Gout treatment considerations
Treatment is directed to relieve pain and inflammation
NSAIDs, steroids and narcotics are the mainstays of treatment. All 3 should be used in combination.
Aspirin should be avoided as it may increase uric acid levels
Note: not in prevention doses (81mg) in treatment doses (325-650mg q4h)
NSAIDs and steroids take time to be effective. Provide appropriate analgesia with oral narcotic medication for short term relief
Don't forget the benefit of splinting a "hot" joint (the ankle or wrist for example)
NSAIDs: Use may be limited in the elderly and in those on coumadin or with peptic ulcer disease. 5-7 days of treatment is usually sufficient. Indomethacin is most commonly used (50 mg TID, which may be tapered to 25 mg TID after 3 days)
Steroids: Likely more effective than NSAIDs. Oral prednisolone is more effective than naproxen (1). Use prednisone 30-50 mg for 3-5 days without tapering (as we use for asthma). May be useful to supplement with NSAIDs on the tail end to prevent a rebound flare. If tapping the joint consider intraarticular steroids. If there is concern for medical noncompliance with oral steroids consider IM steroids (triamcinolone 60mg or methylprednisolone).
Gout Part 2
Knee dislocations are uncommon, and prosthetic knee dislocations even rarer. Some general facts about prosthetic knee dislocations are:
GOUT part 1
Gout is an inflammatory arthritis that classically affects the first metatarsal phalangeal joint
Gout prefers cool ambient temperature hence gouty tophi prefer the great toe (one of the coldest parts of the body) and avoids "warmer" joints such as the hip and shoulder.
Remember that gout can affect other joints as well (elbow, wrist, knee and ankle) and can cause painful bursitis and tendonitis
Multiple joints can be involved simultaneously (leading to confusing with RA and OA)
The involved joint will often be red, hot, swollen and very painful leading to easy confusion with cellulitis and or a septic arthritis
Diagnose gout by demonstrating monosodium urate crystals in the synovial fluid.
**Remember previous pearl by Dr. Bond regarding the coexistence of gout with septic joint**
Serum uric acid levels are commonly elevated but can be normal or even low
Use caution with this test because asymptomatic hyperuricemia is much more common than gout
Talar Neck Fractures
Have a high rate of avascular necrosis (AVN), nonunion, and arthritis. Almost all require ORIF
Cubital Tunnel Syndrome aka Radial Tunnel Syndrome
Sever's disease ,aka calcaneal apophysitis, is a common overuse injury in the pediatric and adolescent population.
Occurs secondary to traction of the calcaneus that most often occurs in young athletes (8-12 yo)
-Avg. age of presentation is 11 years 10 months in boys & 8 years 8 months in girls
-Repetitive traction to the weaker apophysis, induced by the pull of the Achilles on its insertion
Hx: Heel pain that increases with activity (running, jumping).
-May involve one (40%) or both (60%) feet
PE: Tenderness of the posterior heel at the Achilles tendon insertion and ankle dorsiflexor weakness
Imaging: Radiography is often normal. When positive, show fragmentation and sclerosis of the calcaneal apophsis. NOTE: These findings are nonspecific and also are observed in asymptomatic feet.
http://t0.gstatic.com/images?q=tbn:ANd9GcQ9R-fx1iyhbhNJpNL2W72bWdK72_mRBLNX5DUDtcMfnDli-x7Ong
DDx: Includes osteomyelitis and tarsal coalition.
Tx: Rest from aggravating activities, NSAIDs, ice (both pre and post sport). When pain free a program of stretching (gastrocnemius-soleus), strengthening (dorsiflexors) and shoe inserts (heel cups, lifts, pads, or orthotics) can provide significant pain relief.
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.
Iliotibial band syndrome (ITBS)
http://footcarexpress.com/foot-orthotics/wp-content/uploads/2009/01/iliotibial-band-syndrome.jpg
Hx -
PE-
Tx
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:
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..
Involves an avulsion of the flexor digitorum profundus (FDP) tendon from its insertion on the distal phalanx.
Ring finger is most commonly involved.
Usually occurs from a grabbing attempt (resulting in forced DIP extension during maximal FDP contraction) as would occur while attempting to grab someone’s jersey such as in football or rugby.
Clinically, there is normal passive DIP ROM with loss of active flexion. Examine this by asking the patient to flex the fingertip at the DIP while the PIP joint is held in extension.
*Remember that patients with a 90% full-thickness tendon laceration may still have normal (albeit painful) range of motion. The examiner must evaluation the strength of the tendon against resistance. This injury is commonly missed as it is diagnosed as a “jammed” finger.
Plain films may show a bony avulsion, but are often negative.
Treatment is primary repair especially with large bony fragments. Partial ruptures can be treated nonoperatively at the discretion of the hand surgeon.
Peroneal Tendon Subluxation: The Other Ankle Sprain
Commotio Cordis
Emergency medicine & sports medicine physicians often cover sporting events where athletes are at risk of commotio cordis
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
Cervical Radiculopathy
The most commonly affected level is C7 (31-81%), followed by C6 (19-25%), C8 (4-12%) and C5 (2-14%)
Anterior compression can selectively affect motor fibers
Posterior compression can selectively affect sensory fibers
-More common due to posterior lateral disc herniation or facet degeneration
Signs and symptoms: Sensory complaints (findings are in a root distribution) and possible weakness and reflex changes.
Dr. Corwell covered Spondyloysis in July 2010 https://umem.org/res_pearls_referenced.php?p=1134 but if you are like me you might have trouble remembering the differences between the following terms:
Chief complaint: “Posterior heel pain”
http://www.aidmybursa.com/_img/ankle-retrocalcaneal-subcutaneous-bursitis.jpg
Retrocalcaneal bursitis
The retrocalcaneal bursa is located between the Achilles tendon and the posterior superior border of the calcaneus.
H&P: Inflammation and pain may follow repetitive dorsi/plantar flexion of the ankle (excessive running, jumping activities). Tenderness anterior and superior to the Achilles insertion on the heel.
Treatment: Minimize weight bearing. ½ inch elevation. NSAIDs.
Posterior calcaneal bursitis
This bursa is subcutaneous, just superficial to the insertion of the Achilles tendon.
H&P: Inflammation and pain may follow irritation from the upper border of the heel counter of a shoe. Posterior heel pain. Tender “bump” (the inflamed and swollen bursa) on the back of the heel.
http://podiatry.files.wordpress.com/2006/12/patient2.jpg
Treatment: Opened-heeled shoes, sandals, or placement of a “U-shaped” pad between the heel and the counter. NSAIDs. Advance to shoes with soft or less convex heel counters.
Evaluation of Potential Intra-Articular Joint Lacerations
Skin and soft tissue injuries in proximity to a joint often prompt concern of whether the injury violated the joint space. Joint Space involvement is important to exclude as it can lead to septic joints and long term disability.
One easy way to determine if the joint capsule has been violated is to inject methylene blue into the joint and watch to see if any of the methylene blue extravasates through the soft tissue.
Indications for a methylene blue injection include:
There are no absolute contraindications. Though clearly the procedure does not need to be done when the injury highly suggests an open joint injury and the patient will require operative debridement and exploration.
To watch a video of a injection head to eMedicine by clicking http://emedicine.medscape.com/article/114453-overview
Transverse Myelitis
A group of inflammatory disorders characterized by acute or subacute motor weakness, sensory abnormalities and autonomic (bowel, bladder, sexual) cord dysfunction.
Symptoms are usually bilateral but both unilateral and asymmetric presentations can occur.
Look for a well-defined truncal sensory level
-below which sensation of pain and temperature is altered or lost.
Causes: Autoimmune after infection or vaccination (60% of cases in children), direct infection, or a demyelinating disease such as MS. No cause is found in 15 – 30% of cases.
Incidence: Bimodal peak at 10-19 years and at 30-39 years.
Diagnostic testing: MRI of the ENTIRE spine to both rule out structural lesions and rule in an intrinsic cord lesion. If MRI is normal reconsider the original diagnosis.
Treatment: Steroids are first-line therapy. Dosing is controversial but generally involves high IV doses for 3-5 days (1000 mg methylprednisolone). Plasma exchange is second line for those who don’t respond to steroids.
Risk Factors for Spinal Epidural Abscesses
Building on Dr. Corwell's pearl from last week concerning Spinal Epidural Abscess, risk factors for Spinal Epidural Abscesses other than IV drug abuse are:
The infection can occur via three routes 1) hematogenous spread 2) Direct Extension from a local infection such as osteoomyelitis, and 3) iatrogenic introduction which is thought to be responsible for 14-22% of the cases. A catheter in the epidural space for more than 2 days has a infection rate of 4.3%.
