Sonoelastography: A powerful technique in musculoskeletal imaging

Sonoelastography is a powerful method available to observe the musculoskeletal system, and appears particularly valuable in detecting early tendinopathies, pursuing complaints of localized musculoskeletal pain, analyzing soft tissue masses, and research applications in musculoskeletal medicine.     

Glenohumeral Joint Range of Motion in Elite Male Golfers: A Pilot Study

Background

Shoulder injuries account for up to 17% of all golf related musculoskeletal injuries. One cause may be the repetitive stresses applied to the lead shoulder during the backswing and follow-through phases, which may contribute to the frequency of these injuries. The “elite” golfer may be pre-disposed to developing a shoulder injury based upon the reported adaptations to the glenohumeral joint.

Objective

To examine and compare bilateral glenohumeral joint rotational range of motion in elite golfers using standard goniometric procedures.

Methods

Twenty-four “elite” male golfers were recruited for this study. Glenohumeral internal (IR) and external rotation (ER) passive range of motion was measured bilaterally at 90° of abduction using a standard universal goniometer. Paired t-tests were utilized to statistically compare the rotational range of motion patterns between the lead and the trailing shoulder.

Results

No statistical differences existed between each shoulder for mean IR or mean ER measures. This finding was consistent throughout different age groups. External rotation measurements were greater than IR measurements in both extremities.

Discussion and Conclusion

Unlike other sports requiring repetitive shoulder function, the “elite” golfers sampled in this pilot investigation did not demonstrate a unique passive range of motion pattern between the lead and trailing shoulders. Factors, including subjects'' age, may have confounded the findings. Further studies are warranted utilizing cohorts of golfers with matching age and skill levels. Additional shoulder range of motion measures should be evaluated.     

Efficacy of an Ibuprofen/Codeine Combination for Pain Management in Children Presenting to the Emergency Department with a Limb Injury: A Pilot Study

Background

Fractures and severe sprains generate moderate to severe pain (>3/10). Despite this fact, pain management in children presenting to the Emergency Department (ED) with a musculoskeletal trauma is still suboptimal. Few studies have focused on the efficacy of a combination of an opioid with an anti-inflammatory drug to relieve this type of pain.

Study Objective

To compare the efficacy of a combination of codeine with ibuprofen to ibuprofen alone on the intensity of pain experienced by children presenting to the ED with a musculoskeletal trauma to a limb.

Methods

This randomized, double-blind, placebo-controlled trial included patients aged 6 to 18 years. After triage, subjects were randomized to either ibuprofen (10 mg/kg, max 600 mg) and codeine (1 mg/kg, max 60 mg) orally, or ibuprofen (10 mg/kg, max 600 mg) and a placebo orally. Pain was assessed with the visual analog scale (0 to 10) at triage, and at 60, 90, and 120 min after medication administration. Differences on mean pain scores were compared between groups over time.

Results

We recruited 81 patients, 40 in the experimental group and 41 in the control group. No significant differences were observed in mean pain scores between groups at any time point. Mean pain scores were moderate at 90 min in both experimental and control groups (4.0 ± 2.4 vs. 4.1 ± 2.0, respectively). Side effects were minimal.

Conclusion

The addition of codeine to ibuprofen did not significantly improve pain management in children with musculoskeletal trauma to a limb. Pain control provided by the medications remained suboptimal for most patients.     

Traumatic brain injury as a relevant cause of growth hormone deficiency in adults: A KIMS-based study

OBJECTIVES: To characterize further the clinical manifestations and the efficacy of growth hormone (GH) replacement therapy in patients with adult-onset growth hormone deficiency (GHD) reported in the KIMS (Pfizer's international metabolic database) as caused by traumatic brain injury (TBI) and to compare them with nonirradiated patients whose GHD was due to a nonfunctioning pituitary adenoma (NFPA). DESIGN: Observational study. SETTING: Subjects selected from the KIMS database. PARTICIPANTS: Fifty-one patients with GHD resulting from TBI and 688 patients with GHD resulting from NFPA. Both groups were selected from the KIMS and had adult-onset GHD with GH replacement therapy only after KIMS entry and before and after KIMS entry. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Age, body mass index, age at disease onset, age at disease diagnosis, age at KIMS entry, final height, GH peak at testing, GH replacement dose, routine biochemical analysis, clinical manifestations of disease, and quality of life measurements. RESULTS: Patients with TBI were significantly younger at study entry and were younger both at pituitary disease onset and at GHD diagnosis, but they showed a significant delay in treatment. When comparing patients not treated with GH before entering in the KIMS, patients with TBI were significantly shorter (167.2+/-1.7 cm) than those with NFPA (171.6+/-0.4 cm) in final height. TBI patients had lower GH reserves than NFPA patients, and although the latter group experienced more positive changes, both groups benefited from GH replacement therapy. CONCLUSIONS: Patients with GHD due to TBI showed a significant reduction in height and a reduction in pituitary GH reserve and were diagnosed and treated with inappropriate delay.     

The use of ultrasound to facilitate spinal anesthesia in a patient with previous lumbar laminectomy and fusion: A case report

We describe a case of ultrasound (US)‐facilitated spinal anesthesia in a patient with a prior lumbar laminectomy and spinal fusion who presented for total knee arthroplasty. Traditional, landmark‐guided spinal anesthesia had previously failed. Although pre‐procedural US identified a soft‐tissue window at L3/4, a 25G pencilpoint needle encountered resistance. Reassured from US imaging that this was not bone, we used a 22G cutting tip needle successfully. We believe spinal anesthesia would not have been possible in this patient without US, adding to the evidence that US‐facilitated neuraxial anesthesia is useful, particularly in technically difficult, if not ‘impossible,’ cases. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2009     

Review article: Methodology for the ‘rapid review’ series on musculoskeletal injuries in the emergency department

Musculoskeletal injuries are a common presentation to the ED, with significant costs involved in the management of these injuries, variances in care within the ED and associated morbidity. A series of rapid review papers were completed to guide best practice for the assessment and management of common musculoskeletal injuries presenting to the ED. This paper presents the methodology used across the rapid reviews. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2015. The search was repeated consistently for each topic area (injuries of the foot and ankle, knee, hand and wrist, elbow, shoulder, lumbar spine and cervical spine). English‐language primary studies, systematic reviews and guidelines that were published in the last 10 years and addressed acute musculoskeletal injury management were considered for inclusion. Data extraction of each included article was conducted, followed by a quality appraisal. The extracted data from each article was synthesised to group similar evidence together. For each rapid review, the evidence has been organised in a way that a clinician can direct their attention to a specific component of the clinical cycle of care in the ED, such as the assessment, diagnostic tests, management and follow‐up considerations from ED. The series of rapid reviews are designed to foster evidence‐based practice within the ED, targeting the injuries most commonly presenting. The reviews provide clinicians in EDs with rapid access to the best current evidence, which has been synthesised and organised to assist decision‐making.     

Chronic Physical Health Conditions After Injury: A Comparison of Prevalence and Risk in People With Orthopedic Major Trauma and Other Types of Injury

ObjectivesTo determine (1) the prevalence of chronic physical health conditions reported preinjury, at the time of injury, up to 1 year postinjury, and 1 to 5 years postinjury; and (2) the risk of chronic physical health conditions reported 1 to 5 years postinjury in people with orthopedic and other types of major trauma.DesignCohort study using linked trauma registry and health administrative datasets.SettingThis study used linked data from the Victorian State Trauma Registry (VSTR), the Victorian Registry of Births, Deaths and Marriages (BDM), the Victorian Admitted Episodes Dataset (VAED), and the Victorian Emergency Minimum Dataset (VEMD).ParticipantsMajor trauma patients (N=28,522) aged 18 years and older who were registered by the VSTR, with dates of injury from 2007 to 2016, and who survived to at least 1 year after injury, were included in this study. Major trauma cases were classified into 4 groups: (1) orthopedic injury, (2) severe traumatic brain injury (s-TBI), (3) spinal cord injury, and (4) other major trauma.InterventionNot applicable.Main Outcome MeasurePrevalence of chronic physical health conditions.ResultsThe cumulative prevalence of any chronic physical health condition for all participants was 69.3%. The s-TBI group had the highest cumulative prevalence of conditions. The most common conditions were arthritis and arthropathies, cancer, and cardiovascular diseases. Preinjury chronic conditions were most common in people with s-TBI (19.3%) and were least common in people with other types of major trauma (6.6%). The highest prevalence of new-onset conditions after injury was found in people with s-TBI (21.7%) and orthopedic major trauma (21.4%), whereas the lowest prevalence was found in people with other types of major trauma (9.2%). For the orthopedic injury group, there were no significant differences in the adjusted risk of conditions reported 1 to 5 years postinjury compared with other major trauma groups.ConclusionsChronic physical health conditions were common among all injury groups. There was no significant difference in the risk of chronic conditions among injury groups. Rehabilitation practitioners should be aware of the risk of chronic conditions in people with orthopedic and other types of major trauma. Long-term follow-up care after injury should include prevention and treatment of chronic conditions.     

Improving Nutrition in Extremely Low Birth Weight Infants: A Quality Improvement Project

The nutritional management of the extremely low birth weight infant has been a source of controversy and practice variation between and within facilities [Clin Perinatol 29 (2002) 225–244]. By using proven quality improvement methods, a multidisciplinary team implemented processes such as Feeding Guidelines and a Feeding Intolerance Algorithm to standardize nutrition and impact clinically relevant outcomes including (1) reduced days to initiate feedings, add fortifier, and reach full fortified feedings; (2) central line days reduced by 30%; (3) increased discharge weight; and (4) more than 50% reduction of infants discharged home with head circumference less than the third percentile. This project is a straightforward improvement process of getting “back to the basics” and improving quality and consistency of nutrition in extremely low birth weight Infants. By researching the supporting evidence, achieving staff and physician buy-in, and having the commitment of a dedicated team, this project can be safely implemented and result in standardization of nutrition practice leading to reduction in practice variation and improved clinical outcomes.     

The opinion and experiences of Dutch orthopedic surgeons and radiologists about diagnostic musculoskeletal ultrasound imaging in primary care: A survey

Introduction and aimThe use of diagnostic musculoskeletal ultrasound (DMUS) in primary health care has increased in the recent years. Nevertheless, there are hardly any data concerning the reliability, accuracy and treatment consequences of DMUS used by physical therapists or general practitioners. Moreover, there are no papers published about how orthopedic surgeons or radiologists deal with the results of DMUS performed in primary care. Therefore, our aim is to evaluate the opinion, possible advantages or disadvantages and experiences of Dutch orthopedic surgeons and radiologists about DMUS in primary care.MethodsA cross-sectional survey in which respondents completed a self-developed questionnaire to determine their opinion, experiences, advantages, disadvantages of performing DMUS in primary care.ResultsQuestionnaires were sent to 838 Dutch orthopedic surgeons and radiologists of which 213 were returned (response rate 25.4%). Our respondents saw no additional value for health care for diagnostic DMUS in primary care. DMUSs were generally repeated in secondary care. They perceived more disadvantages than advantages of performing DMUS in primary care. Mentioned disadvantages were: ‘false positive results’ (71.4%), ‘lack of experience’ (70%), ‘insufficient education’ (69.5%), not able to relate the outcomes of DMUS with other forms of diagnostic imaging’ (65.7%), and ‘false negative results’ (65.3%).ConclusionRadiologists and orthopedic surgeons sampled in the Netherlands show low trust in DMUS knowledge of physical therapists and general practitioners. The results should be interpreted with caution because of the small response rate and the lack of representativeness to other countries.