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221-240 of 475 results with category "Orthopedics"
Orthopedic documentation
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)
Sensory
Vascular
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
Metacarpal Fractures
* 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
Pearls
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)
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:
- Acetaminophen is ineffective as a single-agent in the treatment of OA.
- Diclofenac 150 mg/day had best evidence to support it as the most effective NSAID available presently with respective to its effectiveness in relieving pain and improving function.
- They found no evidence that treatment effects varied over the duration of treatment ( no tolerance)
You can find the article here http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2930002-2/abstract
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Femoral neck fracture
- The most commonly missed hip fracture
We typically think of the presentation of the displaced fracture severe pain, writhing in the bed, unable to ambulate, limited ROM
* However, patients with nondisplaced fractures (15 20%) may walk with a limp
* Occurs primarily in the elderly & osteoporotic population after a fall directly onto the hip
* Look for a cortical step-off in the femoral neck (w/ foreshortening)
* A patient with a minimally displaced fracture may only complain of hip, knee, or groin pain and may be able to walk (albeit with a limp)
* Almost 9% of hip fractures are radiographically normal (Nondisplaced or impacted fractures)
* Fractures which were initially nondisplaced, may become displaced upon re-presentation
* Remember the limitations of plain x-ray in the evaluation of femoral neck fractures!
* Because of the significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip
Achilles tendon rupture
More common in
men, ages 30 - 40yo, s/p steroid injections, fluoroquinolone use, and episodic athletes "weekend warriors
Mechanism: usually during an athletic endeavor, sudden forced planar flexion or violent dorsiflexion of a plantar flexed foot
Location: Usually occurs 4 to 6 cm ABOVE the Achilles calcaneal insertion (hypovascular region)
Patient will report a sudden pop, gunshot like sound
History: Will report heel and calf pain and weakness/inability to walk
Physical examination: Palpable gap, weakness with plantar flexion, + Thompsons test
https://www.netterimages.com/images/vpv/000/000/007/7714-0550x0475.jpg
Consult orthopedics and splint in resting equinus
http://img.medscape.com/fullsize/migrated/408/535/mos0216.01.fig5b.jpg
Spondylolysis
Prevalence 3-6% in the general population (Higher in athletes)
Location: L4 (5-15% of cases) & L5 (85-95% of cases)
Population: More likely in the skeletally immature athlete due to the vulnerability of the immature pars interarticularis to repeated stress
Symptoms: Lumbar pain worse with extension
Higher risk sports: Gymnastics, diving, weightlifting, wrestling
Treatment: Bracing and activity modification, physical therapy
- Good results in 80% with conservative management allowing return to play.
- Those who fail benefit from iliac crest bone grafting and posterolateral fusion.
-Return to play is controversial in this group
Please review th images below for anaomy and imaging appearence
http://orthoinfo.aaos.org/figures/A00053F01.jpg
http://www.sonsa.org/images/spondylolysis.jpg
http://www.physio-pedia.com/images/2/22/Spondylolysis_x_ray_.docx.jpg
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Recommended follow-up for common orthopedic injuries
The Salter Harris Classification System is used in pediatric epiphyseal fractures. The higher the type of fracture the greater the risk of complications and growth disturbance.
Some common exam facts about Salter Harris Fractures are:
- The type II fracture is the most common.
- The small metaphyseal fragment in Salter Harris type II and IV fractures is called the Thurston Holland Sign.
- Type III and IV fractures often require open reduction and internal fixation due to the fracture extending into the joint.
- Type V fractures may appear normal, but the epiphyseal plate is crushed and the blood supply is interrupted.
The Classification system as listed by Type:
- Type I: A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened or displaced..
- Type II: A fracture through the physeal growth plate and metaphysis.
- Type III: A fracture through the physeal growth plate and epiphysis.
- Type IV: A fracture through the epiphysis, physeal growth plate and metaphysis.
- Type V: A crush injury of the physeal growth plate.
For Maite, a helpful mnemonic is SALTR , Slipped (Type I), Above (Type II), Lower (Type III), Through (Type IV), and Ruined or Rammed (Type V)
A image of the fractures can be found on FP Notebook at http://www.fpnotebook.com/ortho/fracture/ephyslfrctr.htm
Sever's disease also known as calcaneal apophysitis, is the most common cause of heel pain in the young adolescent (ages 8 to 12).
It can be thought of as the Achilles tendon equivalent of Osgood-Schlatter's disease (patellar tendon insertion pain).
It is a non inflammatory chronic repetitive injury.
Commonly seen bilaterally in up to two -thirds of cases.
Patients will complain of activity related pain to the heel.
There may be tenderness and local swelling at the Achilles tendon insertion.
Radiographs are not necessary for acute cases.
Treat with activity modification, heel raise, physical therapy.
Protracted Recovery from Concussion
Age and sex may influence concussion recovery time frame
Methods: 266 adolescent athletes presenting to a sports medicine concussion clinic
Female athletes had a longer recovery course (P=0.002) and required more treatment interventions (p<0.001).
Female athletes were more likely to require academic accommodations (p<0.001), vestibular therapy (P<0.001) and medications (P<0.001).
Be aware that not all concussion patient subgroups with concussions recover in the same manner. Further study is needed to support whether female adolescent athletes require unique management and treatment guidelines.
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Quick pearl for those that are trying to complete their holiday shopping.
Mulder's sign is not a sign that there is an extra-terrestial in your ED, But rather a sign that your patient is suffering from a Morton's Neuroma (see pearl from 2012)
Patients will often complain of pain in 3rd and 4th intermetatarsal space and if you can reproduce the pain by compressing the metatarsal heads together then you have a Positive Mulder's sign. Check out the original pearl at https://umem.org/educational_pearls/1684/
Parental Knowledge of pediatric concussion
Sample: Parents of children brought to pediatric hospital or outpatient clinics for evaluation of orthopedic injuries.
Participants scored an average of 18.4 (0-25) on knowledge and 63.1 (15-75) on Attitudes toward concussions.
Safest attitudes were seen in white females. Knowledge increased with income and education levels.
Parents from low income or education levels may benefit from additional education in the ED prior to discharge in addition to providing paper information which may not be read or understood.
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Medial elbow pain is common among baseball pitchers and is also seen in other sports including football, javelin and gymnasts.
More than 97% of elbow pain in pitchers is located medially.
The ulnar collateral ligament of the elbow is an important structure in these patients.
http://www.aafp.org/afp/2014/0415/afp20140415p649-f3.jpg
While initially primarily seen in professional throwers, these injuries are now being seen in younger athletes.
Initially, patients may only note changes in stamina or strength of throws.
Later, they will note pain during the acceleration and follow through-phase of throwing
http://stlhealthandwellness.com/wp-content/uploads/2013/02/elbow03.jpg
The Valgus stress test for UCL deficiency is similar to the valgus test for the knee
https://www.youtube.com/watch?v=f6YvPSVk6G8
Treatment: splinting, ice, NSAIDs
Surgical indications: Failure of non-operative treatment with desire to return to same or higher level competition.
Hook of Hamate Fracture
Rare (2% of all carpal fractures)
Mechanism usually direct blow from a stick sport (golf, hockey, baseball)
Presents with hypothenar pain and pain with gripping activities
Physical examination - local swelling and tenderness to palpation over hook of hamate
Diagnostic test - Hook of hamate pull test
https://www.youtube.com/watch?v=A-mjRnC1yWQ
XR - standard wrist series but add carpal tunnel view
http://openi.nlm.nih.gov/imgs/512/60/2904904/2904904_256_2009_842_Fig1_HTML.png
http://www.cmcedmasters.com/uploads/1/0/1/6/10162094/7851913.png?359
Happy Halloween!!
I hope you have had a safe and fun Halloween. Thank you to all the people that are staffing the EDs on a Saturday Night Halloween.
Prostate-Selective Alpha Antagonists have been tied to Falls and increased risk of fractues in elderly men. These medications can lead to syncope and hypotension putting patients at increased risk of falls. A recent canadian study showed that at 90 days of use; individuals on alpha antagonists were at increased risk of hospital visits for falls (1.45% vs. 1.28%) or fractures (0.48% vs. 0.41%). There was also an increased risk of head trauma.
Please warn patients that are on these medications of the risks, so that injuries can be minimized. They should take specific care when changing postural positions, and report episodes of lightheadedness to their PCPs.
The article can be found at http://www.bmj.com/content/351/bmj.h5398
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A traditional ED practice has been to combine promethazine as an anxiolytic adjunct to morphine for patients with musculoskeletal pain (eg back pain).
However, when compared to morphine alone, this combination does not lead to greater analgesia or decrease anxiety. It does however prolong ED length of stay.
This use of this "pain cocktail" is not recommended
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Most common mass in popliteal fossa
Incidence 10 to 58%
Intra-articular pathology results in flow of synovial fluid from the joint into the bursa, forming a cyst
Association with concomitant intra-articular disorders 94%
Possible pathology - Meniscus, ligamentous, arthritis, other osteochondral defects
In children this is not a pathologic finding
Symptoms - Posterior knee bulging, posterior tightness/stiffness esp. with knee flexion
Ultrasound - 100% sensitive/specific
DDx: DVT
Tx: Refer for ultrasound guided aspiration, fenestration and steroid injection
http://www.caringmedical.com/wp-content/uploads/2013/11/Bakers-Cyst-treatment.jpg
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Shoulder Dislocation Reduction
Do you have a chronic dislocated that frequents your ED? Are you interested in teaching them a way to relocate their shoulder without looking like Mel Gibson from Lethal Weapon, https://youtu.be/Igrdi_lhhW4, then the newly described GONAIS method might be what you are looking for.
This technique has the patient grab the top of a chair with the hand on the affected side, and then slowly equating, effectively bringing the hand and arm above their head. Once in the full squat position the patient can step backwards which should reduce the shoulder. If not they can use the opposite hand to apply pressure to push the humerus backward and reduce the location.
The full article can be found at http://bit.ly/1iZ8a9z
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Policeman's Heel:
When patient's present complaining of heel pain we often think immediately of plantar fascititis,and heel spurs. If they jumped and landed on the heel with are concerned for calcaneal fracture. However, a policeman's heel can occur from repetitive bounding of the heel or from landing on it as in a fall or jump.
Policeman's heel has been descirbed as a plantar calcaneal bursitis, inflammation of the sack of fluid (bursa) under the heel bone, or a contusion of the heel bone due to flattening and displacement of the heel fat pad, which leaves a thinner protective layer allowing the bone to get bruised.
Regardless of cause this responds well to NSAIDs, limiting weight bearing, or taping the foot. If the repetitive activity is not reduced this can easily become a chronic cause of heel pain. A short video showing how to tape the foot can be found at https://youtu.be/nQtkwfJrhXo
Sodium Supplementation and Exercise-Associated Hyponatremia (EAH) during Prolonged Exercise (ultramarathon running)
Weight loss of around 4% body weight (relative to pre race weight) can be anticipated to maintain euhydration in such a prolonged event
Those who become symptomatic with EAH have either gained weight or lost less that 3-4% body weight
Overhydration rather than inadequate supplemental sodium intake is a greater contributor to the development of EAH
There is a suggested link between EAH and rhabdomyolysis. The mechanism remains unknown and it is unclear which condition may augment the other. Further research is needed.
Take home: Avoid overhydration during prolonged exercise to prevent EAH.