Recommended Citation: Reyes J. The Cheese - When Less Is More With Orthopedic Complaints [Internet]. Cook County Emergency Medicine Residency;Available from: https://cookcountyem.com/blog/2024/4/23/the-cheese-when-less-is-more-with-orthopedic-complaints
We’ve all been told to x-ray above and below the area in question. How much we do it varies, but we have all done it at one point, and rarely do I find an abnormality that was occult. Here we question when we can do less in a couple of orthopedic-specific issues.
Do I have to x-ray the “joint above and below” an area of interest when evaluating a traumatic extremity injury?
Joint “above and below” X-rays are commonly practiced in pediatric emergency care due to a theorized inability to accurately report areas of discomfort, particularly when there is a distracting injury (1). This has not been established in any previous research, and, therefore, Koetter et al. in 2022 aimed to evaluate the incidence of concomitant ipsilateral fracture. In a retrospective cohort of 241 patients aged 1 to 17, they found 85 (35.3%) of patients had “above and below” fractures. 9 (3.7%) concomitant fractures were identified out of the 241 patient cohort. When patients were separated into high- (e.g., trauma activation or MVC, peds vs auto, etc. ) versus low-risk (e.g., non-trauma activation or falls, contusions, etc.) mechanisms of injury, the incidence of a concomitant fracture was approximately 15% and 2%, respectively. A high-risk mechanism resulted in an odds ratio of 21.3 (95% CI 3.6-131.5). Notably, this is limited by it’s retrospective design, the single-center nature of the study, and the lack of “above and below” imaging in approximately 65% of patients as other occult injuries may have been found. Although this study is overall moderate to weak evidence suggesting limited benefit of “above and below” X-rays when evaluating pediatric extremity injuries, there is no data whatsoever to support it’s practice.
Answer: Given an incidence of less than 2% concomitant bony injury in low-risk mechanisms, with none of the injuries resulting in clinically significant changes in management, routine “above and below” x-rays should not be routinely conducted but may still occasionally be useful.
Does a torus (buckle) fracture of the wrist require immobilization?
Torus fractures, or buckle fractures, are the most common wrist fractures. A recent Cochrane review evaluating 695 patients with torus fractures found no difference in recovery whether a patient had a plaster splint, removable splint, or bandage (e.g., ACE wrap, etc.) (2). Although this was published in a Cochrane review, its uptake has been limited as the supporting data was deemed low quality. Perry et al. in 2022 published a randomized controlled equivalence trial among 24 hospitals in the UK recruiting 695 patients age 4-15 years old (3). This equivalence trial measured whether a simple bandage compared to rigid immobilization with either a removable plastic splint or plaster resulted in similar levels of pain at 3 days. The minimally acceptable difference margin, or the minimal difference in pain better than rigid immobilization or worse than immobilization, was 1 point on the Wonger-Baker scale on a 10-point scale. Therefore, if the difference in pain was within 1 point above or below that of rigid immobilization, a simple bandage was considered equivalent to rigid immobilization. Pain at day 3 was 3.21 and 3.14 for the group offered a bandage compared to the group placed in rigid immobilization, respectively, which was within the minimally acceptable difference margin, indicating a bandage is equivalent to rigid immobilization. Of note, 7% of patients in the bandage group crossed over to the rigid immobilization group secondary to pain compared to 0.2% in the rigid immobilization group.
Answer: In pediatric patients with a wrist torus (buckle) fracture, ACE bandage is equivalent to rigid immobilization and has strong data to support it being the primary intervention offered to parents and their child.
In a patient with osteoarthritis of the knee refractory to first-line supportive measures or with contraindications to supportive measures, are there any interventions I can offer aside from the absolute last-line intervention of a knee glucocorticoid injection?
Knee pain secondary to arthritis is a very common low-acuity complaint. The standard of care is now and will continue to be RICE and NSAIDs with or without acetaminophen. Most of the time, patients do not adhere to this treatment, and education is the best option for them. Occasionally, patients may present with refractory pain or may have contraindications to some of the components of standard care, such as NSAIDs in patients with CKD or ESRD. The KIS randomized controlled noninferiority trial published in JAMA Network Open in 2022 whether 40 mg triamcinolone injected intraarticular (IA) versus intramuscular (IM) in the ventrogluteal of the ipsilateral leg resulted in improved pain at 4-week intervals up to 12 weeks in addition to standard care. The minimally acceptable difference was set at a 7-point difference in pain on a 100-point pain scale. At 4 weeks, IA versus IM not noninferior, so patients with the IA injection had pain greater than 7 points on a 100-point scale at 4 weeks. At 8 weeks and 12 weeks, the pain was observed to be non-inferior; therefore, the pain had a difference of less than 0.7 points. Notably, more adverse events occurred in the IA group, but none were serious, and the majority consisted of hot flashes or headaches. Although no adverse events were found, intraarticular steroids can predispose patients to infection soft tissue infections adjacent to the tissue, hyperglycemia in diabetics, and tendon rupture (5).
Answer: In patients with contraindications to standard care, such as those with CKD or ESRD, or who have failed standard of care with significant functional deficits to the point of needing admission for PT/OT pain control (and who are not at high risk for infection, hyperglycemia, or tendinopathy), an IM injection of 40 mg IM triamcinolone in the ipsilateral ventrogluteal space can improve baseline pain.
Authored by Jose Reyes, MD
References:
Koetter P, Gallo R, Kasmire KE. Assessing the Necessity for the "Joint Above and Below" Radiography Approach for Lower-extremity Long Bone Fractures in Children. Pediatr Emerg Care. 2022;38(1):e316-e320. doi:10.1097/PEC.0000000000002274
Handoll HH, Elliott J, Iheozor-Ejiofor Z, Hunter J, Karantana A. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev. 2018;12(12):CD012470. Published 2018 Dec 19. doi:10.1002/14651858.CD012470.pub2
Perry DC, Achten J, Knight R, et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK [published correction appears in Lancet. 2022 Jul 23;400(10348):272] [published correction appears in Lancet. 2022 Oct 1;400(10358):1102]. Lancet. 2022;400(10345):39-47. doi:10.1016/S0140-6736(22)01015-7
Wang Q, Mol MF, Bos PK, et al. Effect of Intramuscular vs Intra-articular Glucocorticoid Injection on Pain Among Adults With Knee Osteoarthritis: The KIS Randomized Clinical Trial. JAMA Netw Open. 2022;5(4):e224852. Published 2022 Apr 1. doi:10.1001/jamanetworkopen.2022.4852
Holland C, Jaeger L, Smentkowski U, Weber B, Otto C. Septic and aseptic complications of corticosteroid injections: an assessment of 278 cases reviewed by expert commissions and mediation boards from 2005 to 2009. Dtsch Arztebl Int. 2012;109(24):425-430. doi:10.3238/arztebl.2012.0425