UMEM Educational Pearls - Orthopedics

Does mild traumatic brain injury increase risk of dementia?

Background: Most studies of moderate to severe TBI have found an association with increased risk of dementia and earlier onset of Alzheimer’s. There is growing concern that repeated TBIs, even if more mild, can lead to neurodegenerative conditions such as chronic traumatic encephalopathy (CTE). However, the link between mild TBI and dementia risk has not fully been elucidated, especially in the case of mild TBI without loss of consciousness (LOC).

Recent Data: A recent JAMA study evaluated the association between TBI severity, LOC, and dementia diagnosis in 350,000 veterans between 2001-2013. After adjusting for demographics as well as medical and psych comorbidities, veterans with even mild TBI without LOC had more than a 2-fold increase in risk of dementia diagnosis than those with no TBI. The risk increased only slightly if there was LOC (from a hazard ratio of 2.4 to 2.5). Risk was >3-fold for those with moderate-severe TBI.

Take home: TBI of any severity, even without LOC, appears to be associated with long term neurodegenerative consequences. Avoidance of TBI is of the utmost importance, and if TBI occurs, close neurocognitive follow up should occur.  

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Exercise talking points for the pregnant patient

(from ACSM 2017 Consesnsus statement)

Exercise throughout pregnancy is generally safe but should be monitored

No evidence of higher rates of preterm or prolonged labor, or deliveries that require induction or episiotomy

No evidence of negative effect on APGAR scores

Other benefits:

Avoidance of excessive weight gain, improved balance, and decreased back pain

Improved well-being, energy levels, and sleep patterns

Improved labor symptoms and facilitation of post-partum recovery

Lower risk of C-section

Reduced risk of having a large for gestational age (LGA) or small for gestational age (SGA) infant

Risks include environmental exposure, dehydration, hypoxia, and uterine trauma:

High impact or high-strain physical activity during the fetal implantation phase may lead to slightly higher risk of miscarriage

Sports with high risk of trauma last in pregnancy could result in placental abruption

Scuba diving is contraindicated because the fetus is not protected from decompression problems

Limit use of sauna or hot tub to fewer than ten minutes or omit altogether

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Female Athlete Triad

1. Low energy availability
   1. With or without eating disorders
2. Menstrual dysfunction
3. Low bone mineral density (BMD)

Energy availability considers the amount of remaining energy for metabolic processes based on calories takin in with eating and calories burned through exercise or both.

Menstrual dysfunction occurs as a result of low energy availability causing decreased GnRH inhibition and ovarian suppression and decreased estrogen.

Low bone mineral density occurs due to amenorrhea and decreased energy availability. Estrogen limits bone resorption (stimulates calcitonin and renal calcium retention).

This is very important for young girls as by age 12 they have 83% of their total BMD & 95% two years after menarche.

If you see an athlete in the ED with one component of the triad, inquire about the other two. A 15yo athlete with a stress fracture may not realize that her disordered eating, excessive exercise or amenorrhea may by contributing factors and may benefit from follow up with PCP, dietitian, Gyn, etc.

Boutonniere Deformity
aka buttonhole deformity

Misdiagnosed as a “jammed” or “sprained” finger

• Deformity occurs at the PIP joint
• Trauma to the PIP joint can cause the joint capsule to tear, the head of the phalanx can buttonhole thru the defect and the lateral bands of the extensor tendons fall laterally & contract
• The lateral bands then function as PIP flexors and not extensors
• DIP hyperextension due to excessive pull of the displaced lateral bands
• As a result, the pateint WILL be able to flex the DIP joint, but WILL NOT be able to extend   the PIP joint                                                                    
• OCCURS 1 - 3 weeks post injury
• May not present with classic textbook deformity
• The Elson test is the best way to detect the injury pattern before the deformity is evident
• https://www.youtube.com/watch?v=G9HY0qXWUvE

Pectoralis Major Rupture

Most commonly seen in male weightlifters

Usually occurs as a tendon avulsion

Incidence is increasing

Hx: Sudden, sharp, tearing sensation with pain and weakness with arm movement

PE: Palpable defect and deformity of anterior axillary fold. Bruising and swelling.

               Deformity may not be obvious with arm by side and relaxed

Testing: Weakness with ADDuction and internal rotation

https://lh3.googleusercontent.com/wQcuu_sG76t_DLWocO_c2344IT69g_vWXY0FKtqhR4L37qrrsIuW607LZkVFT8QTLAdaTeU=s170

Treatment:  Operative treatment has better outcomes but depends on patient subgroups

Nonoperative treatment generally indicated for partial ruptures and tears in the body of the pec and muscle tendon junction

               Sling, ice and pain control.

Operative treatment generally for high demand patients (athletes) and bony avulsion injuries

The search for an objective reliable test for mild traumatic brain injury found an early promising result last week.

               May be arriving in your hospital in the near future.

               A handheld sideline version is sure to follow

The FDA approved the first blood test for concussion/mild TBI

               Called the Banyan BTI (Brain Trauma Indicator)

This test measures 2 neural protein biomarkers released into the blood following mild TBI

The FDA approved this test within 6 months after reviewing data on just under 2,000 blood samples.

               They concluded the Banyan BTI can predict the absence of cranial CT lesions with an accuracy greater than 99% and may reduce imaging in up to a 1/3^rd

Be optimistic but consider the small sample size and remember that this test looks for biomarkers and may miss subtle cases where proteins didn’t leak. This test is NOT ready to be used for return to play decisions. It takes 3 to 4 hours to result and costs about $150. Other biomarkers are being investigated and may prove to be better

https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm596531.htm

Femoral neck stress fractures

Adults>kids

Represents 5% of all stress fractures

Usually due to repetitive abductor muscle contraction

As with all stress fractures can occur in 2 types

1)      Insufficiency type (normal physiologic stress on abnormal bone)

2)      Fatigue type (abnormal/excessive physiologic stress on normal bone)

2 locations on interest:

1)      Compression side (inferior femoral neck)

2)      Tension side (superior femoral neck)

History: Insidious onset of groin or lateral hip pain associated with weight bearing

Exam: Antalgic gait, pain with hip log roll and with FABER (hip flexion, Abduction and external rotation test)

Treatment:

Compression side: reduced weight bearing and activity modification

Tension side:  Non weight bearing (due to high risk of progression to displacement with limited weight bearing) AND surgical consultation for elective pinning to prevent displacement. If displaced, will require ORIF

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Dental Avulsion in the field/sporting event

-  Only replace avulsed secondary teeth

-  Handle the tooth by the crown only

-  Rinse tooth with cold running water gently (the root should not be wiped)

-  Immediate attempt to reimplant permanent tooth into socket by 1st capable person:

*  Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%

*  Best chance of success if reimplant done within 5–15 min*?  Poor tooth viability if avulsed for >1 hr

-  If unsuccessful, place tooth in a transport solution (from most to least desirable):

-  Hanks balanced salt solution (HBSS)

*  Balanced pH culture media available commercially in the Save-A-Tooth kit

*  Effective hours after avulsion

-  Cold milk:

*  Best alternative storage medium

*  Place tooth in a container of milk that is then packed in ice (prevents dilution)

-  Saliva:

*  Store in a container of parent or child's saliva

-  Never use tap water or dry transport

Concussion – Where are we now?

The Sport Concussion Assessment Tool 5^th edition (SCAT 5) was released in 2017

It is a standardized tool to assist health care professionals in the evaluation of sport associated concussions

It should be used for those 13 years and older (there is a child version for younger athletes)

Print and bring to the sideline for your next coverage event!

http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf

Some points to consider:

It should take at least 10 minutes to complete. Any less and you may not be performing the test correctly

The SCAT5 is the standard tool used in concussion assessment in the NCAA and NFL and other professional sports

Some symptoms of concussion appear over time. For example, an athlete may have zero or minimal symptoms immediately after yet be considerably symptomatic in 10 to 15 minutes.

               -Follow up screening evaluations are essential even in those with a negative initial sideline screening test

The SCAT5 should be used immediately after injury

               -Utility decreases post injury after days 3-5

               -The included symptom checklist has utility in tracking recovery

               -Attempt to perform in an environment free of distractions (crowd noise, bad weather)

The clinical utility of the SCAT5 can be enhanced by adding assessment of other factors such as reaction time, balance assessment, video-observable signs (if available) and oculomotor screening.

CC: 12yo boy presents with pain to base of 5^th metatarsal

Osteochondrosis overuse syndromes associated with development of secondary ossification or apophyseal centers

Iselin disease – Osteochondrosis of 5^th MT base

Lateral 5th foot pain with weight bearing and activity in early adolescence

Child may limp or walk on inner part of foot

               Adolescents:  Girls >10, Boys >12

               Commonly seen in soccer, basketball, gymnastics and dance

Exam: Tenderness to palpation at proximal 5^th MT at peroneal brevis insertion

Area may show edema and redness

Pain with foot inversion and resisted eversion and dorsiflexion

XR: May be normal or show enlargement or fragmentation of epiphysis

Obliquely oriented small bony fleck at 5^th MT base. Parallel to long axis of 5^th MT. Best seen on oblique view. Unlike fractures which tend to be horizontally oriented.

Treatment: Immobilize for comfort if severe (walking boot) or simple activity modification if mild. Ice and calf muscle stretching.

http://https://images.radiopaedia.org/images/2343487/d3478d2024c845ba0f2fffffd7d51c_big_gallery.jpg

Tibial shaft stress fractures

An overuse injury where the tibia is subjected to repetitive stress resulting in progressive microfractures

Commonly seen in runners and military recruits

Location of injury is very important for prognosis and treatment

1)      Medial tibia (compression side) – Most common stress fracture site in athletes (runners)

2)      Anterior tibia (tension side) – Seen in repetitive jumping  athletes

History: Change in routine (volume or surface), Insidious onset of pain, worse with activity better with rest

Exam: Focal tenderness to palpation (versus larger diffuse area with shin splints)

Radiology: Plain film often normal in first 2 to 3 weeks

Lateral X-ray may show the “dreaded black line” on the anterior tibia

MRI has replaced bone scan as most sensitive for early diagnosis. Fracture line surrounded by edema.

Treatment:

Medial fractures: relative rest (avoid painful activities), avoid NSAIDs, PT, gradual return to activity as dictated by symptoms

VERSUS

Anterior stress fractures:  Very high risk injury pattern (delayed union and non union). Non weight bearing splint/cast. Intramedullary nail often used for failure of conservative treatment or earlier return to sport in competitive athletes.

Dreaded black line picture:

https://www.researchgate.net/profile/Brian_Werner2/publication/265054294/figure/fig2/AS:295959096512514@1447573555901/Figure-2-A-Lateral-plain-radiograph-showing-the-%27%27dreaded-black-line%27%27-highlighted.png

A recent article from JAMA (link below) showed that Ibuprofen and opioids are similarly effective in the short term relief of acute extremity pain when used in combination with acetaminophen.  The study looked at adults with fractures and sprains and randomized them to one of four groups.

• 400mg Ibuprofen and 1000mg acetaminophen
• 5mg Oxycodone and 325mg acetaminophen 
• 5mg Hydrocodone and 300mg acetaminophen
• 30mg Codeine and 300mg acetaminophen

Pain relief was similar in all groups.

With the growing increase in opioid abuse/addiction it is good to know that in our patients that are not allergic to acetaminophen and ibuprofen (or all medications except for that one that begins with a “D”) we can provide good pain relief without using opioids.

https://jamanetwork.com/journals/jama/article-abstract/2661581

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Parsonage Turner syndrome aka Neuralgic amyotrophy

30 cases per 100,000

Under recognized and often missed

Unknown cause, perhaps post viral. Also reported post stress (surgery, pregnancy)

Can be B/L in 10 to 30%

CC: sudden onset of severe pain in the shoulder.

Can last for hours to weeks.

Radiates to upper arm.

As pain begins to subside, muscle weakness and sensory loss follows.

Can preferentially involve the suprascapular and axillary nerve.

Outpatient workup may include MRI and EMG

Treatment: Supportive. Consider a trial of oral steroids. Provide good pain control.

Majority of patients improve within 3 months. Though up to a third have persistent pain/functional deficit.

Question

Quadriceps Contusion

Mechanism: Blunt trauma to the anterior thigh (frequently football helmet or opponents knee)

Usually involves the anterior quadriceps (rectus femoris and vastus intermedius)

Pain on passive stretch and active contraction

Can develop large hematomas

Loss of knee flexion is a poor prognosticator

Complication: Myositis Ossificans (MO) (5-17%)

               Increased risk with delay in treatment > 3 days

               Radiographs can lag. Ultrasound in more sensitive

               Painful firm area in region of contusion occurring 2 to 3 weeks post injury

http://fifamedicinediploma.com/wp-content/uploads/2015/12/myositis_ossificans_lateral-1.jpg

Prompt treatment….key to good outcome and earlier return to sports

Large hematoma can be aspirated. NSAIDs may reduce edema and risk of MO. Splinting

Place quadriceps in 120 degrees of flexion for 24 hours following injury (keep muscle lengthened)

https://upload.orthobullets.com/topic/3103/images/quad%20contusion_moved.jpg

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Complete or incomplete separation of the articular cartilage and subchondral bone

               -70% occur at the lateral aspect of the medial femoral condyle

               -Also seen in the talar dome and capitellum

Repetitive overloading leads to fragmentation and separation from surrounding bone

Prognosis better in kids than in adults

http://www.eorif.com/KneeLeg/Images/OCD4w.jpg

CC: Vague difficult to localize activity related pain and swelling. Mechanical symptoms only if loose body is present

PE: Wilson’s test

Internal tibial rotation and knee extension impinges the tibia on the OCD lesion causing pain. Pain abates with external rotation and flexion.

https://www.youtube.com/watch?v=e7zrKo41Pos

Plan of care: Limit activity and trial period of non-weight bearing for 6 weeks.

50% resolve in 10 to 18 months with conservative care.

Detached, loose or unstable fragments or failure of non-operative care will need surgery

Lever Sign/Lelli’s test

A new test for diagnosing ACL tears

Higher sensitivity (94 - 100%) than the Lachman test (highest sensitivity test to date)

               With time and more study, this may become our new gold standard physical examination test

Very easy to learn and apply to bedside care

Can help with diagnosing partial tears

Area of manipulation is the femur and not the tibia (as in other tests)

Consider incorporating into your standard knee examination

https://www.youtube.com/watch?v=T9ujIYIctdw

Original study

https://www.ncbi.nlm.nih.gov/m/pubmed/25536951/

Validation

https://www.ncbi.nlm.nih.gov/pubmed/26753117

Thank you to Ari Kestler for sending

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Viscosupplementation

Hyaluronic acid (HA) is a high-molecular weight polysaccharide

A major component of synovial fluid and of cartilage

Major role of HA is as a lubricant, shock absorption, antinociceptive effect

               Used in veterinary medicine for decades

Multiple brands exist with differences based on the molecular weight and how they are produced

Use supported by the Cochrane database (2007, 2014) for knee OA

Post injection strength gains are due to pain relief

May have a role for those who cannot receive steroid injections

Inject in similar manner to intra articular steroids

Caution in those with known allergy to poultry /eggs

Risks: Local reaction (likely from preservative), injection site pain, infection, bleeding.

There is tremendous interest in identifying factors that may influence outcome from sports related concussion.

The strongest predictor of slower recovery is the severity of symptoms in the 1-2 days post injury

     -Fewer Sx's in this time period predict a quicker recovery

Pre injury history of mental health problems, depression or migraine headaches predict a longer recovery course

Teenagers might be more vulnerable to having persistent symptoms with greater risk for girls than boys

Having a prior concussion is a risk for having a future concussion

The large majority of injured athletes recover from a clinical perspective within the first month of injury many within the first 10 days

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PCL injuries can sometimes have involvement of the posterolateral corner (PLC)

The dial test can be used to diagnose posterior lateral instability and help differentiate it from isolated PCL injuries

The dial test involves comparing the amount of external rotation of the lower leg at the knee while the knees are in 30° and in 90° of knee flexion.

https://www.youtube.com/watch?v=rnk62Y-nDSQ

An isolated injury to the posterolateral corner will result in more than 10° of external rotation in the injured knee that is present at 30° but not at 90° of knee flexion.

http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST.jpg

http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST-90.jpg

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Question

Take Home Points:

1. A radial head subluxation that is common in 1-3 year olds
2. Often secondary to a longitudinal traction on an extended arm
3. With a classic story radiographs are not required
4. The hyperpronation technique has been show to be more effective and less painful in reducing it

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