Common Foot Fractures.

Foot fractures account for about one-third of lower extremity fractures in adults. They are typically caused by a crush injury or an axial or twisting force on the foot. Patients usually present with bony point tenderness and swelling of the affected area. Weight-bearing varies based on the extent of the fracture and the patient's pain tolerance. When a foot or toe fracture is suspected, anteroposterior, lateral, and oblique radiography with weight-bearing should be obtained. The Ottawa foot and ankle rules can help determine the need for radiography after an acute ankle inversion injury. Many foot fractures can be managed with a short leg cast or boot or a hard-soled shoe. Weight-bearing and duration of immobilization are based on the stability of the fracture and the patient's pain level. Most toe fractures can be managed nonsurgically with a hard-soled shoe for two to six weeks. Close attention should be paid to the great toe because of its role in weight-bearing, and physicians should follow specific guidelines for orthopedic referral. Meta-tarsal shaft fractures are managed with a boot or hard-soled shoe for three to six weeks. The proximal aspect of the fifth metatarsal has varied rates of healing due to poor blood supply, and management is based on the fracture zone. Lis-franc fractures are often overlooked; radiography with weight-bearing should be obtained, and physicians should look for widening of the tarsometatarsal joint. Other tarsal bone fractures can be managed with a short leg cast or boot for four to six weeks when nonsurgical treatment is indicated. Common foot fracture complications include arthritis, infection, malunion or nonunion, and compartment syndrome.

A Comparison of Family Medicine Resident Documentation Following Implementation of an Asynchronous vs Synchronous Telemedicine Curriculum.

Introduction: Prior to the start of the 2020 COVID pandemic, the use of telemedicine among family physicians was limited; telemedicine curriculum in undergraduate and graduate medical education (GME) was even more scarce. In response to the need for training, we developed synchronous and asynchronous versions of a telemedicine curriculum focused on documentation, communication, and virtual physical exam. As the evaluation of the curriculum, this study compares the documentation behaviors of the clinicians participating in the curriculum. Methods: We compared the documentation practice of asynchronous learners to those participating in synchronous learning over 1 month. We reviewed each clinical note for five practice behaviors: (1) consent for delivery of care via telemedicine, (2) time on the phone, (3) physical examination, (4) procedure code, and (5) billing code. Results: We reviewed notes from 11 interns (synchronous) and 22 senior residents (asynchronous). Notes written by an intern were significantly more likely to include documentation of consent and a focused exam. Notes written by senior resident were significantly more likely to include documentation of length of the encounter. We detected no significant differences for documenting the billing or procedure code. Conclusion: Our analysis determined that correct documentation behaviors can be taught through asynchronous mediums. Components requiring effective communication (consent for care and a virtual physical exam) are more effectively taught when there is deliberate practice and immediate feedback on the skills.

A Stepwise Transition to Telemedicine in Response to COVID-19.

INTRODUCTION: With the emergence of COVID-19, many primary care offices closed their physical space to limit exposure. Despite decades of telemedicine in clinical practice, it is rare to find it used in small-metro and academic settings. Following the decision to limit face-to-face care, we tracked our practice's transition to telemedicine. METHODS: This was a prospective quality improvement project following Plan-Do-Study-Act (PDSA) cycles to optimize the use of telemedicine (both telephone and video in this practice) encounters. Central to the PDSA cycles was the use of a post-encounter questionnaire to track patient, appointment, and physician factors. Throughout the cycles, inferential statistics were used to inform process improvement. RESULTS: In Cycle 2, a logistic regression model showed length of encounter, need for physical examination, and physician satisfaction correctly predicted a physician's preferred medium (χ2(3) = 40.56, P < .001). In Cycle 3, a χ2 test showed the reason for visit predicted the preferred medium (χ2(4) = 47.30, P < .001). In cycle 4, week of telemedicine, need for physical examination, length of encounter and physician satisfaction predicted the preferred medium (χ2(9) = 172.52, P < .001). DISCUSSION: Using the variables that predicted preference for telemedicine, we were able to adjust our processes through PDSA cycles. CONCLUSION: Early use of the PDSA cycle allows for informed quality improvement at the local level. Our findings highlight factors to consider when implementing telemedicine such as need for physical examination and type or length of encounter. In addition, physician satisfaction can encourage use of telemedicine, and tools for learning and practicing telemedicine should be available.

Peripheral Nerve Entrapment and Injury in the Upper Extremity.

Peripheral nerves in the upper extremities are at risk of injury and entrapment because of their superficial nature and length. Injury can result from trauma, anatomic abnormalities, systemic disease, and entrapment. The extent of the injury can range from mild neurapraxia, in which the nerve experiences mild ischemia caused by compression, to severe neurotmesis, in which the nerve has full-thickness damage and full recovery may not occur. Most nerve injuries seen by family physicians will involve neurapraxia, resulting from entrapment along the anatomic course of the nerve. In the upper extremity, the brachial plexus branches into five peripheral nerves, three of which are commonly entrapped at the shoulder, elbow, and wrist. Patients with nerve injury typically present with pain, weakness, and paresthesia. A detailed history and physical examination alone are often enough to identify the injury or entrapment; advanced diagnostic testing with magnetic resonance imaging, ultrasonography, or electrodiagnostic studies can help confirm the clinical diagnosis and is indicated if conservative management is ineffective. Initial treatment is conservative, with surgical options available for refractory injuries or entrapment caused by anatomic abnormality.