Orthopedic

Rapid Review

• Background
  • Commonly known as ‘frozen shoulder’, it involves inflammation of the glenohumeral joint causing capsular fibrosis and severe restriction in range of motion.
  • Follows progressive “freezing” and “thawing” stages over the course of 15-24 months.
• Signs/Symptoms
  • Diffuse shoulder pain w/ progressive stiffness
  • Limited ROM
• Diagnosis
  • Clinical diagnosis
• Treatment
  • Analgesia (NSAIDS, PO steroids, intra-articular corticosteroid)
  • Encourage physical therapy and frequent mobilization. 
• Disposition
  • Discharge with orthopedic/physical therapy follow-up

Pearls

• Oral steroids (typically 3 week tapered course of prednisone) has been shown to be quite beneficial in relieving pain and improving ROM for these patients. 
• Adhesive capsulitis typically resolves on it’s own, though it may take between 1- 3 years. It is important to set appropriate expectations. 

Deep Dive

• Adhesive Capsulitis (Ortho Bullets)

Rapid Review

• Background
  • Inflammation of costal cartilages or sternal articulations, typically origination from trauma or rheumatological conditions
  • Common cause of non-cardiac chest pain
• Signs/Symptoms
  • Reproducible chest wall pain
  • May be sharp, dull, pleuritic
• Diagnosis
  • Clinical diagnosis
  • EKG and CXR helpful and ruling out more serious pathology
• Treatment
  • Rest, ice/heat, stretching, PT
  • Analgesia (NSAIDS, acetaminophen, diclofenac cream)
• Disposition
  • Discharge with primary care/orthopedic follow-up

Pearls

• Symptoms of costochondritis may persist beyond 1 year in about half of patients.
• Do not give a diagnosis of costochondritis from chest pain unless symptoms are clearly reproducible with movements/palpation.

Deep Dive

• Costochondritis (Physiopedia)

Rapid Review

• Background
  • This condition occurs due to compression of the cauda equina, which is the last segment of the spinal cord. It can be caused by disc herniation, epidural abscess or tumor. In a patient with back pain, findings concerning for cauda equina include bowel or bladder dysfunction, lower extremity weakness or loss of sensation
  • Most commonly caused by herniated disk. May also be caused by spinal cord infection or spinal epidural abscess (IV drug use is large risk factor)
• Signs/Symptoms
  • Acute low back pain
  • Saddle anesthesia, decreased rectal tone, urinary incontinence/retention
• Diagnosis
  • Clinical diagnosis
  • Confirmed with emergent MRI (first-line) or CT myelogram 
• Treatment
  • High-dose methylprednisolone
  • Consult neurosurgical for emergent operative decompression
• Disposition
  • Admit to neurosurgical service (if acute)
  • Patients with established cauda equina and no new deficits can be discharged with close neurosurgical follow-up.

Pearls

• If there is any concern for cancer or  infection as the source of the compression, be sure to get the MRI with and without contrast.
• Although prognosis is best if surgery is performed within 8 hours, patients presenting late (> 48 hours) may still benefit from surgery.

Deep Dive

• Cauda Equina Syndrome (Orthobullets)

Rapid Review

• Background 
  • Syndrome that occurs due to increased tissue pressure within a closed fascial space, resulting compromised blood flow and tissue ischemia
  • Most commonly occurs in the anterior compartment of the leg following a tibial fracture.
• Signs/Symptoms
  • Progressive worsening pain
  • “5 P’s” (pain, paresthesia, pallor, paralysis, pulselessness)
• Diagnosis
  • Compartment pressure measurement ( >30 suggestive of compartment syndrome)
• Treatment
  • Provide analgesia and maintain limb at level of the heart
  • Fasciotomy is the definitive management
• Disposition
  • Admission with orthopedic or surgical consultation for any pressures > 20
  • If compartment pressures are < 15, they may discharged so long as they can reliably follow up for repeat measurements. 

Pearls

• Compartment syndrome is a time-sensitive process. Irreversible changes occur following 6 hours of ischemia. Be sure to get specialists on board quickly.
• Always consider concomitant rhabdomyolysis, especially in crush injuries.

Deep Dive

• The Dreaded Acute Compartment Syndrome (emDOCs)