Creating an Assessment Tool for Clinical Musculoskeletal Knowledge.

ABSTRACT: Studies show that medical school curriculums do not prepare graduates to manage the most common musculoskeletal (MSK) injuries they will encounter in the outpatient setting. The authors proposed a new multiple-choice assessment to identify individual and program deficiencies for curriculum improvement. A multiple-choice MSK assessment tool was administered to learners at various stages of training. Students took the examination after completing their core clerkship year; residents took the examination near the beginning of their respective academic year. Outcome measures included average examination score, percent correct for each question, and overall examination reliability. Average examinees scores were 75.6% with higher scores based on training years. No statistical differences were found between MD/DO, male/female, or military/civilian examinees. The tool was found to be a statistically valid method of determining cognitive knowledge in basic MSK topics, identifying individual deficiencies, and highlighting gaps in training programs' MSK curriculums.

Clinical Practice Guidelines for Exertional Rhabdomyolysis: A Military Medicine Perspective.

ABSTRACT: Exertional rhabdomyolysis (ER) is an uncommon condition with a paucity of evidence-based guidance for diagnosis, management, and return to duty or play. Recently, a clinical practice guideline for diagnosis and management of ER in warfighters was updated by a team of military and civilian physicians and researchers using current scientific literature and decades of experience within the military population. The revision concentrated on challenging and controversial clinical questions with applicability to providers in the military and those in the greater sports medicine community. Specific topics addressed: 1) diagnostic criteria for ER; 2) clinical decision making for outpatient versus inpatient treatment; 3) optimal strategies for inpatient management; 4) discharge criteria; 5) identification and assessment of warfighters/athletes at risk for recurrent ER; 6) an appropriate rehabilitative plan; and finally, 7) key clinical questions warranting future research.

Nerve Blocks: Part II. Lower Extremity.

Family physicians use anesthesia to provide diagnostic and procedural analgesia for conditions such as neuropathies, fracture reduction, foreign body removals, and complex wound management. Local infiltration of anesthetics is commonly used in this setting because of the ease of use, safety, and effectiveness of the procedure. Nerve blocks are a specific regional anesthesia technique that blocks nerve function distal to the injection site. An understanding of the sensory distribution of the peripheral nervous system is essential in determining the safest and most effective nerve block for the procedure. There are various nerve block techniques, including landmark-guided and ultrasound-guided. Ultrasound guidance increases the effectiveness of the nerve block while decreasing complications when compared with other techniques. Depending on the required area of anesthesia for the procedure, various points throughout the lower extremity can be used to block the lateral femoral cutaneous, common peroneal, saphenous, tibial, deep peroneal, superficial peroneal, and sural nerves.

Nerve Blocks: Part I. Upper Extremity.

Procedural anesthesia is administered by family physicians for a variety of conditions, including neuropathies, fracture reduction, foreign body removals, and complex wound management. A nerve block may be preferred because it provides effective regional anesthesia with less anesthetic. Nerve blocks require a thorough understanding of relevant anatomy, aiding the physician in optimizing the anesthesia effect while minimizing complications. Nerve blocks can be guided by bony landmarks, peripheral nerve stimulation, or ultrasonography. Ultrasound-guided nerve blocks are superior in decreasing procedural complications and procedure time. Physicians should be aware of these techniques to appropriately counsel their patients on procedural options. Nerve blocks of the ulnar, median, and radial nerves at the wrist and elbow provide effective anesthesia for a wide range of medical procedures in the upper extremity.

Chronic Exertional Compartment Syndrome: A Clinical Update.

Chronic exertional compartment syndrome is a debilitating condition primarily associated in highly active individuals with an estimated incidence of approximately 1 in 2000 persons/year. The etiology remains unclear to date. The differential diagnosis includes, but is not limited to stress fractures, medial tibial stress syndrome, and popliteal artery entrapment syndrome. Clinical signs and symptoms include pain in the involved compartment with exertion dissipating quickly after activity. Diagnostic tests include intramuscular compartment pressure testing, magnetic resonance imaging, near-infrared spectrometry as well as shear wave electrography. Treatments consist of nonsurgical, surgical, or the combination of the two. Gait retraining and the use of botulinum toxin appear most promising. Diagnostic lidocaine injections are emerging as a prognostic and mapping tool. Minimal invasive surgical options are being utilized allowing quicker return to activity and decreased morbidity. This article reviews the anatomy, clinical signs and symptoms, diagnostics, nonsurgical, and surgical treatments for chronic exertional compartment syndrome.

Musculoskeletal Issues in Children and Adolescents: Adolescent Idiopathic Scoliosis.

Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis in children older than 10 years in the United States. AIS is defined as a lateral spine curvature of 10° or more in the coronal plane, without congenital or neuromuscular comorbidities. The U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians (AAFP) do not recommend for or against AIS screening in asymptomatic patients. Physical examination includes the forward bend test with or without scoliometer, wherein scoliometer rotation between 5° and 7° warrants further evaluation with x-rays. Definitive diagnosis with x-rays allows for measurement of the Cobb angle. For Cobb angles less than 20°, watchful waiting and/or referral for physical therapy are indicated. Referral to a spine specialist for bracing is reasonable for curves between 20° and 26° and is recommended for curves between 26° and 45°. Surgical intervention is considered for initial Cobb angles greater than 40° and recommended for Cobb angles greater than 50°.

Musculoskeletal Issues in Children and Adolescents: Abnormal Findings on the Newborn Musculoskeletal Examination.

Prenatal and delivery history guides a thorough musculoskeletal examination of the newborn. Amniotic bands from amniotic sequence/syndrome typically are apparent on visual inspection but may present as limb amputation. Management is guided by the degree of tissue compromise. Risk factors for birth trauma are maternal obesity, pelvic anomalies, macrosomia, and operative delivery. Fractures of the clavicle, humerus, and femur heal well with few sequelae. Splinting recommendations differ for each. Polydactyly, syndactyly, and clinodactyly are associated with syndromic conditions. In general, most are managed by orthopedists or plastic surgeons. Talipes equinovarus (clubfoot) can be diagnosed on prenatal ultrasonography, and 20% of cases are part of a syndromic condition. Treatment is via the Ponseti method and is followed by bracing, typically until age 5 years. Developmental dysplasia of the hip is a spectrum where the natural course is not clearly defined. Most instability initially discovered spontaneously resolves by age 2 months, and 90% resolves by age 12 months. Abduction splinting results in sustained hip reduction in 90% of infants requiring treatment.

Musculoskeletal Issues in Children and Adolescents: Common Childhood Musculoskeletal Injuries.

Active children and adolescents have unique risk factors for musculoskeletal injuries compared with adults. Physes and developing bones are at higher risk of injury than tendons and ligaments. Children's bone remodeling is robust, allowing most clavicle fractures and torus fractures of the forearm to be managed conservatively. Radial head subluxation is managed with reduction. Apophyseal injuries are traction or overuse injuries that typically can be managed nonoperatively. Osteochondritis dissecans and other osteochondroses require frequent monitoring and occasionally surgical intervention.

Musculoskeletal Issues in Children and Adolescents: Genetic Musculoskeletal Disorders.

Duchenne muscular dystrophy (DMD) is an X-linked recessive genetic disorder with progressive proximal weakness as the principal sign. Glucocorticoids and physical therapy are the mainstay of treatment. Exercise intolerance is the hallmark of metabolic myopathies, which require a combination of laboratory testing, electrodiagnostic testing, and muscle biopsy for diagnosis. Joint hypermobility may be an isolated finding or be associated with hypermobility Ehlers-Danlos syndrome (EDS), other variants of EDS, or marfanoid syndromes. The latter conditions are associated with aortic and cardiac valvular abnormalities. Osteogenesis imperfecta encompasses a group of disorders characterized by bone fragility presenting with a low-impact fracture as a result of minimal trauma. Management includes multidiscipline specialists. Down syndrome (DS), or trisomy 21, is the most common chromosome abnormality identified in live births. Routine evaluation of atlantoaxial instability with x-ray is no longer recommended for children with DS without symptoms of atlantoaxial instability; however, clinical evaluation of symptoms is required for sports preparticipation. Achondroplasia is the most common skeletal dysplasia. Clinical signs are macrocephaly, short limb, short stature with disproportionately shorter humerus and femur, along with characteristic findings in pelvis and lumbar spine x-rays. Caregivers should be educated on proper positioning and handling to avoid complications, including car seat-related deaths.

Facial injuries in the National Basketball Association: 2013-14 through 2017-18.

OBJECTIVE: To describe the epidemiology, mechanisms, treatment, and disability for facial injuries in National Basketball Association (NBA) athletes. METHODS: This was a retrospective descriptive epidemiological chart review using NBA Electronic Medical Record (EMR) system. Responses to injuries reported in games, practices, and other activities were used for all data analysis, except for game incidence rates. Incidence rates were calculated by the game-related facial injury incidence per total athlete exposure (player-games). RESULTS: There were 440 facial injuries among 263 athletes during the 5 NBA seasons with an overall single-season risk of 12.6% and a game incidence of 2.4 per 1000 athlete-exposures (95% CI: 2.18-2.68). The majority of injuries were lacerations (n = 159, 36.1%), contusions (n = 99, 22.5%), or fractures (n = 67, 15.2%), with ocular (n = 163, 37.0%) being the most commonly injured location. Sixty (13.6%) injuries resulted in at least one NBA game missed (224 cumulative player-games) with ocular injuries resulting in the most cumulative games missed (n = 167, 74.6%). Nasal fractures (n = 39, 58.2%) were the most common fracture location followed by ocular fractures (n = 12, 17.9%) but were less likely to lead to games missed (median = 1, IRQ: 1-3) than ocular (median = 7, IQR: 2-10) fractures. CONCLUSIONS: An average of one in eight NBA players sustained a facial injury each season with ocular injuries being the most common location. While most facial injuries are minor, serious injuries, especially ocular fractures, can result in games missed.