Which test for rotator cuff tear following shoulder dislocation?

There are of course a number of papers looking at the same thing but I saw this one recently.

Yuen, Chi Kit, Ka Leung Mok, and Pui Gay Kan. “The Validity of 9 Physical Tests for Full-Thickness Rotator Cuff Tears After Primary Anterior Shoulder Dislocation in ED Patients..” The American Journal of Emergency Medicine 30, no. 8: 1522–1529. doi:10.1016/j.ajem.2011.12.022. PMID 22386341

Great study question  – in shoulder dislocation can we pick up full thickness tears at 10 day follow up using clinical exam?

METHODS

  • ultrasound by the trained EPs as gold standard – this could easily be questioned both in terms of training and in terms of modality – is MRI better?
  • the big problem was the EPs doing the ultrasound were the same guys who did the exam – there was no blinding here so you can effectively find what you want to.

RESULTS

  • 50 pts over 4 years (another problem…)
  • 40% had a tear
  • they conclude that the empty can test was the best – which is nice because that’s what I’ve been doing.
  • even at that sens was 90% and spec 55% for the empty can.

 

Desptite the obvious weaknesses of the paper tears are common and contribute to morbidity so they’re worth looking for

Here’s a video of the empty can test just as a refresher

Differentiating ‘benign’ from ‘dangerous’ vertigo/dizziness

First off – “dizziness” as a symptom is a bit of a mess. We can’t blame the patients for that but we must be clear that we’re not entirely sure what it means when a patient tells us they’re dizzy.

Next, you may well be better spending your time reading this article than my brief, bastardized summary of it.

Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh Y-H, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 2011 Jun.;183(9):E571–92. PMC3114934

I found it via the wonderful R&R in the fast lane project where the esteemed Dr Weingart had recommended it.

I shall try and be brief.

So what’s useful for differentiating a central, serious cause of vertigo (about 85% vascular and 10% demyelination) from a benign, peripheral one (mainly vestibular neuritis, meniere’s etc…)?

Suggesting Stroke:

  • multiple prodromes
  • recent trauma (ie think dissection)
  • any “hard” neurological signs like cranial nerve palsies etc…
  • a normal head impulse test strongly suggests stroke [Link goes to video]
Suggesting benign:
  • gradual onset as opposed to sudden
  • a negative HINTS test [Link goes to video]

In brief, nystagmus towards the side of the gaze suggests badness.

There are lots of others but I wanted to keep it brief.

The two videos linked to above are in the appendix of the article along with some others. They were both new to me. Dix-Hallpike was the only real test I used to use for this thing and the article doesn’t see it having much of a role in differentiating.  I think it’s gonna take me a bit of practice to get good at this stuff as I find nystgamus pretty difficult in general.

When I get a bit of time I’ll try and put something together on the neuroanatomy of all this as it might be useful to understand what’s going on.

UPDATE

Patrick Linehan has made some great points in the comment below so I’ve added them on in here so you all get to read them.

A few comments on that paper:

1) The authors (who work at a tertiary referral centre) had to MAKE UP a case with a good outcome to show utility of the HINTS test, which means they have never actually seen it be useful in emergency practice! (Note that the fact that they made up the case is not mentioned in their case report, but only in the caption of the MRI under the case report!)

2) The study that showed excellent sensitivity and specificity of the HINTS test was study of 121 referred patients (half referred from the ED and half from other hospitals) that had a 75% prevalence of stroke. This means that the ED physicians already had a strong suspicion that the patients had a stroke. If you think that the patient you see in the ED with dizziness has a 75% chance of stroke, are you going to skip referring them to a neurologist or working them up further based on this test?

3) The paper deals only with people who have acute vestibular syndrome (continuous dizziness for 24 hours) so the Dix-Hallpike is not useful in their population, as BPPV is not continuous.

Tasty Morsels of EM 024

I keep a little, ever-expanding note on my phone where I jot down little morsels of goodness that I pick up while listening to or reading one of the many excellent sites/podcasts in the useful resource section.

I’ll try and transfer them here for your enlightenment.

I confess I don’t quite know where I pulled this from but it seems pretty smart to me. I know it’s elementary eye stuff, but to be perfectly honest no one has ever taught me how to use a slit lamp, I’ve been making it up as I go and obviously didn’t pick up everything!

When using the slit lamp

  • the ant chamber exam needs the light source at 45 degrees to the angle of vision
  • “flare” means cells caught in the beam (like dust caught in the beam of a movie projection)
  • cobalt BLUE is what you need for fluroscein not green.

Tasty Morsels of EM 020

I keep a little, ever-expanding note on my phone where I jot down little morsels of goodness that I pick up while listening to or reading one of the many excellent sites/podcasts in the useful resource section.

I’ll try and transfer them here for your enlightenment.

Again from the August EMJ a great and reasonable article from an orthopod on ACL injuries. And yes I meant to type that – a great and reasonable article from an orthopod…

Despite a detailed knowledge of the anatomy I still get a bit befuddle by knees. I suspect a lot of this is due to lack of confidence and any real serious teaching on orthopaedics. Like most of my training it’s been picked up on the job and in a very disorganised way.  this review gives a lovely simple account of the ACL and in particular I appreciate the diagnostic tips and the refusal to use the “skip to an MRI” option.

  • isolated ACL in only 10%
  • ACL composed of two bundles; anteromed and posterolat
  • main supply is mid geniculate art
  • if no bony injury but immediate swelling then high proportion of ACL injury (to whatever degree)
  • Lachman better than pivot-shift and better than ant drawer
  • Note that the Lachman test was found to have high 90s for both sens and spec
  • exam probably best 10 days later when less pain and spasm
  • MRI has sens of only 85% and they state that is an adjunct to diagnosis
  • two signs on x-ray
    • segond – lt capsular avulsion
    • avulsion of tibial eminence

In terms of treatment:

  • mobilisation can’t be overemphasised
  • unclear if functional braces are useful
  • physio good for ROM and needed prior to delayed repair
  • because of variable response many don’t need repair
  • feeling of not trusting knee or give way is reasonable indication for surgery