Olecranon Bursitis is inflammation and swelling of the bursa overlying the olecranon process of the ulna. Can result from trauma, overuse, or infection.
Treatment can consist of:
Remember aspiration has some major risks that need to be explained to the paitent:
They also need to know that the fluid will likely reaccumulate. So aspiration is not a guaranteed cure.
Placing a foley catheter in a patient with BPH or acute urinary retention can be very difficult at times. Here are some tips to increase your chance of a successful placement.
If all else fails, a suprapubic catheter may need to be placed. For a great review on evaluation and treatment please see Drs. Vilke, Ufberg, Harrigan, and Chan's article in the August edition of Journal of Emergnecy Medicine entitled Evaluation and treatment of acute urinary retention.
When examining a knee for a meniscal injury the commonly described tests are the McMurray Test and Apley Test. However, these tests have sensitivities of 48-68% and 41% respectfully, and specificities of 86-94% and 86-93% respectfully. Depending on whether you are looking at the medical or lateral meniscus.
The Tessaly Test that was first described in 2005 can be performed with knee in either 5 or 20 degrees of flexion and has a senstivity of 89-92% and specificity of 96-97% when performed in 20 degrees flexion. The test also tends to be easier to perform.
To perform the test:
Essentially you and your patient will look like you are doing the twist as they rotate their knee with you holding their hands.
Most people are now using Ultrasound to aid in cannulation of the femoral and internal jugular veins, but if you find yourself without the ultrasound machine you can increase your chance of successful cannulation of the femoral vein by positioning the leg properly.
Werner et al looked at the common femoral veins of 25 healthy volunteers and noted that the femoral vein was accessable more often when the hip was abducted and external rotated. This simple position change increased the mean diameter of the vein, and prevented the vein from being directly posterior to the artery.
Fracture Management:
In order to maximize billing when caring for patients with fractures two things should be done:
Finally, you should obtain post-reduction x-rays on any fracture that you manipulate and document that the patient is neurovascularly intact prior to discharge.
SCAPHOID FRACTURE:
Joint Fluid Analysis:
This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain. For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.
| Diagnosis | Appearance | WBC | PMNs | Glucose % of Blood Level | Crystals | |
| Normal | Clear | <200 | <25 | 95 - 100 | None | |
| Degenerative Joint Disease | Clear | <4000 | <25 | 95 - 100 | None | |
| Traumatic Arthritis | Straw colored | <4000 | <25 | 95 - 100 | None | |
| Acute Gout | Turbid | 2000 - 50,000 | >75 | 80 - 100 | Negative birefringence | |
| PseudoGout | Turbid | 2000 - 50,000 | >75 | 80 - 100 | Positive birefringence | |
| Septic Arthritis | Purulent / turbid | 5000 - > 50,000 | >75 | < 50 | None | |
| Rheumatoid Arthritis | Turbid | 2000 - 50,000 | 50-75 | ~75 | None |
To view a gout crystal click this link.
To view a pseudogout crystal. Click this link
Pearls:
Calcaneus Fractures
Normally occur due to axial loading mechanism such as:
Miscellanous Facts:
Pearls:
Hip Fractures:
Typically divided into four types:
Here is a link to a picture with a good representation of the different types of fractures.
Now that we have entered the session of cookouts, picnics, and family get togethers I thought I would review some of the more common causes of food poisoning and the typical foods that they are found in.
| Bacteria | Foods Typically Found In | Onset of Symptoms |
| Staphylococcus aureus | Meat and seafood salads, sandwich spreads and high salt foods. | 4-6 hours |
| Salmonella | Meat; poultry, fish and eggs and now tomatoes | 12 to 24 hours. Assoociated with fever |
| Clostridium perfringens | Meat and poultry dishes, sauces and gravies. | 12 to 24 hours. |
| Vibrio parahaemolyticus | Raw and cooked seafood. | 12 to 24 hours. Associated with fever |
| Bacillus cereus | Starchy food. Typically Chinese Fried Rice in test questions | 12 to 24 hours. |
| Campylobacter jejuni | Meat, poulty, milk, and mushrooms. | 24 hours |
Treatment of Wernicke's Encephalopathy
Traditionally the treatment dose of thiamine in those that we suspect to have Wernicke's Encephalopathy is 100mg per day. The problem is that this does was arbiarily picked by two physicians, Victor and Adams, in the 1950's. They thought that 100mg a day would be a large dose. They also made their recommendation without fully understanding the pharmacokinetics of thiamine which has a half life of 96 minutes or less. Compound this with case reports of individuals dying of Wernike's Encephalopathy despite being given 100mg of Thiamine daily.
Several authors are now advocating that patients with Wernicke's Encephalopathy be treated with 500mg of IV thiamine daily, but with the short half life some are advocating that the thiamine be given 2 to 3 times a day. There are no good studies to refute or support the claims that higher doses are needed, but there are well documented cases of treatment failures at the lower dose.
PEARLs:
Lisfranc Fracture:
Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid. Common current mechanism is when a person steps into a hole and twists the foot.Originally described when a horseman would fall of their horse with their foot still trapped in a stirrup.
Diagnosis should be considered if patient has difficult weight bearing with pain on palpation over the 2nd and 3rd metacarpal head with an appropriate mechanism.
Pearls:
I remember being taught as a medical student that clavicle fractures could be treated conservatively. A direct quote was "if both ends of the clavicle are in the same room it will heal".
Though conservative treatment with a sling for 6 weeks with early pendulum ROM exercises for the shoulder is appropriate for the vast majority of clavicle fractures surgery should be considered for those that have:
Extensor Tendon Injuries [Mallet Finger]
Posterior Interosseous Nerve Compression Syndrome
As eluded to last week Posterior Interosseous Nerve (PIN) Compression Syndrome, a deep branch of the radial nerve, is felt to be radial tunnel syndrome with paralysis.
For those at the University of Maryland that got the chance to hear my lecture this week, you learned about Cubital tunnel syndrome [ulnar neuropathy], the second most common compressive neuropathy. Carpal Tunnel syndrome remains the number one compressive neuropathy, and this pearl, for the sake of completeness, will address Radial tunnel syndrome.
Stay tuned for next week for Posterior Interosseous Nerve syndrome.
Turf Toe:
Most commonly seen in atheletes who compete on artificial turf. Presents as pain over the 1st Metatarsalphalangeal (MTP) joint.
Achilles Tendon Rupture
This addition was sent in my Dr. Andrew Milstein:
Thanks for the Orthopedics update. A few pearls for Achilles Tendon Rupture --> often these patients may present like a typical ankle sprain patient and are placed in a hallway chair. You can't do an adequate Thompson Test while someone is sitting in a chair. If you're concerned, lay them down on a stretcher to do the test.
Some simple facts about Pancreatitis:
Bacterial Vaginosis
