A teaching unit in primary care sports medicine for family medicine residents.

The authors describe their experience in setting up a sports medicine teaching unit within a family practice center of a teaching hospital. The unit's patient population more closely resembles that of a typical family practice than that of a traditional musculoskeletal teaching clinic (e.g., orthopedics, emergency room). The teaching program includes direct observation of residents performing history taking and physical examinations through one-way mirrors, close supervision for each case, and a sports therapist who educates patients and residents about home exercise programs when physiotherapy within private clinics is not necessary or affordable. At the end of each session 20-30 minutes are devoted to teaching specific physical examination skills. The authors describe how their clinic interacts with other services within the hospital and how certain obstacles they encountered when setting up the clinic might be avoided by others. They feel that this type of unit complements other existing programs in the family medicine department and provides an excellent learning experience for family medicine residents, who are likely to see a high proportion of patients with muskuloskeletal injuries in their practices.

Quantifying delays in the recognition and management of acute compartment syndrome.

OBJECTIVE: To identify where most efforts should be made to decrease ischemia time and necrosis in acute compartment syndrome (ACS) and to determine the causes for late interventions. METHODS: This was a multicentre, historical cohort study of patients who underwent fasciotomy for ACS within the McGill Teaching Hospitals between 1989 and 1997. Patients studied had a clinical diagnosis of ACS or compartment pressures greater than 30 mm Hg. In all cases, ACS was confirmed at the time of fasciotomy. Patients were stratified into traumatic and non-traumatic groups, and a step-by-step analysis was performed for each part of the process between injury and operation. RESULTS: Among the 62 traumatic ACS cases, the longest delays occurred between initial assessment and diagnosis (median time 2h56, range from 0 to 99h20) and between diagnosis and operation (median 2h13, range 0h15-29h45). Among the 14 non-traumatic ACS cases, delays primarily occurred between inciting event and hospital presentation (median 9h19, range 0h04-289h29) and between initial assessment and diagnosis (median 8h18, range 0-104h15). CONCLUSIONS: ACS is a limb-threatening condition for which early intervention is critical. Substantial delays occur after the time of patient presentation. For traumatic and non-traumatic ACS, increased physician awareness and faster operating room access may reduce treatment delays and prevent disability.

Poisoning-induced acute atraumatic compartment syndrome.

Acute Atraumatic Compartment Syndrome (AACS) can be a potentially life and limb threatening complication of either drug abuse or medication injection. Prompt recognition followed by emergency fasciotomy is required to avoid permanent disability. A better understanding of the different clinical presentations may lead to improved outcomes through more expedient diagnosis and treatment. We describe five new cases of AACS caused by illicit drug abuse within the McGill University Hospitals, with a review of all 102 similar patients previously documented in the literature between January 1970 and May 1997. The average age for all cases was 29 years, with 74% being male. The presence of edema, pain, tension, and skin changes were the most frequent symptoms and signs reported. There appear to be two distinct mechanisms of poisoning-induced AACS: (1) direct vasotoxicity and (2) limb compression caused by prolonged comatose state. Direct vasotoxicity is more likely to lead to eventual amputation, whereas prolonged limb compression is more likely to progress to systemic complications such as azotemia, hypotension, cardiac arrhythmia, and renal failure (Crush Syndrome). Long-term sequelae of motor loss, sensory disruption, and development of contracture were common in AACS of both causes. Because Compartment Syndrome is a surgical emergency, primary care and emergency physicians must have a high index of suspicion to promptly recognize and treat this problem.