When Sandra Fryhofer, MD, needed an orthopaedic surgery voice to co-author an editorial she was writing on Vaccination-Induced Bursitis, she didn’t have to look far.

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“I looked to the orthopaedic surgeon most easily available,” said Dr. Fryhofer, an Atlanta-based internist who is also a member of the AMA Board of Trustees. “It was very convenient.”

The convenience was that she didn’t even need to leave her own home. The resident was her son, George Fryhofer, MD, an orthopaedic surgery resident at the Perelman School of Medicine at the University of Pennsylvania. In the midst of a research year, George was forced out of the lab at Penn by the COVID-19 pandemic.

“When my mom talked to me about this opportunity to work on this editorial with her on vaccine-related bursitis, I was obviously excited to be involved, because this topic really does connect our two specialties,” George said. “And as it happened, I was finishing up my research year in the McKay Lab at Penn, but was back home in Georgia “social distancing” since the lab had been shut down since March due to COVID-19. So it was the perfect time to be able to work on this editorial together in the same place.”


Overlapping interests

The importance of vaccines is heightened during the COVID-19 pandemic. The Fryhofers cited recent data presented by the Advisory Committee on Immunization Practices (ACIP) which suggests that patients who are co-infected with COVID-19 and influenza B are much more likely to die.

Published in Annals of Internal Medicine, the Fryhofer’s editorial cites data from the CDC-funded Vaccine Safety Datalink study that identified an increased risk for shoulder bursitis after flu vaccination. Although subdeltoid bursitis impacts about 1% of the population, likely stemming from injury or overuse, this and other studies and case reports suggest that vaccination administration technique may have a role in this adverse result. In essence, if things go wrong with vaccination application—injecting too high or too deep—a patient could end up sitting in front of an orthopaedic physician like George.

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“There’s overlap [between the two specialties],” George said. “Patients need to get vaccinations for the flu and other things, but sometimes, because of that, you can end up with persistent shoulder pain or bursitis that may get referred to the orthopaedic surgeon. This just highlights how communication between the specialties is important.”

To prevent that adverse result, the editorial suggests a “tune-up” in vaccination technique. Needle placement and needle length matter. The editorial refers to a handy CDC infographic demonstrating proper vaccination administration technique. “Know your landmarks. Aim for the midpoint of the deltoid muscle 2 to 3 fingers’ width below the acromion process (and above the armpit). Inject at a 90-degree angle.”

“Now, with the prospect of more drive-thru clinics and needing to administer vaccines sometimes in non-traditional settings, it is more important than ever to have proper vaccination technique,” Sandra said.

A rare opportunity

With Sandra having worked extensively with the ACIP, editors from Annals of Internal Medicine reached out to her to author the editorial. While his mother is an expert on the topic, George has a strong research background and is co-editor of the University of Pennsylvania Orthopaedic Journal. Their divergent expertise made the writing process a seamless one.

“My mom laid the foundation with the main ideas, and then I went through and helped tie the ideas together including transitions and also making sure all of our numbers and facts were correct, and finally got the citations and figure laid out properly,” George said. “There were a few key phrases or one-liners that she liked that were hers and so we kept those in, and of course she took some of my input as well.”

For her part, Sandra was able to see her son in a different light—as a colleague.

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“These last couple of months have been so difficult during the pandemic,” she said. “George was so disappointed his lab was shut down, but it was a real bright spot for both of us that the shelter-in-place mandate for the pandemic allowed us to work together.”

In addition to the Fryhofers authoring the article, they were able to work together on a video to accompany it. The video is technically impressive and contains all necessary facts. It ends with a reminder of the special circumstances that were involved in its creation—as mother and son say together, “for the Annals of Internal Medicine, Fryhofer and Fryhofer signing off.”  

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