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Category: Orthopedic Surgery

HOW TO DIAGNOSE SEPTIC ARTHRITIS

HOW TO DIAGNOSE SEPTIC ARTHRITIS

The biggest challenge in diagnosing septic arthritis is to think of it. Once you think of it, there is a diagnostic process that you activate. The second biggest challenge is that that diagnostic process we learn in training is flawed. We have no alternatives right now, so I will share with you my thoughts on how we should use our judgment as clinicians.   Triggers to consider septic arthritis essentially are the same triggers as infection anywhere. Celsus’ cardinal signs…

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REAPPROXIMATING MID FOREARM FRACTURES THROUGH ANGULATION

REAPPROXIMATING MID FOREARM FRACTURES THROUGH ANGULATION

A patient presents with a mid forearm fracture. Reduction is tough because it is 100% displaced. Unlike distal fractures, you can not grab the bone as it is surrounded by muscle. It is hard to pull enough traction to reapproximate. Now what?   Try angling more during your reduction, exaggerating the angulation. Now it is slack enough you can put the distal piece on the proximal piece. Use your other hand to guide it on manually. Once the two pieces…

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UNLOCKING SHOULDER DISLOCATIONS

UNLOCKING SHOULDER DISLOCATIONS

A patient presents with a recurrent anterior shoulder dislocation. Milch fails but Spaso works. The next month she is back and the procedure feels different, with more resistance. This time Spaso fails and Milch works. Same shoulder, so what is different? Why did the efficacy reverse?   Milch’s 1938 article started with a question: why do some reductions seem impossible and then under general anesthesia they become very easy, almost going in spontaneously? It was the muscle and tendon opposition,…

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KOCHER INTENDED FOR SUBCORACOID DISLOCATIONS, NOT SUBGLENOID

KOCHER INTENDED FOR SUBCORACOID DISLOCATIONS, NOT SUBGLENOID

The Kocher technique, one of the oldest and most popular techniques, was developed for the subcoracoid anterior dislocation. Review Neil Cunningham’s resources at shoulderdislocation.net for insight on this, as well as his translation of the original Kocher article.   The goal of Kocher’s method, which was worked out on cadavers in 1870, is to roll the greater trochanter of the humeral head on the glenoid rim. It might have been named the “shoulder rim roll.” Here are the steps:  …

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LISFRANC JOINT INJURIES: PALPATE AND TWIST

LISFRANC JOINT INJURIES: PALPATE AND TWIST

We think of the foot as a simple thing but it actually comprises one fourth of all the bones of the body, with 26 overall. Although some stability comes from the arch structure (the Roman arches did not require mortar) most of the stability of the foot is ligamentous. It therefore should not be surprising that diagnosing foot injury and predicting complications is difficult. Ligaments are essentially invisible on xray. Weight-bearing radiographs, recommended by the American College of Radiology, are…

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PHYSICAL DIAGNOSIS OF OCCULT HIP FRACTURES

PHYSICAL DIAGNOSIS OF OCCULT HIP FRACTURES

An elderly female presents after a fall. You were concerned about hip fracture but the x-rays were negative. You go back to examine her and she is able bear weight but she has a very slow and antalgic gait. You order a CT scan of the hip and this also comes back normal. You go back to examine her wondering whether you can use physical diagnosis to exclude a fracture. LIMITATIONS OF ADJUNCTIVE TESTING X-rays are only 90% sensitive for…

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LUMBAR SPINE NEUROLOGICAL EXAMINATION TEMPLATE

LUMBAR SPINE NEUROLOGICAL EXAMINATION TEMPLATE

The neurological examination is relative to the pathology you are investigating. This should not be used in a cut and paste fashion but rather for reference.   MOTOR Hip flexion “pull your knee to your chest” (L2/3) 5/5 Hip adduction “pull your knees into each other” (L2/3) 5/5 Hip abduction “pull your knees apart” (L4/5/S1) 5/5 Hip extension “pull your thigh back” (L4/5) 5/5 Knee extension “hold your knee straight” (L3/4) 5/5 Knee flexion “pull your heel to your bottom”…

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TWIST AND SHOUT – DIAGNOSING OCCULT TODDLER’S FRACTURE

TWIST AND SHOUT – DIAGNOSING OCCULT TODDLER’S FRACTURE

A 2 year old presents with leg pain and a limp after slipping on a “slip and slide” water toy slide. X-rays are negative. The child will step when asked but will not walk on his own. Is this an occult fracture? This is a situation where the reference standard, radiography, has limitations in sensitivity. Studies show that using alternative tests reveal evidence of fracture, such as hematoma elevation on ultrasound (Lewis J Clin Ultrasound 2006) or MRI or delayed…

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HAND LACERATION: TEST RESISTED RANGE OF MOTION

HAND LACERATION: TEST RESISTED RANGE OF MOTION

A patient presents with a laceration to the flexor side of her left forefinger. The student tells you function was normal. “How did you determine that?” you ask. “Range of motion.” You ask the patient to repeat the range of motion test, but this time you apply active resistance and simultaneously check the opposite side for comparison. There is significant weakness on the left compared to the right. You just discovered a partial tendon laceration and prevented an easy misdiagnosis….

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GAIT ASSESSMENT: WALK THE WALK  

GAIT ASSESSMENT: WALK THE WALK  

A mother brings her 2 year old child in for a limp. The student believes the patient has ankle pain because she cried when she grabbed the ankle. After that she cried with everything. After calming the child down you watch her walk and it is abnormal but you wonder how to interpret this.   The last time I tried really hard to analyze gait and make recommendations, it was so complicated that no one could remember it. I now…

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