orthopedic literature 2011″>American Journal of Emergency Medicine (2012) 30, 1296-1305

Diagnostics

The orthopedic literature 2011

Daniel L. Lemkin MD ^a,?, Michael C. Bond 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, USA

Received 22 February 2012; revised 7 April 2012; accepted 14 April 2012

Pain management

Wakai A, O’Sullivan R, McCabe A. Intra-articular lignocaine versus intravenous analgesia with or without sedation for Manual reduction of acute anterior Shoulder dislocation in adults. Cochrane Database Syst Rev. 2011;(4):CD004919.

Cheok CY, Mohamad JA, Ahmad TS. Pain relief for reduction of acute anterior Shoulder dislocations: a prospective randomized study comparing intravenous seda- tion with intra-articular lidocaine. J Orthop Trauma. 2011;25:5-10.

The reduction of dislocations can consume a large amount of time and resources in the emergency department (ED). Many reductions are performed with the aid of procedural sedation, which requires cardiopulmonary monitoring and additional clinicians to assist in the care of the patient. The ability to reduce a shoulder under a local anesthetic reduces the consumption of clinical resources and has the potential to decrease ED length of stay. The review by Wakai and colleagues as well as the study by Cheok and associates compared the use of general sedation and local anesthesia for pain control during shoulder reduction.

The Cochrane review examined published studies that compared the efficacy of intra-articular lignocaine (lido- caine) (IAL) and conventional intravenous analgesia with or without sedation (IVAS). The authors identified 1041 publications through their search strategy and examined that 9 were felt to be clinically relevant, with 5 meeting the inclusion criteria. The 5 studies analyzed for this review

* Corresponding author.

E-mail address: [email protected] (D.L. Lemkin).

encompassed a total of 221 patients. Examined outcomes were procedural success, rate of complications, and proce- dure length.

No significant difference was identified for procedural success for IAL vs IVAS (risk ratio, 0.95; 95% confidence interval [CI], 0.83-1.10). Significantly fewer adverse effects were associated with IAL than with IVAS (risk ratio, 0.16; 95% CI, 0.06-0.43). One of the 5 trials documented a decreased procedure length with IAL.

This review concedes that individual and overall small sample sizes preclude the ability to draw any definitive conclusions. However, even with this inherent bias, this review helps to heighten awareness that the use of a local anesthetic for reduction of shoulder dislocation appears to have fewer complications, requires fewer clinical resources, and reduces overall length of stay in the ED. Additional studies are needed to definitely prove this point, but IAL appears to be an effective alternative to procedural sedation. Cheok et al assessed the efficacy of IAL compared with that of intravenous sedation (IVS) for uncomplicated anterior shoulder reductions in the ED. Their outcome measures were cost-effectiveness, ED length of stay, procedural success,

complications, and patient comfort.

The study was performed in Malaysia from September 2000 to March 2002. The agents that were chosen for procedural sedation (meperidine [Demerol, Sanofi Aventis Bridgewater NJ] and diazepam [Valium, Genentech San Francisco, CA]) are no longer commonly used for this application in the United States. This difference may be partly responsible for the variance in outcomes compared with other studies using agents such as etomidate, propofol, and fentanyl.

During the 18-month study period, 85 patients with an Anterior shoulder dislocation were admitted. Patients who were unstable, had complicated injuries, were allergic to the

0735-6757/$ - see front matter (C) 2012 doi:10.1016/j.ajem.2012.04.020

study agents, or were younger than 15 years were excluded. Sixty-three patients were enrolled and randomized to receive either IAL (32 patients) or IVS (31 patients).

Using sterile technique, a single injection of 20 mL of a 1% concentration of lidocaine was administered. Correct placement was assumed based on physical examination and injection without resistance. Based on a review of the literature noting that aspiration was not a reliable predictor of intra-articular positioning, the authors elected to not use aspiration as a confirmatory measure for intra-articular placement of the lidocaine. Instead, they injected radiopaque Contrast material into the joint, which could be visualized on postreduction films confirming correct placement. Reduction attempts were delayed at least 15 minutes to ensure that adequate anesthesia had been achieved.

Sedation was induced with a titrated combination of meperidine (1 mg/kg) and diazepam (0.1 mg/kg). Patients’ cardiac function and pulse oximetry readings were monitored. Both groups underwent closed manual reduction using the traction/countertraction technique. Reduction was attempted with the patient lying supine. If the procedure was not successful, an alternative reduction technique could be performed, and if still not successful within 30 minutes, an alternative method of anesthesia was instituted: the IAL group advanced to procedural sedation, and the IVS group

advanced to general anesthesia in an operating suite.

Reductions were successful in all patients in the IVS group and in 81% of the patients in the IAL group. There was a 19% failure rate in the IAL group with the initial traction/ counter traction method; however, all these patients were successfully reduced with an alternative reduction technique. No patients in the IAL group needed IVS to achieve their reduction. All complications that were documented occurred in the IVS group: respiratory compromise requiring intervention (b 12 breaths/min) (13%), vomiting (6%), allergic reaction (6%), and thrombophlebitis (20%). The overall complication rate was 29%.

The outcome measures demonstrated a statistically significant cost savings of US $21 (67% reduction) per patient for IAL compared with IVS (P = .00). This figure must be considered in context because the overall cost for these procedures in Malaysia is US $31 for the IVS group vs US $10 for the IAL group. The mean ED length of stay for the IAL group was 2.2 hours compared with 8.1 hours for the IVS group (statistically significant with P = .00).

Before patients underwent IVS, they were asked to try to remember their level of pain during the procedure. The levels were documented with visual analog pain scores upon awakening. In both groups, patients with a first-time dislocation achieved similar pain reduction: 77% in the IAL group and 76% in the IVS group. Repeat dislocators reported less pain reduction: 52% and 68% for IAL and IVS, respec- tively. The difference in pain relief between the IVS and IAL groups was not significant. satisfaction scores trended toward greater satisfaction with IVS (90%) than with IAL (69%); however; this difference was also not statistically significant.

This study demonstrates the relative ease and safety of IAL injection, and although on first glance, it appears that IAL is not as successful as IVS, none of the patients who received IAL required IVS to achieve a reduction. No shoulder Reduction method has a 100% success rate, so one would expect some failures on the first technique regardless of the technique used. A follow-up study using more contemporary sedatives and anesthetics would benefit this discussion. Regardless, Cheok and colleagues demonstrated that IAL is an acceptable means of providing procedural analgesia, especially if performing IVS at your institution is difficult. Intra-articular lignocaine also benefits from a shorter length of stay and fewer complications, although this difference may be lessened with

newer sedation medications such as propofol and etomidate.

Blaivas M, Adhikari S, Lander L. A prospective compar- ison of procedural sedation and ultrasound-guided inter- scalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med. 2011;18:922-927.

There is a need for alternatives to procedural sedation for closed-reduction techniques because procedural sedations increased resource requirements and Recovery time. Blaivas et al comparED procedural sedation with the novel technique of interscalene nerve block (INB) achieved under ultrasound guidance at the bedside in the ED. Over the past decade, ultrasound has become an indispensable tool with ever- expanding applications in the ED. Ultrasound guidance for Intravenous line placement is routine in many institutions. Less well known is the application of ultrasound for real-time guidance in establishing regional nerve blocks.

Blaivas et al compared ultrasound-guided INB with etomidate sedation (ES) for the facilitation of uncomplicated anterior shoulder reduction in an ED setting. The primary outcome measure was ED length of stay. Secondary measures included “one-on-one” provider time, patient pain, and patient satisfaction. The study was conducted at an academic level I trauma center with an annual census of 80 000 patient visits. Patients were enrolled as a convenience sample to accommodate the 2 credentialed investigators who performed the reductions. Forty-two patients were random- ized prospectively into either the INB or the ES group.

Two emergency medicine (EM) physicians with training in ultrasound underwent didactic (2 hours) and practical hands-on training specifically addressing ultrasound-guided regional anesthesia. Each had accrued more than 2 years of experience with ED ultrasound before receiving this additional training, and each had performed at least 10 interscalene blocks before the study.

Interscalene nerve block was performed by, first, identifying the brachial plexus at the interscalene position. Vasculature and nerve positions were verified using color- ftow Doppler. Using sterile technique and under direct visualization using a SonoSite MicroMaxx (SonoSite, Inc, Bothell, WA) with a high frequency (10-5 MHz) linear array transducer, 20 to 30 mL of lidocaine with epinephrine was

injected using a 21-gauge 1.5-in noncutting needle adjacent to the nerve roots. efficacy of anesthesia was tested at 10- minute intervals. Once it was deemed effective, reduction was performed using a nonstandardized but generally accepted reduction technique. Procedural sedation was induced using etomidate as the sole agent. Procedural sedation included monitoring and staffing to conform to the standard of care at the time. The investigators reported 2 patients with hypoxia (10%) and 2 patients with hypotension (10%) in the ES group. After the procedure, patients’ levels of subjective pain and satisfaction with the procedure were scored.

Length of stay (in minutes) was 43% lower in the INB group than in the ES group (100.3 +- 28.2 and 177.3 +- 37.9, respectively; P b .0001). Even more impressive is the reported reduction in direct one-on-one patient-provider time (defined as the amount of time spent by either the nurse or physician directly monitoring the patient; 5 +- 0.7 minutes for the INB group vs 47.1 +- 9.8 minutes for the ES group). Subjective scoring of pain and satisfaction demonstrated no statistical differences. Pain score medians were zero in both groups (P = .79). Satisfaction mean scores were 8.3 +- 1.1 and

8.2 +- 1.3 for the INB and ES groups, respectively (P = .93). Based on the volume of patients studied, hypoxia and hypotension complications failed to reach statistical signif- icance (P = .49).

Patients in the INB group in this study did not experience any complications, but the authors of the report addressed many potential complications that might dissuade some providers from choosing this alternative method. Interscalene nerve block in proximity to the brachial plexus can result in Horner syndrome, hoarseness, or diaphragmatic paralysis from involvement of the recurrent laryngeal or phrenic nerves. In addition, nerve damage can occur from a direct injection into a nerve. Parenteral complications such as hematoma and infection are also potential risks of this procedure. All patients were given the regional anesthetic experienced transient motor paralysis distal to the injection site. The degree and duration of this Paralysis and anesthesia were neither quantified nor followed as part of the study. The authors did note that, on medical record review, no patients returned to the ED with complaints of persistent paralysis or anesthesia.

The study is limited by an unavoidable lack of blinding, which may have inadvertently altered care providers’ behaviors, which could affect the length of stay. Also, many emergency providers are neither currently familiar with nor credentialed to perform the INB technique, so there will likely be some time before this technique sees widespread use.

This study introduces a technique that complements the intra-articular block as a viable alternative to procedural sedation for the facilitation of uncomplicated anterior shoulder reductions in the ED. Its technical and anatomical complexity may deter some clinicians from using it. Further studies comparing the efficacy and complication rates of INB with those of an intra-articular block will help drive changes in practice. For those with the technical expertise to perform

this block, INB provides adequate pain relief to facilitate shoulder reduction while decreasing the patient’s length of stay and one-on-one provider time.

Orthopedic radiology

Orloski J, Eskin B, Allegra PC, Allegra JR. Do all patients with shoulder dislocations need prereduction x- rays? Am J Emerg Med. 2011;29:609-612.

Do we need prereduction plain radiographs to evaluate patients with shoulder dislocation for fracture? This question was addressed by Orloski and colleagues in a retrospective cohort medical record review study. The purpose of the study was to determine whether patients of a certain age have a fracture rate low enough to warrant forgoing plain radiographs before manipulation of an anterior shoulder dislocation.

A consecutive electronic medical record sample of 5.4 million visits from 19 New Jersey and New York EDs from January 1, 1996, to November 20, 2007, was queried using the International Classification of Diseases, Ninth Revision diagnostics and billing codes for a final diagnosis of shoulder dislocation or shoulder fracture; 7209 patient records (34% were female) were identified for analysis.

Patients were grouped by decade of life and analyzed for fracture frequency. The median age for dislocations was 35 years (interquartile range, 23-56 years). The total fracture rate was 6.5% (465/7209). All fractures were humeral, and there were no scapular fractures found. The distribution of fractures was skewed, with an increased frequency seen in older patients. Fracture-dislocations were present in 9 (0.7%) of 1233 patients (95% CI, 0.3%-1.2%) in the second decade and in 14 (0.8%) of 1682 patients (95% CI, 0.4%-1.3%) in the third decade of life. The odds ratio for fracture vs no fracture for patients 18 to 40 years old vs those older than 40 years was 11.4 (8.2-15.9).

The authors report that omitting all prereduction radio- graphs in patients in the second and third decades of life would miss 0.8% of fractures regardless of mechanism, history, or suspicion of fracture. This would result in a 40% decrease in prereduction radiograph use. The authors also acknowledge that an emergency provider is unlikely to omit prereduction radiographs in patients with high-energy traumatic mechanisms of injury or in patients who are believed to be at high risk for a fracture. However, for patients who do not have a Suspicious mechanism of injury, omitting prereduction radiographs could be safe and help reduce the cost of care.

The main limitation of the study is that coding errors could have caused underestimation or overestimation of the frequency of fractures associated with dislocation. The overall incidence of 6.5% is lower than that reported in 2 prior studies by Emond et al [1] (25.5% and 18%) . The difference can be attributed to the fact that younger populations were not included in the previous studies. The

population shift would, thereby, skew results toward the higher-risk older population.

This study identifies patients in their 20s and 30s as low risk (b 1%) for fracture associated with dislocation. The authors conclude that it may be safe to forgo prereduction plain radiographs in this population. Orloski et al did not address the medicolegal implications of finding a fracture on a post-reduction radiograph and not having a prereduction radiograph to prove that it was not the reduction that caused the fracture. This concern alone will likely prevent most clinicians from forgoing prereduction radiographs.

Petinaux B, Bhat R, Boniface K, Aristizabal J. Accuracy of radiographic readings in the emergency department. Am J Emerg Med. 2011;29:18-25.

Emergency medicine physicians routinely read plain radiographs contemporaneously with a patient’s visit, and the radiographs are then read later by a radiologist. Any discrepancies between the 2 readings must be addressed through a Quality assurance program that ensures that clinically significant misreads are addressed in a timely manner. Petinaux and colleagues conducted a retrospective review of their QA database from June 1996 to May 2005 for discrepancies between readings by EM attendings and radiologists. The study was conducted at an urban, university-affiliated level 1 trauma center with a residency training program in EM.

Discrepancies were categorized as false positives (an abnormality noted by the Emergency Practioner that radiology did not feel was present) or false negatives (an abnormality missed by the EP). Additional classifications were tracked as to the degree of certainty of the radiologist and the clinical significance of the discrepancy.

A total of 151 693 were reviewed, and 4605 (3%) discrepancies were noted. Twenty-nine percent (1349/4605) of the discrepancies were deemed to require no follow-up, 3515 cases had follow-up actions noted, 775 patients had discrepancies judged to be significant enough that the primary care or admitting physician was contacted to alert them to the discrepancy, and 109 patients had findings significant enough that they were called back and asked to return to the ED immediately. The most common abnormal- ities missed on plain radiographs are noted in Table.

Numerous factors could confound the conclusions drawn from this analysis. For example, if EM physicians failed to document a reading, it was considered a false negative if the authors were not able to determine, by review of the database, that the attending EM physician acted on the pertinent finding. This situation applied to 19% (889/4605) of the discrepancies. Furthermore, if the radiologist inter- preted the film while the patient was still in the ED, the patient’s management could have changed and this would not have been recorded in the database. In addition, 18% (859/4605) of cases were classified as having a questionable false-negative reading based on an equivocal read by the

Table Most common abnormalities that were missed on plain radiographs.

Category Abnormality

bone radiographs

Number of missed findings

878

263

24

78

abdominal radiographs

Chest radiographs

Fracture Questionable fracture Dislocation Questionable dislocation

Foreign body Abdominal masses Bowel obstruction Missed Free air Air space disease Pneumothorax Questionable pneumothorax Aortic pathology

Pulmonary nodules Free air

27

40

26

2

765

23

9

83

283

8

One radiograph could have more than 1 missed finding.

radiologist. As is common practice, the definitive interpre- tation is assumed to be the radiologist’s reading; however, numerous authors have purported that this assumption is not always valid [2-5]. Occasionally, the ED interpretation is correct, and a significant provider-provider variance exists even among radiologists. These factors are difficult to overcome in an observational study. Finally, the ED that this study was conducted sees few pediatric patients, so the results cannot be extrapolated to the pediatric population.

Even given the limitations noted above and the possible overestimation of false reads, EM physicians missed approx- imately 3% of abnormal radiologic findings that resulted in an emergent change in medical management in 85/4605 (1.84%) of cases, or 0.056% of the total number of plain radiographs read during the study period (ie, 151 693).The authors took reasonable care to err on the conservative side when classifying interpretations as a false negative. This approach increases the sensitivity and safety of their QA process.

In summary, this article highlights that EM providers are competent in interpreting plain radiographs and have few misses that result in a change in clinical management. Educational efforts to help reduce missing fractures, disloca- tions, air space disease, and pulmonary nodules would further reduce the number of discrepancies seen in this study.

Austin LS, O’Brien MJ, Zmistowski B, et al. Additional x- ray views increase decision to treat clavicular fractures surgically. J Shoulder Elbow Surg. November 16, 2011 [Epub ahead of print].

As highlighted in past articles in this series, the treatment of clavicle fractures is changing [6,7]. In contrast to the days of Neer [8], many more fractures are being treated operatively because it has been shown that nonoperative

management is associated with higher rates of nonunion, malunion, and disability. This article by Austin and associates demonstrates that Orthopedic surgeons are more likely to treat a clavicle fracture operatively when shown a 4- view radiograph series that includes orthogonal viewing angles than when they rely on a standard 2-view series. The 4-view series consists of an anterior-posterior (AP) view, 20? cephalic tilt, 45? cephalic tilt, and 45? caudal tilt. A standard clavicle series consists of AP and 20? cephalic tilt views only.

Most surgeons base the decision to treat operatively on the degree of displacement and the activity level of the individual. Several studies have shown that patients have improved outcomes if treated operatively when the ends of the clavicle are displaced more than 20 mm. Austin and colleagues postulated that the additional cephalic and caudal tilt views would improve the assessment of any AP displacement.

The authors randomized 50 consecutive patients with confirmed acute midshaft clavicle fractures into 2 groups. Their radiographs were divided into 2 folders-2-view and 4-view-and randomly shown to the following orthopedic physicians: a general orthopedic resident, a general ortho- pedic attending physician, a shoulder and elbow fellow physician, and a shoulder and elbow attending physician on 2 separate occasions. The interobserver reliability of Treatment decisions was calculated to be 0.87 (95% CI, 0.80-0.92) for the 2-view radiographs and 0.88 (95% CI, 0.81-0.92) for the 4-view series. However, the intraobserver reliability in- creased from 0.64 (95% CI, 0.55-0.71) for the 2-view series to 0.76 (95% CI, 0.70-0.82) for the 4-view series; the difference was statistically significant (P = .013). Sixty-one (31%) of the 200 cases reviewed using 2 radiograph views were considered for Surgical repair; although 81 (40.5%) of the 200 cases were considered surgical when the surgeons reviewed all 4 radiograph views. This was statistically significant (P = .05).

Thus the authors concluded that the 4-view series provided better visualization of AP displacement. The degree of displacement inftuences an orthopedic surgeon’s opinion about whether the fracture should be treated operatively.

This study is limited by the fact that the surgical decision was based purely on the radiograph interpretation and no consideration was given to the patient’s history, physical examination findings, or occupation status. However, these factors would have biased the provider’s decision, when the authors were purely trying to determine whether 2 or 4 views of the fractured clavicle improved interobserver reliability and improved visualization of any anteroposterior displace- ment of the fracture.

Emergency care providers should consider obtaining a 4- view clavicle series on all patients with midshift clavicle fractures to ensure that the anteroposterior fracture displace- ment can be assessed adequately. There is still reluctance by some orthopedist to treat clavicle fractures operatively, although there is a growing body of literature showing that

there are improved outcomes (decreased rates of malunions, nonunions, and chronic pain) in patients with more than 2 cm of displacement when they are treated operatively [6,7].A 4- view clavicle series might improve long-term outcomes in these patients by helping the orthopedist better visualize the total displacement of the clavicular ends.

Cervical spine clearance

Duane TM, Mayglothling J, Wilson SP, Wolfe LG, Aboutanos MB, Whelan JF, Malhotra AK, Ivatury RR. National Emergency X-Radiography Utilization Study cri- teria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography. J Trauma. 2011;70:829-831.

Patients presenting to the ED after blunt trauma are routinely screened for Cervical spine injuries-at times, via the history and examination only, whereas at other times, with various Imaging techniques. In 2000, the National Emergency X-Radiography Utilization Study found that a subset of patients meeting the following criteria can be safely screened for cervical spine injury without the use of radiography [9]: a Glasgow Coma Scale score of 15 and the absence of a distracting (painful) injury, clinical evidence of intoxication, midline cervical (C) spine tender- ness, and neurologic deficit.

Duane and colleagues studied the efficacy of the NEXUS

criteria in the subset of patients who qualified for trauma team activation at their level 1 trauma facility from January 2008 to June 2010. They prospectively evaluated 2606 consecutive adult patients (age N 16 years) with blunt trauma. All patients in this series were screened using Nexus criteria and underwent computed tomography (CT) of the cervical spine as part of the traditional trauma workup.

Computed tomography identified 157 (6%) of the 2606 patients as having a cervical spine fracture. A total of 1057 (41%) patients were categorized as NEXUS negative, but 26 of this group actually had cervical spine fractures. These calculations translate to a sensitivity of 59.4%, a specificity of 79.5%, a positive predictive value of 12.5%, and a negative predictive value of 97.5%. Three of the patients with injuries missed by NEXUS screening required operative stabilization or halo placement, 16 needed prolonged stabilization with a cervical collar, and 7 did not require any further workup.

The authors note that the specificity derived from this

study was inconsistent with data reported from the original NEXUS trial. They attribute this inconsistency to a lack of risk stratification based on the mechanism of injury and other factors. The authors cite the Canadian C-spine trial, which achieved a greater level of sensitivity after including mechanism of injury parameters [10].

The NEXUS trial achieved a negative predictive value of 99.97% [9]. It involved 34 000 patients with 818 cervical spine fractures, 810 of which were identified using NEXUS

criteria. Duane et al achieved a negative predictive value of 97.5% using a population already risk stratified to be of higher acuity. The NEXUS screening tool is not sensitive enough in this higher-acuity population. Caution should be exercised when choosing to forgo radiographic imaging in the setting of significant blunt trauma that warranted trauma team activation. This result-and their conclusion-is appropriate in this higher-risk population; once a trauma team is activated, a more thorough evaluation is most often appropriate.

Como JJ, Leukhardt WH, Anderson JS, Wilczewski PA, Samia H, Claridge JA. Computed tomography alone may clear the cervical spine in obtunded blunt trauma patients: a prospective evaluation of a revised protocol. J Trauma. 2011;70:345-351.

Patients with trauma presenting to the ED with altered mental status are assumed to have a cervical spine injury until proven otherwise. Common protocols require a CT of the cervical spine to exclude fracture, dislocation, and vascular injury. If the CT result is negative, magnetic resonance imaging (MRI) can be used to evaluate for ligamentous injury, or a cervical collar can be placed until the patient awakens and the cervical spine can be cleared clinically.

This article by Como and associates reports on a follow- up study examining outcome data resulting from a change in hospital policy regarding cervical spine clearance. From 2004 to 2006, follow-up MRI was performed in 115 patients with negative CT findings to evaluate them for ligamentous injury. No clinically relevant injuries were identified, and hospital policy was amended to forgo follow-up MRI. From 2006 to 2008, the new hospital protocol was used in the assessment of 197 patients with altered mental status. Patients underwent an initial CT of the cervical spine; a negative CT scan finding resulted in immediate cervical clearance and removal of the cervical collar.

Follow-up on patients was performed in person (63.5%), by telephone interview (12%), or by autopsy review (12.7%). The remaining patients (11.8%) were lost to follow-up. Five (2.5%) of the reexamined patients reported persisting cervical spine tenderness. These patients under- went MRI, and all results were negative for significant ligamentous injury.

Numerous studies have examined the sensitivity of isolated CT for the identification of significant ligamentous injury [11-14]. Most of them reported a significant number of acute traumatic Ligamentous injuries that were not identified by CT. However, the general consensus is that most of these injuries do not significantly alter management or pose a risk to patients.

An outlier study by Menaker et al [12] identified 18 patients (9.4%) with abnormal MRI findings. Two patients in this series had Significant injuries requiring operative repair. The authors of this study question the reproducibility of the outcome of Menaker et al, given other published literature, especially because a previous study at Menaker’s institution did not identify any abnormalities on MRI [14].

Protocols that require MRI follow-up studies come with a cost. Delays in clinical clearance can lead not only to significant discomfort for the patient but also to pressure sores from the continued immobilization. Dunham et al [15] postulated that patients with trauma may have greater risk of secondary brain injury due to complications associated with prolonged cervical collar use and procedures associated with MRI. The financial implications of routine MRI use are significant. During a 2-year follow-up period, Dunham et al performed 110 fewer MRIs for cervical spine clearance. They also noted a reduction in hospital length of stay, which might have been attributable, in part, to reduction in delays for cervical spine clinical clearance.

Although some studies revealed no unstable injuries in patients being cleared for cervical spine injury, the frequency of CT’s detection of unidentified ligamentous, soft tissue, and disk-related injuries is cause for concern. No study quoted had an MRI-identified acute traumatic injury rate of less than 5.8%, with injury rates reaching 21%. Given the potential seriousness of missing a cervical spine injury and the data variability in existing studies, this study does not provide a definitive answer, and thus, the debate will continue. As CT technology continues to improve with 64- and 256-slice scanners, it is very likely that CT will be able to identify most of these injuries in the near future. For now, these patients should continue to wear a cervical collar until they are able to be cleared clinically or with a MRI if obtunded.

Horodyski MB, Conrad BP, Del Rossi G, DiPaola CP, Rechtine GR. Removing a patient from the spine board: is the lift and slide safer than the log roll? J Trauma. 2011;70:1282-1285.

Standard practice for the treatment of patients with trauma presenting on a Long spine board includes controlled transfer using a log-roll technique. Horodyski and associates investigated the angular and translational motion of C5 and C6 created during the application of the log-roll technique as opposed to a lift-and-slide technique.

The research team prepared 5 lightly embalmed cadavers to create 3-column, global instability at C5 and C6 by surgically sectioning the facet capsules, intervertebral disk, interspinous ligament, supraspinous ligament, ligament ftavum, and anterior and posterior longitudinal ligaments. The cadavers were placed in a Vista collar (Aspen Medical Products, Irvine, CA), and electromagnetic sensors were placed to measure the amount of relative angular motion and linear translational between C5 and C6.

Each cadaver was positioned on a long spine board, with a cervical collar placed in a standard fashion. The cadaver was then log-rolled 90? while a trained individual maintained manual inline cervical stabilization and 3 other individuals (2 at torso, and 1 at feet) assisted with the log roll. For execution of the lift-and-slide technique, 8 people were situated around the body, which was then lifted approximately 4 in, allowing clearance for removal of the spine board. Each maneuver was

randomly repeated 3 times, as they recorded the amount of ftexion-extension, lateral bending, axial rotation, and AP, medial-lateral, and axial translation.

Quantitative measures from the electromagnetic sensors revealed increased axial rotation with a log-roll compared with the lift-and-slide technique (P b .05). The authors did not report actual measurements quantitatively, but figures appear to demonstrate a difference of 2.2? +- 1? or 2?. The log-roll technique was also associated with more medial- lateral translation and AP translation compared with the lift-and-slide technique (P b .05). Again, the authors did not present quantitative measures; however, the actual differences appear to be approximately 2 +- 1 or 3 mm. They discovered no significant difference in spinal move- ment for the log-roll technique performed by experienced vs novice immobilizers.

Based on the data presented in this study and others referenced in the article [16-18], the authors recommend substituting the log-roll technique for the lift-and-slide maneuver. Although the authors were able to quantitatively demonstrate greater spinal movement using the log-roll technique, they did not address the issue of causality relating to exacerbation of existing spinal cord injuries. In addition, if a patient with trauma is not rolled during the initial assessment, the emergency care providers risk missing significant injuries hidden by the patient’s positioning. The authors address this limitations and suggest that a visual inspection of the back could be realized after the patient’s cervical spine is appropriately evaluated radiographically.

Before a change in practice can be recommended, the issue of causality needs to be addressed. Does transient translational and rotational movement of 1 to 2 mm (1?-2?) exacerbate existing injuries? The personnel requirement also should be considered. The lift-and-slide technique requires approximately 8 people for proper execution. In a trauma center, staffing is less of an issue than in a smaller ED. Factors such as the patient’s size, weight, provider strength, and the presence or absence of a draw sheet further complicate the logistics of executing this procedure. However, Horodyski and associates conducted an interest- ing cadaveric study that suggests that the log-roll technique may not be a spine-friendly maneuver.

Septic arthritis“>Septic arthritis

Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18:782-796.

Swollen and painful joints are a common complaint in the ED, and it is often difficult to discern whether the cause is an infectious or inftammatory process. The decision to perform arthrocentesis is driven by physical examination findings and laboratory study results; however, the results can be equivocal, and an evidence-based medicine approach to management is lacking.

Carpenter and associates conducted a meta-analysis of the existing literature to review the sensitivity, specificity, and Likelihood ratios associated with various diagnostic studies to determine the optimal test for excluding the diagnosis of septic joint. Their search of medical databases, PubMed, and EMBASE yielded 4085 publications. Prelim- inary screening resulted in 32 primary studies, which were reviewed for this publication.

The authors found a prevalence of 27% for nongonococ- cal septic arthritis in ED patients with monoarticular arthritis. No specific physical examination findings were identified as either appropriately sensitive or specific for septic arthritis to make them clinically useful.

The sensitivity, specificity, and positive and negative LRs were determined for a range of laboratory studies. The peripheral white blood cell count was found to be neither sensitive nor specific for septic arthritis. Erythro- cyte sedimentation rate (ESR) was reported in multiple studies; however, the sensitivity varied greatly. Similar discordance was identified with C-reactive protein (CRP). The authors noted, “No cutoff for [serum] ESR or CRP significantly increases or decreases the posttest probability of septic arthritis.”

Synovial ftuid tests were also analyzed. “[Inspection of the joint ftuid by] a rheumatologist was found to be 94% sensitive and 50% specific in differentiating inftammatory from non-inftammatory causes of acute arthritis.” Synovial WBC counts with a range of 50 to 100 x 10⁹/L had an interval LR of 3.59, whereas a WBC count less than 25 x 10⁹/L had an LR of 0.33. No polymorphonuclear differential, synovial glucose concentration, or synovial protein value had sufficient sensitivity or specificity to be useful diagnostically. A Synovial lactate concentration greater than 10 mmol/L had the best diagnostic accuracy, with a

+LR of ? and a -LR of 0.16.

This meta-analysis was limited by the overall poor quality of the data available in each of the individual studies. The overwhelming consensus is that the standard practice of reliance on serum markers (WBC count, CRP, ESR) is not justified by the test characteristics of each of the individual tests. The results of serum tests should not significantly impact a clinician’s decision regarding the need to perform a diagnostic arthrocentesis and the ultimate diagnosis.

Among those patients in which the clinician is concerned regarding septic arthritis, arthrocentesis should be performed and the synovial ftuid evaluated-unless, of course, contraindications exist, such as an overlying cellulites. A synovial lactate concentration greater than 10 mmol/L and a synovial WBC count greater than 50 x 10⁹/L are highly suggestive of septic arthritis. However, a patient with lower values can still have septic arthritis.

The authors recommend additional Prospective trials to evaluate the sensitivity, specificity, and LRs associated with findings from the patient’s history and physical examination. Prospective quantitative analysis of synovial lactate is the most useful test in differentiating infectious

from inftammatory arthritis. Other laboratory tests and physical examination findings need to be taken in context, and no single test should be used to exclude the diagnosis of septic arthritis.

Posterolateral corner injuries of the knee

Pacheco RJ, Ayre CA, Bollen SR. Posterolateral corner injuries of the knee: a serious injury commonly missed. J Bone Joint Surg Br. 2011;93:194-197.

The posterior lateral corner (PLC) of the knee has been recognized as a critical stabilizing area of this joint. Although it was initially described in 1982 [19], many providers are not familiar with the PLC. Therefore, injuries in this area are often not recognized and misdiagnosed. The PLC consists of static and dynamic restraints. The static restraints are the lateral collateral ligament, arcuate ligament, fabellofibular ligament, popliteofibular ligament, coronary ligament, and joint capsule. The dynamic restraints are the biceps femoris and the popliteus muscle tendon.

Posterior lateral corner injuries account for 5% to 9% of all injuries to the knee and are often associated with injuries to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). If these injuries go unrecognized, they can lead to significant knee instability, chronic pain, and osteoarthritis. Many of these injuries require surgical repair, which is best accomplished within the first 2 to 3 weeks after injury.

Pacheco and colleagues conducted a retrospective review of patients with a PLC injury managed by an orthopedic surgeon specializing in the management of knee injuries between 2005 and 2009. Records were reviewed to determine whether there was an associated ligamentous injury, the interval to diagnosis, whether the injury was identified at the initial presentation or the time of referral, and the subjective history. A total of 68 patients with a PLC injury were identified. The diagnosis was confirmed by a combination of clinical assessment, imaging (eg, plain radiographs and MRI), and arthroscopy. The clinical assessment included the tibial external rotation test, varus stress tests, and signs of varus thrust gait pattern. The tibial external rotation was considered positive if there was more than 10? of external rotation compared with the uninjured sided.

Another test for the PLC is the external rotation recurvatum test [20]. This test is performed with the patient lying supine and the examiner standing at the foot of the bed. The examiner grasps both great toes and lifts the legs straight up. While lifting, the examiner should watch and feel for posterior translation of the femur on the tibia and external rotation of the tibia, which is suggestive of an injury to the PLC. A video of this test is available at http://youtu.be/ OpMhQ7nSn3Y.

Eight (11.8%) of the patients in this study had an isolated injury to the PCL. An associated ACL injury was seen in 29

(42.6%), a PCL injury in 19 (27.9%), and ACL and PCL injuries in 11 (16.2%). Sixty-three (93%) of the patients complained of instability in their knee. The injury was not diagnosed in 49 (72%) patients at their initial presentation, with a mean delay of 30 months. Only the 11 patients with multi-ligamentous injuries related to knee dislocation were correctly diagnosed on initial presentation, likely secondary to an emergent MRI being obtained. Magnetic resonance imaging correctly identified an injury to the PLC complex in 14 of the 15 patients who had an MRI within 12 weeks of injury but in only 4 of the 15 patients who had an MRI more than 12 weeks after injury.

Of course, this study has numerous methodological problems including its small size, retrospective nature, and single clinician involvement. Nonetheless, it highlights that emergency care providers must be aware of PLC injuries and that their natural history often leads to chronic pain and instability of the knee; furthermore, the article stresses that these injures are often misdiagnosed initially and that MRI is most sensitive acutely (and loses its diagnostic sensitivity when the injury is more than 12 weeks old). It also suggests that the emergency care provider should become comfortable performing the external rotation recurvatum test.

Reduction techniques

Hendey GW, Avila A. The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011;58:536-540.

Numerous techniques are available to reduce a hip dislocation, but none has been shown to be 100% successful. The most commonly used are the Allis and Bigelow techniques [21,22],which require emergency care providers to stand on a stretcher and, thus, put themselves at risk for falling and subsequent injury. Hendey and Avila provide information on a new technique, a modification of the Lefkowtiz method [23]. In the Lefkowtiz method, the provider stands on the ipsilateral side of the dislocation and places the patient’s knee over his or her thigh. The provider then exerts downward pressure on the patient’s ipsilateral ankle, using the knee as a fulcrum, to exert anterior force on the hip to achieve the reduction.

The Captain Morgan technique should be performed with the patient lying supine on a backboard with a strap placed across the pelvis (Fig. 1). This approach provides a firm footing for the provider and stabilizes the pelvis. The provider then stands on the ipsilateral side of the dislocation and places one foot on the backboard; the other remains on the ftoor. The ipsilateral knee is draped across the provider’s knee. The provider places one hand on the ipsilateral ankle, holding the knee ftexed, and the other under the ipsilateral thigh. The provider can then attempt to reduce the dislocation with anterior force by lifting up on the patient’s toes (plantar ftexion) and lifting with the hand that is under the patient’s thigh. If this technique does not reduce the hip, the provider

Fig. The Captain Morgan technique. Place the patient in a supine position on a gurney, and fix the pelvis to a backboard with a strap. Flex the patient’s hip and knee to 90?. The physician places one foot on the board, with a knee behind the patient’s knee. Hold the patient’s knee in ftexion by holding the ankle down and applying an upward force to the hip by lifting with the calf and then gently rotating the lower leg. Reproduced with permission from Elsevier. Hendey GW, Avila A. The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med. 2011;58:536-540.

can internally and externally abduct and adduct the hip while maintaining the anterior force. This additional manipulation typically will reduce the dislocation.

The article by Hendey and Avila describes their experience with hip dislocation in a tertiary care, academic medical center ED from January 1, 2007, through December 31, 2010. Seventy-seven patients with hip dislocations underwent reduction attempts. Forty (52%) of the patients were male, and 35 (45%) had prosthetic hips. closed reduction was successful in 67 (87%) of the patients. Thirteen cases were attempted with the Captain Morgan technique: 12 (92%) were reduced successfully and 1 procedure failed. Eight (62%) of these patients had a prosthetic hip. The patient for whom the reduction was not successful had a dislocation and acetabular fracture and underwent open reduction in the operating room, during which an intra-articular bony fragment was found. For the original 67 closed-reduction attempts, inadequate informa- tion was documented in the medical record to allow determination of the method attempted in 52 of the cases, 8 of those closed-reduction attempts failed. If the assumption is made that the Captain Morgan technique was used in all 8 of the failed cases, the success rate could be as low as 57%. The authors point out that this study was limited by the lack of information on the reduction technique in 52 cases. It is also unknown whether this technique would be effective in

the less common anterior hip dislocation. Finally, because the number of cases using the Captain Morgan technique is low, it is unknown whether the technique could have a risk of fracture, Neurovascular injury, or damage to the knee. None of these complications occurred in the 13 reduction attempts made in this study.

Emergency care providers should be aware of the Captain Morgan technique. It offers the advantages of requiring only a single provider when the patient’s pelvis is stabilized on a backboard, allows providers to use their powerful leg muscles to overcome any muscular resistance of the patient, and provides additional safety because it does not require the provider to stand over the patient. Further investigation in the medical literature is required to explore its use.

Caudevilla Polo S, Estebanez de Miguel E, Lucha Lopez O, Tricas Moreno JM, Perez Guillen S. Humerus axial traction with acromial fixation reduction maneuver for anterior shoulder dislocation. J Emerg Med. 2011;41:282-284.

Numerous methods can be used to reduce an anterior shoulder (glenohumeral) dislocation. No single method has a 100% success rate. Most methods have disadvantages that need to be considered with each case. For instance, the traction/countertraction method requires considerable force and 2people.The Kocher method uses leverage that places considerable stress on the joint and Proximal humerus, which can result in fractures. Others require the use of weights that do not respond to increased Muscle spasm during the maneuver. Caudevilla Polo and colleagues describe their technique, which they feel eliminates many of the disadvan- tages of the existing techniques.

This new reduction maneuver-humerus axial traction with acromial fixation-is performed ideally with the patient sitting up on the stretcher or in a chair. The provider grasps the affected humerus at its distal end and ftexes the elbow so that the patient’s ipsilateral hand rests on the provider’s forearm. Using the other hand, the provider grasps the lateral caudal aspect of the prominent acromion process. This hand helps to neutralize scapular movements during the humerus axial traction. The authors then recommend moving the shoulder into a position that feels the “most loosely packed” (ie, the position that has the least amount of muscular and ligaments stress and allows the most amount of humeral movement). This position should also be the one that causes the least amount of pain to the patient. The provider can use his or her fingers to gently massage the deltoid and trapezius to help the patient’s muscles relax. Once the humerus is in this “loosely packed” position, the provider then applies gentle, constant progressive downward traction on it. This force should overcome the muscle spasm and allow the humeral head to relocate itself. Interestingly, the authors only describe this new technique and do not report their success rate or any complications that have occurred with its use. The article focuses on an in-depth discussion of the biomechanical forces that need to be

overcome for a successful shoulder reduction and how their technique addresses these with minimal force, no leverage, and the use of a single provider. Although the success rate has not been reported in a case series, the technique is simple and seemingly carries a low risk for complications, so EM practitioners should be aware of it and keep it in their armamentarium of shoulder reduction techniques. As with the Captain Morgan method for hip dislocation reduction, we will need to review its clinical use with this anterior glenohumeral dislocation reduction technique.

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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