UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: MRI for Concussion Testing in the ED

Keywords: mTBI, concussion, MRI (PubMed Search)

Posted: 5/9/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

MRI for Concussion Testing in the ED

 

The increased sensitivity of MRI may have a role in detecting more subtle intracranial injuries.

135 patients with mild TBI were prospectively evaluated for acute head injury in emergency departments of 3 LEVEL I trauma. 

27% of these patients with a normal initial head CT had an abnormal brain MRI including contusions and microhemorrhages. A greater number of these subtle findings was associated with neuropsychological defects on both short-term memory function and with poorer 3 month cognitive outcomes. Inherent difficulties of access, actionable results and reimbursement issues prevent application of MRI for concussion evaluation in the ED.

Note: Mild TBI defined as GCS 13-15 is not the same as sport or activity related concussion which I consider to be GCS 14-15.

 

Take home: There is currently no role for MRI in the acute evaluation of concussion in the ED.

 

 

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Category: Orthopedics

Title: Acute pain treatment in the ED

Keywords: ibuprofen, analgesia, pain (PubMed Search)

Posted: 4/25/2020 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Comparison of Oral Ibuprofen at Three Single-dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial

 

Ibuprofen is one of the most commonly used medications in the ED for the acute treatment of pain. Analgesic ceiling doses are not well supported. Some adverse effects of NSAIDs are dose dependent (GI and cardiovascular).

 

A recent study looked to compare the analgesic effect of oral ibuprofen at 3 different doses 

 

Population:  Adult ED patients (aged 18 and older) with acute pain.

Methods: Randomized double-blind trial.

Goal: To examine the efficacy of ibuprofen at 400, 600 and 800mg.

Only 225 patients enrolled (75 per group). Outcome was difference in pain scores at 60 minutes.

Results:  Difference in mean pain scores at 60 minutes between 400 and 600mg (0.14), 400 and 800mg (0.14) and 600 and 800mg (0.00).

Conclusion:  Reduction in pain scores was similar between all 3 dosing groups. Consider lower dosing of ibuprofen in ED patients presenting with acute pain. 

 

This analgesic ceiling dose is lower than recommended by the FDA and most EM textbooks.

Consider using the 400mg ibuprofen dose for ED patients with acute pain

 

 

 

 

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Category: Orthopedics

Title: Tramadol and analgesic prescribing patterns for patients with back pain in the ED

Keywords: Analgesia, muscle injury, pain control (PubMed Search)

Posted: 3/28/2020 by Brian Corwell, MD (Emailed: 4/11/2020) (Updated: 4/11/2020)
Click here to contact Brian Corwell, MD

Question

A recent study looked at analgesic prescribing patterns for patients with back pain in EDs in the United States.

Back pain is the most common pain complaint worldwide

-Accounted for about 9% of all ED visits.

Summary:  ED use of tramadol for back pain doubled from 2007 to 2016 despite an overall decrease in opioid use (in that period)

Tramadol -- either administered in the ED or prescribed -- was used in 8.4% of back pain visits in 2016, up from 4.1% in 2007 (P=0.001).

In 2007, overall opioid use was 53.5%; in 2016, it was 46.5% (P=0.001). The largest drop was in hydrocodone use.

A recent study in JAMA looked at the risk of death in 90,000 people one year after filling a Rx for tramadol vs. one of several other analgesics such as naproxen, diclofenac or codeine.

All patients were aged 50 years or older and has osteoarthritis.

Initial Rx for tramadol was associated with a higher rate of mortality than with NSAIDs (but not compared to codeine).

 

 

 

 

 

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Studying the demographics of all both sports and recreation related injuries is important for the development of effective preventive strategies.

Methods: National electronic injury surveillance system all injury program from 2005 to 2013 (367,300 sports and recreation related ED visits).  

18 common sports and recreational activities in the United States

Results:  A fracture occurred in 20.6% and a joint dislocation in 3.6% in ED visits for a sport related visit

Most of the fractures occurred in football (22.5%) and occurred in autumn and summer. Most fractures occurred in arm/hand (finger most common). Most fractures occurred in school or sporting venues.

The OR for fracture was greatest for inline skating (6.03), males (1.21) and those between 10 and 14 years of age and those older than 84 years (4.77).

Dislocations were highest in basketball (25.7%) and occurred in the autumn and on weekends. Most dislocations occurred in school or sporting venues.

The OR for dislocation was greatest in gymnastics (4.08), males (1.50) and those aged 20 to 24 years (9.04)

The most common fracture involved the finger and the most common dislocation involved the shoulder, followed by finger and knee.

 

 

 

 

 

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Taking an accurate history to diagnose Cauda Equina Syndrome (CES)

 

Classic teaching is to inquire specifically about bowel and bladder function, sexual dysfunction, and/or loss of sensation in the groin.

Rather than asking about urinary incontinence, clinicians should ask specifically about difficulty passing urine, new leakage and retention.

Discussing issues related to sexual dysfunction are difficult for both clinicians and patients.

Rather than asking if there are any issues with sexual function, a more direct and informative way would be to ask if the patient has a “change in ability to achieve an erection or ejaculate” or “loss of sensation in genitals during sexual intercourse.”

Saddle anesthesia has the highest predictive value in diagnosing MRI-proven CES. Loss of sensation may be incomplete and patchy. Ask about change in sensation with wiping after a bowel movement.

 

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Category: Orthopedics

Title: Timeliness of Concussion Referral

Keywords: Concussion, (PubMed Search)

Posted: 1/25/2020 by Brian Corwell, MD (Updated: 8/17/2022)
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Timeliness of Concussion Referral

 

Do patients with a self-limited diagnosis of “concussion” require specialty follow up?

If so, is there a benefit to earlier evaluation?

Recently published research from the University of Pittsburgh Sports Medicine Concussion Program suggests so.

Subjects: 162 concussed athletes between the ages of 12 and 22

Findings: Athletes treated in the first week after injury recovered faster than those who did not receive care until 8 to 21 days post injury.

Note: Once in care the length of time spent recovering was the same for both groups. This suggests that the amount of time prior to the initiation of care may explain the longer recovery time of the 2nd group.

Earlier recovery can help minimize effects on mood, quality of life and lost time in school/work.

Take home:  Consiuder early follow up referral to a qualified provider for all concussed patients seen in the ED

 

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Category: Orthopedics

Title: Radiology in Slipped Capital Femoral Epiphysis

Keywords: Klein's line, S sign, AVN (PubMed Search)

Posted: 12/14/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Slipped Capital Femoral Epiphysis (SCFE)

 

  • Progressive, posterior medial displacement (slipping) of the proximal femoral epiphysis
    • Complicated by AVN and premature physis closure

http://www.raymondliumd.com/images/SCFE%20illustrated%20and%20cropped.jpg

Early Diagnosis:

  • Allows best chance for intervention and good functional outcome
  • Subtle and difficult with X-ray
  • Classic teaching is Klein’s line

Klein’s Line on AP view

  • A line drawn from the superior aspect of the femoral neck will not intersect the femoral head epiphysis
  • Modified line
    • >2mm difference in width lateral to line between each side

https://pedemmorsels.com/wp-content/uploads/2018/01/Slipped-Capital-Femoral-Epiphysis-3.png

 

Another virtual line may assist in diagnosis

S-sign

  • The S-sign is a curvilinear line drawn on the inferior margin of the proximal femoral head neck junction along the proximal femoral physis.
  •  Discontinuity or an abrupt sharp turn are abnormal

https://images.squarespace-cdn.com/content/v1/562149a6e4b0bca6fa53cb35/1530197888065-AOF0LA079Y81Q6M89RJU/ke17ZwdGBToddI8pDm48kE2XMWnCJSZ3ROkmIxQ7DdsUqsxRUqqbr1mOJYKfIPR7LoDQ9mXPOjoJoqy81S2I8N_N4V1vUb5AoIIIbLZhVYxCRW4BPu10St3TBAUQYVKcIZH9X6Fb-UKi0lvZd9RVmtFt1P_lj4JzgsdTxe78uiejbzfgXQaCWxJNArJhpf7P/Screen+Shot+2018-06-26+at+10.09.17+AM.png?format=1500w

Klein's line and S-sign

  • A group of 20 orthopedic surgeons, radiologists, and pediatricians viewed 35 radiographs of SCFE using Klein's line on the AP view and the S-sign on frog-leg lateral view to make the diagnosis. 
  • Overall diagnostic accuracy was better with the S-sign than Klein's line, 92% vs 79%.
    • Sensitivity of the S-sign was 89%, specificity 95%. 
    • Sensitivity of Klein's line was 68%, specificity 89%. 
  • Combined S-sign + Klein's line sensitivity was 96%, specificity 85%.

 

Consider adding both of these virtual lines/signs to your review of the pediatric hip plain film

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The role of skeletal muscle relaxants in the management of lower back pain in the ED

 

Patients with lower back pain (LBP) presenting to the ED are often treated with NSAIDs plus skeletal muscle relaxants.

A recent study in Annals of Emergency Medicine compared functional outcomes and pain in ED patients with acute non radicular LBP with 4 different treatment regimens.

 

  1. Ibuprofen plus placebo
  2. Ibuprofen plus baclofen
  3. Ibuprofen plus metaxalone
  4. Ibuprofen plus tizanidine

 

Conclusion: Adding a muscle relaxant to ibuprofen did not improve pain or improve function at 1 week following an ED visit for LBP.

 

Note: Prior studies have found no benefit to adding opioids or diazepam to NSAIDs  for ED patients with acute non radicular LBP

 

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Category: Orthopedics

Title: Pain Management in Geriatric Orthopaedic Patient

Keywords: geriatrics, orthopaedic, fractur (PubMed Search)

Posted: 11/16/2019 by Michael Bond, MD (Updated: 8/17/2022)
Click here to contact Michael Bond, MD

Pain management is an essential component of care for all patients with orthopedic emergencies, however, one needs to be careful of how pain medication activity can change in a geriatric patient due to:
  1. Decreased hepatic function
  2. Decreased renal function
  3. Multiple comorbidities and polypharmacy that can affect pharmokinetics of pain medications.

Therefore, pain medications must be dosed carefully, which runs the risk of underdosing.  Pain medications can also contribute to delerium, and decreased functional status.

Recommendations:

  1. Start with non-opioid medications in most cases. Consider combination acetaminophen and ibuprofen/naproxen.
  2. Consider regional nerve blocks where applicable due to the decreased risk of systemic side effects and excellent analgesic properties.
  3. If using opioids, start low and reassess and use the lowest dose possible. Remember half-lifes are often prolonged so patient may not need the standard dosing interview.

Category: Orthopedics

Title: Lateral hip pain

Keywords: Hip pain, bursitis (PubMed Search)

Posted: 11/9/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Lateral hip pain is a common presentation of hip pain.

Typically seen in runners and women over the age of 40 who start unaccustomed exercise.

Pain from OA of the hip which is typically medial (groin pain)

Lateral hip pain has traditionally been diagnosed at trochanteric bursitis.

Research suggests that lateral hip pain may be multifactorial and better termed Greater trochanteric pain syndrome.

Pain from the gluteal medius and/or minimus due to non-inflammatory tendonopathy is likely causative. This may cause a secondary bursitis.

Pain is insidious, gradual worsens and is variable based on activity type.

Also, can be seen after a fall resulting in tearing.

Pain is described as a deep ache or bruise. It can stay localized or radiate down lateral thigh towards knee.

Patients report night/early morning pain and when rolling over onto the outer hip on affected side.

Fatigue from prolonged sitting, walking and single leg loading activities such as walking up stairs.

Provoking activities and postures cause compressive forces on the involved tendons.

            These generally occur when the hip is adducted across midline such as with

Side sleeping,

            Place pillow between legs to align pelvis and keep knee and hip in line

Crossed leg sitting

            Sit w/ knees at hip distance and feet on floor

Selfie poses - Standing w a hitched hip (pushing hip to the side).

Attempt to correct biomechanical issues before progressing directly to bursal steroid injection

            May only be a temporary fix if underlying issue not addressed.

A helpful clinical guide

https://bjgp.org/content/bjgp/67/663/479/F1.large.jpg?download=true

 


Category: Orthopedics

Title: High School Concussions

Keywords: Concussion Incidence, epidemiology, (PubMed Search)

Posted: 10/26/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

A recent epidemiology study in Pediatrics looked at concussions in 20 high school sports during the 2013–2014 to 2017–2018 school years.

For every athlete, one practice or competition was counted as one exposure.

Overall, 9542 concussions were reported for an overall rate of 4.17 per 10 000 athletic exposures (AEs).

Football continues to have the highest incidence with a concussion rate of 10.40 per 10 000 AEs.

As in previous studies, rates in competition (33.19 to 39.07 per 10 000 AEs) are increasing and higher than rates in practice which are lower and decreasing over the study period (5.47 to 4.44 per 10 000 AEs).

            This may reflect better reporting or increasing injury rate

In all 20 sports, recurrent concussion rates decreased from 0.47 to 0.28 per 10 000 AEs.

Confirming prior studies, among sex-comparable sports, concussion rates were higher in girls than in boys (3.35 vs 1.51 per 10 000 AEs).

Also, among sex-comparable sports, girls had larger proportions of concussions that were recurrent than boys (9.3% vs 6.4%).

This study may reflect effective implementation of strategies to reduce concussion incidence such as mandatory removal from play and more stringent requirements associated with return to play.

 

 

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Category: Orthopedics

Title: Synthetic turf playing fields

Keywords: Playing surface, concussion (PubMed Search)

Posted: 10/12/2019 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Synthetic turf playing surfaces have been growing in popularity over the last decade and seem to have become a new standard.

Due to the need for durable fields that can accommodate multiple teams/activities, in addition to the high cost of maintaining grass and the need to conserve water, many parks and schools have switched from grass to turf. Turf is advertised as maintenance free but ….this is not the case.

Locally, at M&T Bank Stadium, groundskeepers drive a LitterKat turf sweeper across the field for 4 hours 2-3 times a week to ensure that the synthetic rubber is cleaned and distributed evenly. The field is also repainted every 4 games because the paint may become hard. The cost of this level of maintenance is beyond what many parks and local high schools can afford.

A recent study examined high school concussion data at almost 2000 high schools with over 14,000 recorded concussions. Researchers concluded that more concussions occurred in games than practices. Interestingly, they also found that playing surface was significantly associated with concussion. Almost 90% of all injuries occurred on turf-based surfaces. Turf outweighed all other mechanisms of injury, including helmet-to-helmet hits and grass playing surface. Between 10 and 15.5% of concussions occur from helmet to ground contact. In the NFL, this mechanism accounts for about 1 in 7 concussions.

 

Attempting to limit total exposure time in practice and games on turf surfaces may be beneficial until more study is needed.

 

 


Category: Orthopedics

Title: Intersection Syndrome

Keywords: Tenosynovitis, wrist pain (PubMed Search)

Posted: 9/28/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Intersection Syndrome

 

De Quervain’s is a common tenosynovitis is involving the  the 1st dorsal compartment of the wrist/forearm.

Intersection syndrome is a tenosynovitis that occurs at the intersection of the 1st and 2nd dorsal compartments.

Pathology located at crossing point of the 1st compartment structures (APL and EBP) with the radial wrist extensors (ECRB and ECRL)

Occurs most commonly from repetitive wrist extension and is common in rowers, weight lifters, and in those playing racquet sports.

Occurs about 4 to 6cm proximal to the radiocarpal joint VERSUS De Quervain’s which occurs near the level of the radial styloid.

Pain worse with resisted wrist and thumb extension

Radiographs not required

Splint and start NSAIDs

Recalcitrant cases can be referred for corticosteroid injection

 

https://stemcelldoc.files.wordpress.com/2012/09/intersection-syndrome-referral-pain-pattern1.jpg

 

 

 

 

 

 

 


Category: Orthopedics

Title: Imaging of Lisfranc Injuries

Keywords: foot fracture, radiology (PubMed Search)

Posted: 9/14/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Imaging of Lisfranc Injuries

Tarsometatarsal fracture-dislocation

Anatomy

         3 Columns of the midfoot, divided by the tarsometatarsal joints

  1. Medial
    1. First TMT joint
  2. Middle
    1. 2nd and 3rd TMT joints
  3. Lateral
    1. 4th and 5th TMT joints

The Lisfranc ligament

     - Extends from the 2nd MT to the medial cuneiform

     - Critical to structure and stabilization of the 2nd MT and the midfoot arch

 

Imaging 

Plain films: AP/lateral/oblique

Consider weight bearing view with contralateral comparison if high suspicion

CT: Can be useful to confirm abnormal plain films

MRI: not done in ED but can be used to diagnose pure ligament injuries

Below is a review of the lines of the foot which will ensure not missing this diagnosis. May be helpful to review with sample imaging.

Plain films findings: https://prod-images.static.radiopaedia.org/images/49189279/86408d5bae08ab80ae9ef377337ab7_big_gallery.jpeg

 

On AP view:

  1. Discontinuity of a line drawn from the medial part of 2nd MT to the medial side of the 2nd cuneiform
  2. Widening of the interval between the 1st and 2nd ray
  3. Bony fragment in 1st MT space (fleck sign) – Lisfranc ligament avulsion

On Lateral view:

  1. Dorsal displacement of the proximal 1st or 2nd MT (may be subtle)

On the Oblique view:

  1. Discontinuity of a line drawn from the medial border of the 3rd cuneiform with the medial border of the 3rd MT
  2. Discontinuity of a line drawn from the medial side of the 4th MT with the medial side of the cuboid 

Remember that the lateral margin of the 5th MT can project lateral to the cuboid (up to 3 mm)

 

Lines drawn on 2 view foot for review

https://radiopaedia.org/cases/lisfranc-ligament-normal-alignment

 

 

 

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Category: Orthopedics

Title: Lisfranc injury

Keywords: Foot, instability, dislocation (PubMed Search)

Posted: 8/24/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Tarsometatarsal fracture-dislocation

The Lisfranc ligament is critical for stabilization of the midfoot arch and the 2nd MT

Injuries can range from mild (sprains) to severe (gross dislocation)

Injury may be purely ligamentous injuries or a fracture-dislocations

Difficult diagnosis to make

https://www.aafp.org/afp/1998/0701/afp19980701p118-f4.jpg

 

Mechanisms: MVAs, fall from height or athletic injuries

            Common athletic mechanism: Axial load to a hyperplantar flexed forefoot

https://thumbs.dreamstime.com/z/vector-illustration-healthy-human-foot-foot-lisfranc-injury-weight-bearing-mechanism-injury-100392176.jpg

Injury severity is often underestimated

Severe pain and inability to weight bear

Plantar bruising and bruising throughout midfoot

https://footeducation.com/wp-content/uploads/2019/02/Figure-3-Bruising-from-Lisfranc-Injury-600x781.png

No specific tests as exam is limited due to pain

Midfoot stress tests

-Often positive but unlikely to be allowed by patient due to pain

https://www.youtube.com/watch?v=v8SGVwz2RHs

Midfoot instability test

Grasp metatarsal heads and apply dorsal force to forefoot.

Other hand palpates the TMT joints and feels for dorsal subluxation

 


Category: Orthopedics

Title: Plica Syndrome

Keywords: Anterior knee pain (PubMed Search)

Posted: 8/10/2019 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Plica Syndrome

-A painful impairment of knee function resulting from thickened and inflamed synovial folds

Plicae are embryologic remnant inward folds of the synovial lining present in most knees

Most plica are asymptomatic

A pathological synovial plica can become inelastic, thickened and fibrotic. It may bowstring across the femoral trochlea at 70 to 100 degrees of knee flexion

Can be a cause of anterior knee pain/mechanical Sxs

Medial patellar plica most commonly involved

 

Hx: Snapping sensation, pain w/ sitting or repetitive activity

Anterior knee pain, clicking, clunking, and a popping sensation on knee loading activity such as squatting/stairs or with prolonged sitting

Many present with history of blunt trauma to the anterior knee

 

PE: A taut band of tissue that reproduces concordant pain with palpation

Tenderness in the medial parapatellar region

Painful, palpable medial parapatellar cord

-This can be rolled and popped beneath the examiners finger

 

The knee may be tender to the touch, swollen, and stiff 

Can be difficult to distinguish from other intra-articular conditions such as meniscal tears, articular cartilage injuries, or osteochondral lesions,

The examiner can then palpate for the plica by rolling one finger over the plica fold, which is located around the joint lines in anterior knee compartment

https://www.ortho.com.sg/wp-content/uploads/2018/04/medial-plica-syndrome-31-e1478966479644.jpg

 

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Category: Orthopedics

Title: Bone stress injury (BSI) in Adolescents

Keywords: Bone stress reaction, fracture, overuse injury (PubMed Search)

Posted: 7/27/2019 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Bone stress injury (BSI) in Adolescents

 

A BSI occurs along a pathology continuum that begins with a stress reaction and may progress all the way to a stress fracture.

Difficult to diagnose clinically.

Identifying risk factors as part of the history is very important.

Common sites for BSI are most frequently in the lower extremity and include the tibia, fibula, tarsals and metatarsals, calcaneus, and femur.

When considering this in an ED setting, image the involved area and if there is no fracture, advise discontinuing the activity until time of PCP/sports medicine follow up. For those with rest pain, pain with minimal weight bearing or in whom a fracture was suspected but not present, consider providing a walking boot or crutches.

BSIs occur more frequently in young athletes than in adults.         

          Almost 50% of BSIs occur in those younger than 20 years of age

Primary care and sports medicine providers are seeing more of these patients due to many factors.

Year-round training, sports specialization at younger ages and increase in training intensity/duration contribute to the increase incidence in adolescents.

Not surprisingly, participation in organized sports as an adolescent is a known risk factor.

Just as a change in sporting level from high school to college is a known risk factor for BSI, young “gifted” athletes who are promoted to competing with the varsity team may be at similar risk.

Shin pain lasting more than 4 weeks may represent a unique subset of MSK pain complaints increasing risk of BSI.

A prior history of BSI is a strong predictor of future BSI.

Inquire about night pain, pain with ambulation, and pain affecting performance.

Athletes with BSIs have a significantly lower BMI than controls (<21.0 kg/m2).

Athletes with BSIs sleep significantly less than controls.

Athletes with BSIs have significantly lower dairy intake than controls.

Inquire about components of the female athlete triad (low energy availability, menstrual dysfunction and low bone mineral density)

 

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Long head of biceps tendon (LHBT) Testing

 

Overhead activities can cause anterior shoulder pain due to LHBT instability. A review of 3 physical exam maneuvers for bedside evaluation.

 

Speed test

Shoulder at 90° of flexion with arm fully supinated and elbow extended

Patient attempts to fwd. elevate arm against a downward force

Positive test is pain localized to bicipital groove.

Sensitivity 54% and specificity 81% for biceps pathology

https://youtu.be/N00gA4Pvsbw

 

Yergason test

Elbow at 90° of flexion with arm fully pronated and held against thoracic wall. Examiner grips patient’s hand and resists attempts at supination.

Positive test is pain localized to bicipital groove or LHBT subluxation.

Sensitivity 41% and specificity 79% for biceps pathology

https://youtu.be/_ot2S75mZ3o

 

Upper Cut test

Shoulder neutral with Elbow at 90° of flexion, arm fully supinated and hand in a fist. Patient moves hand toward chin in an uppercut motion like a boxer. Examiner places hand over patient’s fist and resists upward movement.

Positive test is pain localized to bicipital groove or LHBT subluxation.

Sensitivity 73%, specificity 78%, +LR 3.38 for biceps pathology

https://youtu.be/EE-WhlWFZvk

 

 

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Category: Orthopedics

Title: Pediatric back pain

Keywords: Disc, infection, back pain (PubMed Search)

Posted: 6/22/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Children are prone to inflammation and infection of the intervertebral discs

-Mean age 3-5years at presentation.

 

Lumbar region frequently involved

 

Although disc biopsy is not necessary for diagnosis, as many as 60% of biopsied discs grow bacteria

-Usually Staphylococcus aureus.

 

Untreated - may spontaneously resolve or progress to vertebral osteomyelitis or abscess

 

Chief complaint: Back pain and irritability, often associated with a limp or refusal to crawl or walk.

Fever is absent or low grade. 

Physical examination findings are nonspecific and may include a tendency to lie still and percussion tenderness over the involved spine.

Blood culture is generally sterile,

WBC count can be normal early in the disease course

 

However, the ESR is elevated in >90% of patients.

 

Plain radiographs are normal at the start of the illness, and generally take 2-3 weeks to demonstrate narrowing of the intervertebral space.

 

Therefore imaging study of choice is MRI.

 

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Category: Orthopedics

Title: Acute transverse myelitis (ATM)

Keywords: Spine, Autonomic Dysfunction (PubMed Search)

Posted: 6/8/2019 by Brian Corwell, MD (Updated: 8/17/2022)
Click here to contact Brian Corwell, MD

Acute transverse myelitis (ATM) refers to inflammation of gray and white matter in one or more adjacent spinal cord segments leading to acute/subacute dysfunction of all cord functions (i.e., motor, sensory, and autonomic).

 

There is a bimodal peak between ages 10-19 years and ages 30-39 years.

Most cases are idiopathic

Some patients may have had a preceding viral infection or autoimmune disorder.

The thoracic cord is most commonly involved.

Onset is characterized by acute/subacute development of neurologic signs and symptoms consistent with motor weakness, sensory changes or autonomic dysfunction.

Pain in the head, neck, and/or back may occur.

Motor and sensory changes occur below the level of the lesion and are more likely to be bilateral.

Motor symptoms include a rapidly progressing paraparesis.

Autonomic dysfunction may include urinary urgency or difficulty voiding, bowel or bladder incontinence, tenesmus, constipation, and sexual dysfunction.

Despite its low incidence, consider in a patient presents with a classic constellation of symptoms,

Rapid identification, and early initiation of treatment predicts the best outcomes

Diagnosis: whole spine MRI with and without gadolinium

Management: goals include reducing cord inflammation (IV glucocorticoids), alleviating symptoms (pain management, bladder decompression), and treating underlying causes (e.g., infections, autoimmune) as appropriate.