Rosen & Barkin's 5-Minute Emergency Medicine Consult (701 page)

• Ampicillin/sulbactam: 3 g IV q6 (peds: 200 mg/kg/d IM or IV div. q6h)
  
• Cefazolin: 1 g IV piggyback (peds: 100 mg/kg/d IM or IV div. q6h, followed by 40 mg/kg/d PO QID for 5–7 days)
  
• Tetanus toxoid: 0.5 mL IM (peds: <7 yr–diphtheria–pertussis–tetanus vaccine preferred; in those >7 yr, adult dose tetanus toxoid if immunization series not completed), tetanus immune globulin, as required, 250 IU administered IM
  

FOLLOW-UP

• Patients with infected tendon lacerations must be admitted for operative débridement.
  
• Any patients with tendon injury secondary to human bite must be admitted for operative débridement and IV antibiotics.
  
• Any patients with significant flexor tendon laceration may be admitted for timely operative repair or transferred to the nearest hand surgeon.
  

• Patients with an extensor tendon laceration that is not infected, nor associated with other significant injury or underlying fracture, which was repaired by the ED physician and is now properly splinted, may be discharged with timely surgical follow-up.
  
• Patients with an extensor tendon laceration requiring surgeon referral for repair (wrist, forearm, proximal IP joint), which has been properly treated and splinted, with the patient placed on antibiotics, may be discharged for timely surgical follow-up.
  

• Partial lacerations are common but more difficult to diagnosis than complete disruptions because they may demonstrate intact function:
  
  • Alterations of the normal resting hand position may indicate partial laceration.
    
• Lacerations over the metacarpophalangeal joint should be considered the result of a human bite until proven otherwise:
  
  • Look for associated extensor tendon injury while metacarpophalangeal joint flexed.
    
• It is very important to test strength because tendon injuries with up to a 90% full-thickness laceration can have normal range of motion. Therefore, test strength against resistance.
  
• Tendon laceration with >20% cross-sectional area of involvement need repair
  

• Fitoussi F, Badina A, Ilhareborde B, et al. Extensor tendon injuries in children.
  J Pediatr Orthop
  . 2007;27(8):863–866.
  
• Matzon JL, Bozentka DJ. Extensor tendon injuries.
  J Hand Surg Am.
  2010;35(5):854–861.
  
• Nassab R, Kok K, Constantinides J, et al. The diagnostic accuracy of clinical examination in hand lacerations.
  Int J Surg
  . 2007;5(2):105–108.
  
• Sokolove PE. Extensor and flexor tendon injuries in the hand, wrist, and foot. In: Roberts JR, Hedges JR, eds.
  Clinical Procedures in Emergency Medicine
  . 5th ed. Philadelphia, PA: Saunders Elsevier; 2009.
  
• Wu TS, Roque PJ, Green J, et al. Bedside ultrasound evaluation of tendon injuries.
  Am J Emerg Med
  . 2012;30(8):1617–1621.
  

CODES

• 848.9 Unspecified site of sprain and strain
  
• 884.2 Multiple and unspecified open wound of upper limb, with tendon involvement
  
• 891.2 Open wound of knee, leg [except thigh], and ankle, with tendon involvement
  

BASICS

• The term “tendinitis” has been used to describe chronic painful tendon injuries before the underlying pathology was understood. This term has led to confusion about the cause, chronicity, and treatment of the underlying disorder. The terms “tendinosis” or “tendinopathy” should be used to describe chronic tendon disorders.
  
• Overuse syndrome:
  
  • Clinical syndrome of chronic pain and tendon thickening
    
  • Synovial cells increase in thickness
    
  • Excess synovial fluid collection
    
  • Constant irritation
    
• If no further injury occurs, the acute process may last from 48 hr–2 wk.
  
• Tendinopathy is described as fibrosis being present without inflammatory cells and symptoms persist longer than 3 mo.
  

• Mechanical overload or repetitive microtrauma to the musculotendinous unit:
  
  • Intrinsic factors:
    
    • Inflexibility
      
    • Muscle weakness or imbalance
      
  • Extrinsic factors:
    
    • Excessive deviation, frequency, or activity
      
  • In tendinopathies, the collagen is in a state of disrepair, with proliferation and chronic irritation of neurovascular repair tissue in the tendon and its linings.
    
• Chemotactive and vasoactive chemical mediators are released:
  
  • Vasodilatation and cellular edema increasing the number and activity of PMNs
    

DIAGNOSIS

• The patient’s history should explain what movement led to the injury.
  
• Repetitive stress and mechanical overload
  
• The classic inflammatory signs include pain, warmth, erythema, and swelling.
  
• Pain will resolve quickly after initial movement, only to become a throbbing pain after exercise.
  

• Defined as inflammation of the tendon only
  
• There is a poor distinction between tendonitis and tenosynovitis (degree of inflammation). These are now termed as tendinopathies.
  
• Clinical findings:
  
  • Warmth
    
  • Presence of an effusion
    
  • Decreased range of motion
    
  • Instability
    
  • Pain on motion
    
  • Tenderness over tendon site
    

Specific Conditions Supraspinatus Tendinopathy

Supraspinatus and other rotator cuff tendons:

• Compressed between humerus and acromion
  
• Overuse of the extremity may lead to microtrauma of the tendons and fibers.
  
• Neer classification:
  
  • Stage 1:
    
    • Age <25
      
    • Involved in sports requiring repetitive overhead motion (e.g., swimmers or pitchers)
      
    • Edema and hemorrhage of the tendon
      
    • Flexion–abduction motion will elicit pain.
      
    • “Dull aches”
      
  • Stage 2:
    
    • Age 25–40
      
    • Pain is constant and worsens at night.
      
    • Active motion is limited by pain.
      
    • Passive range of motion is preserved.
      
    • Diffuse, intense pain
      
    • Fibrosis and thickening of the tendon
      
  • Stage 3:
    
    • Partial or complete tendon tears
      
    • Raising the humerus in a forced forward flexion while preserving scapular rotation causes impingement.
      

Calcific Tendonitis

• Age older than 40 yr with unknown etiology.
  
• Any tendon of the rotator cuff can be affected, but there is a predisposition for the supraspinatus.
  
• Most cases are asymptomatic and are found on routine radiographs.
  
• Calcium is deposited within the tendon over time, undergoes spontaneous resorption, causing pain.
  
• Acute attacks may develop from crystal release.
  

Bicipital Tendinopathy

• Pain to the anterior shoulder, which radiates down the radius
  
• Discomfort when rolling on the shoulder or trying to reach a hip pocket or back zipper
  
• Focal tenderness is between the greater and lesser tuberosities of the humerus.
  
• Yergason test:
  
  • Elbow at 90° and arm against the body
    
  • Pain increases with resisted supination of the wrist.
    
• Speed test:
  
  • Pain along the bicipital groove with resisted forward flexion and forearm supination
    

Lateral Epicondylitis (Tennis Elbow)

• Rotational repetitive motion causes pain.
  
• Dull ache on the outside of the elbow that increases with grasping and twisting
  
• Inflammation at the insertion of the common extensor tendon at lateral epicondyle of humerus
  
• Resisted active dorsiflexion of the wrist on extension of the middle finger against resistance can reproduce pain with the elbow extended.
  
• Inflammation at site of insertion of the flexor carpi radialis on the medial epicondyle:
  
  • Bowlers, golfers, pitchers
    
  • Active flexing of the wrist against resistance causes pain.
    

Wrist/Hand

• Inflammatory changes of the synovial lining between tendons and the retinaculum
  
• De Quervain tenosynovitis:
  
  • Inflammation of the abductor pollicis longus and extensor pollicis brevis
    
  • Finkelstein test:
    
    • Patient makes fist with thumb curled in palm.
      
    • Wrist is deviated in the direction of the ulna.
      
    • Pain occurs in 1st extensor compartment.
      
  • Osteoarthritis of the carpal metacarpal joints or GC tenosynovitis causes the same pain.