Article

The orthopedic literature 2010

Unlabelled imageAmerican Journal of Emergency Medicine (2012) 30, 606-614

Review

The orthopedic literature 2010

Michael C. Bond MD a,?, Daniel L. Lemkin MD a, William J. Brady MD b

aDepartment of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA

bDepartment of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA

Received 10 February 2011; accepted 12 February 2011

  1. Pediatric orthopedic issues
    1. Vander Have KL, Perdue AM, Caird MS, Farley FA. Operative versus Nonoperative treatment of midshaft clavicle fractures in adolescents. J Pediatr Orthop 2010;30:307-312.

In 1960, Neer [1] published his experience with 2235 patients with clavicle fractures. In this series, the nonunion rate associated with medical treatment was 0.13%, compared with 4.6% among the 45 patients who underwent surgery. Based on that report, medical students have been taught that most fractures should be treated nonoperatively. More recent articles that were included in our 2009 edition of orthopedic summaries [2] presented evidence that nonoperative treatment in adults results in higher rates of malunion, nonunion, chronic pain, and disability than Operative repair [3-5]. The cohort of Neer included a large number of children and adolescents, who typically heal well without sequelae. The article by Vander Have et al highlights that Younger children are different from adolescents, in that children have more effective “remodeling with continued growth.” Adolescents nearing maturity may benefit from Surgical repair.

Clavicle fractures account for approximately 15% of the fractures sustained by adolescents [6]. The majority are displaced midshaft fractures that are traditionally treated conservatively with a figure-of-eight brace or arm sling. Although there is general agreement that nondisplaced fractures should be treated nonoperatively, there is considerable debate about how to treat displaced fractures. The approach in adolescents is further complicated by the fact that they are often grouped with younger children, confounding outcome analysis.

Vander Have et al followed up adolescents (ages 12-18 years) who were admitted to their trauma center between 2000 and 2008. They excluded patients with pathologic fractures, Open fractures, and fractures associated with a Neurovascular injury with objective neurologic deficits on physical examination and those who had a medical contraindication to surgery or anesthesia. Patients were offered surgical correction if their fracture was displaced more than 2 cm compared with the uninjured side within the first 3 weeks after injury. The primary outcomes were rates of delayed union (no fracture union at 16 weeks), nonunion (no fracture union at 24 weeks), malunion, and complications. Malunion was defined as loss of anatomical alignment or asymmetry of the shoulder compared

* Corresponding author.

E-mail address: [email protected] (M.C. Bond).

with the uninjured side. It was considered symptomatic if the patient experienced pain with overhead use, weakness, fatigability, or neurologic symptoms. Complications were defined as any event that required additional surgery or medical treatment.

The authors identified 42 consecutive patients with a total of 43 clavicular fractures. Their average age was 15.4 years. Twenty-five of them were initially treated nonoperatively with a sling (n = 21) or a figure-of-eight brace (n = 4) for a mean of 4 weeks. For the nonoperative group, the mean time to radiographic union was 9.9 weeks (range, 6-16 weeks); 4 patients eventually required operative repair. There were no nonunions, and patients returned to activity at 16 weeks on average. Seventeen patients were treated operatively. All of them had at least 2 cm of fracture displacement. The fracture displacement developed within 2 weeks of the injury in 7 of them. Average time to union was 7.5 weeks (range, 6-10 weeks), and return to activity was 12 weeks on average from the date of injury. There were no significant intraoperative or postoperative complications. Three patients elected to have the hardware removed because of local prominence.

Symptomatic malunion developed an average of 14 months after injury in 5 of the 25 patients in the nonoperative group whose fractures were displaced less than 2 cm. Of those 5, 4 elected to have corrective osteotomy and returned to activity at a mean of 12 weeks postoperatively.

This study adds to the literature that supports a shift from nonoperative to operative management of displaced midshaft clavicle fractures [3-5]. The combination of these results with those of other recent studies leads to the recommendation that all patients older than 12 years who have more than 2 cm of displacement of fracture fragments should be referred to orthopedics for consideration of operative repair. The complication rate from surgery is low, and restoring the clavicle to its normal length improves shoulder strength, endurance, and motion while preventing long-term complications (ie, pain, weakness, and fatigability of the shoulder).

  1. Pain management
    1. Saunders M, Adelgais K, Nelson D. Use of Intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med 2010;17:1155-1161.
    2. Shear ML, Adler JN, Shewakramani S, et al. transbuccal fentanyl for rapid relief of orthopedic pain in the ED. Am J Emerg Med 2010;28:847-852.

One of the primary reasons that patients come to an emergency department (ED) is for treatment of a painful condition. Patients with severe

0735-6757/$ – see front matter (C) 2012 doi:10.1016/j.ajem.2011.02.017

pain wait an average of 72 minutes for the first dose of an analgesic agent, and those with moderate pain wait nearly 4 hours [7]. These delays are often related to the time needed to obtain Intravenous access and the need to withhold Oral medications in case the patient requires surgery. intramuscular and subcutaneous routes are available for administration of narcotic medications; but absorption via these routes can be erratic, necessitating repeat dosing and inflicting additional pain. The 2 articles highlighted here assess whether administering fentanyl via the transbuccal or intranasal route is effective in relieving pain caused by orthopedic or extremity trauma.

Saunders et al asked the following question: Is a single 2 ug/kg dose of intranasal fentanyl effective in relieving the pain associated with painful orthopedic injuries? They specifically looked at the use of intranasal fentanyl to eliminate additional pain and anxiety associated with IV or IM administration of opioids while maintaining a patient’s nothing by mouth (NPO) status. This prospective, interventional trial was conducted between July and November 2006. A convenience sample of 81 children between the ages of 3 and 18 years were enrolled when a research assistant was available. Patients were included if they had moderate to severe pain suspected of being caused by a fracture. Patients were excluded if they had received narcotic pain medications before ED presentation, had multiple trauma, were hemodynamically unstable, had an allergy to fentanyl or other opiate medications, or had a severe upper respiratory tract infection.

Patients received 2 ug/kg of fentanyl, up to a maximum dose of 100 ug, using a mucosal atomizer device. The total dose was limited by volume constraints, as it equated to a maximum of 1 mL of fentanyl being instilled in each nostril. All patients were monitored. If the pain did not decrease

levels were monitored every 5 minutes for an hour. Hemodynamics and side effects were monitored for an additional hour.

Fentanyl, at a dose of 100 ug, showed a statistical advantage over oxycodone/acetaminophen, at a dose of 5/325 mg, in time to significant reduction in pain, defined as a 2-point drop on the 0-to-10 pain score (10 vs 35 minutes in the oxycodone group [P = .0001]), minutes to maximal pain reduction (40 vs 55 minutes [P = .01]), and maximal pain score reduction (6 vs 3 points [P = .0004]). rescue analgesics were administered to 22 patients (17% in the fentanyl group and 57% in the oxycodone group [P = .003]). Twenty-seven percent of the patients in the oxycodone group had slight nausea compared with 0% in the fentanyl group. There were no instances of significant decreases in heart rate, blood pressure, respiratory rate, or pulse oximetry.

One limitation of the study of Shear et al is that, in an attempt to provide equivalent Analgesic doses of fentanyl and oxycodone, patients were given a single oxycodone/acetaminophen 5-/325-mg tablet that is a lower dose than what is commonly used in their ED and less than the truly equivalent dose of oxycodone, which is 7.5 mg.

Both studies are important, as they show that intranasal and buccal fentanyl are quick and effective for providing pain relief to patients with extremity pain. Fentanyl is well tolerated with no observed effects on any hemodynamic parameters. For patients who might not require IV access for other reasons or in whom IV access would be difficult, these alternative administration routes should be considered as a means of providing effective narcotic analgesia.

significantly within 20 minutes, the care provider was notified and could

provide rescue pain medications as deemed appropriate.

Of the 53 children who were 8 years or younger, 39 (74%) had a clinically significant decrease in pain scores 10 minutes after fentanyl administration. Of the 39, 35 (90%) had a sustained reduction in pain for the entire 30-minute study period. At the 30-minute interval, 46 (87%) of the 53 patients described a clinically significant decrease in pain. Of the 28 children older than 8 years, 19 (67.8%) had onset of pain relief in 10 minutes and statistically significant pain relief at all time intervals. Of those 19, 15 (78.9%) had sustained pain relief for the entire 30-minute study period. Of the 81 patients in the 2 age groups, 19 (23%) were considered for Rescue analgesia (10 in the younger group and 9 in the older group) because they did not experience a significant decrease in pain by 20 minutes. Seven of them received rescue analgesia. Six of the remaining patients required IV access to undergo conscious sedation for fracture reduction. The remaining 6 patients did not receive any additional sedation or Rescue medication. Overall, patient and provider satisfaction was high; and no patients experienced any vomiting, hypoxia, or hypotension. There were no reports of rhinorrhea, epistaxis, or nasal complaints after medication administration.

If not for the volume constraints of fentanyl, approximately 40% of the patients older than 8 years would have received a higher dose of the drug. The lower rate of administration probably attributed to the increased need (32.1% vs 18.9%) for rescue analgesia in this age group, although the authors speculate that increased anxiety in the older group may have affected their pain perception.

The second study by Shear et al was designed to assess whether fentanyl buccal tablets were associated with a more rapid onset of pain relief than that achieved with Oral oxycodone/acetaminophen. The study was based on a convenience sample of 60 adult patients (18-60 years old) who presented to the ED with an extremity injury judged to need radiographs to exclude a fracture. To be included in the study, the patients needed to have pain severe enough to require something stronger than acetaminophen or ibuprofen. Patients were ineligible for the study if they required IV analgesia or if participation in the study would interfere with their care. Patients were also excluded if they were pregnant or breast-feeding, had an allergy to any of the study drugs, were taking any medications or had ingested anything that could interact with opioids, had already received pain medication before arrival or in the ED, or had a history of Opioid abuse.

Participants each received a pair of study medications–an active analgesic and a nonanalgesic comparator in double-blind fashion. Pain

Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with Hip fractures. Am J Emerg Med 2010;28:76-81.

Hip fractures are extremely common in the elderly population and are associated with considerable pain. Comorbidities in the elderly often limit the amount of systemic pain medication that can be administered before there is a change in the patient’s hemodynamic status. local anesthesia or a regional nerve block is an attractive alternative for providing pain relief in this population without the risk of respiratory depression or hypotension. The 3-in-1 femoral nerve block is a well-established perioperative analgesic adjunct for hip fractures and has been shown to effectively anesthesize the lateral cutaneous, obturator, and femoral nerves with a single injection. Several previous studies have demonstrated the efficacy of this method of pain relief in the ED. These studies used a landmark technique, which carries the risk of inadvertant injection of anesthetic into the vasculature, which can lead to life-threatening systemic adverse events [8,9]. Beaudoin et al sought to determine the feasibility of ultrasound (US)-guided femoral nerve blocks with bupivacaine in elderly patients in the ED.

The US technique involved placing a 7.5-MHz linear array transducer 1 cm distal to the inguinal ligament on the side of the affected hip while the patient was supine and in Trendelenburg position. The femoral vessels and nerve were identified in cross section (the nerve is a hyperechoic structure approximately 1 cm lateral to the femoral artery). A local skin wheal of 0.5% bupivacaine was induced 2 cm lateral to the US probe. An 18-gauge needle was then used to puncture the skin at the same site to more easily allow access by a 22-gauge Whitacre noncutting spinal needle. The spinal needle was introduced at a 45? angle relative to the US probe, and 25 mL of 0.5% bupivacaine was injected along the nerve sheath. Direct visualization of the needle was maintained at all times to ensure that no vascular puncture occurred and to ensure that the medication was delivered to the nerve sheath. Immediately after injection, the needle was removed; and manual pressure was held 1 cm below the injection site for 5 minutes. Manual pressure and the Trendelenburg positioning ensured that the Anesthetic spread cephalad. This prospective, observational study involved a convenience sample of

13 patients (mean age, 83 years) who had hip fractures. Seven subjects had Femoral neck fractures, and the remainder had intertrochanteric fractures. The average time to complete the procedure was 8 minutes (range, 7-11 minutes). All procedures were completed on the first attempt, with no reported complications. Pain relief and sensory anesthesia of the thigh were

achieved in all patients. On average, patients experienced a 47% and 67% relative reduction in pain at 15 and 30 minutes, respectively, which remained stable from 30 minutes to 4 hours. Of the 13 subjects, 3 required a rescue analgesic. One received 5 mg of morphine 4 hours after the nerve block was placed.

One limitation of the study is that the procedures were performed by only 2 individuals. One was an emergency medicine physician who had completed a US fellowship, and the other was a emergency medicine resident trained in the technique. Therefore, the success rate that can be achieved by others may not be the 100% seen in this study. The landmark technique is also not associated with a 100% success rate.

This study does show that US guidance of a femoral nerve block provides effective, long-lasting (4 hours) pain relief in elderly patients with hip fractures and can be done relatively quickly (8 minutes on average; maximum time, 11 minutes). This approach minimizes the risk of intravasculature administration of bupivacaine. Patients required fewer parenteral pain medications, which have the potential for Hemodynamic compromise and systemic adverse events.

Miner JR, Gray RO, Bahr J, Patel R, McGill JW. Randomized clinical trial of propofol versus ketamine for procedural sedation in the emergency department. Acad Emerg Med 2010;17:604-611.

Procedural sedation is often performed in the ED to assistant with fracture or dislocation reductions, drainage of large abscesses, and other painful procedures. The ideal drug for procedural sedation has rapid onset and a Short duration of action with minimal effect on the patient’s respiratory status and hemodynamics. Fentanyl and midazolam have a long history of administration to induce procedural sedation. The combination of those 2 drugs is associated with respiratory depression and the need for airway interventions. Patients have a wide range of responses to fentanyl and midazolam, so frequent titration is needed; and the dose needed to provide adequate sedation varies greatly. In addition, this combination has a relatively slow onset of action and prolonged Recovery time, making it far from ideal. The shortcomings of fentanyl and midazolam have led to an increase in the use of propofol and ketamine as primary anesthetics for procedural sedation. Propofol and ketamine have a more rapid onset of action and shorter Duration of action than midazolam and fentanyl.

At some hospitals, the use of propofol is restricted because of concerns about respiratory depression and hypoxia. Administration of ketamine is often limited to pediatric patients because of its association with potential emergence reactions. Ketamine is not generally associated with respiratory depression, although it has been reported after being given as an IV bolus [10-13].

cessation of Gas exchange at any time. clinical interventions related to respiratory depression included an increase in the flow of oxygen, the use of bag-valve-mask ventilation, repositioning of the patient’s airway, or stimulation of the patient to induce breathing.

Of the 100 patients randomized for this study, 97 receivED procedural sedation. Three patients in the ketamine group were not sedated because they no longer needed the procedure. The initial baseline characteristics of the patients were similar, except that more patients who received propofol received supplemental oxygen before the procedure and that the ketamine group was heavier (82 kg [range, 55-158 kg] compared with 72 kg [range, 50-141 kg] for propofol).

The rate of subclinical respiratory depression was higher in the ketamine group than in the propofol group (64% vs 40% [95% confidence interval

{CI}, 4.5%-43.1%; P = .02]). The number of Clinical interventions related to respiratory depression was not different between the 2 groups. Emergence reaction or recovery agitation was reported in 17 patients (36.2%) in the ketamine group; 4 of them required IV midazolam. Four patients in the propofol group experienced recovery agitation.

In total, 5 patients had a systolic blood pressure less than 100 mm Hg at some point during the procedure. The lowest pressure for the 3 of them in the ketamine group was 79 mm Hg and, for the 2 patients in the propofol group, 73 mm Hg. Systolic blood pressure normalized in all patients within 2 minutes after initiation of IV fluids. No negative sequelae were documented. Patients in the propofol group returned to their preprocedure baseline in an average of 5 minutes (range, 0-32 minutes) compared with 14 minutes (range, 2-47 minutes) in the ketamine group. The results of this study are surprising in that more patients in the ketamine group experienced respiratory depression (63.8% of cases) than in the propofol group (40.0%).

Ketamine appeared to be a viable option for procedural sedation, except for recovery agitation. The rate of respiratory depression associated with ketamine in the study by Miner et al, combined with the delay in return to preprocedural baseline, supports the use of propofol as the agent of choice for procedural sedation in the ED. For patients who have an egg or soy allergy and, thus, cannot receive propofol, ketamine remains an attractive alternative over fentanyl and versed, as its rate of recovery agitation requiring treatment is relatively low (occurring in 4 [8.5%] of the 47 patients in this study). A comparison of propofol with lower doses of ketamine or its IM administration may answer questions regarding its efficacy in achieving successful procedural outcomes better than the side effect profile seen in this study. A lower dose of ketamine might mitigate the side effects (ie, respiratory depression or emergence reaction) without negatively affecting sedation efficacy.

  1. Adult issues

Miner et al compared the use of propofol and ketamine in adults,

assessing subclinical respiratory depression and the rate of clinical interventions needed to compensate for respiratory depression. They conducted a prospective, randomized, nonblinded clinical trial between January 2007 and March 2009. All patients, 18 years or older, who were to receive Procedural sedation with propofol were eligible. Patients were excluded if they could not provide consent, had an American Society of Anesthesiologists physical assessment score greater than 2, had a known hypersensitivity to one of the study agents, were pregnant, or had evidence of intoxication before the start of the procedure or if the treating physician planned to use deep sedation instead of moderate sedation.

Patients who were experiencing pain were treated with IV morphine (0.1 mg/kg IV, followed by 0.05 mg/kg IV every 10 minutes as needed or tolerated). The last dose was given no later than 20 minutes before the start of the procedure. Trained research assistants watched patients’ status with continuous cardiopulmonary, pulse oximetry, and end-tidal CO2 monitors. Patients were randomized to receive either propofol (1 mg/kg IV, followed by 0.5 mg/kg every 3 minutes as needed for sedation) or ketamine (1 mg/kg IV, followed by 0.5 mg/kg every 3 minutes as needed for sedation).

Subclinical respiratory depression was defined as a change from the baseline end-tidal CO2 greater than 10 mm Hg, an oxygen saturation less than 92% at any time during the procedure, or airway obstruction with

  1. Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial Septic arthritis in adults. Lancet 2010;375:846-855.

The differential diagnosis for patients presenting to the ED with joint pain is very broad. Septic arthritis is the most serious of the possible causes because of its potential for causing permanent disability. This article very nicely reviews this important topic with an evidence-based consideration of the Early diagnosis and management issues.

The actual incidence of septic arthritis is difficult to determine because there is no standardized definition of the disease and most studies are restricted to cases that are confirmed bacteriologically–although some organisms cannot be cultured successfully in the laboratory. Despite these limitations, the incidence in Western world is estimated at 4 to 10 cases per 100 000 patient-years per year. The incidence is increasing because of the aging population and increased number of invasive procedures and immunosuppressive treatments. Risk factors for septic arthritis include the following: rheumatoid arthritis, osteoarthritis, joint prosthesis, low socio- economic status, IV drug abuse, alchoholism, diabetes, previous intra- articular corticosteroid injection, cutaneous ulcers, and recent or concurrent skin infection. Interestingly, the population of individuals infected with HIV does not have an increased risk over the general population; yet, within the

HIV population, an increased incidence of septic arthritis is seen in this subgroup of IV drug abusers. The most common causative organism identified is Staphyloccocus aureus, followed by other Gram-positive bacteria. Intravenous drug abusers are at increased risk for mixed bacterial and Fungal infections. Interestingly, Neisseria gonorrheoeae is a very rare cause of septic arthritis; more cases are attributed to Neisseria meningitidis. Mathews et al stress that laboratory studies (ie, serology studies, Gram

or synovial WBC level. These tests cannot reliably discriminate between septic and inflammatory arthritis. The physician should perform, or arrange to have performed, an arthrocentesis and then start antibiotics. The improved outcomes seen in children who received corticosteroids should prompt a discussion with the admitting service about whether corticoster- oids should be started on all ED patients with septic arthritis.

stains, and synovial fluid white blood cell [WBC] measurements) are

unreliable and should not be used to exclude the diagnosis when the clinician’s clinical suspicion is high. The erythrocyte sedimentation rate and C-reactive protein level are generally elevated in patients with septic arthritis, but they also have been low or normal in patients with culture- proven septic arthritis. Yet, these laboratory tests should not be abandoned because elevated levels can be used to monitor the patient’s response to therapy. As is true in other areas of medicine, the value of a negative test is not always significant when very High clinical suspicion is present. Blood cultures and Gram stains of synovial fluid are also unreliable. One referenced study showed that blood cultures were positive in only 24% of the patients in whom organisms were identified in the synovial fluid. Gram stains identify organisms in only 50% of cases [14]. All synovial fluid should be sent for crystal analysis; however, the presense of crystals does not exclude septic arthritis, as it can coexist with gout and pseudogout [15]. The authors dismiss the synovial WBC count as a guide for distinguishing septic arthritis from inflammatory arthritis. Their position is supported by several recent articles that demonstrate similarity between the synovial WBC count seen in both septic and inflammatory arthritis [16-18]. Even a predominance of polymorphonuclear neutrophils (N90%) can be seen in both inflammatory and septic arthritides.

Imaging studies are generally unhelpful in the diagnosis of septic arthritis, although magnetic resonance imaging (MRI) can help to assess whether there is coexistent osteomyelitis. Computed tomography, bone scans, and plain radiographs cannot differentiate between inflammatory and septic arthritis.

Arthrocentesis should be considered to obtain fluid that can allow identification of the causative agent. It was cautioned that the emergency physician should not perform arthrocentesis on a prosthetic joint, because the procedure should be done under complete sterile conditions in the operating room. In addition, arthrocentesis should not be performed through overlying or adjacent cellulitis.

No randomized trials have been conducted to provide guidance on ideal antibiotic coverage. The authors recommend that patients be covered for S aureus. Additional coverage for methicillin-resistant S aureus (MRSA) is indicated if the patient is in a high-risk group or if the local incidence of community-acquired methicillin-resistant S aureus is more than 10%. Because septic arthritis can occur from hematogenous spread, direct innoculation, or local spread, the authors recommend broadening the antibiotics to cover Gram-negative organisms if a urinary tract infection, an intra-Abdominal infection, or some other source of infection is suspected. Administration of vancomycin or linezolid for patients allergic to vancomycin should be started in the ED. A third- or fourth-generation cephalosporin should be added to the treatment for patients in whom a secondary infection is suspected, who have a history of recent hospitali- zation, who reside in a nursing home, or who are immunosuppressed.

When septic arthritis is strongly suspected or has been confirmed (ie, via a positive Gram stain or culture), operative irrigation and debridement or serial Needle aspiration of the affected joint should be undertaken by an Orthopedic surgeon. One study showed no difference in long-term outcomes between the 2 treatment strategies [19].

Most of the damage done to the joint is caused by the immune response, not the infection itself. A double-blind, randomized, placebo-controlled trial assessing dexamethasone treatment in 123 children showed a reduced duration of disease, joint damage, and dysfunction in children who received dexamethasone (0.2 mg/kg every 8 hours for 12 doses) compared with those that received only antibiotics [20].

This article highlights that the EP should treat patients for septic arthritis if their clinical suspicion is high, regardless of the patient’s C- reactive protein level, erythrocyte sedimentation rate, systemic WBC count,

  1. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev 2010:CD007612.
  2. Brotz D, Maschke E, Burkard S, et al. Is there a role for benzodiazepines in the management of lumbar disc prolapse with acute sciatica? Pain 2010;149:470-475.

Back pain is the most common musculoskeletal complaint of patients presenting to the ED. It is estimated that 90% of adults experience back pain sometime in their lives. This contributes to many lost work days, work- related disability, and high Health care use. In 2005, back pain was responsible for 139 million visits to health care professionals, at a cost of

$17.6 billion [21]. The ideal treatment plan to limit lost work days and return the patient to full function is often debated. Should the patient be advised to stay active or be placed on complete bed rest? Should benzodiazepines be used for Muscle relaxation?

The article by Dahm et al, as part of The Cochrane Collaboration, evaluated 10 randomized controlled trials that addressed acute Low back pain and sciatica. The main outcome measures were pain, functional status, and return to work. The authors found moderate evidence that patients with acute muscular LBP have small improvements in pain relief and functional status when they are advised to stay active. For patients with sciatica, there was little or no evidence to support bed rest or sustained activity. In fact, the authors found little to no evidence to support the use of physiotherapy (PT) in patients with sciatica.

This review article points out that more research is needed on the ideal treatment of acute LBP. However, current literature supports a stay-active approach over bed rest, which can be associated with generalized Muscle weakness and deconditioning. For patients with sciatica, it does not appear that any form of therapy (bed rest, activity, or PT) relieves their symptoms or enables them to return to work sooner.

The article by Brotz et al assesses whether PT and nonsteroidal anti- inflammatory drugs (NSAIDs) without benzodiazepines are equivalent to the same therapy with benzodiazepines, specifically diazepam, 5 mg twice a day [22]. Several previous trials demonstrated little efficacy of diazepam in the short-term or long-term management of lower back pain [23-25].

The authors conducted a prospective, randomized, placebo-controlled, double-blinded trial, in which they enrolled 60 patients (median age, 42 years [range, 22-68 years]; 26 women and 34 men) who had sciatica attributed to lumbar disc prolapse with or without neurologic deficit. Individuals with bowel or bladder dysfunction and those who experienced acute development of weakness or paralysis were excluded. Patients were also excluded if they had taken any benzodiazepines in the preceding 2 weeks, had a history of benzodiazepine intolerance, had previous surgery, or had sustained trauma to their vertebral column. All patients had a computed tomography or MRI scan to confirm lumbar disc prolapse.

Enrolled patients were hospitalized and underwent a PT regimen in addition to receiving NSAIDs and their study medications. Patients were permitted to receive additional analgesics but not Muscle relaxants. At the end of the 7-day study period, there was no statistical difference in patients’ subjective report of referred pain. However, the benzodiazepine group had a statistically longer hospital stay (10 vs 8 days [P = .008]). In addition, twice as many patients in the placebo group as in the benzodiazepine group experienced pain reduction by more than 50% (P b .0015).

Forty-five patients (22 in the benzodiazepine group and 23 in the placebo group) were reevaluated at 1 year. Both groups had improved. No long-term differences were seen between the 2 groups.

This study is limited by the fact that the participating clinicians did not ensure that muscle relaxation was achieved in the benzodiazepine group,

and they did not monitor patients for excessive sedation. Excessive sedation could have limited patients’ participation in the PT regimen and delayed discharge from the hospital.

This study and previous reports demonstrate that benzodiazepines do not improve Short-term outcomes (ie, relief of pain, return to work, or activity level) in patients with LBP caused by sciatica; in fact, they seem to delay recovery [23-25]. The routine use of benzodiazepines in patients with LBP should be strongly discouraged.

  1. Ang SH, Lee SW, Lam KY. Ultrasound-guided reduction of Distal radius fractures. Am J Emerg Med 2010;28:1002-1008.

Distal radius fractures are seen commonly in the EDs. Some of these fractures can be reduced manually and splinted blindly (without the aid of fluoroscopy). After reduction, radiographs are obtained to ensure adequate alignment. If the alignment is not deemed acceptable, the patient must undergo additional reduction and splinting procedures. Some EDs are equipped with fluoroscopy to guide fracture reduction; however, the need for special training, the cost of equipment, and the need to monitor radiation exposure limit the accessibility and practicality of this technology for most facilities. Ultrasound is a technology with rapidly expanding applications, especially in the ED. Ang et al conducted a study to determine whether US could be used reliably as a bedside tool to aid fracture reduction.

This before-and-after study involved patients older than 21 years who presented to the ED with a closed distal radius fracture. Sixty-two patients were enrolled prospectively from October 2007 to June 2008 and underwent US-guided manipulation and reduction (M&R). The control group was a retrospective cohort of 102 patients who presented between January and June 2007. All manipulations were performed by junior physicians in the ED under the guidance of senior EPs or by the senior EPs themselves.

The patients underwent M&R under either procedural sedation or regional anesthesia (a Bier block). The EPs who used US were allowed to use it as much as needed to attain proper alignment. They used an anteroposterior view of the dorsal radius and a lateral view on the lateral (radial) aspect of the distal radius. There were no set criteria on what was considered an adequate reduction; this decision was left to the treating physician. To assess adequacy of alignment, the authors reviewed postreduction radiographs and measured radial inclination, radial height, and volar/palmar tilt. They considered the fracture anatomically reduced if the radial inclination was 15? to 25?, the radial height was at least 5 mm, and the volar/palmar tilt was -10? to +20?.

Manipulation and reduction was performed by junior physicians in 83.9% of cases in the US group and 73.6% of cases in the control group; the difference was not statistically different. In the US group, 1 patient (1.6%) required a repeat M&R attempt, compared with 9 patients (8.8%) in the control group. The postreduction radiographs in both groups were acceptable. The mean value of each index fell within the acceptable range; however, the US group had a statistically better Volar tilt (5.93 vs 2.61

need to be reduced at all. Neidenbach et al asked if reduction of distal radius fractures leads to improved function, decreased pain, and fewer disabilities or if outcomes are the same for patients whose wrist is splinted in its position upon ED presentation. Previous studies have shown that closed reduction (CR) does not offer any Long-term benefits and that elderly patients with Unstable fractures, even those that are malaligned, tend to heal well when treated nonoperatively [26,27].

Neidenbach et al conducted a retrospective review of 83 patients with moderately to severely displaced distal radius fractures, who presented to a hospital in the United Kingdom between November 2001 and October 2002. Radiographs were measured on the initial and follow-up visits, and a functional assessment was obtained at 6 weeks, 6 months, and 1 year. Patients were treated with or without CR. Patients were excluded if they had concomitant diseases that adversely affected bone physiology, polytrauma, former surgically treated fracture close to the wrist joint, a history of substance abuse, or were participating in another clinical study. Patients who were treated without CR were placed in a dorsal splint, which was replaced with a full cast after 1 week. The total time of immobilization was 5 or 6 weeks. Patients who were treated with CR underwent a hematoma block. After the fracture was seen, radiographically, to be appropriately reduced, a dorsal splint was applied. Repeat radiographs were obtained after 1 and 2 weeks. If the fracture was still reduced after 1 week, the patient’s wrist was placed in a cast; and if the reduction was lost, the patient underwent surgical reduction with Kirschner wire or open

reduction and internal fixation.

Of the 82 patients, 75 were female. The dominant-handed side was fractured in 11 patients (52%) treated without CR and in 25 (40%) of those treated with CR. Other baseline characteristics were similar between the 2 groups, except for those with a concomitant ulnar fracture. The prevalence of this fracture was significantly higher in the group that underwent CR (37/ 62) than in the non-CR group (8/21).

The outcome of this study was that there was no significant difference in radiologic parameters between the 2 groups at 6 months and 1 year, nor was there any significant difference in functional results (ie, range of motion, grip strength, quality of life, or standardized scoring on the Disabilities of the Arm, Shoulder and Hand and Gartland and Werley scoring systems).

The take-home point from this and prior studies is that patients do not show benefit from CR at 1 year after injury [26,27]. Although this study is limited by the fact that there were only 7 male patients and that it was the experience at a single hospital, the conclusion adds to the growing body of literature that distal radius fractures may be treated conservatively without CR. Given the neurovascular and procedural sedation risks that are associated with fracture reduction and the lack of evidence of long- term patient benefit, these studies support shifting the ED Management strategy for distal radius fractures. Emergency department management may consist of immobilizing a fractured wrist with a dorsal or sugar-tong splint and arranging orthopedic follow-up to determine whether operative repair or CR is required.

[mean difference, 3.31; 95% CI, 0.34-6.59; P = .048]).

Although this study is limited by the fact that an insufficient number of patients were enrolled (a sample size of 96 patients was needed to reach a power of 90%), the results demonstrate that US is an effective alternative to the blind M&R technique, which has a 10% rate of repeat reductions. That US does not add additional cost, radiation exposure, or time to the procedure makes it very attractive for routine use in the ED. Its use has the potential to decrease time and resource use by decreasing the need for repeated manipulation attempts and radiographs.

  1. Neidenbach P, Audige L, Wilhelmi-Mock M, Hanson B, De Boer P. The efficacy of closed reduction in displaced distal radius fractures. Injury 2010;41:592-598.

The typical treatment of distal radius fractures consists of anatomically aligning the fracture and allowing the patient to heal in a cast for 4 to 6 weeks. This article attempts to discern whether certain distal radius fractures

  1. Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am 2010;92:1851-1857.

Similar to the study by Neidenbach et al, Egol et al were interested in quantifying the difference in functional recovery in patients older than 65 years who underwent operative repair with plate and screw fixation or external fixation and those who received conservative treatment with CR and casting. Evidence demonstrates no functional outcome difference in patients treated with or without CR. Questions remain whether operative repair improves outcome [26-28].

The authors conducted a retrospective case-control study of 90 patients older than 65 years who were treated with or without surgery for a displaced distal radius fracture between October 2004 and October 2008. All patients were treated initially with CR and a sugar-tong splint; those who were felt to have failed CR were offered operative repair. Patients who refused surgery were treated with cast immobilization.

Forty-six patients (mean age, 76 years) were treated nonoperatively, and 44 (mean age, 73 years) were treated operatively. This age difference was statistically significant (P = .03). Although statistically significant improvement was evident on radiographic evaluation of the fracture in the operative group at all follow-up periods, there was no difference in complication rate or functional status between the 2 groups, as measured by Disabilities of the Arm, Shoulder and Hand and pain scores.

This study and previous reports show that although radiographic

Compared with the Hippocratic and Kocher methods, the FARES technique is faster and less painful and offers the additional benefit of requiring only a single provider. The key to being successful with this technique is to get adequate muscle relaxation by oscillating the arm. Because no single reduction technique is known to be 100% successful, the FARES technique is another technique that EPs can include in their armamentarium for the treatment of anterior Shoulder dislocations.

outcomes (ie, volar tilt, radial inclination, radial length, and ulnar variance)

are improved with operative repair, there do not appear to be any differences in functional outcome at 1 year [29-32]. For elderly patients with distal radius fractures, the ideal treatment might indeed be splinting, followed by cast immobilization for 5 to 6 weeks, with no need for CR or operative repair. This treatment strategy offers significant cost savings and would eliminate the risk of surgical and anesthetic complications.

  1. Sayegh FE, Kenanidis EI, Papavasiliou KA, et al. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am 2009;91:2775-2782.

The most common Joint dislocation seen in the ED is Anterior shoulder dislocation resulting from trauma. Shoulder dislocations represent 50% of the Joint dislocations and are anterior in 90% to 98% of cases [33]. Numerous techniques (eg, Hippocratic, Kocher, traction-countertraction, Milch, and Spaso) have been proposed to reduce a shoulder dislocation. Most require multiple providers or sedation to achieve success. The external rotation method requires only a single provider and does not require sedation [2,34]. Sayegh et al describe a new technique, the Fast, Reliable, and Safe (FARES) method for treatment of anterior shoulder dislocations.

The FARES method is done with the patient lying supine and as comfortably as possible. Neither analgesics nor sedation is administered. With the injured arm at the patient’s side, with the elbow extended and the forearm in neutral position, the provider performing the reduction holds the hand of that arm. The provider then applies gentle longitudinal traction, while creating continous, brief (2-3 full cycles per second), and short-range (approximately 5 cm above and beneath the horizontal plan) vertical oscillating movements of the arm. The arm is then slowly abducted above the patient’s head. The oscillating movements help to relax the patient’s muscles increasing the success of the reduction. After the arm is abducted past 90?, it is gently rotated externally, whereas abduction and the vertical oscillations are continued. Reduction is usually achieved at around 120? of abduction. Once reduction is achieved, the arm is gently rotated internally, placing the forearm across the patient’s chest.

The authors compared their new FARES method with the Hippocratic and Kocher methods. Their description of the Hippocratic method is more consistent with the traction/countertraction method, as they used a sheet for countertraction as opposed to placing their foot in the patient’s axilla. The authors randomized 154 patients (121 men and 33 women; mean age, 43.6 years) among the 3 treatment methods. Patient demographics were similar between the 3 groups as was the prevalence of a coexisting fracture of the greater tuberosity and the mean time between the injury and the first attempt at reduction. Providers were able to attempt the assigned technique twice before it was considered unsuccessful. No patients received any analgesics or sedation. Patients in whom the attempts were unsuccessful were taken to the operating room for sedation and further reduction procedures. In this group, all dislocations were reduced on the

first attempt; and no patient required open reduction.

The FARES technique was successful in reducing 47 (88.7%) of 53 shoulder dislocations compared with 37 (72.5%) of 51 for the Hippocratic method and 34 (68%) of 50 for the Kocher method (P = .033). The average time to reduction using the FARES technique was 2.36 +- 1.24 minutes, with an average visual analog pain score of 1.57 +- 1.43. Both parameters were statistically better (P = .001) than those associated with the Hippocratic method (5.55 +- 1.58 minutes and 4.88 +- 2.17, respectively) and Kocher

method (4.32 +- 2.12 minutes and 5.44 +- 1.92, respectively).

  1. Chuang CH, Pinkowsky GJ, Hollenbeak CS, Armstrong AD. Medicine versus Orthopedic service for hospital management of hip fractures. Clin Orthop Relat Res 2010;468:2218-2223.

There is no debate that patients with hip fractures require admission to the hospital and that most of them should undergo operative repair as soon as possible. However, there is often debate over whether the orthopedic or medicine service should have primary responsibility for the patient. Whether the primary service has any effect on the rate of complications, length of stay, or time to surgery is unknown. The authors of this study, which included members of the departments of medicine, public health sciences, orthopedics, and surgery, sought to find the answers to these questions.

This was a retrospective cohort study conducted at a university-based academic medical center. It involved 151 patients who were admitted for hip fracture surgical repair in 2006. Patients were excluded if they were managed nonoperatively; had previous surgery on the same hip; were admitted to a service other than orthopedics, internal medicine, or Family Medicine; were younger than 50 years; had pathologic or bilateral hip fractures; or had sustained multiple trauma. Fractures of the femur at the femoral head or neck, intertrochanteric, and subtrochanteric regions were included. Of the 151 patient charts that were reviewed, 98 were included in the final analysis. Sixty-five patients were admitted to the orthopedic service; and 33, to a medical service. Fifty-three (81.5%) of the patients admitted to the orthopedic service had a medical consult.

Baseline demographics showed that patients with dementia, chronic obstructive pulmonary disease, congestive heart failure, coronary heart disease, end-stage renal disease, and peripheral arterial disease and those requiring an ambulatory aid before their fracture were statistically more likely to be admitted to a medical service. Those patients on the medical service were also statistically more likely to have severe complications, defined as inhospital death, respiratory failure, acute myocardial infarction, renal failure requiring dialysis, cardiac arrest, and pulmonary embolism. A history of coronary heart disease was the only predictor of having a severe or intermediate complication (adjusted odds ratio, 13.47; 95% CI, 3.61-50.28; P = .0001).

Hospital length of stay was not statistically different between the 2 groups, with a 4-day average (range, 3-7 days) day for orthopedics and a 6-day (range, 4-10 days) day average for a medical service. Time to surgery was delayed for patients on the medical service an average of

6.5 hours longer than for those on the orthopedic service (P = .04). The delay in the time to surgery is probably secondary to this group’s underlying comorbidities, which necessitated additional evaluation and treatment to minimize perioperative risk.

A major limitation of this study is that it is a retrospective chart review, so it cannot be assumed that the same results would be seen if the patients were randomly assigned to a service. Could these patients be managed effectively on the orthopedic service with a medicine consultation? Would the groups then have the same perioperative complication rate?

Because most perioperative complications (eg, respiratory failure, pulmonary embolism, acute myocardial infarction, and renal failure) are caused by a medical condition, patients with significant comorbidities should be admitted to a medical service, where the physicians and nurses are more comfortable with managing these disease processes. Vidan et al

[35] showed that a multidisciplinary approach reduces morbidity and major complications in elderly patients with hip fractures. The EP should be an advocate for their patients, recommending that an elderly patient with a hip fracture and significant medical comorbidities be admitted to a medical service.

  1. Yin TC, Wang JW, Lao ML, Chung HY. A simple technique for reducing posterior hip dislocation: the foot-fulcrum manoeuvre. Injury 2010; 41:665-667.

The incidence of hip dislocations seems to be on the rise in North America. Most traumatic hip dislocations (90%) are posterior and generally the result of the knee striking the dashboard in a motor vehicle collision. Nontraumatic hip dislocations are generally caused by postoperative dislocation of the hip after total hip arthroplasty, with a reported incidence of 1% to 4.9% [36]. Just as in the management of shoulder techniques, various techniques have been described to reduce a posterior hip dislocation. Some are not amenable to use in the ED because they require the patient to be prone or in a lateral position. Others, such as the methods of Allis [37] and Bigelow [38], are physically demanding and put the EP at risk for injury if performed while standing on the stretcher. The authors of this article present the foot-fulcrum maneuver as a safer and less strenuous method.

This technique involves gently flexing the hip as much as possible after the patient is given analgesics and medication to aid in muscle relaxation. The EP sits on the stretcher below the patient while keeping the patient’s affected hip in flexion, with the patient’s ipsilateral foot on the bed as a fulcrum. The EP then crosses his or her leg that is closest to the patient’s midline and lays it against the patient’s foot that is acting as the fulcrum. The EP’s other foot is then placed against the posterolateral aspect of the patient’s dislocated hip, which enables the physician to palpate the femoral head. The EP then grips the patient’s flexed knee and applies a constant traction force by leaning backward. This traction generates an inferior- anterior longitudinal force onto the dislocated femoral head, which reverses the mechanism of injury and relocates the dislocated hip.

The authors performed this technique on 17 patients (7 men and 10 women) between June 2008 and May 2009, for a total of 19 CR attempts (2 patients sustained recurrent hip dislocations). Sixteen of the patients had dislocation of prosthetic hips, and 1 patient had a traumatic hip dislocation. The technique was successful in 15 of the 19 cases; 2 unsuccessful cases were reduced by the technique of Allis [37] after additional sedation was given, and the other 2 were reduced in the operating room with the patient under general anesthesia. The technique led to no complications such as

prevents full muscular expansion and acts to reduce the force of transmission across the inflamed muscle and tendon of ECRB. The brace still allows the ECRB muscle to be contracted; the forearm strap reduces the force of transmission by 13% to 15%. The wrist holds the extensor muscles in a position of rest, and it is a constant visible reminder to the patient to limit activities.

Garg et al conducted a prospective randomized study of 509 patients who presented to their office with symptoms of lateral epicondylitis between 2005 and 2008. Patients were included if they had lateral-sided elbow pain, tenderness to palpation over the lateral extensor origin, and pain with wrist and long-finger extension against resistance. Individuals were excluded if they had received Physical therapy, bracing, or steroid injections in the preceding 6 months. Patients were also excluded if they had signs of cervical radiculitis or compressive neuropathy or radiographic evidence of arthritis or other pathology of the same arm.

Seventy patients (74 elbows) met the inclusion criteria; 25 were lost to follow-up; and 3 did not complete their outcome measurement form, leaving 42 patients who could be randomized into the 2 treatment groups (forearm strap [20 elbows] vs wrist splint [24 elbows]). Patients were instructed to wear their brace daily during daylight hours for 6 weeks. They were followed up until the brace was removed. At the 6-week follow-up, the wrist group reported significantly less pain (initially 7.5 +- 1.8 reduced to 5.8 +- 2.0) compared with the forearm strap group (initially 6.7 +- 2.7 reduced to 6.4 +- 2.6). There was no difference in their function, as measured by the American Shoulder and Elbow Society elbow assessment form or the Mayo Elbow Performance criteria.

The limitations of this study are that the patients were followed up for only 6 weeks, so long-term outcomes are unknown. The investigators did not control for analgesic use. Patients were allowed to use over-the-counter NSAIDs as needed, and their use was not quantified.

The take-home point from this study is that lateral epicondylitis is the most common cause of lateral elbow pain seen in outpatient medicine; most affected individuals are in the fourth and fifth decades of life. Most patients improve within 1 year with conservative treatment. The Wrist extension splint does not change short-term (6 weeks) functional outcomes compared with the forearm strap, but its use is recommended because it provides greater pain control.

fractures or neurovascular injuries. Two providers performed all of the

reductions-1 is a 48-kg female orthopedic surgeon who was successful in 3 (75% success rate) of 4 attempts; and the other is a 66-kg male orthopedic surgeon who was successful in 11 (78.6% success rate) of 14 attempts.

This article demonstrates a surprisingly simple and eloquent technique to reduce posterior hip dislocation. It can be done easily by providers who are small in stature and on obese patients who can be especially challenging. Although no single technique has a 100% success rate, the approximate 75% success rate of the foot-fulcrum maneuver is very promising and, it is hoped, will be reproduced in subsequent studies at other locations.

  1. Garg R, Adamson GJ, Dawson PA, Shankwiler JA, Pink MM. A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. J Shoulder Elbow Surg 2010;19:508-512.

Lateral epicondylitis, often referred to as tennis elbow, is the most common cause of lateral elbow pain and typically occurs in the fourth and fifth decades of life [39]. It is typically caused by inflammation or degeneration of the common extensor origin, where the extensor carpi radialis brevis (ECRB) and extensor digitorum communis are attached to the lateral epicondyle. Lateral epicondylitis is typically treated conservatively with NSAIDs, rest, modification of activities, corticosteroid injections, and splints. Most patients (70%-80%) will improve with conservative treatment within a year [40]. The authors of this study compared the efficiency of a forearm counterforce strap vs a wrist extension splint.

The forearm counterforce strap is placed on the proximal forearm distal to the origin of the ECRB muscle and provides a compressive force that

  1. Chiodo CP, Glazebrook M, Bluman EM, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of Achilles tendon rupture. J Bone Joint Surg Am 2010;92:2466-2468.

Achilles tendon rupture is one of the most common sports-related injuries. The injury is most common in men in the fourth and fifth decades of life. The injury typically occurs when the patient engages in running, sprinting, jumping, or explosive maneuvers [41]. There is also an association between fluoroquinolone use and Achilles tendon rupture [42-45]. Patients typically present to the ED complaining of a sudden popping sound or pain in their posterior ankle. The American Academy of Orthopaedic Surgeons compiled an Evidence-based approach to the evaluation and treatment of Achilles tendon ruptures, leading to 16 recommendations. Many of the recommendations do not pertain to the acute management of Achilles tendon rupture. Those issues that are pertinent to the ED are listed below with the accompanying orthopedic surgery level of agreement:

    • There is no preferred physical examination technique to make the diagnosis of Achilles tendon rupture. Physicians should evaluate the patient by performing at least 2 or more of the following maneuvers: Thompson Test (ie, Simmonds squeeze test), decreased ankle plantar flexion strength, presence of a palpable gap, or increased passive ankle dorsiflexion with gentle manipulation (grade, consensus).
    • The routine use of MRI, US, or radiographs to confirm the diagnosis of Achilles tendon rupture cannot be recommended (grade, inconclusive).
    • nonsurgical treatment is an option (grade, weak).
    • Surgical repair is an option (grade, weak).

The overall take-home point is that there is no conclusive, appropriate, evidence-based information to guide the diagnosis and management of Achilles tendon rupture. In particular, the evidence for surgical vs nonsurgical treatment is weak. The diagnosis does not need to be confirmed in the ED by MRI, US, or radiographs, as there is no evidence to recommend its routine use. However, radiographs may be needed to exclude an underlying fracture. There is inconclusive evidence that placing a patient in a posterior splint or Bledshoe (Grand Prairie, Texas, USA) boot improves outcomes. The most effective management in the ED will be pain control, the use of crutches to assist with ambulation, and referral to a foot and ankle specialist for definitive care.

Acknowledgment

The manuscript was copyedited by Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine at the University of Maryland School of Medicine.

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