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Part 1 book “Current diagnosis & treatment - Family medicine” has contents: Failure to thrive, neonatal Hyperbilirubinemia, breastfeeding & infant nutrition, common acute infections in children, skin diseases in infants & children, eating disorders, adolescent sexuality, menstrual disorders, sexually transmitted diseases,… and other contents.
a L A N G E medical book Current Diagnosis & Treatment: Family Medicine FOURTH E d i t i on Jeannette E South-Paul, MD, FAAFP Andrew W Mathieson UPMC Professor and Chair Department of Family Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Samuel C Matheny, MD, MPH, FAAFP Professor and Nicholas J Pisacano, MD, Chair of Family Medicine Department of Family and Community Medicine Assistant Provost for Global Health Initiatives University of Kentucky College of Medicine Lexington, Kentucky Evelyn L Lewis, MD, MA, FAAFP Deputy Director W Montague Cobb/NMA Health Institute Washington DC Adjunct Associate Professor Department of Family Medicine and Community Health Rutgers, Robert Wood Johnson Medical School Piscataway, New Jersey New York Chicago San Francisco Athens London Madrid Mexico City Milan New Delhi Singapore Sydney Toronto South Paul-FM_pi-xx.indd 1/12/15 9:45 AM Copyright © 2015 by McGraw-Hill Education All rights reserved Printed in the United States of America Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-182775-1 MHID: 0-07-182775-7 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-182745-4, MHID: 0-07-182745-5 eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs To contact a representative, please visit the Contact Us page at www.mhprofessional.com Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs TERMS OF USE This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill Education and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise We would like to dedicate this book to all family physicians who deliver care in austere environments, especially our colleagues in uniform, and the families that support them Jeannette E South-Paul, MD, FAAFP Samuel C Matheny, MD, MPH, FAAFP Evelyn L Lewis, MD, MA, FAAFP South Paul-FM_pi-xx.indd 1/12/15 9:45 AM This page intentionally left blank Contents Authors ix Preface xix Section II Adolescence 10 Physical Activity in Adolescents Section I Infancy & Childhood Well-Child Care Christopher W Bunt, MD, FAAFP Mark B Stephens, MD, MS, FAAFP Sukanya Srinivasan, MD, MPH Donald B Middleton, MD Failure to Thrive 11 Eating Disorders 12 Adolescent Sexuality 20 13 Menstrual Disorders 14 Sexually Transmitted Diseases 34 Section III Adults 15 Health Maintenance for Adults 63 16 Preconception Care Richard Kent Zimmerman, MD, MPH Donald B Middleton, MD Behavioral Disorders in Children 162 Essam Demian, MD, FRCOG 70 17 Prenatal Care Richard Welsh, LCSW Marian Swope, MD 9 Seizures 145 Stephen A Wilson, MD, MPH, FAAFP Lora Cox-Vance, MD Paul R Larson, MD, MS Rachel Simon, PharmD, BCPS David Yuan, MD, MS 52 Mark A Knox, MD Barry Coutinho, MD Routine Childhood Vaccines 128 Robin Maier, MD, MA Peter J Katsufrakis, MD, MBA James C Dewar, MD Stephanie B Dewar, MD Skin Diseases in Infants & Children 119 LTC Mary V Krueger, DO, MPH 27 Tracey D Conti, MD Mamta Patel, MD Samidha Bhat, MD Common Acute Infections in Children 112 Amy Crawford-Faucher, MD, FAAFP Andrew B Symons, MD, MS Martin C Mahoney, MD, PhD, FAAFP Breastfeeding & Infant Nutrition 100 Rachel M Radin, MA, MS Lisa M Ranzenhofer, MS Marian Tanofsky-Kraff, PhD Evelyn L Lewis, MD, MA, FAAFP 12 James C Dewar, MD Stephanie B Dewar, MD Neonatal Hyperbilirubinemia 89 170 Martin Johns, MD Gregory N Smith, MD 75 18 Contraception Donald B Middleton, MD 178 Susan C Brunsell, MD v South Paul-FM_pi-xx.indd 1/12/15 9:45 AM vi ▲ 19 Adult Sexual Dysfunction Contents 187 Charles W Mackett, III, MD 20 Acute Coronary Syndrome 195 Stephen A Wilson, MD, MPH, FAAFP Jacqueline Weaver-Agostoni, DO, MPH Jonathan J Perkins, MD 21 Heart Failure 205 217 222 234 250 261 268 278 Anja Dabelić, MD 29 Evaluation & Management of Headache 293 C Randall Clinch, DO, MS 30 Osteoporosis Maureen O’Hara Padden, MD, MPH Kevin M Bernstein, MD, MMS 381 37 Endocrine Disorders 390 Pamela Allweiss, MD, MSPH William J Hueston, MD Peter J Carek, MD, MS 38 Acute Musculoskeletal Complaints 401 Nicole Powell-Dunford, MD, MPH, FAAFP 28 Respiratory Problems 369 Belinda Vail, MD, MS, FAAFP Garry W K Ho, MD, CAQSM Thomas M Howard, MD, FASCM 27 Cancer Screening in Women 362 Patricia Evans, MD, MA 36 Diabetes Mellitus Charles W Webb, DO Francis G O’Connor, MD, MPH 26 Neck Pain 345 Samuel C Matheny, MD, MPH Kristin Long, MD J Scott Roth, MD, FACS 35 Hypertension Bruce E Johnson, MD 25 Low Back Pain in Primary Care: An Evidence-Based Approach 33 Hepatobiliary Disorders 34 Vaginal Bleeding Joe Kingery, DO 24 Arthritis: Osteoarthritis, Gout, & Rheumatoid Arthritis 332 Brian A Primack, MD, PhD, EdM, MS Kiame J Mahaniah, MD Brian V Reamy, MD 23 Urinary Tract Infections 314 Cindy M Barter, MD, MPH, IBCLC, CTTS, FAAFP Laura Dunne, MD, CAQSM, FAAFP Carla Jardim, MD 32 Anemia Michael King, MD, MPH Oscar Perez, Jr., DO 22 Dyslipidemias 31 Abdominal Pain Jeanne Doperak, DO Kelley Anderson, DO 39 Common Upper & Lower Extremity Fractures 420 W Scott Black, MD Robert G Hosey, MD Joshua R Johnson, MD Kelly Lee Evans-Rankin, MD Wade M Rankin, DO 298 Jeannette E South-Paul, MD South Paul-FM_pi-xx.indd 1/12/15 9:45 AM Contents Section IV Geriatrics 50 Complementary & Alternative Medicine 40 Healthy Aging & Geriatric Assessment 433 Lora Cox-Vance, MD 41 Common Geriatric Problems 446 453 Robert J Carr, MD 43 Elder Abuse 464 David Yuan, MD, MS Jeannette E South-Paul, MD, FAAFP 44 Movement Disorders 469 486 Deepa Burman, MD, D.ABSM William Markle, MD, FAAFP, DTM&H 562 54 Tuberculosis 570 55 HIV Primary Care 582 56 Depression in Diverse Populations & Older Adults 599 Ruth S Shim, MD, MPH Annelle Primm, MD, MPH Jennie Broders Jarrett, PharmD, BCPS Elizabeth Cassidy, PharmD, BCPS Lauren M Sacha, PharmD 57 Anxiety Disorders 512 523 606 Philip J Michels, PhD M Sharm Steadman, PharmD 58 Personality Disorders W Allen Hogge, MD South Paul-FM_pi-xx.indd 548 Section VI Psychosocial Disorders 494 47 Pharmacotherapy Principles for the Family Physician 505 Matthew D Krasowski, MD, PhD 52 Travel Medicine Ramakrishna Prasad, MD, MPH, AAHIVS Section V Therapeutics, Genetics, & Prevention 49 Pharmacogenomics 540 N Randall Kolb, MD Wanda C Gonsalves, MD 48 Genetics for Family Physicians 51 Chronic Pain Management Niladri Das, MD, UPMC Archana M Kudrimoti, MD Saranne E Perman, MD 46 Oral Health 529 Wayne B Jonas, MD Mary P Guerrera, MD 53 Tickborne Disease Yaqin Xia, MD, MHPE 45 Hearing & Vision Impairment in the Elderly vii Ronald M Glick, MD Dawn A Marcus, MD Daphne P Bicket, MD, MLS 42 Urinary Incontinence ▲ 618 William G Elder, PhD 59 Somatic Symptom Disorder (Previously Somatoform Disorder), Factitious Disorder, & Malingering 626 William G Elder, PhD 1/12/15 9:45 AM viii ▲ Contents 60 Substance Use Disorders 633 Robert Mallin, MD Maribeth Porter, MD 61 Tobacco Cessation 645 653 687 67 Hospice & Palliative Medicine 698 Eva B Reitschuler-Cross, MD Robert M Arnold, MD 660 Evelyn L Lewis, MD, MA, FAAFP Ronald J Koshes, MD, DFAPA 68 The Patient-Centered Medical Home 713 Larry S Fields, MD Elizabeth G Tovar, PhD, RN, FNP-C Index 721 Section VII Physician-Patient Issues 64 Cultural & Linguistic Competence 66 Caring for Lesbian, Gay, Bisexual, & Transgender Patients Steven R Wolfe, DO, MPH Amy Crawford-Faucher, MD, FAAFP Lovie J Jackson-Foster, PhD, MSW 63 Combat-Related Posttraumatic Stress Disorder & Traumatic Brain Injury 678 Jeannette E South-Paul, MD Evelyn L Lewis, MD, MA, FAAFP Martin C Mahoney, MD, PhD, FAAFP K Michael Cummings, PhD, MPH 62 Interpersonal Violence 65 Health & Healthcare Disparities 671 Kim A Bullock, MD, FAAFP Darci L Graves, MPP, MA, MA South Paul-FM_pi-xx.indd 1/12/15 9:45 AM Authors Pamela Allweiss, MD, MSPH Susan C Brunsell, MD Community Faculty Department of Family and Community Medicine University of Kentucky College of Medicine Lexington, Kentucky pallweiss@windstream.net Endocrine Disorders Medical Director Executive Medicine Clinic Walter Reed National Military Medical Center Assistant Professor of Family Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland Susan.c.brunsell.civ@mail.mil Contraception Robert Arnold, MD Leo H Criep Professor of Medicine Section of Palliative Care and Medical Ethics University of Pittsburgh Pittsburgh, Pennsylvania Hospice & Palliative Medicine Kim A Bullock, MD, FAAFP Director Community Health Division Director HRSA Fellowships Assistant Director Service Learning Associate Clinical Professor Department of Family Medicine Georgetown Medical School Washington DC kimabullock@hotmail.com Cultural and Linguistic Competence Cindy M Barter, MD, MPH, IBCLC, CTTS, FAAFP Residency Faculty Hunterdon Family Medicine Residency Program Flemington, New Jersey cindy@thebarters.net Abdominal Pain Kevin Bernstein, MD, MMS, LT, MC, USN Chief Resident Naval Hospital Pensacola, Florida Kevin.bernstein@med.navy.mil Hypertension Christopher W Bunt, MD, FAAFP Assistant Professor Family Medicine Uniformed Services University Major USAF Bethesda, Maryland christopher.bunt@usuhs.edu Physical Activity in Adolescents Samidha Bhat, MD Family Medicine Resident University of Pittsburgh Medical Center McKeesport Family Medicine Resdiency Program McKeesport, Pennsylvania samidha.bhat@gmail.com Breastfeeding & Infant Nutrition Deepa Burman, MD, D.ABSM Family Medicine Faculty Director of Sleep Clinic and Resident Scholarly Activity UPMC McKeesport McKeesport, Pennsylvania burmand@upmc.edu Travel Medicine Daphne P Bicket, MD, MLS UPMC McKeesport Family Medicine Residency Program McKeesport, Pennsylvania bicketdp@upmc.edu Common Geriatric Problems Robert J Carr, MD Medical Director Primary Care of Southbury, Southbury Connecticut Danbury Office of Physician Services Danbury, Connecticut robber.carr@charter.net Urinary Incontinence W Scott Black, MD Associate Professor Department of Family and Community Medicine Lexington, Kentucky wsblac0@uky.edu Common Upper & Lower Extremity Fractures ix South Paul-FM_pi-xx.indd 1/12/15 9:45 AM 418 ▲ Chapter 38 demonstrating displacement of the femoral head The LCPD radiographic findings present a continuum of changes as the disease progresses In the early stages of LCPD, plain radiographs may be normal However, over time there can be widening of the joint space, sclerosis of the femoral head, cystic changes, and coxa magna, which is defined as flattening and widening of the femoral head `` Differential Diagnosis The differential diagnosis includes developmental dysplasia of the hip, septic arthritis, transient synovitis, labral pathology, and benign or malignant neoplasms Inflammatory causes (juvenile rheumatoid arthritis, spondyloarthropathies, Lyme disease arthritis) are possible as well `` Treatment Legg-Calves-Perthes disease is a self-limiting condition, but symptoms may persist for ≤4 years The primary goal of treatment for LCPD is pain reduction, and this sometimes requires bracing/casting and protected weight bearing Operative intervention may be indicated in older patients or those with advanced disease Surgery is the preferred treatment for SCFE and typically involves emergent stabilization of the femoral head with metallic fixation devices Delays in treatment may lead to further displacement and osteonecrosis, ultimately compromising postoperative outcomes Peck D Slipped capital femoral epiphysis: diagnosis and management Am Fam Physician 2010; 82(3):258–262 Wheeless CR, ed Legg Calve Perthes disease In: Wheeless’ Textbook of Orthopaedics (available at http://www.wheelessonline com/ortho/legg_calve_perthes_disease; published Jan 3, 2013; accessed March 26, 2013) OSTEOCHONDRITIS DESSICANS ESSENTIALS OF DIAGNOSIS `` `` Clinical Findings A Symptoms and Signs The clinical presentation is poorly localized knee pain that is worsened by activity There may be a mild limp In more advanced disease the patient may report mechanical symptoms, such as locking or catching An effusion is present in only 1 mm, (2) scapholunate angulation >60°, or (3) radiolunate angulation >15° Associated injuries to look for include perilunate dislocation, lunate dislocation, trapezium fractures, triquetrum fractures, radial styloid fractures, distal radius fractures (Colle fractures), fractures of metacarpals and 2, and capitate fractures Patients present with a painful wrist and may report swelling or paresthesias of the affected hand On examination, there is maximal tenderness in the anatomic snuffbox, pain with radial deviation of the wrist, and pain with axial compression of the thumb Bone healing occurs at different rates depending on the location of the fracture A tuberosity fracture usually heals in 4–6 weeks, and a scaphoid waist fracture in 10–12 weeks A proximal pole fracture can require 16–20 weeks for healing `` Treatment Nondisplaced or minimally displaced (3 weeks after the injury Alshryda S, et al Acute fracture of the scaphoid bone: systemic review and meta-analysis Surgeon 2012;10(4):218–219 Kawamura K, Chung KC Treatment of scaphoid fractures and nonunions J Hand Surg Am 2008;33(6):988–997 METACARPAL FRACTURES `` Clinical Findings A Symptoms and Signs Metacarpal fractures encompass up to two-thirds of all hand fractures Most are due to trauma from either a direct blow to the hand or a fall Patients present with local tenderness and swelling, decreased grip strength, and decreased range of motion The majority of these fractures are nondisplaced and extraarticular Often, these fractures are stable and may be managed conservatively Complications arise from unstable comminuted, displaced, spiral, and oblique fractures resulting in metacarpal shortening and angulation Such fractures affect functional outcomes and often require surgical consultation and subsequent intervention B Imaging Studies At a minimum, AP and lateral radiographs are recommended and comparison views are sometimes helpful In addition, it is recommended that initial radiographs of fractures of the fourth and fifth metacarpals include oblique pronated views A CT scan may be helpful for fractures of the metacarpal head and base and intraarticular fractures `` Complications ▲ 423 3–4 weeks with range-of-motion (RoM) activities beginning thereafter If there is no tenderness, no motion at the fracture site, and adequate callus formation, a protective splint can be considered for an additional weeks; otherwise casting should continue until symptomatic resolution and clinical healing have occurred At weeks postcasting a radiograph should be checked for loss of correction Bridging callus should be seen at 4–6 weeks Spiral or oblique fractures, multiple metacarpal shaft fractures, open fractures, fractures with significant shortening, and intraarticular base fractures require further surgical consultation and intervention Specific considerations for metacarpal fracture treatment depend on the metacarpal involved, location, ability of the fracture to be reduced, and ultimate stability once reduction is obtained Fractures are typically described in four distinct locations: base, shaft, neck, and head A fracture at the base of the first metacarpal resulting in two dislocated bony segments is known as a Bennett fracture These fractures require either closed reduction and percutaneous fixation or open reduction with internal fixation For the remainder of extraarticular, minimally displaced metacarpal base fractures, closed reduction with casting for 4–6 weeks until bony healing is usually appropriate Displaced or intraarticular fractures often require surgical intervention to restore bony congruity and ensure proper return of range of motion and strength Shaft and neck (eg, boxer’s fracture) fractures usually display apex dorsal angulation due to interosseous muscle pull For shaft fractures closed reduction is required for angulation >10° in second and third metacarpals, 20° in fourth metacarpal, and 30° in fifth metacarpal fractures (Figure 39-4) Accepted angulation for neck fractures is 2 mm or angulation >30° Type III: comminuted fractures Type IV: fracture with associated elbow dislocation `` Treatment Mason type I fractures can be managed without orthopedic referral The elbow can be placed in a posterior splint or sling for ≤7 days as needed to control pain Early movement should be encouraged If symptoms allow, these fractures can also be treated without immobilization with patients allowed movement of the elbow as tolerated Repeat x-rays in 1–2 weeks to ensure alignment has been maintained Resolution of pain and return of normal elbow function are usually obtained by 2–3 months Orthopedic referral is generally indicated for Mason type II–IV fractures Black WS, Becker JA Common forearm fractures in adults Am Fam Physician 2009; 80(10):1096–1102 1/9/15 2:51 PM Common Upper & Lower Extremity Fractures ▼▼LOWER EXTREMITY FRACTURES STRESS FRACTURES `` General Considerations Management of traumatic fractures of the lower extremity long bones is relatively straightforward if a few simple rules are recognized Orthopedic referral is required for any traumatic fracture that is displaced or involves a joint line The goal of this section is to guide the primary care physician through a basic understanding of concepts surrounding bone stress pathogenesis, including epidemiology, clinical signs and symptoms, physical examination, radiographic diagnostic aids, and treatment of four difficult-to-treat areas of stress reaction in the lower extremities The population most at risk for stress reaction is athletes This population presents therapeutic challenges secondary to their increased activity, predilection to overuse injury, and desire to return to competition as quickly as possible, which may lead them to compete before the stress injury fully resolves Stress fractures are estimated to make up 10% of all athletic injuries Ninety-five percent of stress injuries occur in the lower extremities secondary to the extreme repetitive weight-bearing loads placed on these bones The peak incidence occurs in people aged 18–25 years There is a decreased incidence of stress fracture in men secondary to greater lean body mass and overall bone structure It has been estimated that female military recruits have a relative risk of stress fracture that is 1.2–10 times greater than men while engaging in the same level of training In athletic populations a gender difference is not as evident, possibly because athletic women are more fit and better conditioned Incidence is estimated to be comparable for all races Stress fracture is most common after changes in an athlete’s training regimen Injury is especially prevalent in unconditioned runners who increase their training regimen Training error, which can include increased quantity or intensity of training, introduction of a new activity, poor equipment, and change in environment (ie, surface), is the most important risk factor for stress injury Low bone density, dietary deficiency, low BMI, menstrual irregularities, hormonal imbalance, sleep deprivation, and biomechanical abnormalities also place athletes at risk Keeping this in mind and recognizing the increasing incidence of female athletic triad (amenorrhea, disordered eating and osteoporosis), it is easy to understand why women can have an increased risk for stress injury `` Clinical Findings A Symptoms and Signs Stress fractures are related to a maladaptive process between bone injury and bone remodeling Bone reacts to stress by South Paul-Ch39_420-432.indd 425 ▲ 425 early osteoclastic activity (old-bone resorption) followed by strengthening osteoblastic activity (new-bone formation) With continued stress, bone resorption outpaces new-bone formation and a self-perpetuating cycle occurs, with continued activity allowing weakened bone to be more susceptible to continued microfracture and ultimately progressing to frank fracture The initiation of stress reaction is unclear It has been postulated that excessive forces are transmitted to bone when surrounding muscles fatigue The highly concentrated muscle forces act across localized area of bone, causing mechanical insults above the stress-bearing capacity of bone Athletic stress fracture follows a crescendo process Symptoms start insidiously with dull, gnawing pain at the end of physical activity Pain increases over days to the point where the activity cannot be continued At first pain decreases with rest, then shorter and shorter duration of activity causes pain More time is then needed for pain to dissipate until it is present with minimal activity and at night After a few days of rest, pain resolves, only to return once again with resumption of activity More specific historical and physical examination findings are discussed below in conjunction with specific anatomic regions B Imaging Studies The diagnosis of stress fracture is primarily clinical and is based on history and physical examination It is prudent to start with plain radiographs, which have poor sensitivity but high specificity, as the initial study The presence of stress reaction is confirmed by the presence of periosteal reaction, intramedullary sclerosis, callus, or obvious fracture line Plain films typically fail to reveal a bony abnormality unless symptoms have been present for at least 2–3 weeks The technetium triple-phase bone scan is often employed to improve diagnostic power Stress reactions can often be visualized within 48–72 hours from symptom onset Triplephase bone scan can differentiate soft-tissue and bone injuries All three phases can be positive in an acute fracture In soft-tissue injuries, with no bony involvement, the first two phases are often positive, whereas the delayed image shows minimal or no increased uptake In conditions such as medial tibial stress syndrome (MTSS), in which there is early bony stress reaction, the first two phases are negative and the delayed image is positive Nuclear medicine bone scans should not be used to monitor fracture healing because the fracture line is not clearly visualized and delayed images continue to demonstrate increased uptake for ≥12 months after initial studies Computed tomographic scans can identify conditions that mimic stress fracture on bone scan, confirm fracture suspected on bone scan, or help to make treatment decisions as with navicular stress fractures Magnetic resonance imaging offers the advantage of visualizing soft-tissue changes in anatomic regions in which the 1/9/15 2:51 PM 426 ▲ Chapter 39 soft-tissue structures often cloud the differential diagnosis Clinically the high sensitivity of bone scan and MRI is necessary only when the diagnosis of stress fracture is in question or the exact location or extent of injury must be known in order to determine treatment MRI is currently the gold standard for stress fracture imaging Kaeding CC, Najarian RG Stress fractures: classification and management Phys Sportsmed 2010;38(3):45–54 Knapp TP, Garrett WE Stress fractures: general concepts Clin Sports Med 1997; 16:339 [PMID: 9238314] Femoral Stress Fractures `` General Considerations Stress fractures involving the femur can occur in a variety of locations, most commonly the femoral shaft and neck One study that looked at 320 athletes with bone scan–positive stress fractures revealed the femur to be the fourth most frequent site of injury The most common site of injury in athletes is the midmedial or posteromedial cortex of the proximal femur Once diagnosis is confirmed, treatment depends on the underlying causes responsible for the injury If the fracture is consistent with a compression-sided fracture (Figure 39-6), treatment consists of rest with gradual resumption of activity This usually is adequate for healing of nondisplaced fractures Treatment protocols are based on empiric data gathered from clinical observation An example of a treatment protocol may consist of rest for a period of 1–4 weeks of toe-touch weight bearing progressing to full weight bearing This would be followed by a phase of low-impact activity (ie, biking, swimming) Once patients are able to perform low-impact activity for a prolonged time without pain, they may gradually advance to high impact Resumption of full activity averages between and 16 weeks Surgical treatment should be considered if there is displacement of the fracture, delayed union, or nonunion following conservative therapy `` Differential Diagnosis The symptom most commonly encountered with stress fractures of the femur is pain at the anterior aspect of the hip Differentiating the diagnosis can be difficult secondary to the multiple number of structures in the hip that have the potential to produce similar pain syndromes and the deep nonpalpable structures of the anatomic region Diagnosis can be made complex by the multitude of structures in this region from which pain may emanate; thus, the physician must be attuned to the history to narrow the differential down to a list in which stress fracture is prominent This is important in order to avoid severe complications associated with fractures of the femoral neck `` Femoral Shaft Fractures Femoral shaft stress fractures are more common than expected, with an incidence of 3.7% among athletes Onset of pain can be gradual over a period of days to weeks Average time from symptom onset to diagnosis is approximately weeks The fulcrum test is well suited to act as a guide for ordering radiologic tests and thereby decreasing time to diagnosis It is also a useful clinical test to assess healing For this test, the athlete is seated on the examination table with legs dangling as the examiner’s arm is used as a fulcrum under the thigh The examiner’s arm is moved from the distal to proximal thigh as gentle pressure is applied to the dorsum of the knee with the opposite hand A positive test is elicited by sharp pain or apprehension at the site of the fracture Plain films are rarely sensitive in detecting stress fractures within the first 2–3 weeks of symptoms Bone scan or MRI may be useful in this time period to aid in diagnosis South Paul-Ch39_420-432.indd 426 ▲▲ Figure 39-6. Compression-sided stress fracture of the right femoral neck Note sclerotic line perpendicular to medial cortex (Reproduced with permission of Justin Montgomery, MD; University of Kentucky Radiology.) 1/9/15 2:51 PM Common Upper & Lower Extremity Fractures `` Femoral Neck Fractures Stress fractures of the femoral neck are uncommon but carry a high complication rate if the diagnosis is missed or the fracture is improperly treated The primary presenting symptom is pain at the site of the groin, anterior thigh, or knee Pain is exacerbated by weight bearing or physical activity The athlete may have an antalgic gait or painful, limited hip range of motion in internal rotation or external rotation MRI is the diagnostic modality of choice for evaluating femoral neck stress fractures Stress fractures of the femoral neck are divided into two categories: compression (occurring along the inferior or medial border of the neck) and tension (along the superior or lateral neck) type Compression fractures are more common in younger patients The fracture line, if seen on the radiograph, can propagate across the femoral neck A nondisplaced, incomplete compression fracture is treated with rest until the patient is pain free with full motion Non-weight-bearing ambulation with the patient on crutches follows until radiographic healing as shown on plain films is complete Frequent radiographs may need to be obtained to monitor propagation of the fracture If the compression fracture becomes complete, or fails to heal with rest, then internal fixation may be necessary Patients treated nonsurgically may not achieve full activity for several months Tension (distraction)-sided femoral neck fractures are an emergency because of the potential for complications (ie, nonunion or avascular necrosis) The patient is immediately rendered non-weight-bearing and will acutely need internal fixation If the fracture is displaced, the patient will need open reduction and internal fixation urgently McCormick F, Nwachukwu BU, Provencher MT Stress fractures in runners Clin Sports Med 2012; 31:291–306 Tibial Stress Fracture `` General Considerations Tibial stress fractures account for half of all stress fractures diagnosed Most tibial stress fractures in athletes are secondary to running Two sites located within the tibia are most commonly associated with stress fractures The first of these is located between the middle and distal third of the tibia along the posteromedial border This type of injury is most often associated with running The second site is along the middle third of the anterior cortex This injury is most commonly associated with activities involving a great deal of jumping (eg, dancing, basketball, gymnastics) `` Clinical Findings A Symptoms and Signs On history the patient commonly describes pain occurring in the region of the fracture with activity (eg, running or South Paul-Ch39_420-432.indd 427 ▲ 427 jumping) and resolving with rest The pain eventually progresses and lasts longer after the activity until the patient is symptomatic at rest Physical examination often reveals localized pain to palpation Sometimes persistent thickening, secondary to periosteal reaction, can be appreciated by palpation along the tibia B Imaging Studies Diagnosis by radiographic plain film may be possible if symptoms have been present for at least 4–6 weeks Triple-phase bone scan is very sensitive and may allow diagnosis within 48–72 hours of symptom onset Tibial stress fractures can be seen clearly on MRI with sensitivity comparable to that of triple-phase bone scan Both bone scan and MRI allow differentiation of medial tibial stress syndrome and stress fracture `` Differential Diagnosis Medial tibial stress syndrome (MTSS) is the most commonly confused diagnosis in the classification of tibial stress injuries with stress fracture MTSS usually occurs diffusely along the middle and distal third of the posteromedial tibia and is commonly seen in runners This condition, however, can also be seen with activities involving persistent jumping The symptom spectrum commonly progresses, as does that of stress fractures, with continued activity MTSS represents a stress reaction within bone whereby the usual remodeling process becomes maladaptive This injury responds well to rest in a shorter time period as compared with stress fracture and is easily differentiated from stress fracture on triplephase bone scan `` Treatment Once the diagnosis of tibial stress fracture has been made, a distinction between a compression versus tension-sided injury must be made Fractures along the posteromedial border are considered compression stress injuries and respond well to conservative therapy (Figure 39-7) The average recovery time for this injury is approximately 12 weeks when the patient is treated with rest alone Most guidelines for treatment of this injury involve relative or absolute rest These stress fractures can be effectively treated in a pneumatic leg brace Athletes treated in the pneumatic brace (long leg air cast) showed decreased time to pain-free symptoms (14 ± days) and time to competitive participation (21 ± days) versus traditional mode non-weight-bearing treatment (77 ± days) Athletes in the brace may continue exercising, but modifications of the training routine must be made to maintain pain-free activities Patients are treated on the basis of a functional activity progression as outlined by Swenson and colleagues Tibial stress fractures of the midanterior cortex, also known as “the dreaded black line,” radiographically (Figure 39-8), are 1/9/15 2:51 PM 428 ▲ Chapter 39 ▲▲ Figure 39-8. Dreaded black line at the anterior medial aspect of the tibia Shindle MK, Endo Y, Warren RF, et al Stress fractures about the tibia, foot, and ankle J Am Acad Orthop Surg 2012; 20(3):167–176 ▲▲ Figure 39-7. Periosteal stress reaction at the posterior medial aspect of the tibia very difficult to manage conservatively This fracture occurs at the tension side of the tibial cortex, most commonly in athletes who jump Delayed union and complete fracture are two significant complications associated with this area The average time to symptom-free return to activity from symptom onset is >12 months with conservative care Conservative treatment revolves around rest, or immobilization, or both Patients who not respond to conservative treatment or are involved in activities (career or competitive athletics) would benefit from surgical treatment with tibial intramedullary nailing Patients with these fractures should be referred to a sports medicine specialist McCormick F, Nwachukwu BU, Provencher MT Stress fractures in runners Clin Sports Med 2012; 31:291–306 South Paul-Ch39_420-432.indd 428 Tarsal Navicular Stress Fracture `` General Considerations Tarsal navicular stress fractures are an underdiagnosed source of prolonged, disabling foot pain predominantly seen in active athletes involved in sprinting and jumping One study, involving 111 competitive track and field athletes, found that navicular stress fractures are the second most common lower extremity stress fracture `` Clinical Findings A Symptoms and Signs These fractures are prone to misdiagnosis secondary to the vague nature of the pain The pain may radiate along the medial arch and not directly over the talonavicular joint Sometimes pain radiates distally, causing the physician to suspect a Morton neuroma or metatarsalgia The pain often 1/9/15 2:51 PM Common Upper & Lower Extremity Fractures disappears with a few days of rest, often tricking the athlete into not believing the potential seriousness of the diffuse foot pain The diagnosis is also clouded because the fractures are rarely seen on plain film Symptoms suggesting a clinical diagnosis consists of (1) insidious onset of vague pain over the dorsum of the medial midfoot or over the medial aspect of the longitudinal arch; (2) ill-defined pain, soreness, or cramping aggravated by activity and relieved by rest; (3) well-localized tenderness to palpation over the navicular bone or medial arch; and (4) little swelling or discoloration Certain foot abnormalities, including short first metatarsal and metatarsus adductor and limited dorsiflexion of the ankle, may concentrate stress on the tarsal navicular region, predisposing to stress B Imaging Studies Initial imaging for tarsal navicular stress fractures includes plain radiographs Plain radiographs should be obtained in AP, lateral, and oblique standing positions Unfortunately, sensitivity is low because a majority of these fractures are incomplete and therefore difficult to see on plain radiographs Also, bony resorption requires 10 days to weeks to allow visualization Most fractures are located in the central third of bone along the proximal articular surface, which is a relatively avascular region The next recommended diagnostic procedure is a triplephase bone scan These are positive at an early stage and almost 100% sensitive CT scanning is the gold stardard for optimal evaluation once bone scan has demonstrated increased uptake in the navicular bone The best images are obtained with ≤1.5-mm slices As imaging devices and technique have improved, MRI has been used with increased frequency and is almost as sensitive as bone scan in the detection of these fractures MRI carries the additional advantage of no radiation exposure and evaluation of surrounding structures `` Treatment Data indicate that 6–8 weeks of non-weight-bearing cast immobilization compares favorably with surgical treatment for failed weight-bearing treatment Surgery is recommended for a displaced, complete fracture with a small transverse fragment (ossicle), or failure of conservative management Surgical treatment often consists of either bone graft or screw fixation followed by non-weight-bearing cast immobilization for weeks After weeks of non-weight-bearing cast immobilization, fracture healing is followed clinically by palpation of the fracture site along the dorsal proximal region of the navicular bone Persistent tenderness over this “N” spot requires an additional weeks of non–weight-bearing immobilization before reassessment If the fracture site is not tender after casting, the patient may begin weight bearing South Paul-Ch39_420-432.indd 429 ▲ 429 Imaging may remain positive up to months following the injury For this reason the recommendation is not to repeat imaging, but instead to rely on clinical examination (palpation of the N spot) Fowler JR, Gaughan JP, Boden BP, Pavolov H, Torg JS The non-surgical and surgical treatment of tarsal navicular stress fractures Sports Med 2011; 41(8):613–619 Khan KM, et al Outcome of conservative and surgical management of navicular stress fracture in athletes: eighty-six cases proven with computerized tomography Am J Sports Med 1992;20:657 Metatarsal Stress Fractures `` General Considerations Metatarsal stress fractures in athletes are very common Depending on the study referenced, they are either third or fourth in incidence These fractures are also known as “march fractures” because of the large numbers of military recruits who obtained these fractures after sudden increases in their level of activity The second metatarsal is the most common location, followed by the third and fourth metatarsals The second metatarsal is subjected to 3–4 times body weight during loading and pushoff phases of gait `` Clinical Findings A Symptoms and Signs Clinical suspicion for this injury is raised when the athlete complains of forefoot or midfoot pain of insidious onset On examination these injuries present as areas of point tenderness overlying the metatarsal shaft B Imaging Studies Radiographs are usually sufficient to document stress fracture, which is visualized as a frank fracture or periosteal reaction at the affected site As with most stress fractures, the patient may be symptomatic 2–4 weeks prior to visualizing the fracture on radiograph If the diagnosis is in question, bone scan and MRI have significantly higher sensitivity and specificity for detecting these injuries at an earlier timeframe C Treatment Treatment is easily managed by the primary care physician The injury is treated symptomatically, allowing the athlete to participate in activities that are not painful Immobilization in the form of a steel shank insole or stiff, wooden-soled shoe may be necessary for a limited time, until the pain disappears At times the patient may benefit from a short leg walking cast or removable walking boot for severe pain Four weeks of rest is usually sufficient for healing During these 1/9/15 2:51 PM 430 ▲ Chapter 39 Peroneus longus Peroneus brevis Peroneus tertius First cuneiform Cuboid Fifth metatarsal Calcaneus Achilles Area of Jones fracture Greater tuberosity ▲▲ Figure 39-9. Anatomy of the proximal fifth metatarsal (Reproduced with permission of Ellsworth C Seeley, MD.) weeks, the athlete may continue modified conditioning with non-weight-bearing exercises (eg, swimming and pool running), followed by cycling and stair climbing Although most of these fractures heal well with conservative management, fractures of the proximal fifth metatarsal have a high incidence of delayed union and nonunion A thorough understanding of the classification and anatomy of fractures in this location is required for proper identification to determine conservative versus surgical treatment comminuted fractures involving >30% of the cubometatarsal articular surface or stepoff of >2 mm Sometimes small displaced fractures at this site may require surgical removal if bony union does not occur secondary to chronic irritation FRACTURES OF THE PROXIMAL FIFTH METATARSAL The fifth metatarsal consists of a base tuberosity, shaft (diaphysis), neck, and head (Figure 39-9) Fractures of the proximal fifth metatarsal include tuberosity avulsion fractures, acute Jones fractures, and diaphyseal stress fractures Tuberosity Avulsion Fractures Tuberosity fractures are typically known as “dancer fractures” because they are usually associated with an ankle inversion plantar flexion injury This injury is likely secondary to the plantar aponeurosis pulling from the base of the fifth metatarsal Nondisplaced fracture carries an excellent prognosis, almost always healing in 4–6 weeks with conservative therapy The athlete’s treatment consists of limited weight bearing to pain with modified activity such as that used with second, third, and fourth metatarsal injuries If needed, the athlete can be immobilized in a walking cast, wooden (or steel shank)-soled shoe, or walking boot The immobilization can usually be removed by weeks (average 3–6 weeks) in favor of modified footwear if pain has diminished The patient then may gradually return to vigorous activity; most athletes return to full sports activity in 6–8 weeks Bony union usually takes place by weeks Orthopedic referral is needed for displaced fractures or South Paul-Ch39_420-432.indd 430 ▲▲ Figure 39-10. The Jones fracture (Reproduced with permission of Justin Montgomery, MD; University of Kentucky Radiology.) 1/9/15 2:52 PM Common Upper & Lower Extremity Fractures Jones Fractures Jones fractures consist of a transverse fracture at the junction of the diaphysis and metaphysis (Figure 39-10) The Jones fracture is believed to occur when the ankle is in plantar flexion and a large adduction force is applied to the forefoot It is important to realize that this is a midfoot injury with no prodromal symptoms Therefore, the injury is classified as acute Torg and colleagues showed that this fracture, in nonathletes, could heal in 6–8 weeks with strict non-weight-bearing immobilization However, secondary to low vascularization and high stresses at the site of the Jones fracture, the injury is associated with a poor outcome; it is plagued by delayed union and nonunion if treated conservatively in athletic patients Those who undergo conservative treatment are placed on a non-weight-bearing immobilization protocol and in a plaster cast for 6–8 weeks If there is lack of clinical healing by 6–8 weeks, therapy is individualized If clinical healing is present by 6–8 weeks, immobilization is continued in a fracture brace with range of motion and gradual weight bearing If there are no signs of clinical healing, treatment must be individualized either with continued cast immobilization or surgical intervention Surgical intervention for Jones fracture consists of either intramedullary screw fixation or bone grafting Diaphyseal Fractures Stress fractures distal to the site of Jones fractures and acute-on-chronic fractures occurring in the same position as Jones fractures are commonly seen in athletes who run South Paul-Ch39_420-432.indd 431 ▲ 431 Pain is usually over the lateral aspect of the foot, over the fifth metatarsal base Usually no significant trauma has been associated with these fractures Prodromal symptoms occurring weeks to months in advance of an acute injury can often be elicited in the history Treatment of choice for acute nondisplaced diaphyseal stress fracture is non-weight-bearing immobilization More extensive fractures require individualized treatment Conservative treatment may take ≤20 weeks and result in nonunion Complications of prolonged immobilization include recurrence of fracture and significant dysfunction from muscle atrophy and loss of range of motion For athletes, surgical options are recommended Casting and prolonged immobilization of acute or chronic fractures frequently fail, giving rise to delayed or nonunion fractures Surgery is often needed and is the recommended procedure of choice The difference between screw fixation and bone grafting is recovery time It takes up to 12 weeks to return to prefracture activity with grafting versus 6–8 weeks with screw fixation Grafting carries a higher failure rate Screw fixation is now recommended first and bone grafting if fixation fails Kerkhoffs GM, Versteegh VE, Sierevelt IN, Kloen P, van Dijk CN Treatment of proximal metatarsal V fractures in athetes and non-athletes Br J Sports Med 2012; 46:644–648 Polzer H, Polzer S, Mutschler W, Prall W Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence Injury 2012; 43:1626–1632 Shindle MK, Endo Y, Warren RF, et al Stress fractures about the tibia, foot, and ankle J Am Acad Orthop Surg 2012; 20(3):167–176 1/9/15 2:52 PM This page intentionally left blank ... publisher ISBN: 97 8-0 -0 7 -1 8277 5 -1 MHID: 0-0 7 -1 8277 5-7 The material in this eBook also appears in the print version of this title: ISBN: 97 8-0 -0 7 -1 8274 5-4 , MHID: 0-0 7 -1 8274 5-5 eBook conversion by... dystrophy 1: 4500 Congenital adrenal hyperplasia 1: 10,000 1: 18,000 Phenylketonuria 1: 14,000 Galactosemia 1: 30,000 Cystic fibrosis 1: 44,000 1: 80,000 (depending on population) Biotinidase deficiency 1: 60,000... Paul-FM_pi-xx.indd 14 1/ 12 /15 9:45 AM Authors Saranne E Perman, MD Lexington Clinic Family Medicine Jessamine Medical and Diagnostics Center Nicholasville, Kentucky spearman1@gmail.com Hearing &