The asymptomatic groin swelling

A 75-year-old patient is admitted. He has had a palpable swelling in the right groin for 3 months. He is referred by his general practitioner to rule out a femoral hernia.

Upon admission, a slender man in an age-appropriate general condition is observed. The abdomen appears normal. In the area of the right groin, a roughly 5 cm firm elastic swelling can be palpated medial to the vessels on the ventral side of the thigh. The soft tissues show no redness. Auscultation reveals no bowel sounds. The medial and lateral inguinal rings are unremarkable. No insufficiency can be felt during provocation maneuvers.

The range of motion of the hips is free, but there is pain on the right side beyond 80° of flexion. Peripheral foot pulses are palpable.

Ultrasound shows an approximately 5 cm large, septated cystic structure. The hernial orifices are intact. Doppler sonography shows no indication of an aneurysm.

The subsequent CT scan showed the following findings:

This reveals bilateral but right-dominant labrum cysts associated with pincer impingement and advanced coxarthrosis. The therapeutic procedure discussed with the patient was alloplastic hip joint replacement.

Discussion:

Labrum cysts of the hip are relatively common findings, often discovered incidentally during imaging studies such as MRI. They are synonymous with terms like ganglion, ganglion cyst, juxta-articular cyst, mucous dorsal cyst, mucoid cyst, myxomatosis nodularis cutanea, or "bump" on the hand. These refer to a cystic pseudotumor in the area of a joint capsule or tendon sheath. They arise as a result of nonspecific proliferation of mesenchymal cells, degeneration of collagenous connective tissue, or overproduction of hyaluronic acid by fibroblasts.

Synovial cysts are pseudo-cysts lined with synovial epithelium, with a thick wall of granulation tissue, histiocytes, and giant cells. They are usually filled with clear, serous, or xanthochromic fluid rich in mucopolysaccharides. In contrast, ganglion cysts are structures filled with mucin without synovial lining and without direct connection to a joint. They often contain blood, hemosiderin, and air. They may develop from synovial cysts.

Both forms appear clinically and radiologically largely identical, hence the terms are used synonymously. Seventy percent of synovial cysts occur between the ages of 25 and 40, more frequently in women than in men. In 16% of cases, they are incidental findings in healthy individuals and cause no symptoms (Goldmann 2013). Diagnosis is usually made via CT or MRI.

Causes can include overuse or previous labrum lesions. The latter occur as a result of trauma or degeneratively in femoroacetabular impingement, where cysts form from the escaped joint fluid.

Therapeutically, the approach depends on size and symptomatology. Small cysts or incidental findings are treated conservatively. Only larger cysts with pain symptoms, movement restrictions, and impingement in the hip joint are treated surgically.

Conservative treatment options include:

- Resting the hip joint

- Anti-inflammatory medications such as ibuprofen or diclofenac

- Physical therapy for pain relief and muscle strengthening

- Injections of hyaluronic acid into the hip joint to reduce friction

- Joint aspiration, though there is a high likelihood of recurrence

- Joint-friendly sports such as swimming, cycling, or walking

Surgical treatment options include:

- Hip arthroscopy for suturing/refixation of the torn labrum in complete tears

- Partial removal (resection) of the damaged parts of the labrum

- Removal of bony overgrowths (offset correction) to prevent further damage

The choice of treatment depends on the extent of the lesion, symptoms, and the patient's activity level. For smaller tears, conservative therapy is initially attempted. For larger tears or labrum detachments, surgical treatment is often necessary.

Citations:

Upon request

Cement burns

Cement burns are a rare injury, which can occur after long exposure to the skin. We present the case of a 72-year-old man who sustained a cement burn of his lower leg. The late presentation of the injury in conjunction with his comorbidities resulted in an amputation of his lower leg.

In the process of making concrete, cement and water induce a chemical reaction, which releases heat up to 70° C. When exposed to the skin, burns can be caused. The severity largely depends on the exposure time. In most cases, cement can be removed early enough before it causes injuries. As such, the most common cases present themselves with a dermatitis type of redness. In our case, however, prolonged exposure led to extensive soft tissue necrosis resulting in the amputation of the lower leg due to the patient's comorbidities and neglect.

A 72-year-old man presented himself in the A&E department. Three weeks ago, he had helped his son pour a foundation during renovation work. During the process, liquid concrete had flowed into his rubber boot. He only noticed it when the concrete became hot inside the boot. He then took off the boot and his pants. His lower leg and foot showed severe redness. He briefly cooled the redness with water and was able to continue working after changing his clothes. In the following days, he paid little attention to the redness. He apparently ignored the discoloration until it reached its current extent. He did not seek medical attention for the injury.

The patient is, considering his age, quite active and, along with his wife, self-sufficient. There is a history of coronary heart disease. He has been smoking 20 cigarettes per day since his youth and suffers from an insulin-dependent diabetes mellitus with a known diabetic polyneuropathy.

The left lower leg and foot present as follows: extensive, deep, circular, and medially emphasized necrosis formation in the distal third of the lower leg and the entire dorsal surface of the foot, with mummification of all the toes.

For treatment planning, an angiography CT scan was initiatd. It revealed a massive sclerosis below the trifurcation with long-segmented stenosis and complete occlusion of the arteries as from the mid third of the lower leg.

Admission was made with the intention of a soft tissue debridement. In accordance with the CT findings, deep necrosis was found in an overall atrophic soft tissue envelope. Debridement followed by vacuum therapy and two-stage soft tissue coverage was no longer considered feasible. Therefore, a lower leg amputation was performed.

In the production of concrete, cement is often used. Cement contains calcium oxide, silicon dioxide, aluminum oxide, iron oxide, and sulfate. Calcium oxide reacts with water to form calcium silicate hydrate (CSH) with the release of heat. During the curing process of concrete, temperatures of about 50 to 70 degrees Celsius can be generated, known as "hydration heat". Additionally, the chemical reaction induces an alkaline pH. This can cause further tissue damage by dissolving proteins and collagen, dehydrating cells, and saponifying fat. Both factors, heat and an alkaline surrounding,  can lead to injuries that are referred to as "cement burns."

In 1995, a classification of cement burns was done by Xiao and Cai, taking into consideration the mechanism of cement injury on the skin (Xiao 1995)[i]. Three types of burns can be produced by cement: by abrasion, blast or heat (Spoo 2001)[ii]:

·       Abrasion burns are the most frequent injuries and are located mostly on the lower limbs, affecting knees and lower legs with less than 5% of the skin surface (Spoo 2001).

·       Blast burns are produced by explosions and are rare, but more severe, with systemic damages (Xiao 1993)[iii].

·       Heat burns are explained by thermal damage, a chemical process that induces the production of alkaline substances with destructive effects on the skin (Catalano 2013)[iv].

The injuries are relatively rare. Even in specilized burns centres, their share varies between 1 and 2% (Lewis 2004)[v]. Almost 80% of them occur in do-it-yourselfers, and more than half of this group do not work with adequate protective equipment or are unaware of the risks. Most injuries involve the lower legs and knees. In all cases, less than 10% of the skin's surface is affected (Rycroft 1980[vi], Spoo 2001, Besset 2014[vii], Lewis 2004). The studies found full-thickness burns in 50 to 66% of their cases, with an operation being required in 20 to 34%.

In 1963, a first case of a grade 3 burn to the shins was described by Rowe (1963)[viii]. Their patient had been kneeling for 21/2 hours in ready-mixed cement. A similar injury was described by Vickers (1976)[ix] in two patients that spent several hours with wet cement inside their boots. Further reports found the same injury pattern. They had a long exposure time with wet cement, in general 2 to 6 hours, in common (Fisher 1979[x], Hannuksela 1979[xi], Buckley 1982[xii]).

When wet cement does come into contact with the skin there are often no immediate symptoms, and this may lead the worker to maintain contact. The extent of tissue damage then depends on the temperature and duration of exposure. Denaturation of cellular proteins can occur as early as 40 to 44°C, while cell death occurs at 45°C with an exposure time of about one hour. At 70°C, a third-degree burn can occur in just one to two seconds.

One particularity of thermal injuries is that the full extent may not be immediately apparent due to the presence of the "stasis zone." This refers to a narrow zone of thermally damaged skin cells that can progress to complete necrosis, known as "afterburning." The stasis zone is caused by impaired microcirculation due to blood vessel constriction, edema formation and subsequent reduced blood circulation. Thus, a superficial second-degree burn (grade 2a) with blistering can progress to a deep second-degree burn (grade 2b), which then requires an expanded treatment approach involving necrosectomy and skin grafting.

Initial treatment must therefore aim at removing all cement immediately by washing with liberal amounts of water. The exposed area needs to be kept dry. In the case of inflammation or blistering, the affected skin needs to be dressed and carefully followed up for the development of a deeper burns.

In cases of advanced injury, treatment for a thermal injuries of grade 2b or higher involves surgical intervention, which must be tailored to the general treatment plan. Since thermal injuries of grade III or higher often accompany complex overall injuries, they must be taken into consideration. The surgical approach involves necrosectomy followed by soft tissue coverage. Depending on the condition of the wound, definitive wound closure can be achieved with a clean wound bed. Temporary vacuum therapy is available to reduce the burden of dressing changes for the patient and promote wound bed granulation.

The aesthetic and functional outcome after treatment can be limiting. Besset (2014)[xiii] found sequelae in 88% of medically treated patients and in 18% of patients treated surgically.

In the case of our patient, the removal of the necrotic tissue would not have been beneficial. The extent of the necrosis was too advanced in the periphery, and preserving or partially preserving the tissue through amputation was not possible due to the lack of perfusion. The underlying distal polyneuropathy likely contributed to the delayed recognition of the thermal reaction, allowing for the profound development of the injury.

Fall 83: More than just back pain

 A 68-year-old man attended A&E with the ambulance. Prior to admission, he had experienced acute pain in the lower lumbar spine when getting up from bed during a twisting motion. Subsequently, he was unable to move due to pain. He complained of neurological symptoms with reduced sensation in the left thigh.

There is no previous medical history. He smokes 20 cigarettes per day. He has been experiencing chronic back pain for 2 years. Six weeks ago, he saw an orthopaedic specialist who ordered an MRI. He was informed that "cysts" were observed. Based on these findings, an appointment was made at a nearby university hospital.

Findings:

The 63-year-old patient is in good nutritional condition and has an age-appropriate general condition. Mobilization from the stretcher to a seated position cannot be tolerated. Rotation of the spine in a supine position is indicated as painful. There is tenderness on palpation of the spinous processes of the lower lumbar spine during a log-roll manoeuvre. Peripheral circulation and neurological status are normal.

Given the previous abnormal MRI findings, a CT scan of the lumbar spine is being request. It reveals a large lytic lesion in the L5 vertebral body with infiltration of the adjacent soft tissues, suggestive of an unstable fracture.

 In the absence of a known tumor, staging is performed to determine the primary site. Liver metastases are identified on ultrasound. A CT scan of the thorax shows a central bronchial carcinoma with additional rib metastases. Bronchoscopy reveals infiltration of the right main bronchus, from which a histological sample is taken. The histology confirms a mucinous adenocarcinoma.

Therapy and Course:

After an oncological consultation, the patient was transferred to a neurosurgical department for stabilization with spinal fusion of the lumbar vertebral metastasis and initiation of chemotherapy. Local postoperative radiation therapy for the metastasis was discussed.

 Discussion:

The patient had been experiencing back pain for 2 years without any trauma. Diagnostic evaluation at this time revealed the presence of metastatic bronchial carcinoma.

According to guidelines, in the absence of acute treatment-requiring conditions based on history and examination, further diagnostic measures are not indicated for back pain. They are only recommended after a duration of 4 to 6 weeks with guideline-compliant treatment and then only once. Imaging is recommended only if there are indications of a specific condition, e.g.  trauma, tumor in older age, steroid therapy, neurological symptoms, spondylarthritis, general symptoms like recent onset of fever or chills, loss of appetite, rapid fatigue, recent bacterial infection, intravenous drug abuse, immunosuppression, consuming underlying diseases, recent spinal infiltration treatment, or severe nocturnal pain. This was not done for our patient. The symptoms were managed with analgesia as needed but not further investigated.

The guidelines do not consider the patient's age. It can be interpreted that age can be used to rule out specific causes and initiate imaging even at the initial contact. In young patients under 20 and in "older" patients over 55, back pain may indicate a specific origin. Imaging should be used in conjunction with additional investigations depending on the underlying suspected diagnosis. From the age of 20 to under 50, the incidence of back pain is very high, and the course is usually benign and self-limiting (Chou 2011).

However, with increasing age, the causes of extraspinal back pain also increase. This includes mainly abdominal and visceral processes, e.g.  cholecystitis, pancreatitis; vascular changes, particularly aortic aneurysms (Takeyachi 2008), gynecological causes, e.g.  endometriosis, urological causes, e.g.  urolithiasis, kidney tumors, perinephric abscesses, neurological diseases, e.g.  polyneuropathies, and psychosomatic and psychiatric diseases. Their share is estimated at 2% (Deyn 2001). Therefore, a significant portion of these diseases can be promptly detected through additional abdominal ultrasound and urinalysis.

In malignant underlying diseases, back pain is usually a late manifestation due to metastasis, particularly from the stomach, lungs, prostate, kidneys, lymphomas, gastrointestinal tumors, and breast. They account for 80% (Greenberg 2016). Back pain due to metastasis occurs in approximately 10% of cancer patients. Patients in middle age (40-65 years) are particularly affected. In contrast, metastases are very rare in childhood and usually occur intramedullary with brain tumors.

Metastasis primarily occurs hematogenously in the vertebral bodies. With increasing infiltrative growth, the pedicles can also be affected, and the spinal canal can be compressed. Rarely does the tumor invade the dura and spread intradurally (Abeloff 2008).

The thoracic spine is most commonly affected, accounting for 50-60% of cases. The segments affected are T4 to T7. In prostate cancer, on the other hand, metastasis in the lumbar spine is predominant. In more than half of the patients, multiple levels of the spine are affected.

Therapy

The choice of therapy depends primarily on the underlying primary tumor. The treatment of vertebral metastases is determined by the localization, remaining stability, duration and severity of neurological symptoms, and the overall condition of the patient. Classification systems such as the Tomita Score, Tokuhashi Score, or Spinal Instability Neoplastic Score can help in the decision-making process, but they have limited practical applicability and serve more as aids.

The primary goal of therapy is tumor reduction or, ideally, resection to relieve the spinal canal and nerve roots and achieve pain relief.

-        Medical Treatment

Corticosteroids can reduce acute swelling and pressure on the nerve structures.

Bisphosphonates are used to prevent bone loss and thus provide pain relief.

Some tumors grow in a hormone-dependent manner, so hormone preparations can also be used.

-        Radiation Therapy

Radiation therapy reduces tumor cells. This can be done as monotherapy or in combination after surgery.

            - Surgery

- Kyphoplasty or vertebroplasty

- Laminectomy and spinal fusion

During laminectomy, parts of the bony vertebral body are removed to relieve the spinal canal. The tumor may not always be completely removed. The surgery can create instability, which can be supplemented with spinal fusion. Classification systems such as the SINS score are used for assessment. These systems consider the localization of the metastasis, extent of damage, and position of the vertebral bodies relative to each other (Fisher 1976).

 

Prognosis

The overall prognosis depends significantly on the primary tumor and the tumor stage. Pain control is a crucial component of the treatment plan, as well as the stability of the spine to prevent further neurological complications, e.g.  spinal cord compression.

Favorable prognostic factors include solitary metastasis to the spine and primary tumors e.g.  breast cancer, kidney cancer, lymphomas, or multiple myeloma. Unfavorable factors include multiple metastases, the occurrence of pathological fractures, and lung cancer as the primary tumor, as well as neurological symptoms or their loss (Bauer 1996). The location of the metastasis does not have a prognostic value in principle, but it significantly determines the possibilities of surgical intervention.

The preoperative status of neurological functions or other therapies also plays a crucial role in the outcome. In particular, ambulation and sphincter function are important, as complete loss of sphincter function is an unfavorable prognostic factor and is usually irreversible (Greenberg 2016).

Impingement symptoms after low velocity car accidents: Is there a whiplash of the shoulder joint?

Impingement symptoms after low velocity car accidents: Is there a whiplash of the shoulder joint?

After low-velocity rear-end accidents, a plethora of symptoms can arise. In addition to neck pain, there are particularly complaints radiating into the shoulder, which can either radiate from the trapezius or be localized in the shoulder joint, which in turn can radiate back into the neck.

In 9% of cases, signs of impingement can be present. We examined patients with impingement signs from an expert clinic. In their case, clinical criteria for impingement had to be fulfilled.

It was found that patients are generally older and female. Manual laborers recovered from complaints faster. MRI and ultrasound showed pre-existing degenerative changes up to tears in the rotator cuff. Signs of a seatbelt injury could not be found.

The examiner and expert can assume that the type of accident is not suitable for causing bodily harm. Studies have shown that patients develop an altered scapulothoracic rhythm.

We argue that acceleration/deceleration alters proprioception and thus muscular guidance. This, in turn, leads to functional impingement, which makes pre-existing changes clinically apparent. This would also explain why complaints can develop on both sides or only on the non-seatbelted shoulder.

The therapy consists of targeted physiotherapy aimed at stabilizing the shoulder girdle muscles rather than focusing on the neck muscles.

Literature

E Pietsch. “Shoulder Impingement after Low Velocity Car Accidents - Is there a "Whiplash" for the Shoulder Joint?” EC Orthopaedics 10.10 (2019): 816-822.

What is effective in chronic lower back pain?

A 2007 American College of Physicians guideline addressed pharmacologic options for low back pain. Now, new evidence and medications have now become available.

The number of trials ranged from 9 (benzodiazepines) to 70 (nonsteroidal anti-inflammatory drugs). New evidence found that acetaminophen was ineffective for acute low back pain, nonsteroidal anti-inflammatory drugs had smaller benefits for chronic low back pain than previously observed, duloxetine was effective for chronic low back pain, and benzodiazepines were ineffective for radiculopathy. For opioids, evidence remains limited to short-term trials showing modest effects for chronic low back pain; trials were not designed to assess serious harms. Skeletal muscle relaxants are effective for short-term pain relief in acute low back pain but caused sedation. Systemic corticosteroids do not seem to be effective. For effective interventions, pain relief was small to moderate and generally short-term; improvements in function were generally smaller. Evidence is insufficient to determine the effects of antiseizure medications.

Conclusion:Several systemic medications for low back pain are associated with small to moderate, primarily short-term effects on pain. New evidence suggests that acetaminophen is ineffective for acute low back pain, and duloxetine is associated with modest effects for chronic low back pain.

Literature:
Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, et al. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. [Epub ahead of print 14 February 2017] doi: 10.7326/M16-2458

http://annals.org/aim/article/2603229/systemic-pharmacologic-therapies-low-back-pain-systematic-review-american-college

The Break Pedal Injury - Always not too obvious

Injuries to the foot in connection with traffic accidents are difficult to diagnose. The linked case report gives an overview on injuries to the midfoot. This injury, better known as brake peadl injury, is easily missed.

Read more on EC Orthopaeics:

https://www.ecronicon.com/ecor/pdf/ECOR-03-000072.pdf

Frustrating: Back schools without reliable benefit in low back pain

Back schools are interventions comprised of exercise and education components. We aimed to systematically review the randomized controlled trial evidence on back schools for the treatment of chronic low back pain.

By searching MEDLINE, EMBASE and COCHRANE CENTRAL as well as bibliographies we identified 31 studies for inclusion in our systematic review and five of these for inclusion in meta-analyses.

Meta-analyses for pain scores and functional outcomes revealed statistical superiority of back schools versus no intervention for some comparisons but not others. No meta-analysis was feasible for the comparison of back schools versus other active treatments. Adverse events were poorly reported so that no reliable conclusions regarding the safety of back schools can be drawn, although some limited reassurance in this regard may be derived from the fact that few adverse events and no serious adverse events were reported in the back school groups in the studies that did report on safety.

Overall, the evidence base for the use of back schools to treat chronic low back pain is weak; in nearly a half-century since back schools were first trialled no unequivocal evidence of benefit has emerged.




Read more:

Straube S, Harden M, Schröder H, Arendacka B, Fan X, Moore RA, Friede T: Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research - systematic review and meta-analysis. Pain:Post Acceptance: June 01, 2016 doi: 10.1097/j.pain.0000000000000640