Musculoskeletal

PAINE #PANCE Pearl – Rheumatology

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Question

49yo woman, with a history of hypertension and GERD, presents to your clinic with a six month history of bilateral shoulder weakness that she first noticed when putting on sweaters and jackets and carrying in groceries. She denies any history of pain, repetitive trauma, or weakness in the hands. On physical examination, she has 3.5/5 strength in shoulder abduction and flexion, as well as the below rash. She reports the rash has been present for about the same time, but doesn’t really bother her.

  1. What lab is likely to be profoundly elevated and what lab is most specific to this condition?
  2. What is the most likely diagnosis?

Answer

  1. Due to the inflammatory myopathy, muscle enzymes are often extremely elevated and are helpful in initial screening. Creatine kinase (CK) is most commonly ordered, but lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) are often elevated as well. The most common myositis-specific autoantibody is Anti-Jo 1 with others being Anti-SRP and Anti-MI-2.
  2. Given this history and dermatologic “shawl sign”, dermatomyositis is most likely. Polymyositis does not present with skin findings.

Ep-PAINE-nym

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Kienböck Disease

Other Known Aliases – none

Definition – avascular necrosis of the lunate

Clinical Significance – most often results from trauma with biomechanical and vascular abnormalities that lead to progressive bone death. Patients will report wrist pain with decreased range of motion and grip strength. MRI is best for early diagnosis and treatment depends on the stage of disease using the Lichtman Classification system.

History – Named after Robert Kienböck (1871-1953), who was an Austrian radiologist and received his medical doctorate from the University of Vienna in 1895. He would explore the new and blossoming field of radiology before becoming the head of the radiological department at Vienna General Hospital before becoming professor of radiology in 1926. He was a pioneer in the use of x-rays for medical diagnosis and would co-found the Vienna Radiology Society in 1923. He would publish his eponymous condition in 1910 in his treatise Über traumatische Malazie des Mondbeins und ihre Folgezustände (Traumatic malacia of the lunate and its consequences).

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. Orthobullets. Kienbock Disease. https://www.orthobullets.com/hand/6050/kienbocks-disease
  7. Wagner JP, Chung KC. A Historical Report on Robert Kienböck and Kienböck Disease. The Journal of Hand Surgery. 2005;30(6):1117-1121. [link]
  8. Kienböck R. Über traumatische Malazie des Mondbeins und ihre Folgezustände: Entartungsformen und Kompressionfrakturen. Fortschritte auf dem Gebiete der Röntgenstrahlen. 1910–1911; 16: 77-103.

#63 – Osteoarthritis Treatment

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***LISTEN TO THE PODCAST HERE***

Quick Osteoathritis Review

  • Signs and Symptoms
    • Progressive joint pain
      • Stage 1 – Intermittent, Predictable, limits only high-impact activities
      • Stage 2 – Constant, effects daily activities
      • Stage 3 – Constant with intermittent, unpredictable, intense pain with severe limitations
    • Worse in the afternoon
    • Decreased ROM
    • Joint-line tenderness
    • Swelling and effusions
  • Radiography
    • 4 Radiographic Criteria of Osteoarthritis
      • Diminished joint space
      • Bony sclerosis
      • Osteophytes
      • Subchondral cyst

General Osteoarthritis Treatment Principles

  • Education
    • Discuss modifiable risk factors
    • Prognosis
    • Treatment options and timeline
  • Goal Setting
    • Identify current issues
    • Set priorities
    • Develop realistic plan
      • Multiple short term goals to achieve long term goal
      • Directed at minimizing pain, optimizing function, and modify joint damage
  • Clinical Assessment and Follow-up
    • Should be every 3 months by provide
    • Factors to be addressed and discussed during visits:
      • Impact of pain on daily living and quality of life
      • Functional limitations
      • Recreational and/or occupational aspirations
      • Sleep disturbances
      • Fall risk assessment
      • Expectations of treatment

Updated Guidelines from ACR/AAF

2019 updated guidelines from American College of Rheumatology and American Arthritis Foundation

Non-Pharmacologic Treatment

  • Should be first line either alone or with pharmacologic therapy
  • Physical therapy is the mainstay of non-pharmacologic treatment
    • Usually 6 weeks
  • Weight loss
    • Loss of 10% of body weight equals 50% reduction in pain scores
    • Adipokines (leptin and adiponectin) released by adipose tissue are known inflammatory factors
    • Consultation with dietician can be helpful
  • Exercise
    • Exercising have comparable effects on pain and function compared to NSAIDs
    • Low-impact is best, but tailor to patient’s function and limitations
    • Activities to help with core strength and balance can have significant reductions in falls
  • Braces and Splints
    • When possible, these aids can have significant benefit in pain reduction during activities

Pharmacologic Treatments

  • Topical NSAIDs should be considered prior to oral NSAIDs
    • Knee > hand efficacy
    • Diclofenac 1% gel – 4g (large joints) or 2g (small joints) applied 3-4x/day
      • Now available OTC
  • Oral NSAIDs > acetaminophen
    • COX-2 selective NSAID
      • Celecoxib 100-200mg daily or BID
      • Diclofenac 75mg BID
      • Meloxicam 10-15mg daily
  • Duloxetine can be helpful
    • Desensitizes central nociceptive pain processing
    • 60-120mg daily
  • Intrarticular glucocorticoid injections have limited role
    • Can be used for short-term relief
      • Most helpful with the hip
      • Long-term use can damage cartilage
    • Triamcinolone 40mg
  • Hyaluronic acid is controversial with limited data
  • Avoid recommended glucosamine, chondroitin, vitamin D, and fish oil due to lack of clear data showing benefit

Surgical Indications and Management

Cottage Physician (1893)

References

  1. Hawker GA, Stewart L, French MR, et al. Understanding the pain experience in hip and knee osteoarthritis–an OARSI/OMERACT initiative. Osteoarthritis Cartilage. 2008; 16(4):415-22. [pubmed]
  2. French SD, Bennell KL, Nichols PJ, Hodges PW, Dobson FL, Hinman RS.  What do people with knee or hip osteoarthritis need to know? An international consensus of essential statements for osteoarthritis.  Arthritis Care Res (Hoboken). 2015;57(6):809. [pubmed]
  3. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002; 288(19):2469-75. [pubmed]
  4. Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013; 310(12):1263-73. [PDF]
  5. Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010; 18(4):476-99. [pubmed]
  6. 2019 American College of Rheumatology/Arthritis Foundation Guideline for Management of Osteoarthritis of the Hand, Hip, and Knee.  Arthritis Care Res (Hoboken). 2020;72(2):149-162. [pubmed]

PAINE #PANCE Pearl – Rheumatology

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Question

43yo woman, with a history of hypertension and GERD, presents to your clinic with a six month history of bilateral shoulder weakness that she first noticed when putting on sweaters and jackets and carrying in groceries. She denies any history of pain, repetitive trauma, or weakness in the hands. On physical examination, she has 3.5/5 strength in shoulder abduction and flexion, as well as the below rash. She reports the rash has been present for about the same time, but doesn’t really bother her.

  1. What lab is likely to be profoundly elevated and what lab is most specific to this condition?
  2. What is the most likely diagnosis?

Ep-PAINE-nym

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Monteggia Fracture

Other Known Aliases – none

Definition – proximal 1/3 ulnar fracture with radial head dislocation

Clinical Significance – This type of injury pattern is most commonly seen with FOOSH injuries and is more common in children than adults with a peak incidence of 4-10 years of age. There are four different classifications depending on the injury pattern. There is also high incidence of neurovascular compromise and a good bedside exam is paramount prior to surgical repair.

History – Named after Giovanni Battista Monteggia (1762-1815), who was an Italian surgeon and received his medical doctorate from the University of Pavia in 1789 at the age of seventeen. He would begin his career as a surgery apprentice at the Great Hospital in Milano in 1790 culminating in professor of anatomy and surgery in 1795. His knowledge of anatomy and skill as a surgeon impressed his a very famous colleague at the University of Pavia, one Antonio Scarpa. He published his eponymous injury in 1814 in his textbook entitled “Institziono Chirurgiche”. Of note, the first radiograph was not taken until 1895.

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. Orthobullets. Monteggia Fractures. https://www.orthobullets.com/trauma/1024/monteggia-fractures
  7. Monteggia GB. Instituzioni Chirurgiches. Vol. 5. Maspero; Milan, Italy: 1814.

PAINE #PANCE Pearl – Orthopaedics

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Question

57yo woman comes into clinic complaining of a six-month history of right shoulder pain. She states that the pain is worse with overhead activities of the shoulder and when she is lifting and pulling with that arm. She has been more playing more tennis with her husband during this time as well, but has never had any other issues with this shoulder or arm before. She also reports painful arc of shoulder rotation with clicking that she feels on the anterior part of her shoulder. On physical examination, she has a negative drop arm and empty can test with no significant pain on resisted external rotation.

  1. What are two (2) maneuvers that you should perform next?
  2. If these are positive, what would the most likely diagnosis be?

Answer

Given the history and negative findings on rotator cuff maneuvers, the next two maneuvers shoulder be the Yergason and Speed tests. If the patient has pain with either of these then it suggests biceps tendonitis as the cause of their shoulder pain. Anatomically, the origin of the long head of the biceps is near the insertion of the supraspinatus tendon. This is why you always assess biceps tendonopathy in patient presenting with shoulder pain.

Ep-PAINE-nym

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De Quervain Tenosynovitis

Other Known Aliases – BlackBerry thumb, mother’s wrist, washerwoman’s sprain

Definition – inflammation of the abductor pollicis longus and extensor pollicis brevis tendons in the first extensor compartment at the styloid process of the radius.

Clinical Significance – The pathogenesis is not well understood, but is most accepted to be caused by repetitive activities that maintain the thumb in extension and abduction. Treatment is graded from thumb spica splinting, NSAIDs, corticosteroid injections, up to surgical release of the first extensor compartment.

History – Named after Fritz de Quervain (1868-1940), who was a Swiss surgeon and received his medical doctorate from the University of Bern in 1892. He would start his career training under Hugo Kronecker, Theodor Langhans, and Theodor Kocher, before becoming director of the surgical department at the La Chaux-de-fonds in Neuchâtel in 1897, and culminating in professor of surgery and director of the Inselspital at the University of Bern in 1918. He was a strong proponent of the generalist approach to patient care rather than the specialization of physicians and surgeons. He would describe his eponymous findings in his classic textbook series Spezielle chirurgische Diagnostik (Special Surgical Diagnosis) in 1907.

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. Spezielle chirurgische Diagnostik. Leipzig, 1907; 9th edition, 1931.

PAINE #PANCE Pearl – Orthopaedics

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Question

57yo woman comes into clinic complaining of a six-month history of right shoulder pain. She states that the pain is worse with overhead activities of the shoulder and when she is lifting and pulling with that arm. She has been more playing more tennis with her husband during this time as well, but has never had any other issues with this shoulder or arm before. She also reports painful arc of shoulder rotation with clicking that she feels on the anterior part of her shoulder. On physical examination, she has a negative drop arm and empty can test with no significant pain on resisted external rotation.

  1. What are two (2) maneuvers that you should perform next?
  2. If these are positive, what would the most likely diagnosis be?

Ep-PAINE-nym

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Finkelstein’s Test

Other Known Aliases – Eichoff’s test

Definition – physical examination maneuver that is used to diagnose de Quervain’s tenosynovitis.

Clinical Significance – this maneuver is performed by deviating the wrist in the ulnar direction while pushing the thumb towards the palm. A positive illicits pain along the radial aspect of the wrist along the abductor pollicis longus and extensor pollicis brevis tendons.

History – Named after Henry Finkelstein (1883-1975), who was an American surgeon and recieved his medical doctorate from the College of Physicians and Surgeons in 1904. He would go on to have a modest career in orthopaedic surgery serving as a consultant at Beth Israel Hospital and chief of orthopaedic surgery at Trinity Hospital in Brooklyn, NY. He also was one of the original founding staff of the Hospital for Joint Diseases (now known as NYU Langone Orthopaedic Hospital). He published his eponymous maneuver in a manuscript entitled “Stenosing tendovaginitis at the radial styloid process” in 1930.

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. Finkelstein H. Stenosing tendovaginitis at the radial styloid process. The Journal of Bone and Joint Surgery, 1930, 12: 509-540 [link]
  7. https://www.nytimes.com/1975/01/25/archives/dr-harry-finkelstein-91-orthopedic-surgeon-dies.html

#53 – Ottawa Rules

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***LISTEN TO THE PODCAST HERE***

Background

  • These studies are conducted at the Ottawa Hospital Research Institute and University of Ottawa starting in 1992 and the main researcher behind these is Ian Stiell.
  • They are international recognized and have been validated multiple times to decrease unnecessary radiographic testing and decrease healthcare costs

Disclaimer for Using Clinical Decision Instruments

  • Your clinical judgement should ALWAYS trump using any CDI
    • Distracting injuries
    • Intoxication
    • Inability to fully examine
    • Gestalt

Ottawa Rules of the Foot and Ankle

  • The Numbers
    • Ankle xrays are the second most commonly ordered film in the ED
    • < 15% fracture incidence rate
  • The study
    • Published in 1992, validated in 1995
    • 7 months long
    • 750 patients
    • 21 EM physicians looking at 32 clinical variables
  • Variables
    • Lateral malleolus tenderness
    • Medial malleolus tenderness
    • Base of 5th metatarsal tenderness
    • Navicular tenderness
    • Inability to bear weight immediately and in the emergency department for four steps
      • Limping counts
  • Outcomes
    • Identified 100% of clinically significant fractures
    • Decreased ankle imaging 36% and foot imaging 21%
  • Clinical Pearls
    • Be sure to palpate the entire 6cm of the distal tibia and fibula
    • Do not confuse soft tissue tenderness for bony tenderness

Ottawa Rules of the Knee

  • The Numbers
    • >600,000 patients annually present to ED with knee complaints
    • 80% of these patients have radiography
      • Majority have soft tissue injuries
  • The study
    • Published in 1995, validated in 1996
    • 14 months long
    • 1,047 patients
    • 33 EM physicians looking at 23 clinical variables
  • Variables
    • > 55 years of age
    • Isolated patella tenderness
    • Fibular head tenderness
    • Inability to flex knee to 90o
    • Inability to bear weight immediately and in the emergency department for four steps
      • Limping counts
  • Outcomes
    • Identified 100% of clinically significant fractures
    • Decreased knee imaging by 28%
  • Clinical Pearls
    • Use only for injuries < 7 days old
    • Patella tenderness only significant if an isolated finding

Ottawa Rules of the Cervical Spine

  • The Numbers
    • C-spine series is the most common radiograph for trauma
    • > 1,000,000 series performed annually
      • > 98% being negative
  • The study
    • Published in 2001, validated in 2003
    • 3 years long
    • 8,924 patients
      • Blunt trauma only
      • Stable vital signs
      • GCS of 15
    • Looked at 20 clinical variables
  • Variables
    • ≥ 65 years of age
    • Dangerous mechanism
      • Fall from height > 3 feet or 5 stairs
      • Axial load
      • High speed (> 60mph) MVC, rollover, or ejection
      • Motorized recreational vehicle accident
      • Pedestrian or cyclist versus automobile accident
    • Immediate pain
    • Non-ambulatory at scene
    • Inability to rotate neck
  • Outcomes
    • Identified 100% of clinically significant fractures
    • Decreased cervical spine imaging by 42%
  • Clinical Pearls
    • Not applicable if:
      • Non-trauma
      • GCS < 15
      • Unstable vital signs
      • Age < 16 years of age
      • Acute paralysis
      • Known vertebral disease
      • Previous cervical spine history

Canadian Head CT Rule

  • The Numbers
    • > 2 million ED visits annually for minor head trauma
      • Average cost of CT scan ~ $1200
        • Average annual cost > $900 million
    • < 3% incidence of clinically significant intracranial injuries
  • The study
    • Published in 2001, validated in 2005
    • 3 years long
    • 3,121 patients
      • Blunt trauma only
      • GCS between 13-15
      • < 24 hours on presentations
      • Must have loss of consciousness, altered mental status, or amnesia
    • Across 10 academic hospitals
    • Looked at 22 clinical variables
  • Variables
    • High risk variables (need for neurosurgical intervention)
      • GCS < 15 at 2 hour after injury
      • Suspected open/depressed skull fracture
      • Signs of basilar skull fracture
      • ≥ 2 episodes of vomiting
      • ≥ 65 years of age
  • Variables
    • Medium risk variables (predicting clinically important brain injury)
      • Retrograde amnesia ≥ 30 minutes
      • Dangerous mechanism
        • Pedestrian versus auto
        • MVC ejection
        • Fall from height > 3 feet or > 5 stairs
  • Outcomes
    • Identified 100% of high risk patients and 98.4% of medium risk patients
    • Reduction in head CT by > 30%
  • Clinical Pearls
    • Not applicable if:
      • < 16 years of age
      • On anticoagulation
      • Witnessed seizure post-injury
      • Unstable vital signs
      • Acute focal neurologic deficit

Ottawa Rules for Subarachnoid Hemorrhage

  • The Numbers
    • 2% of all ED visits are for headache
    • 2% incidence of subarachnoid hemorrhage
    • 51% mortality if missed
  • The study
    • Published in 2010, validated in 2013
    • 5 years long
    • 1999 patients
      • Non-traumatic
      • < 1 hour from onset
      • GCS 15
    • Looked at 13 clinical variables
  • Original Study
  • Validation Study
  • Variables
    • ≥ 40 years of age
    • Neck pain
    • Witnessed loss of consciousness
    • Exertional onset
    • Added on validation study:
      • Thunderclap headache
      • Limited neck flexion on exam
  • Outcomes
    • Identified 100% of subarachnoid hemorrhages
    • 100% negative predictive value
    • Decreased head CT or lumbar puncture rates by 20%

The Cottage Physician (1893)

References

  1. The Ottawa Rules. [online] Available at: http://www.theottawarules.ca/ [Accessed 10 Nov. 2019].
  2. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Annals of emergency medicine. 1992; 21(4):384-90. [pubmed]
  3. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993; 269(9):1127-32. [pubmed]
  4. Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. JAMA. 1994; 271(11):827-32. [pubmed]
  5. Stiell I, Wells G, Laupacis A, et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ (Clinical research ed.). 1995; 311(7005):594-7. [pubmed]
  6. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Annals of emergency medicine. 1995; 26(4):405-13. [pubmed]
  7. Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA. 1996; 275(8):611-5. [pubmed]
  8. Stiell IG, Wells GA, Hoag RH, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. JAMA. 1997; 278(23):2075-9. [pubmed]
  9. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001; 286(15):1841-8. [pubmed]
  10. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. The New England journal of medicine. 2003; 349(26):2510-8. [pubmed]
  11. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet (London, England). 2001; 357(9266):1391-6. [pubmed]
  12. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005; 294(12):1511-8. [pubmed]
  13. Perry JJ, Stiell IG, Sivilotti ML, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ (Clinical research ed.). 2010; 341:c5204. [pubmed]
  14. Perry JJ, Stiell IG, Sivilotti ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013; 310(12):1248-55. [pubmed]