Keywords: cancer, pediatrics (PubMed Search)
Bone tumors can present as MSK pain!
Pain may be activity related initially (can lead to misdiagnosis)
Over time will progress to rest pain and night pain
1) Primary osteosarcoma - most common primary malignant bone tumor
Adolescents, male > female
70% occur about the knee (also in hip/pelvis and upper arm)
pain, swelling, tenderness to palpation
Consider in the presentation of non traumatic knee pain!
2) Ewing's sarcoma
Peak incidence ages 10-20, male > female
pain, swelling, tendernes to palpation
Elevated temps and ESR
Consider in the differential of osteomyelitis!!
Variable location - lusually the extremities but also pelvis, scapula, ribs
Keywords: Rotation, Fracture, Phalanx (PubMed Search)
Remember to evaluate for any rotational deformity when evaluating patients with a phalanx fracture.
The easiest way to do this is to have the patient flex all their fingers. They should all point to the scaphoid. If a finger deviates or overlaps another finger there is a rotational deformity. One should also make sure that all the nailbeds align.
This video shows how to evaluate for rotation https://www.youtube.com/watch?v=Dhp25UVn7RQ
Even if the finger is reduced otherwise, persistent rotational deformities should be referred to a hand surgeon for consideration of corrective surgery.
Keywords: Hyperthermia, cold water immersion (PubMed Search)
The TACO method (tarp assisted cooling with oscillation)
Cold water immersion (CWI) remains the standard for cooling in exercise induced hyperthermia
A low cost alternative is modified cold water immersion.
Sometimes, monetary reasons and location venue prevent the feasibility of CWI
Benefits: fast, cheap, portable
Portable – Allows for on site location at area of collapse
Cheap: Equipment required – 3 providers, 1 tarp, 20 gallons of water and 10 gallons of ice
Fast: Average time to set up – 3.4 minutes
The TACO method – fast effective reduction in core temperatures
May be up to 75% as effective as CWI
Hosokawa, Yuri et al.
Annals of Emergency Medicine , Volume 69 , Issue 3 , 347 - 352
Keywords: Spine infection, back pain (PubMed Search)
Laboratory testing for Spinal Epidural Abscess
The CBC is poorly sensitive/specific
The WBC count may be nml or elevated
Left shift and bandemia may or may not be present
ESR and CRP
Sensitive but not specific
Elevated in >80% with vertebral osteomyelitis.
Reihsaus E, et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000.
Keywords: back pain, back emergency (PubMed Search)
Cauda Equina Syndrome (CES)
A recent pearl discussed CES. This is a very challenging diagnosis to make, especially on initial presentation
The 5 “classic” characteristic features are
Not all symptoms will be present in a given patient and there is no sign/symptom combination that either reliably diagnoses or excludes CES.
To illustrate how difficult this diagnosis is to make, a study looked at the predictive abilities of Neurosurgical residents.
Positive MRI for CES was accurately predicted by senior neurosurgical residents in approximately 50% of patients suspected of CES based on history and physical findings. As clinical certainty only becomes apparent with the classic symptoms (which are generally late findings) waiting to initiate MRI will delay decompressive surgery and can lead to worsened functional outcomes. This leads to increased MRI demand with more negative MRIs. Not surprisingly, only ~20% of MRI scans for suspected CES are positive.
Bell DA et al. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 2007;21:201-3.
Keywords: low back pain, analgesia (PubMed Search)
In patients with lower back pain, there is good evidence that muscle relaxants reduce pain as compared to placebo and that different types are equally effective. However, the high incidence of significant side effects such as dizziness and sedation limits their use. Muscle relaxants may be beneficial in an every bedtime capacity thereby limiting side effects.
If cyclobenzaprine is used during daytime hours, a lower dose schedule may work as well as a higher dose with somewhat less somnolence (5 mg three times a day vs 10 mg three times a day. In general, muscle relaxants should only be used when patients cannot tolerate NSAIDs but can tolerate the side effect profile.
We commonly add muscle relaxants to NSAIDs hoping for a larger analgesic effect. However, combination therapy does not appear to be better than monotherapy.
Adding cyclobenzaprine to high-dose ibuprofen does not seem to provide additional pain relief in the first 48 hours in ED patients with acute myofascial strain. Among an ED population with acute non radicular low back pain, a randomized trial found that adding cyclobenzaprine/other muscle relaxants to Naproxen did not improve functional outcomes or pain at one week or 3 months compared to naproxen alone.
Take home: Consider the limited usefulness use of muscle relaxants in ED patients with back pain
Friedman et al., 2015. JAMA.
Keywords: Neck pain, radiculopathy (PubMed Search)
Spurling’s maneuver and modified Spurling’s maneuver aka neck compression test.
This maneuver is highly specific for the presence of cervical root compression
Can be used to reproduce radicular pain/symptoms.
Perform this maneuver with caution as it should not be performed in patients who have potential cervical spine instability.
Keeping the patient’s head in a neutral position pressing down on the top of the head. If this fails to reproduce the patient's pain, the test is repeated with the head extended, rotated and tilted to the affected side (the modified Spurling’s maneuver).
Reproduction of symptoms (limb pain or paresthesias) beyond the shoulder is considered positive. Neck pain alone is nonspecific and constitutes a negative test.
The test has a high specificity (0.89 to 1.00) but low sensitivity (0.38 to 0.97).
Meaning a positive test is helpful but a negative test does not rule out radicular pain.
This test should be used in conjunction with a thorough history and physical examination (strength, sensation and reflex testing)
Thoomes, Spine J 2018 Value of physical tests in diagnosing cervical radiculopathy: a systematic review.
Keywords: anesthetic, orthopedics, wound (PubMed Search)
When caring for a patient with a laceration we often do lcoal infiltration prior to suturing but remember the benefits of regional nerve blocks
Benefits of Regional Nerve Blocks
Quick reminder of properities of common anesthetic
|Anesthetic||Onset of Action||Duration of Action|| Max Dose |
| Max Dose |
|Bupivicaine||Seconds +||> 6 hrs||2mg/kg||3mg/kg|
Final reminder: There is no evidence that epinephrine causes necrosis and it can be used safely in digital blocks. Duration of action is max 90 minutes. Even individuals that have injected themselves with EpiPens into their hands have not had any long term sequelue or necrosis seen. Vast majority required no treatment at all.
Keywords: Skiing, gamekeeper (PubMed Search)
Epidemiology of Alpine Skiing Injuries
Mean age of injury 30.3 (range 24 to 35.4 years)
Populations at greatest risk are children and adolescents and possibly adults over 50 (increased risk of tibial plateau fractures)
Sex: Males> females
Knee injuries, esp to ACL, are higher among females
Fractures greater in males
Injury location greatest at lower extremity (primarily to knee)
Primarily sprains to MCL and ACL (increasing incidence)
14% occur to upper extremity and primarily involve the thumb and shoulder
Skiers thumb – FOOSH with thumb Abducted gripping pole
Pole is implicated as this injury is rare among snowboarders
The pole acts as a lever to amplify the forced Abduction of the thumb as the outstretched hand hits the ground.
Let go before you hit the ground!!
13% occur to head and neck
The number of all type injuries has decreased over time with advances in equipment and helmet use
Proportion of skiers wearing a helmet exceeds 80%
However, the number of traumatic fatalities has remained constant
Accidents involving fatalities exceed the protective capacity of helmets
Helmets likely decrease risk of mild and moderate head injury
Ekeland et al., 2018. Epidemiology of Alpine Skiing Injuries. J Sci Med Sport
Davey et al., 2018. Alpine Skiing Injuries. Sports Health
Keywords: head injury, medication (PubMed Search)
Retrospective chart review at a headache clinic seeing adolescent concussion patients
70.1% met criteria for probable medication-overuse headache
Once culprit over the counter medications (NSAIDs, acetaminophen) were discontinued,
68.5% of patients reported return to their preinjury headache status
Take home: Excessive use of OTC analgesics post concussion may contribute to chronic post-traumatic headaches
If you suspect medication overuse, consider analgesic detoxification
Heyer and Idris., 2014. Pediatr Neurol. Does analgesic overuse contribute to chronic post-traumatic headaches in adolescent concussion patients?
Keywords: head injury, sports medicine (PubMed Search)
In which age groups should children with Sport Related Concussion be managed differently from adults?
Are there targeted subgroups who would benefit from closer outpatient and specialty follow-up?
Predictors of Prolonged Recovery in Children
Davis et al., 2017. What is the difference in concussion management in children as compared with adults? A systematic review.
Zemek et al., 2016. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.
Keywords: head injury (PubMed Search)
Concussion Management in Children
What are the predictors of prolonged recovery of concussion in children?
Female sex, age greater than 13, prior physician diagnosis of migraine, prior concussion with symptoms lasting longer than 1 week, history of multiple concussions, headache, sensitivity to noise, dizziness, fatigue, answering questions slowly and four or more errors on tandem stance testing.
Age: As compared to younger children, adolescents have a greater number of and more severe postconcussive symptoms. They take longer to recover and return to school and sport.
Subjects: Math tends to pose greater problems followed by reading/language, arts, sciences and social studies.
Computer testing: The widespread use of computer neuropsychological testing is not recommended in children and adolescents. This is due to issues with reliability over time and insufficient evidence of both diagnostic and prognostic value. When used, reference to normative data should be done with caution. Testing should also NOT be used in isolation in concussion diagnosis and management.
Davis et al., 2017. Br J Sports Med 2017.
Keywords: Concussion, return to play, school, head injury (PubMed Search)
You have successfully diagnosed a concussion, explained everything to the parents, closed the encounter, reached for the doorknob and….
“What about school?”
An athlete should not return to play until they have successfully returned to school
Several studies have demonstrated that intense cognitive stimulation and intense intellectual stimulation result in worsening symptoms
-school work, TV, videogames, texting
Attempt to limit cognitive activity to the point where it begins to reproduce or worsen symptoms!
Step 1: 24 to 48 hours of rest
Step 2: Daily at home activities that do not increase symptoms. Starting with 5 – 10 minutes and gradually build up to a goal of tolerating 30 minutes of cognitive activity without worsening symptoms.
Home work, reading assignments, other cognitive activities
Step 3: Attempt Return to school (will not be completely symptoms free!) with either part time, partial days, or with extended breaks. Goal of tolerating an entire school day without symptoms.
Most students recover fully within 4 weeks and adjustments can then be discontinued. Others with ongoing symptoms may require ongoing academic modifications (extra time for tests, papers, etc).
Suggested examples of adjustments: Shortened days, 15 minute break for every 30 minutes of instruction, providing class notes, tutoring, decreasing course expectations, decreasing exposure to classes which exacerbate symptoms, no computer work, untimed tests and quizzes, lunch in a quiet place.
Bass & Valasek Auguest 2018 Contemporary Pediatrics
Keywords: thrower, insability (PubMed Search)
25yo baseball pitcher presents with medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Mild paresethesias in 4th and 5th digits.
What physical examination maneuvers can you do at the bedside to assist in the diagnosis?
Exam opposite elbow first to establish baseline and to assist patient relaxation and understanding.
Flexing elbow to 20 to 30 degrees unlocks the olecranon
Keywords: Ulnar nerve (PubMed Search)
Tests for motor weakness of the Ulnar nerve
Patient asked to hold piece of paper in both hands, grasping with the thumb and radial side of index finger of both hands
Examiner then pulls on the paper
Test is positive if patient flexes the thumb IP join in an attempt to hold onto paper
Keywords: Heat illness (PubMed Search)
Exertional Heat Stroke (EHS)
With football preseason starting across the country, it is important to review this topic
EHS is a medical emergency resulting from progressive failure of normal thermoregulation
EHS has a high mortality
-2nd most common cause of death in football players
History and Exam
Hyperthermia/Core temperature greater than 40°C (104°F)
Initial profuse sweating with eventual cessation of sweating with hot, dry skin
CNS dysfunction – disorientation, confusion, dizziness, inappropriate behavior, difficulties maintaining balance, seizures, coma
Other: Tachycardia/hyperventilation, fatigue, vomiting, headache
Multi-organ involvement: CNS, cardiac damage, renal failure, hepatic necrosis, muscle (rhabdomyolysis), GI (ischemic colitis), heme (DIC), ARDS
The single most important thing you can do on the field is recognize this entity. Early recognition leads to earlier initiation of treatment which is life saving.
Rapid cooling is key. This is often stated but what this means is whole body immersion in ice water. This should be available and ready for all summer practices.
The temperature needs to be lowered to below 39°C (102°F)
Also consider a cooling blanket, fanning, ice to body
DO NOT put them on ambo without initiating cooling!!!
Sustaining heat injury predisposes to subsequent heat related injury
Keywords: Muscle pain, exercise (PubMed Search)
Delayed Onset Muscle Soreness (DOMS), aka “muscle fever”
Muscle pain and weakness following unfamiliar exercise
Occurs after high force, novel (unaccustomed) eccentric muscle contractions
Occasionally isometric in an extended position
Eccentric exercise – controlled elongation
Slowly lowering yourself to start position doing pullups for example
Time of onset
Begins 6 to 12 Hours after exercise, Peaks 2-3days post and resolves in 5-7 days
Speed of onset and severity are often related
How do you know if you have it?
Much like the flu, you know it when you have it. The simple act of getting out of a car, sitting down or walking down stairs is excruciatingly painful.
Exact cause is unknown. Thought to be due to sarcolemma damage leading to intra cellular calcium release and activation of proteolytic enzymes. Creatine kinase leaks from muscle cells into plasma attracting inflammatory cells.
Best treatment is prevention: Repeated bout effect – a bout of eccentric or isometric exercise can prevent DOMS from the same exercise for 4-12 weeks.
Stretching before exercise has not been shown to be effective prevention
Other modalities: rest, ice, heat, massage, electrical stimulation
Eccentric exercises or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of the sporting season or the start of a new, novel exercise routine. For example, not starting the Insanity day one workout without “pretraining.” This will reduce the level of physical impairment and/or training disruption and lead to gains with much less pain.
Keywords: Cervical spine, neuropraxia (PubMed Search)
Stingers and Burners
Also known as transient brachial plexus neuropraxia, “dead arm syndrome,” or brachial plexopathy. Symptoms such as pain, burning, and/or paresthesias in a single upper limb, lasting seconds to minutes.
Usually involves more than one dermatome
May be associated with weakness.
-Common in collision sports that involve tackling, such as football.
-Most common C-spine injury in American Football.
-More than 50% of college football players sustain a stinger each year
-Having 1 stinger increases the risk of having another 3 fold
Mechansims: C5, C6 (deltoid,biceps) most commonly involved
-Traction injury due to forcible lateral neck flexion away with downward displacement of arm
-Nerve root compression during combined neck extension and lateral neck flexion
-Direct trauma to the brachial plexus in the supraclavicular fossa
-Examine muscle strength in the deltoid, biceps, and infraspinatus muscles
-Check sensation and reflexes in upper extremities
-Check C-spine range of motion and perform Spurling’s Test
Consider MRI for symptoms lasting more than 24 hours, bilateral symptoms or for recurrent stingers
Return to play guidelines vary:
-No neurologic symptoms
-Can return to play in same game if symptoms resolve within 15 minutes and no prior stingers that season.
-If 2nd stinger in that season, do NOT return to play in the same game
-if 3rd stinger in a season, consider imaging before return to play and consider sitting out the remainder of the season.
ED visits for acute gout increased almost 27% between 2006 & 2014, a 26.8% increase
Presentation: Acute severe pain, swelling, redness, warmth.
Pain peaks between 12 to 24 hours and onset more likely at night
Quiet, calm period between flares vs other arthritic disorders
Signs of inflammation can extend beyond the joint
Normal to low serum urate values have been noted in 12 to 43% of patients with gout flares
Accurate time for assessment of serum urate is greater than 2 weeks after flare subsides
Most hyperuricemic individuals never experience a clinical event resulting from urate crystal deposition.
Gout flares may occasionally coexist with another type of joint disease (septic joint, psedugout),
A clinical decision rule has shown to be more accurate than clinical diagnosis (17 versus 36%)
*Male sex (2 points)
*Previous patient-reported arthritis flare (2 points)
*Onset within one day (0.5 points)
*Joint redness (1 point)
*First metatarsal phalangeal joint involvement (2.5 points)
*Hypertension or at least one cardiovascular disease (1.5 points)
*Serum urate level greater than 5.88 mg/dL (3.5 points)
Scoring for low (≤4 points), intermediate (>4 to <8 points), and high (≥8 points) probability of gout identified groups with a prevalence of gout of 2.2, 31.2, and 82.5 percent, respectively.
Consider supplementing your clinical decision with this in the future
Miathal A, Singh G. Emergency department visits for gout: a dramatic increase in the past decade. Oral presentation at the EULAR 2018 European Congress of Rheumatology in The Netherlands, June 13–16.
Kienhorst LB, et al. The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study.Rheumatology (Oxford). 2015;54(4):609.
Becker, MA. Clinical manifestations and diagnosis of gout. Up to date. 2018
Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.
In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.
Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571