Medial elbow pain is common among baseball pitchers and is also seen in other sports including football, javelin and gymnasts.

More than 97% of elbow pain in pitchers is located medially.

The ulnar collateral ligament of the elbow is an important structure in these patients.

http://www.aafp.org/afp/2014/0415/afp20140415p649-f3.jpg

While initially primarily seen in professional throwers, these injuries are now being seen in younger athletes.

Initially, patients may only note changes in stamina or strength of throws.

Later, they will note pain during the acceleration and follow through-phase of throwing

http://stlhealthandwellness.com/wp-content/uploads/2013/02/elbow03.jpg

The Valgus stress test for UCL deficiency is similar to the valgus test for the knee

https://www.youtube.com/watch?v=f6YvPSVk6G8

Treatment: splinting, ice, NSAIDs

Surgical indications: Failure of non-operative treatment with desire to return to same or higher level competition.

Hook of Hamate Fracture

Rare (2% of all carpal fractures)

Mechanism usually direct blow from a stick sport (golf, hockey, baseball)

Presents with hypothenar pain and pain with gripping activities

Physical examination - local swelling and tenderness to palpation over hook of hamate

Diagnostic test - Hook of hamate pull test

https://www.youtube.com/watch?v=A-mjRnC1yWQ

XR - standard wrist series but add carpal tunnel view

http://openi.nlm.nih.gov/imgs/512/60/2904904/2904904_256_2009_842_Fig1_HTML.png

http://www.cmcedmasters.com/uploads/1/0/1/6/10162094/7851913.png?359

Happy Halloween!! 

I hope you have had a safe and fun Halloween. Thank you to all the people that are staffing the EDs on a Saturday Night Halloween.

Prostate-Selective Alpha Antagonists have been tied to Falls and increased risk of fractues in elderly men.  These medications can lead to syncope and hypotension putting patients at increased risk of falls. A recent canadian study showed that at 90 days of use; individuals on alpha antagonists were at increased risk of hospital visits for falls (1.45% vs. 1.28%) or fractures (0.48% vs. 0.41%). There was also an increased risk of  head trauma.

Please warn patients that are on these medications of the risks, so that injuries can be minimized. They should take specific care when changing postural positions, and report episodes of lightheadedness to their PCPs.

The article can be found at http://www.bmj.com/content/351/bmj.h5398

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A traditional ED practice has been to combine promethazine as an anxiolytic adjunct to morphine for patients with musculoskeletal pain (eg back pain).

However, when compared to morphine alone, this combination does not lead to greater analgesia or decrease anxiety. It does however prolong ED length of stay.

This use of this "pain cocktail" is not recommended

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Most common mass in popliteal fossa

Incidence 10 to 58%

Intra-articular pathology results in flow of synovial fluid from the joint into the bursa, forming a cyst

Association with concomitant intra-articular disorders 94%

Possible pathology - Meniscus, ligamentous, arthritis, other osteochondral defects

In children this is not a pathologic finding

Symptoms - Posterior knee bulging, posterior tightness/stiffness esp. with knee flexion

Ultrasound - 100% sensitive/specific

DDx: DVT

Tx: Refer for ultrasound guided aspiration, fenestration and steroid injection

http://www.caringmedical.com/wp-content/uploads/2013/11/Bakers-Cyst-treatment.jpg

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Shoulder Dislocation Reduction

Do you have a chronic dislocated that frequents your ED? Are you interested in teaching them a way to relocate their shoulder without looking like Mel Gibson from Lethal Weapon, https://youtu.be/Igrdi_lhhW4, then the newly described GONAIS method might be what you are looking for.

This technique has the patient grab the top of a chair with the hand on the affected side, and then slowly equating, effectively bringing the hand and arm above their head. Once in the full squat position the patient can step backwards which should reduce the shoulder. If not they can use the opposite hand to apply pressure to push the humerus backward and reduce the location.

The full article can be found at http://bit.ly/1iZ8a9z

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Policeman's Heel:

When patient's present complaining of heel pain we often think immediately of plantar fascititis,and heel spurs. If they jumped and landed on the heel with are concerned for calcaneal fracture.  However, a policeman's heel can occur from repetitive bounding of the heel or from landing on it as in a fall or jump.

Policeman's heel has been descirbed as a plantar calcaneal bursitis, inflammation of the sack of fluid (bursa) under the heel bone, or a contusion of the heel bone due to flattening and displacement of the heel fat pad, which leaves a thinner protective layer allowing the bone to get bruised.

Regardless of cause this responds well to NSAIDs, limiting weight bearing, or taping the foot. If the repetitive activity is not reduced this can easily become a chronic cause of heel pain.  A short video showing how to tape the foot can be found at https://youtu.be/nQtkwfJrhXo

Sodium Supplementation and Exercise-Associated Hyponatremia (EAH) during Prolonged Exercise (ultramarathon running)

Weight loss of around 4% body weight (relative to pre race weight) can be anticipated to maintain euhydration in such a prolonged event

Those who become symptomatic with EAH have either gained weight or lost less that 3-4% body weight

Overhydration rather than inadequate supplemental sodium intake is a greater contributor to the development of EAH

There is a suggested link between EAH and rhabdomyolysis. The mechanism remains unknown and it is unclear which condition may augment the other. Further research is needed.

Take home: Avoid overhydration during prolonged exercise to prevent EAH.

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Handcuff Neuropathy

Compression of the superficial radial nerve against the radius.

Tends to occur with prisoners (too tight cuffs or person struggling)

Usually purely sensory lesion

Nerve regeneration can take 8 weeks (about an inch a month)

Document sensory exam to sharps or 2 point sensation.

DDx: De Quervain's, Carpal tunnel, Gamekeeper's thumb,

No need to splint

Triquetral fractures are the 2nd most common carpal fractures (scaphoid).

Dorsal surface most commonly.

Usually occur from impingement from the ulnar styloid, shear injury or from ligamentous avulsion.

XR: best seen on the lateral projection

http://images.radiopaedia.org/images/902179/42b3487baf4fb66183c51cd982477d_big_gallery.jpg

Remember this injury/radiographic appearance the next time you see an avulsion fracture dorsal to the proximal row of carpal bones on the lateral film but are unsure of the donor site.

Compartment Syndrome

Compartment syndrome is a diagnosis that needs to be made quickly in order to prevent long term muscle, nerve, and vascular compromise.

Two pieces of information are needed to determine if the patient has compartment syndrome.

1. The patient's diastolic blood pressure (DBP) value
2. The pressure value obtained from the compartment of concern (Compartment pressure)

Diastolic Pressure - Compartment pressure < 30 makes the diagnosis of compartment syndrome

So if a diastolic blood pressure is 80 and the compartment pressure is 40 the difference is 40 mmHg and the patient likely does not need a fasciotomy.  The diagnosis can only be 100% onfirmed by a trip to the OR so these values should still be discussed with your local orthopaedist.  When calling them just make sure you know both the DBP and the compartment pressure so that it can be interpreted correctly.

A sports hernia is a painful musculotendinous injury to the medial inguinal floor.

It is the result of repetitive eccentric overload to the abdominal wall stabilizers of the pelvis.

It is common in sports that require sudden changes of direction or intense twisting movements.

Despite the term "hernia" in the title, it is not a true hernia as there is no "herniation" of abdominal contents

http://www.ssorkc.com/wp-content/uploads/2014/09/publagia.gif

Figure description: The upward and oblique pull of the abdominal muscles on the pubis fights against the downward and lateral pull of the adductors on the inferior pubis. This imbalance of forces can lead to injury.

PE: Evaluation of other GU/GYN/other intra-abdominal pathology comes first.

Clinician may note tenderness of the pubic ramus and medial inguinal floor.

Pain is more severe with resisted hip adduction and with resisted sit-up.

Combining these maneuvers (resisted situp while adducting hips) recreates the pathophysiology described above and is a good exam maneuver.

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Colles fracture

Almost 90% of distal radius fractures

Mechanism: Fall on the outstretched, hyperextended, radially deviated wrist with the forearm in pronation

Often seen in older patients and in those with osteoporosis

Distal radius fracture with dorsal angulation/displacement and/or radial shortening. "Dinner fork deformity"

https://en.wikipedia.org/wiki/Colles'_fracture#/media/File:Colles_fracture.JPG

Smith fracture (aka reverse Colles fracture)

Mechanism: Fall on the outstretched, flexed, radially deviated wrist with the forearm in pronation

Usually younger patients with high energy mechanism

Distal radius fracture with volar angulation or volar displacement. "Garden spade" deformity

Often unstable requiring ORIF

http://www.radiologyassistant.nl/data/bin/w440/a50979780ec887_Smith'-tek.jpg

Radial styloid fracture aka Chauffeur fracture

Fall causing compression of scaphoid against the styloid with wrist in dorsiflexion and ulnar deviation

Often associated with intercarpal ligamentous injuries (i.e., scapholunate dissociation, perilunate dislocation)

Often requires ORIF

http://images.radiopaedia.org/images/611818/cc52cce7bcfd8c905bcc7b5d2b6a65.jpg

Steroid Use in the treatment of Acute Sciatica

Have you used oral steroids in the treatment of your patient with acute sciatica thought to be secondary to a herniated disk.

Well a recent randomizaed, double-blind, placebo-controlled trial from 2008 to 2013 in a large integrated health care system in Northern California enrolled 269 patients to look at whether steroids improved pain or function. The intervention arm (twice as large as placebo arm) received a tapering 15-day course of oral prednisone (5 days each of 60 mg, 40 mg, and 20 mg; total cumulative dose = 600 mg; n = 181).

In the end there were no differences in surgery rates at 52-week follow-up, and the steroid arm had a modest improvement in function but no improvement in pain. There were also more adverse events at 3-week follow-up in the prednisone group than in the placebo group.

Conclusion: Giving steroids for acute sciatica does not appear to improve the patients pain, only has a modest improvement in function, and was associated with more adverse events. Put another way there was minimal benefit and more harm.

You can check out the full article at http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.4468

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Posterolateral Corner Injury

Hx: hyperextension injury (contact and non contact), varus directed blow to flexed knee, direct blow to anteriomedial knee. Report instability symptoms when knee is in full extension.

PE: Varus stress testing

Varus laxity at 0 indicate LCL and cruciate ligament (ACL/PCL) injury

Varus laxity at 30 indicates LCL injury

Dial test - inspects the external rotation at the knee joint/performed in both 30 and 90 knee flexion. The dial test inspects the external rotation at the knee joint

https://www.youtube.com/watch?v=pW4yv0zg4RY

Positive at 30 = > 10 external rotation asymmetry = isolated PCL injury

Positive at 30 & 90 = Posterior lateral corner injury and PCL injury

Sx: pain to lateral arm, worse with overhead activity and sleeping/lying on arm

Anatomy: Pain generating structures include the rotator cuff, subacromial bursa, labrum and biceps tendon.

http://www.ortho-md.com/images/proceduresImg/SHOULDER2.jpg

Testing: Neer and Hawking tests

https://www.youtube.com/watch?v=U8-yLHQ_JaM

https://www.youtube.com/watch?v=OYK5qL2om-c

Done indepedently, Hawkings is more sensitive, however best to combine both tests.

Imaging: not indicated

Tx: rest, ice, physical therapy (modalities), subacromial steroid injection

Tensor Fascia Latae (Iliotibial Band) Pain Syndrome:

Some patients will complain of hip and back pain and can have multiple visits before somebody considers Tensor Fascia Latae Pain Syndrome AKA Iliotibial Band Syndrome.

The tensor fascia latae helps with thigh flexion at the hip, abduction, and medial rotation; and stabilizes the knee laterally

When this muscle/fascia gets tight and overcontracted it will lead to dysfunction of the gluteus and rectus femoralis muscles leading to increased hip pain due to abnormal movement of the joint.

Patients often complain of increased pain with running, especially downhill and exam is notable for local tenderness (approx. 2cm above lateral joint line) & occasional swelling over the distal lateral thigh.

Most patients respond to conservative treatment involving NSAIDs, stretching of the iliotibial band, physical therapy, strengthening of the gluteus medius, and altering their running regimens.

Posterior Shoulder Dislocations are uncommon (strong supporting structures vs. anterior)

But commonly missed by physicians

Mechanism: Direct blow anterior shoulder/FOOSH with shoulder internally rotated and ADDucted)

May also see with seizure/electric shock (tetanic contraction)

Clinical findings subtle

Shoulder held in ADDuction and internal rotation. Patient unable to externally rotate arm from this position. If habitus allows, anterior shoulder depression/posterior fullness.

Radiology: Decreased overlap between humeral head and glenoid fossa. Proximal humerus fixed in internal rotation looks like a light bulb on a stick.

Y view will show subtle posterior displacement of humeral head (not as dramatic as is in anterior dislocations!)

http://cdn.lifeinthefastlane.com/wp-content/uploads/2009/06/posterior_shoulder_dislocation_005.jpg

http://eorif.com/Shoulderarm/Images/Shoulder-dislocationP1.jpg

In cases of suspected spinal infection, the sensitivity of an elevated WBC count (35-61%), ESR (76-95%) and CRP (82-98%) may help guide further evaluation or consideration of other entities.

Incorporation of ESR/CRP into an ED decision guideline may help differentiate those patients in whom MRI may be performed on a nonemergent basis.

An elevated ESR (>20 mm/hour) also has a role in the diagnostic evaluation of occult malignancy (sensitivity 78%, specificity 67%).

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Is acetaminophen good for pain control in patients with Osteoarthritic of the Knee or Hip or Low Back Pain?  Most of my patients request narcotics, but conventional teaching is that we should try to start with Acetaminophen or NSAIDs.

This recent study, http://www.bmj.com/content/350/bmj.h1225, published in the BMJ analyzed 13 studies looking at over 5400 patients.  In the end, they found that acetaminophen did not appear to improve pain, disability or the patient’s quality of life in patients with back pain. Also, there was a small improvement in pain and disability in those with hip and knee pain, but it was not deemed clinically significant.

Even worse, patients taking acetaminophen had a 4x greater chance of having abnormal liver function tests.

This meta-analysis really questions whether Acetaminophen should be first line therapy in patients with osteoarthritis of the knees or hips, or in those with low back pain.  For now I will stick with a course of a NSAID.  Especially with the risk of unintentional overdose if they are taking other over the counter medicaitons that might also contain acetaminophen.

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