Common Finger Fractures and Dislocations - April 15, 2012 - American Family Physician
Spring greetings to all. Of course, spring means more spring sports, and that means hand injuries in our express cares. I linked up to a very informative and succinct hand injury summary. Please read the article, as I promise you will be a better healthcare provider because of it...and that is the highest compliment I can give an article. Here are some quick highlights that I thought really stood out:
1. Be sure to counsel and remind patients with distal phalanx (tuft) fractures that these fractures are routinely complicated by hyperesthesia, pain and numbness for up to SIX months post injury. This counseling will likely prevent patient worry, doubt, and unneeded callbacks.
2. For mallet fractures (forced flexion at the DIP joint producing a bone fragment at the dorsal surface of the proximal part of the distal phalanx..whew, say that 3 times fast), recall that the clinical result is a DIP that cannot be extended. For these, 2 caveats. First, splint in full extension for EIGHT, not 6, weeks. Document and remind patients that the extension/splint MUST never be taken off in this period, because if you remove the splint, you "break the healing"and essentially reset the healing clock back to zero. Second, for these mallet FRACTURES, once you splint in full extension, REPEAT an x-ray with the splint to document and ensure congruity between the fractured piece and the distal phalanx.
3. Conversely, for the jersey fingers (forced extension at the DIP joint producing a bone fragment at the VOLAR surface of the proximal distal phalanx), along with the fracture you have clinically an inability to flex the DIP. Note that these volar surface DIP issues also involve damage to the flexor digitorum profundus tendon. Take home point- unlike the dorsal DIP mallet finger/fractures, it is very important to have these jersey fingers sent to orthopedics/hand specialists, due to tendon retraction risk.
4. Feel free to comment below, but I was always told in my training that in your exam, be sure to ISOLATE, each joint individually, say on the edge of a table, to avoid "tendon and collateral cheating" to ensure each DIP/PIP/MCP is fully evaluated. From the edge of the table, flex and extend each joint individually, with the other joints fully at rest. Don't forget to check active and passive ROM.
5. One last reminder-we are all human and as such we forget things. Hence, when reviewing this or any other hand article, don't be shy or ashamed to open up and have the old Netter/ Grants atlas at your side. Often, these anatomy reviews really help your mind correlate the injury mechanism with the x-rays and the possible complications.
Please email me if you cannot access the article, and I will gladly let you borrow my AAFP password. Review the article though- you will be glad you did!
Wednesday, April 25, 2012
Sunday, April 8, 2012
Pediatric Pneumonia Tips
http://www.medscape.org/viewarticle/749312
http://www.medscape.com/viewarticle/752596
Recently in August 2011, the Infectious Disease Society of America (IDSA) composed its first ever expert opinion guidelines on pediatric community acquired pneumonia (CAP). We all have been well versed in this group's adult community acquired pneumonia guidelines (the usual Levaquin or the combo of Rocephin and Zithromax), but little guidance has been given for pediatrics.
Please note that for all you evidence based medicine fans (Is that an oxymoron?) the IDSA admits to a relative paucity of studies in the area of pediatric community acquired pneumonia. After all, it is hard to get a randomized trial going, let alone a meta-analysis, of kids with respiratory distress and pneumonia. Still, a broad ranged panel of 13 experts sifted through the data and came up with the guidelines above. Both of the Medscape articles are summary articles, while the end IDSA link is the full 52 page document for all you OCD providers (like myself and Dr. Chao).
Here is a rough sumary, but I do encourage people to check out the fairly succinct first link above- #749312.
Point 1: For preschool and school aged children who have been previously healthy and IMMUNIZED, the recommended first line agent is (believe it or not) amoxicillin. The ID experts cite the extreme success of the previous Prevnar 7, and now the newer Prevnar 13, against the real "bad boy" resistant Strep. pneumoniae that previously wreaked havoc on pediatric workups. REMEMBER- immunization is crucial to this guideline!
Point 2: Don't forget macrolides (good ol' "Vitamin Z"-Zithromax) for MAINLY school aged children who have clinical histories consistent with atypical pneumonia.
Point 3: Don't forget antivirals for confirmed pneumonia with flu-like histories.
Point 4: The IDSA guidelines bluntly suggest for all children with suspected pneumonia aged 3-6 months old, hospitalization should be done. The experts cite the vulnerability of this age group to encapsulated bacteria like Strep pneumoniae, and the lack of full immunization at this age.
Point 5: For amoxicillin failures, don't forget CA-MRSA as a potential pathogen. I would be interested in comments on this matter, as the IDSA always suggests CA-MRSA pneumonia needs vancomycin, but does anyone know if Bactrim has the needed respiratory/lung penetration to treat lung infections? Just food for thought...
Lastly, we all realize the challenge with pediatric guidelines is not the credibility of the science per se, but instead getting the parents on board. Still, I hope this update lets you practice with more confidence and awareness.
Here is the full IDSA paper:
http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2011%20CAP%20in%20Children.pdf
http://www.medscape.com/viewarticle/752596
Recently in August 2011, the Infectious Disease Society of America (IDSA) composed its first ever expert opinion guidelines on pediatric community acquired pneumonia (CAP). We all have been well versed in this group's adult community acquired pneumonia guidelines (the usual Levaquin or the combo of Rocephin and Zithromax), but little guidance has been given for pediatrics.
Please note that for all you evidence based medicine fans (Is that an oxymoron?) the IDSA admits to a relative paucity of studies in the area of pediatric community acquired pneumonia. After all, it is hard to get a randomized trial going, let alone a meta-analysis, of kids with respiratory distress and pneumonia. Still, a broad ranged panel of 13 experts sifted through the data and came up with the guidelines above. Both of the Medscape articles are summary articles, while the end IDSA link is the full 52 page document for all you OCD providers (like myself and Dr. Chao).
Here is a rough sumary, but I do encourage people to check out the fairly succinct first link above- #749312.
Point 1: For preschool and school aged children who have been previously healthy and IMMUNIZED, the recommended first line agent is (believe it or not) amoxicillin. The ID experts cite the extreme success of the previous Prevnar 7, and now the newer Prevnar 13, against the real "bad boy" resistant Strep. pneumoniae that previously wreaked havoc on pediatric workups. REMEMBER- immunization is crucial to this guideline!
Point 2: Don't forget macrolides (good ol' "Vitamin Z"-Zithromax) for MAINLY school aged children who have clinical histories consistent with atypical pneumonia.
Point 3: Don't forget antivirals for confirmed pneumonia with flu-like histories.
Point 4: The IDSA guidelines bluntly suggest for all children with suspected pneumonia aged 3-6 months old, hospitalization should be done. The experts cite the vulnerability of this age group to encapsulated bacteria like Strep pneumoniae, and the lack of full immunization at this age.
Point 5: For amoxicillin failures, don't forget CA-MRSA as a potential pathogen. I would be interested in comments on this matter, as the IDSA always suggests CA-MRSA pneumonia needs vancomycin, but does anyone know if Bactrim has the needed respiratory/lung penetration to treat lung infections? Just food for thought...
Lastly, we all realize the challenge with pediatric guidelines is not the credibility of the science per se, but instead getting the parents on board. Still, I hope this update lets you practice with more confidence and awareness.
Here is the full IDSA paper:
http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2011%20CAP%20in%20Children.pdf
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