Common Finger Fractures and Dislocations.

Finger fractures and dislocations are commonly seen in the primary care setting. Patients typically present with a deformity, swelling, and bruising with loss of function. Anteroposterior, lateral, and oblique radiography should be performed to identify fractures and distinguish uncomplicated injuries from those requiring referral. Uncomplicated distal phalanx fractures, caused by a crush injury to the end of the finger, require splinting of the distal interphalangeal joint for four to six weeks. Uncomplicated dorsal avulsion fractures (mallet finger) of the distal interphalangeal joint, caused by forced flexion against resistance, require strict splint immobilization for eight weeks. Flexor digitorum profundus fractures are caused by forceful extension of the distal interphalangeal joint when in a flexed position, resulting in an avulsion fracture at the volar base of the distal phalanx, and usually require surgery. Uncomplicated middle and proximal phalanx fractures, typically caused by a direct blow, can be treated with buddy splinting if there is minimal angulation (less than 10 degrees); however, larger angulations, displacement, and malrotation often require reduction or surgery. Dorsal proximal interphalangeal joint dislocations require reduction and buddy splinting in slight flexion with an extension-block splint. Volar proximal interphalangeal joint dislocations require reduction and splinting in full extension for four to six weeks. Distal interphalangeal joint dislocations require reduction and splinting in full extension (for volar dislocations) or 15 to 30 degrees of flexion (for dorsal dislocations) for two to three weeks. Dorsal metacarpophalangeal joint dislocations are managed with reduction and splitting, but referral to an orthopedic specialist is required if the dislocation is not easily reduced. Volar metacarpophalangeal dislocations are rare and warrant referral.

Neck Pain: Initial Evaluation and Management.

Neck pain is a common presenting symptom in the primary care setting and causes significant disability. The broad differential diagnosis requires an efficient but global assessment; therefore, emphasis is typically placed on red flags that can assist in the early recognition and treatment of more concerning diagnoses, such as traumatic injuries, infection, malignancy, vascular emergencies, and other inflammatory conditions. The critical element in appropriate diagnosis and management of these conditions is an accurate patient history. Physical examination findings complement and refine diagnostic cues from the history but often lack the specificity to be of value independently. Diagnostic tools such as imaging and electrodiagnostic tests have variable utility, especially in chronic or degenerative conditions. Treatment of mechanical or nonneuropathic neck pain includes short-term use of medications and possibly injections. However, long-term data for these interventions are limited. Acupuncture and other complementary and alternative therapies may be helpful in some cases. Advanced imaging and surgical evaluation may be warranted for patients with worsening neurologic function or persistent pain.

Nonspecific Low Back Pain and Return To Work.

Nonspecific low back pain refers to a condition without a distinct etiology to explain its associated symptoms. This pain may become chronic and is a major cause of work loss around the world. Without a specific explanation for a patient's symptoms, the family physician is charged with providing reassurance, while also guiding the patient toward a return to function, which often includes maintaining employment. Evaluating for red flag signs and symptoms helps to eliminate concerning causes of low back pain, such as malignancy, fracture, infection, and cauda equina. Prescribing physical activity, including core strengthening, physical therapy, or yoga, is an important therapeutic intervention. Early return to work should be encouraged when appropriate. There is limited evidence to support workplace modification, medication, or steroid injection for nonspecific low back pain. Early assessment for barriers to recovery, such as fear avoidance beliefs and psychosocial factors, is helpful. Stress management counseling may also be beneficial. Disability guidelines can serve as guideposts for return to work recommendations.

Common Foot Problems: Over-the-Counter Treatments and Home Care.

Most foot disorders do not require podiatry referral or complex interventions. After the clinical diagnosis is made, these conditions can typically be managed with over-the-counter (OTC) and home remedies, with guidance from the primary care physician. Stretching and strengthening exercises, along with the use of heel cups, resolve most plantar fasciitis cases and are at least as effective as nonsteroidal anti-inflammatory drugs or steroid injections. Hallux rigidus is best managed with a hard-soled shoe or rigid insert that relieves pain by restricting motion across the metatarsophalangeal joint. Hallux valgus responds to use of wide toe box shoes, and surgery is not clearly beneficial beyond one year. Plantar warts can be treated effectively at home with OTC salicylic acid and cryotherapy topical agents, which have equal effectiveness to liquid nitrogen. In patients with corns and calluses, OTC topical salicylic acid has short-term benefits, and pads and inserts that more evenly redistribute contact forces have long-term benefits. Inserts are commonly recommended to redistribute forefoot pressure and relieve pain. Several OTC preparations are available for the treatment of tinea pedis, with topical allylamines being the most effective. Although OTC topical treatments have been widely used for onychomycosis, they have poor long-term cure rates compared with prescription oral medications.

Spine Conditions: Cervical Spine Conditions.

There are a variety of causes of neck pain, including trauma and degenerative changes. The history of onset helps to direct evaluation, including the need for imaging or ancillary testing. Patterns of pain, weakness, and other specific physical examination findings also aid in diagnosis. Management of most soft tissue injuries involves early mobilization, whereas fractures are managed based on patterns of instability. Acute spinal cord injury requires emergent care, to include possible decompressive surgery. The role of hypothermia and corticosteroids in these patients remains unclear. Cervical radiculopathy (eg, disk herniation, arthritic changes) can be managed conservatively in most patients. Central cord compression, or myelopathy, often is overlooked but is a common condition among older patients. Although certain patients may benefit from surgery, many have a stable course or slow progression that can be managed nonsurgically. Rheumatoid arthritis can have significant effects on the cervical spine. Patients with inflammatory conditions may improve with steroids, nonsteroidal anti-inflammatory drugs, or biologic drugs, but these drugs rarely have lasting benefit in degenerative conditions. Stretching, strengthening, and other physical therapy modalities have been shown to be helpful for patients with chronic and acute but stable neck conditions.

Spine Conditions: Occupational Spine Conditions.

Neck and back conditions have significant effects on employee health and productivity. More than $7 billion in lost revenue in the United States annually can be attributed to workplace back pain among employees ages 40 to 65 years. According to the Bureau of Labor Statistics, in 2012 back pain was the most prevalent musculoskeletal condition resulting in workplace absenteeism. The incidence of these conditions is higher among individuals in certain professions, such as bus drivers, police officers, and correctional officers. Risk factors include obesity, depression, nicotine dependence, and alcohol abuse. There is limited evidence about whether modifying risk factors decreases the incidence of neck and back conditions. Specific efforts to reduce the burden in the workplace have shown mixed results. Use of simple interventions, such as braces and orthotics, has not consistently shown benefit. In addition, limited data show minimal or no evidence of effective prevention or management with back school programs and instruction on lifting techniques. The most consistent data support regular exercise as a method to prevent back pain. However, attempts to include exercise in workplace activities have shown mixed results. Lower rates of workplace absenteeism have been show to result from employee education on these issues.

Nonoperative Management of Cervical Radiculopathy.

Cervical radiculopathy describes pain in one or both of the upper extremities, often in the setting of neck pain, secondary to compression or irritation of nerve roots in the cervical spine. It can be accompanied by motor, sensory, or reflex deficits and is most prevalent in persons 50 to 54 years of age. Cervical radiculopathy most often stems from degenerative disease in the cervical spine. The most common examination findings are painful neck movements and muscle spasm. Diminished deep tendon reflexes, particularly of the triceps, are the most common neurologic finding. The Spurling test, shoulder abduction test, and upper limb tension test can be used to confirm the diagnosis. Imaging is not required unless there is a history of trauma, persistent symptoms, or red flags for malignancy, myelopathy, or abscess. Electrodiagnostic testing is not needed if the diagnosis is clear, but has clinical utility when peripheral neuropathy of the upper extremity is a likely alternate diagnosis. Patients should be reassured that most cases will resolve regardless of the type of treatment. Nonoperative treatment includes physical therapy involving strengthening, stretching, and potentially traction, as well as nonsteroidal anti-inflammatory drugs, muscle relaxants, and massage. Epidural steroid injections may be helpful but have higher risks of serious complications. In patients with red flag symptoms or persistent symptoms after four to six weeks of treatment, magnetic resonance imaging can identify pathology amenable to epidural steroid injections or surgery.

The practice of prescribing: discovering differences in what we tell patients about prescription medications.

OBJECTIVE: This study explored patient recall of clinician presentation of information about prescription medication, looking specifically for communication patterns and differences by patient individual characteristics and by medication availability type. METHODS: A cross sectional survey collected information about 216 patients' perceptions of clinician presentations of medication information. RESULTS: Demographically, males recalled receiving more information about reasons, risks, and regimen in medication discussions. By medication type, patients reported receiving more medication information when the clinician presented a prescription-only medication as opposed to a medication that was also available over the counter. CONCLUSION: Given the broad and unmonitored use of over-the-counter products, coupled with the increasing awareness of risks associated with many of these medications, it is concerning that patients report receiving less information about these products. PRACTICE IMPLICATIONS: The emphasis on appropriate medication counseling should not be limited to medications available only by prescription. Prescribers should be mindful of these potential tendencies when discussing medications.

Refining the Practice of Prescribing: Teaching Physician Learners How to Talk to Patients About a New Prescription.

BACKGROUND: Clinician counseling about medication can improve patient understanding and adherence. This study developed a teaching session for physician learners about medication prescribing and communication, with evaluation at the physician and patient levels. OBJECTIVE: We analyzed whether patients would perceive and report more comprehensive clinician presentation of medication information when receiving prescriptions from their physician in the intervention clinic. METHODS: We conducted a single site, prospective intervention study that included lectures, role play, an objective standardized clinical examination (OSCE), and reminders displayed in patient care areas. For physician-level assessment, pretests and posttests included a written case presentation and a OSCE. For patient-level assessment, we used a cross-sectional observational design that included study of patient recall information, and assessment of patient satisfaction before and after intervention. RESULTS: Twenty-seven family medicine residents and sports medicine fellows participated in the teaching session, focused on presenting patients the reasons, risks, and regimen of prescribed medication. In written testing, learners presented significantly more comprehensive information in posttests. In the OSCE (n  =  14), all learners presented risks and regimen information. However, patient-level assessment showed no significant difference between before and after intervention. Notably, the covariates patient activation and satisfaction with communication both had a significant association with patient recall information. CONCLUSIONS: Our intervention improved learner presentation of medication information. However, patient recall of the information conveyed did not change. Although physician training did not have a positive effect on patient recall, patient activation emerged as a critical influence of patients' perceptions of medication discussions.

Management of chronic tendon injuries.

Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.

Exploring patient activation in the clinic: measurement from three perspectives.

OBJECTIVE: To further conceptualize and operationalize patient activation (PA), using measures from patient, physician, and researcher perspectives. DATA SOURCE/STUDY SETTING: Multimethod observation in 2010 within a family medicine clinic. STUDY DESIGN: Part of an intervention with 130 patients with type 2 diabetes, this observational study further looked at PA in 19 physician-patient dyads. Data Collection. Observations occurred in a teaching hospital, which served as recruiting and study site. PRINCIPAL FINDINGS: PA correlated with knowledge, self-efficacy, promotion orientation, and exercise intent. Patient-reported PA did not correlate with researcher-observed or physician-reported PA behavior. Researcher-observed PA correlated with physician-observation items. CONCLUSIONS: Results provide evidence for measuring different perspectives in studies of PA. When patients report they are activated in self-management, behavior does not indicate they are active in clinical communication, a critical component of collaborative decision making.

Extending Physician ReACH: influencing patient activation and behavior through multichannel physician communication.

OBJECTIVE: Despite evidence-based recommendations, physical activity as a self-management technique is underutilized. Many physical activity interventions require significant resources, ranging from repeated phone follow-up with nursing staff to intensive sessions with cooperating physical therapists. This intervention, Extending Physician ReACH (Relationship And Communication in Healthcare), examined physician to patient communication tactics for promoting walking exercise to patients with type 2 diabetes, using limited clinic time and financial resources. METHODS: This was a single-site, six-month prospective intervention, which implemented theoretically driven, evidenced-based information factor strategies. Of the 128 volunteers who participated in the initial clinic visit, 67 patients with type 2 diabetes completed the six-month intervention. RESULTS: Significant intervention effects were detected risk perception, social norms, and patient activation. CONCLUSIONS: This study was designed to identify information factors that could affect physician success in motivating patients with type 2 diabetes to enact the ADA physical activity recommendations. PRACTICE IMPLICATIONS: The success of this intervention models a strategy through which clinicians can reach beyond "one-shot" persuasion without placing onerous time and resource demands on physicians.

Resident scholarship expectations and experiences: sources of uncertainty as barriers to success.

BACKGROUND: Scholarly activity during residency is vital to resident learning and ultimately to patient care. Incorporating that activity into training is, however, a challenge for medical educators. Most research on medical student and resident attitudes toward scholarly activity to date has been quantitative and has focused on level of interest, desire to perform scholarship, and perceived importance of scholarship. OBJECTIVE: We explored attitudes, expectations, and barriers regarding participation in scholarly activity among current residents and graduates of a single family medicine residency program. METHODS: Using a phenomenologic approach, we systematically analyzed data from one-on-one, semistructured interviews with residents and graduates. Interviews included participant expectations and experiences with scholarly activity in residency. RESULTS: The 20 participants (residents, 15 [75%]; residency graduates, 5 [25%]) identified uncertainty in their attitudes toward, and expectations regarding, participation in scholarly activity as an overarching theme, which may present a barrier to participation. Themes included uncertainty regarding their personal identity as a clinician, time to complete scholarly activity, how to establish a mentor-mentee relationship, the social norms of scholarship, what counted toward the scholarship requirements, the protocol for completing projects, and the clinical relevance of scholarship. CONCLUSIONS: Uncertainty about scholarly activity expectations can add to learner anxiety and make performing scholarly activity during residency seem like an insurmountable task. Programs should consider implementing a variety of strategies to foster scholarly activity during residency, including clarifying and codifying expectations and facilitating mentoring relationships with faculty.

Exertional collapse in the runner: evaluation and management in fieldside and office-based settings.

Exertional collapse is a commonly encountered phenomenon among runners, particularly in the setting of long distances and extreme environments. Although exertional collapse is generally a benign event occurring in an exhausted finisher at race completion, the multifactorial nature of this disorder creates a broad differential diagnosis. The ability of the sports provider to appropriately recognize and treat these various potential concerns is critical, because collapse may represent several life-threatening conditions. It is especially challenging to determine the appropriate course of evaluation and management of collapse in the context of a mass participation event. This article presents a discussion of the etiology and pathophysiology of collapse as well as strategies for the effective assessment and treatment of collapsed runners, whether in the fieldside setting or in an outpatient office-based environment.

Practical management: a systematic approach to the evaluation of exercise-related syncope in athletes.

Syncope and presyncope are relatively common presentations among athletes. The distinction between post-exercise and during-exercise syncope is critically important. While the great majority of these episodes occur just after exercise and are benign, syncope can be an indication of serious underlying cardiovascular disease if it occurs during exercise. Syncope presents a challenging differential diagnosis, as well as a daunting array of diagnostic tests and advanced imaging strategies. Sequencing a proper evaluation, and deciding who requires consultation and restriction, can be difficult for the medical provider. We present a systematic approach that assists the sports physician in arriving at a diagnosis and organizing an initial management strategy.