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.
What is the main risk factor for this condition?
What radiographic abnormality is seen?
What is the management of this condition?
What is the most serious adverse event associated with this condition?
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.
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.
What is your main concern at this point?
How do you test for it?
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.
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
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]
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]
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]
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]
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
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
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
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]
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]
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]
Mehta S, Gimbel JA, Soslowsky LJ. Etiologic and pathogenetic factors for rotator cuff tendinopathy. Clinics in sports medicine. 2003; 22(4):791-812. [pubmed]
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]
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]
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]
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]
Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford, England). 2006; 45(5):508-21. [pubmed]
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]
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.
Definition – passive accessory movement test of the knee performed to identify the integrity of the anterior cruciate ligament
Clinical Significance – Place the patient’s knee in about 20-30 degrees flexion and externally rotated slightly. The examiner should place one hand behind the tibia and the other on the patient’s thigh. It is important that the examiner’s thumb be on the tibial tuberosity. On pulling the tibia anteriorly, an intact ACL should prevent forward translational movement of the tibia on the femur. A positive test is > 2mm of movement compared to the unaffected knee.
History – Named after John Lachman (1919-2007), who was an American orthopaedic surgeon and received his medical doctorate from the Temple University School of Medicine in 1945. He was described as a prolific teacher, mentor, and surgeon making his mark across students, faculty, and patients over illustrious career. As a testament to this, his eponymous test was published by one of his colleagues who named and attributed it to him in 1987.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Gurtler RA, Stine R, Torg JS. Lachman test evaluated. Quantification of a clinical observation. Clinical orthopaedics and related research. 1987; [pubmed]
