Improving Outcomes, Improving Throughput

POCUS guided Flexor Tenosynovitis

It feels good to be back! Now, fresh off the inaugural AAPA18 iScan ultrasound event, its only right that my next post is on two of my favorite things- POCUS and infectious disease.

This is a review of 73 patients presenting to an emergency hand clinic (!) over the course of 3.25 years with a pyogenic flexor tenosynovitis.  Yep, a whole 22 patients a year… at an emergency hand clinic.

All patients underwent a resident and attending surgeon eval as well as labs including CRP and films. 16 confirmed pyogenic flexor tenosynovitis patients were excluded (these were the slam dunk obvious ones)- while the remaining 57 underwent POCUS while pending labs. POCUS was done by either a resident with 2 years experience in MSK sono, an attending surgeon with sono training, or senior radiologist.  Suffice to say, that this isnt exactly us work-a-day EM providers.

Of the remaining 57 patients, there were 29 were ultrasound negative (non-thickened tendon sheath without hyperemia and no peritendonous effusion); all were given PO antibiotics and discharged with every other day follow up until symptom resolution; only one required OR intervention.

Of the 27 patients with positive ultrasound findings- 17 of these had either a positive OR culture or significant purulence seen at the time of OR washout.  While this results in a decreased PPV of 63%, and a decreased specificity of 74% – I maintain POCUS is actually much better; keep in mind these numbers do not include the 16 slam dunks on clinical exam.  It doesnt take into account the rapid sterilization after a single dose of antibiotics seen in CSF and ascites; nor the 30% negative OR-culture rate seen in other pyogenic flexor tenosynovitis studies.  Nor does it take into account that POCUS approaches MRI for sensitivity and specificity in prior studies.

Ultimately, it would be fantastic (and likely better medicine!) if, stateside, we could adopt an ultrasound first strategy (especially with a 97% NPV and 94% sensitivity!).  If POCUS negative, patients could get expedited follow up and oral antibiotics.  This is pretty much exactly what this group has done.  Presumably with this strategy, a small fraction of these more ugly “slam dunk” tenosynovitis cases may not require the OR (the group did not comment on positive OR-culture rates), and the patients in the middle ground could get expedited follow up or overnight observation and serial sonography.  It should be noted that “delayed” diagnoses which resulted in poor outcomes were >10 days out from the initiation of symptoms (!); so a day or two may not make much of a difference.  This study comes with the usual caveats- there are few MSK ultrasound courses in the USA (I contacted the Jefferson MSK fellowship, no dice for hand sonography!), different equipment than our usual sonosite machines, more training.  But that certainly does not mean we can not have something to aspire to.


Class Warfare – Ortho Follow-up Style.

This paper is glimpse into the sad realities brought about by the class warfare unveiled by the current US public/private insurance system.

They looked at all 102 Dallas-Fort Worth orthopaedic groups. All groups were called twice from a patient discharged from the ED with an ankle fracture who utilized a standardized script- one call saying they were uninsured, another saying they had either private insurance or medicaid. All in all, 204 calls were made (59 private, 43 medicaid, 102 uninsured).

Success rate for ability to make a follow up appointment:

83.1% for privately insured

81.4% for uninsured

14% for medicaid callers

Controlling for paired calls to same practice, an uninsured caller had almost a 6x higher rate of follow up than medicaid callers. Also despicable is that the uninsured had to bring a median of $350 to their first appointment (less than 2% were asked to bring $100 or less) – or, 48% more than the usual total payment collection from a privately insured patient ($236), and 273% more than the usual payment collected from medicaid ($128).

Want more heinous activity? 48% of uninsured patients were directed to the ED when they asked where they could go.

Wait, you want more? Of the ortho practices that appeared on medicaids list of practices accepting new patients:

15 of 38 told callers they did not accept medicaid

11 said they did not treat ankles

9 had non-working numbers

3 actually scheduled an appointment

Less than 10% of medicaid patients were able to secure an appointment with ortho practices that were on medicaid’s list of providers accepting new patients! Either their database needs updating, or the practices are outright lying. Given the difference in payments between the uninsured, private patients, and medicaid patients, I suspect the problems lay on the side of the individual practices.

Emergency Medicine- the front lines and safety net.

Improving Throughput, Mythbusting, Pediatrics, Pediatrics, Pediatrics

Should you MRI Salter Harris 1’s?

As I’ve discussed, oh, once, twice, or maybe three times in the past, ankle or wrist sprains (or even buckle fractures) do NOT need a splint.  Today’s article from JAMA Pediatrics  echoes this sentiment. 

We’ll keep this simple: 271 patients aged 5-12, with a clinically suspected Salter Harris Type one ankle fracture were approached, 140 parents consented to participate.  All patients were initially placed with a removable brace (hooray!), then underwent bilateral ankle MRI imaging (?!?! boo!!!) one week later. 

Of the 135 patients that underwent MRI imaging, 4 (3%) had MRI confirmed Salter Harris type 1 fractures, 2 of which had partial growth plate injuries.  108 (80%) pateitnts had ligamentious injuries and 27 (22%) patients had isolated bone contusions.  38 patients had radiographically occult fibular avulsion injuries. 

Importantly, of those with MRI detected fractures, there was no difference in outcomes from those without fractures (82% vs 85.5% on the Activity scale for Kids score).

So… while you can certainly MRI these patients – and find things – the question is, if they are not clinically relevant, why do it in the first place?


Platelet Rich Plasma… in the ED? For an ankle???

This was a prospective, randomized, double-blinded, placebo-controlled trial – THAT INVOLVED INJECTIONS INTO AN ANKLE FOR AN ANKLE SPRAIN.  The kind me and you do, oh, I dont know, at least 2-3 times a year.  And manage to do just fine.  But this was not just any injection, but platelet rich plasma.  Which just does not sound cheap, and sounds like terrible indication creep if I’ve ever heard it.

After 37 patients were randomized to placebo or platelet rich plasma intra-articular injections, both groups had were evaluated for their visual analog scale (VAS) pain scores and Lower Extremity Functional Scale (LEFS) on days 0, 3, and 8. LEFS and a numeric pain score were obtained via phone call on day 30. All participants were splinted, given crutches, and instructed to not bear weight for 3 days; at which time patients were reevaluated.

This seems like a colossal waste of time, money, and resources.  Perhaps they were really testing to see if they could find 37 patients silly enough to accept an intra-articular injection for a low risk injury, then have a splint placed (I wont get into my thoughts on placing a splint for injuries like this, instead I’ll refer you to here and here).  Then again, if we continue to provide patients with other sham procedures despite evidence that demonstrates their are useless, then perhaps ED platelet rich injections are merely the next evolutionary step after back surgery and knee arthroscopies.

Improving Throughput, Mythbusting, Pediatrics, Pediatrics

Paging Dr Buckle, Part Two.

We can add two more pieces of literature to suggest that removable splinting alone is sufficient for the management of distal forearm torus fractures. This piece looked at 142 pediatric patients randomized to short arm cast or removable wrist splint for 3 weeks without a significant difference in pain, compliance, or complications.

Then there is this article that looked at 119 consecutive pediatric torus fractures over a one year period seen by an APRN who were immobilized with a soft cast. There were no adverse events, and no subsequent visit to fracture clinic. In comparison to previous standards of fracture clinic referral, there was a cost savings of $18596 euro (20k USD) in total.

The AAOS says, “The use of removable splints is an option when treating minimally displaced distal radius fractures.”  Since this 2009 recommendation, there are now 5 publications (the two articles above, plus three from this previous post suggesting nondisplaced pediatric Torus fractures can be safely treated with a removable splint at a significant cost savings to all involved.

Improving Throughput, Mythbusting

Less paperwork, equal efficacy with shoulder blocks.

Raise your hand if setting up conscious sedation is a small act of God in your ED.

Glad to see you’re all still here. Now, lets talk about how we can reduce that paperwork, and make the best use of nursing & clinician time in a busy ED.

The June AJEM issue compares suprascapular blocks (21 patients) to Ketamine procedural sedation (20 patients) for shoulder dislocations. There was no difference in success or patient/physician satisfaction. Time spent in the ED was significantly longer in the sedation group, and side effects were not observed in either group.

Previous studies looking at intra-articular lidocaine vs conscious sedation (here, hereand here)  also showed a decreased LOS without a difference in satisfaction, pain control, or efficacy.  Shoulder blocks and intra-articular have great efficacy in all the studies I was able to find, all showing excellent pain control and improved LOS. The caveat is this study  which shows that if a patient has had conscious sedation for a shoulder reduction in the past, they would prefer conscious sedation over a block.

You can review how to do an intra-articular block on YouTube  thanks to Mike Stone and Academic Life in EM.


Colles Who?

Let’s face it, you went into Emergency Medicine for the glory, not for the twisted ankles/FOOSHes.  But you went into medicine to help people, so let’s start (and finish) there.  Even for the bread and butter EM / Urgent Care ankle/wrist sprains (and straight forward, uncomplicated, non-displaced distal fibula/radius fractures!) you can help people!

Simply by *NOT* placing a splint.

Ability to bear weight at 48 hrs? 56.6% vs 42%, Aircast vs splint for ankles.

Normal activity at 2 weeks for wrist buckle fractures? 95% vs 67% in favor for Aircast.

Function at 1, 2, 3, & 4 months? All better in Aircast.

Comfort at 24 hrs? Swelling? Better with Aircast.

Return to work sooner? Go Aircast.

The high school athlete wants nothing more than to get back on the field sooner. Why not help them by not placing them in a splint? You’ll increase comfort, ability to bear weight at 48 hours, and improve their chances at normal function at 1, 2, 3, and 4 months.

For what its worth, there is somewhat less data, but a similar trend for pediatric wrists (ie, buckle fractures) to have less pain and a sooner resumption to normal function.

For fractures, I’d make sure ortho is on the same page, but for the number of ankle/wrist sprains/breaks you see in a day in an ED, you can probably make a measurable difference for the better every single day by not splinting.






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Improving Outcomes, Improving Throughput, Mythbusting

Why Are You Not Doing Femoral Blocks?

     I’ve been on a bit of a rant lately about how the ED sets the course for the remainder of the inpatient stay. The most recent eye-catching paper to come across my QxMD feed reinforces this.

     326 patients with an acute hip fracture who received a fascia iliaca compartment block in the ED were compared to 100 patients who had received “standard of care” – IV, IM, or oral meds at the teams discretion. Not surprisingly, there was a reduction in pain score and opiate requirement with the iliaca block. Most surprisingly was the 9.9 to 15 day difference in length of stay, as well as inpatient mortality of 5.5% vs 15% in the iliaca nerve block vs standard treatment, respectively. The authors admit there may be confounding factors at play, however, these are striking numbers and the largest study of a nerve block I have seen in the acute setting, and these are hard to argue with. For those of you wondering, this study then retrospectively looked at 1586 patients that were given an iliac block at their participating institutes, and noted only 2 (TWO) incidences of systemic anesthetic toxicity.

     Now, given the above, lets compare iliaca to femoral nerve blocks. A previous study of 110 patients showed a statistically significant pain improvement with the femoral nerve block vs the iliaca block, and that the femoral block arm required less parenteral narcotics.

     If you have not yet done a sono guided femoral nerve block – try it out! ( Its pretty easy, and takes about five minutes to do the procedure, plus a few more for set up.  If admin gives you grief, its hard to argue with improved pain control, LOS & mortality.




PMID: 23789738

PMID: 24949565

Improving Outcomes, Mythbusting

Bier me, STAT!

For distal radius fractures, hematoma blocks are cruel. Think about it: you are injecting several CC’s into a fresh, painful, fracture site. I have yet to see a patient * not * cringe, no matter who does the block. To top this all off, I have yet to see it provide adequate analgesia during reduction. So, not only are we making them miserable by providing an injection into their fracture, we are then manipulating them-sometimes more than once- after not providing significant analgesia. It’s not really a nice thing to do. I’ve seen mid-levels, ED attendings, and orthopods all do this with pretty much the same results.  The definition of insanity if doing the same thing repeatedly and expecting a different result. So let’s try and stop the insanity by having a Bier (block).

Doing a literature dive, let’s start by saying there is an overblown concern over lidocaine toxicity. In a study of 1816 Bier blocks by anesthesia for hand surgery, there were 9 adverse reactions (1 medical error, 3 with improper cuff inflation, 5 with inadequate analgesia). None of the adverse reactions resulted in failure to complete the procedure or in serious morbidity / mortality. A second study of 416 patients showed no morbidity or mortality, but 39 episodes of transient hypotension or bradycardia of which none required an intervention. A third study was done on 484 patients. The block was ineffective for 1 patient, tourniquet related problems were reported in 5 patients, but no anesthetic toxicity. The block was given by the operating surgeon and not by anesthesia – thus it is likely safe for ED providers to perform.

Now let’s compare it to hematoma blocks. Over four studies looking at over 400 patients total, there is significantly more pain during manipulation with hematoma block than with a Bier’s block, and the Bier’s block had fewer re-manipulations, better pain control, and better radiological outcome.

Lastly, there is a modified Bier’s Block involving a single tourniquet. In comparison to the two tourniquet technique, there is no significant difference between forearm and conventional Bier’s block for pain control, and no major complications, looking at three different studies, totaling about 150 patients. Patients were also given less lidocaine in the forearm group (160mg vs 300mg).

So, there you have it. The Bier’s block is safe and more effective than a hematoma block for distal radius fractures, and you can even use a single tourniquet rather than two pneumatic cuffs. So go ahead, enjoy a Bier with your patient.



PMID: 17123673
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