Acute finger injuries: part II. Fractures, dislocations, and thumb injuries

Family physicians can treat most finger fractures and dislocations, but when necessary, prompt referral to an orthopedic or hand surgeon is important to maximize future function. Examination includes radiography (oblique, anteroposterior, and true lateral views) and physical examination to detect fractures. Dislocation reduction is accomplished with careful traction. If successful, further treatment focuses on the concomitant soft tissue injury. Referral is needed for irreducible dislocations. Distal phalanx fractures are treated conservatively, and middle phalanx fractures can be treated if reduction is stable. Physicians usually can reduce metacarpal bone fractures, even if there is a large degree of angulation. An orthopedic or hand surgeon should treat finger injuries that are unstable or that have rotation. Collateral ligament injuries of the thumb should be examine with radiography before physical examination. Stable joint injuries can be treated with splinting or casting, although an orthopedic or hand surgeon should treat unstable joints.     

Acute bacterial rhinosinusitis in adults: part I. Evaluation

Acute rhinosinusitis is one of the most common conditions that physicians treat in ambulatory practice. Although often caused by viruses, it sometimes is caused by bacteria, a condition that is called acute bacterial rhinosinusitis. The signs and symptoms of acute bacterial rhinosinusitis and prolonged viral upper respiratory infection are similar, which makes accurate clinical diagnosis difficult. Because two thirds of patients with acute bacterial rhinosinusitis improve without antibiotic treatment and most patients with viral upper respiratory infection improve within seven d antibiotic therapy should be reserved for use in patients who have had symptoms for more than seven days and meet clinical criteria. Four signs and symptoms are the most helpful in predicting acute bacterial rhinosinusitis: purulent nasal discharge, maxillary tooth or facial pain (especially unilateral), unilateral maxillary sinus tenderness, and worsening symptoms after initial improvement. Sinus radiography and ultrasonography are not recommended in the diagnosis of uncomplicated acute bacterial rhinosinusitis, although computed tomography has a role in the care of patients with recurrent or chronic symptoms.     

Acute renal failure in hospitalized patients: part I

BACKGROUND: Acute renal failure (ARF) is a common condition in hospitalized patients. Morbidity, mortality, and health resource use are considerable, but the true magnitude of the problem is not well described in the literature. OBJECTIVE: To provide a detailed discussion of the epidemiology, economic costs, and classification of ARF. DATA SOURCES: A MEDLINE search (1996-December 2001) was conducted using the search terms kidney and acute kidney failure: epidemiology, etiology, and drug therapy/drug effects. Bibliographies of selected articles were also examined to include all relevant investigations. Economic data were identified using the terms costs and cost analysis and cost of illness. STUDY SELECTION AND DATA EXTRACTION: Review articles, meta-analyses, and clinical trials describing epidemiology and classification of hospital-acquired ARF were identified. Results from prospective, controlled trials were given priority when available. CONCLUSIONS: ARF occurs in up to 25% of critically ill patients, resulting in significant morbidity and high mortality. Characterization of ARF is difficult due to multiple etiologic factors and variable definitions. Limited cost data describe the extensive economic burden associated with the disorder, although further pharmacoeconomic research is needed. Epidemiology and classification of ARF allow prospective management of at-risk patients.     

Osteoporosis: part I. Evaluation and assessment

Osteoporosis afflicts 75 million persons in the United States, Europe and Japan and results in more than 1.3 million fractures annually in the United States. Because osteoporosis is usually asymptomatic until a fracture occurs, family physicians must identify the appropriate timing and methods for screening those at risk. Prevention is the most important step, and women of all ages should be encouraged to take 1,000 to 1,500 mg of supplemental calcium daily, participate in regular weight-bearing exercise, avoid medications known to compromise bone density, institute hormone replacement therapy at menopause unless contraindicated and avoid tobacco and excessive alcohol intake. All postmenopausal women who present with fractures as well as younger women who have risk factors should be evaluated for the disease. Physicians should recommend bone mineral density testing to younger women at risk and postmenopausal women younger than 65 years who have risk factors for osteoporosis other than being postmenopausal. Bone mineral density testing should be recommended to all women 65 years and older regardless of additional risk factors. Bone mineral density screening should be used as an adjunct to clinical judgment only if the results would influence the choice of therapy or convince the patient to take appropriate preventive measures.     

Prevention of childhood injuries. Part I: Motor vehicle injuries.

Unintentional (accidental) injuries are the leading cause of death in childhood and adolescence. In this article, interventions to reduce death and disability among children from motor vehicle injuries are identified. The major categories of injury are listed, the magnitude of the problem is defined, the risk factors are described, and selected interventions of the National Committee for Injury Prevention and Control are summarized. Recommendations for practice are discussed.     

A review of mallet finger and jersey finger injuries in the athlete

Purpose of review

The purposes of this review are to discuss the diagnosis and management of mallet and jersey finger injuries in athletes and to highlight how treatment impacts return to play.

Recent findings

Mallet finger: although numerous non-operative and operative techniques have been described, there continues to be little consensus regarding the optimal procedure. Jersey finger: ultrasound appears to be a cost-effective imaging modality that may be useful for preoperative planning. Wide-awake surgery offers optimal intraoperative assessment of the tendon repair. Tendon repair with volar plate augmentation has been shown to improve the strength of the repair in the laboratory, and early clinical results are encouraging.

Summary

Most mallet finger injuries will heal with non-operative treatment over a period of 8–12 weeks, even when treatment is delayed up to 3–4 months. An acute diagnosis of jersey finger requires surgical treatment and generally means 8–12 weeks of inability to compete in most contact sports.

     

Health and safety needs of older farmers: part II. Agricultural injuries.

A random sample (N = 87) of older Illinois farmers was surveyed to assess their experiences with traumatic injuries and the relationship between injury rate and age, type of farm activities, amount of stress, and hours of work per week. Farmers' knowledge of safety was assessed. Findings revealed that the number of hours worked, age, and type of farm activities were not significantly related to the number of injuries reported. However, self-reported stress, when stratified by age, was found to be related to injury among farmers aged 55 to 59 years. Also, scores on a farm safety quiz were found to be higher (less knowledge) among farmers who reported more injuries. Items in the safety quiz frequently missed by farmers included falls as a source of injury (29.2%), children being commonly injured on farms (19%), the cause of farmers' lung disease (46.9%), and animals as a cause of injury on farms (12.9%).     

The painful shoulder: part II. Acute and chronic disorders

Fractures of the humerus, scapula and clavicle usually result from a direct blow or a fall onto an outstretched hand. Most can be treated by immobilization. Dislocation of the humerus, strain or sprain of the acromioclavicular and sternoclavicular joints, and rotator cuff injury often can be managed conservatively. Recurrence is a problem with humerus dislocation, and surgical management may be indicated if conservative treatment fails. Rotator cuff tears are often hard to diagnose because of muscle atrophy that impairs the patient's ability to perform diagnostic maneuvers. Chronic shoulder problems usually fall into one of several categories, which include impingement syndrome, frozen shoulder and biceps tendonitis. Other causes of chronic shoulder pain are labral injury, osteoarthritis of the glenohumeral or acromioclavicular joint and, rarely, osteolysis of the distal clavicle.     

Hand and wrist injuries: Part I. Nonemergent evaluation

Diagnosis of upper extremity injuries depends on knowledge of basic anatomy and biomechanics of the hand and wrist. The wrist is composed of two rows of carpal bones. Flexor and extensor tendons cross the wrist to allow function of the hand and digits. The ulnar, median, and radial nerves provide innervation of the hand and wrist. A systematic primary and secondary examination of the hand and wrist includes assessment of active and passive range of motion of the wrist and digits, and dynamic stability testing. The most commonly fractured bone of the wrist is the scaphoid, and the most common ligamentous instability involves the scaphoid and lunate.     

Chronic shoulder pain: part I. Evaluation and diagnosis

Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.     

Acute bacterial rhinosinusitis in adults: part II. Treatment

Although most cases of acute rhinosinusitis are caused by viruses, acute bacterial rhinosinusitis is a fairly common complication. Even though most patients with acute rhinosinusitis recover promptly without it, antibiotic therapy should be considered in patients with prolonged or more severe symptoms. To avoid the emergence and spread of antibiotic-resistant bacteria, narrow-spectrum antibiotics such as amoxicillin should be used for 10 to 14 days. In patients with mild disease who have beta-lactam allergy, trimethoprim/sulfamethoxazole or doxycycline are options. Second-line antibiotics should be considered if the patient has moderate disease, recent antibiotic use (past six weeks), or no response to treatment within 72 hours. Amoxicillin-clavulanate potassium and fluoroquinolones have the best coverage for Haemophilus influenzae and Streptococcus pneumoniae. In patients with beta-lactam hypersensitivity who have moderate disease, a fluoroquinolone should be prescribed. The evidence supporting the use of ancillary treatments is limited. Decongestants often are recommended, and there is some evidence to support their use, although topical decongestants should not be used for more than three days to avoid rebound congestion. Topical ipratropium and the sedating antihistamines have anticholinergic effects that maybe beneficial, but there are no clinical studies supporting this possibility. Nasal irrigation with hypertonic and normal saline has been beneficial in chronic sinusitis and has no serious adverse effects. Nasal corticosteroids also may be beneficial in treating chronic sinusitis. Mist, zinc salt lozenges, echinacea extract, and vitamin C have no proven benefit in the treatment of acute bacterial rhinosinusitis.