ALiEM AIR Series | Orthopedics Lower Extremity Module

AIR Orthopedics Lower Extremity badge module

 

Welcome to the AIR Orthopedics Lower Extremity Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to related to neurologic emergencies in the Emergency Department. 4 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 3 Honorable Mentions. We recommend programs give 2 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Orthopedics Lower Extremity Module at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Orthopedic Lower Extremity Emergencies

SiteArticleAuthorDateLabel
PedEM MorselsLisfranc Injuries in Pediatric PatientsChristyn Magill, MD3/18/22AIR
Rebel EMCompartment SyndromeAnand Swaminathan, MD5/4/22HM
EM CasesEmergency Orthopedics Differential: SCARED OF Mnemonic – When X-rays LieArun Sayal, MD and Yatin Chadha, MD10/25/22HM
PedEM MorselsTibial Shaft Fractures in ChildrenSean Fox, MD5/6/22HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

 

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

SAEM Clinical Images Series: A Rare Cause of Post-traumatic Neck Pain

neck pain

A 15-year-old male presents to the pediatric Emergency Department (ED) for evaluation of neck pain for three weeks. The patient is vague as to the development of his symptoms, but his mother reveals patient was assaulted by peers three weeks ago and has had progressively worsening neck pain and stiffness. The patient states symptoms have gotten to the point where he is unable to turn his head but denies fevers, chills, nausea, vomiting, focal weakness, or sensory changes.

Vitals: Temp: 99.4°F; HR 80; RR 18; SpO2 98% on room air

Constitutional: No distress, sitting rigidly in bed.

Neck: Cervical midline tenderness noted with rigid neck and severe tenderness with manipulation, no swelling, erythema, or masses noted.

HEENT: No pharyngeal injection, no visible masses in the oropharynx, no trismus.

CV: Regular rate and rhythm, no murmurs, rubs, or gallops. Good peripheral perfusion.

Abdomen: Soft, non-distended and non-tender.

Neuro: 5/5 motor function to the bilateral upper and lower extremities, normal sensory examination, cranial nerves intact. Negative Kernig’s sign.

White blood cell (WBC) count: 9.5

Platelets: 639

Glucose: 105

CRP: 128

ESR: 100

CSF: Color- Clear; Nucleated Cells- 1; Protein- 25; Glucose- 6

This patient was found to have septic arthritis of the atlantooccipital (AO) joint, noted on the CT shown above, with joint space narrowing and erosion (red arrow) of the right AO joint with associated soft tissue swelling and effusion. Seen on the MRI is further confirmation of the findings suggested on CT of septic arthritis, with additional noting of attenuation of the prevertebral space of C2/C3 suggestive of phlegmon, bilateral AO joint arthritis, and involvement of the atlantoaxial joint, all of which can be seen on the above sagittal cut of the MRI, with the most notable being the pre-vertebral phlegmon (red arrow).

Septic arthritis of the facet joints is a rarity, particularly in pediatrics and in the cervical spine; case reports largely describe a lumbar location in elderly adults with predisposing comorbidities (intravenous drug use, diabetes, immunosuppression) for spontaneous infection. There are no published case reports of traumatic, pediatric AO joint septic arthritis. This patient developed septic arthritis following trauma. As with peripheral septic arthritis, the most common cause is hematogenous spread, and even non-penetrating trauma can predispose a joint to infection as likely occurred in this case. Septic arthritis of the facet joints presents similarly to spondylodiscitis, generally with fever, neck or back pain, and elevated inflammatory markers such as CRP/ESR. If left untreated, it can be a dangerous and refractory cause of sepsis that leads to deadly complications such as concomitant epidural access formation. Oftentimes patients are initially misdiagnosed and re-present multiple times as the preferred image modality for diagnosis is MRI which is not always readily available or ordered. In general, treatment generally includes weeks-long courses of intravenous (IV) antibiotics, though this patient was discharged on oral antibiotics after significant symptomatic improvement on IV therapy after four days.

Take-Home Points

  • Septic arthritis of the cervical facet joints, namely the AO joint, is a rare cause of neck pain in patients with fever and elevated inflammatory markers, and can present after trauma. Generally, it is hematogenously spread and associated with comorbidities such as diabetes, intravenous drug use, and immunosuppression, it should be considered in patients with refractory symptoms or in which there is strong suspicion as it can have dangerous complications.
  • The preferred imaging modality for diagnosis is MRI, though CT can be useful in making the diagnosis radiographically. Treatment generally consists of weeks of IV antibiotics.

  • Sethi S, Vithayathil MK. Cervical facet joint septic arthritis: a real pain in the neck. BMJ Case Rep. 2017 Aug 3;2017:bcr2016218510. doi: 10.1136/bcr-2016-218510. PMID: 28775081; PMCID: PMC5612571.
  • Narváez J, Nolla JM, Narváez JA, Martinez-Carnicero L, De Lama E, Gómez-Vaquero C, Murillo O, Valverde J, Ariza J. Spontaneous pyogenic facet joint infection. Semin Arthritis Rheum. 2006 Apr;35(5):272-83. doi: 10.1016/j.semarthrit.2005.09.003. PMID: 16616150.

SAEM Clinical Images Series: Hey Doc, Can You Come Look at This Urine?

urine

A 4-year-old male with no significant past medical history presents as a transfer from an outside hospital for suspected inhalation burn secondary to a house fire. The patient was home with his father and sibling when the apartment caught fire from a suspected flame in the kitchen. The patient was evacuated from the building by fire rescue after an unknown period of time. He was intubated at the outside hospital due to concern for inhalation injury. It is unknown if the patient sustained any trauma prior to extraction.

Vitals: T 98.1°F; BP 120/64; P 126; RR 29; O2 Sat 100% on vent

General: Intubated and sedated.

HENT: Singed hair and soot noted to nares, soot in mouth and secretions.

Cardiovascular: Regular rate and rhythm.

Lungs: CTABL, no wheezing or stridor.

GU: Normal appearing genitalia, no blood at meatus or from rectum, dark red urine noted in foley bag.

Skin: 0% TBSA burns, no obvious signs of trauma.

CBC: WNL

ABG at outside hospital: pH 7.0, carboxyhemoglobin 10, methemoglobin 3, lactate 3.7

Repeat ABG after transfer: pH 7.22, carboxyhemoglobin 1.7, methemoglobin 3.7, lactate 2.1

Hydroxocobalamin should be given in any case of suspected cyanide toxicity. House fires are the most common cause of cyanide toxicity in industrialized nations. Cyanide toxicity can also occur due to occupational exposures, medications, foods, or intentional ingestion. Cyanide inhibits the electron transport chain thus blocking aerobic metabolism, leading to hypoxia. Patients can present with altered mental status, hemodynamic instability, and dysrhythmias. Labs will be significant for lactic acidosis. Hydroxocobalamin should be given as soon as cyanide toxicity is suspected. Hydroxocobalamin works by chelating cyanide and forming cyanocobalamin which is renally excreted. Hydroxocobalamin is relatively safe and non-toxic but can cause transient hypertension. It also can cause a reddish discoloration of the urine, skin, and mucous membranes that can last up to several days. This is not harmful to the patient but can cause interference in urinalysis results.

Take-Home Points

  • Hydroxocobalamin is the antidote for cyanide toxicity and should be given as soon as possible in suspected cases.
  • Hydroxocobalamin binds cyanide to form cyanocobalamin, which is excreted in the urine.
  • Hydroxocobalamin is relatively safe but can cause transient hypertension and a red urine discoloration that can interfere with urinalysis results.

  • Cescon DW, Juurlink DN. Discoloration of skin and urine after treatment with hydroxocobalamin for cyanide poisoning. CMAJ. 2009 Jan 20;180(2):251. doi: 10.1503/cmaj.080727. PMID: 19153403; PMCID: PMC2621289.
  • Wong SL, Pudek M, Li D. Wine-Colored Plasma and Urine from Hydroxocobalamin Treatment. J Gen Intern Med. 2017 Feb;32(2):225-226. doi: 10.1007/s11606-016-3782-3. Epub 2016 Jun 23. PMID: 27338592; PMCID: PMC5264665.
  • Desai, S. & Su, Mark K. (2021). Cyanide Poisoning. In: UpToDate, Post TW (Ed), UpToDate,Waltham, MA. (Accessed on January 04, 2022.)
  • Lexicomp. (n.d.). Hydroxocobalamin (vitamin B12a supplement and cyanide antidote): Druginformation. UpToDate. Retrieved January 8, 2022,from https://www.uptodate.com/contents/hydroxocobalamin-vitamin-b12a-supplement-and-cyanide-antidote-drug-information

By |2023-02-11T20:46:19-08:00Feb 13, 2023|SAEM Clinical Images, Tox & Medications|

Trick of the Trade: Antibiotic ointment for removal of artificial nail glue from eyelids

A bottle of nail glue and timolol eye drops (reproduced with permission from BMJ Publishing Group Ltd [1])

You are working a busy shift in your department’s fast track area and sign up for a patient with a complaint of “eye pain.” The patient is a fan of glue-on nails and mistook her nail glue bottle for her eyedrops. Now she is unable to open her eyelid for the exam and you struggle to open it yourself. You want to avoid cutting the adhered eyelashes and wonder if there’s a better solution.

Background rise of artificial, press-on nails

Artificial acrylic or “press-on” nails were first invented in the 1950s; however, they did not gain in popularity until the 1980s as nail art became a trend [2]. Shortly thereafter, they fell out of style until a resurgence occurred with the COVID pandemic forcing the closure of nail salons. Compared to pre-pandemic values, Google searches for “press on nails” increased 300% [3]. Application of most nails requires nail glue, which often contains a mixture of alcohol, cyanoacrylate (superglue), or photo-bonded methacrylate [4].

Nail glue complications

Use of nail glue at home can result in adverse exposures with the most common location being the eye [5]. Because nail glue is often packaged in small containers identical to eye drop bottles, patients can mistake the nail glue for ophthalmic drops — especially those with visual impairment [6]. This exposure was first described in the medical literature in 1982 and has been described many times since despite repeated calls for manufacturers to modify the bottles to be safer [1].

In the presence of water, cyanoacrylate rapidly polymerizes, leading to the bonding effect [5]. If the glue gets into a person’s eye, reflexive blinking pushes the glue to the eyelid margins resulting in the eyelashes or eyelid margins sticking together [5], also known as inadvertent tarsorrhaphy. Methods to open the eyelids include removal of glue with forceps, removal or cutting of the eyelashes, or soaking the eye for hours to days with a moist gauze [1, 6, 7].

Although the most successful solvent to dissolve dried glue is acetone, this can cause corneal and conjunctival injuries [8]. The effectiveness of other solvents has been debated in the literature with mixed reports of efficacy [9].

Trick of the Trade: Apply petroleum-based topical antibiotic ointment

Our personal experience managing several of these cases suggests that a petroleum-based topical antibiotic ointment, such as Bacitracin, can help loosen the glue bond. It is an inexpensive option with minimal harm to fix inadvertent eyelid adhesion from nail glue (or other superglue). It is worth trying before attempting more aggressive techniques.

eyelid nail glue adhesion inadvertent tarsorrhaphy ointment

Before and after application of topical antibiotic ointment to remove inadvertent nail glue causing eyelid adhesion

Materials Needed

  • Bacitracin ointment (1-2 tubes)
  • Cotton-tipped applicatiors (Q-tips)

Technique

  1. Apply the topical ointment liberally to the affected eye.
  2. Let rest undisturbed for 15-20 minutes.
  3. Gently pull the eyelids and eyelashes apart.
    • Be careful not to massage the area too vigorously onto the eye itself, as any residual local glue can result in corneal trauma.
    • You can use cotton-tipped applicators to help gently tease the lid margins apart.
  4. Copiously irrigate the eye.
  5. Perform an eye exam to assess for ocular injury.
  6. Consider obtaining an ophthalmology consult.

References

  1. Yusuf IH, Patel CK. A sticky sight: cyanoacrylate “superglue” injuries of the eye. BMJ Case Rep. 2010;2010:bcr11.2009.2435. doi:10.1136/bcr.11.2009.2435
  2. Quinn J. Not Your ’80s Press-Ons: Why the Press-On Manicure Trend Is a Must-Try. Sunday Edit. Published June 10, 2022. Accessed October 26, 2022.
  3. Google Trends on “press on nails”. Google Trends. Accessed October 26, 2022.
  4. Brambilla E, Crevani M, Petrolini VM, et al. Exposure to Nail and False Eyelash Glue: A Case Series Study. Int J Environ Res Public Health. 2020;17(12):E4283. doi:10.3390/ijerph17124283
  5. Forrester MB. Characteristics of ocular nail glue exposures reported to the National Electronic Injury Surveillance System during 2000-2019. Clin Toxicol Phila Pa. 2021;59(7):633-638. doi:10.1080/15563650.2020.1834115
  6. Samet A, Li DQ, Al-Qahtani A, Arthurs B, El-Hadad C. Nail glue injuries to the eye: assessment of two cases. Can J Ophthalmol. 2022;57(1):e11-e13. doi:10.1016/j.jcjo.2021.04.026
  7. Cohen J. Super Glued Shut. Brown Emergency Medicine. Published Apr 12, 2017. Accessed February 5, 2023.
  8. Reddy SC. Superglue injuries of the eye. Int J Ophthalmol. 2012;5(5):634-637. doi:10.3980/j.issn.2222-3959.2012.05.18
  9. Prouty H, Adams DS, Heard K. Evaluation of Treatments for Cyanoacrylate Eyelash Adhesion Using an In-Vitro Model. Cutan Ocul Toxicol. 2008;27(1):11-14. doi:10.1080/15569520701856732

By |2023-02-06T13:59:27-08:00Feb 8, 2023|Ophthalmology, Tricks of the Trade|

SAEM Clinical Images Series: An Adult with a Lower Extremity Rash

vasculitis

A 37-year-old male with a past medical history of type 2 diabetes presents to the Emergency Department (ED) with a rash. Initial symptoms began one week prior with small spots on the right leg with associated itching and burning. He initially presented to an outside facility where he was diagnosed with an allergic reaction versus scabies and was given a short course of oral steroids and topical permethrin that provided some relief. The rash progressed to bilateral lower extremities prompting re-presentation to the ED. He also reports associated dark urine and nausea.

GI: Abdomen soft, non-tender, non-distended.

MSK: No joint swelling, tenderness, erythema or warmth.

Skin: Numerous scattered bright red palpable purpuric papules and plaques, most concentrated on bilateral lower extremities extending to lower abdomen at the level of the umbilicus.

White blood cell (WBC) count: 14.5 k

Creatinine: 1.1 mg/dL on day of presentation, peaked at 2.2 mg/dL approximately 10 days later.

C-reactive protein (CRP): 32.7 mg/L

Erythrocyte sedimentation rate (ESR): 34 mm/hr

Urinalysis: 3+ protein, 2+ blood, 11-20 RBC, 26-50 WBC, rare bacteria

This is a case of IgA vasculitis, formerly called Henoch-Schonlein purpura or HSP. This diagnosis is suspected when a patient has purpuric skin lesions predominantly on the lower limbs as well as at least one of the following: abdominal pain, joint involvement, renal involvement (proteinuria/hematuria), and biopsy demonstrating IgA deposition. This vasculitis is more commonly seen in children and has a male predominance.

Similar to children with IgA vasculitis, adults presenting with this palpable purpuric rash can have associated joint involvement and GI involvement, though intussusception is less common in the adult population. Renal manifestations are more common in adults with this diagnosis and range from proteinuria and hematuria to renal failure. Our patient initially presented with hematuria/proteinuria and less than two weeks later had a doubled his creatinine. A renal biopsy later confirmed IgA nephropathy.

Take-Home Points

  • Consider IgA vasculitis in patients with lower extremity purpuric skin lesions with associated abdominal pain/GI bleed, arthralgia, renal involvement, and/or biopsy confirming IgA deposition.
  • In adults with IgA vasculitis, renal involvement is more common and often more severe.

  • Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, Buoncompagni A, Lazar C, Bilge I, Uziel Y, Rigante D, Cantarini L, Hilario MO, Silva CA, Alegria M, Norambuena X, Belot A, Berkun Y, Estrella AI, Olivieri AN, Alpigiani MG, Rumba I, Sztajnbok F, Tambic-Bukovac L, Breda L, Al-Mayouf S, Mihaylova D, Chasnyk V, Sengler C, Klein-Gitelman M, Djeddi D, Nuno L, Pruunsild C, Brunner J, Kondi A, Pagava K, Pederzoli S, Martini A, Ruperto N; Paediatric Rheumatology International Trials Organisation (PRINTO). EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis. 2010 May;69(5):798-806. doi: 10.1136/ard.2009.116657. PMID: 20413568.
  • Yaseen K, Herlitz LC, Villa-Forte A. IgA Vasculitis in Adults: a Rare yet Challenging Disease. Curr Rheumatol Rep. 2021 Jul 1;23(7):50. doi: 10.1007/s11926-021-01013-x. PMID: 34196893.

By |2023-01-20T15:48:31-08:00Jan 30, 2023|Dermatology, Renal, SAEM Clinical Images|
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