Are discharged patients who suffer minor thoracic injury at risk of developing delayed pneumonia?

Prospective study of 1,057 patients age 16 and older with minor thoracic injury who were discharged from the ED. 

32.8% had at least one rib fracture

8.2% had asthma

3.4% had COPD

Only 6 patients developed pneumonia!!

Sex, smoking, atelectasis on CXR, and alcohol intoxication were not significantly associated with delayed pneumonia.

However, for patients with preexistent pulmonary disease (asthma or COPD) AND rib fracture, the relative risk of delayed pneumonia was 8.6. Patients without either of these conditions are at extremely low risk of future development of pneumonia.  

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Hematoma blocks for distal radius fractures

Hematoma blocks provide safe, effective analgesia without an increased risk of post procedural infections when compared with other regional blocks

Provide equal reduction quality AND pain control as procedural sedation with Propofol.

However, mean time to reduction (0.9 vs. 2.6 hours) and time to discharge post procedure (0.74 vs. 1.17 hours) were reduced with hematoma blocks.

Consider this option next time the department is busy or the patient is not an ideal procedural sedation candidate.

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Tarsal Tunnel Syndrome (TTS)

Prior pearls have addressed Carpal Tunnel Syndrome and Cubital Tunnel Syndrome, which affect the median and ulnar nerves, respectively.  Tarsal tunnel syndrome, is a similar compression neuropathy of the tibial nerve as it transverses through the tarsal tunnel of the foot.

The tarsal tunnel is located behind the medial malleolus, and is where the posterior tibial artery, tibial nerve and several tendons transverse.  Patients will present complaining of numbness of the foot radiating into  Digits 1-4, pain, burning , and tingling of the base of the foot and heel.  TTS has many causes and is more common in athletes.

Consider the diagnosis in patients with foot pain and numbness.  If interested in more information about TTS please consider reading this eMedicine article, http://emedicine.medscape.com/article/1236852-overview

Injury is often caused by sudden dorsiflexion on a plantar flexed foot w/ the knee in extension or similarly sudden knee extension with the ankle in a dorsiflexed position.

Injury has a predilection for the poorly conditioned middle-aged athlete, with "thick calves" who are engaged in strenuous activity

Strains are treated with ice, analgesics, and compression (decreases hematoma size and facilitates healing)

Also, consider casting/splinting as dictated by injury severity, such as with a night splint or a CAM boot.

Severe strains and ruptures can be splinted in plantar flexion for 3 weeks.

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Distal radius fractures are common in children

Traditional management includes closed reduction +/- procedural sedation

The downside of this approach includes: patient risks, cost, physician time, ED bed time and tying up resources.

Kids have excellent bone remodeling potential...displaced and angulated fractures heal well without reduction

Crawford et al - 51 children aged 3 to 10 (avg 6.9 yrs)  w/closed distal radius fractures.

Exclusions: open or growth plate fractures, metabolic bone disease or neurovascular injury.

No sedation, analgesia or fracture reduction was performed

Treatment: simple casting and gentle molding to correct angulation... i.e. fractures were left in a shortened, overriding position

Outcome: All patients had clinical and radiographic union and full range of motion of the wrist at one year w/ good patient (parent) satisfaction. This was associated w/ significant cost savings.

Consider this approach in consultation with orthopedist

Remember exclusions: open fractures, fracture dislocations, growth plate injuries and neurovascular injury.

Children w/ excessive angulation or rotational deformity should have standard care (closed reduction w/ sedation)

Multiple guidelines exist for "excessive angulation" but as a general rule

Age < 5 Up to 35 degrees

Age 5- 10 Up to 25 degrees

Age >10 Up to 20 degrees

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Congratulations to today's Baltimore marathoners and the medical race staff

In honor of them:

Marathons are becoming increasingly popular with participation rising from an estimated 143,000 US marathon finishers in 1980 to a record high of 507,000 during 2010.

Most victims of exercise-related sudden cardiac arrest have NO premonitory symptoms

Autopsy reports show that

1) 65 - 70% of all adult sudden cardiac deaths are attributable to coronary artery disease.

2) 10% due to other structural heart diseases (HOCM, congenital artery abnormalities)

3) 5 - 10% due to primary cardiac conduction disorders (prolonged QT, ion channel disorders)

4) Remainder are due to non cardiac etiologies

Overall risk of sudden cardiac arrest is approximately from 1 in 57,000 and the risk of sudden cardiac death is approximately 1 in 171,000. Mortality without intervention after sudden cardiac arrest  is greater than 95%. The majority occur in middle to late aged males.

V fib/V tach are the most common arrhythmias leading to sudden cardiac arrest. Most events occur in the last 4 miles of the racecourse.

Survival decreases by 7 - 10%  with each minute of delayed defibrillation. Defibrillation within 3 minutes can produce survival rates as high as 67 - 74%. After 8 minutes, there is a dramatic decrease in survival. Prompt CPR increases survival from 2.5% to greater than 8%.

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Fight Bites

• Any abrasion or laceration over the knuckles should be presumed to be a fight bite.  Patients will often lie about the circumstances of the laceration.
• Radiographs should be obtained on all of these patients to exclude
  • Retained foreign bodies (e.g., tooth fragments)
  • Fracture of the metacarpal head
• Place patient on amoxicillin/clavulanic acid or clindamycin to cover mouth flora
• Irrigate wound well, and explore through the fingers full range of motion to exclude joint or tendon injury.
• Refrain from suturing the wound, as this will increase the risk of infection.
• Splint in position of function and have them follow up in 2 days.

SLAP tear/lesion – Superior labral tear anterior to posterior

Glenoid labrum – A rim of fibrocartilaginous tissue surrounding the glenoid rim, deepening the “socket” joint and is integral to shoulder stability

http://www.orthospecmd.com/images/shoulder_labral_tear_anat_02.jpg

Injury is most commonly seen in overhead throwing athletes

Or from a fall on the outstretched hand, a direct shoulder blow or a sudden pull to the shoulder

Sx’s:  A dull throbbing pain, a “catching” feeling w/ activity. Some describe clicking or locking of the shoulder. May also include nighttime symptoms. Pain is located to the anterior, superior portion of the shoulder.

Athletes may describe a significant decrease in throwing velocity

http://sitemaker.umich.edu/fm_musculoskeletal_shoulder/o_brien_s_test

Apprehension test for patellar dislocation

Test is used to access for the possibility of a patellar dislocation, prior to evaluation, now spontaneously reduced.                                                   

Similar to the shoulder apprehension test

Designed to place the patella in a position of imminent subluxation or dislocation

http://mulla.pri.ee/Kelley%27s%20Textbook%20of%20Rheumatology,%208th%20ed./HTML/f4-u1.0-B978-1-4160-3285-4..10042-7..gr16.jpg

http://www.youtube.com/watch?v=9AJxcbd9g8A

Place the knee in 20 - 30 degrees of flexion with the quadripces relaxed. Grasp the patella and attempt to place lateral directed stress.

If the patella is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion by contracting the quadriceps

Apprehension test for shoulder dislocation

Tests for chronic shoulder dislocation                                                       

Similar to the patellar apprehension test

Designed to place the humeral head in a position of imminent subluxation or dislocation

http://www.maitrise-orthop.com/corpusmaitri/orthopaedic/112_kelly/kelly-fig11.jpg

ABduct and externally rotate arm to a position where the shoulder may dislocate

If the shoulder is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion.

The Analysis of Synovial Fluid Analysis

When trying to diagnosis a septic joint, it is common to order the following labs on the synovial fluid:

• Synovial WBC count
• Glucose
• Protein
• Gram Stain
• Culture

Unfortunately, there is no value of glucose or protein that has enough sensitivity and specificity to make the tests diagnostically helpful.  Gram stains are only postive in culture positive septic joints in approximately 50% of the cases.  Cultures take too long to be helpful in the ED.  The synovial WBC count can be helpful if very high, but a low value does not ensure that the patient does not have a septic joint.

The one test that has been shown to have a Positive Likelihood ratio of Infinity is a synovial lactate level >10.  A synovial lactate should be sent on all synovial fluid as a level of 10 and greater makes the diagnosis of septic arthritis, regardless of the gram stain or synovial WBC level.

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Humerus Fractures, Proximal

• Proximal fractures of the humerus only account for about 5% of all fractures but account for 45% of all humeral fractures.
• We should be familar with the Neer Classication System for Humeral fractures, which can also be seen at http://health-7.com/Handbook%20of%20Fractures/15%20-%20Proximal%20Humerus%20Fractures
   
• The classification system classifies fractures based on
  • 1-part
  • 2-part
  • 3-part
  • 4-part
• The bony segments that make up the parts are
  • Greater Tuberosity (GT)
  • Lesser Tuberosity (LT)
  • Humeral Head
  • Humeral Surgical Neck (SN)
• A part is defined as displaced if >1 cm of fracture displacement or >45 degrees of angulation.
• The greater the number of parts the more likely the patient will require surgery or have increased complications.
  • 3 and 4 part fractures are often fixed surgical due to the increased risk of vascualr compromise to the humeral head.

The median nerve is not the only compression neuropathy of the wrist

The ulnar nerve can become compressed at the level of the wrist as it 1) enters Guyon's canal or 2) or as the deep branch curves around the hook of the hamate

Compression can occur due to carpal bone fractures, local inflammation, ganglias, lipomas, anatomic abnormalities, etc

In sports medicine, the most common mechanism is injury is seen in cyclists (cyclist/handlebar palsy)

http://www.hughston.com/hha/b_15_3_2a.jpg

Also seen in those who participate in racquet sports, baseball, and golf

Symptoms can be isolated motor (claw hand = rare), sensory or both

http://en.academic.ru/pictures/enwiki/85/Ulnar_claw.jpg

Can be associated w/ median nerve compression

Tx: Activity modification such as wearing padded gloves, padding the object, or changing hand position on the handlebars

If above fails, surgical decompression is very effective.

First Metacarpal Fractures:

There are two types of fractures that commonly occur at the base of the 1st metacarpal.  They are:

Bennett Fracture:  This is an intraarticular fracture at the base of the 1st metacarpal that always involves some degree of subluxation or dislocation of the 1st carpometacarpal joint. 

Image from Wikipedia Commons

• This is the most common fracture of the thumb. 
• This fracture is typically caused by axial loading the thumb while the metacarpal is partially flexed.  A common mechanism is when a person punches a wall or hard object with their thumb take the brunt of the force.
• Most of these fractures will require surgical repair but can be treated in the ED with a Thumb Spica Splint.

Rolando Fracture:  This is a communited intraarticular fracture at the base of the first metacarpal that typically has a T or Y shaped configuration with 3 fragments.

Image courtesy of WikiPedia Commons

• Less common then Bennett Fractures
• Associated with a worse prognosis
• Requires surgical repair but can be splinted in the ED with a thumb spica splint.

I am often asked whether physical activity has a positive or negative effect on the overall health of knee cartilage. The answer is unclear. Published data are conflicting.

What is known and generally agreed on:

1) Physical activity has been shown to facilitate cartilage development in children

2) Forced immobility (spinal cord injury) results in rapid cartilage loss

3) The medial knee compartment experiences significant mechanical loads during weight-bearing activity and is often the primary site of knee OA

A recent study attempted to answer whether 1) long-term (10yrs) participation in vigorous physical activity would benefit knee cartilage in healthy adults and 2) whether there were certain subgroups with asymptomatic preexisting structural knee changes which predict a harmful cartilage response to long-term physical activity.

Vigorous = activity generating sweating or SOB at least 20min 1/wk

Healthy older adults (mean age 57.8 yr) performing persistent vigorous physical activity had an increased risk (odds ratio 1.5) of worsening medial knee cartilage defects but not of a change in cartilage volume

In those w/ asymptomatic preexisting structural knee changes, there was worsening of cartilage defects (odds ratio 3.4) and a trend toward increased rate of loss of cartilage volume (again in the medial knee compartment)

Long-term effects of vigorous physical activity may depend on the preexisting health of the joint

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• Wedge compression fractures

• Account for 50 – 70% of all thoracolumbar compression fractures
• Usually results from motor vehicle collisions and falls where an axial load is applied to the spine in flexion causing injury to the anterior column without posterior column injury
• Best seen on the lateral radiograph
• Simple wedge fractures are stable and have no associated neurologic injury
• Instability is present if
  • There is severe compression (>50%)
  • Kyphosis greater than 20 degrees
  • Multilevel compression fractures

http://jbjs.org/data/Journals/JBJS/855/JBJA0851224560G02.jpeg

Hamate Fractures

Occur in two locations: the body of the hamate and the hook (hamular process) of the hamate

Fractures are present in 2 to 4% of carpal bone fractures

Body fractures are less common and are associated with dislocation of the fourth and fifth metacarpals

                Axial force transmitted down the metacarpal shaft (a fall or fist strike)

Hook fractures occur from a direct force from an object strikes the palm such as that from a bat, golf club or racket

Have increased suspicion in these athletes who present w/ ulnar sided wrist pain

Diagnosis is frequently missed;  chronic fractures are associated w/ flexor tendon rupture and ulnar neuropathy

PE:  Tenderness localized over the hamate (in the hypothenar eminence) and over the dorsal ulnar aspect of the wrist. Swelling may be present. Look for resisted flexion of the 5^th digit when the wrist is held in ulnar deviation. May note sensory changes in ulnar nerve distribution

Imaging: PA and lateral views of the wrist will show a body fracture but will frequently MISS a fracture of the hook of the hamate. In those with a clinical suspicion for this entity, order a “carpal tunnel view.”  In the proper clinical setting, CT imaging is excellent for those with high suspicion and normal plain films.

http://mulla.pri.ee/Kelley%27s%20Textbook%20of%20Rheumatology,%208th%20ed./HTML/f4-u1.0-B978-1-4160-3285-4..10044-0..gr2.jpg

Panner's disease refers to osteochondrosis of the capitellum.

Affects the dominant elbow of boys between the ages of 5 and 10

Associated with the repetitive trauma of throwing

Must be differentiated from osteochondrosis dissicans (occurs in the older child >13yo)

Hx: Intermittent pain and stiffness of the elbow. Better w rest, worse w activity.

PE: tenderness over capitellum w/ slight effusion. Loss of 20 degrees full extension

The articular surface of the capitellum appears irregular with areas of radiolucency.

Tx: Symptomatic treatment with rest. In severe cases a long arm splint/cast may be applied for 2-3 weeks.

http://www.ultrasoundcases.info/files/Jpg/org_34277-Afbeelding1.jpg

Luxatio erecta, aka inferior shoulder dislocation, is an uncommon form of shoulder dislocation (0.5-2%)

2 Mechanisms: 1) Forceful, direct axial loading of an ABducted arm.

2) Hyperabduction of the arm leads to impingement of the humeral head against the acromion, If forceful enough, this leverage can rupture the capsule and drive the humeral head downward, resulting in an inferior dislocation. This mechanism is more common.

Classic presentation: Arm locked in marked ABduction with the flexed forearm lying above the head.

http://uconnemig.files.wordpress.com/2011/11/emimages-8c.jpg

http://img.medscape.com/pi/features/slideshow-slide/sdrt/fig1.jpg

http://www.mypacs.net/repos/mpv3_repo/viz/full/76563/3828172.jpg

One may palpate the humeral head against the lateral chest wall

Bony injuries include fractures to surrounding structures such as the coracoid process, acromion, glenoid rim, clavicle, greater tuberosity and humeral head.

Nerve injuries include damage to the brachial plexus/axillary nerve (usually reversed with reduction)

Vascular injuries: Axillary artery thrombosis

Some quick board review pearls.  Remember these fractures/dislocations and the neurologic injury that is associated with them

• Acetabular fracture – sciatic nerve
• Anterior shoulder dislocation – axillary and musculocutaneous nerve
• Elbow dislocation – ulnar or median nerve
• Hip dislocation
  • Anterior – femoral nerve
  • Posterior – sciatic nerve
• Humerus – radial nerve
• Knee Dislocation – peroneal or tibial nerve
• Olecranon fracture – ulnar nerve
• Supracondylar fracture – median, radial or ulnar nerve
• Tibia plateau fracture – peroneal nerve