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septic arthritis vs. transient synovitis in kids

3 Nov

repost of an old entry, but came up again recently, worth a review:

HOW CAN WE TELL THE DIFFERENCE?
–lots of overlap in signs/symptoms
–one article came up with a decent decision rule

J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.
–looked at 282 cases, excluded 114 atypical patients (e.g. immunocompromised), leaving 168
–38 had “true” septic arthritis
septic arthritis defined by positive culture or joint WBC >= 50,000 cells/mm3

–four things they decided on that might differentiate:

  • history of fever
  • non-weight-bearing
  • erythrocyte sedimentation rate (ESR) >= 40 mm/hr
  • serum WBC > 12,000 cells/mm3

–predicted probability of septic arthritis using these four predictors:

  • < 0.2 percent for zero predictors
  • 3.0 percent for one predictor
  • 40.0 percent for two predictors
  • 93.1 percent for three predictors
  • 99.6 percent for four predictors

BOTTOM LINE:
–septic arthritis is bad, transient synovitis not so bad
–hard to tell sometimes, signs/symptoms are often similar
–useful: history of fever, non-weight bearing, ESR>40, WBC>12k
–if none of the above: unlikely septic arthritis
–more of the above: worry a bit more

Reference(s): kocher article, picture

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Kanavel signs for flexor tenosynovitis

12 Mar

(some via an old post, but came up recently, and was the most basic evidence found on a pubmed biopsy.  if anyone knows of any larger data/studies, please share in the comments section)

CLASSIC TEACHING:
Kanavel signs for flexor tenosynovitis

  • pain on passive extension (early finding)
  • finger held in flexion
  • uniform swelling of finger
  • tenderness to percussion along flexor tendon sheath (late finding)



HOW GOOD IS OUR H&P?
incidence of H&P findings in 75 patients with flexor tenosynovitis

  • fusiform swelling (97%)
  • pain on passive extension (72%)
  • semiflexed posture (69%)
  • subcutaneous purulence (68%)
  • tenderness along flexor sheath (64%)
  • elevated WBC (59%)
  • diabetes mellitus (35%)
  • skin necrosis (23%)
  • fever (17%)

 

overall, the 4 signs aren’t perfect, but are there individually in at least 2/3rds of patients

one study of 41 patients with flexor tenosynovitis:

  • all patients had tenderness along the flexor tendon sheath and pain with passive extension.
  • only 22/41 patients (54%) had all four Kanavel signs

TREATMENT TOOLBOX:

IV antibiotics: staph and strep coverage, think pasturella for bite-associated infections

–surgery: consult your hand surgeon ASAP

Kanavel signs for flexor tenosynovitis (REVISITED)

  • pain on passive extension (early finding)
  • finger held in flexion
  • uniform swelling of finger
  • tenderness to percussion along flexor tendon sheath (late finding)
 

Reference(s): uptodate.com: infectious tenosynovitis; study; picture.; article

possible open joint: how much do I infuse?

22 May

RAGING HYPOTHETICAL:
–patient arrives with wound around the knee
–want to inject saline in the joint capsule to see if it is open (if it leaks)
–how much saline do I put in there?

Keese et al. The Accuracy of the Saline Load Test in the Diagnosis of Traumatic Knee Arthrotomies. J. Orthop Trauma. 21;7. Aug 2007.

–study of 30 patients undergoing arthroscopy


–after arthroscopy hole was made each knee was injected with saline and measure how much it took until extravasation was seen.


–50ml of saline gave 46% sensitivity
–194ml of saline gave 95% sensitivity. 




FOOD FOR THOUGHT:
–standard 50ml injection not great sensitivity in this small study
–200cc NS seemed to do the trick




Submitted by T. Boyd.




Reference(s): article, picture

Kanavel signs for flexor tenosynovitis

10 May

CLASSIC TEACHING:
Kanavel signs for flexor tenosynovitis

  • pain on passive extension (early finding)
  • finger held in flexion
  • uniform swelling of finger
  • tenderness to percussion along flexor tendon sheath (late finding)



HOW GOOD IS OUR H&P?
–study of 75 patients with flexor tenosynovitis


–incidence of H&P findings 

  • fusiform swelling (97%)
  • pain on passive extension (72%)
  • semiflexed posture (69%)
  • subcutaneous purulence (68%)
  • tenderness along flexor sheath (64%)
  • elevated WBC (59%)
  • diabetes mellitus (35%)
  • skin necrosis (23%)
  • fever (17%)
overall, the 4 signs aren’t perfect, but are there individually in at least 2/3rds of patients

–hard to find data on sensitivity/specificity of these signs combined on brief pubmed biopsy



TREATMENT TOOLBOX:
IV antibiotics: staph and strep coverage, think pasturella for bite-associated infections

–surgery: consult your hand surgeon ASAP


Kanavel signs for flexor tenosynovitis (REVISITED)

  • pain on passive extension (early finding)
  • finger held in flexion
  • uniform swelling of finger
  • tenderness to percussion along flexor tendon sheath (late finding)

fat pad on x-ray

19 Apr

WHAT IS THE FAT PAD?
–might be only subtle sign of a fracture on x-ray

–broken bones leak fat & blood, which also moves existing soft tissue



COOL TRICK:
–courtesy of EM News article (check out the pic on their website)
–if you’re aspirating a joint (e.g. knee effusion), and you aspirate blood, take a look under a light, look for the sheen of fat on top (suggests fracture)

–might want to get a CT or MRI next, if those x-rays were negative

Reference(s): EM News article with picture, x-ray, diagram, oil&water

septic arthritis vs. transient synovitis in kids

29 Mar

HOW CAN WE TELL THE DIFFERENCE?
–lots of overlap in signs/symptoms
–one article came up with a decent decision rule

J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.
–looked at 282 cases, excluded 114 atypical patients (e.g. immunocompromised), leaving 168
–38 had “true” septic arthritis
septic arthritis defined by positive culture or joint WBC >= 50,000 cells/mm3

–four things they decided on that might differentiate:

  • history of fever
  • non-weight-bearing
  • erythrocyte sedimentation rate (ESR) >= 40 mm/hr
  • serum WBC > 12,000 cells/mm3

–predicted probability of septic arthritis using these four predictors:

  • < 0.2 percent for zero predictors
  • 3.0 percent for one predictor
  • 40.0 percent for two predictors
  • 93.1 percent for three predictors
  • 99.6 percent for four predictors

BOTTOM LINE:
–septic arthritis is bad, transient synovitis not so bad
–hard to tell sometimes, signs/symptoms are often similar
–useful: history of fever, non-weight bearing, ESR>40, WBC>12k
–if none of the above: unlikely septic arthritis
–more of the above: worry a bit more

Submitted by S. Lee.

Reference(s): kocher article, picture

indications for inpatient operative management of an ankle fracture

5 Mar

Submitted by E. Hawkins.

Reference(s): quick read, worth the trip–Management of ankle fractures. Mordecai S, Al-Hadithy N. BMJ. 2011 Oct 28;343:d5204. doi: 10.1136/bmj.d5204. http://www.ncbi.nlm.nih.gov/pubmed/22039272