MSK & GU/Renal (Feb 2016)
Research: Fogel et al. Dexamethasone Therapy for Septic Arthritis in Children. Pediatrics, 2015.
Review: Tsyrulnik. ED Evaluation and Treatment of Wrist Injuries. EM Clin N Am 2015.
AIR: GU/Renal
Research: Fogel et al. Dexamethasone Therapy for Septic Arthritis in Children. Pediatrics, 2015.
Review: Tsyrulnik. ED Evaluation and Treatment of Wrist Injuries. EM Clin N Am 2015.
AIR: GU/Renal
15 comments
One aspect of writing a review article is balancing treatment recomendations vs areas of uncertainty or limitations in the evidence vs providing a treatment recommendation.
As an example:
I noted in the review on wrist injuries for treatment of suspected scaphoid fractures (no radiographic fracture) that “Typically,when a scaphoid fracture is suspected without radiographic confirmation, a thumb spica splint should be applied with hand surgeon follow-up in 7 to 10 days” with no reference.
There is controversy about this and some suggest it is reasonable with low risk occult scaphoid use a volar splint vs thumb spicca.
One ref (note include “occult fx”)
Steven J Rhemrev, Daan Ootes, Frank JP Beeres, Sven AG Meylaerts, Inger B Schipper.Current methods of diagnosis and treatment of scaphoid fractures Int J Emerg Med. 2011; 4: 4. Published online 2011 February 4. doi: 10.1186/1865-1380-4-4PMCID: PMC3051891
“Cast immobilisation
In case of an occult or stable scaphoid fracture according to the current Herbert classification, cast immobilisation is still the therapy of choice.
Scaphoid fractures are hard to immobilise, since nearly every motion of the hand, wrist and forearm causes movement of the bone and pressure on the fracture line. Therefore, even an “above the elbow” cast may be applied [32].
There are different types of cast immobilisation for a scaphoid fracture either with or without inclusion of the thumb. There is no study proving a better consolidation with regard to the type of cast that is used; however immobilisation in slight dorsal extension seems to have a positive effect on the grip strength and range of motion of the wrist joint [33-35].”
One guideline EBM review recs
“Published research in this area is very limited (see table 14), but the available evidence suggests that a Scaphoid cast offers no benefit over a standard “Colles” cast, and is more disabling for the patient. There may be some benefit to immobilising a Scaphoid fracture in an above elbow cast, but the two studies in this area do not agree.”
http://www.rcem.ac.uk/code/document.asp?ID=7431
Best Bet EBM review http://bestbets.org/bets/bet.php?id=1673
“The first paper compared the use of colles’ and scaphoid casts in the treatment of scaphoid fractures and showed that fracture healing seems to occur equally well in both. As a scaphoid cast involves thumb immobilisation as far as the interphalangeal joint and a colles’ cast does not, it could be inferred that a wrist splint with thumb extension would give no benefit to fracture healing, over a standard wrist splint. The second paper seems to support this finding as it looked at a small group of both patients and cadaveric wrists with scaphoid fractures and found that thumb position had no effect on fracture displacement, as long as the wrist was not in ulnar deviation.
Clinical Bottom Line
While there is no direct evidence to answer the clinical question, the research available strongly suggests that it is reasonable to continue using standard wrist splints to immobilise patients with suspected scaphoid fractures. ”
This was updated as of 2011Emerg Med J2011;28:1075-1076 doi:10.1136/emermed-2011-200894
It is concluded that while there is no direct evidence to answer the clinical question, the research available strongly suggests that it is reasonable to continue using standard wrist splints to immobilise patients with suspected scaphoid fractures.
My point is that it is reasonable in suspected or possible scaphoid fx (neg fx) to use a volar splint with clear pt instructions and appropriate referral as this is the most important part of this injury. We could also consider a patient centered approach of obtaining an MRI or CT at the initial evaluation to increase the diagnostic accuracy vs splint/refer/immobilize and whether this would be worthwhile. The author indicates “Recent studies looking at the costs incurred with prolonged immobilization (lost income, lost productivity, repeat imaging, follow-up appointments) versus immediate CT scan or MRI are showing mixed results.14 and ref 14 is a review article.
My point in raising this is this is perhaps among the most common dilemmas we face.
Can’t miss one.
Great points Jim. I’m glad that many find a resting volar splint acceptable, since that’s easy for us send the patient out on in the ED.
Considering the high morbidity of missed scaphoid fractures, it’s unfortunate we have such limited evidence to guide us on the management.
ED Eval and Treatment of Wrist Injuries:
– How has this review changed my practice: When I look at the percentages of carpal bone fractures that are missed with plain films I may pause in the future and consider ordering a CT in a patient with a convincing clinical examination. False negative reads for scaphoid fractures of 16% are just too high when we have superior imaging modalities and when you consider the possibility of lifelong disability in an appendage required for fine motor skills.
-What belief has been debunked by reading this article: I was unaware that triquetrum fractures accounted for up to 20% of carpal bone fractues. I have never seen one and assumed the percentage to be much smaller.
-What new information have I learned from reading this review article: I was unaware that the three lines used to assess correct anatomical position of the intrinsic carpal bones were called the lines of Gilula. I may come across that term in medical school but have no recollection.
What information is uncertain or could possibly be an area of research: The review article states that in the younger group of people who sustain distal radius fractures the rate has been increasing because of the rise in obesity and resulting greating impact from falls. Has this actually been looked at? It seems to me that an equally likely culprits would include the razor scooter, the rise of the comman man’s trampoline and the oh so sexy hoverboard!
Dexamethasone Therapy for Septic Arthritis in Children:
What are the strengths: Overall the study was able to reproduce and support the findings of two earlier studies.
What are the limitations: The study had a relatively small sample size and lacked power. The authors recognize a selection bias in the patients who received both antibiotics and a course of steroids. Those who had lage joint infections (knee, hip) were more likely to receive steroids as well as antibiotics. There decision to start steroids was left up to the provider and there were no guidelines on who should get dexamethasone. The authors also note the relatively small number of patients in the study who had positive blood cultures (27.6%).
What were the outcomes: This study helps to confirm earlier reports from previous studies that a short course of adjunctive corticosteroids in children with septic arthritis can shorten the severity of their symptoms and reduced residual dysfunction in the affected joint.
Does this study change your practice? If so, how:
Previously I hadn’t considered giving dexamethasone for an acute presentation of septic arthritis. Objectively it makes sense in terms of relieving pain and inflammation. I would consider using it going forward in the future.
I agree. Consideration of steroids is reasonable. I’m not sure if this changes my practice completely yet. It’s worth a discussion with ortho colleagues in pediatrics.
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There’s gotta be an adult study on this coming soon as well.
Fogel et al. Steroids in Pediatric Septic joint.
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Retrospective study. Despite Table 1 showing similar patient characteristics in both groups, the P values are high and it is possible that the groups are simply different and there was some undiscovered reason that clinicians opted to use steroids in one group, but not the other. For instance, they noted that large joint infections received more steroids, while small joints received mostly abx only regimen.
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I’m also curious why they did a retrospective study after two RCT’s have already been done on this.
I am not sure that the protocol would generalize or whether this reflects practice here or other childrens hospitals? Medical, aspiration, needle irrigation unless hip?
Issue on Table 1- many epidemiologists and major journals discourage hypothesis test to compare groups- sample size effect, multiple testing- they could have included large v small joints or similar and one could assess whether seemed to be different.
I agree with you Alex re: adult study indicated as this was one of example of medical myths, steroids contraindicated and why we would not inject any joints in ED concern culture later positive even if evident gout or OA.
Tsyrulnik et al. Review of Wrist injuries
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It might look long (14 pages), but it’s a quick read since it has big font and many pictures.
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Keep an eye out for those hook of hamate fractures as they are frequently missed on x-rays.
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X-rays are not the gold standard for a lot of these high morbidity injuries. Definitely review this article carefully.
– How has this review changed my practice:
Since very early in medical school (gross anatomy), I learned about radiographically occult scaphoid fractures and empirically splinting/casting them in the setting of high clinical suspicion, but I had learned very little about other wrist injuries and how easily they, too, could be missed by plain films. This review has expanded my thinking to include the majority of wrist, especially carpal bone injuries and to consider the benefits of empiric treatment and follow up vs advanced imaging for other clinically suspected carpal bone fractures.
-What belief has been debunked by reading this article: Overall, I thought that plain films were adequate for evaluation of most wrist injuries (except the high profile missed scaphoid), but I now see that radiographically occult injuries can happen (and pretty commonly) in all of the carpal bones.
-What new information have I learned from reading this review article: Through this article and also reading for my ortho QCC, I learned about clinical sequelae of missed hamate and pisiform fractures, the most obvious being ulnar neuropathy from impingement in Guyon’s canal. Another sequela of missed hamate (esp hook) fractures is delayed rupture of the flexor carpi ulnaris tendon due to friction against the rough surface of a fractured hamate passing through the canal, and I do not believe that this was specifically mentioned in this review.
– What information is uncertain or could possibly be an area of research: In general, I think it is interesting to ask whether there is greater cost to the health system and society as a whole if we jump to obtain advanced imaging on a wider range of wrist injuries vs simply casting/splinting empirically and sending for hand follow-up. This was hinted at in the discussion of treatment for scaphoid fractures, but it might be worthwhile to ask the question for other carpal bone injuries as well. Of course, given that they are less common, it might be difficult to design a prospective study that would be adequately powered and cost-effective itself.
“Dexamethasone Therapy for Septic Arthritis in Children”
– What are some strengths of the study?
I think that one of the greatest strengths of this study is that it comes in the wake of two RCTs on the topic. It makes the findings more believable despite the limitations of an observational design. I think the authors do a good job discussing the strengths and weaknesses of their particular study.
– What are the limitations?
The biggest limitations are due to selection bias and baseline differences between the two groups as well as external generalizability. One of the most interesting things was the large group of patients with concurrent osteomyelitis in the antibiotics only group. One would expect the recovery course to be slower for osteo as opposed to isolated septic joint, and given that there were no osteo patients in the steroids group, this would have artificially inflated the impact of steroids on the clinical course. The authors discussion of the high prevalence of K. kingae and absence of MRSA in the cohort also raise questions about the benefits that could be expected in our own population, where the microbiology is likely to differ significantly.
– What are the main outcomes of the study?
The study looked at duration of fever, days until resolution of pain and limitation, decrease in CRP levels, duration of parenteral abx therapy, and length of hospital stay. They showed both a statistically and clinically (by my judgement) significant difference in all of these outcomes, favoring the dexamethasone group.
-Does reading this article change your practice? If so, how?
This was a fascinating article because I had never heard of adjunctive steroids as being part of treatment for septic joint, so it was great to learn that there are already two trials and a pretty good observational study on this issue! I’m certainly not going to rush to give dex to all of these kids, given that this is not our practice pattern at this time, but will be interested to have further converstations with pedi ED attendings and ortho consultants about this. As Alex says, looking forward to the adult trial as well…
Wrist Injuries
Practice changing?
This article made me more aware of the “other” types of wrist injuries besides scaphoid, colles, and smith fractures, which we see more frequently. It was also a great review on wrist anatomy, especially b/c we are still in “ice season” and see many FOOSHs.
I think reading Dr. Feldman’s comments also changed my practice re: thumb spica splints and would consider sending a patient out in a wrist splint, which would be more efficient for us and more comfortable for the patient.
What information had you believed in previously that were debunked by reading this article?
I did not know that DRUJ instability required emergent ortho referral (we would do this at BMC but important for community practice) or that distal radius fractures are the most common fx for children <16.
What new information did you learn from reading this article?
New information?
Lots! I have not seen may non-scaphoid fractures but will use the table on p.291 as a future reference to figure out management for these patients. I also learned some new PE maneuvers to test for scalloped fractures.
What are current areas of uncertainty on this topic that can be potential areas for research?
Is it more beneficial to just get a wrist CT of all suspected scaphoid fractures? We get CTs for a lot less and this is a debilitating condition if missed, might make sense to scan more of them.
Study strengths?
Evaluated a relatively novel idea (steroids + abx in septic arthritis). Decent #s for a pediatric study.
Limitations?
Many. Not RCT. I’m left wondering the same question as Alex and Dr. Feldman…why didn’t they just do a prospective study? Also, I’m perplexed on what mandated that some (26) patients received steroids while other patients did not (90). They state it was at the discretion of the admitting physician and “policy of the specific admitted department.” I feel they could’ve discussed this more,
Main outcomes?
Compared with monotherapy, antibiotics+dexamethasone treatment
was associated with a shorter duration of fever, more rapid
clinical improvement, faster CRP decline, shorter ABX duration and time in the hospital.
Does reading this article change your practice? If so, how?
Not really. I may bring up this article to discuss if we’re treating a suspected pediatric septic arthritis but the limitations of the control group (26 patients, no MRSA, etc.) are tough for me to overlook.
Study strengths:
Interesting content in that it takes bench research about synovial fluid in septic arthritis, steroids, host immune response, etc and translates that into something that is clinically pretty interesting and counter to what a lot of us learned.
Limitations?
As everyone has said, a lot of limitations. I’m glad people who are more research-literate than me also are confused about why they chose this methodology — it doesn’t feel particularly compelling to me. Also really hard to generalize given that their hospital has such specific practice patterns that are not the gold standard at a lot of places.
Main outcomes?
Abx plus dex was better! Shorter fevers, shorter abx, shorter hospitalization, faster clinical and lab improvement.
Practice changing?
Again, I echo everyone else in that I would toss this out as a thought in the appropriate (rare) pt but would not fight for it. I think it does contribute to a broader conversation about the role of steroids in infection, so from that more holisitic perspective, it does alter my overall viewpoint.
Dex Therapy for Septic Arthritis in Children
1.) Strengths: Clear and fairly robust choice in terms of outcomes (pain, biomarkers, follow up, interventions, etc.). Like that they looked at culture data.
2.) Limitations: Retrospective cohort study. Large age range (2 months to 18 years). Only one dosing/frequency of dex was studied. Selection bias x2 (larger joints more likely to get steroids; multiple joint infects and/or osteo less likely to get steroids and increase hospital stay which may have biased data). Low rate of positive bacterial cx (i.e., 78.4% were negative! What exactly were you treating!).
3.) Main outcomes: Abx + dex tx a/w with more rapid clinical improvement, faster decrease in bio-markers, shorter parenteral abx use, shorter hospital stay vis-à-vis abx only in children with septic arthritis.
4.) Does it change my practice? While this study is retrospective in nature, it follows to smaller RCT studies suggesting a beneficial role for dex in children with septic arthritis. It’ll likely require more studies and subsequent meta-analysis, reviews, etc. suggesting similar findings before it becomes standard of care. However, I’d lean on the side of treating with steroids as a short course of steroids carries very few risks. Also, will def speak with ortho consults and peds attendings should the matter present itself.
Wrist Injury Review
1. Changed my practice? Yes. Not so much changed, but rather added as my knowledge of carpal injuries was rather limited especially with regard to ortho f/u. I incorrectly assumed all these fx are “f/u ortho in 10 days.” However, the author does a good job at explaining what type of ortho f/u (urgent vs emergent vs 1 week) is needed depending on the fracture. We’re lucky that ortho typically comes to ED to evaluate almost every ortho injury and provide recs. But for the community ED doc, this info is great.
2. Debunked info? Plain radiographs cannot dx or r/o a large % of injuries. I knew they weren’t perfect (ie, scaphoid fx) but didn’t realize the extent.
3. New info learned? Timing of ortho f/u for different distal fx types. Women over 50 years of age have a 15% (!) lifetime risk of radius/ulna fx. Thumb spica is not only for scaphoid fx – but also for fx of more lateral carpal bones (trapezium, trapezoid, capitate). CTS isn’t just for people who type a lot…but quite common in distal radius fx. A significant portion of the complications a/w distal radius fx are iatrogenic (eg, CTS, close open fx in elderly during reduction, compartment syndrome). My go to scaphoid test had just been “snuff box tenderness” – good to know that you can also palpate tenderness at scaphoid tubercle, tenderness with longitudinal compression of thumb to increased sensitivity/specificity for dx scaphoid fx.
4. Potential areas of research? The authors states plainly that the dx of a scaphoid fx via plain radiographs can lead to false negative (ie, we’re always taught to put that thumb spica on if there’s snuffbox tenderness, regardless of xray result). The author notes that in this case, have the pt f/u in 7-10 days for repeat imaging and that the cost of CT/MRI at the initial visit was too high to justify immediate use of these modalities. Furthermore, she goes on to argue that results are mixed when comparing f/u with immediate CT/MRI. It would be interesting to set up research question that would address when one would be more likely to pull the trigger and get the CT (ie, i/s/o of additional risk factors?). For example, an elderly women with known osteopenia and severe snuffbox tenderness BUT neg scaphoid xray….would you pull the trigger?