Turf Toe:

Most commonly seen in atheletes who compete on artificial turf.  Presents as pain over the 1st Metatarsalphalangeal  (MTP) joint. 

• Due to a tear of the Metatarsal phalangeal Joint Capsule
• Results in subluxation or dislocation of the MTP joint
• Occurs due to:
  • Hyperextension (most common)
  • Hyperflexion
  • Valgus stress
• Treatment:
  • NSAIDS
  • Rest
  • Orthosis -- Prevents dorsiflexion during athletic activities

 

Achilles Tendon Rupture

• Most commonly occurs in males age 30-50 years that participate in occasional high intensity sports that are associated with jumping or quick starts.  [i.e.: Basketball, racquetball, tennis, squash, etc].
  • Exact mechanism is a sudden eccentric force that is applied to a dorsiflexed foot.
• Rupture is also associated with fluoroquinolone and glucocorticoid use.
• Patient will often hear or feel a sudden snap in the back of the ankle or calf.
• Typically ruptures 2-6cm proximal to its insertion on to the calcaneous where its blood supply is the least.
• On physical exam:
  • the patient is unable to plantar flex the foot, raise up on toes, and may have calf swelling. 
  • You may be able to palpate a gap in the achilles tendon.
  • Two specific tests for achilles tendon rupture.
    • Thompson test:  with the leg extended and the foot in neutral position, squeeze the calf muscles.  A positive test is when the foot does not plantar flex when the muscles are squeezed.
    • O’Brien needle test:  Insert a small gauge needle perpendicular to the skin into the proximal (about 10 cm from the calcaneous) achilles tendon. Passively dorsiflex and plantar flex the ankle and foot. If the needle moves in the opposite direction of the movement then the achilles tendon is intact.
• Treatment
  • Refer to orthopedics
  •  Place the patient in a posterior splint with the foot and ankle in slight plantar flexion. 
    • Ideally this will bring the two tendon ends together and speed healing.

This addition was sent in my Dr. Andrew Milstein:

Thanks for the Orthopedics update.  A few pearls for Achilles Tendon Rupture --> often these patients may present like a typical ankle sprain patient and are placed in a hallway chair.  You can't do an adequate Thompson Test while someone is sitting in a chair.  If you're concerned, lay them down on a stretcher to do the test.

DeQuervain and Intersection Syndromes:
 

• DeQuervain's Syndrome (Tenosynovitis of the Abductor Pollicus Longus and Extensor Pollicus Brevis tendons) is a common disorder that has received a lot of press lately as BlackBerry Thumb or Gamer's Thumb.
  • This condition can be diagnosised by the Finklestein test [Have the patient bend their thumb into the palm of their hand, and then make a fist.  They should then ulnar deviate their wrist.  Pain along the tendons secures the diagnosis.]
  • The pain of DeQuervain's syndrome is typically along the distal end of the radius at the base of the thumb.
• Intersection syndrome is a less common disorder though closely related to DeQuervain's Syndrome
  • The pain is usually felt on the top of the forearm about three inches proximal to the wrist. 
  • The pain from this condition is due to tenosynovitis of the Extensor carpi radialis longus and Extensor Carpi radialis brevis muscles/tendons caused by the intersection of them with the Extensor pollicus brevis and Abductor pollicus longus tendons.
  • Occurs due to excessive wrist movements.
  • Intersection syndrome can be seen in weight lifters, skiers, and can be seen in homeowners in the fall and winter when they rake a lot of leaves or shovel snow.
• Treatment is the similar for both conditions and consists of:
  • NSAIDS
  • Cortisone injections can be effective
  • Thumb and wrist immobilization with a Thumb Spica Splint or Cock Up Wrist Splint
     

Sternoclavicular Dislocation:

• A rare cause of chest/shoulder pain following trauma, but one that can be associated with serious vascular injuries.
• Anterior dislocations of the Sternoclavicular(SC) Joint are much more common  than posterior and  usually resulting from  blow to the anterior shoulder that rotates the shoulder backward and transmits the stress to the medial clavicle and SC joint.
• A blow to the posteior shoulder that drives the shoulder forward or a direct blow to the medial clavicle can cause a posterior dislocation.
• Anterior SC dislocations
  
  • Generally not associated with any underlying injury and can be safely reduced in the ED. 
  • Ligaments and joint capsule entrapment can make it difficult to reduce the joint, and often it is difficult to maintain the reduction. 
  • It is not uncommon for these to require open reducation and internal fixation.
  • Can be reducted by abducting, extending, and applying traction to the ipsilateral arm/shoulder while applying posterior and inferior pressure on the medial clavicle.
• Posterior SC dislocations
  
  • Rare
  • Associated with injuries to the underlying vasculature,  dyspnea due to tracheal compression, and parasthesias.
  • Often missed on plain films (CXR, Shoulder Series or Clavicular Series)
  • Best visualized with enhanced CT Scan of the Chest.  IV enhancement recommended to ensure that their is no associated vascular injury.
  • Can be reducted by abducting, extending, and applying traction to the ipsilateral arm/shoulder while pulling the clavicle forward.  Several references recommend using a towel clip to grasp the clavicle if you are unable to grab it effectively with your fingers. 

Sorry this is being delivered to you late.

 

Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5^th Metacarpal)

Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.

• 2^nd and 3^rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
• 4^th Metacarpal fracture <20۫ angulation allowed
• 5^th Metacarpal fracture <30۫ angulation. 
  • Studies have shown that even 30۫ angulation will decrease normal function by 20%.  
  • Normal excursion of the 5^th MCP is 15۫ to 25۫.
• No amount of rotation deformity should be allowed.

Some quick facts about Knee Injuries:

 

• The most common cause of acute traumatic hemarthrosis of the knee is an anterior cruciate ligament tear.
  • Most patients with an ACL injury will give a history of immediate pain, disability, knee swelling and audible pop.
• The most common ligament injuried in the knee is the medial collateral ligament.
• Patella dislocations
  • Usually lateral dislocations and often spontaneous reduce.
  • Hyperextend the knee to make the reduction easier.
• Dislocation of the knee:
  • Anterior is the most common and usually secondary to hyperextension
  • Popliteal artery injury is commonly seen and must be looked for.  Easy bedside test is Ankle Brachial Indexs.

 

Pediatric Strain versus Fracture

• Due to the fact that tendons are much stronger than the physeal growth plate in pre-pubescent children, one should be extremely cautious when diagnosing a strain/sprain. 
• Pre-pubescent pediatric patients should be treated as if they have a Salter Harris I fracture with an appropriate splint and close follow up.

Review of Salter Harris Fractures

1. A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened.
2. A fracture through the physeal growth plate and metaphysis.
3. A fracture through the physeal growth plate and epiphysis.
4. A fracture through the physis, physeal growth plate and metaphysis.
5. A crush injury of the physeal growth plate.

Please click here for a pictorial of Salter Harris Fractures from FP Notebook.

Low Back is one of the most common complaints that we see in the Emergency Department.  Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…).  However, most of the back pain that we will see is musculoskeletal in origin.

The American College of Physicians (ACP) and the American Pain Society (APS) recently released some joint recommendations on the evaluation of treatment of individuals with back pain.

In summary their key recommendations are:

1. Routine imaging is not required. However, diagnostic imaging and testing should be obtained for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.
2.  For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
3. Medications that have good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain).

Links to the Clinical Guidelines are listed below:

• Evaluation and Treatment
• Nonpharmacologic Therapies for Acute and Chronic Low Back Pain
• Medications for Acute and Chronic Low Back Pain

Supracondylar fractures in children: To assess the likelihood of a supracondylar fracture in a child look at the anterior humeral line. This is a line drawn down the anterior portion of the humerus on the lateral view of the elbow. This line should pass through the center of the capitellum in the distal humerus. If the line does not pass through the center there is a very high likelihood of a supracondylar fracture. Review of the Appearance of Ossification Centers in Children's Elbows CRITOE Capitellum 1 to 8 months Radial Head 3 to 5 years Medial (Internal)Epicondyle 5 to 7 years Trochlea 7 to 9 years Olecranon 8 to 11 years Lateral ( External) Epicondyle 11 to 14 yeras