Acute Fracture of the Third Metacarpal in a Handball Player.

A 20-year-old right hand-dominant male military cadet presented to the direct-access physical therapy clinic complaining of pain and swelling of his right hand, which was injured while competing in a team handball match the day before. Due to suspicion of a third metacarpal fracture, fluoroscopy was performed on the cadet's hand in the physical therapy clinic, and an apparent oblique fracture was noted. Confirmatory radiographs were ordered and the cadet was referred for orthopaedic consultation. J Orthop Sports Phys Ther 2020;50(1):44. doi:10.2519/jospt.2020.9034.

DIAGNOSTIC IMAGING IN A DIRECT-ACCESS SPORTS PHYSICAL THERAPY CLINIC: A 2-YEAR RETROSPECTIVE PRACTICE ANALYSIS.

BACKGROUND: While advanced diagnostic imaging is a large contributor to the growth in health care costs, direct-access to physical therapy is associated with decreased rates of diagnostic imaging. No study has systematically evaluated with evidence-based criteria the appropriateness of advanced diagnostic imaging, including magnetic resonance imaging (MRI), when ordered by physical therapists. The primary purpose of this study was to describe the appropriateness of magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) exams ordered by physical therapists in a direct-access sports physical therapy clinic. STUDY DESIGN: Retrospective observational study of practice. HYPOTHESIS: Greater than 80% of advanced diagnostic imaging orders would have an American College of Radiology (ACR) Appropriateness Criteria rating of greater than 6, indicating an imaging order that is usually appropriate. METHODS: A 2-year retrospective analysis identified 108 MRI/MRA examination orders from four physical therapists. A board-certified radiologist determined the appropriateness of each order based on ACR appropriateness criteria. The principal investigator and co-investigator radiologist assessed agreement between the clinical diagnosis and MRI/surgical findings. RESULTS: Knee (31%) and shoulder (25%) injuries were the most common. Overall, 55% of injuries were acute. The mean ACR rating was 7.7; scores from six to nine have been considered appropriate orders and higher ratings are better. The percentage of orders complying with ACR appropriateness criteria was 83.2%. Physical therapist's clinical diagnosis was confirmed by MRI/MRA findings in 64.8% of cases and was confirmed by surgical findings in 90% of cases. CONCLUSIONS: Physical therapists providing musculoskeletal primary care in a direct-access sports physical therapy clinic appropriately ordered advanced diagnostic imaging in over 80% of cases. Future research should prospectively compare physical therapist appropriateness and utilization to other groups of providers and explore the effects of physical therapist imaging privileging on outcomes. LEVEL OF EVIDENCE: Diagnosis, Level 3.

Primary renal lymphoma mimicking a subcapsular hematoma: a case report.

Primary renal lymphoma (PRL) is a rare entity with a history of controversy regarding its existence. Lymphomatous involvement of the kidney is more commonly seen secondarily to spread from an adjacent lymphomatous mass, rather than arising primarily from the kidney. PRL can mimic other renal lesions such as renal cell carcinoma, renal abscess, and metastasis; therefore, an early diagnosis is crucial to guide treatment and properly assess prognosis. We present a rare case of a 77 year-old male who presented with hematuria and PRL mimicking a subcapsular hematoma.

Pulmonary embolism at follow-up outpatient CT pulmonary angiography: implications on patient risk stratification.

The purpose of this study was to determine the prevalence of pulmonary embolism in outpatients who return to care with clinical suspicion of pulmonary embolism and are evaluated by computed tomography pulmonary angiogram (CTPA) after an initial CTPA was negative for pulmonary embolism within the preceding 12 months. Following institutional review board approval, we performed a retrospective review of all CTPAs performed at our institution from June 2006 through June 2009. One hundred and seventy-two outpatients [102 women; mean age 56.7±18.8 (SD)] with an initial CTPA that was negative for pulmonary embolism and a subsequent CTPA within 12 months of their initial study were included in our analysis. Each patient's CTPA was assessed for evidence of pulmonary embolism and their electronic medical records (EMR) reviewed for the presence of risk factors associated with venous thromboembolism (VTE). Fisher exact test (two-tailed) analysis was used to assess whether thromboembolic risk factors had an effect on developing pulmonary embolism after an initial negative CTPA. CTPAs were negative for pulmonary embolism in 165 (96%) of 172 outpatients who returned to care within 12 months after an initial negative CTPA. Eighty-five (49.4%) of 172 patients had no identified thromboembolic risk factors. In the group with no risk factors none (0%) of 85 patients (P=0.028) had pulmonary embolism at the time of repeat CTPA. This may help appropriately triage patients evaluated for pulmonary embolism and reduce the number of unnecessary CTPAs.