Author: Kristopher Maday PA-C

PAINE #PANCE Pearl – Orthopaedics

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Question

11yo male presents to pediatrician with a 3 week history of a painful left hip. He and his parents denies any inciting or traumatic event and he denies fever, chills, recent illness, or past symptoms. On physical examination, he has a noticeable limp and you elicit pain with passive internal rotation of the hip. Radiograph is below.

  1. What is the main risk factor for this condition?
  2. What radiographic abnormality is seen?
  3. What is the management of this condition?
  4. What is the most serious adverse event associated with this condition?

Answer

Diagnosis – Slipped Capital Femoral Epiphysis

1. The main risk factor is obesity in adolescence with > 60% of cases occurring in children ≥90th percentile weight for age.

2. Diagnosing SCFE on plain radiographs is accomplished by drawing a parallel line from the lateral femoral neck towards the femoral head. This line is called Klein’s Line. In normal patients, this line should intersect the lateral portion of the femoral head. In SCFE patient, it does not.

3. The mainstay of management of SCFE is operative stabilization by way of percutaneous in situ fixation

4. The most serious complication seen with SCFE is avascular necrosis of the femoral head, but other complications include chondrolysis and femoroacetabular impingement.

References

  1. Loder RT. The demographics of slipped capital femoral epiphysis. An international multicenter study. Clinical orthopaedics and related research. 1996; [pubmed]
  2. https://www.orthobullets.com/pediatrics/4040/slipped-capital-femoral-epiphysis-scfe
  3. http://www.wheelessonline.com/ortho/treatment_scfe

Ep-PAINE-nym

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Klein’s Lines

Other Known Aliases – Line of Klein

Definition – Virtual line drawn parallel from the femoral neck that should intersect the lateral upper edge of the femoral head

Clinical Significance – Used in the radiographical diagnosis of slipped capital femoral epiphysis and allows for early diagnosis and surgical management to prevent avascular necrosis as an adult. The sensitivity and specificity are the highest if modified by a ≥2mm difference in the epiphyseal width lateral to Klein’s line compared to the unaffected side.

History – Named after Armin Klein (1892-1954), who was an American orthopaedic surgeon and received his medical doctorate from Harvard Medical School in 1927. He completed his residency at Boston City Hospital and upon completion joined the faculty at Massachusetts General Hospital. It was here in 1952 that Klein and three colleagues published a case series on children with previously undiagnosed SCFE, but with positive findings using his technique. He would later go on to become Chief of Orthopaedic Surgery at the new Beth Israel Hospital in Boston and obtained teaching positions at Harvard Medical School and Tufts College Medical School.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. KLEIN A, JOPLIN RJ, REIDY JA, HANELIN J. Slipped capital femoral epiphysis; early diagnosis and treatment facilitated by normal roentgenograms. The Journal of bone and joint surgery. American volume. 1952; 34-A(1):233-9. [pubmed]
  7. https://journals.lww.com/jbjsjournal/Citation/1954/36040/ARMIN_KLEIN_1892_1954.29.aspx

PAINE #PANCE Pearl – Orthopaedics

Posted by

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Question

11yo male presents to pediatrician with a 3 week history of a painful left hip. He and his parents denies any inciting or traumatic event and he denies fever, chills, recent illness, or past symptoms. On physical examination, he has a noticeable limp and you elicit pain with passive internal rotation of the hip. Radiograph is below.

  1. What is the main risk factor for this condition?
  2. What radiographic abnormality is seen?
  3. What is the management of this condition?
  4. What is the most serious adverse event associated with this condition?

Ep-PAINE-nym

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Sjögren’s Syndrome

Other Known Aliases – Gougerot’s syndrome

Definition – chronic autoimmune inflammatory disease characterized by diminished lacrimal and salivary gland function

Clinical Significance – Patients affected by this disease have dry eyes, dry mouth, dry skin, and various other systemic abnormalities. The exact mechanism is unknown, but is believed to be a combination of genetics (HLA association) and environmental triggers (viral pathogens).

History – Named after Henrik Samuel Conrad Sjögren (1899-1986), who was a Swedish ophthalmologist who received his medical doctorate from the Karolinksa Institutet in 1922. He married a classmate of his (Maria Hellgren), who also happened to be the daughter of one of the most prominent ophthalmologists in Stockholm. He first encountered his future eponymous disease in 1925, and published a case report of five patients in 1930. He completed his doctoral thesis in 1993 on “Zur Kenntnis der keratoconjunctivitis sicca”, but unfortunately did not earn him the title of docent to pursue a career in academia. He did however enjoy a prolific career with numerous honorific appointments…..including docent at the University of Göteborg in 1961.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. https://hekint.org/2018/09/11/henrik-sjogren-and-his-syndrome/
  7. Sjögren H. Zur Kenntnis der keratoconjunctivitis sicca. Keratitis filiformis bei Hypofunktion der Tränendrüsen. Acta Ophthalmol. 1933;2:1–151
  8. Murube J. Henrik Sjögren, 1899-1986. The ocular surface. 2010; 8(1):2-7. [pubmed]

PAINE #PANCE Pearl – Orthopaedics

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Question

31yo male was involved in a pedestrian vs car accident and presents as a trauma transfer to your facility 3 hours after the injury. On initial presentation, the patient is in extreme distress and pain. Physical examination shows decreased dorsalis pedis and posterior tibial pulses, significant swelling, decreased sensation in the lower leg, and increased pain with passive dorsiflexion. Radiograph reveals a minimally displaced proximal tibia and fibula fracture.

  1. What is your main concern at this point?
  2. How do you test for it?
  3. What do you do about it?

Answer

  • The main concern given the mechanism of injury and physical examination findings is compartment syndrome. This is a limb-threatening condition and needs to be acted upon immediately.
    • The hallmark findings of compartment syndrome are:
      • Pain
        • Out of proportion
        • With passive stretching of muscles
      • Paralysis
      • Pulselessness
      • Paresthesias
      • Pallor
      • Poikilothermia
  • Testing for compartment syndrome involves directly measuring the pressure within the compartment. Commercial devices (such as Stryker) are common, but simple 18g needles attached to arterial line pressure monitors can also be used.
    • Normal pressure of tissue compartments should be < 10 mmHg.
    • Delta pressure = DBP – measured compartment pressure
      • Delta pressure < 30 indicates need for fasciotomy
    • Measuring of pressures SHOULD NOT delay transfer or consultation
  • Management of compartment syndrome is to perform a 4-compartment fasciotomy
    • Double-incision technique is most common to release all four compartments
      • Lateral incision – between fibular shaft and crest of tibia
      • Medial incision – 2cm medial to tibial margin

References

  1. Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. The Journal of the American Academy of Orthopaedic Surgeons. 2005; 13(7):436-44. [pubmed]
  2. Shadgan B, Menon M, O’Brien PJ, Reid WD. Diagnostic techniques in acute compartment syndrome of the leg. Journal of orthopaedic trauma. 2008; 22(8):581-7. [pubmed]Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. The Journal of the American Academy of Orthopaedic Surgeons. 2005; 13(7):436-44. [pubmed]
  3. Hammerberg EM, Whitesides TE, Seiler JG. The reliability of measurement of tissue pressure in compartment syndrome. Journal of orthopaedic trauma. 2012; 26(1):24-31; discussion 32. [pubmed]
  4. Nelson JA. Compartment pressure measurements have poor specificity for compartment syndrome in the traumatized limb. The Journal of emergency medicine. 2013; 44(5):1039-44. [pubmed]
  5. Fasciotomy. Wheeless’ Textbook of Orthopaedics. http://www.wheelessonline.com/ortho/12806

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Thompson’s Test

Other Known Aliases – Simmond’s Test

Definition – passive accessory movement test of the ankle to test for a ruptured achilles tendon

Clinical Significance – To perform, place the patient in a pron position or kneeling on the injured extremity’s knee without supporting the foot and ankle. The grasp the muscle belly of the gastrocnemius and observe for passive plantarflexion. A positive test results in inability to plantarflex and confirms a complete rupture of the achilles tendon.

History – Named after Theodore Thompson (1902-1986), an American orthopaedic surgeon who received his medical doctorate from Johns Hopkins University in 1928. Prior to enrolling at Hopkins, he was involved in a traumatic arm injury working at a steel mill where his arm went through a planer. Luckily, a local orthopaedic surgeon, knowing Thompson want to go into medicine, did not amputate and reconstructed his arm to regain full function. His career achievements include heading the amputation center at Walter Reed Hospital during World War II and becoming president of the American Academy of Orthopaedic Surgeons in 1954. He described his eponymous finding in 1962 in two separate articles….which was AFTER Franklin Adin Simmonds (1910-1983), a British orthopaedic surgeon, published the same findings in 1957. Thompson did however acknowledge and reference Simmonds in his 1962 paper. Depending on what side of the pond you trained on will determine how you learned the name of this test.

References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. THOMPSON TC, DOHERTY JH. Spontaneous rupture of tendon of Achilles: a new clinical diagnostic test. The Journal of trauma. 1962; 2:126-9. [pubmed]
  7. THOMPSON TC. A test for rupture of the tendo achillis. Acta orthopaedica Scandinavica. 1962; 32:461-5. [pubmed]
  8. Simmonds FA. The diagnosis of the ruptured achilles tendon. The Practitioner. 1957;179(1069-1074):56-58 [article]
  9. Physiopaedia. Thompson Test. https://www.physio-pedia.com/Thompson_Test

#50 – Rotator Cuff Injuries

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Epidemiology

  • Up to 30% of the US population report having “shoulder pain”
    • 11 cases per 1000 patients per yearRotator cuff pathology is the most common reason patients seek treatment
  • Rotator cuff injuries also account for up to 40,000 surgeries per year in the US
  • Increases prevalence with age

Risk Factors

  • Repetitive, overhead activities
    • Swimming, weightlifting, tennis, throwing
  • Subacromial impingement
  • Scapular instability or dyskinesis
  • Older age
  • Diabetes
  • Hyperlipidemia and statin use
  • Trauma

Anatomy

  • There are four muscles of the rotator cuff
    • Supraspinatus (most commonly injured)
    • Infraspinatus
    • Subscapularis
    • Teres minor
  • The main function of the rotator cuff muscles is to assist in abduction and external rotation of the shoulder
    • Subscapularis assists internal rotation
  • Also compresses humeral head into the glenoid fossa
    • Stabilizes the glenohumeral joint
    • Counterbalances the elevating force of the deltoid

Mechanisms of Injury

  • Intrinsic mechanisms
    • Emphasize injury within the tendon that decrease integrity over time
      • Overload        
        • During eccentric muscle contraction in overhead activities
      • Degeneration
        • Microtears and calcifications from aging
        • Hypovascularity of the tendons
  • Extrinsic mechanisms
    • Emphasize compressive forces from structures surrounding the rotator cuff that can lead to impingement
      • Acromion, coracoclavicular ligaments, coracoid process
      • Glenohumeral instability

Signs and Symptoms

  • Pain with overhead activities and night pain
    • Over lateral deltoid
  • Weakness
    • Can be apparent even in asymptomatic individuals

Physical Examination

  • Need to evaluate the entire shoulder for other differential diagnoses, including:
    • Biceps tendonitis
    • Labral tears
    • Cervical radiculopathy
    • Thoracic outlet syndromes
  • Inspection
    • Chronic pathology can show atrophy of supraspinatus and infraspinatus
    • Asymmetric movement on active range of motion
      • Particularly with the scapula
  • Palpation
    • Tenderness of affected muscle
    • Focal subacromial tenderness
  • Range of Motion
    • Pain is usually elicited with:
      • 90o abduction
      • Internal rotation
    • Passive range of motion is better than active
  • Rotator cuff specific maneuvers include:

Diagnostic Studies

  • Plain radiographs are generally not helpful, but can be useful for:
    • Assessment when there is no response to conservative therapy
    • Recurrent rotator cuff tendinopathy
    • Anatomical evaluation prior to subacromial or glenohumeral joint injection
  • Ultrasound
    • Rapidly being considered the new gold standard
      • Allows for visualization of tendons in motion
      • Allows for comparison to contralateral side
o https://www.youtube.com/watch?v=p9m3NDN5ONA
  • Magnetic Resonance Imaging
    • Considered when:
      • Ruling out a tear when conservative therapy fails
      • Assess for a tear if clinically suspected
      • Aid in the diagnosis when pathology is unclear
    • Findings suggested of tears are:
      • Discontinuity on T1-weighted image and fluid signal on T2-weighted images
      • Fluid in the subacromial space on T2 images
      • Loss of subacromial fat plane on T1
      • Proliferative spur formation of acromion or AC joint

Treatment

  • Conservative Treatment for tendinopathy or chronic, partial tears
    • Cryotherapy
    • Rest
    • NSAIDs
    • Physical therapy (minimum of 6 weeks)
      • Initial stage – mobility
      • Second stage – strength
      • Third stage – function
    • Corticosteroid injections
  • Indications for Surgical Management
    • Acute, full-thickness tears in normal rotator cuff
    • New functional deficit with a known, partial tear
Arthroscopic Repair
“Full” Open Repair
“Mini” Open Repar

Cottage Physician

References

  1. Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Indications for rotator cuff repair: a systematic review. Clinical orthopaedics and related research. 2007; 455:52-63. [pubmed]
  2. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. Journal of shoulder and elbow surgery. 2014; 23(12):1913-1921. [pubmed]
  3. Lin TT, Lin CH, Chang CL, Chi CH, Chang ST, Sheu WH. The effect of diabetes, hyperlipidemia, and statins on the development of rotator cuff disease: a nationwide, 11-year, longitudinal, population-based follow-up study. The American journal of sports medicine. 2015; 43(9):2126-32. [pubmed]
  4. Mehta S, Gimbel JA, Soslowsky LJ. Etiologic and pathogenetic factors for rotator cuff tendinopathy. Clinics in sports medicine. 2003; 22(4):791-812. [pubmed]
  5. Sørensen AK, Bak K, Krarup AL, et al. Acute rotator cuff tear: do we miss the early diagnosis? A prospective study showing a high incidence of rotator cuff tears after shoulder trauma. Journal of shoulder and elbow surgery. ; 16(2):174-80. [pubmed]
  6. Kim HM, Teefey SA, Zelig A, Galatz LM, Keener JD, Yamaguchi K. Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs. The Journal of bone and joint surgery. American volume. 2009; 91(2):289-96. [pubmed]
  7. Lew HL, Chen CP, Wang TG, Chew KT. Introduction to musculoskeletal diagnostic ultrasound: examination of the upper limb. American journal of physical medicine & rehabilitation. 2007; 86(4):310-21. [pubmed]
  8. Roy JS, Braën C, Leblond J, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. British journal of sports medicine. 2015; 49(20):1316-28. [pubmed]
  9. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford, England). 2006; 45(5):508-21. [pubmed]
  10. Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. British journal of sports medicine. 2007; 41(4):200-10. [pubmed]