Keywords: Ankle Sprains (PubMed Search)
Incidence and Cost of Ankle Sprains US Emergency Departments
In a sample of 225,114 ED patients with ankle sprains:
Lateral ankle sprains represent the vast majority of all ankle sprains (91%).
Lateral ankle sprains incur greater ED charges than medial sprains ($1008 vs. $914).
Lateral ankle sprains were more likely to have associated pain in the limb, sprain of the foot and abrasions of the hip/leg than medial sprains.
Medial sprains were more likely to include imaging.
Hospitalizations were more likely with high ankle sprains than lateral sprains.
There is a higher incidence of ankle sprains in younger patients (≤25 years) and in female patients (57%).
Shah et al., 2016. Incidence and Cost of Ankle Sprains in United States Emergency Departments. Sports Health Novemebr 2016.
Young toddler presents with left lower leg pain. What is the diagnosis??
Metaphyseal Corner Fracture.
These are often very subtle findings! This fracture pattern was first seen in association with children with subdural hematomas.
It occurs due to shearing forces on the growth plate.
Most frequently seen in the distal femur, proximal humerus and tibia.
Can be bilateral.
Similar to bucket handle fracutres
Keywords: MI, exercise (PubMed Search)
Many of us use exercise as a coping strategy when emotionally stressed or to blow off steam when angry. This may place your heart at risk.
A recent observational study in Circulation surveyed 12,000 first MI patients about potential triggers. The associations didn't depend on age, smoking status, hypertension, or baseline physical activity.
Anger or emotional upset in the hour before onset elevated odds of MI 2.44 fold
A similar 2.31 fold elevation was observed form heavy exertion
However, the combination of the two raised the odds to 3.05 fold (P<0.001 for interaction)
Keywords: Davos, Shoulder, Reduction (PubMed Search)
Davos Shoulder Reduction Technique
Take Home Points
Interested, well find out more by watching this video by Larry Mellick https://www.youtube.com/watch?v=u2MsnjVNoPM or clicking the link below.
The Davos technique is a novel technique that requires no exertion on the part of the provider and can be done without sedation
Do the technique by:
The original article can be found here http://www.jem-journal.com/article/S0736-4679(16)00030-5/abstract
Keywords: Shoulder dislocation (PubMed Search)
Recurrence depends on age and activity level
27% if >30yo and 72% if <23yo
Large bony Bankart lesion, glenoid or humeral head defect >25%, recurrent instability, event near the end of season
Non surgical return to play:
If event occurs at beginning/early in season
Rehabilitation for 2 to 3 weeks (most return to play in this time frame)
Immobilization for 3 to 7 days in simple sling, gentle range of motion, cryotherapy
Physical therapy to strengthen dynamic stabilizers
Shoulder stabilization brace for non overhead throwing and contact sports
Keywords: Back pain, groin pain (PubMed Search)
The pathophysiology is unknown. Some hypothesize that occult vasculopathy and arteriosclerosis of the small vessels in the retroperitoneum may render them friable and therefore prone to rupture. This can be seen in minor trauma in sports and forceful vomiting or coughing. Spontaneous bleeding starts at the microvascular level, and large vessels become disrupted or stretched as the hematoma enlarges.
Retroperitoneal hemorrhage occurs in a variety of clinical circumstances, including spontaneous hemorrhage into a pre-existing benign adrenal cyst or bleeding from a left inferior phrenic artery, tumors of the adrenal gland and kidney, rupture of any blood vessel (most commonly infrarenal aorta); percutaneous interventions (such as cardiac catheterization), trauma, and polycythemia vera,
It is most commonly seen in association with patients with bleeding abnormalities, in HD patients and with anticoagulation therapy,. Risk is much greater with unfractionated heparin therapy than with warfarin. In most of the heparin patients studied, their coagulation parameters were in the therapeutic range.
Patients may present to the non acute area of the ED with back, lower abdominal or groin discomfort, Over time, this may progress to hemodynamic instability, and a fall in hemoglobin, Early identification is crucial to improving patient morbidity and mortality. Early symptoms depend on the location of the bleeding.
Hematoma near or within the iliopsoas muscle usually presents as femoral neuropathy (groin pain or leg weakness).
Femoral neuropathy caused by retroperitoneal hematoma can present with sudden onset severe pain in the affected groin and hip, with radiation to the anterior thigh and the lumbar region. This can easily be missed as the presentation is similar to a pulled msucle or strained hip/back. Iliopsoas muscle spasm often results in the characteristic flexion and external rotation of the hip, and any attempt to extend the hip will result in severe pain. Over time, pain and parasthesia in the antero-medial thigh and leg is seen.
Chan, Morales; et al., 2008. Int J Clin Pract.
Keywords: Patellofemoral Syndrome (PubMed Search)
Patellofemoral Syndrome Treatment options
Patients do best with a combined intervention (ie, exercise therapy, education, manual therapy and taping) plan or patellofemoral bracing may improve outcomes for people with patellofemoral syndrome and the subtype of patellofemoral osteoarthritis.
For for the ED, we can start NSAIDs, and then have them follow up with Physical Therapy, A sports trainer if in organized sports, or with a sports medicine physician/PCP. Physical therapy is targeted at strengthening the quadricep muscle particularly vastus medialis, which improves the patella’s tracking with knee flexion.
Young athletes, especially around the age of puberty, are at higher risk for pelvic avulsion fractures
Often seen in sports that require sprinting, rapid changes in movement or jumping
Caused by sudden, forceful contraction of the muscles of the abdominal, the hip and thigh or the hamstring
Avulsion fractures can occur at many areas of the pelvis.
A mnemonic is: Alabama’s stoned rappers got ill hunting armadillos
· Iliac crest: Abdominal muscles
· Anterior superior iliac crest: Sartorius
· Anterior inferior iliac crest: Rectus femoris
· Greater trochanter: Gluteal muscles
· Lesser trochanter: Iliopsoas **(rare in adults)
· Ischial tuberosity: Hamstrings
· Pubic symphysis: Adductor group
** Isolated nontraumatic avulsion fractures of the lesser trochanter in adults is a pathognomonic sign of metastatic disease
This site has some good images of common injury patterns
Keywords: Patellofermoral Syndrome (PubMed Search)
According to the 4th International Patellofemoral Pain Research Retreat recently published in British Journal of Sports Medicine, the core criterion required to define Patelofemoral Pain (PFP) syndrome is pain around or behind the patella, which is aggravated by at least one activity that loads the patellofemoral joint during weight bearing on a flexed knee (eg, squatting, stair ambulation, jogging/running, hopping/jumping).
Additional criteria (not essential):
PFP is common in young adolescents, with a prevalence of 7–28%, and incidence of 9.2%.
Stay tuned for recommendations on treatment and diagnosis.
Keywords: Hand infection (PubMed Search)
47yo M chef presents to your ED with 2 days of worsening left hand pain after sustaining a puncture wound to hand at work. The hand is red and swollen and he complains of pain. Interestingly, his index and middle digits are in an ABducted position at rest.
Collar Button Abscess
Web space infection of the palmer AND dorsal hand
The Palmer aponeurosis prevents volar extension (but promotes dorsal encroachment)
The pus spreads between the MC bones and erupts dorsally....creating a DORSAL abscess.
Loss of palmer concavity is seen.
ABduction of the adjacent digits, resulting in a "V" configuration with the apex pointing to the site of infection. This would not happen from simple pus in the dorsal space!
Can be missed if only focused on the dorsal hand. The palm will show the original injury (splinter, cut, foreign body)
Treatment is urgent surgical drainage.
Collar Button Abscess 2016
|Elle Kalbfell, BSa, Nicholas S. Adams, MDa,b, and William T. Cullen, MD, MA, FACSa,b,c|
Keywords: Chest, muscle injury (PubMed Search)
30yo male weight lifter who 10 days ago had a painful left shoulder injury after bench press. The next morning his left anterior chest wall and left upper arm were bruised and swollen. He went to see his PCP who diagnosed him with a muscle strain. 8 days later the bruising and swelling have resolved but he still cant move his shoulder and comes to the ED.
The pec major attaches to the humerus and originates from the sternum and clavicle
Injury is usually due to tendon rupture off the humerus but can also occur at the muscle tendon junction or within the muscle belly itself.
Injury is becoming increasingly common due to the popularity in power lifting sports.
Mechanism: excessive tension on a maximally eccentrically contracted muscle.
Patients will complain of pain and weakness of the shoulder.
PE: Swelling and bruising to anterior medial arm. Palpable defect and deformity or anterior axially fold (may be hidden by swelling).
Weakness and pain with adduction and internal rotation and forward flexion
Chronic presentations can be challenging to diagnose. Consider ultrasound
Non operative treatment may be indicated for partial tears (sling, ice, NSAIDs)
Operative repair of tendon avulsions is very successful. Patients age, occupation/activity level and location of injury and condition of tear are considered.
Keywords: Foot injury, bipartate (PubMed Search)
Unlike other bones in the human body that are connected to each other at joints, sesamoid bones are only connected via tendons (or are imbedded in muscle).
The largest sesamoid bone is the patella.
2 small sesamoid bones lie on the plantar foot near the great toe
Sesamoid bones can fracture and the surrounding tendons can become inflamed (sesamoiditis)
Traumatic injury is usually due to hyperextension and axial loading
Sx: Pain located under the great toe on the ball of the foot (Gradual with sesamoiditis and acutely with a fracture).
There may be associated swelling and bruising. Pain with palpation, flexion and extension.
The medial/tibial sesamoid is larger, has great weight bearing status and is more commonly injured that its lateral counterpart.
In many people (10 - 25%) the medial sesamoid of the foot has two parts (bipartite). This finding is bilateral in 25% of people.
This may confuse some providers as it may appear to be a fracture
Look for a smooth contour to the bones and clinically correlate (bruising, soft tissue swelling, etc.) if it is an incidental finding.
Other radiographic clues include
1) The fractured sesamoid is usually slightly larger than the lateral sesamoid while the bipartite sesamoid has a much larger medial sesamoid than lateral sesamoid
2) The fractured sesamoid shows a sharp, radiolucent, uncorticated line between the two fragments while the bipartite sesamoid has two corticated components
3) The fractured sesamoid fragments often fit together like pieces of a puzzle while the bipartite sesamoid has two components that do not fit together snugly
4) Other means to differentiate the two involve MRI and bone scanning
Treatment involves a stiff-soled shoe or applying a cushioning pad or J-shaped pad around the area to relieve pressure.
It may take months for the pain to subside.
Chu and Resnick, MRI Web Clinic June 2014.
Keywords: Trauma, pelvis, plain films (PubMed Search)
Plain films are commonly used to screen children for pelvic fractures or dislocations following blunt torso trauma
The sensitivity of this common screening practice is unknown
A recent study looked at this question.
Of 451 patients with pelvic fractures or dislocations, 382 had AP radiographs. Injury was correctly identified in 297 patients (sensitivity 78%).
The sensitivity was greater in the sicker subgroups :92% for those requiring operative intervention and 82% for those with hypotension
Plain AP pelvic radiographs should have a limited role in the sole evaluation of children with blunt torso trauma.
They should be incorporated in the assessment of hemodynamically unstable children and those in whom the clinician is not planning on otherwise obtaining an abdominal/pelvis CT.
Kwok et al., 2015 Annals of Emergency Medicine
Keywords: Concussion, headache (PubMed Search)
Medication-overuse headache (MOH) is one of the most common chronic headache disorders
Worldwide prevalence of 1 2%
Characterized by chronic headache and overuse of different headache medications
Withdrawal of the overused medication is the treatment of choice
A 2014 study looked at adolescent patients treated in a headache clinic with chronic post traumatic headaches (concussion headaches)
77 had chronic post-traumatic headache of 3-12 months' duration
54 of 77 (70.1%) met criteria for probable medication-overuse headache.
After the OTC medicine was stopped 68.5% had resolution or improvement !!
Excessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents.
Sometimes the advise of "just keep taking the motrin and it'll get better" isnt the answer
Heyer et al., 2014 Pediatric Neurology
Keywords: X-ray, radiographs (PubMed Search)
Radiographs of the sacrum and coccyx in the emergency department (ED) have no quantifiable clinical impact, according to a study published in the American Journal of Roentgenology.
Researchers from Emory University Midtown Hospital and Morehouse School of Medicine in Atlanta, GA, sought to determine the yield and clinical impact of sacrum and coccyx radiographs performed in the ED.
Sacrum and coccyx X-rays performed on 687 consecutive patients over a six-year period in level-1 and level-2 trauma centers (4 total hospitals). The patients’ mean age was 48.1, 61.6% were women. The images were categorized as positive for acute fracture or dislocation, negative, or other.
The researchers then analyzed:
• Follow-up advanced imaging in the same ED visit
• Follow-up advanced imaging within 30 days
• New analgesic prescriptions
• Clinic follow-up
• Surgical intervention within 60 days
The researchers found positive results in 58 of the 687 patients, a positivity rate of 8.4%.
None of the 58 positive cases had surgical intervention.
There was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical follow-up among the patients evaluated at the level-1 trauma centers.
However at the level-2 trauma centers, 34 (97.1%) of 35 patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals. Negative cases were at 82.9%.
Of all cases, 39 patients (5.7%) underwent advanced imaging in the same ED visit and 29 patients (4.3%) underwent imaging within 30 days.
“Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit,” the authors wrote. “There was no significant difference in 30-day advanced imaging at the level-1 trauma centers, but there was at the level-2 trauma centers.”
The researchers concluded that routine sacrum and coccyx radiography should not be part of ED practice and that patients should be treated conservatively based on clinical parameters.
Sacrum and Coccyx Radiographs Have Limited Clinical Impact in the Emergency Department.
Keywords: MI, Sport (PubMed Search)
What is their risk of MI???
Anger outbursts are bad for your heart. Out of 300 patients with an acute MI, just over 2% reported losing their temper within 2 hours of the event. A review of nine studies of rage and cardiovascular events all found an increase in cardiovascular events in the 2 hours preceding an anger outburst. Examples included arguments at home, at work or by road rage. Compared with their usual anger levels, the relative risk of heart attack from a fit of rage was 8.5.
What about those of us who are just fanatics, I mean fans....A recent study of World Cup soccer found that the intense strain and excitement of viewing a dramatic soccer match more than doubles the risk of acute heart attack, particularly in men with known coronary heart disease. This was regardless of the outcome of the match!
Eichner, E. Randy. Current Sports Medicine Reports: March/April 2016
Keywords: Sudden cardiac death, physical activity (PubMed Search)
Exercise and the heart
Exercise increases the risk of sudden cardiac death (SCD) acutely.
Exercise decreases the risk of SCD in the long term.
Regular physical activity (even as little as 15 mins/day) reduces the risk of cardiovascular disease (CVD).
Up to 15% of MIs occur during or soon after vigorous physical exercise. This is typically in sedentary men with coronary risk factors.
In a 1993 study, in the first hour after heavy exertion, risk of heart attack rose more than 100-fold from baseline for habitually inactive persons. However, for frequent exercisers, this risk rose less than three-fold. Think of snow shoveling after a winter storm.
Both the Physicians’ Health Study and the Nurses’ Health Study show that the risk of SCD during exertion is reduced by habitual exercise.
If you are physically active, stay active. If you are not active, you should be because exercise has innumerable personal benefits. However, it is important to start gradually Some individuals at higher risk need to start under the guidance of a physician.
1) Document location with specificity and laterality.
2) Document the location with as much specificity as possible
-Name of specific bone and specific site on bone (Shaft, head, neck, distal, proximal, styloid)
3) Document fractures as open/closed, displaced vs. non-displaced, routine or delayed healing,
-Orientation of fractures, such as transverse, oblique, spiral
- Document intra-articular or extra-articular involvement
4) For a particular injury, a complete note will include mention of the following
The joint above (e.g. for shoulder injuries this would be the neck, for hip injuries - the back)
The joint below
Motor (e.g. for arm injuries document the distal median, radial and ulnar motor innervation)
Skin (for all fractures document intact overlying skin esp. when covering with a splint)
Compartments (a simple mention of compartments are grossly soft/not tense will suffice)
*Especially relevant for forearm and tib/fib injuries
Keywords: Metacarpal Fractures (PubMed Search)
* Localize fracture to head, neck or shaft (neck most common)
5th metacarpal most commonly fractured
* Note amount of angulation, shortening and the presence of malrotation
*Treatment is based on which metacarpal is fractured and the location of the fracture
*The amount of acceptable angulation varies by the digit involved
For example for index and long finger - acceptable angulation of the shaft is 10-20 degrees and neck is 10 to 15 degrees
Whereas for the 5th digit - acceptable angulation for the shaft is 40 degrees and neck is 50 degrees
No degree of malrotation is acceptable (document the absence of this!)
Strongly suspect fight bite injury with abrasions/lacerations overlying metacarpal heads
Highly prone to infection given the proximity to the joint capsule
Consider lacerations over metacarpal fractures as open fractures (do not close/discuss management with hand surgery re timing of washout. Many prefer delayed fixation for suspected infections )
Document integrity of the extensor tendon (can be lacerated and retracted)
Keywords: osteoarthritis, nsaids (PubMed Search)
A meta-analysis of 74 randomized trials with a total of 58,556 patients was recently published in the Lancet that looked at the effectiveness of NSAIDs in the treatment of osteoarthritis (OA) pain.
Briefly, their conclusion was that:
You can find the article here http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2930002-2/abstract