Category: Orthopedics
Keywords: knee dislocation, vascular and nerve injury (PubMed Search)
Posted: 11/22/2014 by Brian Corwell, MD
(Updated: 12/26/2014)
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Knee dislocation 2
Most commonly occur after MVCs but also seen after falls, industrial accidents and sports related trauma.
Up to 50% of knee dislocations will have spontaneously reduced by time of presentation to the ED.
Strongly consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability (3 or more ligaments torn).
A thorough neurovascular examination is a must due to the risk of vascular (34%)(5-79%) and nerve (23%)(16-40%) injuries. There is a must higher incidence of these injuries in high force trauma such as from a MVC. The popliteal artery and common peroneal nerve are at the greatest risk
Though the absence of distal pulses suggests vascular injury, the presence of pulses cannot be used as evidence of the lack of a vascular injury.
After reduction, the knee should be immobilized in 15-20° of flexion in a knee immobilizer.
Category: Orthopedics
Keywords: felon, management (PubMed Search)
Posted: 11/15/2014 by Michael Bond, MD
(Updated: 8/14/2024)
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Management of Felons
For good photos of the incision technique please visit the reference article listed.
Category: Orthopedics
Keywords: trauma, knee, dislocation (PubMed Search)
Posted: 11/8/2014 by Brian Corwell, MD
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Beware of spontaneous reduction masking the true injury!
Knee dislocations are rare due to supporting ligaments (MVCs, falls, sports)
but can be seen after minor trauma in obese patients.
Named by the direction of the displacement of the tibia relative to the femur
- Anterior and posterior are most common
Dislocations involve disruption of at least 2 of the major knee ligaments (ACL/PCL most common)
Usually associated with large hemarthrosis however capsular tearing may allow dissipation of the blood into adjacent soft tissue.
Consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability,
Category: Orthopedics
Keywords: Osteoporosis, elderly, (PubMed Search)
Posted: 10/25/2014 by Brian Corwell, MD
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Iliocostal syndrome aka iliocostal friction syndrome
Consider this entity in an elderly patient with osteoporosis with unexplained abdomen/flank or back pain.
Osteoporosis and/or vertebral compression fractures can result in a narrowing of the distance between .
the lowest anterior rib and the top of the iliac crest producing pain where this rib contacts the pelvis.
This can be perceived as side or back pain. This pain can restrict walking leading to a possible misdiagnosis of spinal stenosis. Treatment is with physical therapy and therapeutic injection.
http://www.caringmedical.com/wp-content/uploads/2013/09/iliocostalis.syndrome.jpg
Category: Orthopedics
Keywords: Segond, Reverse, Fracture (PubMed Search)
Posted: 10/19/2014 by Michael Bond, MD
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The Reverse Segond Fracture
Most people have heard of a segond fracture (avulsion fracture of the lateral tibeal platuea) seen on knee xrays which is a marker for Anterior Cruciate Ligament and medial meniscus injuries. See Pearl https://umem.org/educational_pearls/1015/
However, there is also a Reverse Segond Fracture that is another benign appearing avulsion fracture of the medial tibeal plateau that is marker for significant injury to the Posterior Cruciate Ligament (PCL).
If a Segond or Reverse Segond Fracture is seen consider immobilzing the patients knee until they can follow up with Orthopedics and/or get an MRI to determine if additional injuries are present.
Category: Orthopedics
Keywords: Sciatica, radiculopathy, imaging (PubMed Search)
Posted: 9/19/2014 by Brian Corwell, MD
(Emailed: 9/27/2014)
(Updated: 9/27/2014)
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Back pain with radiculopathy can be very distressing to a patient and they have heard from their medically savvy neighbor that a MRI is the way to go. Now, armed with this knowledge, they are in your ED with earplugs in hand...
A few minutes of reassurance and education can save in both cost and ED throughput.
In one study researchers performed MRIs on asymtomatic adult patients.
Almost two-thirds (64%) had abnormal discs
Just over half (52%) had bulging discs
Almost a third (31%) had disc protrusions
Further, finding a bulging disc already suggested by your history and physical examination does not change management. The majority of these patients improve with conservative treatment within four to to six weeks.
Restrict ED MRI use for the evaluation of suspected cauda equina, epidural abscess and spinal cord compression.
Category: Orthopedics
Keywords: Tendon, Laceration, Repair (PubMed Search)
Posted: 9/19/2014 by Michael Bond, MD
(Emailed: 9/20/2014)
(Updated: 9/20/2014)
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Tendon Lacerations:
A reasonable approach to all tendon lacerations is to loosly reapproximate the wound and splint 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, and with the high rate of complications it is probably best to discuss with your hand surgeon before attempting a repair.
Wheeless Textbook of Orthopaedics. http://www.wheelessonline.com/ortho/extensor_tendon_lacerations
Category: Orthopedics
Keywords: back pain, x-ray (PubMed Search)
Posted: 9/13/2014 by Brian Corwell, MD
(Updated: 8/14/2024)
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Back pain accounts for more than 2.6 million visits
30% of ED patients receive X-rays as part of their evaluation
Imaging can be avoided in a majority of these patients by focusing on high risk (red flags) findings in the history and physical exam.
Patients who can identify a an acute inciting event without direct trauma likely have a MSK source of pain.
Imaging rarely alters management
Attempt to avoid imaging in patients with nonspecific lower back pain of less than 6 weeks duration, with a normal neurologic exam and without high risk findings (fever, cancer, IVDA, bowel or bladder incontinence, age greater than 70, saddle anesthesia, etc)
Patients with radiculopathy (sciatica) and are otherwise similar to the above also do not require emergent imaging
Category: Orthopedics
Keywords: radiology, ankle, fracture (PubMed Search)
Posted: 8/30/2014 by Michael Bond, MD
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Some radiology pearls concerning ankle pain and fractures courtesy of David Bostick and Michael Abraham
Maisonneuve fracture – fracture of the medial malleolus with disruption of the tibiofibular syndesmosis with associated fracture of the proximal fibular shaft (http://radiopaedia.org/articles/maisonneuve-fracture)
When to look for high fibular fracture
Always look for avulsion fracture of 5th metatarsal styloid in patients with ankle pain and
no obvious fractures
Dans-Weber Classification – for lateral malleolar fractures (http://radiopaedia.org/articles/ankle-fracture-classification-weber)
Category: Orthopedics
Keywords: Jumpers knee, knee pain (PubMed Search)
Posted: 8/24/2014 by Brian Corwell, MD
(Updated: 8/14/2024)
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Patellar tendonitis aka jumpers knee
Activity related knee pain due to degenerative, micro injury rather than an inflammatory process
Up to 20% in jumping athletes
Anterior knee pain during or after activity
Bassett Sign:
a) Tenderness to palpation with knee in full extension (patellar tendon relaxed)
b) No tenderness with knee in flexion (patellar tendon tight)
Category: Orthopedics
Keywords: Back Pain, Prednisone (PubMed Search)
Posted: 8/17/2014 by Michael Bond, MD
(Updated: 8/14/2024)
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Is there any benefit to the use of prednisone in the treatment of lower back pain? One study showed that about 5% of patients receive prednisone for the treatment of their low back pain, but does it work.
A recent study by Eskin et al published in the Journal of Emergency Medicine looked at this question. They conducted a randomized controlled trial of 18-55 year olds with moderately severe low back. Patients were randomized to receive prednisone 50mg for 5 days or placebo.
The study enrolled a total of 79 patients, and 12 were lost to follow up. At followup there was no difference in their pain, or in them resuming normal activities, returning to work, or days lost from work. To make matters worse more patients in the prednisone group sought additional medical treatment 40% versus 18%.
Conclusion: With the results of this study we should continue the treatment of low back pain with non-steroidials, muscle relaxants and exercise. There does not appear to be any role for steroids in the treatment of these patients.
Eskin B, Shih RD, Fiesseler FW, et al. Prednisone for emergency department low back pain: a randomized controlled trial. Journal of Emergency Medicine. 2014;47(1):65–70. doi:10.1016/j.jemermed.2014.02.010.
Category: Orthopedics
Keywords: mono, spleen (PubMed Search)
Posted: 8/9/2014 by Brian Corwell, MD
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Return to Play After Infectious Mononucleosis (IM)
-Long incubation period make it difficult to determine source or onset
Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.
DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)
Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)
Symptoms then progress into the classic “triad” of IM
Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)
May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)
Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)
Most commonly seen in patients treated with PCN antibiotics
Splenomegaly is an important complication in the athletic population
Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)
- Lymphocytic proliferation enlarges the spleen beyond protection from the ribs
- Physical examination has been shown to be unreliable for determining splenomegaly
- Highest risk is in the first 21 days (rare after 28 days)
Ultrasound is the modality of choice
-Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks
Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.
Category: Orthopedics
Keywords: Spinal Cord injury (PubMed Search)
Posted: 7/13/2014 by Brian Corwell, MD
(Emailed: 7/26/2014)
(Updated: 7/23/2014)
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Cervical Cord Neuropraxia (CCN)
A concussion of the spinal cord as a result of an on-field collision.
A transient motor and/or sensory disturbance, lasting less than 24 hours.
A distinct and separate entity from spinal cord injury resulting in quadriplegia
Incidence 7.3 per 10,000 athletes
Approx. 50% of players experiencing CCN who return to play, have a second episode
The risk of this second episode is inversely proportional to the size of the cervical bony canal
Athletes with narrow canal diameter are more likely to have a 2nd episode
Those with normal canal diameter (14 mm on MRI) have a 5% risk
Those with a narrow canal (9 mm or less)) have a greater than 50% risk.
Whether repeat episodes lead to permanent spinal cord injury is unknown
Bell, Gordon. Return to play after Cervical Cord Neuroplraxia.2014
Category: Orthopedics
Keywords: cervical spine injuries, football (PubMed Search)
Posted: 7/12/2014 by Brian Corwell, MD
(Updated: 8/14/2024)
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Football helmets
A review of head and neck injuries from football from 1959 to 1963 found the rates of intracranial hemorrhage /intracranial death were 2-3X higher than the rates of cervical spine fracture/dislocation or cervical quadriplegia. In contrast, a study of football injuries from 1971 to 1975, revealed a dramatic reversal in rates. Cervical injuries now exceeded the rate of ICH by 2-4X.
A 66% reduction in ICH
A 42% reduction in craniocerebral deaths
A 204% increase in cervical spine fractures and dislocations
The shift was attributed to the modern football helmet, whose superior protection promoted “spearing” (headfirst tackling technique). Spearing involves hitting with the crown of the helmet leading to axial loading of the spine. Spearing accounted for 52% of the quadriplegia injuries from 1971 to 1975. Research by Joesph Torg, M.D., resulted in rule changes that led to an immediate 50% reduction in quadriplegia in NCAA football.
As a parent, coach or team physician, teach and enforce proper form and protect our young athletes.
Category: Orthopedics
Keywords: Elbow extension test (PubMed Search)
Posted: 5/27/2014 by Brian Corwell, MD
(Emailed: 6/28/2014)
(Updated: 6/28/2014)
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Jie KE et al. Extension test and ossal point tenderness cannot accurately exclude significant injury in acute elbow trauma. Ann Emerg Med 2014
Category: Orthopedics
Keywords: knee, injury, dislocation (PubMed Search)
Posted: 6/21/2014 by Michael Bond, MD
(Updated: 8/14/2024)
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Some quick facts about Knee Injuries:
Category: Orthopedics
Posted: 6/1/2014 by Michael Bond, MD
Click here to contact Michael Bond, MD
When examining a knee for a meniscal injury the commonly described tests are the McMurray Test and Apley Test. However, these tests have sensitivities of 48-68% and 41% respectfully, and specificities of 86-94% and 86-93% respectfully. Depending on whether you are looking at the medical or lateral meniscus.
The Thessaly Test that was first described in 2005 can be performed with knee in either 5 or 20 degrees of flexion and has a senstivity of 89-92% and specificity of 96-97% when performed in 20 degrees flexion. The test also tends to be easier to perform.
To perform the test:
Essentially you and your patient will look like you are doing the twist as they rotate their knee with you holding their hands.
A video of the technique can be found at http://youtu.be/R3oXDvagnic
The Journal of Bone and Joint Surgery (American). 2005;87:955-962.
Category: Orthopedics
Keywords: lisfranc, fracture (PubMed Search)
Posted: 5/17/2014 by Michael Bond, MD
(Updated: 8/14/2024)
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Lisfranc Fracture:
Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid. Common current mechanism of injury is when a person steps into a hole and twists the foot. The original mechanism of injury that was described was when a horseman would fall of their horse with their foot still trapped in a stirrup.
Diagnosis should be considered if patient has difficultly weight bearing with pain on palpation over the 2nd and 3rd metacarpal head with an appropriate mechanism.
Pearls:
Category: Orthopedics
Keywords: Concussion, recovery, head injury (PubMed Search)
Posted: 4/6/2014 by Brian Corwell, MD
(Emailed: 5/10/2014)
(Updated: 5/10/2014)
Click here to contact Brian Corwell, MD
Risk Modifiers for Concussion and Prolonged Recovery
A history of prior concussion is a risk factor for future concussion (>2x risk).
For individual sports, boxing has the highest risk.
For team sports, football, ice hockey and rugby have the highest risk.
Women’s soccer confers the highest risk for female athletes.
Younger age confers increased risk.
Female sex confers higher risk when comparing similar sports with similar rules.
Those with migraine headaches may be at increased risk.
Risk of prolonged concussion
Most athletes have symptom resolution within one week
Post traumatic amnesia (both retrograde and anterograde) predict increased number and longer duration of symptoms.
Younger age also predicts pronged recovery.
Other studies have found associations with headache lasting greater than 60 hours, fatigue, “fogginess,” or greater than 3 symptoms at initial presentation. Cognitive studies have identified deficits in visual memory and process speed as predictors of prolonged recovery.
Risk modifiers for concussion and prolonged recovery.
Sports Health. 2013 Nov;5(6):537-41
Category: Orthopedics
Keywords: DeQuervain, Intersection, Syndrome, Tenosynovitis (PubMed Search)
Posted: 3/30/2014 by Michael Bond, MD
(Updated: 8/14/2024)
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DeQuervain and Intersection Syndromes: