UMEM Educational Pearls - By Brian Corwell

Distal radius fractures are common in children

Traditional management includes closed reduction +/- procedural sedation

The downside of this approach includes: patient risks, cost, physician time, ED bed time and tying up resources.

Kids have excellent bone remodeling potential...displaced and angulated fractures heal well without reduction

Crawford et al - 51 children aged 3 to 10 (avg 6.9 yrs)  w/closed distal radius fractures.

Exclusions: open or growth plate fractures, metabolic bone disease or neurovascular injury.

No sedation, analgesia or fracture reduction was performed

Treatment: simple casting and gentle molding to correct angulation... i.e. fractures were left in a shortened, overriding position

Outcome: All patients had clinical and radiographic union and full range of motion of the wrist at one year w/ good patient (parent) satisfaction. This was associated w/ significant cost savings.

Consider this approach in consultation with orthopedist

Remember exclusions: open fractures, fracture dislocations, growth plate injuries and neurovascular injury.

Children w/ excessive angulation or rotational deformity should have standard care (closed reduction w/ sedation)

Multiple guidelines exist for "excessive angulation" but as a general rule

Age < 5 Up to 35 degrees

Age 5- 10 Up to 25 degrees

Age >10 Up to 20 degrees

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Congratulations to today's Baltimore marathoners and the medical race staff

In honor of them:

Marathons are becoming increasingly popular with participation rising from an estimated 143,000 US marathon finishers in 1980 to a record high of 507,000 during 2010.

Most victims of exercise-related sudden cardiac arrest have NO premonitory symptoms

Autopsy reports show that

1) 65 - 70% of all adult sudden cardiac deaths are attributable to coronary artery disease.

2) 10% due to other structural heart diseases (HOCM, congenital artery abnormalities)

3) 5 - 10% due to primary cardiac conduction disorders (prolonged QT, ion channel disorders)

4) Remainder are due to non cardiac etiologies

Overall risk of sudden cardiac arrest is approximately from 1 in 57,000 and the risk of sudden cardiac death is approximately 1 in 171,000. Mortality without intervention after sudden cardiac arrest  is greater than 95%. The majority occur in middle to late aged males.

V fib/V tach are the most common arrhythmias leading to sudden cardiac arrest. Most events occur in the last 4 miles of the racecourse.

Survival decreases by 7 - 10%  with each minute of delayed defibrillation. Defibrillation within 3 minutes can produce survival rates as high as 67 - 74%. After 8 minutes, there is a dramatic decrease in survival. Prompt CPR increases survival from 2.5% to greater than 8%.

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SLAP tear/lesion – Superior labral tear anterior to posterior

Glenoid labrum – A rim of fibrocartilaginous tissue surrounding the glenoid rim, deepening the “socket” joint and is integral to shoulder stability

http://www.orthospecmd.com/images/shoulder_labral_tear_anat_02.jpg

Injury is most commonly seen in overhead throwing athletes

Or from a fall on the outstretched hand, a direct shoulder blow or a sudden pull to the shoulder

Sx’s:  A dull throbbing pain, a “catching” feeling w/ activity. Some describe clicking or locking of the shoulder. May also include nighttime symptoms. Pain is located to the anterior, superior portion of the shoulder.

Athletes may describe a significant decrease in throwing velocity

http://sitemaker.umich.edu/fm_musculoskeletal_shoulder/o_brien_s_test

Apprehension test for patellar dislocation

Test is used to access for the possibility of a patellar dislocation, prior to evaluation, now spontaneously reduced.                                                   

Similar to the shoulder apprehension test

Designed to place the patella in a position of imminent subluxation or dislocation

http://mulla.pri.ee/Kelley%27s%20Textbook%20of%20Rheumatology,%208th%20ed./HTML/f4-u1.0-B978-1-4160-3285-4..10042-7..gr16.jpg

http://www.youtube.com/watch?v=9AJxcbd9g8A

Place the knee in 20 - 30 degrees of flexion with the quadripces relaxed. Grasp the patella and attempt to place lateral directed stress.

If the patella is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion by contracting the quadriceps

Apprehension test for shoulder dislocation

Tests for chronic shoulder dislocation                                                       

Similar to the patellar apprehension test

Designed to place the humeral head in a position of imminent subluxation or dislocation

http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/112_kelly/kelly-fig11.jpg

ABduct and externally rotate arm to a position where the shoulder may dislocate

If the shoulder is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion.

Apologies for the long pearl, I did not want to split this into 3 parts)

Disruptions in sleep and circadian rhythms (from travel across time zones and jet lag) are known to alter cognitive functions. Mood and complex mental performance tasks deteriorate faster than do simpler mental performance tasks.

An athlete’s circadian rhythms are believed to be optimal for performance in the early evening (reaction time to light and sound in the fastest). Interestingly, the evening is the time of day when most world records have been broken. However, activities that require fine motor control and accuracy (hand steadiness and balance) are best in the morning.

In the normal population, travel effects are seen in inattention and an increase in errors and injuries in the workplace.

Athletes who perform in international competitions immediately after time zone transitions demonstrate a decline in performance involving complex mental activities, with an associated feeling of lethargy and a general loss of motivation.

British Olympic athletes demonstrated a decrease in leg and back strength in addition to reaction time when traveling westward across 4 time zones. In the NFL, west coast teams consistently beat east coast teams in evening games.

Of course, this type of outcome data is multifactorial and travel effects likely are only one of many complex factors.

Treatment:

Full adaptation to the new time zone is NOT recommended for short trips (1 – 2 days), only for longer stays (> 3 days).

Nonpharmacologic: 

Preadaptation and bright light therapy: Remember that exposure to light is the primary cue for circadian rhythms. Bright light exposure in the mornings (after eastward travel) will advance the body clock, while exposure in the evenings (after westward travel) will delay it (Level B).

Shifting the sleep schedule 1 - 2 hours towards the destination time zone in the days preceding departure may shorten the duration of jet lag (Level B).

Strategic napping: Napping in the new time zone during typical sleep times in the destination time zone will delay adaptation. Power naps (20 minutes) may be helpful in decreasing daytime sleepiness in those with jet lag (Level B). The best time to nap (in flight or post flight) is nighttime in the destination time zone (Level B).

Pharmacologic:

Melatonin: Cochrane review concludes that it is safe and effective in both treating and preventing jet lag. It is recommended for adults traveling across 5 or more times zones; and may be effective for travel across 2 to 4 time zones. Take melatonin in the morning when traveling westward, and at the local bedtime when traveling eastward (Level B). Doses of 0.5 to 5mg were similarly effective. Melatonin taken in the evening and at higher doses are effective at inducing sleep (Level A).

Sleep aids:  Hypnotic sleep aids reliably induce insomnia secondary to jet lag. Benzodiazepines improve sleep quality but may cause a “hangover” effect the next day, possibly impairing performance.

Ambien (zolpidem) and Lunesta (zopiclone) can be effective while limiting the hangover effect especially in those who have previosly tolerated the medication (Level A). Zolpidem may be more effective than melatonin and placebo at countering jet lag symptoms. Note: the use of both medicines together was not more effective than zolpidem alone but did cause daytime somnolence.

Stimulants: Care should be used in the athlete as most of these medications are banned in competition. There is a potential off label use for Provigil (modafinil) for improving daytime sleepiness associated with jet lag (currently approved for narcolepsy).

Caffeine, while not banned for the World Anti-Doping Agency, is a monitored substance.  It increases daytime alertness and may accelerate entrainment in new time zones when consumed in the morning (later ingestion may interfere with sleep induction) (Level A).

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Travel across time zones is regularly required of profession and collegiate athletes (in addition to the some of us professionally)

Jet lag is defined as insomnia or excessive daytime sleepiness/malaise following travel across at least 2 time zones

                Symptoms usually persist 1 day for each time zone crossed

The sleep schedule is primarily modulated by light and melatonin

Secretion of melatonin helps induce sleep

Exposure to light stimulates arousal and inhibits melatonin secretion

Who is at risk?

Those with more rigid sleep habits have more symptoms

“Morning” people have less difficulty flying eastward

“Evening” people have less difficulty flying west

However, overall, eastward travel causes the most severe symptoms which persist for up to 7 days (versus <3 days with westward travel)

                (The length of the day gets shortened and the circadian system must shorten to reestablish a normal rhythm. The human body demonstrates a natural tendency toward periods longer than 24 hours)

Those with higher levels of physical fitness adjust more quickly

Effects similar in men and women

Midday arrivals experience fewer symptoms than morning arrivals

Symptoms are less in those who have traveled the journey previously

Symptoms are less in those who had a shorter interval their last full nocturnal sleep in the departure city and their first full nocturnal sleep in the destination city

The median nerve is not the only compression neuropathy of the wrist

The ulnar nerve can become compressed at the level of the wrist as it 1) enters Guyon's canal or 2) or as the deep branch curves around the hook of the hamate

Compression can occur due to carpal bone fractures, local inflammation, ganglias, lipomas, anatomic abnormalities, etc

In sports medicine, the most common mechanism is injury is seen in cyclists (cyclist/handlebar palsy)

http://www.hughston.com/hha/b_15_3_2a.jpg

Also seen in those who participate in racquet sports, baseball, and golf

Symptoms can be isolated motor (claw hand = rare), sensory or both

http://en.academic.ru/pictures/enwiki/85/Ulnar_claw.jpg

Can be associated w/ median nerve compression

Tx: Activity modification such as wearing padded gloves, padding the object, or changing hand position on the handlebars

If above fails, surgical decompression is very effective.

I am often asked whether physical activity has a positive or negative effect on the overall health of knee cartilage. The answer is unclear. Published data are conflicting.

What is known and generally agreed on:

1) Physical activity has been shown to facilitate cartilage development in children

2) Forced immobility (spinal cord injury) results in rapid cartilage loss

3) The medial knee compartment experiences significant mechanical loads during weight-bearing activity and is often the primary site of knee OA

A recent study attempted to answer whether 1) long-term (10yrs) participation in vigorous physical activity would benefit knee cartilage in healthy adults and 2) whether there were certain subgroups with asymptomatic preexisting structural knee changes which predict a harmful cartilage response to long-term physical activity.

Vigorous = activity generating sweating or SOB at least 20min 1/wk

Healthy older adults (mean age 57.8 yr) performing persistent vigorous physical activity had an increased risk (odds ratio 1.5) of worsening medial knee cartilage defects but not of a change in cartilage volume

In those w/ asymptomatic preexisting structural knee changes, there was worsening of cartilage defects (odds ratio 3.4) and a trend toward increased rate of loss of cartilage volume (again in the medial knee compartment)

Long-term effects of vigorous physical activity may depend on the preexisting health of the joint

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• Wedge compression fractures

• Account for 50 – 70% of all thoracolumbar compression fractures
• Usually results from motor vehicle collisions and falls where an axial load is applied to the spine in flexion causing injury to the anterior column without posterior column injury
• Best seen on the lateral radiograph
• Simple wedge fractures are stable and have no associated neurologic injury
• Instability is present if
  • There is severe compression (>50%)
  • Kyphosis greater than 20 degrees
  • Multilevel compression fractures

http://jbjs.org/data/Journals/JBJS/855/JBJA0851224560G02.jpeg

Hamate Fractures

Occur in two locations: the body of the hamate and the hook (hamular process) of the hamate

Fractures are present in 2 to 4% of carpal bone fractures

Body fractures are less common and are associated with dislocation of the fourth and fifth metacarpals

                Axial force transmitted down the metacarpal shaft (a fall or fist strike)

Hook fractures occur from a direct force from an object strikes the palm such as that from a bat, golf club or racket

Have increased suspicion in these athletes who present w/ ulnar sided wrist pain

Diagnosis is frequently missed;  chronic fractures are associated w/ flexor tendon rupture and ulnar neuropathy

PE:  Tenderness localized over the hamate (in the hypothenar eminence) and over the dorsal ulnar aspect of the wrist. Swelling may be present. Look for resisted flexion of the 5^th digit when the wrist is held in ulnar deviation. May note sensory changes in ulnar nerve distribution

Imaging: PA and lateral views of the wrist will show a body fracture but will frequently MISS a fracture of the hook of the hamate. In those with a clinical suspicion for this entity, order a “carpal tunnel view.”  In the proper clinical setting, CT imaging is excellent for those with high suspicion and normal plain films.

http://mulla.pri.ee/Kelley%27s%20Textbook%20of%20Rheumatology,%208th%20ed./HTML/f4-u1.0-B978-1-4160-3285-4..10044-0..gr2.jpg

Panner's disease refers to osteochondrosis of the capitellum.

Affects the dominant elbow of boys between the ages of 5 and 10

Associated with the repetitive trauma of throwing

Must be differentiated from osteochondrosis dissicans (occurs in the older child >13yo)

Hx: Intermittent pain and stiffness of the elbow. Better w rest, worse w activity.

PE: tenderness over capitellum w/ slight effusion. Loss of 20 degrees full extension

The articular surface of the capitellum appears irregular with areas of radiolucency.

Tx: Symptomatic treatment with rest. In severe cases a long arm splint/cast may be applied for 2-3 weeks.

http://www.ultrasoundcases.info/files/Jpg/org_34277-Afbeelding1.jpg

Luxatio erecta, aka inferior shoulder dislocation, is an uncommon form of shoulder dislocation (0.5-2%)

2 Mechanisms: 1) Forceful, direct axial loading of an ABducted arm.

2) Hyperabduction of the arm leads to impingement of the humeral head against the acromion, If forceful enough, this leverage can rupture the capsule and drive the humeral head downward, resulting in an inferior dislocation. This mechanism is more common.

Classic presentation: Arm locked in marked ABduction with the flexed forearm lying above the head.

http://uconnemig.files.wordpress.com/2011/11/emimages-8c.jpg

http://img.medscape.com/pi/features/slideshow-slide/sdrt/fig1.jpg

http://www.mypacs.net/repos/mpv3_repo/viz/full/76563/3828172.jpg

One may palpate the humeral head against the lateral chest wall

Bony injuries include fractures to surrounding structures such as the coracoid process, acromion, glenoid rim, clavicle, greater tuberosity and humeral head.

Nerve injuries include damage to the brachial plexus/axillary nerve (usually reversed with reduction)

Vascular injuries: Axillary artery thrombosis

Chronic exertional compartment syndrome (CECS)

An overuse injury common in young endurance athletes

In athletes with lower leg pain, CECS was found to be the cause in 13.9% - 33%.

*This is likely under diagnosed as most recreation athletes will discontinue or modify their activity level at early symptom onset

Common in runners and most often involves the anterior compartment

Occurs due to increased pressure within the fascial compartments, primarily in the lower leg

Symptoms are bilateral 85 - 95% of the time

Exercise increases blood flow to leg muscles which expand against tight surrounding noncompliant fascia. This, in turn, increases compartment pressures and eventually reduces blood flow which leads to ischemic pain. Pain usually begins within minutes of starting exercise and experienced athletes can often pinpoint the time/distance required for symptom onset.

Symptoms are primarily pain (tightness, cramping, squeezing) but may also include paresthesias and numbness. Symptoms gradually abate with cessation of activity.

Diagnosis:  Although some physicians’ make a clinical diagnosis based on Hx and exam, definitive diagnosis requires measurement of compartment pressures both at rest and post exercise.

Nonsurgical treatment: activity modification and rest

Surgical treatment: >80% success with anterior and lateral compartments vs. 50% with deep posterior compartment.

Exertional leg pain in the athlete carries a wide range of possible etiologies. In a recent review article, etiologies included, stress fracture (25%), exertional compartment syndrome (33%), medial tibial stress syndrome (13%), nerve entrapment (10%), and popliteal artery entrapment syndrome.

Medial Tibial Stress Syndrome (MTSS) is also known as shin splints. It is a repetitive-stress overuse injury.

Risk factors include: hyperpronation, higher BMI, increased hip internal rotation, and hyperplantar flexion.

While MTSS may be on a stress reaction spectrum that includes fracture, the causes are likely to also include tendinopathy and muscle dysfunction (tibialis anterior, posterior and soleus).

Radiographs will be normal with this condition. MRI and bone scan may show signal abnormality along the posterior medial tibial surface.

Treatment: In most cases participation in sports may continue. Also consider, rest/activity modification, ice, NSAIDs, physical therapy for calf stretching and strengthening,  and rigid orthotics (to correct foot hyperpronation). Semi rigid and neoprene orthotics may be considered for prevention in those with a prior history.

A recent study looked at the risk of sudden cardiac death during a marathon.

Many isolated reports of sudden death make headlines in the national news.

However, of nearly 11 million runners, only 59 went into cardiac arrest during a race. This equates to an incidence rate of 0.54 per 100,000 participants,

This rate appears to be on par with sudden death from other athletic endeavors such as triathlons and college athletics.

Median age was 42. Men affected more than women (men also more likely to die from the event).

71% of events were fatal.

Further, risk is greater for both cardiac arrest and sudden death for full marathons than half marathons.

Interestingly, older patients fared better (increased survival in those >40yo), thought to be due to an increased incidence of hypertrophic cardiomyopathy in younger aged runners.

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The plantar fascia arises from the medial tuberosity of the calcaneous and extends to the proximal phalanges of the toes.

Pkantar Fasciitis is the most common cause of heel pain in adults.

Etiology is thought to be from a degenerative tear at the fascial origin followed by a tendinosis type reaction and .

Affects women 2x> men

More common in overweight patients.

Onset is insidious and not related to trauma.

Hx: Pain and tenderness directly over the medial calcaneal tuberosity and 1-2cm distally along the plantar fascia.

Pain is worse with prolonged standing/walking. Pain is most intense however when rising from a resting position such as first thing in the morning.

PE: Pain is increased with passive dorsiflexion of the toes. Tenderness to palaption over the medial calcaneal tuberosity and 1-2cm distally along the plantar fascia.(At times, one may have to apply increased pressure to approximate weight bearing type stress)

XR: Usually not necessary with a good history and exam. Heel spurs are seen in up to 50% with the disease (and in up to 20% without it!)

DDx: Tarsal tunnel syndrome. Calcaneal stress fracture. Fat pad atrophy. traumatic rupture of planter fascia.

Severs disease

- Perhaps the most common overuse injury

-Pain is due to inflammation of the calcaneal apophysis growth plate

- Caused by repetitive microtrauma from the pull of the Achilles tendon on the apophysis.

- Occurs in young athletes ages 7-14

Sx’s bilateral in >50%

Hx – Gradual onset of posterior heel pain, worse with activity, better with rest.

PE – Tenderness at the insertion of the Achilles tendon onto the calcaneous. Swelling is mild.

This is a self limited condition because as the adolescent ages, the physis closes

Tx – Rest (no running or jumping), ice, NSAIDs, heel lifts/arch supports. Outpatient physical therapy for stretching and strengthening exercises.

Common herbs and supplements used to treat pain

1) Turmeric root - used for arthritis pain. Little evidence to support its use. May slow blood clotting/enhance anticoagulant/antiplatelet effects.

2) Boswellia - used for OA and RA pain. Little evidence to support its use.May interfere with anticoagulant drugs and leukotreine inhibitors.

3) St. John's Wort - used for HA, migraine, neuralgia, muscle pain, sciatica, fibromyalgia. Little to no evidence to support its use.May interfere with numerous medications including anticoagulants, digoxin and SZ medications.

4) Glucosamine and Chondroitin - used for OA, knee pain, back pain. The glucosamine/chondroitin arthritis intervention trial found that "the dietary supplements Glucosamine and Chondroitin, taken alone or in combination are generally ineffective for OA pain of the knee." May increase the effect of Warfarin.

5) KavaKava - used for HA, muscle pain. Insufficient evidence demonstrating effectiveness for treatment of painful conditions. May cause severe liver damage and potentiate drowsiness side effects of other medications.

6) Echinacea - used for pain, migraines, arthritis. Little evidence to support its use. May exacerbate symptoms of autoimmune disorders.

7) Valerian root – used for joint and muscle pain. Insufficient evidence to support its use. May potentiate sedative side effects of barbiturates and benzos.

8) Chinese Thunder God Vine – used for arthritis. There is some evidence to suggest that this agent has anti-inflammatory properties. Long term this agent may decrease bone mineral density in women, decrease fertility in men, and may produce GI side effects.

9) Feverfew – used for muscle pain, arthritis. Some evidence to suggest that may reduce frequency of migraine headaches. No evidence for benefit in RA. May enhance effects of anticoagulants and some drugs that undergo hepatic metabolism.

10) Cat’s claw – used for herpes zoster, bone pain, arthritis. Possible benefit for OA and RA in small studies in humans but no large study has shown benefit. May interact with clotting agents, BP meds and cyclosporine.

11) Black Cohosh – used for muscle pain and arthritis. Insufficient evidence demonstrating benefit. May be associated with severe liver side effects.

12) Bromelain – used for muscle pain, arthritis, knee pain. The NIH reports that bromelain may be effective for arthritis when used in combination with trypsin and rutin. May interact with amoxicillin and other antibiotics, anticoagulants and antiplatelet drugs.

13) Devil’s claw – used for muscle pain, back pain, arthritis, migraine. The NIH reports that “taking devil’s claw alone or with NSAIDs seems to help decrease OA related pain.” May increase effects of warfarin.

Our old friend Captain Morgan (the rum pirate) may now be able to assist us during a shift, not just afterwards.

http://www.inquisitr.com/wp-content/2011/08/captain-morgans-pirate-ship-satisfaction-panama.jpg

In a small case series in last months Annals of Emergency Medicine, a new reduction maneuver was described as an alternative to the traditional Aliis's maneuver.

The maneuver is named after the pirate spokesperson for the similarities in body positioning.

The patient is placed supine on a stretcher. The pelvis is fixed to a backboard with a strap. The patient's hip and knee are flexed to 90 degrees. The physician places one foot on the back board with the same knee behind the patient's knee. By holding the patient's ankle down, the patient's knee is kept in flexion. The physician then lifts his/her calf, thereby applying an upward force to the hip while gently rotating the lower leg from side to side.

http://www.youtube.com/watch?v=l07K-mO2X84

with a slight variation

http://www.youtube.com/watch?v=sGQZaqB48rw

The success rate was 12 of 13 cases. The single failure occurred in a patient with an acetabular fracture with an intra-articular fragment requiring open reduction. There were no described neurovascular complications or injuries to the knee. The technique limits the physician's risk of back strain and of falling from the stretcher.

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