Lever Sign/Lelli’s test

A new test for diagnosing ACL tears

Higher sensitivity (94 - 100%) than the Lachman test (highest sensitivity test to date)

               With time and more study, this may become our new gold standard physical examination test

Very easy to learn and apply to bedside care

Can help with diagnosing partial tears

Area of manipulation is the femur and not the tibia (as in other tests)

Consider incorporating into your standard knee examination

https://www.youtube.com/watch?v=T9ujIYIctdw

Original study

https://www.ncbi.nlm.nih.gov/m/pubmed/25536951/

Validation

https://www.ncbi.nlm.nih.gov/pubmed/26753117

Thank you to Ari Kestler for sending

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Viscosupplementation

Hyaluronic acid (HA) is a high-molecular weight polysaccharide

A major component of synovial fluid and of cartilage

Major role of HA is as a lubricant, shock absorption, antinociceptive effect

               Used in veterinary medicine for decades

Multiple brands exist with differences based on the molecular weight and how they are produced

Use supported by the Cochrane database (2007, 2014) for knee OA

Post injection strength gains are due to pain relief

May have a role for those who cannot receive steroid injections

Inject in similar manner to intra articular steroids

Caution in those with known allergy to poultry /eggs

Risks: Local reaction (likely from preservative), injection site pain, infection, bleeding.

There is tremendous interest in identifying factors that may influence outcome from sports related concussion.

The strongest predictor of slower recovery is the severity of symptoms in the 1-2 days post injury

     -Fewer Sx's in this time period predict a quicker recovery

Pre injury history of mental health problems, depression or migraine headaches predict a longer recovery course

Teenagers might be more vulnerable to having persistent symptoms with greater risk for girls than boys

Having a prior concussion is a risk for having a future concussion

The large majority of injured athletes recover from a clinical perspective within the first month of injury many within the first 10 days

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PCL injuries can sometimes have involvement of the posterolateral corner (PLC)

The dial test can be used to diagnose posterior lateral instability and help differentiate it from isolated PCL injuries

The dial test involves comparing the amount of external rotation of the lower leg at the knee while the knees are in 30° and in 90° of knee flexion.

https://www.youtube.com/watch?v=rnk62Y-nDSQ

An isolated injury to the posterolateral corner will result in more than 10° of external rotation in the injured knee that is present at 30° but not at 90° of knee flexion.

http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST.jpg

http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST-90.jpg

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Question

Idiopathic osteonecrosis of the femoral head

Children as young as 2 or as old as 12 but generally 4 to 8 (worse in older children)

Fare better than adults with osteonecrosis of femoral head

1 in 10,000

4-5x more common in males, much less common ini African Americans

Unilateral femoral head involvement 90% of the time (Bilateral 10% of the time)

Long term consequences are deformity and arthritis

Typical presentation: Subacute limping for weeks (Painless)

As activity worsens limp, it is maximal at the end of the day (Intermittent)

As in adults with hip pathology, IF pain is reported, it is located at the upper anterior thigh and groin

On examination, look for restriction in range of motion of the hip (compare with contralateral side)

May only present with mild to moderate decreased range of motion of the hip

            30 versus 60 degrees for example

             ABduct both legs with pelvis in neutral OR Place one hand on contralateral pelvis and ABduct affected leg with other hand.

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Adhesive Capsulitis aka Frozen Shoulder

Spontaneous gradual onset stiffness and pain of the Glenohumeral joint

Shoulder capsule becomes thickened and contracted

Often affects patients between 40 and 60 years old

Left> Right shoulder

Women> men

Association with diabetes and thyroid disease

3 clinical stages

1)      Pain – gradual onset, diffuse, severe, disabling, often worse at night

2)      Stiffness – decreased ROM, affects ADLs, improved pain

3)      Thawing – gradual return of motion

Physical examination: Painful and decreased ROM. Evaluate active and passive movement, external rotation and ABduction of the shoulder most affected

Surgical or post traumatic shoulder stiffness usually resolves within 12 months.

Adhesive capsulitis is generally self-limiting lasting an average of 18-36 months.

DDX: Chronic locked posterior shoulder dislocation (VERY IMPORTANT), tumor.

Treatment: NSAIDs, Physical therapy, Intra articular steroids

If this fails, manipulation under anesthesia and/or arthroscopic surgical release

Shin Splints

Medial tibial stress syndrome (MTSS) aka shin splints is an overuse injury of the tibia

Very common

-10 to 15% of running injuries and over 50% of leg pain syndromes

3 Characteristics

1)      Pain along the posteromedial border of the tibia

2)      Diffuse pain

3)      Pain that is activity related

Risk  Factors

Female sex, increased weight, previous running injury, and

Higher navicular drop (amount of foot pronation) and

Greater hip external rotation with the hip in flexion

Differential  Diagnosis

Tibial stress fracture, compartment syndrome, nerve entrapment (sural), lumbar radiculopathy and popliteal artery entrapment. 

Distal Radius Fractures

High energy mechanism in younger patients

Falls more common in older patients

Higher incidence in older women due to osteoporosis

     May indicate overall poor bone health

  Avoid splinting in positions of flexion (palmer) and ulnar deviation

    Palmer flexed positions may have a higher rate of displacement

Non operative treatment

Extra-articular fx, less than 5mm shortening of radius, Less than 5 degrees of dorsal angulation.

     Consider fractures than are only stable in extreme positions to be unstable

If fx involves the ulnar styloid or DRUG (distal radial ulnar joint) place in long area posterior splint with arm in mid supination (anatomic position of forearm)

Iliotibial band tendonitis

IT band is the continuation of the tensor fascia lata and inserts on the tibia at Gerdy's tubercle

Common cause of lateral knee pain seen in Primary care/Sports med clinics

Mechanism: May be due to excessive friction between the IT band and the lateral femoral condyle

Second most common overuse injury of the knee (PF syndrome). Not an acute event.

Affects up to15% of active individuals

Impingement zone is at 30 degrees of knee flexion

Most common in runners and cyclists

Pain localized over the lateral femoral condyle. Better w/ rest. Often occurs at a predictable distance into the run and not at onset.

Exacerbated with changes to mileage or running terrain.

Additional risks include poor shoes (best to change every 300 to 500 miles), excessive foot pronation (pes planus), quad versus hamstring strength asymmetry, weak hip ABductors, leg length discrepancy, tight IT band.

Septic Arthritis in Children

Classic presentation: Pain, fever (may not always be present)

Limited range of motion of joint or refusal to bear weight,

 Joint swelling (difficult to visualize in hip or shoulder),

Limb held in position that allows greatest capsular volume (elbow held in 30° flexion for example)

Diagnostic testing may include diagnostic markers (ESR, CRP) or imaging (US/MRI)

Most common organisms: Staph and Strep, Neisseria (adolescents), HACEK organisms, consider gram negatives in immunocompromised children

DDX: Transient synovitis, osteonercrosis or osteomyelitis, Psoas abscess, acute leukemia, Lyme disease

A common ED presentation is the child with the painful limp

               35% of all cases of septic arthritis

>50% of cases occur in children younger than 2yo

Hip held in flexion, Abduction, external rotation

Fever and inflammatory markers are more sensitive than WBC count and refusal to bear weight

Kocher criteria:

1)     Refusal to weight bear on affected side

2)     Sed rate greater than 40mm/hr

3)     Fever (>38.5°C

4)     WBC count of >12,000 mm3

IF
                 - 4/4 criteria are met, there is a 99.6% chance of septic arthritis; 
                 - when 3/4 criteria are met, there is a 93% chance of septic arthritis; 
                 - when 2/4 criteria are met, there is a 40% chance of septic arthritis; 
                 - when 1/4 criteria are met, there is a 3% chance of septic arthritis; 

CRP can also be incorporated into a diagnostic algorithm

CRP>2.0 (mg/dl) in a child who refuses to bear weight yields a 74% probability of septic arthritis

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Most of our knowledge of the athlete’s EKG is based on white athletes.

African/Afro-Caribbean athletes are more likely to have an abnormal EKG than white athletes in multiple studies.

Different selective criteria have been developed to minimize classification of benign normal patterns as abnormal.

The 2010 ESC criteria classified 40.4% of black athletes as abnormal versus the Refined criteria which resulted in 11.5% of EKGs classified as abnormal.

This reduction was aided by the recognition that isolated anterior TWI in asymptomatic black athletes is considered a benign finding.

               Note this does NOT apply if the TWI extend to the lateral leads

For example, T-wave inversion (TWI) was present in 23% of African/Afro-Caribbean athletes vs. 3.7% of white athletes (usually in contiguous anterior leads).

Other changes included a higher prevalence of early repolarization, RV hypertrophy, and LA/RA enlargement.

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Question

Physicians are often called upon to serve as a team physician for a local high school in an official or unofficial capacity.

To aid in preparedness for sport-related emergencies, multiple national organizations have defined institutional best practices.

Knowledge of the following 3 best practice recommendations is important before taking on the role of “Doc covering the game”

     1)The written Emergency Action Plan (EAP) – details the standard of emergency care at the particular venue.

     2)The availability of life saving equipment: AED – where is it, charged and working?

     3)Are the coaches trained in use of the AED and CPR. You can’t be everywhere and often multiple sporting events occur on campus simultaneously. It’s imperative that your first responder (coach or athletic trainer) can perform these tasks until you are able to respond

Please investigate these best practice recommendations before agreeing to serve as the physician for the local high school.

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22yo college track athlete presents with 3 weeks of gradual onset groin and thigh pain, worse with running, better with rest.

Stress fractures are a common cause of groin pain in athletes, particularly in long distance runners

Fractures occur in the pubic rami and femoral neck 

Ask about a sudden change in training regimens

PE: check for tenderness to deep palpation over the pubic ramus. Ask athlete to stand and support full weight on affected leg or perform one legged hop on affected side. Pain out of proportion to physical examination findings. 

Imaging: XR usually negative. Bone scans can be positive as early as 4 to 8 days after symptom onset. MRI used to diagnose and rule out other causes of groin pain.

Treatment: Rest for 4 to 6 weeks. Consider making patient non weight bearing if walking causes pain especially with femoral neck fractures on the superior side. Inferior side neck fractures may benefit from prophylactic fixation.

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The Essex-Lopresti injury pattern is the lesser known of the triad of forearm injuries (Monteggia & Galeazzi).

It follows the “rule of the ring” aka the life saver candy rule: You can’t break a life saver in just one place.

These injury patterns are frequently missed because our eyes are drawn to the fracture and miss the associated dislocation.

The Essex-Lopresti fracture pattern involves a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint (DRUG)

               -With associated interosseous membrane disruption

Think of it as the Maisonneuve fracture of the forearm.

Mechanism: fall from height/high energy forearm trauma.

PE: Suspect if patient has significant tenderness at the DRUG with a radial head fx.

Patients have worse outcomes if injury is missed on initial presentation due to radial migration and instability.

Take home point: Remember the rule of the ring. Remember to exam the elbow with wrist injuries and the wrist with all elbow injuries

https://image.slidesharecdn.com/tgc9gbsusz6yf9gnomzq-signature-b704f322087ef3e158e7aa08078573cfc5a04ec6f8a3a982d1fcb26597be3f6d-poli-150513093239-lva1-app6891/95/elbow-injury-13-638.jpg?cb=1431509645

Is that a fracture or a growth plate?

Pediatric elbow x-rays are complicated to interpret due to the large number of ossification centers.

Elbow trauma is common in pediatrics.

Ossification centers of the elbow appear in a reliable chronologic pattern which aids in distinguising fractures from growth plates.

Note the age ranges are an estimate with great variability. For example, girls can develop these up to 2 years earlier than boys.

The numbers 1/3/5/7/9/11 correspond to the average age of development of each ossification center

Years of fusion shown below in ()

Capitellum (12-14yo)

Radial head (14-16yo)

Medial epicondyle (16-18yo)

Trochlea (12-14yo)

Olecranon (15-17yo)

Lateral epicondyle (12-14yo)

Pneumonic: "Can't Resist My Team Of Lawyers"

Consider ordering films of both elbows to compare if in doubt.

How is this useful? If the trochlear center is present, but there is no medial epicondyle then you are most likely looking at a fx where the ossification center has been avulsed and displaced. 

During a busy ED shift, your 40yo charge nurse asked you to look at his hand. He is known avid mountain biker. He has pain in his right 4^th and 5^th digits. . He feels a lack of coordination and a feeling of “clumsiness” of the hand. Where is his possible nerve compression and what do you expect to find on exam?

Ulnar nerve entrapment is sometimes called “handlebar palsy.” 

Compression location is Guyon’s canal.

The ulnar nerve supplies the intrinsic muscles of the hand AND the extrinsic muscles for flexion of the 4^th and 5^th digits. This is what aids in a “power grip” and why he may have diminished grip strength on exam.

               Also innervates the ADDuctor pollicis and 1^st dorsal interosseous muscles (pinch)

Note the ulnar nerve also passes through the radial tunnel at the elbow. Entrapment here is called Radial tunnel syndrome or Cubital tunnel syndrome and causes forearm pain and paresthesias in the 4^th and 5^th digits with grossly normal motor and sensory function.

You are covering a sporting event or working an ED shift when a young adolescent athlete without significant PMH presents with SOB and wheezing associated with exercise.

You immediately think exercise-induced asthma, prescribe a short-acting bronchodilator and pat yourself on the back.

While you may be right, there is increasing recognition of an alternative diagnosis

Exercise-induced laryngeal obstruction (EILO)

During high intensity exercise, the larynx can partially close, thereby causing a reduction in normal airflow. This results in the reported symptoms of SOB and wheezing.

This diagnosis has previously been called exercise induced vocal cord dysfunction. As the narrowing most frequently occurs ABOVE the level of the vocal cord, EILO is a more correct term.

While exercise induced bronchoconstriction has a prevalence of 5-20%, EILO is less common with a prevalence of 5-6%.

Patients are typically adolescents, with exercise associated wheezing and SOB, frequently during competitive or very strenuous events. Wheezing is inspiratory and high-pitched. Symptoms are unlikely to be present at time of medical contact unless you are at the event as resolution occurs within 5 minutes though associated cough or throat discomfort can persist after exercise cessation. EIB symptoms typically last up to 30 minutes following exercise.

Inhaler therapy is unlikely to help though some athletes report subjective partial relief. This may be explained as approximately 10% of individuals have both EIB and EILO.

In athletes with respiratory symptoms referred to asthma clinic, EILO was found in 35%.

Consider EILO in athletes with unexplained respiratory symptoms especially in those with ongoing symptoms despite appropriate therapy for EIB.

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Concussions are associated with an elevated risk of musculoskeletal injury

Significant associations were found between concussion and

Lateral ankle sprain (P = 0.012)

Knee injury (P = 0.002)

Lower extremity muscle injury (P = 0.031)

Keep in mind that 50 – 80% of concussions may go undiagnosed or unreported.

A discussion about risks of early return after concussion should include mention of risks beyond repeat head injury/2nd impact syndrome

Study limits: Retrospective design limits ability to establish causation/reporting bias

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Incidence and Cost of Ankle Sprains US Emergency Departments

In a sample of 225,114 ED patients with ankle sprains:

Lateral ankle sprains represent the vast majority of all ankle sprains (91%).

Lateral ankle sprains incur greater ED charges than medial sprains ($1008 vs. $914).

Lateral ankle sprains were more likely to have associated pain in the limb, sprain of the foot and abrasions of the hip/leg than medial sprains.

Medial sprains were more likely to include imaging.

Hospitalizations were more likely with high ankle sprains than lateral sprains.

There is a higher incidence of ankle sprains in younger patients (≤25 years) and in female patients (57%).

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Question

https://images.radiopaedia.org/images/3173801/1ee24da1a6fe907a27d2bf20481174.jpg

Young toddler presents with left lower leg pain. What is the diagnosis??

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