AFP Journal Review September 15, 2007 Issue

1. AFP Journal ReviewSeptember 15, 2007 Issue Marzena Slater, M.D. PGY-2 Emory Family Medicine

2. Articles Featured • Gout: An Update • Metatarsal Fractures • Ocular Emergencies • Lateral Epicondylitis

3. Gout: An Update • Gouty Arthritis accounted for 3.9 million outpatient visits in U.S in 2002. • Prevalence is increasing due to aging, obesity and diuretic treated HTN. • Often under diagnosed and under treated • Questionable association of gout and MI in men.

4. Gout: Pathophysiology • Uric acid a metabolic bi-product of purine catabolism • In humans and great apes uricase is mutated • Hyperuricemia (>6.5 mg/dL) is caused by high purine diet combined with alcohol use, diuretics, and reduced renal clearance • Monosodium urate crystals deposit in tissues leading to: • Arthritis • Soft tissue masses (tophi) • Nephrolithiasis • Urate Nephropathy

5. Gout: Risk Factors • Most people with elevated serum uric acid level do not develop gout: • Uric Acid 7-8.9 mg/dL 0.5% develop gout • Uric Acid >9 mg/dL  4.5 % develop gout • Modifiable risk factors: • High Purine Diet– Red Meat & Seafood • Alcohol Use • Obesity • Diuretic Therapy • Protective: • Diary Products • Non-modifiable triggers: • Infection • IV contrast material • Acidosis • Rapid fluctuations in uric acid levels- ex. Trauma, surgery, psoriasis flair, stopping or starting allopurinol

6. Clinical Presentation • Acute Gout • Attacks of pain, erythema, and swelling of one or a few joints in the lower extremities. • Common joints: First metatarsal (podagra), midtarsal, ankle, knee • Often begins early morning, escalates and peaks within 24-48 hours • Bed sheets and socks not tolerated. • Can resemble cellulites or septic arthritis- causing fever and leukocytosis– joint aspirate will differentiate • Chronic Gout • Often chronic tophaceous- deposits in helix of ear, olecranon process, interphalageal joints • In advanced dz may lead to joint erosion and destruction • May mimic Rheumatoid arthritis- joint aspirate will differentiate

7. Gout: Diagnosis

8. Ddx of Acute Gout If gout diagnosis is in question, synovial fluid analysis should be attempted.

9. Gout Treatment • Goals: • Symptom control for acute attacks • Risk factor modification • Pharmacotherapy

10. Pharmacotherapy in Acute Gout

11. Urate Lowering Rx in Chronic Gout • Up to 60 % of patients with 1st gout attack will have another in 12 months • Non-Pharmacologic treatment should begin with 1st attack: • Diet (limit red meat, increase dairy) • Limit alcohol intake • Substitute diuretics with other anti-HTN med • Pharmacology (urate lowering rx): • Recommended for Pt with >2 attacks per year, tophi, or joint damage or Xray. • Options: • Xanthine Oxidase Inhibitors: • Allopurinol- 1st line, adjust for renal insufficiency • Febuxostat- Investigational, not FDA approved.- metabolized thru liver. May be viable option for pt that can’t tolerate allopurinol secondary to renal insufficiency • Urosidic Agents (Probenecid)- second line, if pt doesn’t tolerate allopurinol or may be used as adjunct for pt w/ refractory hyperuricemia • Do Not start in acute attack phase • May use in concurrence with low dose Colchicine for 3-6 mo. • Target Uric Acid Level <6 mg/dL- titrate medications to goal.

12. Summary of Recommendations

13. Question 1 Which of the following is recommended first line therapy for lowering uric acid levels in patients with chronic gout? • Colchicine • Allopurinol (Zyloprim) • Probenecid • Colchicine/probenecid combination

14. Question 1 Which of the following is recommended first line therapy for lowering uric acid levels in patients with chronic gout? • Colchicine • Allopurinol (Zyloprim) • Probenecid • Colchicine/probenecid combination

15. Question 2 Which of the following statements about the diagnosis of gout is correct? • A synovial fluid analysis is required before the initiation of treatment. • A 24 hour urine collection to detect uric acid excretion is an important part of the diagnostic evaluation • The presence of podagra and tophi strongly supports the diagnosis • A normal uric acid level during a suspected gout attack rules out the diagnosis

16. Question 2 Which of the following statements about the diagnosis of gout is correct? • A synovial fluid analysis is required before the initiation of treatment. • A 24 hour urine collection to detect uric acid excretion is an important part of the diagnostic evaluation • The presence of podagra and tophi strongly supports the diagnosis • A normal uric acid level during a suspected gout attack rules out the diagnosis

17. Metatarsal Fractures • Represent 5-6 % of fx seen in primary care offices • Article divides these fractures up into three anatomical regions: • Metatarsal shaft • Proximal 5th metatarsal • Proximal 1st thru 4th metatarsals • Each anatomic region has unique diagnostic/Rx considerations

18. General Concepts

19. General Concepts

20. Fractures of the Metatarsal Shaft • Usually not displaced, unless multiple fx’s or fx near the metatarsal head • When displaced, metatarsal head goes in plantar direction • Acute fractures: • Mechanism: Direct blow or twisting forces. • Hx: Pain with axial loading, severe swelling, ecchymosis, point tenderness. • Xrays: AP and oblique views best. Lateral may miss fx. • Acute Rx: • Refer for reduction if: • More than 3-4 mm dorsal or plantar displacement • Dorsal/plantar angulation >10 degrees • RICE, Soft padded dressing or posterior splint • Weight bearing as tolerated • Cast for 2-3 wks if pain refractory to rx above • Repeat Xrays at 1 week to assure alignment & 4-6 weeks to document healing • Ankle ROM and stretching after resolution AP Oblique Lateral

21. Fractures of the Metatarsal Shaft • Stress Fractures • Hx: Abrupt increase in activity or chronic overload. Initially pain only with activity • PE: Point tenderness over fx site. Axial loading at the metatarsal head produces pain. • Xray: Rarely visible until 4-6 wks of sx. • MRI or bone scan will confirm • If H&P typical, Rx presumptively • Treatment: • Typically no immobilization needed • Stop causative activity for 4-8 wks. • If pain w/ walking- may use crutches/partial weight bearing • If severe pain- may use short leg cast for 3-4 wks

22. Proximal Fifth Metatarsal fractures • Three distinct fractures: • Tuberosity (styloid) fx • Occur Proximal to base of 4th metatarsal • Heal well • Metaphyseal-diaphyseal junction fx (Jones fx) • Extend toward base of 4th metatarsal • Heal less well • Diaphyseal stress fx • Occur distal to base of 4th metatarsal • Heal poorly Styloid fx Diaphyseal fx Jones fx

23. Proximal Fifth Metatarsal fractures • History • Tuberosity Avulsion fx • Ankle inversion, while foot plantar flexed • Hx often suggests lateral ankle sprain and they can be missed- avoid by using Ottawa ankle rules • Jones fx • Vertical or mediolateral force on base of 5th metatarsal, while patient’s weight is over lateral aspect of plantar flexed foot. • Diaphyseal stress fx • Chronic overloading- Jumping and pivoting in young athletes • Physical Exam • All of these will cause lateral foot pain and point tenderness on exam • Xray • If point tenderness present over proximal 5th metatarsal (Ottawa rules) get ankle series (AP and mortise view) • Accesory bones may be mistakened for fx (usually smooth and rounded) • Treatment: • Tuberosity avulsion fx- • soft dressing or hard soled shoe. Weight bear as tolerated. • Refer if : Displaced fx , more than 1-2 mm step-off with cuboid, nonunion • Jones fx • Non-weight bearing cast 6-8 weeks, consider early surgical fixation in athletes • Diaphyseal fx • Type I (early)- ie no widening of fx line and sharp margins. • Same as Jones fx above • Type II (delayed)- ie widened fx or evidence of sclerosis. • Early sugical fixation & non-weight bearing cast for 20 weeks • Type III (nonunion)- Wide fx line, Perisoteal new bone, sclerosis • Surgical Fixation, pulsed EM fileds, non-weight bearing cast- up to 16 weeks

24. Proximal 1st-4th Metatarsal Fx • Less Common, but important since may be associated with injury to Lisfranc ligament • Lisfranc ligament holds base of metatarsals in place, and maintains arch of foot. Even subtle injuries to this ligament can result in long term disability • In children: • The physis of 1st metatarsal located proximally • Physis of 2nd-5th metatarsal located distally

25. Proximal 1st-4th Metatarsal Fx • Mechanism: • Crush injuries, direct blow. • Axial load on plantar-flexed foot (most common in athletes)- should raise suspicion for Lisfranc injury • Xrays • Standard Xrays may be normal, but if suspicion high- refer • Further eval- weight bearing AP and lateral Xrays • Three classic findings of LisFranc injury: • Widened space between bases of 1st & 2nd metatarsal • Fleck fx adjacent to base of first metatarsal • Loss of alignement of medial edge of proximal second metatarsal with medial edge of second cuneiform

26. Proximal 1st-4th Metatarsal Fx • Treatment: • If no injury to Lisfranc ligament and no other indications for referral- use posterior splint and no weight bearing for 1st 3-5 days • Then place short leg, non-weight bearing cast. • In 7-10 days repeat xrays to confirm fx position • Cast should be worn for 3-4 more weeks • Initiate ROM exercises on cast removal • If stage I Lisfranc fx cannot be ruled out- cast them for 4-6 weeks or obtain ortho referral • If Stage II-III Lisfrance fx--- refer

27. Summary of Recommendations

28. Question 3 Which of the following statements about proximal fifth metatarsal fractures is correct? • These fractures always require casting • Patients recover from tuberosity (styloid) fractures more quickly without casting • Diaphyseal stress fractures usually heal without treatment • Stress fractures usually cause an acute onset of pain

29. Question 3 Which of the following statements about proximal fifth metatarsal fractures is correct? • These fractures always require casting • Patients recover from tuberosity (styloid) fractures more quickly without casting • Diaphyseal stress fractures usually heal without treatment • Stress fractures usually cause an acute onset of pain

30. Question 4 • Which of the following statements about metatarsal shaft fractures is/are correct? • Malalignment of a first metatarsal fracture is less well tolerated than malalignement of a lesser metatarsal • Reduction is required regardless of the degree of displacement • Most non-displaced fractures require only a soft elastic dressing or firm, supportive shoe • Casting is recommended only if patient has significant pain

31. Question 4 • Which of the following statements about metatarsal shaft fractures is/are correct? • Malalignment of a first metatarsal fracture is less well tolerated than malalignement of a lesser metatarsal • Reduction is required regardless of the degree of displacement • Most non-displaced fractures require only a soft elastic dressing or firm, supportive shoe • Casting is recommended only if patient has significant pain

32. Ocular Emergencies • Prompt recognition and appropriate treatment of ocular emergencies are essential in the primary care setting– outcome depends on prompt management. • Article discusses: • Penetrating Globe Injury • Chemical Injuries • Central Retinal Artery Occlusion • Acute Angle Closure Glaucoma • Retinal Detachment • Initial Assessment should include: • Visual acuity testing- if limited 2/2 to pain- use topical anesthetic • PE: Inspect eyelids, globes, orbits, forehead and cheeks. Perform EOM. Check pupillary reflex & visual fields.

33. Mechanical Injury to Globe • Signs/Sx: • Normal or damaged cornea • Moderate to severe pain • Normal or decreased vision • Hyphema • Red eye/subconjuctival hemorrhage in the area 360 deg around cornea • Slit Lamp Exam • Decreased ant chamber depth relative to uninjured eye • Irregular or deviated pupil toward the direction of injury • Positive Seidel test • Treatment • Eye shield • Tonometry CONTRAindicated • Leave embedded foreign body in place • Scheduled analgesia and antiemetics- to prevent Valsalva • Systemic abx within 6 hours of injury (IV fluoroquinolones, aminoglycosides & cephalosporins good options) • Update Tentanus shot • Immediate referral to ophthalmologist • CT of head & orbits recommended • Eye Injury from a high-velocity trauma should be treated as a penetrating injury—immediate referral to ophthalmology warranted Hyphema Seidel Test Subconjunctival Hemorrhage

34. Chemical Injuries • General: • Eye exposure to alkali more common and detrimental than acid injury • Only eye emergency where treatment should not be delayed to asses visual acuity • Signs/sx: • Cornea may have minor epithelial damage or be opaque (severe- ischemia of conjuctival and scleral vessels • Moderate to severe pain • Blurred vision • Reflex blepharospasm • Photophobia • Sensation of foreign body • Red eye/conjunctivae • Slit lamp Exam • Findings depend of severity • Corneal & Scleral Melting may occur if severe • Treatment • Eye Irrigation with normal saline or LR until pH normal (7.0) or at least 1-2 L of irrigation completed or 30 min • Irrigate for 30 min, close eye for 5 min and then check pH with litmus paper • Once pH stable- give cycloplegic agent (0.25% scopolamine) and broad spectrum abx (floxacin, tobrex) • Continue eye washing on the way to ER or an ophthalmologist

35. Central Retinal Artery Occlusion • Signs/sx: • Clear Cornea • Amaurosis fugax (painless, unilateral, transient) • Or permanent vision loss • Red eye/conjunctivae • Slit lamp exam • Interrupted columns of blood within the retinal vessels (boxcarring) • Attenuation of retinal arteries • Cherry-red spot in fovea • Pale fundus • Pupil may be dilated and react poorly to light • Treatment • Lower IOP with : • Mannitol 0.25-2 per kg IV once • acetazolamide 500 mg IV or po once • carbogen inhalation • oral nitrates • lay patient on back • Occular digital massage • Immediate referral to ophthalmologist- damage occurs within 100 minutes. • Further workup: • Carotid USD • TEE • Treat RF- DM, HTN, HLD

36. Acute Angle Closure Glaucoma • Signs/sx: • Acute onset of severe pain, blurred vision, frontal headache, halos around lights • Increased IOP (>30 mm Hg) • Red eye/conjunctivae • Precipitants: dim light, dilating drops, anticholinergics, antidepressants • Slit lamp exam: • Mid-dilated (4-6 mm) and sluggish pupil • Normal or hazy cornea • Shallow anterior chamber • Treatment • Lowering IOP with acetazolamide 500 mg po once • One drop each of 0.5% timolol (Timoptic), 1% apraclonidine (Iopidine) and 2% pilocarpine (Isopto Carpine) one minute apart and repeat three times at 5 minute intervals • Immediate referral to ophthalmologist • if left untreated damage to optic nerve and permanent vision loss can occur within hours. • Definitive Rx: Laser iridotomy

37. Retinal Detachment • Risk Factors: • Myopia (55% cases) • Cataract Surgery • Diabetic retinopathy • Trauma • Older Age • Signs/Sx: • Normal or peripheral or central vision loss • Absence of pain • Increasing floaters • Unilateral photopsia (flashing lights) • Metamorphopsia (wavy distortion of objects) • Slit lamp exam • Normal conjunctivae and cornea • Normal pupil • Pale, detached retina • Treatment: • Antitussives & antiemetics (if needed) • Referral to ophthalmologist within 24 hours

38. Summary of Recommendations

39. Question 5 In the event of chemical injury to the eye, which one of the following management options is correct? • Irrigate the eye until the pH is moderately basic (i.e. at least 8.0) • Irrigate the eye with base if exposed with acid and vice versa • Irrigate the eye for at least 30 minutes or with 1-2 L of eye-washing solution • Irrigate the eye for five to 10 minutes

40. Question 5 In the event of chemical injury to the eye, which one of the following management options is correct? • Irrigate the eye until the pH is moderately basic (i.e. at least 8.0) • Irrigate the eye with base if exposed with acid and vice versa • Irrigate the eye for at least 30 minutes or with 1-2 L of eye-washing solution • Irrigate the eye for five to 10 minutes

41. Question 6 • Which of the following is/are signs or symptoms of central retinal artery occlusion? • Painful loss of vision • Painless loss of vision • Previous transient vision loss • Dilated pupil with sluggish reaction to light

42. Question 6 • Which of the following is/are signs or symptoms of central retinal artery occlusion? • Painful loss of vision • Painless loss of vision • Previous transient vision loss • Dilated pupil with sluggish reaction to light

43. Treatment of Lateral Epicondylitis • Common overuse syndrome of extensor tendons of forearm • AKA tennis elbow • More common in people >40 yo, Men=Women • Mechanism- repetitive wrist dorsiflexion with supination and pronation • If left untreated persists 6-24 months

44. Treatment of Lateral Epicondylitis • Diagnosis: • Hx: occupational or activity related pain at the lateral elbow • PE: Sx reproduced with resisted supination or wrist dorsiflexion, when arm in full extension. Pain located just distal to lateral epicondyle over the extensor tendon mass • Imaging: Rarely required for diagnosis

45. Treatment of Lateral Epicodylitis • Watchful waiting: • Evidence rating: C • Comparable to PT and superior to corticosteroids at 1 year follow-up • Avoidance of aggravating activities recommended • NSAIDs • Evidence rating: • Short-term topical: A • Short-term oral: B • Corticosteroid injection • Evidence Rating: B • Short term (2-6 wks) benefits in pain reduction, global improvement, & grip strength. These benefits do not persist beyond six weeks. • Extracorporeal Shock Wave therapy • Unlikely to be helpful: • Evidence Rating: A • Orthoses • Evidence Rating: B • Inelastic, nonarticular proximal forearm strap may decrease pain and increase grip strength after 3 weeks. • Laser Therapy • Unlikely to be helpful • Evidence Rating: B

46. Treatment of Lateral Epicodylitis • Physical Therapy • Exercise • Evidence Rating: B • Strength training and stretching • Electrotherapy • NSAID ionophoresis • Evidence Rating: B • Ultrasonography • Evidence Rating : B • Mobilization • Insufficient Evidence • Acupuncture • Evidence Rating: B • Conflicting studies • Autologous Blood injection • Insufficient Evidence • Botulism Toxin Type A injection • Evidence Rating: B • Facilitates healing by temporarily paralyzing the common extensor origin • Topical Nitrates • Evidence Rating: B • Works by stimulating collagen synthesis by wound fibroblasts • Surgery • Evidence Rating: C • Recommended when conservative therapy fails after 6-12 mo • Excision of abnormal tissue at the origin of the extensor carpi radialis brevis tendon at lateral epicondyle

47. Summary of Recommendations

48. Treatment of Lateral Epicondylitis

49. Question 9 • Which of the following therapies has been shown to improve outcomes in patients with lateral epicondylitis • Iontophoresis with NSAIDs • Extracoporeal Shock Wave Therapy • Laser Therapy • Electromagnetic Field Therapy

50. Question 9 • Which of the following therapies has been shown to improve outcomes in patients with lateral epicondylitis • Iontophoresis with NSAIDs • Extracoporeal Shock Wave Therapy • Laser Therapy • Electromagnetic Field Therapy