EMERGENCY DEPARTMENT INTRAARTICULAR CORTICOSTEROID INJECTION FOR SACROILIAC JOINT DYSFUNCTION.

BACKGROUND: Sacroiliac joint (SIJ) dysfunction is a common but underrecognized source of low back pain (LBP). With provocative testing, emergency physicians can diagnose SIJ dysfunction and begin appropriate treatment in the emergency department (ED). DISCUSSION: For patients with significant pain from SIJ dysfunction, ultrasound-guided SIJ injection of anesthetic and corticosteroid can reduce patients' pain considerably. CONCLUSIONS: For patients who are good candidates for SIJ injection, emergency physicians can begin treatment in the ED, before the patient follows up with a specialist.

Posterior Tibial Nerve Block for the Treatment of Plantar Fasciitis in the Emergency Department.

BACKGROUND: Plantar fasciitis (PF) is a common, painful condition for which patients sometimes seek treatment in the emergency department. Although corticosteroid injections are helpful for PF, they are painful. DISCUSSION: A posterior tibial nerve block provides immediate pain relief and allows the physician to also perform a corticosteroid injection into the heel, which could provide up to 1 month of analgesia. CONCLUSIONS: Patients may not have to wait until an appointment with a specialist to begin experiencing analgesia for PF.

Ultrasound-Guided Trigger Point Injections for the Treatment of Neck and Back Pain in the Emergency Department: A Randomized Trial.

OBJECTIVES: Patients frequently present to the emergency department (ED) with neck or back pain, which can be difficult to treat. We sought to compare ultrasound-guided trigger point injection (TPI) to standard medications for patients with neck or back pain. METHODS: We performed a single-center, open label, randomized controlled trial on ED patients with neck or back pain from myofascial pain syndrome comparing ultrasound-guided TPIs to those who received the combination of a nonsteroidal anti-inflammatory drug (NSAID) and a muscle relaxant (MR). The primary outcome of this study was the reduction in mean pain score at the time of ED disposition. RESULTS: In total, we analyzed 196 patients. At the time of ED disposition, patients in the TPI group had a mean reduction in their pain scores of 45.0 mm as compared to 49.9 mm in the NSAID plus MR group (difference: 4.9 [95% confidence interval (CI) -3.0 to 12.7], P = .22). At the first reassessment, patients in the TPI group had greater pain reduction by 10.7 mm (95% CI 3.1 to 18.4). The rate of rescue therapy use was higher in the NSAID plus MR group (difference: 17.5% [95% CI 4.4 to 36.2]). CONCLUSIONS: We found no difference in pain reduction at the time of ED disposition between patients randomized to the ultrasound-guided TPI group as compared to those who received an NSAID plus a MR. However, patients in the TPI group had greater pain reduction at the time of first reassessment and lower rates of rescue therapy use.

Utilisation of musculoskeletal ultrasonography for the evaluation of septic arthritis in a patient presenting to the emergency department with fever during the era of COVID-19.

Prompt recognition and treatment of septic arthritis are crucial to prevent significant morbidity and mortality in affected patients. During the current COVID-19 pandemic, anchoring bias may make an already challenging diagnosis like septic arthritis more difficult to diagnose quickly and efficiently. Musculoskeletal (MSK) point of care ultrasonography (POCUS) is an imaging modality that can be used to quickly and efficiently obtain objective findings that may help a clinician establish the diagnosis of septic arthritis. We report a case where MSK POCUS was a key element in establishing the diagnosis of glenohumeral joint septic arthritis and subdeltoid septic bursitis for a patient that presented to the emergency department with a fever during the era of the COVID-19 pandemic.

Pyogenic Flexor Tenosynovitis as a Rare Complication of Dyshidrotic Eczema.

INTRODUCTION: Pyogenic flexor tenosynovitis is an unusual complication of dyshidrotic eczema. The diagnosis has traditionally been made by Kanavel's signs. Point-of-care ultrasound can be a useful adjunct in the diagnosis of this surgical emergency. CASE REPORT: We report the case of a 23-year-old male who presented with right middle finger pain and swelling and an overlying eczematous rash. The use of point-of-care ultrasound was performed to aid in the diagnosis of pyogenic flexor tenosynovitis. An incision and drainage was performed with deep wound cultures positive for Staphylococcus aureus. DISCUSSION: The presentation of pyogenic flexor tenosynovitis with underlying concomitant dermatological disease can complicate this challenging diagnosis. Point-of-care ultrasound can be an effective adjunct in revealing pyogenic flexor tenosynovitis rather than relying solely on the classical Kanavel's signs, leading to earlier treatment. CONCLUSION: Our case demonstrates that point-of-care ultrasound can be a rapid and effective tool for the diagnosis of pyogenic flexor tenosynovitis in the setting of superimposed dermatological diseases.

Emergency Medicine Resident-Driven Point of Care Ultrasound for Suspected Shoulder Dislocation.

OBJECTIVE: To determine the impact of implementing a musculoskeletal in-service educational intervention for emergency medicine (EM) residents on the use of point-of-care ultrasound (POCUS) to diagnose and manage shoulder dislocations in the emergency department (ED). METHODS: This study was conducted in the ED of an academic teaching hospital in Miami, Florida. It consisted of a short in-service educational intervention on how to perform and interpret POCUS, followed by an open, prospective convenience sample study in patients with clinical suspicion of shoulder dislocation. Twenty EM residents, with no prior shoulder scanning training, participated in the study. In all of the cases, the findings of the shoulder US were compared with radiographs, which were considered the reference standard. EM residents enrolled patients, and obtained and interpreted the shoulder US images. RESULTS: Seventy-eight patients were evaluated to rule out shoulder dislocation and/or fracture. Diagnosis of the dislocated shoulder was made in 55 of 78 patients, 53 of whom had anterior dislocations. Resident-driven POCUS had a sensitivity and specificity of 100% to diagnose and rule out, respectively, shoulder dislocations and relocations. There were no differences in the number of dislocations diagnosed and relocated by early and advanced EM residents. Results from a POCUS were available 22 ± 2.8 minutes sooner than x-ray for initial diagnosis and 27 ± 2.9 minutes (P < 0.0001) sooner than x-ray for assessment of reduction. CONCLUSIONS: EM resident physicians, with no previous training in shoulder US imaging, exposed to a brief in-service musculoskeletal education intervention, were able to diagnose shoulder dislocations via POCUS with high sensitivity and specificity. Shoulder US for dislocation should be a core component in EM training.

Osteochondral defects of the talus with a focus on platelet-rich plasma as a potential treatment option: a review.

OBJECTIVE: To provide a review of osteochondral lesions of the talus, to discuss the evidence of the risks and benefits of platelet-rich plasma (PRP) as a viable treatment option, and to measure the efficacy of PRP using MRI evidence of cartilage regeneration, as well as scales that measure improvement in 'pain' and 'functionality'. ELIGIBILITY CRITERIA: Studies that use PRP in either conservative or intraoperative settings to treat osteochondral defects of the talus. RESULTS: There are seven studies that compare hyaluronic acid or standard surgical options against PRP in treating osteochondral lesions of the talus. Five studies use PRP as supplemental treatment in intraoperative settings, while two studies use PRP conservatively as intra-articular injections. There were minimal adverse effects. Pain and functionality scores consistently improved in those who underwent PRP treatments over the course of 4 years. MRI showed significant but inconsistent results in chondral regeneration. CONCLUSION: PRP may show clinical benefit in those with osteochondral lesions of the talus in terms of pain and functionality, although chondral regeneration via MRI is inconsistent. Limitations include the small sample sizes in these seven studies, as well as no standardised formula for PRP preparation. CLINICAL RELEVANCE: To serve as an overview of the literature regarding PRP treatment for osteochondral lesions of the talus and how this modality may improve patient outcomes in pain, functionality and chondral regeneration. A case is reported to complement the subject review.