tenderness at the syndesmosis and compression of the tib/fib at the mid calf level causing syndesmosis pain (squeeze test)
Median recovery time is almost 4 times as long as a lateral ankle sprain 62days vs. 15days
Emergency department care is similar tto that of other ankle sprains but the added benefit of patient education and advice may improve overall care and follow-up.
Category: Orthopedics
Keywords: Herpes Gladiatorum, skin rash, sports medicine (PubMed Search)
Posted: 3/9/2014 by Brian Corwell, MD
(Updated: 3/29/2024)
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Herpes Gladiatorum in Wrestlers
HSV causes non genital cutaneous infections primarily in wrestlers, commonly called herpes gladiatorum (HG)
Annual incidence in NCAA wrestlers is 20% to 40%
Most common cutaneous infection leading to lost practice time (40.5% of all infections)
Transmission is skin to skin.
Incubation period is 4 to 7 days from exposure. Healing usually occurs within 10 days after the initial lesion (without scaring).
Appearance: Numerous grouped uncomfortable (painful) vesicles/pustules on an erythematous base…evolve into moist ulcerations, followed by crusted plaques. Lesions typically get abraded during competition therefore may have an atypical appearance and may be mistaken for other infections such as staph. Distribution typically more diffuse than typical HSV infections. Occurs on body surfaces areas that typically come into contract with opponents (face, head, neck, ears, upper extremities). Lesion location typically on side of patient’s handedness. Recurrences occur at location of initial outbreak, a useful diagnostic aid.
Perform a thorough examination as ocular involvement was seen in 8% of high school wrestlers in one HG outbreak.
Typical treatment for primary infection is Valacyclovir 1g PO b.i.d. for 7 days. This is best started within 24h of symptom onset.
Cutaneous Infections in Wrestlers. Wilson et al., 2013. Sports Health.
Category: Orthopedics
Keywords: MRSA, arthocentesis (PubMed Search)
Posted: 2/22/2014 by Brian Corwell, MD
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The clinical examination is often unreliable in ruling out septic arthritis in the ED.
Diagnostic arthrocentesis is often performed.
Traditional teaching involved very high WBC count thresholds as part of diagnosis.
In one 2009 study, synovial leukocyte counts in cases of MRSA were often less than 25,000 cells/uL
Have a low threshold for empiric antibioitics even in the face of low WBC counts (and incredulous consultants)
How Common is MRSA in Adult Septic Arthritis? Frazee et al., 2009
Category: Orthopedics
Keywords: Overtraining syndrome, exercise (PubMed Search)
Posted: 2/8/2014 by Brian Corwell, MD
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Overtraining syndrome
A maladaptive response to excessive exercise without adequate functional rest
-Results in disturbances of multiple body systems (neurologic, endocrinologic, immunologic and psychologic).
- May be caused by systemic inflammation and resultant neurohormonal changes
- Multiple hypotheses exist
-Symptoms
Parasympathetic alterations: fatigue, depression, bradycardia
Sympathetic alterations: insomnia, irritability, agitation, tachycardia, hypertension, restlessness
Other: anorexia, weight loss, poor concentration, anxiety
Usual presentation is prolonged underperformance despite adequate rest and recovery (weeks to months).
Category: Orthopedics
Keywords: MCL, knee, (PubMed Search)
Posted: 1/17/2014 by Brian Corwell, MD
(Emailed: 1/25/2014)
(Updated: 1/25/2014)
Click here to contact Brian Corwell, MD
Pelllegrini-Stieda lesion
Ossified post-traumatic lesions at the MCL adjacent to the femoral attachment site of the medial femoral condyle.
Mechanism is likely from an avulsion injury that subsequently calcifies after the initial trauma.
Often an incidental finding on plain films.
If symptomatic, refer to ortho as an outpatient
If not symptomatic, no treatment is indicated
http://images.radiopaedia.org/images/30076/b62e61e83241e30f2da693901edcdc_gallery.jpg
http://www.imageinterpretation.co.uk/images/knee/PELLEGRINI%20STIEDA2.jpg
Category: Orthopedics
Keywords: Osteoarthritis, treatment (PubMed Search)
Posted: 1/11/2014 by Brian Corwell, MD
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Chronic OA Management, Marc C. Hochberg. Volume 3 December 2013