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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Many of us use exercise as a coping strategy when emotionally stressed or to blow off steam when angry. This may place your heart at risk.

A recent observational study in Circulation surveyed 12,000 first MI patients about potential triggers. The associations didn't depend on age, smoking status, hypertension, or baseline physical activity.

Anger or emotional upset in the hour before onset elevated odds of MI 2.44 fold

A similar 2.31 fold elevation was observed form heavy exertion

However, the combination of the two raised the odds to 3.05 fold (P<0.001 for interaction)

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Recurrence depends on age and activity level

27% if >30yo and 72% if <23yo

Surgical Recommendations:

Large bony Bankart lesion, glenoid or humeral head defect >25%, recurrent instability, event near the end of season

Non surgical return to play:

If event occurs at beginning/early in season

Rehabilitation for 2 to 3 weeks (most return to play in this time frame)

Immobilization for 3 to 7 days in simple sling, gentle range of motion, cryotherapy

Physical therapy to strengthen dynamic stabilizers

Shoulder stabilization brace for non overhead throwing and contact sports

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Retroperitoneal hemorrhage

The pathophysiology is unknown. Some hypothesize that occult vasculopathy and arteriosclerosis of the small vessels in the retroperitoneum may render them friable and therefore prone to rupture. This can be seen in minor trauma in sports and forceful vomiting or coughing. Spontaneous bleeding starts at the microvascular level, and large vessels become disrupted or stretched as the hematoma enlarges.

Retroperitoneal hemorrhage occurs in a variety of clinical circumstances, including spontaneous hemorrhage into a pre-existing benign adrenal cyst or bleeding from a left inferior phrenic artery, tumors of the adrenal gland and kidney, rupture of any blood vessel (most commonly infrarenal aorta); percutaneous interventions (such as cardiac catheterization), trauma, and polycythemia vera,

It is most commonly seen in association with patients with bleeding abnormalities, in HD patients and with anticoagulation therapy,. Risk is much greater with unfractionated heparin therapy than with warfarin. In most of the heparin patients studied, their coagulation parameters were in the therapeutic range.

Patients may present to the non acute area of the ED with back, lower abdominal or groin discomfort, Over time, this may progress to hemodynamic instability, and a fall in hemoglobin, Early identification is crucial to improving patient morbidity and mortality. Early symptoms depend on the location of the bleeding.

Hematoma near or within the iliopsoas muscle usually presents as femoral neuropathy (groin pain or leg weakness).

Femoral neuropathy caused by retroperitoneal hematoma can present with sudden onset severe pain in the affected groin and hip, with radiation to the anterior thigh and the lumbar region. This can easily be missed as the presentation is similar to a pulled msucle or strained hip/back. Iliopsoas muscle spasm often results in the characteristic flexion and external rotation of the hip, and any attempt to extend the hip will result in severe pain. Over time, pain and parasthesia in the antero-medial thigh and leg is seen.

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Young athletes, especially around the age of puberty, are at higher risk for pelvic avulsion fractures

Often seen in sports that require sprinting, rapid changes in movement or jumping

Caused by sudden, forceful contraction of the muscles of the abdominal, the hip and thigh or the hamstring

Avulsion fractures can occur at many areas of the pelvis.

A mnemonic is: Alabama’s stoned rappers got ill hunting armadillos

·  Iliac crest: Abdominal muscles

·  Anterior superior iliac crest: Sartorius

·  Anterior inferior iliac crest: Rectus femoris

·  Greater trochanter: Gluteal muscles

·  Lesser trochanter: Iliopsoas **(rare in adults)

·  Ischial tuberosity: Hamstrings

·  Pubic symphysis: Adductor group

http://roentgenrayreader.blogspot.com/2010/07/pelvic-avulsion-fractures.html

** Isolated nontraumatic avulsion fractures of the lesser trochanter in adults is a pathognomonic sign of metastatic disease

This site has some good images of common injury patterns

http://radiopaedia.org/articles/apophyseal-avulsion-fractures-of-the-pelvis-and-hip

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47yo M chef presents to your ED with 2 days of worsening left hand pain after sustaining a puncture wound to hand at work. The hand is red and swollen and he complains of pain. Interestingly, his index and middle digits are in an ABducted position at rest.

Collar Button Abscess

Web space infection of the palmer AND dorsal hand

The Palmer aponeurosis prevents volar extension (but promotes dorsal encroachment)

The pus spreads between the MC bones and erupts dorsally....creating a DORSAL abscess.

Loss of palmer concavity is seen.

ABduction of the adjacent digits, resulting in a "V" configuration with the apex pointing to the site of infection. This would not happen from simple pus in the dorsal space!

Can be missed if only focused on the dorsal hand. The palm will show the original injury (splinter, cut, foreign body)

Treatment is urgent surgical drainage.

http://www.eplasty.com/article_images/eplasty16ic06_fig1.gif

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30yo male weight lifter who 10 days ago had a painful left shoulder injury after bench press. The next morning his left anterior chest wall and left upper arm were bruised and swollen. He went to see his PCP who diagnosed him with a muscle strain. 8 days later the bruising and swelling have resolved but he still cant move his shoulder and comes to the ED.

http://321gomd.com/wp-content/uploads/2015/01/pec-major-tears.jpg

The pec major attaches to the humerus and originates from the sternum and clavicle

Injury is usually due to tendon rupture off the humerus but can also occur at the muscle tendon junction or within the muscle belly itself.

Injury is becoming increasingly common due to the popularity in power lifting sports.

Mechanism: excessive tension on a maximally eccentrically contracted muscle.

Patients will complain of pain and weakness of the shoulder.

PE: Swelling and bruising to anterior medial arm. Palpable defect and deformity or anterior axially fold (may be hidden by swelling).

Weakness and pain with adduction and internal rotation and forward flexion

Chronic presentations can be challenging to diagnose. Consider ultrasound

Non operative treatment may be indicated for partial tears (sling, ice, NSAIDs)

Operative repair of tendon avulsions is very successful. Patients age, occupation/activity level and location of injury and condition of tear are considered.

Sesamoid Injuries

Unlike other bones in the human body that are connected to each other at joints, sesamoid bones are only connected via tendons (or are imbedded in muscle).

The largest sesamoid bone is the patella.

2 small sesamoid bones lie on the plantar foot near the great toe

Sesamoid bones can fracture and the surrounding tendons can become inflamed (sesamoiditis)

Traumatic injury is usually due to hyperextension and axial loading

Sx: Pain located under the great toe on the ball of the foot (Gradual with sesamoiditis and acutely with a fracture).

There may be associated swelling and bruising. Pain with palpation, flexion and extension.

The medial/tibial sesamoid is larger, has great weight bearing status and is more commonly injured that its lateral counterpart.

In many people (10 - 25%) the medial sesamoid of the foot has two parts (bipartite). This finding is bilateral in 25% of people.

This may confuse some providers as it may appear to be a fracture

Look for a smooth contour to the bones and clinically correlate (bruising, soft tissue swelling, etc.) if it is an incidental finding.

Other radiographic clues include

1) The fractured sesamoid is usually slightly larger than the lateral sesamoid while the bipartite sesamoid has a much larger medial sesamoid than lateral sesamoid

2) The fractured sesamoid shows a sharp, radiolucent, uncorticated line between the two fragments while the bipartite sesamoid has two corticated components

3) The fractured sesamoid fragments often fit together like pieces of a puzzle while the bipartite sesamoid has two components that do not fit together snugly

4) Other means to differentiate the two involve MRI and bone scanning

Treatment involves a stiff-soled shoe or applying a cushioning pad or J-shaped pad around the area to relieve pressure.

It may take months for the pain to subside.

http://www.apfmj-archive.com/afm5_3/afm50.htm#F1

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Plain films are commonly used to screen children for pelvic fractures or dislocations following blunt torso trauma

The sensitivity of this common screening practice is unknown

A recent study looked at this question.

Of 451 patients with pelvic fractures or dislocations, 382 had AP radiographs. Injury was correctly identified in 297 patients (sensitivity 78%).

The sensitivity was greater in the sicker subgroups :92% for those requiring operative intervention and 82% for those with hypotension

Plain AP pelvic radiographs should have a limited role in the sole evaluation of children with blunt torso trauma.

They should be incorporated in the assessment of hemodynamically unstable children and those in whom the clinician is not planning on otherwise obtaining an abdominal/pelvis CT.

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Medication-overuse headache (MOH) is one of the most common chronic headache disorders

Worldwide prevalence of 1 2%

Characterized by chronic headache and overuse of different headache medications

Withdrawal of the overused medication is the treatment of choice

A 2014 study looked at adolescent patients treated in a headache clinic with chronic post traumatic headaches (concussion headaches)

77 had chronic post-traumatic headache of 3-12 months' duration

54 of 77 (70.1%) met criteria for probable medication-overuse headache.

After the OTC medicine was stopped 68.5% had resolution or improvement !!

Excessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents.

Sometimes the advise of "just keep taking the motrin and it'll get better" isnt the answer

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Radiographs of the sacrum and coccyx in the emergency department (ED) have no quantifiable clinical impact, according to a study published in the American Journal of Roentgenology.  

Researchers from Emory University Midtown Hospital and Morehouse School of Medicine in Atlanta, GA, sought to determine the yield and clinical impact of sacrum and coccyx radiographs performed in the ED.

Sacrum and coccyx X-rays performed on 687 consecutive patients over a six-year period in level-1 and level-2 trauma centers (4 total hospitals). The patients’ mean age was 48.1, 61.6% were women. The images were categorized as positive for acute fracture or dislocation, negative, or other.

The researchers then analyzed:

• Follow-up advanced imaging in the same ED visit

• Follow-up advanced imaging within 30 days

• New analgesic prescriptions

• Clinic follow-up

• Surgical intervention within 60 days

The researchers found positive results in 58 of the 687 patients, a positivity rate of 8.4%.

None of the 58 positive cases had surgical intervention.

There was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical follow-up among the patients evaluated at the level-1 trauma centers.

However at the level-2 trauma centers, 34 (97.1%) of 35 patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals. Negative cases were at 82.9%.

Of all cases, 39 patients (5.7%) underwent advanced imaging in the same ED visit and 29 patients (4.3%) underwent imaging within 30 days.

“Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit,” the authors wrote. “There was no significant difference in 30-day advanced imaging at the level-1 trauma centers, but there was at the level-2 trauma centers.”

The researchers concluded that routine sacrum and coccyx radiography should not be part of ED practice and that patients should be treated conservatively based on clinical parameters.

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https://www.youtube.com/watch?v=sCFOObsx_W4

What is their risk of MI???

Anger outbursts are bad for your heart. Out of 300 patients with an acute MI, just over 2% reported losing their temper within 2 hours of the event. A review of nine studies of rage and cardiovascular events all found an increase in cardiovascular events in the 2 hours preceding an anger outburst. Examples included arguments at home, at work or by road rage. Compared with their usual anger levels, the relative risk of heart attack from a fit of rage was 8.5.

What about those of us who are just fanatics, I mean fans....A recent study of World Cup soccer found that the intense strain and excitement of viewing a dramatic soccer match more than doubles the risk of acute heart attack, particularly in men with known coronary heart disease. This was regardless of the outcome of the match!

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Exercise and the heart

Exercise increases the risk of sudden cardiac death (SCD) acutely.

Exercise decreases the risk of SCD in the long term.

Regular physical activity (even as little as 15 mins/day) reduces the risk of cardiovascular disease (CVD). 

Up to 15% of MIs occur during or soon after vigorous physical exercise. This is typically in sedentary men with coronary risk factors.

In a 1993 study, in the first hour after heavy exertion, risk of heart attack rose more than 100-fold from baseline for habitually inactive persons. However, for frequent exercisers, this risk rose less than three-fold. Think of snow shoveling after a winter storm.

Both the Physicians’ Health Study and the Nurses’ Health Study show that the risk of SCD during exertion is reduced by habitual exercise.

If you are physically active, stay active. If you are not active, you should be because exercise has innumerable personal benefits. However, it is important to start gradually Some individuals at higher risk need to start under the guidance of a physician.

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Orthopedic documentation

1) Document location with specificity and laterality.

2) Document the location with as much specificity as possible

-Name of specific bone and specific site on bone (Shaft, head, neck, distal, proximal, styloid)

3) Document fractures as open/closed, displaced vs. non-displaced, routine or delayed healing,

-Orientation of fractures, such as transverse, oblique, spiral

- Document intra-articular or extra-articular involvement

4) For a particular injury, a complete note will include mention of the following

The joint above (e.g. for shoulder injuries this would be the neck, for hip injuries - the back)

The joint below

Motor (e.g. for arm injuries document the distal median, radial and ulnar motor innervation)

Sensory

Vascular

Skin (for all fractures document intact overlying skin esp. when covering with a splint)

Compartments (a simple mention of compartments are grossly soft/not tense will suffice)

*Especially relevant for forearm and tib/fib injuries

Metacarpal Fractures

* Localize fracture to head, neck or shaft (neck most common)

5th metacarpal most commonly fractured

* Note amount of angulation, shortening and the presence of malrotation

*Treatment is based on which metacarpal is fractured and the location of the fracture

*The amount of acceptable angulation varies by the digit involved

For example for index and long finger - acceptable angulation of the shaft is 10-20 degrees and neck is 10 to 15 degrees

Whereas for the 5th digit - acceptable angulation for the shaft is 40 degrees and neck is 50 degrees

Pearls

No degree of malrotation is acceptable (document the absence of this!)

Strongly suspect fight bite injury with abrasions/lacerations overlying metacarpal heads

Highly prone to infection given the proximity to the joint capsule

Consider lacerations over metacarpal fractures as open fractures (do not close/discuss management with hand surgery re timing of washout. Many prefer delayed fixation for suspected infections )

Document integrity of the extensor tendon (can be lacerated and retracted)