Ketorolac Injections for Musculoskeletal Conditions: A Narrative Review.

Musculoskeletal conditions of the upper and lower extremities are commonly treated with corticosteroid injections. Ketorolac, a parenteral nonsteroidal anti-inflammatory drug, represents an alternative injectant for common shoulder, hip, and knee conditions. A review of the current literature was conducted on the efficacy of ketorolac injection in musculoskeletal diseases. Several studies support the use and efficacy of ketorolac injection in subacromial bursitis, adhesive capsulitis, and hip and knee osteoarthritis. Given the systemic effects of glucocorticoid injections, ketorolac may be a safe and effective alternative in patients with musculoskeletal disease. However, more evidence is required to better understand the effects ketorolac has on the human body during inflammatory processes.

Pediatric ankle and foot injuries: identification and management in the emergency department.

Pediatric ankle and foot injuries are common complaints in the emergency department, and proper identification and management of these injuries is critical for uninterrupted limb development. This issue reviews the presentation, systematic evaluation, and management of common pediatric orthopedic injuries of the ankle and foot. Recommendations are given for the disposition of pediatric patients with ankle and foot injuries, with a focus on which patients need immediate orthopedic evaluation and which patients can be discharged home with appropriate follow-up.

Popliteus Tendon Injuries.

Popliteus tendinopathies are rare injuries that can occur from overuse, trauma, or secondary causes, such as sesamoid bones or calcifications. They present with nonspecific symptoms and should be considered in any patient with posterolateral knee pain, instability, popliteus tenderness, and a positive Garrick test. Diagnosis can be made with magnetic resonance imaging, but arthroscopy remains the criterion standard. For minor popliteus tendinopathies, initial management involves conservative treatment, including rest, activity modification, physical therapy, and quadriceps strengthening. For more severe or refractory disease, corticosteroid injections and arthroscopy should be considered. [Orthopedics. 2023;46(4):e193-e198.].

Bedside ultrasound-guided aspiration and corticosteroid injection of a baker's cyst in a patient with osteoarthritis and recurrent knee pain.

Baker's cyst accompanying knee osteoarthritis represents a common cause of knee pain presenting to the emergency department. In this case report, a 56-year-old male presented with atraumatic left knee pain and swelling. Radiographically, he had tricompartmental osteoarthritis and was found to have a baker's cyst on duplex ultrasound. Using point-of-care ultrasound, the cyst was aspirated and corticosteroids were injected. The patient tolerated the procedure well and was discharged with a compression wrap and orthopedic follow-up. Baker's cyst aspiration with corticosteroid injection represents a safe alternative treatment option for patients. In some cases, this treatment may be definitive. Orthopedists currently use this procedure to reduce pain and improve function for patients with chronic knee ailments related to baker's cysts. As demonstrated in this case report, implementing this bedside procedure in the emergency department with orthopedic follow-up expands non-surgical, non-narcotic treatment options for patients with chronic knee pain secondary to Baker's cysts with osteoarthritis.

Inferior hip dislocation in a 16 year old.

Inferior hip dislocations are the least common form of hip dislocation. They require a high energy mechanism of injury and are often associated with other traumatic limb and life threatening injuries. This article reviews the case of a 16 year old male who presented to the emergency department (ED) following a high speed motor vehicle crash. On arrival he was diagnosed with a right inferior hip dislocation among other critical findings. This case report provides a brief literature review of this poorly studied clinical entity and seeks to educate physicians providing emergency, traumatic, orthopedic or critical care to patients who present with acute inferior hip dislocations.

Recommended Musculoskeletal and Sports Medicine Model Curriculum for Emergency Medicine Residency Training.

ABSTRACT: Musculoskeletal and sports medicine conditions are common in the emergency department (ED). Emergency physicians may not be receiving adequate education to achieve clinical competency in musculoskeletal medicine during residency training. This article aims to provide a standardized musculoskeletal and sports medicine curriculum for emergency medicine training. Broad curriculum goals include proficiency in evaluating and managing patients presenting to the ED with acute and chronic musculoskeletal complaints and other medical conditions related to or affected by physical exertion, sports participation, or environmental exposure. Specific objectives focus on knowledge of these disorders, physical examination skills, procedural skills including musculoskeletal ultrasound, appropriate consultation and referral, and patient education for these conditions. Educational methods will consist of didactics; online self-directed learning modules; simulation; and supervised clinical experiences in the ED, primary care sports medicine clinics, and orthopedic clinics if available. Curriculum implementation is expected to vary across programs due to differences in residency program structure and resources.

It might be a tumor: a unique presentation of a chronic rotator cuff tear.

A 59 year-old male presented to the county emergency department (ED) in southeastern United States for evaluation of a progressively worsening lump on his left shoulder. He describes it as painful and suggests "it might be a tumor". There were no other associated complaints. On physical examination, there was a firm, non-tender, non-mobile mass without erythema or warmth, superior to the patient's left acromioclavicular (AC) joint. Both hawkins and empty can test were positive for pain. Point-of-care ultrasound identified a fluid filled structure overlying the AC joint. Initial radiographs demonstrated the so-called geyser sign, a finding of synovial fluid expressed through the AC joint consistent with rotator cuff tear. Subsequent CT scan identified atrophy of the supraspinatus muscle most consistent with rotator cuff tear. This case represents a unique presentation of a chronic rotator cuff tear.

Triceps Tendon Injuries.

Triceps tendon injuries are an uncommon clinical entity poorly described in the literature. This review discusses the spectrum of pathology, effective diagnosis, nonsurgical treatment, surgical treatment, rehabilitation, and surgical complications of triceps tendon injuries. Management of triceps tendinopathies depends on the mechanism of injury and the patient's motor examination. Triceps tendinopathies and partial tendon tears with intact strength can be managed conservatively with rest, ice, immobilization, nonsteroidal anti-inflammatory drugs, and physical therapy. If conservative management fails for 6 months or there are strength deficits on examination, surgery should be considered. Based on the current evidence, there are no clear guidelines for "best" surgical approach. Although rare, the most significant surgical complication to be concerned about is rerupture. Rerupture rate is 4.62% among the articles we reviewed.

Acute ascites and abdominal pain from ovarian hyperstimulation syndrome (OHSS).

A healthy 30 year old female G1P1 presented to the ED with a chief complaint of abdominal pain, shortness of breath and bloating 72 hours after an egg retrieval out of state. She states she had two injections of an unknown hormone therapy and that the retrieval was uncomplicated. On arrival, heart rate is is 130-140s and her blood pressure is soft (99/76). Her abdomen is distended and non-focally tender but not peritoneal. Point-of-care FAST exam was immediately performed showing free fluid (Fig. 1) and enlarged, cystic appearing ovaries (Fig. 2).

Concussion management knowledge among residents and students and how to improve it.

AIM: Recognition and management of concussion is an area of growing importance. The objective was to measure concussion knowledge among residents and medical students (MS). METHODS: Baseline knowledge was assessed by a standardized questionnaire. Control group (family medicine [FM], pediatric medicine [PM] and emergency medicine) residents were given reading material, and intervention group rotated in a clinic (sports medicine residents and MS). Subjects were retested after 36.82 (16.1) days. Pre- and post-intervention test scores were compared. RESULTS: The average baseline knowledge scores were 79.2% for emergency medicine residents, 61.4% for FM, 68.5% for PM, 71.7% for sports medicine residents and 68.0% for MS. Knowledge increase for control group was 1.16% compared with 14.41% for the clinical rotation group (p < 0.0001). CONCLUSION: PM and FM residents can benefit from more focused education about concussion.

Diversity of approaches to classic galactosemia around the world: a comparison of diagnosis, intervention, and outcomes.

Without intervention, classic galactosemia is a potentially fatal disorder in infancy. With the benefit of early diagnosis and dietary restriction of galactose, the acute sequelae of classic galactosemia can be prevented or reversed. However, despite early and lifelong dietary treatment, many galactosemic patients go on to experience serious long-term complications including cognitive disability, speech problems, neurological and/or movement disorders and, in girls and women, ovarian dysfunction. Further, there remains uncertainty surrounding what constitutes a 'best practice' for treating this disorder. To explore the extent and implications of this uncertainty, we conducted a small but global survey of healthcare providers who follow patients with classic galactosemia, seeking to compare established protocols for diagnosis, intervention, and follow-up, as well as the outcomes and outcome frequencies seen in the patient populations cared for by these providers. We received 13 survey responses representing five continents and 11 countries. Respondents underscored disparities in approaches to diagnosis, management and follow-up care. Notably, we saw no clear relationship between differing approaches to care and long-term outcomes in the populations studied. Negative outcomes occurred in the majority of cases regardless of when treatment was initiated, how tightly galactose intake was restricted, or how closely patients were monitored. We document here what is, to our knowledge, the first global comparison of healthcare approaches to classic galactosemia. These data reinforce the idea that there is currently no one best practice for treating patients with classic galactosemia, and underscore the need for more extensive and statistically powerful comparative studies to reveal potential positive or negative impacts of differing approaches.

Pandemic influenza a in residential summer camps--Maine, 2009.

OBJECTIVE: The aim of this study was to evaluate the preparedness for and response of Maine summer camps to the 2009 pandemic influenza H1N1 (pH1N1). METHODS: We conducted a retrospective web-based survey of the Maine Youth Camping Foundation members at the end of the 2009 camping season. The outcome measures were responses to the pandemic including educational efforts, isolation practices and antiviral usages as well as percentage of influenza-like illness (ILI) and laboratory-confirmed influenza outbreaks among Maine residential summer camps. RESULTS: Of 107 residential camps queried, 91 (85%) responded. Although 43 (47%) of 91 camps reported cases of ILI, and 19 (21%) had outbreaks (ie, 3 or more confirmed cases of pH1N1), no respondents reported closing camps or canceling sessions. Most camps reported that they communicated with campers' families about pH1N1 and implemented control measures, including educating campers and staff about symptoms, isolating ill campers and staff, encouraging increased hand washing and hygiene practices and increasing the availability of hand sanitizers. Of the 43 camps with cases of ILI or laboratory-confirmed pH1N1, 25 (58%) used antiviral medication for treatment, and 18 (42%) used antiviral medications for prophylaxis; antiviral practices varied among camps. CONCLUSIONS: Summer camps in Maine were in general well prepared for pH1N1. Most camps followed public health guidance and implemented preventive measures. Many camps experienced ILI and outbreaks during the season, but did not report major disruptions. Camps should review their preparedness and disease control plans annually and public health authorities should keep guidance and recommendations simple and consistent.