Peter P. Yonclas

Osteoarthritis of the acromioclavicular joint: a review of anatomy, biomechanics, diagnosis, and treatment.

Shoulder pain is a frequent presenting complaint to physiatrists. Commonly encountered pathogeneses include rotator cuff pathology, bursitis, biceps tendonitis, and labral tears. Because the majority of shoulder pain originates within the subacromial region and the glenohumeral joint, the acromioclavicular, sternoclavicular, and scapulothoracic articulations may be overlooked. Osteoarthritis of the acromioclavicular joint is a common source of shoulder pain that is often neglected by clinicians and researchers. The proper diagnosis of acromioclavicular joint osteoarthritis requires a thorough physical exam, plain-film radiograph, and a diagnostic local anesthetic injection. Current treatment options are rather limited. Initial therapies are similar to that of osteoarthritis in other joints and include oral analgesics or anti-inflammatories and an emphasis on activity modification. Physical therapy, unfortunately, has little to offer, as therapeutic exercise and range of motion play only a minor role. If a diagnostic local anesthetic injection provides relief, there may be a role for corticosteroid injections. It seems that the administration of local corticosteroids into the acromioclavicular joint may provide short-term pain relief. The judicious administration of such injections remains controversial, and most experts agree that steroid injections do not alter the natural progression of the disease. Surgical options, indicated typically after a minimum of 6 mos of unsuccessful conservative treatment consist of open or arthroscopic distal clavicle resection.

The temporal course of intracranial haemorrhage progression: How long is observation necessary?

INTRODUCTION Patients with mild traumatic brain injury (MTBI) and intracranial haemorrhage (ICH) are hospitalized and monitored for progression of injury. The timeframe for ICH progression is unknown, and so the optimal duration and location of observation are generally discretionary. The goal of this study was to examine the temporal course of injury progression and establish a timeframe for when haemorrhage ceases. METHODS We performed a retrospective review of all adult patients (age ≥ 18) with MTBI (GCS ≥ 13) and ICH admitted to a level 1 trauma centre over a consecutive 36 month period, who underwent a minimum of 2 cranial CT scans (HCT) within 48 h from ED presentation prior to any neurosurgical intervention (NSI). Patients with a history of NSI or nontraumatic cerebral lesions were excluded. Data collected include demographics and the number, timing and findings of serial HCT scans. RESULTS A total of 341 patients met inclusion criteria. The timing for cessation of bleeding could not be confirmed in 37 patients (11 had NSI after 2nd HCT, 1 died of coagulopathy prior to NSI and 25 had no repeat HCT that could confirm the cessation of bleeding). Of the remaining 304 ICH, 96% stopped progressing by 24h and 99% by 48 h. The remaining 1% stopped by 72 h. Of all 341 ICH, 236 (69%) showed no progression after initial HCT, indicating that haemorrhage had stopped by that time (1.2h (SD ± 1.1h) from admission). None required a NSI. CONCLUSION Almost all ICH in MTBI stop progressing within the first 24h post injury, supporting a 24-h observational period. In fact, over 3/4s of ICH has stopped by the time of the initial HCT (<2h from arrival). This suggests that early repeat HCT may identify those ICH no longer progressing, and possibly avoid unnecessary admission and prolonged observation in those patients not requiring admission for post-TBI symptom management. Prospective data are needed to evaluate this proposed paradigm change in the management of MTBI.

Delirium prevention program in the surgical intensive care unit improved the outcomes of older adults

BACKGROUND Hospital-acquired delirium is a known risk factor for negative outcomes in patients admitted to the surgical intensive care unit (SICU). Outcomes worsen as the duration of delirium increases. The purpose of this study was to evaluate the efficacy of a delirium prevention program and determine whether it decreased the incidence and duration of hospital-acquired delirium in older adults (age>50 y) admitted to the SICU. METHODS A prospective pre- or post-intervention cohort study was done at an academic level I trauma center. Older adults admitted to the SICU were enrolled in a delirium prevention program. Those with traumatic brain injury, dementia, or 0 d of obtainable delirium status were excluded from analysis. The intervention consisted of multidisciplinary education, a pharmacologic protocol to limit medications associated with delirium, and a nonpharmacologic sleep enhancement protocol. Primary outcomes were incidence of delirium and delirium-free days/30. Secondary outcomes were ventilator-free days/30, SICU length of stay (LOS), daily and cumulative doses of opioids (milligram, morphine equivalents) and benzodiazepines (milligram, lorazepam equivalents), and time spent in severe pain (greater than or equal to 6 on a scale of 1-10). Delirium was measured using the Confusion Assessment Method for the ICU. Data were analyzed using Chi-squared and Wilcoxon rank sum analysis. RESULTS Of 624 patients admitted to the SICU, 123 met inclusion criteria: 57 preintervention (3/12-6/12) and 66 postintervention (7/12-3/13). Cohorts were similar in age, gender, ratio of trauma patients, and Injury Severity Score. Postintervention, older adults experienced delirium at the same incidence (pre 47% versus 58%, P=0.26), but for a significantly decreased duration as indicated by an increase in delirium-free days/30 (pre 24 versus 27, P=0.002). After intervention, older adults with delirium had more vent-free days (pre 21 versus 25, P=0.03), shorter SICU LOS (pre 13 [median 12] versus 7 [median 6], P=0.01) and were less likely to be treated with benzodiazepines (pre 85% versus 63%, P=0.05) with a lower daily dose when prescribed (pre 5.7 versus 3.6 mg, P=0.04). After intervention, all older adults spent less time in pain (pre 4.7 versus 3.1 h, P=0.02), received less total opioids (pre 401 versus 260 mg, P=0.01), and had shorter SICU LOS (pre 9 [median 5] versus 6 [median 4], P=0.04). CONCLUSIONS Although delirium prevention continues to be a challenge, this study successfully decreased the duration of delirium for older adults admitted to the SICU. Our simple, cost-effective program led to improved pain and sedation outcomes. Older adults with delirium spent less time on the ventilator and all patients spent less time in the SICU.

Utility of repeat head computed tomography in patients with an abnormal neurologic examination after minimal head injury.

BACKGROUND Previous studies proposed that repeat head computed tomography (RHCT) is of no value in patients with a minimal head injury (MHI) and normal neurologic examination (NE). The goal of our study was to investigate the value of RHCT in patients with MHI with an abnormal NE. METHODS A retrospective chart review of adult patients presenting to a Level I trauma center from July 2002 to December 2006 with MHI was performed. Demographics, injury severity, and HCT findings were collected. Patients with an abnormal NE at the time of RHCT were divided into three subgroups: acute deterioration NE (AD-NE), persistently abnormal NE (PA-NE), and unknown NE (U-NE). Changes in the management and outcomes after RHCT were compared. RESULTS One hundred seven patients had a MHI with an abnormal NE. Of those, seven (6.5%) had a change in management after RHCT. At the time of RHCT, 68 patients (63%) had a PA-NE, 21 AD-NE, and 18 U-NE. Six patients (29%) with AD-NE, 1 patient (6%) with an U-NE, and no patients with PA-NE required changes in management after RHCT. Compared with a RHCT, NE had higher positive and negative predictive values in determining the need for management changes. CONCLUSIONS Of all patients with MHI with an abnormal NE at the time of RHCT, 63% had a PA-NE. Although a RHCT is beneficial to patients with an acutely deteriorating or U-NE, it appears to be of little value in patients with a PA-NE. Compared with RHCT, serial NE may be a stronger predictor for the need for intervention in patients with MHI.

Risk factors for delirium in older trauma patients admitted to the surgical intensive care unit

BACKGROUND Adults (age > 50 years) admitted to the surgical intensive care unit (SICU) are at high risk for delirium. Little is known about the role traumatic injury plays in the development of delirium because these patients have often been excluded from studies. Identification of specific risk factors for delirium among older adults following injury would be useful to guide prevention strategies. We attempted to identify modifiable factors that would predict delirium in an older trauma population admitted to the SICU. METHODS Data were collected prospectively from July 2012 to August 2013 at a Level I trauma center on consecutive trauma patients, older than 50 years, admitted to the SICU. Patients who died in the SICU were excluded. Delirium was assessed every 12 hours using the Confusion Assessment Method for the ICU scale. Demographic, injury, social, and clinical variables were reviewed. Bivariate analysis determined significant factors associated with delirium. A multivariate logistic regression model was used to predict delirium risk. After preliminary results, additional analysis compared patients with chest injury (defined as chest Abbreviated Injury Scale [AIS] score ≥ 3) with those without. RESULTS A total of 115 patients met criteria, with a mean age of 67 years, Injury Severity Score (ISS) of 19, and Glasgow Coma Scale (GCS) score of 14. The incidence of delirium was 61%. Variables present on admission, which were positive predictors of delirium, were as follows: age, ISS greater than 17, GCS score less than 15, substance abuse, and traumatic brain injury (defined as head AIS score ≥ 3). Chest injury (defined as chest AIS score ≥ 3) was a negative predictor of delirium. Significant risk factors influenced by clinical treatment included doses of opioids and propofol, restraint use, and hours deeply sedated (Richmond Agitation Sedation Scale [RASS] score ⩽ −3). Clinical treatments with negative predictability were ventilator-free days/30 (vent-free), benzodiazepine-free days/30 (benzo-free), and restraint-free days/30. In a regression model considering age, vent-free days, chest injury, traumatic brain injury, GCS score, benzo-free days, and hours sedated, only age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.01–1.1; p = 0.03) was a predictor of delirium, while vent-free days (OR, 0.79; 95% CI, 0.65–0.96; p = 0.02) and chest injury (OR, 0.3; 95% CI, 0.09–0.83; p = 0.02) were significant negative predictors of delirium. Patients with chest injury had lower delirium incidence (44%) versus those without (75%) (p = 0.002) despite similar GCS score, ISS, and clinical variables. CONCLUSION Delirium is common in older trauma patients admitted to the SICU, and for every year for those older than 50 years, the chance of delirium increases by 10%. While higher ISS increases delirium risk, we identified several modifiable treatment variables including days patients were deeply sedated, mechanically ventilated, and physically restrained. Interestingly, patients with chest injury experienced less delirium, despite similar injury severity and clinical variables, perhaps owing to frequent health care provider interactions. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Orthotics and assistive devices in the treatment of upper and lower limb osteoarthritis: an update.

Yonclas PP, Nadler RR, Moran ME, Kepler KL, Napolitano E: Orthotics and assistive devices in the treatment of upper and lower limb osteoarthritis: An update. Am J Phys Med Rehabil 2006;85(Suppl):S82–S97

Presence of a dedicated trauma center physiatrist improves functional outcomes following traumatic brain injury.

BACKGROUND Maximizing long-term recovery following traumatic brain injury (TBI) is an important end point. We hypothesized that the addition of a dedicated physiatrist specializing in brain injury medicine to the trauma team would lead to improved functional outcomes. METHODS Data from the Northern NJ TBI Model Systems were queried for all patients admitted to rehabilitation from four regional trauma centers, one with a full-time TBI physiatrist (PHYS) and three without (NO-PHYS). Patient demographics, mechanism of injury, Glasgow Coma Scale (GCS) score, length of posttraumatic amnesia, length of stay, and Functional Independence Measure (FIM) were abstracted. TBI severity was determined by GCS score and length of posttraumatic amnesia. FIM motor and cognitive scores at rehabilitation admission and discharge were the primary outcome measure. TBI medications (stimulants, sleep, and neurodepressants) administered in acute care were reviewed to evaluate prescription patterns. RESULTS A total of 148 patients treated at four trauma centers and discharged to a single acute inpatient rehabilitation center between 2005 to 2013 were divided into two groups, PHYS with 44 patients and NO-PHYS with 104 patients. Compared with those in the NO-PHYS group, patients from the PHYS group had significant improvement in FIM motor and cognitive scores (p < 0.05). Prescription patterns differed. Patients from the PHYS group received significantly more neurostimulants (p < 0.001) and sleep medications (p = 0.02) compared with the NO-PHYS group. Analysis of covariance was conducted to examine FIM (motor and cognitive) changes from rehabilitation admission to discharge based on medications initiated in acute care. Those who received neither a neurostimulant nor a sleep medication had significantly lower FIM motor scores compared with those who received at least one of these medications (p = 0.047) and compared with those who received both types of medication (p = 0.17). No significant differences were found in FIM cognitive scores. CONCLUSION The addition of a dedicated physiatrist providing early specialized care to patients who sustained a moderate or severe TBI was associated with improved functional outcomes upon discharge from rehabilitation. The presence of a dedicated trauma center physiatrist, trained in TBI rehabilitation, was also associated with a change in neuroprotective medication management in the acute care setting. LEVEL OF EVIDENCE Therapeutic study, level IV.

The Ankle and the Foot

In many general musculoskeletal practices, injections into the foot and ankle regions are not as commonly performed as are injections into other body regions. For example, in a 2-year musculoskeletal injection teaching study, injections into the foot/ankle region were the least commonly performed (1.6% of the total) [1]. Perhaps one reason for the relative paucity of injections into the foot and ankle regions is the principle that injections into the foot should generally be avoided if possible in diabetic patients. In addition, aspiration/injection procedures have not been proven to be of benefit as part of the typical treatment algorithm for typical soft tissue ankle injuries such as the usual (inversion) ankle sprain, one of the most common musculoskeletal conditions involving the foot/ankle region [2]. Furthermore, injections into this body region can be quite uncomfortable. Finally, it has traditionally been taught that corticosteroid injection procedures should be avoided into regions of weight-bearing tendons, particularly the posterior tibial tendon and the Achilles tendon regions. In contrast to their comparatively smaller incidence in general musculoskeletal practice, these injections obviously play a potentially large role in the practice of orthopedic foot/ankle surgeons and podiatrists both for therapeutic purposes and by offering diagnostic information, particularly when arthrodesis or other surgical interventions are being considered [3–5].

First rib fracture: A harbinger of severe trauma?

BACKGROUND Prior to routine CT scanning, first rib fractures (FRFs) were considered a harbinger of great vessel injuries. We hypothesized FRFs identified on screening CXR have significant associated injuries, while those identified on CT alone do not. METHODS We reviewed adult blunt thoracic trauma patients 2014-2015 to identify all FRFs and then tabulated demographics, injury characteristics, and outcomes. RESULTS Of 429 patients with chest trauma, 56 had a FRF. CXR diagnosed 20% and CT 80%. Those diagnosed on CXR were older (61 vs 48 p = 0.03), had more severe chest trauma (45% vs 13% chest AIS>3, p = 0.029), longer ICU stays (10 vs 4 days, p = 0.046), and risk for intubation (73% vs 27%, p = 0.011). There was only one major vascular injury in each group. Most FRF patients had associated injuries, including 82% with pelvic fractures. CONCLUSIONS Widespread use of CT scanning has resulted in a 5-fold increase in FRF diagnoses. While vascular injuries are not common, especially when identified on initial CXR, FRFs correlate with morbidity and associated injuries.

Poster 30 Use of Delirium Triggering Medications Among Patients with Delirium at Admission to Inpatient Rehabilitation Facility

gain, hirsutism, and progressive proximal muscle weakness. Electromyography and nerve conduction studies prior to admission were normal e consistent with glucocorticoid-induced myopathy. Laboratory work-up revealed low adrenocorticotropic hormone levels andmarkedly elevated 24-hour cortisol. Biopsy of a left adrenal mass seen on MRI confirmed the diagnosis of adrenocortical carcinoma.Mifeprostinonewas initiated,with satisfactory control of endogenous steroid production. Setting: Inpatient Rehabilitation Hospital/Academic Rehabilitation Hospital. Results: The patient was transferred to an inpatient rehabilitation hospital for continued medical treatment and rehabilitation with a focus on strength and endurance. On admission, motor strength was 3/ 5 in bilateral hip flexors, 4/5 in other proximal muscles with relative sparing of distal muscles. She was dependent to maximal assist with all mobility and ADLs except wheelchair use. On discharge she required minimum to moderate assistance; however, she remained non-ambulatory and did not have significant return of strength despite continued control of her DM and cortisol levels. Discussion: Glucocorticoid-induced myopathy is a well-known complication of Cushing Syndrome resulting from iatrogenic steroid exposure. However, its incidence and relation to endogenous cortisol production has not been reported. While the mechanisms underlying myopathy are likely the same, details regarding the associated severity, prognosis, and outcome remain unclear. This patient’s lack of early recovery, despite eliminating endogenous cortisol production, possibly prognosticates a course with minimal strength return. This is in contrast to iatrogenic steroid-induced myopathy. Conclusions: Iatrogenic steroid-induced myopathy is not uncommonly seen in both inpatient and outpatient physiatry. We present a case of glucocorticoid-induced myopathy from endogenous steroid production, which previously has not been reported. It is important for physiatrists to be aware of this syndrome to promote early diagnosis and intervention, and to set appropriate rehabilitation goals. Level of Evidence: Level V