Questions of the Week for 12/12/2023

Author: Christian Gerhart

A 2-year-old male presents with left leg pain and refusal to walk. He has pain with passive range of motion of the left hip on exam. He is afebrile in the ED but his mom says that he had a temperature of 99.2 F at home. What diagnostic studies should this patient undergo? 

  • Given the patient’s refusal to walk and pain with passive range of motion of the hip, a CBC, ESR, CRP and left hip x-ray should be obtained as septic arthritis is possible. A blood culture should be considered especially if the patient is febrile. Arthrocentesis is generally the most helpful test but can be challenging in young children, particularly when the hip or shoulder is involved. Recall that the original Kocher criteria were developed to aid in distinguishing between septic arthritis and transient synovitis in children of the HIP ONLY. They are listed below:

    History of fever >38.5 C

    Non-weight bearing

    White blood cell count >12,000 cells/mm3

    Erythrocyte Sedimentation Rate >40mm/hour

    Patients with zero of these had a rate of <0.3% of septic arthritis. The rate when patients had one, two, three or four predictors was 3%, 40%, 93% and 99% respectively. In subsequent validation studies there have been varying results and none have had as convincing of results as the original Kocher study. Most authors have found that the calculated probability of septic arthritis of the hip would probably be approximately 2% or less if all of the above are absent and the CRP is less than 20 mg/L (Modified Kocher Criteria). If this patient continues to not be ambulatory, consultation with orthopedics for joint aspiration should be considered.

A 3-year-old male presents with left hip pain and fever of 102 F in triage. What imaging modalities should be used to evaluate this patient? 

  • Plain radiographs are generally the starting point. These can assess for traumatic injury, evidence of osteomyelitis or tumor or another process such as Legg-Calvé-Perthes disease or a slipped capital femoral epiphysis (SCFE). If the concern for septic arthritis persists then an ultrasound of the bilateral hips can be useful for identifying an effusion of the hip. This is helpful for facilitating arthrocentesis. Septic arthritis usually produces a unilateral effusion, whereas transient synovitis or a systemic arthritis often produce bilateral effusions. If MRI can be obtained from the ED (and if the child can tolerate it), then this can be considered if the diagnosis remains in question. This is particularly helpful in identifying associated osteomyelitis. Discuss antibiotic initiation timing with orthopedics as MRI is a time-consuming test.

You are taking care of a 34-year-old male patient with two days of left lower extremity pain. He has palpable DP pulses bilaterally but is in severe pain. An image of his leg is shown below. What clinical syndrome is this most likely to represent? 

Image from James Heilman, MD via Wikipedia

  • Phelgmasia cerulea dolens. This is caused by a large vessel deep venous thrombus (DVT), usually with involvement of the iliocaval system. The blue discoloration is caused by extension of the thrombus into venous collaterals, leading to venous hypertension and, if untreated, obstruction of arterial flow and compartment syndrome. Diagnosis is made with venous duplex confirming a DVT and clinically in a patient with severe pain, impressive limb swelling, and an extremity with bluish discoloration that is generally non-blanching. These patients require an emergent vascular surgery consult in addition to anticoagulation.

You are in TCC and get a page for a 55-year-old male with no known medical history who experienced sudden onset chest pain and presents in cardiac arrest. You take report from EMS and the patient had a witnessed arrest with bystander CPR and 15 minutes of downtime. His rhythm has been ventricular fibrillation at each pulse check. He has been unsuccessfully defibrillated 3 times and received 3 rounds of epinephrine and an amiodarone bolus. He was intubated in the field and his end tidal CO2 is 35 on the LUCAS device. What are the next interventions that should be considered? 

  • ECMO should be seriously considered at this point for this patient in refractory ventricular fibrillation. Early activation is key, since longer downtime portends a worse survival. The ELSO criteria favor patients like this who are healthy, have a witnessed arrest with minimal downtime and who have a shockable rhythm when considered ECMO8.

    The other treatment option for refractory ventricular fibrillation, especially if ECMO is not readily available, is esmolol. This has been hypothesized to combat the excessive beta-adrenergic stimulation from epinephrine and the arrest itself, both of which contribute to refractory ventricular fibrillation. The dose is 500 mcg/kg, followed by an infusion at 50 mcg/kg/min.  A meta-analysis in Resuscitation from 2020 examined this and found a number-needed-to-treat (NNT) NNT of 6 for survival with favorable neurologic function, though the sample size was limited, and the studies have been small and heterogenous9.

You have a patient who was in an MVC who presents with left ankle pain and has the following X-ray. What is the diagnosis and management? 

  • This is a medial subtalar dislocation. It is important to distinguish between a tibiotalar dislocation and a subtalar dislocation as subtalar dislocations are often more challenging to reduce and more commonly require operative management. Medial dislocations such as this can usually be managed with closed reduction under sedation, while lateral dislocations are very likely to require open reduction.

References 

 

  1. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999;81(12):1662-1670. doi:10.2106/00004623-199912000-00002 

  2. Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. 2006;88(6):1251-1257. doi:10.2106/JBJS.E.00216 

  3. Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004;86(8):1629-1635. doi:10.2106/00004623-200408000-00005 

  4. Sultan J, Hughes PJ. Septic arthritis or transient synovitis of the hip in children: the value of clinical prediction algorithms. J Bone Joint Surg Br. 2010;92(9):1289-1293. doi:10.1302/0301-620X.92B9.24286 

  5. Erkilinc M, Gilmore A, Weber M, Mistovich RJ. Current Concepts in Pediatric Septic Arthritis. J Am Acad Orthop Surg. 2021;29(5):196-206. doi:10.5435/JAAOS-D-20-00835 

  6. Chinsakchai K, Ten Duis K, Moll FL, de Borst GJ. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011;45(1):5-14. doi:10.1177/1538574410388309 

  7. Ibrahim B, Kattimani R. Phlegmasia Cerulea Dolens, a Deadly Complication of Deep Vein Thrombosis: Case Report and Review of Literature. Cureus. 2021;13(11):e19927. Published 2021 Nov 26. doi:10.7759/cureus.19927. 

  8. Richardson, Alexander (Sacha) C. MD, FCICM; Tonna, Joseph E. MD, MS; Nanjayya, Vinodh MD; Nixon, Paul M; Abrams, Darryl C. MD‡; Raman, Lakshmi MD§; Bernard, Stephen MD; Finney, Simon J. MD; Grunau, Brian MD; Youngquist, Scott T. MD, M; McKellar, Stephen H. MD, MS; Shinar, Zachary MD; Bartos, Jason A. MD, PhD; Becker, Lance B. MD; Yannopoulos, Demetris MD; BˇELOHLÁVEK, Jan MD, PhD; Lamhaut, Lionel MD; Pellegrino, Vincent MD. Extracorporeal Cardiopulmonary Resuscitation in Adults. Interim Guideline Consensus Statement From the Extracorporeal Life Support Organization. ASAIO Journal 67(3):p 221-228, March 2021. | DOI: 10.1097/MAT.00000000000013 

  9. Gottlieb M, Dyer S, Peksa GD. Beta-blockade for the treatment of cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia: A systematic review and meta-analysis. Resuscitation. 2020;146:118-125. doi:10.1016/j.resuscitation.2019.11.019 

  10. Lugani G, Rigoni M, Puddu L, et al. Subtalar dislocation: a narrative review. Musculoskelet Surg. 2022;106(4):337-344. doi:10.1007/s12306-022-00746-x. 

  11. Bibbo et al. Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases. Foot Ankle Int. 2003. 24(2):158-63.  

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