UMEM Educational Pearls - By Michael Bond

Some quick board review pearls.  Remember these fractures/dislocations and the neurologic injury that is associated with them

• Acetabular fracture – sciatic nerve
• Anterior shoulder dislocation – axillary and musculocutaneous nerve
• Elbow dislocation – ulnar or median nerve
• Hip dislocation
  • Anterior – femoral nerve
  • Posterior – sciatic nerve
• Humerus – radial nerve
• Knee Dislocation – peroneal or tibial nerve
• Olecranon fracture – ulnar nerve
• Supracondylar fracture – median, radial or ulnar nerve
• Tibia plateau fracture – peroneal nerve

Morton's Neuroma

1. A benign perineural fibroma of an intermetatarsal plantar nerve.
2. Most commonly affects the third and fourth intermetatarsal space
3. Patient's will often complain of pain and/or numbness in the ball of their foot and toes when the metatarsal heads are compressed together as in when wearing shoes. Pain is often described as burning or shooting.  Some patients report that it feels like they are standing on a pebble.
4. On physical exam you can reproduce the pain by squeezing the metatarsal heads together. (Mulder's sign)
5. Diagnosis can be confirmed with MRI though clearly this does not need to be done in the ED.
6. Treatment includes NSAIDs and referral for orthotics, corticosteroid injection, or surgical removal.

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Flexor Tenosynovitis

• This is a rapidly spreading infection of the finger and hand.
• Often starts as an infection in the finger that then spreads into the hand due to the flexor sheaths.
• The flexor tendon sheaths of the long, index, and ring finger extend from the distal phalanx to the superficial palmar arch, and some even extend to the wrist.
• Most patient will need to be admitted for IV antibiotics and a hand consult for probable operative I&D
• You can diagnosis flexor tenosynovitis by documenting the four Kanavel signs:
  1. Fusiform swelling of the finger
  2. Finger held in partial flexion (position of comfort)
  3. Percussion tenderness along the flexor tendon
  4. Increased pain with passive extension of the finger

You can follow this link, http://www.youtube.com/watch?v=qf9SW0ChsCU  , to see the physical exam findings of flexor tenosynovitis

START Triage

START triage is a simple system to implement that does not require any special equipment in order to determine who needs immediate, delayed or non-urgent care during a mass causality.

START stands for Simple Triage And Rapid Treatment. Patients are triaged based on 4 factors:

• Ability to walk away from the scene
• Respiration > or < 30 respirations per minute
• Pulse (radial pulse present or not) or Capillary refill > or < 2 seconds
• Mental Status – ability to follow simple commands or not

The steps are:

1. If a patient can leave the scene they are minor and do not need immediate help. Category GREEN
2. If there are no respirations or respirations > 30 they require immediate care Category RED
3. Otherwise check pulse. If pulse is absent or capillary refill > 2 seconds they require immediate care Category RED
4. Otherwise check mental status.  If they are not able to follow commands they need immediate care.  Category RED
5. If they can follow commands they are delayed treatment. Category YELLOW

So those that can leave are green, those that do not meet any of the START criteria are YELLOW, and those with any of the four factors are RED or DEAD.

Low Back is one of the most common complaints that we see in the Emergency Department.  Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…).  However, most of the back pain that we will see is musculoskeletal in origin.

The American College of Physicians (ACP) and the American Pain Society (APS)  released  joint recommendations on the evaluation of treatment of individuals with back pain in 2007.

In summary their key recommendations were:

1. Routine imaging is not required. However, diagnostic imaging and testing should be obtained for patients with low back pain when severe or progressive  neurologic deficits are present or when serious underlying conditions are suspected.
2.  For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
3. Medications that have good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain).

Links to the Clinical Guidelines are listed below:

• Evaluation and Treatment
• Nonpharmacologic Therapies for Acute and Chronic Low Back Pain
• Medications for Acute and Chronic Low Back Pain

Sinus Tarsi Syndrome

• A painful syndrome of the ankle normally due to an inversion injury.  Results in pain along the lateral side of the ankle.
• Often misdiagnosed as an ankle sprain.
• Will have pain localized to the sinus tarsi (inferior and anterior to the anterior border of the lateral malleolus.
• Can be diagnosed by injecting lidocaine into the sinus tarsi, which should completely relieve the pain.
• Treatment consists of
  • NSAIDs
  • Ankle immobilization
  • Physical therapy
  • Oral or injected steroids in resistant cases

Posterolateral Corner Injuries

The posterolateral corner “PLC” of the knee is becoming increasingly recognized as an extremely important structure to maintain the stability of the knee joint.

PLC injuries occur with hyperextension, varus load and tibial external rotation.  So the most common mechanism is a posterolaterally directed blow to the anteromedial tibia when the knee is hyperextended. PLC injuries are commonly associated with injury to other ligaments (ACL, PCL, LCL) and occur in isolation in <5% of cases.  If suspected make sure to check for other ligamentous injuries.

Since this injury can be missed and is associated with significant disability it is important to test for it.  This YouTube video, http://youtu.be/bnXaTdvZZ6o, demonstrates several examination techniques that can identify the injury. 

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Sugar Tong Splint

The sugar tong splint is ideal for splinting fractures of the radius, ulna, or wrist.  It prevents flexion and extension at the wrist, limits flexion and extension at the elbow, and prevents supination and pronation.  A posterior long arm splint does not prevent supinaton and pronation, therefore, it is of limited use for radius and ulna fractures.

The traditional sugar tong can be difficult to put on a patient without an assistant as it is often hard to hold the splint in position as you begin to ace wrap it. A variation on the sugar tong, the reverse sugar tong, prevents this frustration.  The splinting material is cut so that a small piece suspends the splint from the web space between the thumb and index finger.  The open ends at the elbow are also easily folded under each other, preventing any bulky splint material from extending out.

The reverse sugar tong is on the left, the original sugar tong on the right.

Check out this video showing how to place a reverse sugar tong splint.

http://www.youtube.com/watch?v=r-RHdttOMf0

Wound Repair

A pearl last year addressed the irrigation of wound and the fact that the type of fluid (sterile versus tap water) does not affect infection rates but rather the volume of irrigation is most important.

Sterile versus unsterile gloves have also been studied, and it turns out that clean unsterile gloves have the same rate of infection as sterile gloves but come with a substantial cost savings.

When caring for a contaminated wound it is most important to remove any gross contamination, and then irrigate the wound as much as possible.  A 20 mL syringe with an 18G angio-catheter provides the proper pressure to remove debris without causing tissue damage. The wound can then be closed wearing the gloves that are most comfortable or accessible to you.

Finally, from a medicolegal standpoint it is always best to inform the patient that you have tried to remove all of the contamination but there is still a chance that the wound can get infected. 

C. Diff Colitis

The general treatment recommendations for C. Diff Colitis are to place the patient on PO metronidazole and if they fail this treatment PO vancomycin (125 mg 4x day).  Vancomycin is generally reserved for resistant cases due to the fear that it could induce Vancomycin resistant enterococcus.

For severally ill patients it is recommended that you prescribe IV metronidazole and PO vancomycin when they are not actively vomiting.  Remember there is no role for IV vancomycin as it does not get into the bowel lumen to eradicate the infection.

There is some great news though, the FDA recently approved a new drug, a macrolide antibiotic fidaxomicin (Dificid), for the treatment of C. Diff Colitis. Fidaxomicin was found to be as effective as vancomycin in preventing recurrence 3 weeks after treatment.  Currently it is recommended that fidaxomicin be reserved for cases where patients are having recurrences after 3 weeks of vancomycin treatment.

The FDA news release can be found at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm257024.htm
 

Kocher Criteria for Septic Arthritis in Children:

Septic arthritis should be suspected in children that have a painful joint especially if they do not want to weight bear.  Orthopedics uses the Kocher Criteria to determine the probability of whether the joint is infected. 

Four elements make up the criteria:

• Erythrocyte Sedimentation Rate >40
• WBC > 12
• Non weight-bearing on the affected joint
• Fever.

If only one sign is present there is a 3% chance the child has a septic joint.

• 2/4 criteria = 40%
• 3/4 criteria = 93%
• 4/4 criteria = 99%

Iliopsoas tendonitis and Iliopsoas Syndrome

• Iliopsoas tendonitis is inflammation of the iliopsoas muscle which can also affect the bursa lying under the iliopsoas muscle tendon.  
• Iliopsoas syndrome is a stretch, tear or complete rupture of the iliopsoas muscle and/or iliopsoas tendon.
• The iliopsoas muscle and tendon are commonly injured from acute trauma and/or overuse resulting from repetitive hip flexion.
• The pain may radiate down the anterior thigh to the knee.
• One variant is the internal snapping hip syndrome which results in an audible snap or click in the hip or groin with hip flexion.
• Treatment consists of rest, stretching exercises, physical therapy and NSAIDs.

Tendon Lacerations:

• Flexor tendon lacerations have historically not been repaired by emergency providers due to the extensive pulley systems involved and possibility of loss of mobility from scarring.
  • However, if both ends of the tendon can be visualized in the ED it is not unreasonable to place 1 or 2 horizontal mattress sutures between the two ends to prevent retraction of the proximal portion which can make a formal repair more difficult.
• Extensor tendon lacerations can be repaired by emergency providers.
  • One technique is to use a running horizontal mattress suture with non-absorbable nylon sutures. 
  • The ultimate strength of the repair is dependent on the number and size of the sutures placed.
  • Careful placement of the sutures can prevent gap formation between the ends when the tendon is stressed.

A reasonable approach to all tendon lacerations is to close the wound and splint in the hand in the position of function until the patient can be seen by a hand surgeon in the next 1-3 days.  These injuries do not require immediate surgical repair.

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Tendon Lacerations:

Hand lacerations need to be carefully explored in order to determine whether there is an associated tendon laceration.  These can be be difficult to find unless a systematic approach is followed:

• The laceration should be explored to its base in a bloodless field while the fingers and wrist are moved through their full range of motion (ROM).  A tendon laceration can easily be missed if the hand is only visualized with the fingers extended. The area of the tendon that was lacerated can retract into the hand, or not be visible if the area was injured when the fingers were flexed. By extending the finger, the location of the injury may not line up with the wound making it impossible to see unless the fingers are moved through their full ROM.
• The fingers and wrist ROM should be tested actively and against resistance as the patient may only experience an increase in pain and have a completely normal ROM if there is only a partial tendon laceration.
• If there is a suspicion of a tendon laceration (decreased ROM, or increased pain with resistance when ROM is tested) the laceration may need to be extended in order to completely visualize the tendon if it can not be done through the wound that was created with the original injury.

Future pearls will cover techniques on how to repair tendon lacerations.  Stay tuned.

Knee dislocations are uncommon, and prosthetic knee dislocations even rarer.  Some general facts about prosthetic knee dislocations are:

• Posterior dislocations typically occur in the post-operative period and are usually the result of trauma that disrupts the PCL ligament.
• Factors that predispose a person to posterior dislocations are valgus deformity of the knee, malposition or improper selection of prosthetic components, patellar instability, and extensor mechanism dysfunction.
• The mechanism for this dislocation is typically flexion and external rotation of the knee when the lateral side of the knee is too loose.
• Anterior dislocations more commonly occur months to years after surgery and usually are not associated with trauma.
• Many of these dislocations result from loss of integrity of the posterior cruciate ligament, which provides anteroposterior stability of the knee and assists in femoral rollback. This motion is essential for the extensor mechanism of the knee to function.
   

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Talar Neck Fractures

Have a high rate of avascular necrosis (AVN), nonunion, and arthritis.  Almost all require ORIF

• Hawkins 1:
  • 0- 13% AVN rate
  • non-displaced fracture
• Hawkins 2:
  • 20- 50% AVN rate
  • Displaced fracture with subluxation or dislocation of the posterior facet of the subtler joint. Subtalar joint usually dislocated posteriory
• Hawkins 3:
  • 20-100% AVN rate
  • Displaced fracture of the talar neck with dislocation of the body of the talus from both the subtalar joint and the ankle joint

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Distal Radius Fractures

Typically distal radius fractures are treated with closed reduction and splinting in the ED, followed by operative repair. This is done because it is felt that patients will have the best functional outcomes if the bones are restored to their normal anatomic alignment.  However, two studies published in 2010 suggest differently.

The study by Neidenbach showed that after one year there was no difference in functional outcomes between patients that were just splinted in the ED in the position the fracture was found versus those that had closed reduction with splinting. 

The second study by Ego showed that there was no difference in outcomes between those that underwent conservative treatment with closed reduction and splinting versus those that underwent operative repair.

The take home point from these studies for the EM physician is that most distal radius fractures can be splinted in the position found with them following up with an orthopaedist.  There is probably little advantage to performing a closed reduction in the ED knowing that this procedure can use a lot of valuable time and resources.

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FARES Method for Reduction of Anterior Shoulder Dislocations.

This method that was recently highlighted in a publication had a ~78% success rate with the authors able to reduce the shoulder in an average of 2.36 ±1.24 minutes  without having to give the patients any analgesics or sedatives. The technique is done by:

• Placing the patient in the supine position.
• Hold the hand of the affected arm while the arm is at the patient’s side with the elbow extended and the forearm in neutral position.  
• Apply gentle longitudinal traction and slowly move the arm into abduction while oscillating the forearm with continuous, brief (two to three full cycles per second) and short range (approximately 5 cm above and beneath the horizontal plane) vertical  movements of the arm.  These oscillations should be done during all   all stages of the reduction as it helps that patient relax their muscles.
• Once the arm is abducted past 90º, gently externally rotate the arm while continuing to abduct it.  Continue the oscillations.
• Reduction is usually achieved at ~ 120º of abduction.  
• Once reduction is achieved, move the arm gently until it is internally rotated and resting on the patients chest.

Consider trying this with your next shoulder dislocation.  No single method of reduciton is 100% successful, but methods like this that only require a single provider and do not require analgesics are extremely helpful in improving patient flow as they do not utilize a lot of ED resources..

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Peroneal Tendon Subluxation: The Other Ankle Sprain

• Peroneal tendon subluxation is an uncommon cause of lateral ankle pain that is often misdiagnosed as a simple ankle sprain.
• It is commonly associated with sports that require cutting such as skiing, basketball, soccer, and football.
• The subluxation occurs when there is a forceful contraction of the peroneal tendon while the foot is dorsiflexed and inverted.
• Patients will often complain of pain at the posterolateral ankle that started as a forceful pop.  They may also complain of snapping or popping around the lateral malleolus as it continues to sublux.
• On clinical exam, the patient will often have pain along the  retrofibular groove. The peroneal tendon can be tested by actively dorsiflexing and everting the ankle from a plantar-flexed and inverted position.  You should be able to see or feel the subluxation. Passive circumduction of the ankle may also recreate the subluxation.
• Conservative management (i.e.: ankle brace, cast or walking boot) is associated with a low success rate; therefore, these patients should be referred to sports medicine or orthopaedics for possible operative repair.

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Septic Arthritis

It is generally taught that if the synovial fluid white blood count (WBC) is less than 50,000 it is not septic, however, there is growing evidence that a clear delineation in the WBC between septic arthritis and inflammatory arthritis is not possible.  In fact, inflammatory arthritis (rheumatoid and gout) actually increases your risk for septic arthritis and the two can coexist.  Gram stains of the fluid  only show organisms in 50% of those with septic arthritis so you also can not rely on them either.  Inflammatory markers (CRP, ESR) can be elevated with inflammatory or septic arthritis so they too can not differentiate between the two.

In the end, because of the risk of permanent joint dysfunction, it is important to make the diagnosis on clinical grounds and treat empirically if you are unsure.  Err on the sound of treatment.  Serial joint aspirations to drain synovial fluid have the same outcomes as operative washout.

A recent article that discusses the concerns with making the diagnosis of septic arthritis is:

Mathews et al. Bacterial septic arthritis in adults. Lancet (2010) vol. 375 (9717) pp. 846-55

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