Radial Neuropathy (Saturday Night Palsy)

9.19 Radial Neuropathy (Saturday Night Palsy)

Presentation
The patient has injured his upper arm, usually by sleeping with his arm over the back of a chair, and now presents holding the affected hand and wrist with his good hand, complaining of decreased or absent sensation on the radial and dorsal side of his hand and wrist, and of inability to extend his wrist, thumb and finger joints. With the hand supinated (palm up) and the extensors aided by gravity, hand function may appear normal, but when the hand is pronated (palm down) the wrist and hand will drop.
What to do:



Look for associated injuries. This sort of nerve injury may be associated with cervical spine fracture, injury to the brachial plexus in the axilla, or fracture of the humerus. Picture



Document in detail all motor and sensory impairment. Draw a diagram of the area of decreased sensation, and grade muscle strength of various groups (flexors, extensors, etc.) on a scale of 1-5.



If there is complete paralysis or complete anesthesia, arrange for additional neurological evaluation and treatment right away. Incomplete lesions may be satisfactorily referred for followup evaluation and physical therapy.



Construct a splint, extending from proximal forearm to just beyond the metacarpophalyngeal joint (leaving the thumb free) which holds the wrist in 90 degree extension. This and a sling will help protect the hand, also preventing edema and distortion of tendons, ligaments, and joint capsules which can result in loss of hand function after stren~th returns.



Explain to the patient the nature of his nerve injury, the slow, rate of regeneration, the importance of splinting and physical therapy for preservation of eventual function, and arrange for followup.
What not to do:



Do not be misled by the patient's ability to extend the inter phalangeal joints of the fingers, which may be accomplished by the ulnar-innervated interosseus muscles.
Discussion
This neuropathy is produced by compression of the radial nerve as it spirals around the humerus. Most commonly it occurs when a person falls asleep, intoxicated, held up by his arm thrown over the back of a chair. Less severe forms may befall the swain who keeps his arm on his date's chair back for an entire double feature, ignoring the growing pain and paresis. If the injury to the radial nerve is at the elbow or just below, there may be sparing of the wrist radial extensors as well as the radial nerve autonomous sensation. The deficient groups will be the wrist ulnar extensors as well as the metacarpophalyngeal extensors. A high radial palsy in the axilla (e.g., from leaning on crutches) will involve all of the radial nerve innervations, including the triceps.

Radial Head Fracture

9.18 Radial Head Fracture

Presentation
A patient has fallen on an outstretched hand and has a normal non-painful shoulder, wrist, and hand, but pain in the elbow joint . The joint may be intact, with full range of flexion, but there is pain or decreased range of motion on extension, supination and pronation. Tenderness is greatest over the radial head and lateral condyle. X rays may show a fracture or dislocation of the head of the radius. In all views, a line down the center of the radius should point to the capitellum of the lateral condyle. Often, however, no fracture is visible, and the only x ray signs are of the elbow effusion or hemarthrosis pushing the posterior fat pad out of the olecranon fossa and the anterior fat pad out of its normal position on the lateral view.
What to do:



Obtain a detailed history of the mechanism of injury, and a physical examination, looking for the features described above, and x rays of the elbow, looking for visible fat pads as well as fracture lines.



If there is any question of a radial head fracture, immobilize the elbow (preventing pronation and supination of the hand) with a gutter splint extending from proximal humerus to hand, or sugar tong splints, or simply a sling, for the next week.



Explain to the patient the possibility of a fracture, despit negative x rays, and arrange for followup, with re- evaluation and repeat films in 1-2 weeks.
What not to do:



Do not jump to the diagnosis of "tennis elbow or "sprained elbow" simply on the basis of a negative x ray.
Discussion
Small, non-displaced fractures of the radial head may show up on x rays weeks later or never at all. Because pronation and supination of the hand are achieved by rotating the radial head upon the capitellum of the humerus, very small imperfections in healing of the radial head may produce enormous impairment of hand function, which may be only partly improved by surgical excision of the radial head. Immobilization at the first question of a radial head fracture may help preserve essential pronation and supination. "Tennis elbow" is a tenosynovitis of the common insertion of the wrist extensors upon the lateral condyle, and results in pain on wrist extension rather than on pronation and supination.

Nursemaid's Elbow

9.17 Subluxation of the Head of the Radius (Nursemaid's Elbow)

Presentation
A toddler has received a sudden jerk on his arm causing enough pain that he holds it motionless. Circumstances surrounding the injury may be obvious (such as a parent pulling the child up out of a puddle); or obscure (the babysitter who reports that the child "just fell down"). The patient and family may not be accurate about localizing the injury, and think that the child has injured his shoulder or wrist. The patient is comfortable at rest, splinting his arm with mild flexion at the elbow and pronation of the forearm. There should be no deformity, crepitation, swelling, or discoloration of the arm. There is also no palpable tenderness except over the radiohumeral joint; the child will start to cry with any movement of the elbow.
What to do:



Rule out any history of significant trauma, such as a fall from a height.



Thoroughly examine the entire extremity, including the shoulder girdle, hand and wrist,.



If there is any suspicion of a fracture, get an x ray.



When subluxation is suspected, place the patient in the parent's lap and inform the mother or father that it appears their child's elbow is slightly out of place and that you are going to put it back in. Warn them that this is going to hurt for a few moments.



Put your thumb over the head of the radius and press down while you smoothly and fully extend the elbow, and at the same time supinate the forearm. Complete the procedure by fully flexing the elbow while your thumb remains pressing against the radial head and the forearm remains supinated. At some point you should feel a click beneath your thumb. The patient will usually scream for a while at this point. Leave for about ten minutes; then return and re-examine to see that the child has fully recovered. Post-reduction immobilization is usually unnecessary. Picture



Reassure the parents, explain the mechanism involved in the injury, and teach them how to prevent and treat recurrences.



Without full recovery, get x rays.



If x rays are negative, but the child still does not use his arrn normally, place the arm in a sling and instruct the family to seek orthopedic followup care if recovery doesn't occur within 24 hours.
What not to do:



Do not attempt to reduce an elbow where the possibility of fracture or dislocation exists.



Do not get unnecessary x rays when all the findings are consistent with nursemaid's elbow. The x rays may appear normal even when the radial head is indeed subluxed. The dislocation is subtle, and requires measurement or comparison to appreciate. (Draw a line down the axis of the radius. It should bisect the capitellum of the lateral humerus.) Associated fractures occur, yet are not common.



Do not confuse nursemaid's elbow with the more serious brachial plexus injury, which occurs after much greater stress and results in a flaccid paralysis of the arm.
Discussion
This injury is an anterior subluxation of the radial head away from the capitellum through the annular ligament, and occurs almost exclusively among children between 18 months and 3 years of age. On occasion, if the subluxation has been present for several hours, edema, pain, and natural splinting will continue even after reduction, or may prevent reduction.
References:



Quan L, Marcuse EK: The epidemeology and treatment of radial head subluxation. Am J Dis Child 1985;139:1194-1197.



Frumkin K: Nursemaid's elbow: a radiographic demonstration. Ann Emerg Med 1985;14:690-693

.

Muscle Strains and Tears

9.15 Muscle Strains and Tears

Presentation
Strains occur during or after a vigorous overstretching of a muscle bundle that leads to an insidious development of pain and tightness which is worse with use and better with rest. Tears of the muscle belly tend to be partial, with sudden onset of pain and partial loss of function. Often a tear occurs with considerable bleeding which can lead to remarkable hematomas, causing swelling at the site and dissecting along tissue planes to create ecchymoses at distant, uninvolved sites. Complete tears are more likely in the tendinous part of the muscle, and produce immediate loss of function, and retraction of the torn end, creating a deformity and bulge.
What to do:



Obtain a history of the mechanism of injury, and test individual muscle functions. A complete tear of a muscle merits orthopedic consultation.



Even for a partial tear of a muscle belly, try to refine the diagnosis to a specific muscle or muscle group, to help exclude other possibilities.



For muscle strains, provide soft splinting, analgesics and instruct the patient to apply warm moist compresses for comfort.



For muscle tears, construct a loose splint to immobilize the injured part, and instruct the patient in rest, elevation, and ice.



Warn the patient that partial tears can become complete, and that blood will change color and percolate to the skin at distan sites, where it does not imply additional injury. Arrange for followup.
Discussion
Some restrict the term "strain" for muscle injuries, and "sprain" for ligament injuries. A complete tear of the plantaris tendon in the leg is difficult to differentiate from a partial tear of the gastrocmius muscle, but the treatment for both is the same.

Knee Sprain

9.14 Knee Sprain

Presentation
An athlete may have planted the foot while decelerating, torn the anterior cruciate ligament allowing the tibia to dislocate anteriorly, fallen to the ground where it spontaneously relocated, and not been able to get up. Alternatively, he may have been clipped on the lateral knee, causing a valgus deformity which tore the medical collateral ligament and perhaps the medial meniscus and anterior cruciate as well. An adolescent girl may have dislocated her patella laterally, tearing the medial retinaculum. These sorts of injury tend to come to the ED within an hour or two, in pain, holding the knee flexed ten to twenty degrees, with a tense joint effusion and quadriceps spasm which prevents detailed diagnosis by physical examination.
What to do:



If the patient has not already done so, ice and elevate the injury.



Load with anti-inflammatory analgesics like ketorolac (Toradol) 60mg im or ibuprofen (Mortin) 800mg po.



Examine as permitted by pain. Clear the back and pelvis. Check hip flexion, extension, and rotation. Thump the sole of the foot as an axial loading clue to a tibia or femur fracture. Document any effusion, discoloration, heat, deformity, loss of function, circulation, sensation, movement.



Document the range of motion, then carry out the rest of the exam with the knee slightly flexed, always comparing to the uninjured knee. Palpate the medial and lateral collateral ligament and test them with varus and valgus stress. Palpate the joint line anteriorly to assess the menisci and tibial plateaux. Drawer the tibia anterior and posterior to test the cruciates (the Lachman test).



Obtain x rays.



Aspirate the joint only if you need to rule out infection or obtain a few hours of mobility.



Discharge the patient with the knee immobilized in a splint or Jones dressing, crutches, a prescription for NSAIDs, and an appointment for orthopedic re-evaluation in 3-4 days.
Discussion
Chronic injuries can also be treated with NSAIDS, immobilization, and crutches. Examples include meniscal tears and joint mice, which may present with a history of the knee catching or giving way, and even flareups of osteoarthritis, degenerative joint disease, and pseudogout.

Ankle Sprain

9.13 Ankle Sprain

Presentation
The patient inverted the foot and either came in immediately or a day later with pain, swelling, and inability to walk. There is tenderness to palpation of the anterior talofibular ligament (anterior to the lateral malleolus) and on stretching of the ATFL with supination or pulling the talus anteriorly (drawer sign).
What to do:



If the patient is not already doing this, elevate the foot and apply ice 15 minutes per hour to treat the reactive inflammation.



Document the mechanism of injury, previous injuries, deformity, swelling, discoloration, circulation, sensation, movement.



Palpate the prominence on the lateral foot that is the base of the fifth metatarsal, where the insertion of the peroneus brevis can be avulsed by an inversion injury, and which may be better seen on foot views.



Palpate the fibula on the lateral leg up to the knee, where spiral fractures can propagate when the ankle breaks, and which also do not show on standard ankle views.



If there is tenderness posterior to the lateral malleolus or the patient cannot take four steps in the ED, obtain ankle x rays to rule out a fracture. Films otherwise are optional and can be deferred.



Immobilize the ankle in a stirrup (or sugar-tong) splint. Provide the patient with crutches for 3-4 days, anti- inflammatory analgesics, and follow up.
What not to do:



Do not rule out a fracture based on a negative x ray.



Do not overlook fractures of the tarsal navicular, talus, or os trigonum, all visible on the ankle view.
Discussion
Although patients continue to visit EDs with ankle sprains, our role remains to rule out other injuries, and teach them how to care for themselves. Patients ask if a bone is broken, but the initial treatment is usually the same regardless of the x ray results. Most ankle sprains could be managed over the telephone, and seen in the office the next day.
References:



Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP, Maloney J: Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. J Am Med Assn 1993;269:1127-1132.



Halvorson G, Iserson KV: Comparison of four ankle splint designs. Ann Emerg Med 1987;16:1249-1252.

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Ligament Sprains (Including Joint Capsule Injuries)

9.12 Ligament Sprains (Including Joint Capsule Injuries)

Presentation
A joint is distorted beyond its normal anatomical limits (as when an ankle is inverted or a shoulder is dislocated and reduced) The patient may complain of a snapping or popping noise at the time of injury, immediate swelling, and loss of function (suggestive of second- or third-degree sprain or a fracture); or he may corne in hours to days following the injury, complaining of gradually increasing swelling and resulting pain and stiffness (suggestive of a first- or second-degree sprain and development of a traumatic effusion).
What to do:



Obtain a detailed history of the mechanism of injury, and examine the joint for structural integrity, function, and point tenderness. Use the uninjured limb as a control.



Obtain x rays (these can be deferred if necessary).



With first-degree and second-degree sprains, gently immobilize the joint using an elastic bandage alone, or in combination with a cotton roll and/or plaster splint, as discomfort demands.



Consider prescribing anti-inflammatory pain medication when the patient complains of pain at rest and provide crutches when discomfort will not allow weight bearing.



If there is a fracture or ligament tear with instability, the limb is usually best immobilized in a splint or cast. Splint ankles at 90 degrees, wrists in extension, fingers at slight flexion.



Instrurt the patient in rest, elevation, and application of ice (10-20 minutes each hour) for the first 24 hours.



Explain to the patient that swelling in acute musculoskeletal injuries usually increases for the first 24 hours, and then decreases over the next 2-4 days (longer if the treatment above is not employed) and that some swelling and discomfort may persist for several weeks and at times for several months



Explain the possibility of occult injuries, the necessity for followups, and the slow healing of injured ligaments (usually 6 months until full strength is regained).
What not to do:



Do not obtain x rays before the history or physical examination. Films of the wrong spot can be very misleading. For example, physicians have been steered away from the diagnosis of an avulsion fracture of the base of the fifth metatarsal by the presence of normal ankle films.



Do not base the diagnosis on x rays. They should be used as confirmatory evidence.
Discussion
Ligamentous injuries are classified as first-degree, (minimal stretching); second-degree (a partial tear with functional loss and bleeding but still holding); and third-degree (complete tear with ligamentous instability, often requiring a cast). A tense joint effusion will limit the physical examination (and is one reason to require re-evaluation after the swelling has decreased) but also suggests less than a third degree ligamentous injury, which is normally accompanied by a tear of the joint capsule.

Bursitis

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9.11 Bursitis

Presentation





Following minimal trauma or repetitive motion, a nonarticular synovial sac, or bursa, protecting a tendon or prominent bone becomes swollen, tender, and inflamed. Because there is no joint involved, there is no decreased range of motion, but, if the tendon sheath is involved, there may be some stiffness and pain with motion.
What to do:



Obtain a detailed history of the injury or precipitating activity document a.thorough physical examination, and rule out a joint effusion (see below).



Prepare the skin with alcohol and antiseptic solution and 1% lidocaine anesthetic. Puncture the swollen bursa with a #18 or #20 needle, using aseptic technique, and withdraw some fluid to drain the effusion and rule out a bacterial infection.



Examine a Gram stain of the effusion and send a sample for leukocyte count and culture. If there is any sign of a bacterial infection, prescribe appropriate oral antibiotics. (Bacterial infections tend to be gram-positive cocci and respond well to cephalexin or dicloxacillin 500mg tid x 7d.)



Bacterial infections may also respond to direct injection of antibiotics. Severe inflammatory bursitis may require injection of local anesthetics (lidocaine, bupivacaine) and corticosteroids like methylprednisolone (Solu-Medrol) 40mg or betamethasone (Celestone Soluspan) 0.25-0.5mg.



Construct,a splint and instruct the patient in rest, elevation, and ice packing. Prescribe nonsteroidal anti- inflammatory medications, and arrange for followup.
Discussion
Common sites for bursitis include several bursae of the shoulder and knee, the olecranon bursa of the elbow, and the trochanteric bursa of the hip. Patients with septic bursitis, unlike those with septic arthritis, can often be safely discharged on oral antibiotics because the risk of permanent damage is much less when there is no joint involvement. Some long-acting corticosteroid preparations can produce a rebound bursitis several hours after injection, when the local anesthetic wears off, but before the corticosteroid crystals dissolve. Patients should be so informed.

Acute Monarticular Arthritis

9.09 Acute Monarticular Arthritis

Presentation
The patient complains of one joint which has become acutely red, swollen, hot, painful, and stiff.
What to do:



Ask about previous, similar episodes in this or other joints, as well as trauma, infections, or rashes, and perform a thorough physical examination looking for evidence of the same. Ask for a history of gout.



Examine the affected joint, and document the extent of effusion, involvement of adjacent structures, et cetera. Fluid can often be detected by pressing on one side of the affected joint and at the same time palpating a wavelike fluctuance on the opposite side of the joint.



Cleanse the skin over the most superficial area of the joint effusion with alcohol and povidone-iodine (Betadine), anesthetize the skin with 1% plain buffered lidocaine, and aspirate as much joint fluid as possible through an 18-20 gauge needle, using aseptic technique throughout. Fluoroscopy may be valuable in guiding needle placement for hip or shoulder joint aspiration.



Grossly examine the joint aspirate. Clear, light yellow fluid is characteristic of osteoarthritis or mild inflammatory or traumatic effusions. Grossly cloudy fluid is characteristic of more severe inflammation or bacterial infection. Blood in the joint is characteristic of trauma (a fracture or tear inside the synovial capsule) or bleeding from hemophilia or anticoagulants.



One drop of joint fluid may be used for a crude string or mucin clot test. Wet the tips of two gloved fingers with joint fluid, and repeatedly touch them together and slowly draw them apart. As this maneuver is repeated 10 or 20 times, and the joint fluid dries, normal synovial fluid will form longer and longer strings, usually to 5-10 cm in length. Inflammation inhibits this string formation. This is a non-specific test, but may aid decision at the bed side.



The essential laboratory tests on joint fluid consist of a Gram stain and culture for possible septic arthritis. (The presence of urate crystals may sometimes be detected on the wet prep or Gram stain.)



A joint fluid leukocyte count is the next most useful test to order. A count greater than 50,000 white cells/mm3 is characteristic of bacterial infection (especially when most are polymorphonuclear leukocytes). In osteoarthritis, there are usually fewer than 2,000 WBCs/mm3, and inflammatory arthritis (such as gout and rheumatoid arthritis) falls in the middle range of 2,000-50,000 WBCs/mm3. If there is more fluid, send to the lab for a glucose level, which will be low in infection compared to serum.



Obtain x rays of the affected joint to detect possible unsuspected fractures, or evidence of chronic disease, such as rheumatoid, crystal-induced or osteoarthritis.



If there is any suspicion of a bacterial infection (based on fever, elevated ESR, cellulitis, lymphangitis, or the joint fluid results above) start the patient on appropriate antibiotics which will have a high concentration in the synovial fluid. The most common, and the most devastating, organism requiring treatment is Staphylococcus aureus, which may be adequately treated with oral dicloxacillin or cephalexin 500mg q6h, but, since patients with this infection must be very closely followed, it is usually more practical to admit them to the hospital on intravenous antibiotics. In sexually-active patients, look for gonorrhea. In nursing home patients with urinary tract infections there could be gram-negative organizms. In intravenous drug abusers both staph and gram-negatives.



Inflammatory arthritis may be treated with non-steroidal anti inflammatory medications, beginning with a loading dose such as indomethacin (Indocin) 50mg or ibuprofen (Motrin) 800mg, tapered to usual maintenance doses.



When joint fluid cannot be obtained to rule out infection, it may be a good tactic to treat simultaneously for infectious and inflammatory arthritis.



Splint and elevate the affected joint and arrange for admission or followup.
What not to do:



Do not tap a joint through an area of obvious contamination such as subcutaneous cellulitis. You may innoculate synovial fluid with bacteria.



Do not be misled by bursitis, tenosynovitis, or myositis without joint involvement. An infected or inflamed joint will have a reactive effusion, which may be evident as fullness, fluctuance, reduced range of motion, or joint fluid which can be drawn off with a needle. It is usually difficult to tap a joint in the absence of a joint effusion.



Do not instil local anesthetics in the inflammed joint as an ED procedure. They will mask symptoms transiently without treating the underlying problem.



Do not use NSAIDs when a patient has a history of active peptic ulcer disease with bleeding. Relative contraindications include renal insufficiency, volume depletion, gastritis, inflammatory bowel disease, asthma and congestive heart disease.



Do not start maintenance NSAID doses for an acute inflammation. It will take a day or more to reach therapeutic levels and pain relief.
Discussion
The urgent reason for tapping a joint effusion is to rule out a bacterial infection, which could destroy the joint in a matter of days. Beyond identifying an infection (with Gram stain, culture, and WBC) further diagnosis of the cause of arthritis is not particularly accurate nor necessary to decide on acute treatment. Reducing the volume of the effusion may alleviate pain and stiffness, but this effect is usually short-lived, as the effusion reaccummulates within hours. Identification of crystals is essential for the diagnosis of gout or pseudogout, but one acute attack may be treated the same as another inflammatory arthitis and exact diagnosis deferred to follow up.
 Infants and young childen may present with fever and reluctance to walk from septic arthitis of the hip or knee, and arthrocentesis may require sedation or general anesthesia.

Fibromyalgia (Trigger Points)

9.08 Fibromyalgia (Trigger Points)

Presentation
The patient, generally between 25 and 50 years old, will be troubled with the gradual onset of fibromuscular pain that at times can be immobilizing. There may be a previous history of acute strain, muscle spasm or nerve root irritation (e.g., whiplash injury of the neck or low back strain). The areas most commonly affected include the posterior muscles of the neck and scapula, the soft tissues lateral to the thoracic and lumbar spine, and the sacroiliac joints. The patient is often depressed or under emotional or physical stress and often has associated fatigue with disturbed sleep as well as sensations of numbness or swelling in the hands and feet. Cold weather may be one of the precipitating causes of pain. There should be no swelling, erythema or heat over the painful areas, but applying pressure over the site with an examining finger will cause the patient to wince with pain . This tender " trigger pont" is usually no larger than your finger tip and when pressed will cause local pain, referred pain, or both. Picture
What to do:



When you find a trigger point, map out its exact location (point of maximum tenderness) and place an X over the site with a marker or ball point pen. If the trigger point is diffuse there is no need to outline its location.



Obtain a careful history and perform a general physical exam to help exclude the possibility of a serious underlying disorder such as rheumatoid arthritis or cancer.



With any suspicion that an underlying problem exists, obtain an x ray or an erythrocyte sedimentation rate. These studies should both be normal in fibromyalgia.



Where trigger points are diffuse, prescribe a nonsteroidal anti-inflammatory such as naprosen (Anaprox) 275mg two tablets stat then one qid or ibuprofen (Motril) 800mg stat then 600mg qid x 5 days. A muscle relaxant like cyclobenzaprine (Flexaril) may also be helpful.



When a focal trigger point is present you can suggest to the patient that he may get immediate relief with an injection. Inject 2-5ml of l% xylocaine or loger-acting 0.5% bupivacaine along with 20-40mg of methylprednisolone (Depomedrol) or 2-5mg of triamcinolone (Aristospan) through the mark you placed on the skin, directly into the painful site. Be sure you are not in a vessel and then "fan" the needle in all directions while injecting the trigger point. In addition, to insure total coverage, massage the area after the injection is complete. The patient will often get complete or near-complete pain relief, which helps to confirm the diagnosis of fibromyalgia. The beneficial effect of this injection may last for weeks or months. A supplementary five day course of non-steroidal anti-inflammatories is optional.



Moist hot compresses and massage may also be comforting to the patient after discharge.



Inform the patient that after trigger point injection there may be a transient painful rebound. Anti-inflammatory analgesics will help to reduce this potential discomfort.



Provide followup care for patients in the event their symptoms do not clear and they require further diagnostic evaluation and therapy. For example, hypothyroidism and polymalgia rheumatica coexist with or predispose to fibromyalgia, or the patient may develop dermatomyositis.
What not to do:



Do not attempt to inject a very diffuse trigger point (more than one square centimeter). Results are generally unsatisfactory.



Do not prescribe narcotic analgesics or systemic steroids. They are no more effective and add side effects and the risk of dependence.
Discussion
Although the pathophysiology of fibromyalgia is unknown it is a very real syndrome. Treatment may provide only partial symptomatic relief. True fibromyalgia syndrome is a chronic conditio requiring long term management that may include physical therapy, exercise, patient education and reassurance along with sleep-enhancing medications like low dose tricyclic antidepressants.
 Emergency physicians often see trigger points associated with simple self-limiting regional myofascial pain syndromes which appear to arise from muscles, muscle-tendon junctions, or tendon-bone junctions. Myofascial disease can result in severe pain, but typically in a limited distribution and without the systemic feature of fatigue. When symptoms recur or persist after the basic therapy above, or are accompanied by generalized complaints, refer the patient to a rheumatologist or primary care physician.
When the quadratus lumborum muscle is involved there is often confusion as to whether or not the patient has a renal, abdominal, or pulmonary ailment. The reason for this is the muscle's proximity to the flank and abdomen as well as its attachment to the 12th rib, which when tender, can create pleuritic symptoms. A careful physical exam, with palpation, active contraction, and passive stretching of this muscle reproducing symptoms, can save this patient from a multitude of laboratory and x ray studies.

Coccyx Fracture (Tailbone Fracture)

9.07 Coccyx Fracture (Tailbone Fracture)

Presentation
The patient fell on his tailbone and now complains of pain which is worse with sitting, and perhaps with defecation. There should be little or no pain with standing but walking may be uncomfortable. On physical examination, there is point tenderness, and perhaps deformity of the coccyx, which is best palpated by a finger in the rectum.
What to do:



Verify the history (was this actually a straddle injury?) and examine thoroughly, including the lumbar spine, pelvis, and the legs. Palpate the coccyx from inside and out, feeling primarily for point tenderness and/or pain on motion. Picture



X rays are optional. Any noticed variation can be an old fracture or an anatomic variant, and a fractured coccyx can appear within normal limits.



Instruct the patient in how to sit forward, resting his weight upon ischial tuberosities and thighs, instead of on the coccyx. A foam rubber doughnut cushion may help. If necessary, prescribe anti-inflammatory pain medications or stool softeners.



Inform the patient that the pain will gradually improve over a week, as bony callus forms and motion decreases, and arrange for followup as needed. Chronic pain is rare but treatable by surgically remiving the coccyx.

Acute Lumbar Strain ("Mechanical" Low Back Pain, Sacroiliac Dysfunction)

9.06 Acute Lumbar Strain ("Mechanical" Low Back Pain, Sacroiliac Dysfunction)

Presentation
Suddenly or gradually after lifting, sneezing, bending, or other movement the patient develops a steady pain in one or both sides of the lower back. At times, this pain can be severe and incapacitating. It is usually better on lying down, worse with movement, and will perhaps radiate around the abdomen or down the thigh, but no farther. There is insufficient trauma to suspect bony injury (e.g., a fall or direct blow); and no evidence of systemic disease which would make bony pathology likely (e.g., osteoporosis, metastatic carcinoma, multiple myeloma). On physical examination, there may be spasm (i.e., contraction which does not relax, even when the patient is supine or when the opposing muscle groups contract, as with walking in place) in the paraspinous muscles; but there is no point tenderness over the spinous processes of lumbar vertebrae and no nerve root signs such as pain or paresthesia in dermatomes below the knee (especially with straight leg raising), foot weakness, or loss of the ankle jerk. There may be point tenderness to firm palpation or percussion over the sacroiliac joint, especially if the pain is on that side.
What to do:



Perform a complete history and physical examination of the abdomen, back, and legs, looking for alternative causes for the back pain.



Consider plain x rays of the lumbosacral spine of those who have suffered injury sufficient to cause bony injury, patients under the age of 20 or over 50 who have had pain more than a month, and patients who are on long term corticosteroid medication or have a history of cancer.



Order an erythrocyte sedimentation rate (ESR) on patients with a history of cancer or intravenous drug abuse or signs or symptoms of underlying systemic disease (e.g., unexplained weight loss, fatigue, night sweats, fever, lymphadenopathy, and back pain at night or unrelieved by bed rest).



For point tenderness over a sacroiliac joint with no neurologic findings to suggest nerve root compression, try an intraarticular injection of a local anesthetic mixed with a corticosteroid. Improvement of pain is both diagnostic and therapeutic. Draw up 10 mL of 0.5% bupivacaine (Marcaine, Sensorcaine) mixed with 1 mL (40 mg) of methylprednisolone (DepoMedrol) or 1-2 mL (6-12 mg) of betamethasone (Celestone, Soluspan). Using a 1.5" 25 gauge needle and sterile technique, inject deeply into the sacroiliac joint at the point of maximal tenderness or into the dimple immediately lateral to the sacrum. When the needle is in the joint there should be a free flow of medication from the syringe without causing soft tissue swelling. During the injection, the patient may feel a brief increase of pain, followed by dramatic relief in 5-20 minutes which is usually permanent.



For point tenderness of the lumbosacral muscles, inject 10-20 mL of 0.25-0.5% bupivicaine (Marcaine, Sensorcaine) deeply into the points of maximal tenderness of the erector spinae and quadratus lumborum muscles, using a 1.5-3.5" 25 gauge needle. Quickly puncture the sin, drive the needle into the muscle belly and inject the anesthetic, slowly advancing or withdrawing, fanning out the medication. Often one fan block can reduce symptoms by 95% after injection and yield a 75% permanent reduction of painful spasms. Following injection, teach stretching exercises.



For severe pain that cannot be relieved by injections of local anesthetic, it may be necessary to provide the patient with one to two days of bed rest, although the majority of patients with acute low back pain recover more rapidly with continuing ordinary activities within the limits permitted by their pain than with bed rest or back-mobilizing exercises.



Consider disk herniation when leg pain overshadows the back pain. Back pain may subside as leg pain worsens. Look for weakness of ankle or great toe dorsiflexion and sensory changes over the medial dorsal foot with compression of the fifth lumbar nerve root or weak plantarflexion, diminished ankle reflex and paresthesias of the lateral foot with the first sacral root. Raise each leg thirty degrees from the horizontal and consider the test positive for nerve root compression if it produces pain down the leg along a nerve root distribution rather than pain in the back, increased by dorsiflexion of the ankle and relieved by plantarflexion. Ipsilateral straight leg raising is a moderatively sensitive but not a specific test--a herniated intervertebral disk is more strongly indicated when radicular pain is reproduced in one leg by raising the opposite leg. Prescribe short term bed rest and non-steroidal anti-inflammatory analgesics and arrange for general medical, orthopedic or neurosurgical referral. Some consultants recommend short term corticosteroid treatment such as prednisone 50 mg qd x5 days. The patient shound try four to six weeks of conservative treatment before submitting to an operation on the herniated disk. Eighty per cent of patients with sciatica recover with or without surgery. The rare cauda equina syndrome is the only complication of lumbar disk herniation that calls for emergent surgical referral. It occurs when a massive extrusion of disk nucleus compresses the caudal sac containing lumbar and sacral nerve roots, producing bilateral radicular leg pain or weakness, bladder or bowel dysfunction, perineal or perianal anesthesia, decreased rectal sphincter tone in 60-80% and urinary retention in 90%.



Prescribe a short course of anti-inflammatory analgesics (aspirin, ibuprofen, naprosyn) for patients who are not already taking NSAIDs. Because gastric bleeding and renal insufficiency are common with long-term use of NSAIDs, consider substituting acetaminophen or salsalate.



Prescribe ice to the acutely injured area, 20 minutes per hour for the first day . (This therapy is unconventional, but works as well as it does for any other musculoskeletal injury.)



Refer patients with uncomplicated back pain to their primary care provider for follow up care in three to seven days. Reassure them that back pain is seldom disabling and that it usually resolves with their return to normal activity. Tell them that cigarette smoking, sedentary activity and obesity are risk factors for back pain. Teach them to avoid twisting and bending when lifting and show them how to lift with the back vertical, using thigh muscles and holding heavy objects close to the chest, to avoid re-injury.
What not to do:



Do not be eager to use narcotic pain medicines. The sensation of pain from an acute musculoskeletal injury reminds the patient not to use the damaged part and exacerbate the injury, but instead to keep it at rest and speed healing. Narcotics are also apt to make the patient constipated, and straining at stool can be especially uncomfortable with a back injury.



Do not be too eager to use anti-spasm medicines. Many have sedative or anticholinergic side effects.



Do not apply lumbar traction. It has not been proven any better than placebo for releiving back pain.
Discussion
Low back pain is a common and sometimes chronic problem which accounts for an enormous amount of disability and time lost from work. The approach discussed above is geared only to the management of acute injuries and flareups, from which most people recover on their own, only about 10% developing chronic problems. With acute pain, reassurance plus limited medication may be the most useful intervention.
 History and physical examination are essential to rule out serious pathologic conditions which can present as low back pain but which require quite different treatment--aortic aneurysm, pyelonephritis, pancreatitis, pelvic inflammatory disease, ectopic pregnancy, retroperitoneal or epidural abscess.
 The standard five-view x ray study of the lumbosacral spine may entail 500 mrem and only 1 in 2500 lumbar spine plain films of adults below age 50 show an unexpected abnormality. In fact, many radiographic anomalies such as spina bifida occulta, single-disk narrowing, spondylosis, facet joint abnormalities and several congenital anomalies are equally common in symptomatic and asymptomatic individuals. It is estimated that the gonadal dose of radiation absorbed from a five-view lumbosacral series is equivalent to that from six years of daily anterioposterior and lateral chest films. The World Health Organization now recommends that oblique views be reserved for problems remaining after review of AP and lateral films. For simple cases of low back pain, even with radicular findings, both CT and MRI are overly sensitive and often reveal anatomic abnormalities that have no clinical significance.
 While adults are more apt to have disk abnormalities, muscle strain and degenerative changes associated with low back pain, athletically active adolescents are more likely to have posterior element derangements like stress fractures of the pars interarticularis. Early recognition of this spondylolysis and treatment by bracing and limitation of activity may prevent nonunion, persistant pain and disability.
 Malingering and drug seeking are major psychological components to consider in patients who have frequent ED visits for back pain and whose responses seem overly dramatic of otherwise inappropriate. These patients may move around with little difficulty when they do not know they are being observed. They may complain of generalized superfician tenderness when you lightly pinch the skin over the affected lumbar area. If you are suspicious that the patient's pain is psychosomatic or nonorganic you can use the axial loading test, in which you gently press down on the head of the standing patient. This should not cause significant musculoskeletal back pain. You can also perform the rotation test, in which the patient stands with his arms at his sides. Hold his wrists next to his hips and turn his body from side to side, passively rotating his shoulders, trunk and pelvis as a unit. This maneuver creates the illusion that you are testing spinal rotation, but in fact you have not altered the spinal axis and any complainst of back pain should be suspect.
References:



Deyo RA, Diehl AK, Rosenthal M: How many days of bed rest for acute low back pain? N Eng J Med 1986;315:1064-1070.



Deyo RA, Rainville J, Kent DL: What can the history and physical examination tell us about low back pain? J Am Med Assoc 1992;268:760-765.



Malmivaara A, Hakkinen U, Aro T et al: The treatment of acute low back pain: bed rest, exercise, or ordinary activity? N Eng J Med 1995;332:351-355.



Carey TS, Garrett J, Jackman A et al: The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropracters and orthopedic surgeons. N Eng J Med 1995;333:913-917.



Elam KC, Cherkin DC, Deyo RA: How emergency physicians approach low back pain: choosing costly options. J Emerg Med 1995;13:143-150.

Shoulder dislocation

9.05 Shoulder dislocation

Presentation
The patient was holding his shoulder abducted horizontally to the side when a blow knocked the humeral head anteriorly. He arrives holding the shoulder abducted ten degrees from his side, unable to move it without increasing the pain. The delto-pectoral groove is now a bulge (caused by the dislocated head of the hymerus) and the acromion is prominent laterally, with a depression below (where the head of the humerus sits on the undislocated shoulder).
What to to:



Provide analgesia. Ketorolac (Toradol) 60mg im or 30mg iv is good, but you may need intravenous narcotics. To abolish muscle spasm and provide conscious sedation for a difficult reduction, but have the patient awake enough to go home in an hour, one recommended regimen is intravenous midazolam (Versed) 5mg and fentanyl (Sublimaze) 0.1mg, given ten minutes before the procedure, with continuous pulse oximetry, iv fluids running, and the physician by the bedside with bag-valve-mask and endotracheal intubation kit ready. Many shoulders, however, can be reduced without conscious sedation.



When analgesia is required, another alternative is th use intra-articular lidocaine. After preparing the skin with povidone-iodine, using a 1.5 inch 20 gauge needle, inject 20 mL of 1% lidocaine 2 cm inferiorly and directly lateral to the acromion, in the lateral sulcus left by the absent humeral head.



If available, obtain a pre-reduction x ray to rule out fractures or unreduceable injuries. This image may be deferred and speed treatment and relief if the injury was recurrent and relatively atraumatic.



Test and record the sensation over the deltoid to establish if there is an injury of the axillary nerve (rare) and confirm the circulation, sensation, and movement in the elbow, wrist and hand.



Gain the patient's confidence by holding his arm securely, asking him to relax, telling him that you will not do anything suddenly and that if any pain occurs you will stop. Then in a very calm and gentle manner ask him to let his muscles go loose so his shoulder can stretch out.



With the elbow flexed at 90 degrees, apply steady traction at the distal humerus. Pull inferiorly and at the same time externally rotate the forearm very, very slowly. If the patient complains of pain, stop rotating, allow him to relax and let the shoulder muscles stretch while you continue to maintain traction along the humerus. Resume external rotation when he is comfortable again. Using this method, full external rotation alone will reduce most anterior shoulder dislocations.



If you do not feel or see the shoulder joint reduce, then, while maintaining traction and external rotation, slowly and gently adduct the humerus until it is against the chest wall and then slowly internally rotate the forearm against the anterior chest. The vase majority of shoulder dislocations can be reduced comfortably this way, often without the use of any analgesics.



An alternative technique when you can palpate the lateral border of the scapula is reduction by scapular manipulation. With the patient sitting up, place the uninjured shoulder firmly against an immovable support such as a wall or the raised head of the stretcher. Have an assistant face the patient and gently lift the outstretched wrist of the affected arm until it is horizontal. The assistant then places the palm of his free hand against the mid-clavicular area of the injured shoulder as counterbalance, and then gently put firmly pulls the patients arm towards him. At the same time manipulate the scapula by adducting the inferior tip using thumb pressure, while stabilizing the superior aspect with your upper hand.



When the patient is comfortable and range of motion has been restored, secure the reduction in a sling and a swath around the arm and chest. Obtain post-reduction x rays, and discharge the patient once he is alert, with a prescription of analgesics as needed and an appointment for orthopedic follow up in a week (sooner if any problem).
What not to do:



Do not use the forearm as a lever to fracture the neck of the humerus.



Do not redislocate the shoulder by repeating the motions of the mechanism of injury.
Discussion
Your strategy is to relocate the shoulder with minimal damage to the joint capsule and anterior labrum of the glenoid fossa, hoping the patient does not become a chronic dislocator with an unstable shoulder. Chronic dislocators are easier to reduce, and come less often to the ED, because they learn how to relocate their own shoulders.
 Posterior dislocations are caused by internal rotation of the shoulder, as during a seizure, and are more subtle to diagnose. Subglenoid dislocation or luxatio erecta is rare and unmistakable, with the arm raised and abducted.

Acromio-clavicular joint separation

9.04 Acromio-clavicular joint separation

Presentation
The patient fell on the point of the shoulder. He may come in right away because it hurts even without movement (first or second degree tear), or he may come in days later without pain, having noted that the injured shoulder hangs lower or the clavicle (collar bone) rides higher (third degree).
What to do:



Examine the shoulder. The diagnosis is supported by tenderness at the lateral end of the clavicle where it joins the acromion process coming up from the scapula and by pain on pulling the humerus down towards the feet, distracting the acromio-clavicular joint. Strength may be decreased because of pain, but other bones, joints, range of motion, sensation and circulation should be documented as intact.



X ray the shoulder to be sure there is no associated fracture of the lateral clavicle or fracture or dislocation of the humerus.



Support the injured joint with a sling.



Provide additional analgesia. Ibuprofen or naproxen usually suffices.



Arrange for re-evaluation by an orthopedic surgeon and physical therapy to begin shoulder range of motion excercises within a week.
What not to do:



Do not bother with weight-bearing x ray views to differentiate first, second and third-degree separations based on the widening of the distance between the clavicle and scapula. These are painful and do not change the initial treatment.



Do not allow the patient to wear a sling and immobilize the shoulder for more than a week without at least beginning pendulum exercises. The shoulder capsule will contract and restrict the range of motion.
Discussion
A partial tear of the ligaments between acromion and clavicle produces pain but no widening of the joint (first degree tear). A second-degree A-C separation shows up on x ray a widened joint, but is otherwise the same on examination and treatment. In a third-degree or complete separation, the ligament from the coracoid process to the clavicle is probably also torn, allowing the collarbone to be pulled superior by the sternocleidomastoid muscle, but often releiving the pain of the stretched A-C joint. Long-term shoulder joint stability and strength remain almost normal, but patients may desire sugical repair to regain the appearance of the normal shoulder or the last few percent of function for athletics.

Collarbone (clavicle) fracture

9.03 Collarbone (clavicle) fracture

Presentation
The patient has fallen onto his shouldr or outstretched arm or more commonly has received a direct blow to the clavicle, and now presents with pain to direct palpation over the clavicle or with movement of the arm or neck. there may be deformity of the bone with swelling and ecchymosis. An infant or small child might present after a fall, not moving the arm, with a normal examination of the arm, but with the bove findings.
What to do:



After completing a musculoskeletal examination, evaluate the neurovascular status of the arm.



Fit a sling or clavicle strap which comfortably immobilizes the arm. Patients probably experience fewer complications and less pain with a simple sling and there is no difference in healing time.



Prescribe analgesics, usually anti-inflammatories like ibuprofen or naproxen, but narcotics when significant pain is present or anticipated.



Obtain x rays to rule out other injuries and document the fracture for follow up.



Arrange for orthopedic follow up in a week, to evaluate healing and begin pendulum excersises of the shoulder. Obtain rapid orthopedic consultation if there is any evidence of neurovascular compromise.
What not to do:



Do not apply a figure-of-eight dressing or clavicle strap if this form of splinting increases patient discomfort.



Do not leave an arm immobilized in a sling for more than a week. This can result in loss of range of motion or "frozen shoulder."
Discussion
In children, fracture of the clavicle requires very little force and usually heals rapidly and without complication. In acults, however, this fracture usually results from a greater force and is associated with other injuries and complications. Clavicle fractures are sometimes associated with a hematoma from the subclavian vein, but other nearby structures, including the carotid artery, brachial plexus and lung, are usually protected by the underlying anterior scalene muscle and the tendency of the sternocleido-mastoid muscle to pull up the medial fragment of bone. A great deal of angulation deformity and distraction on x ray are usually acceptable, because the clavicle mends and reforms itself so well and does not have to support the body in the meantime. As with rib fractures, respiration prevents immobilization, so the relief that comes with callus formation may be delayed another week.
References



Anderson K, Jensen PO, Lauritzen J: Treatment of clavicular fractures: figure-of-eight bandage versus a simple sling. Acta Orthop Scand 1987;58:71-74.



Stanley D, Norris SH: Recovery following fractures of the clavicle treated conservatively. Injury 1988;19:162-164.



Eskola A, Vainionpaa S, Myllynen P et al: Outcome of clavicular fracture in 89 patients. Arch Orthop Trauma Surg 1986;105:337-338.

Torticollis (Wry Neck)

9.02 Torticollis (Wry Neck)

Presentation
The patient complains of neck pain and is unable to turn his head, usually holding it twisted to one side, with some spasm of the neck muscles, with the chin pointing to the other side. These symptoms may have developed gradually, after minor turning of the head, after vigorous movement or injury, or during sleep The pain may be in the neck muscles or down the spine, from the occiput to between the scapulae. Spasm in the occipitalis, sternocleidomastoid, trapezius, splenius cervicis, or levator scapulae muscles can be the primary cause of the torticollis, or it can be secondary to a slipped facette, herniated disc, or viral or bacterial infection. Picture
What to do:



Ask the patient about precipitating factors, and perform a thorough physical examination, looking for muscle spasm, point tenderness, and signs of injury, nerve root compression, masses or infection. Include a careful nasopharyngeal examination, as well as a basic neurologic exam.



When forceful trauma is was involved and fracture, dislocation or subluxation are possible, then obtain lateral, anteoposterior and odontoid roentgenographic views of the cervical spine. If there are neurologic deficits, computed tomography or magnetic resonance imaging may be better to visualize nerve involvement (as well as herniated disks, hematomatas or epidural abscesses).



When there is no suspicion of a serious illness or injury, apply heat (e.g., a Hydrocolator pack wrapped in several thicknesses of towel); give anti inflammatory analgesics (e.g., aspirin, ibuprofen, naproxyn), and perhaps oral cyclobenzaprine (Flexeril) or diazepam (Valium). Alternating heat with ice massages may also be helpful as well as gentle range of motion exercises.



If the onset was gradual, muscle tenderness and spasm are pronounced, neck motion seems constrained only by muscle stretching, and the symptoms are most severe when certain muscles are stretched, myalgias are probably the cause, and the routine above constitutes the treatment.



If there is point tenderness posterior to the sternocleidomastoid muscle (over the vertebral facets) and the head cannot turn toward the side of the point tenderness, suspect a facet syndrome, obtain x rays, and gently test neck motion again after a few minutes of manual tractiton along a longitudinal axis (sometimes this provides some relief).



If there is any arm weakness or paresthesia corresponding to a cervical dermatome, suspect nerve root compression as the underlying cause, and arrange for x rays and neurosurgical or orthopedic consultation.



With signs and symptoms of infection (e.g., fever, toxic appearance, lymphadenopathy, tonsillar swelling, trismus, pharyngitis or dysphagia) take soft tissue lateral neck films and consider complete a blood count and erythrocyte sedimentation rate to help rule out early abscess formation. Arrange for specialty consultation.



For minor causes, discharge the patient with a soft cervical collar for further relief, and arrangements for x rays and followup if the torticollis has not fully resolved in 1 or 2 days.
What not to do:



Do not overlook infectious etiologies presenting as torticollis, especially the pharyngiotonsillitis of young children, which can soften the atlantoaxial ligaments and allow subluxation.



Do not undertake violent spinal manipulations in the ED, which can make an acute torticollis worse.



Do not confuse torticollis with a dystonic drug reaction from phenothiazines or butyrophenones.
Discussion
Although torticollis may signal some underlying pathology, usually it is a local musculoskeletal problem--only more frightening and noticeable for being in the neck--and need not always be worked up comprehensively when it first presents in the ED.

Cervical Strain (Whiplash)

9.01 Cervical Strain (Whiplash)

Presentation
The patient may arrive directly from a car accident, arrive the following day (complaining of increased neck stiffness and pain), or long after (to have injuries documented). The injury occured when the neck was subjected to sudden extension and flexion, possibly injuring intervertebral joints, discs, and ligaments, cervical muscles, or even nerve roots. As with other strains and sprains, the stiffness and pain may tend to peak on the day following the injury.
What to do:



Obtain a detailed history to determine the mechanism and severity of the injury. Was the patient wearing a seat belt? Was the headrest up? Were eyeglasses thrown into the rear seat? Was the seat broken? Was the car damaged? Driveable afterwards? Windshield shattered? Intrusion into the passenger compartment?



Examine the patient for involuntary splinting, point tenderness over the spinous processes of the cervical vertebrae, cervical muscle spasm or tenderness, and for strength, sensation, and reflexes in the arms (to evaluate the cervical nerve roots).



If there is any question at all of an unstable neck injury, start the evaluation with a cross table lateral film of the cervical spine, while maintaining cervical immobilation with a rigid collar. If necessary, the anteroposterior view and open mouth view of the odontoid can also be obtained before the patient is moved.



To evaluate the possibility of head trauma, ask about loss of consciousness or amnesia, and check the patient's orientation, cranial nerves, and strength and sensation in the legs as well.



If any of the above suggest injury to the cervical spine, obtain 3 x ray views of the cervical spine: AP, lateral, and open mouth odontoid. If there is clinical nerve root impairment, or you need to see more detail of the posterior elements of the vertebrae, obliques may also be useful. Flexion and extension views may be needed to evaluate stablity of joints and ligaments, but should only be done under careful supervision, so the spinal cord is not injured in the process.



If x rays show no fracture or dislocation, and history and physical examination are consistent with stable joint, ligament, and muscle injury, explain to the patient that the stiffness and pain are often worse after 24 hours, but usually resolve over the next 3-5 days, and are usually back to normal in a week.



Treat with one or two days of immobilization (a soft cervical collar), topical ice for the first day, then heat for the later spasm, and anti inflammatory analgesics (aspirin, ibuprofen, naproxyn).



Arrange followup as necessary.
What not to do:



Do not forget to tell the patient his symptoms may well be worse a day after the injury.



Do not skimp recording the history and physical. This sort of injury may end up in litigation, and a detailed record can obviate your being subpoenaed to testify in person.



Do not x ray every sore neck. A thousand negative cervical spine x rays are cost effective if they prevent one paraplegic from an occult unstable fracture, but several studies have shown that patients who have no neck pain or stiffness (and are not intoxicated or distracted by other injuries) do not have to be x rayed just because they fell or hit their head.
Discussion
X ray results for whiplash neck injuries seldom add much to the clinical assessment but the sequelae of unrecognized cervical spine injuries are so severe that it is still worth while to x ray relatively mild injuries (in contrast to skull and lumbosacral spine radiographs, which are ordered far less often.) It is often useful to discuss the pros and cons of x rays with the patient, who may prefer to do without, or conversely may be in the ED purely to obtain radiological documentation of his injuries. The term "whiplash" is probably best reserved for describing the mechanism of injury, and is of little value as a diagnosis. Because of the many undesirable legal connotations which surround this term it may be advisable to substitute "flexion/extension injury."

Pelvic Inflammatory Disease

8.09 Pelvic Inflammatory Disease

Presentation
A woman aged 15-30, possibly with a new sex partner, complains of lower abdominal pain. There may be associated vaginal discharge, malodor, dysuria, dyspareunia, menorrhagia or intermenstrual bleeding. Patients with more severe infections may develop fever, chills, malaise, nausea and vomiting. Women with severe pelvic pain tend to walk slightly bent over, holding their lower abdomen and shuffling their feet. Abdominal examination reveals lower quadrant tenderness, sometimes with rebound, and occasionally there will be right upper quadrant tenderness due to perihepatitis (Fitz-Hugh-Curtis syndrome). Pelvic examination demonstrates bilateral adnexal tenderness as well a uterine fundal and cervical motion tenderness.
What to do:



Always perform a pelvic examination on women with lower abdominal complaints or lower abdominal tenderness. The examination should be thorough, yet performed as gently and briefly as possible to avoid exacerbating a very painful condition.



Obtain endocervical cultures for Neisseria gonorrhoeae and Chlamydia trachomatis.



Obtain blood for syphilis serology and recommend HIV testing.



Obtain urine for urinalysis and blood or urine for pregnancy testing.



Consider obtaining a leukocyte count, sedimentation rate and C-reactive protein. These are indicators of clinical severity, but normal results do not rule out PID.



Determine pH of any vaginal discharge and make wet mount examinations and Gram stains of endocervical secretions, looking for Candida, Trichomonas, clue cells and any gram-negative diplococci inside polymorphonuclear neutrophils (almost diagnostic of gonorrhea).



Perform pelvic ultrasound if there is a suspected mass, severe pain, or a positive pregnancy test.



Because no laboratory tests are diagnostic for PID, assume a diagnosis when there are lower abdominal pain with tenderness on examination, bilateral adnexal tenderness and cervical motion tenderness plus one of:temperature > 38 C (100.4 F), leukocytosis > 10,500 WBC/mm3, inflammatory mass on pelvic examination or ultrasound, elevated C-reactive protein, erythrocyte sedimentation rate > 15mm/h, or evidence of gonorrhea or chlamydia in the endocervix (by positive antigen test, Gram stain or mucopurulent cervicitis).



Remove any intrauterine device (IUD).



Treat suspected cases while awaiting diagnostic confirmation.



Hospitalize adolescents with salphingitis and all patients with pelvic or tubo-ovarian abscess, pregnancy, fever >38.5 C, nausea and vomiting that preclude oral antibiotics, current use of an IUD, septicemia or other serious disease, high risk of poor compliance, failed follow up and failure on 48 hours of the outpatient therapy below.



Treat mild to moderate cases as outpatients with one dose of ceftriaxone (Rocephin) 250mg im or cefoxitin (Mefoxin) 2000mg im plus probenecid 1000mg po concurrently, followed by a prescription for doxycycline 100mg bid for 14 days. For more severe cases with a high probability of resistant anerobic infection, add metronidazole 1000mg po bid or clindamycin 450mg po qid. A completely oral alternative is ofloxacin (Floxin) 400mg bid x14d plus either clindamycin 450mg qid or metronidazole 500mg qid, also for 14 days.



Provide for follow up examination in three days.



Provide analgesics as needed.



Instruct the patient to abstain from sexual intercourse for at least two weeks.



Unless sexual acquisition can be excluded with certainty, treat the partner for presumptive gonorrhea and chamydia with ceftriaxone 125mg im once or ciprofloxacin 500mg po once plus doxycycline 100mg po bid x7d or azithromycin 1000mg po once.



Counsel the patient about the sexually transmitted nature of PID and its risks for infertility (15-30% per episode) and ectopic pregnancy. Barrier methods of contraception (condoms and diaphragms) reduce the risk. Vaginal spermicides are also bactericidal.
What not to do:



Do not use ofloxacin in pregnant women or patients under 18.



Do not miss the more unilateral disorders like ectopic pregnancy, appendicitis, ovarian cyst or torsion and diverticulitis. Early consultation by both general surgeon and obstetrician/gynecologist are sometimes necessary.



Do not diagnose PID in a patient with a positive pregnancy test without rulling out ectopic pregnancy, usually with a sonogram.



Do not ignore pelvic symptoms if the patient has perihepatic inflammation.
Discussion
Pelvic inflammatory disease (PID) is defined as salpingitis, often accompanied by endometritis or secondary pelvic peritonitis, that results from ascending genital infection. PID related to N. gonorrhoeae and C. trachomatis is more common within the first one or two weeks after the onset of menstuation. There is increased risk for this disease in sexually active adolescents compared with women over twenty years old. There is also increased risk with multiple sex partners, use of an interuterine device (IUD), previous history of PID and vaginal douching. The incubation period for PID varies from 1-2 days to weeks or months. Laparoscopy is indicated in severe cases, if diagnosis is uncertain or if there is inadequate response to initial antibiotic therapy. A diagnosis of PID in children or young adolescents should prompt an evaluation for possible child abuse.

"Morning after" contraception

8.08 "Morning after" contraception

Presentation
A woman has had unprotected sexual intercourse in the last 24 hours and wants to prevent an unplanned pregnancy. This may be part of the prophylactic treatment of a rape victim.
What to do:



Obtain a urine or serum pregnancy test. If it is already positive, these measures will not be sufficient, and will harm the fetus.



Prescribe a contraceptive in large doses for a short time to prevent implantation. Examples include:



norgestrel and ethinyl estradiol (Ovral) po two now and two in 12 hours. Within 72 hours of intercourse the failure rate is 1.8%



diethylstilbesterol 25mg po bid for five days



conjugated estrogen (Premarin) 30mg po qd for five days



conjugated estrogen (Premarin) 50mg iv qd for two days



Ask about exposure to sexually transmitted diseases, which might require separate testing and prophylaxis.



Arrange for follow up if this treatment fails to prevent pregnancy.
What not to do:



Do not use this emergency rescue technique as a substitute for condoms, which also help prevent sexually transmitted infections.
References:



Med Letter Drugs Ther: Ovral as a morning after contraceptive 1989;31:93.



Association of Reproductive Health Professionals hotline (800) 584-9911



directory of emergency contraception providers

Genital warts (condylomata acuminata)

8.07 Genital warts (condylomata acuminata)

Presentation
Patients complain of perineal itching, burning, pain and tenderness or they may be asymptomatic, especially with cervical and vaginal involvement, but noticed distinctive fleshy warts of the external genitalia or anus. Lesions are pedunculated or borad based with pink to gray soft excrescences, occuring in clusters or individually.
What to do:



External warts seldom require biopsy for diagnosis. The differential diagnosis of anogenital warts includes molluscum cantagiosum, verruca vulgaris (common non-genital wart), secondary syphilis (condyloma lata), hypertrophic vulvar dystrophies and vulvar intraepithelial and invasive neoplasias. Consider atypical, pigmented, intravaginal cervical and persistant warts for referral for biopsy.



Prescribe podofilox 0.5% solution (Condylox) 3.5mL for self-treatment. Patients may apply podofilox with a cotton swab to warts twice daily for three days, followed by 4 days of no treatment. This cycle may be repeated as necessary for a total of 4 cycles. Total wart area treated should not exceed ten square centimeters and total volume of podofilox should not exceed 0.5mL per day. If possible, you should apply the initial treatment to demonstrate the proper application technique and identify which warts should be treated.



Alternatively, apply 25% podophyllin in tincture of benzoin (Podocon-25) 15mL using the above application technique and with the same dosage restrictions. Have the patient thoroughly wash off in 1-4 hours. This may be repeated weekly if necessary but if warts persist after six applications the patient should be referred for alternative therapy.



If the patient is pregnant, has severe involvement or has anal or rectal warts, she should be referred for cryotherapy, application of trichloroacetic acid, ablation with carbon dioxide laser, electrocautery or surgical extirpation.



If the patient's male partner also has visible lesions, he can be treated using the same regimens.



Counsel both about the unpredictable natural history of the disease and the possible increased risk of lower genital tract malignancy. Infected women should have an annual Pap smear.
What not to do:



Do not use podofilox or podophyllin during pregnancy. There have been a few cases of toxicity reported when large amounts of podophyllin have been used.



Do not mistake "pearly penile papules" for warts. These dome-shaped or hairlike projections around the corona of the glans penis are normal variants in up to 10% of men.
Discussion
Genital warts are a result of infection with human papillomavirus (HPV). The virus is currently considered a leading candidate as a causative agent in squamous carcinomas of both the female and male genital tracts. The sexual transmission of HPV is well documented, with the highest prevalence in young, sexually active adolescents and acults. HPV types 6 and 11 are the most prevalent types associated with condyloma accuminata and are not considered to have malignant potential. HPV frequently coexists with other sexually transmitted diseases. HPV lesions are difficult to eradicate, with a very high recurrence rate, and still no definitive therapy.

Contact vulvovaginitis

8.06 Contact vulvovaginitis

Presentation
Patients complain of vulvar itching and swelling. Occationally there will be tenderness, pain, burning and dysuria severe enough at times to cause urinary retention. The vulvovaginal area is inflammed, erythematous and edematous. In more severe cases there may be vesiculation and ulceration and in cases where there is a chronic contact dermatitis there may be lichenification, scaling and skin thickening.
What to do:



try to identify an offending agent and have the patient stop using it. Most reactions are caused by agents that the patient unknowingly applies or uses for hygenic or therapeutic purposes. Chemically scented douches, soaps. bubble baths, deodorants and perfumes as well as dyed or scented toilet paper, dyed underwear, scented tampons or pads and feminine hygene products are the most common causative agents. Less commonly, plant allergens such as poison oak or poison ivy may be the inadvertently-applied substances that trigger the reaction.



Rule out an alternate cause of vulvar puritis such as pinworms or trichomonas. Candida albicans may also be the cause of pruritis but it may present as an overgrowth when contact vulvovaginitis is the primary problem.



Instruct the patient in the use of cool baths and wet compresses using boric acid or Burow's solution (Domboro).



Prescribe liberal amounts of topical corticosteroids like fluocinolone (Synalar cream 0.025%) or triamcinolone (Stistocort 0.025% cream) bid to qid (dispense 15-60 grams).



In more severe cases, also prescribe oral steroids in a tapering dose-pack schedule like prednisone (Sterapred DS or Sterapred DS 12 day), methylprednisolone (Medrol Dosepack) or triamcinolone (Aristo-Pak) for six days of systemic therapy.
What not to do:



Do not have the patient use hot baths or compresses. This will usually exacerbate the burning and pruritis.



Do not prescribe antihistamines. They are relatively ineffective in treating contact vulvitis and may increase discomfort by drying the vaginal mucose.
Discussion
The major problem with managing contact vulvovaginitis is identifying the primary irritant or allergen. In many cases, more than one substance is involved or potentially involved and may be totally unsuspected by the patient (such as the use of scented toilet paper). For this reason, a thorough investigative history is very important.

Bartholin Abscess

8.05 Bartholin Abscess

Presentation
A woman complains of vulvar pain and swelling that has developed over the past 2-3 days, making walking and sitting very uncomfortable. On physical exam in the lithotomy position, there is a unilateral (occasionally bilateral), tender, fluctuant, erythematous swelling at 5 or 7 o'clock within the posterior labium minus.
What to do:



If the swelling is mild without fluctuance (bartholinitis) or if the abscess is not pointing, the patient can be placed on an antibiotic (e.g., ciprofloxacin 500mg and azithromycin 1000mg po once, ofloxacin or doxycycline 100mg po bid x14d) and instructed to take warm sitz baths. Early followup should be provided.



When the abscess is pointing, an incision should be made over the medial bulging surface and the pus evacuated.



After drainage a Word catheter should be inserted through the incision. Inflate the tip of the catheter with sterile water to hold it in place and prevent premature closure of the opening.



After drainage, the patient should be placed on antibiotics and instructed to take sitz baths.



Provide for a followup exam within 48 hours.
What not to do:



Do not mistake a nontender Bartholin duct cyst, which does not require immediate treatment, for an inflamed abscess.



Do not mistake a more posterior perirectal abscess for a Bartholin abscess. The perirectal abscess requires a different treat ment approach.
Discussion
The most common organisms involved in the development of a Bartholin abscess are gonococci, streptococci, Escherichia coli, Proteus and Chlamydia, and often more than one organism is present. Bilateral infections are more commonly characteristic of gonorrhea. The Word catheter is a 5 mL balloon on a 5 cm catheter designed to retain itself in the abscess cavity for 4-6 weeks to help insure the development of a wide marsupialized opening for continued drainage, but they seldom stay in place that long. Iodoform or plain ribbon gauze can be inserted into the incised abscess as a substitute. If a wide opening persists, recurrent infections are not likely to occur, but they are common if the stoma closes.

Vaginal Foreign Bodies

8.04 Vaginal Foreign Bodies

Presentation
This commonly is a problem of children, who may insert a foreign body and not tell their parents. The patient is finally brought to the emergency department with a foul-smelling purulent discharge with or without vaginal bleeding. Vaginal foreign bodies in the adult may be a result of a psychiatric disorder or unusual sexual practices. Occasionally a tampon or pessary is forgotten or lost and causes discomfort and a vaginal discharge.
What to do:



Visualize the foreign body using a nasal speculum in the pediatric patient or a vaginal speculum in the adult.



Pediatric patients may be placed in the knee-chest position and, while performing a rectal examination, you may be able to expell the foreign body from the vagina by pushing with the examining finger in the rectum.



Friable foreign bodies such as wads of toilet paper may be flushed out using warm water, an infant feeding tube, and a standard syringe.



Lost or fogotten tampons can be removed with vaginal forceps that are first pierced through the finger of a latex glove, so that when the malodorous foreign body is extracted, the glove can immediately pulled over it to reduce the odor before it is discarded in a sealed plastic bag. The vagina should then be swabbed with a betadine solution.



In difficult cases, or when large or sharp obects are involved, young and adult patients may require general anesthesia to allow removal under direct vision.



When general anesthesia is not required, conscious sedation should be considered.



The patient should empty her bladder and lie in stirrups in the lithotomy position. Insert a Foley catheter to break any suction between the foreign body and the vaginal mucosa. Most objects can then be grasped with ring forceps or the plaster and tongue blade method.



Reserve x rays for radio-opaque foreign bodies concealed in the bladder or urethra. Objects in the vagina are usually apparent on examination. What not to do:



Do not ignore a vaginal discharge in a pediatric patient or assume it is the result of a benign vaginitis. Perform a bimanual or rectoabdominal examination to palpate a hard object and then do a gentle speculum exam to look for a foreign body or signs of vaginal trauma.



Do not forget to ask about possible sexual abuse and consult with protective services if it cannot be ruled out.
Discussion
Vaginal foreign body removal is generally not a problem, but when large objects make removal more difficult, use the additional techniques described for rectal foreign bodies.

Vaginitis

8.03 Vaginitis

Presentation
A woman complains of itching and irritation of the labia and vagina, perhaps with vaginal discharge or odor, vague low abdominal discomfort, or dysuria. (Suprapubic discomfort and urinary urgency and frequency suggest cystitis.) Abdominal examination is benign but examination of the introitus may reveal erythema of the vulva and edema of the labia (especially with Candida). Speculum examination may disclose a diffusely red, inflamed vaginal mucosa, with vaginal discharge either copious, thin, and foul-smelling (characteristic of Trichomonas or anaerobic overgrowth) or thick, white, and cheesy (characteristic of Candida and associated with more intense vulvar pruritis). Bimanual examination should show a non-tender cervix and uterus, without adnexal tenderness or masses or pain on cervical motion.
What to do:



Take a brief sexual history. Ask if partners are experiencing related symptoms.



Perform speculum and bimanual pelvic exam. Collect urine for possible culture and pregnancy tests which may influence treatment. Swab the cervix or urethra to culture for N. gonorrheae and swab the endocervix to test for Chlamydia. Touch pH indicator paper to the vaginal mucus (a pH>4.5 suggests anaerobic vaginosis, but this is only useful if there is no blood or semen to buffer vaginal secretions).



Dab a drop of vaginal mucus on a slide, add a drop of 0.9% saline and a cover slip, and examine under 400x for swimming protozoa (Trichomonas vaginalis), epithelial cells covered by adherent bacilli ("clue cells" of Gardnerella vaginalis and other anaerobes), or pseudohyphae and spores ("spaghetti and meatballs" appearance of Candida albicans).



If epithelial cells obscure the view of yeast, add a drop of 10% KOH, smell whether this liberates the odor of stale fish (characteristic of Gardnerella, Trichomonas and semen) and look again under the microscope.



Gram stain a second specimen. This is an even more sensitive method for detecting Candida and clue cells, as well as a means to assess the general vaginal flora, which is normally mixed, with occasional predominance of gram-positive rods. Many white cells and an overabundance of pleomorphic gram-negative rods suggests Gardnerella infection. Gram-negative diplococci inside white cells suggests gonorrhea.



If Trichomonas vaginalis is the etiology, discuss with the patient the options of metronidazole (Flagyl) 500mg bid x 7d, or 2000mg once. The latter has practically as good a cure rate, but obviously better compliance, and shortens the time she must abstain from alcohol for 24 hours after the last dose because of metronidazole's disulfiram-like activity. Sexual partners should receive the same treatment. In the first trimester of pregnancy, substitute intravaginal clotrimazole 100mg vaginal suppository qhs x7d, which is less effective, but safer than metronidazole vaginal gel. Metronidazole is contraindicated in the first trimester and controversial thereafter. Treatment of asymptomatic patients can be be delayed until after delivery.



If Candida albicans is the etiology, prescribe miconazole (Monistat) or clotrimazole (Gyne-Lotrimin) 200mg vaginal suppositories to be inserted qhs x 3d. These treatments are available without prescription. Prescription alternatives for recurrences, which is active against fungi other than Candida, are butoconazole (Femstat) and terconazole (Terazol) one 5 gram applicator of cream qhs for three days and seven days, respectively. Use of cream also allows its soothing application on irritated mucosa. A single oral dose of fluconazole (Diflucan) 150mg po is at least as effective as intravaginal treatment of vulvovaginal candidiasis, and many patients seem to prefer it. Gastrointestinal side effects are fairly common and serious side effects can occur. In pregnancy, halve the dose and double the course of topical clotrimazole, (the same as the regimen for Trichomonas above).



If the diagnosis is bacterial vaginosis, which is an overgrowth of Gardnerella vaginalis or other anaerobes, the strongest treatment is metronidazole 500mg bid or clindamycin 300mg bid x 7d. Metronidazole vaginal gel 0.75% 5 grams bid x 7d is an alternative which is more expensive but carries fewer gastrointestinal side effects than the oral form. Sex partners need not be treated unless they have balinitis.



To prevent rebound Candida vaginitis after antibiotics decimate the normal vaginal flora, or for treatment of mild vaginitis, consider douching with 1% acetic acid (half-strength vinegar) to maintain a normal low pH ecology.



remember that any given patient may harbor more than one infection.



Arrange for followup and instruct the patient in prevention of vaginitis .
What not to do:



Do not prescribe sulfa creams for non-specific vaginitis. The treatments above are more effective.



Do not miss underlying pelvic inflammatory disease, pregnancy, or diabetes, all of which can potentiate vaginitis.



Do not miss candidiasis because the vaginal secretions appear essentially normal in consistency, color, volume and odor. Non-pregnant patients may not develop thrush patches, curds or caseous discharge.
Discussion
Both Candida albicans and Gardnerella vaginalis (previously known as Hemophilus vaginalis or Corynebacterium vaginale), are part of the normal vaginal flora. A number of anaerobes share the blame in bacterial vaginosis. An alternate therapy uses active-culture yogurt douches to repopulate the vagina with lactobacilli. Candida vaginitis is more common in the summer, under tight or nonporous clothing (jeans, synthetic underwear, wet bathing suits), and in users of antibiotics and contraceptives (which alter vaginal mucus), as well as in diabetes mellitus, steroid-induced immuinosupression and use of broad-spectrum antibiotics. Trichomonas can be passed back and forth between sexual partners, a cycle that can be broken by treating both. Ask patients with vulvar pruritis, erythema and edema, but with otherwise normal saline, KOH and Gram stain microscopy, about the use of hygene sprays or douches, bubble baths or scented toilet tissue. Contact vulvovaginitis may result from an allergic or chemical reaction to any one of these or similar products and can be treated by removing the offending substance and prescribing a short course of a topical or systemic corticosteroid.
References:



Abbott J: Clinical and microscopic diagnosis of vaginal yeast infection: a prospective analysis. Ann Emerg Med 1995;25:587-591.



Swedberg J, Steiner JF, Deiss F, et al: Comparison of a single-dose vs one-week course of metronidazole for symptomatic bacterial vaginosis. J Am Med Assoc 1985;254:1046-1049.



Martin DH, Mroczkowski TF, Dalu ZA et al: A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis. N Eng J Med 1992;327:921-925.

Vaginal Bleeding

8.02 Vaginal Bleeding

Presentation
A menstruating woman complains of greater than usual bleeding, which is either off her usual schedule (metrorrhagia), lasts longer than a typical period, or is heavier than usual (menorrhagia) perhaps with crampy pains and passage of clots.
What to do:



Obtain orthostatic pulse and blood pressure measurements, a hematocrit, and pregnancy test (urine or serum beta hCG). Try to quantify the amount of bleeding by number of saturated pads used.



If there is significant bleeding, demonstrated by tachycardia, lightheadedness, orthostatic pressure changes, a pulse increase of more than 20 per minute on standing, or a hematocrit below 30%, start an intravenous line of lactated Ringer's solution, and have blood ready to transfuse on short notice.



Obtain a menstrual, sexual, and reproductive history. Are her periods usually irregular, occasionally this heavy? Does she take oral contraceptive pills, and has she missed enough to produce estrogen withdrawal bleeding? Is an IUD in place and contributing to cramps, bleeding, and infection? Was her last period missed or light, or this period late, suggesting an anovulatory cycle or an ectopic? Might she be pregnant?



Perform a speculum and manual vaginal examination, looking particularly for signs of pregnancy, such as a soft, blue cervix, enlarged uterus, or passage of fetal parts with the blood. Ascertain that the blood is coming from the cervical os, and not frorn a laceration, polyp, or other vaginal or uterine pathology or infection. Feel for adnexal masses, as well as pelvic fluid or tenderness.



If there is an intrauterine pregnancy, determine whether this bleeding represents an incomplete, inevitable, or threatened abortion. Spread any questionable products of conception on gauze or suspend in saline to differentiate from organized clot. Press an 8mm curette or dilator against the cervix to see whether the internal os is open (indicating an inevitable or incomplete abortion) or closed (threatened abortion, with roughly even odds of survival, and generally treated by bedrest).



Confirm suspicion of ectopic pregnancy either with a sonogram showing the ectopic gestational sac, a sonogram showing an empty uterus despite a positive pregnancy test, or a culdocentesis, which cannot rule out an ectopic pregnancy, but which can quickly demonstrate blood in the cul-de-sac after an ectopic sac ruptures.



Discharge the stable patient home on oral contraceptive pills (Ortho-Novum 1/50 or Norinyl 1+50) one qid until the bleeding stops, then finishing the 28-day package one qid, followed by low-dose oral contraceptives for the next two to three months.



If the cause of the uterine bleeding was missed oral contraceptive pills, the patient may resume the pills, but should use additional contraception for the first cycle. (If the cause is a new IUD, the patient may elect to have it removed and use another contraceptive.)



The patient should be referred for followup to a gynecologist, and may be evaluated via endometrial biopsy.
What not to do:



Do not leap to a diagnosis of dysfunctional uterine bleeding without ruling out pregnancy.



Do not rule out pregnancy or venereal infection on the basis of a negative sexual history--confirm with physical examination and laboratory tests.
Discussion
The essential steps in the emergency evaluation of vaginal bleeding are fluid resuscitation of shock, if present, and recognition of pregnancy and its complications of spontaneous abortion or ectopic pregnancy. Treatment of more chronic and less severe dysfunctional uterine bleeding usually consists of iron replacement and optional use of oral contraceptives to decrease menstrual irregularity (metrorrhagia) and volume (menorrhagia). Bed rest has not been shown to improve the outcome for a threatened abortion, but is still usually part of the regimen. Medroxyprogesterone (Provera) 10mg po x10d can also be given to stop dysfunctional uterine bleeding, but warn the patient to expect a heavy bleed when it is stopped.
References



Falcone T, Desjardins C, Bourque J, et al: Dysfunctional uterine bleeding in adolescents. J Reprod Med 1994;39:761-764.

Dysmenorrhea (Menstrual Cramps)

8.01 Dysmenorrhea (Menstrual Cramps)

Presentation
A young woman complains of crampy, labor-like pains which began before the visible bleeding of her menstrual period. The pain is focused in the lower abdomen, low back, suprapubic area or thighs, and may be associated with nausea, vomiting, increased defecation, headache, muscular cramps, and passage of clots. The pain is most severe on the first day of the menses, and may last from several hours to several days. Often, this is a recurrent problem, dating back to the first year after menarche. Rectal, vaginal and pelvic examination disclose nothing abnormal.
What to do:



Ask about the duration of symptoms and onset of similar episodes (onset of dysmenorrhea after menarche suggests other pelvic pathology). Ask about appetite, diarrhea, dysuria, dyspareunia and other symptoms suggestive of other pelvic pathology.



Perform a thorough abdominal and speculum and bimanual pelvic examination, looking for signs of infection, pregnancy, or uterine or adnexal disease.



Confirm that the patient is not pregnant with a urine pregnancy test (or serum beta hCG if available stat).



For uncomplicated dysmenorrhea, try nonsteroidal antiinflammatory medications such as ibuprofen (Motrin) 600-800mg, indomethacin (Indocin) 50mg, or naproxen (Naprosyn) 500mg po initially, tapering to maintenance doses (half the loading dose q6h).



Arrange for workup of endometriosis or other underlying causes and suggest aspirin or oral contraceptives for prophylaxis.
What not to do:



Do not treat acute dysmenorrhea with aspirin alone. Aspirin begun three days before the period, 650mg qid, is effective prophylaxis, but it is not as good once symptoms exist.
Discussion
Prostaglandins E and F in menstrual blood appear to stimulate uterine hyperactivity, and thus many of the symptoms of dysmenorrhea.

Blunt scrotal trauma

7.11 Blunt scrotal trauma

Presentation
Blunt injuries to the scrotum usually occur in patients less than 50 years of age as a result of an athletic injury, a straddle injury, an automobile or industrial accident, or an assault. Patients present with various degrees of pain, ecchymosis and swelling.
What to do:



Get a clear history of the exact mechanism of the trauma and the point of maximum impact. Determine if there was any bloody penile discharge or hematuria and whether or not the patient has any pre-existing genital pathology such as prior genitourinary surgery, infection or mass.



Gently examine the external genitalia with the understanding that intense pain may result in a suboptimal examination. If scrotal swelling is not too severe, try to palpate and assess the intrascrotal anatomy.



Obtain a urinalysis. If blood is present in the urine (or at the urethral meatus) do a digital examination of of the prostate (elevation of the prostate implies injury of the menbranous urethra) and obtain urologic consultation.



When pain or swelling prevent demonstration of normal intrascrotal anatomy, then obtain a doppler ultrasound study or testicular scan to help determine the need for operative intervention.



When urologic intervention is not required, provide analgesia, bed rest, scrotal support, a cold pack and urologic follow up.
What not to do:



Do not miss testicular torsion which can be associated with blunt trauma.



Do not miss the rare traumatic testicular dislocation which results in an "empty scrotum." The testis is found superficially beneath the abdominal wall in about 80% of such cases. Imediate urology consultation is required.
Discussion
The majority of blunt testicular injuries result in either contusions or ruptures. If doppler or testicular scan studies demonstrate a serious injury, then early exploration, evacuation of hematoma, and repair of testicular rupture tend to result in an earlier return to normal activity, less infection, and less testicular atrophy.