Carpometacarpal (CMC) Joint Subluxation: Causation Analysis and Impairment Evaluation

2012 ◽  
Vol 17 (5) ◽  
pp. 1-7
Author(s):  
J. Mark Melhorn ◽  
Christopher R. Brigham ◽  
James B. Talmage
Keyword(s):  
Physical Examination ◽  
Radiographic Evaluation ◽  
X Rays ◽  
Plausible Mechanism ◽  
Impairment Ratings ◽  
Sufficient Magnitude ◽  
Causation Analysis ◽  
Injury Causation ◽  
Current Science ◽  
Cmc Joint

Abstract Carpometacarpal (CMC) joint subluxation refers to the changes that occur in the CMC joint as seen on x-rays and observed during physical examination. The CMC joint is the most commonly involved arthritic joint in the hand, and arthritis may appear in localized or systemic forms. A diagnosis of thumb-CMC arthritis is based on symptoms of localized pain, tenderness, and instability on physical examination and radiographic evaluation. The AMA Guides to the Evaluation of Disease and Injury Causation provides a protocol for assessing causation and requires that all three of the following criteria must be met: 1) the patient has an illness compatible with a disease-producing agent or an injury; 2) the worker's exposure in the occupational environment potentially caused the disease or is a plausible mechanism of injury of sufficient magnitude to cause the condition; and 3) the preponderance of evidence supports the disease or injury as occupational in origin. If any one of the three is possible but not probable, causation has not been established. The authors review several published articles and conclude that, based on the clinical facts and current science, CMC joint subluxation is unrelated to work and instead is reflective of aging. The article concludes with a comparison of impairment ratings of CMC-related disability using the fifth and sixth editions of the AMA Guides to the Evaluation of Permanent Impairment, both of which lead to identical impairment ratings but by different means.

Effects of Aging on Impairment Ratings: Part 4: Musculoskeletal Issues

2019 ◽  
Vol 24 (6) ◽  
pp. 3-11
Author(s):  
Stephen L. Demeter ◽  
Charles N. Brooks ◽  
J. Mark Melhorn
Keyword(s):  
Medical Literature ◽  
Diffuse Idiopathic Skeletal Hyperostosis ◽  
Older Individuals ◽  
Repetitive Motion ◽  
Age Related ◽  
Spinal Ligaments ◽  
Impairment Ratings ◽  
Effects Of Aging ◽  
Causation Analysis ◽  
Injury Causation

Abstract This article is the fourth of five in a series on the effects of age-related changes in impairment evaluations as defined by the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth and Sixth Editions. The present article addresses the musculoskeletal system and differs from the first three articles, which focused on apportionment of an impairment rating between aging and other causes. The medical literature supports the notion that age-related osteoarthritis (OA) changes in the hand and digits frequently are associated with injury and/or repetitive motion. Thus, apportionment is indicated, but deciding which came first, the imaging abnormality or the injury, requires consummate skill on behalf of the rating physician. OA also occurs in the knees and hips of older individuals. Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory disorder characterized by calcification and ossification of spinal ligaments and entheses and is unique, in the authors’ opinion, because of a positive correlation between aging and back pain caused by this condition. The article also addresses the association—or the lack thereof—between pathology and aging, as well as degenerative changes and symptoms, to facilitate causation analysis. For a fuller discussion of causation analysis for the spine, readers can consult the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition.

Shoulder Pain at Work: Causation Analysis

2017 ◽  
Vol 22 (1) ◽  
pp. 11-16
Author(s):  
Joel Weddington ◽  
Charles N. Brooks ◽  
Mark Melhorn ◽  
Christopher R. Brigham
Keyword(s):  
Epidemiological Data ◽  
Case Law ◽  
Individual Case ◽  
Shoulder Injury ◽  
Work Related ◽  
Clear Cut ◽  
The Individual ◽  
Causation Analysis ◽  
Injury Causation ◽  
Relevant Factors

Abstract In most cases of shoulder injury at work, causation analysis is not clear-cut and requires detailed, thoughtful, and time-consuming causation analysis; traditionally, physicians have approached this in a cursory manner, often presenting their findings as an opinion. An established method of causation analysis using six steps is outlined in the American College of Occupational and Environmental Medicine Guidelines and in the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, as follows: 1) collect evidence of disease; 2) collect epidemiological data; 3) collect evidence of exposure; 4) collect other relevant factors; 5) evaluate the validity of the evidence; and 6) write a report with evaluation and conclusions. Evaluators also should recognize that thresholds for causation vary by state and are based on specific statutes or case law. Three cases illustrate evidence-based causation analysis using the six steps and illustrate how examiners can form well-founded opinions about whether a given condition is work related, nonoccupational, or some combination of these. An evaluator's causal conclusions should be rational, should be consistent with the facts of the individual case and medical literature, and should cite pertinent references. The opinion should be stated “to a reasonable degree of medical probability,” on a “more-probable-than-not” basis, or using a suitable phrase that meets the legal threshold in the applicable jurisdiction.

scholarly journals Novel Radiographic Indexes for Elbow Stability Assessment: Part B—Preliminary Clinical Study

2021 ◽  
Author(s):  
Francesco Luceri ◽  
Davide Cucchi ◽  
Enrico Rosagrata ◽  
Carlo Eugenio Zaolino ◽  
Alessandra Menon ◽  
...  
Keyword(s):  
Case Series ◽  
Radiographic Evaluation ◽  
Healthy Population ◽  
X Rays ◽  
The Novel ◽  
Level Of Evidence ◽  
Orthopaedic Surgeons ◽  
Joint Congruency ◽  
Radiological Parameters ◽  
The Mean

Abstract Introduction The coronoid process plays a key-role in preserving elbow stability. Currently, there are no radiographic indexes conceived to assess the intrinsic elbow stability and the joint congruency. The aim of this study is to present new radiological parameters, which will help assess the intrinsic stability of the ulnohumeral joint and to define normal values of these indexes in a normal, healthy population. Methods Four independent observers (two orthopaedic surgeons and two radiologists) selected lateral view X-rays of subjects with no history of upper limb disease or surgery. The following radiographic indexes were defined: trochlear depth index (TDI); anterior coverage index (ACI); posterior coverage index (PCI); olecranon–coronoid angle (OCA); radiographic coverage angle (RCA). Inter-observer and intra-observer reproducibility were assessed for each index. Results 126 subjects were included. Standardized lateral elbow radiographs (62 left and 64 right elbows) were obtained and analysed. The mean TDI was 0.46 ± 0.06 (0.3–1.6), the mean ACI was 2.0 ± 0.2 (1.6–3.1) and the mean PCI was 1.3 ± 0.1 (1.0–1.9). The mean RCA was 179.6 ± 8.3° (normalized RCA: 49.9 ± 2.3%) and the mean OCA was 24.6 ± 3.7°. The indexes had a high-grade of inter-observer and intra-observer reliability for each of the four observers. Significantly higher values were found for males for TDI, ACI, PCI and RCA. Conclusion The novel radiological parameters described are simple, reliable and easily reproducible. These features make them a promising tool for radiographic evaluation both for orthopaedic surgeons and for radiologists in the emergency department setting or during outpatient services. Level of evidence Basic Science Study (Case Series). Clinical relevance The novel radiological parameters described are reliable, easily reproducible and become handy for orthopaedic surgeons as well as radiologists in daily clinical practice.

scholarly journals POSTERIOR TIBIAL TENDON INJURY - IS MISSED DIAGNOSIS, A POSSIBILITY? SHOULD IT BE SUSPECTED IN ALLANKLE EVERSION SPRAINS? - A CASE REPORT

2020 ◽  
pp. 1-2
Author(s):  
Chavda Sumant ◽  
Garg Chaitanya ◽  
George, Biji Thomas ◽  
Jad Allah, Bader
Keyword(s):  
Physical Examination ◽  
Ankle Sprain ◽  
Weight Bearing ◽  
Ankle Injuries ◽  
Radiographic Evaluation ◽  
Tibialis Posterior ◽  
Posterior Tibial Tendon ◽  
Persistent Symptoms ◽  
Posterior Tibial ◽  
Ankle Brace

Ankle sprains are one of the most common injuries that occur among people of all ages and accounts for 75% of ankle injuries and for 10 to 30 percent of sports-related injuries in young athletes. Inversion sprain is more common than eversion ankle sprain, to result in injury to the lateral ligament complex. Though injury to the posterior tibial tendon is not a very common injury associated with eversion ankle sprain, it often can be overlooked and missed in the initial physical examination. We present a case of a college student who sustained a twisting injury to his left ankle while playing football. After initial history, physical examination and plain radiographic evaluation, a diagnosis of eversion ankle sprain was made by a general practitioner and treated conservatively. Due to persistent symptoms and local signs, subsequent evaluation with an MRI study revealed tibialis posterior (TP) tendon strain with diffuse soft tissue swelling extending up to lower third of the leg and associated Grade I osteochondral injury to the posterolateral aspect of talus. The injury was successfully treated with medial arch support ankle brace, analgesics, guarded weight bearing and physiotherapy with full functional recovery in 12 weeks.

scholarly journals Burkit-like lymphoma: subileus and ascites as dominant clinical manifestation

2003 ◽  
Vol 131 (11-12) ◽  
pp. 458-460 ◽  
Author(s):  
Olivera Markovic ◽  
Dragomir Marisavljevic ◽  
Vesna Cemerikic-Martinovic
Keyword(s):  
Gastrointestinal Tract ◽  
Complete Remission ◽  
Physical Examination ◽  
X Rays ◽  
Malignant Cells ◽  
Massive Ascites ◽  
Ki 67 ◽  
Precise Diagnosis ◽  
Night Sweats ◽  
Abdominal Fullness

Nodal presentation of Burkitt-like lymphoma is common, particularly in gastrointestinal tract. However, only few cases with massive ascites and signs of subileus due to lymphoma proliferation are described. We report a 31-year-old male patient who presented with fever, night sweats, vomiting and abdominal fullness. Physical examination suggested much ascites. Abdominal X-rays showed hidroaeric levels. Diagnosis of Burkitt-like lymphoma was established on the basis of cytological and imunohistochemical examination of ascites (immune phenotype of malignant cells was EMA -, NSE -, LCA +, CD10 -/+, CD20 +, IgM +, Ki-67 +100%). After treatment with BMF protocol complete remission was achieved and retained for 2.5 years. Authors stressed that imunohistochemical examination of ascites has been proved as simple and efficient method for establishing precise diagnosis. In this way laparotomy was avoided, which otherwise would be necessary due to exclusive abdominal localization of the disease.

Wounds, Fractures, Orthopaedics

2011 ◽  
Author(s):  
Pawan Gupta
Keyword(s):  
Physical Examination ◽  
Soft Tissue Injuries ◽  
Basic Knowledge ◽  
X Rays ◽  
Number Of Patients ◽  
Before And After ◽  
Life Threatening ◽  
Minor Injuries ◽  
High Degree ◽  
Type Of Injury

A significant number of patients attending the ED are those who are often referred to as ‘minors’, ‘streamers’, ‘walking wounded’, etc. These include patients with minor injuries, wounds, fractures or other soft tissue injuries. Therefore, a basic knowledge of anatomy and its application in various circumstances is mandatory. The injuries mentioned above are rarely life-threatening, but they may be limb-threatening and severely disabling. So it is extremely important to avoid errors in diagnosis and management, and to know when to ask for help at the appropriate time. By following the key principles listed below, you will be able to avoid many problems with such patients: • In the history, a detailed description of the mechanism of injury and the patient’s complaint will help in predicting the type of injury sustained. • A careful and thorough physical examination can point to the site and type of injury, on the basis of which appropriate radiological images can then be requested. • A neurovascular examination must be completed and documented in every limb injury, before and after any reductions, and before and after immobilization. • Appropriate radiological imaging, accompanied by a thorough physical examination, can pick up injuries with a high degree of accuracy. Inadequate radiographic films should not be accepted. • Immobilize the patient if a fracture is clinically suspected even if the X-rays are negative. • In cases of dislocations or subluxations, X-rays should be done before and after reductions, except when a delay could be potentially harmful to the patient (for example, when a severe traumatic deformity of a joint threatens to jeopardize the viability of the overlying skin). • The patient should be able to mobilize safely before being discharged from the ED. • Patients should be given proper aftercare instructions before leaving the ED, including how to look after themselves and to recognize limb-threatening features, the follow-up arrangement, and to return if things go wrong. • Ask for senior help if you are not sure about an injury or its management.

scholarly journals RADIOGRAPHIC EVALUATION OF THORACOLUMBAR STABILIZATION USING TWO DIFFERENT ORTHOSIS SYSTEMS

2018 ◽  
Vol 17 (4) ◽  
pp. 300-302
Author(s):  
Murilo Tavares Daher ◽  
Vinício Nunes Nascimento ◽  
Pedro Felisbino Jr ◽  
Nilo Carrijo Melo ◽  
Brenda Cristina Ribeiro Araújo ◽  
...  
Keyword(s):  
Cobb Angle ◽  
Thoracolumbar Junction ◽  
Radiographic Evaluation ◽  
Neutral Position ◽  
X Rays ◽  
Level Of Evidence ◽  
Institutional Review ◽  
Thoracolumbar Region ◽  
Boston Brace ◽  
Orthostatic Position

ABSTRACT Objective: To evaluate radiographically the stability of the thoracolumbar junction comparing the two types of thoracolumbosacral orthosis (TLSO) most used in our environment, the Jewett and the Boston braces. Methods: After approval by the institutional review board, nine participants were submitted to X-rays in the profile view, with the beam focused on T12, in the orthostatic position, maximal flexion without brace and maximal flexion with the Jewett and the Boston braces. The Cobb angle of the thoracolumbar junction (T10-L2) was measured and the values compared using the student T test (p <0.05). Results: The Boston brace promoted greater stabilization of the thoracolumbar junction during flexion of the trunk compared to the Jewett brace (p <0.05). In addition, there was no statistical difference in the Cobb angle of the thoracolumbar junction in the orthostatic (neutral) position and in flexion using the Boston brace. Conclusion: The Boston brace presented greater stabilization of the thoracolumbar region during flexion of the trunk compared to the Jewett brace. Level of Evidence II; Prospective comparative study.

Retained Foreign Bodies after Emergent Trauma Surgery: Incidence after 2526 Cavitary Explorations

2007 ◽  
Vol 73 (10) ◽  
pp. 1031-1034 ◽  
Author(s):  
Pedro G.R. Teixeira ◽  
Kenji Inaba ◽  
Ali Salim ◽  
Carlos Brown ◽  
Peter Rhee ◽  
...  
Keyword(s):  
Foreign Bodies ◽  
Damage Control ◽  
Trauma Surgery ◽  
Radiographic Evaluation ◽  
Trauma Patients ◽  
X Rays ◽  
Chest X Ray ◽  
Cavity Closure ◽  
Level 1 Trauma Center

Trauma patients are thought to be at high risk for iatrogenic retained foreign bodies (RFBs). The objective of this study was to evaluate this incidence. All cases of RFB after cavitary trauma surgery were identified by review of Morbidity and Mortality reports at a Level 1 trauma center from January 1998 to December 2005 and confirmed by the Octagon Risk Management System. Over 8 years, 10,053 trauma operations were performed (2075 laparotomies, 377 thoracotomies, and 74 sternotomies). Three cases (0.1%) of RFB (all sponges) occurred during one single-stage and two damage control laparotomies. The counts were correct before definitive closure in two of three cases. No postoperative x-rays were obtained in any of the cases. RFB diagnosis occurred between days 3 and 9, one on a routine chest x-ray and the other two on abdominal computed tomography scans during a septic workup. Four-month to 8-year follow up documented one pleural effusion and one abscess resulting from the RFB. Iatrogenic RFBs after emergent cavitary trauma surgery occur at a rate of 0.12 per cent and are associated with significant morbidity. In addition to standard preventive strategies, in emergent cases with risk factors such as requiring damage control, before final cavity closure, even with a correct sponge count, radiographic evaluation is warranted.

Clinical Joint Outcome after Joint Bleeds in Patients with Von Willebrand Disease Is Comparable to Moderate and Severe Hemophilia A Despite Fewer Joint Bleeds

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3789-3789 ◽  
Author(s):  
Karin PM van Galen ◽  
Merel Timmer ◽  
Piet de Kleijn ◽  
Frank W.G. Leebeek ◽  
Roger E.G. Schutgens ◽  
...  
Keyword(s):  
Physical Examination ◽  
Research Funding ◽  
Functional Limitations ◽  
Joint Damage ◽  
Von Willebrand Disease ◽  
X Rays ◽  
X Ray ◽  
History Of ◽  
Type 3 ◽  
Von Willebrand

Abstract Background Recurrent joint bleeds are the main cause of joint deterioration (hemophilic arthropathy) in patients with hemophilia. To what extent arthropathy occurs following joint bleeds in patients with Von Willebrand disease (VWD) compared to hemophilia has never been studied. Objectives The primary objective was to compare joint outcome by physical examination between adults with VWD and moderate and severe hemophilia A (HA). The main secondary objectives were to compare joint bleed frequency, radiological joint damage and self-reported functional limitations between VWD and moderate and severe HA. Methods We selected adult patients with VWD (VWF activity <30%) and moderate or severe HA, who had a medical history of treatment for joint bleeds, for this post hoc analysis. To compare joint outcome we used the Hemophilia Joint Health Score (HJHS range 0-124, obtained by physical examination), X-ray Pettersson scores of ankles, knees and elbows (PS range 0-13 per joint) and Hemophilia Activities List scores, a patient administered questionnaire measuring functional limitations (HAL range 0-100). Univariate analyses were performed using Mann Whitney U and Chi2. For multivariate analysis we used negative binomial regression analysis (HJHS) and logistic regression (dichotomized PS>3 and HAL<95) adjusted for age. We performed a subgroup analysis of the patients with type 3 VWD. Results We included 48 patients with VWD, 39 with moderate and 59 with severe HA. The mean age was 45, 38 and 26 years, respectively. Fewer patients with VWD than HA had a lifetime history of more than 5 joint bleeds (56% VWD vs. 77% moderate HA vs. 98% severe HA, p<0.001). Joint dysfunction at physical examination was comparable between the patients with VWD and moderate HA (median HJHS 5 vs. 5.5, p=0.65) but slightly better in VWD compared to severe HA (median HJHS 5 vs. 9, p=0.02). Apparent joint damage on X rays (PS>3 of one or more joints) occurred in 12/46 patients with VWD compared to 27/40 patients with severe HA (26% vs. 68%: OR 0.09; 95%CI 0.03-0.34, p<0.001). In moderate HA insufficient X rays were available for analyses. Functional limitations according to the HAL were comparable between patients with VWD and moderate and severe HA (VWD median HAL total score 88 vs. 95 in both moderate and severe HA, p=0.35). The subgroup analysis of joint dysfunction in patients with type 3 VWD (n=19, median age 40) showed clinical changes comparable to severe HA (median HJHS 14 vs. 9, p=0.83). We found a trend towards less radiological joint damage in type 3 VWD compared to severe HA (PS>3: 47% vs. 68%, OR 0.28; 95%CI 0.07-1.12, p=0.07). However, patients with type 3 VWD reported more functional limitations compared to those with moderate or severe HA (median HAL total score 77 vs. 95, p=0.01; adjusted for age OR 0.38; 95%CI 0.1-1.2, p=0.10). Conclusions Despite fewer joint bleeds, joint function according to the HJHS was comparable between adult patients with VWD and moderate HA with a history of treatment for joint bleeds. Apparent X ray joint damage occurred less often in patients with VWD compared to those with severe HA. The HJHS of patients with type 3 VWD was comparable to those with severe HA, but the patients with type 3 VWD reported more functional limitations, partly explained by their higher age. Knowledge of similarities and differences in joint outcome between VWD and hemophilia can be helpful to improve the awareness and treatment of joint bleeds in VWD to prevent arthropathy and functional limitations. Disclosures van Galen: Bayer: Research Funding; CSL Behring: Research Funding; Baxter: Research Funding. Leebeek:CSL Behring: Research Funding; Baxter: Research Funding. Schutgens:Sanquin: Research Funding; CSL Behring: Research Funding. Fischer:Baxalta/Baxter: Consultancy, Research Funding, Speakers Bureau; Pfizer: Consultancy, Research Funding, Speakers Bureau; CSL Behring: Consultancy, Speakers Bureau; NovoNordisk: Consultancy, Research Funding, Speakers Bureau; Octapharma: Speakers Bureau; Baxter: Consultancy, Research Funding, Speakers Bureau; Wyeth: Research Funding; Biogen: Consultancy; Biotest: Consultancy, Speakers Bureau; Bayer: Consultancy, Research Funding, Speakers Bureau; Freeline: Consultancy. Mauser-Bunschoten:CSL Behring: Research Funding; Bayer: Research Funding; Baxter: Research Funding; Griffols: Research Funding; Novo Nordisk: Research Funding; Pfizer: Research Funding; Biovitrum: Research Funding; Saquin: Research Funding.

Prioritizing Pediatricians’ Neurosurgical Education: Results From a National Survey of Primary Care Pediatricians

2020 ◽  
Vol 59 (9-10) ◽  
pp. 902-909
Author(s):  
Philipp R. Aldana ◽  
Alexandra D. Beier ◽  
Nathan J. Ranalli ◽  
Blake Sisk ◽  
John R. Ragheb
Keyword(s):  
Primary Care ◽  
Head Injury ◽  
Physical Examination ◽  
Continuing Education ◽  
Educational Programs ◽  
X Rays ◽  
Concussion Management ◽  
American Academy Of Pediatrics ◽  
Neurosurgical Education ◽  
Primary Care Pediatricians

Introduction. We surveyed nonretired American Academy of Pediatrics–member US pediatricians regarding common neurosurgical conditions, identifying specific areas of focus in education. Methods. Data were acquired via self-administered electronic questionnaire. Results. Of 505 total respondents, 56% reported neurology was not a required residency rotation, and 86% had diagnosed craniosynostosis, plagiocephaly, or macrocephaly. Craniosynostosis can mostly be diagnosed by physical examination alone, but almost 50% reported relying on skull X-rays. Fifty-four percent reported diagnosing ocular surface disease (OSD; with 15% to 40% not screening an infant despite well-established cutaneous markers). Seventy-four screened OSD in a patient with sacral dimple. Ninety-seven percent reported treating concussion, but nearly 25% did not manage these patients alone. Two out of 3 patients indicated head injury as most important for continuing education. Conclusion. Improved education for craniosynostosis, OSD, head injury, and concussion management are important for earlier diagnosis, management, and referral of some disorders, while decreasing resource utilization in others. These results should be used when considering pediatrician educational programs.

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