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.

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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.

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.

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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)

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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).

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

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No single feature of the history of physical examination reliably rules out ostemyelitis

Aids in making the diagnosis include:

An ulcer area larger than 2 cm² (LR 7.2),

A positive probe to bone test (LR 6.4),

An ESR greater than 70 mm/h (LR 11)

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Treating knee osteoarthritis - from the American College of Rheumatology 

Exercise whether it be aquatic, aerobic (land -based) or resistance can decrease pain and improve functional capacity. Exercise should be performed 3 to 5 times a week. Effects are usually noted after 3 to 6 months.

Weight loss of 5% or greater body weight is associated with a small improvement in pain and physical function. The main benefit of weight loss has more to do to effects on co-morbid conditions.

Walking aids: A single crutch or cane should be held on the side contralateral to the affected knee and should be advanced with the affected limb when walking to reduce the load on the affected joint. 

Cane sizing: The distance from the floor to the patient's greater trochanter (brings the elbow to 15º to 20º of flexion.

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Unexplained respiratory symptoms during exercise are often incorrectly considered secondary to exercise induced asthma/bronchospasm.

An important diagnosis on the differential should be exercise-induced laryngeal obstruction (EILO).

Of 91 athletes referred for asthma workup, 35% had EILO.

The presence of inspiratory symptoms did not differentiate athletes with and without EILO.

61% of athletes with EILO used regular asthma medication at referral.

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Cauda equina syndrome results from compression of multiple lumbar and sacral nerve roots

Causes: Central disc herniation, spinal epidural abscess, malignancy, trauma, hematoma.

Consider this entity in those with back pain and radiculopathy at multiple spinal levels

Urinary retention occurs in >90% of patients

Saddle anesthesia occurs in 75%

Decreased rectal sphincter tone occurs in 60 to 80%

A post void residual volume <100 mL makes this entity very unlikely

 Lateral hip pain

 Findings of weakness and/or pain while testing hip abduction may point to gluteus medius muscle dysfunction with associated with greater trochanteric pain syndrome.

The Trendelenburg test may help. The patient stands on the affected leg. A negative test result occurs when the pelvis rises on the opposite side. A positive test result occurs when the pelvis on the opposite side drops and indicates a weak or painful gluteus medius muscle.

http://www.youtube.com/watch?v=TY-G4ErruUA
 

Prior fracture represents the strongest predictor of stress fracture in both sexes

For girls:  Low body mass index, (<19), late menarche (age 15 or older), previous participation in gymnastics and dance.

For boys: increased number of seasons.

Participation in basketball appears protective in boys.

This may represent a modifiable risk factor for stress fractures.

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The thumb MCP joint is subject to arthritric changes.

Sx's of arthritis will frequently present with pain in a similar region to deQuervain's disease.

The basal joint grind test

          Perform by stabilizing the triquetrum with your thumb and index finger and then dorsally subluxing the thumb metacarpal on the trapezium while providing compressive force with the opposite hand.

http://www.youtube.com/watch?v=oEJH7KFGx_Y

The flexor tendons of the finger may become thickened and narrowed from chronic inflammation and irritation.

 - Causes limitation in range of motion and snapping or locking during flexion

 - Can involve any digit but usually the ring and the long finger

CC: pain, "catching" May awake to finger being "locked" with spontaneous resolution during the day

Stenosis occurs at the MCP level

PE: Distal flexor crease tender to palpation and may have a painful nodule 

Full finger flexion is sometimes not possible

Tx: NSAIDs and steroid injection in tendon sheath. If this fails - surgical release.

Dupuytren disease is a nodular thickening and resultant contraction of the palmer fascia.

Increased in those of Northern European dissent.

One or more painful nodules located near the distal palmer crease.

Over time may result in flexion at the MCP joint.

Most commonly affects the ring finger.

Sensation is normal.

Over time affects ADLs

Tx: night splints and surgery

Tests for distal ulnar nerve entrapment

Ask patient to hold a piece of paper between the thumb and the index finger

Normally this is a fairly simple task.

With an unlar nerve palsy, the patient will substitute with the FPL (flexor pollicis longus - median nerve innervation). This causes flexion of the thumb in order to maintain the grip since the adductor pollicis cannot be used. This causes thumb flexion rather than extension.

http://www.mims.com/resources/drugs/common/CP0042.gif

http://www.youtube.com/watch?v=yJTIhm1VfSI

Tennis Elbow

The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

 The ECRB  muscle helps stabilize the wrist when the elbow is straight.

Ask the patient to straighten the arm at the elbow and then perform resisted long finger extension. This will stress the ECRB and reproduce the pain. One can also ask the patient to lift the top of a chair in the air with the elbow extended.

The adolescent brain has not yet reached full maturation and is in a period of rapid development from ages 14 - 16. 

Adolescents have been found to be more sensitive to the effects of concussion than adults

Concussed adolescents have deficits in attention and executive function lasting up to 2 months post injury.

Be aware that the adolescent brain will require  extended recuperation time following injury

In the future, discharge instructions might need to say more than "don't get hit in the head till your headache goes away." Because of deficits in attention and executive function, physicians should consider recommendations about adolescents and jobs, school work and driving an automobile. 

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Adhesive capsulitis aka frozen shoulder

idiopathic loss of BOTH active and passive motion (this is a significant reduction of at least 50%)

               Motion is stiff and painful especially  at the extremes

Occurs due to thickening and contracture of the shoulder capsule

Affects patients between the ages of 40 and 60

Diabetes is the most common risk factor

Imaging is normal and only helpful to rule out other entities such as osteophytes, loose bodies etc.

Treatment includes NSAIDs, moist heat and physical therapy.

Patients should expect a recovery period of 1-2 years!