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Orthopedic Urgencies and

Emergencies:
Problems You Dont Want to Miss!
Francis G. OConnor, MD, FACSM
Director, Primary Care Sports Medicine
Uniformed Services University

Objectives
Discuss

common orthopedic
urgencies and emergencies that
are not uncommonly
misdiagnosed and/or initially
mismanaged.
Detail pertinent diagnostic
features and clinical criteria for
referral to an orthopedic
colleague.

Case 1
Patient is a 16 y/o soccer player who presents to
the ER with a painful forearm after a FOOSH
injury. He is quite tender to palpation over the
proximal forearm and has visible deformity. The
skin is intact. Neurovascular examination is
normal.
Radiographs.
Patient is placed in a long arm splint.
Prior to discharge from the ED for Ortho f/u in the
am, the patient complains of thumb numbness.

Acute Compartment
Syndrome

Epidemiology
Compartment

Syndrome(CS) is a serious life and


limb-threatening complication of extremity trauma.
Fractures, burns, crush injuries and arterial injuries
can all result in CS.
Three quarters of cases are associated with
fractures; tibia most common.
Other sites include: hand; forearm; arm; shoulder;
back; buttocks; thigh; foot.

Pathophysiology
CS

develops when there is increased pressure


within a closed tissue space
e.g. muscle
compartments bound by fascial sheaths.
Increased pressure compromises the flow of
blood through vessels supplying contained
muscles and nerves.
External:

circumferential cast or burn eschar


Internal: edema or soft tissue hematoma formation

Clinical Anatomy
Each

limb contains a number of


compartments at risk for CS.
Upper

arm: anterior(bicepsbrachialis) and posterior(triceps).


Forearm: volar(flexors) and
dorsal(extensors)
3 gluteal, 2 thigh, 4 in the lower
leg.

Diagnosis
High

index of clinical suspicion, with pain out of


proportion to the mechanism of injury being the
hallmark symptom.
Five Ps: pain; paresthesia; paresis; pallor; pulses.
Loss of normal sensation is the most reliable sign.
Diagnosis is based on the compartment pressure.

Radiographic Findings
Common
tibial

fractures associated with ACS:

fractures
supracondylar fractures of the humerus
humeral shaft
forearm fractures
multiple metacarpal or metatarsal fractures
Lisfranc fractures
calcaneal fractures

Pressure Monitoring
Normal

tissue pressure ranges between 0


and 10mmHg.
Capillary blood flow is compromised at
20 mmHg, while the muscles and nerves
are at risk for ischemic necrosis at
pressures greater than 30 to 40 mmHg.

Treatment
Acute

CS is a surgical emergency.
Delays over 24 hrs can result in myoglobinuria,
renal failure, metabolic acidosis, hyperkalemia,
ischemic contracture.
Indications for fasciotomy:
clinical

signs of CS
tissue pressure over 30 mmHg with clinical picture of
CS
interrupted arterial circulation over 4 hours.

Case 1 Follow-up
Clinical

diagnosis of
ACS made.
Taken to the OR for
ORIF and compartment
fasciotomy.
Delayed skin closure.

Case 2
Pt

is a 45 y/o male with a


history of colon CA, who
presents with a history of
low back pain and a
history of new onset
bladder incontinence.

Cauda Equina
Syndrome

Epidemiology
80% of the population experiences back pain at
some point in their lives.
90% of low back pain resolves in 6 -12 weeks
Red Flag symptoms include: age over 50, trauma,
fever, incontinence, night pain, weight loss,
progressive weakness.
Cauda Equina Syndrome (CES) is a rare disorder,
representing only 0.0004% of all back pain patients

Clinical Anatomy
Three

joint motion complex


consisting of the facets and the
intervertebral disc.
The spinal cord extends from the
foramen magnum to the L1-L2 disk
where the cauda equina continues to
the coccygeal region

Mechanism of Injury
Usually

secondary to extrinsic pressure


from a massive central HNP
Other causes include:
epidural

abscess
epidural tumor
epidural hematoma
trauma

Clinical Presentation
Bilateral leg symptoms that include sciatica,
weakness, sensory changes and gait disturbance.
Physical examination demonstrates bilateral
weakness as well as decreased sensation, in
particular in the saddle region.
Sphincter tone is decreased in 60 to 80% of patients
All patients who complain of urinary or fecal
incontinence should be considered to have CES
until proven otherwise.

Diagnosis
Clinical

diagnosis:

loss

of bladder control; perianal numbness; pain


and weakness involving both legs

Evaluation

of the urinary post-void residual


volume assists with diagnosis:
the

absence of a post-void residual volume of


over 100ml, essentially excludes a diagnosis of
CES, with a negative predictive value of
99.99%

Imaging
Plain

films
MRI imaging
of the entire spine

Treatment
Neurosurgical consultation
High dose systemic
corticosteroids
Emergent surgical
decompression

Case #3
Pt

is a professional football player, wide


receiver, who presents to with wrist pain.
He describes a FOOSH mechanism of
injury and complains of numbness in the
distribution of the median nerve.

Perilunate Injury

Epidemiology
Wrist

injuries account
for 2.5% of all ED
visits.
Lunate and perilunate
injuries are thought to
represent 10% of all
carpal injuries.

Clinical Anatomy
There

are 8 carpal bones


comprising two carpal rows; the
scaphoid bridges both rows.
With radial deviation the
scaphoid and lunate palmar flex
Intrinsic and extrinsic ligaments
maintain carpal stability.

Mechanism of Injury
Perilunate

and lunate dislocations result from


hyperextension injuries.
Most common mechanism of injury is a FOOSH,
followed by an MVA.
Progressive Injuries:
Stage

I: scapholunate dissociation
Stage II: perilunate dislocation
Stage III: dislocation of the triquetrem
Stage IV: lunate dislocation

Clinical Presentation
History

of high energy
mechanism of
hyperextension
Palpable pain over the
dorsum of the wrist
Tenderness distal to Listers
tubercle in the area of the
scapholunate ligament

Diagnosis
High

index of
suspicion
Palpation over the
dorsum of the
wrist
Watson Click Test
Radiographs

Imaging
PA and

lateral radiographs

PA view:

constant 2 mm intercarpal
3 arcs

Lateral

view:

four Cs
capitolunate angle 0-15 degrees
scapholunate 30-60 degrees

Stress

views

joint space

Treatment
Consultation

with a
hand surgeon to
discuss management

Case #4
Pt

is a 23 y/o active duty special operations


soldier who presents with persistent dorsal
foot pain. He stepped in a hole over a week
ago, and has not improved with self-care.

Lisfranc Fracture

Epidemiology
The

articulation between the tarsal and


metatarsal bones in the foot is named
after Jaques Lisfranc, a field surgeon
in Napoleon's Army.
Lisfranc injuries may represent 1% of
all orthopedic trauma, but 20% are
missed on initial presentation.

Clinical anatomy
The

second metatarsal is the


keystone to the Lisfranc joint.
Transverse ligaments join the
metatarsals, excluding the first
and second.
Soft tissue support is abundant on
the plantar surface, leaving the
dorsal surface relatively
vulnerable.

Mechanism of Injury
Lisfranc

injuries are caused by either direct or


indirect trauma.
Indirect injuries account for the majority of
injuries: either a rotational force to the forefoot,
or axial loading on a plantar flexed, fixed foot.
Common source of trauma: falls from a height;
motor vehicle accidents; equestrian and athletic
injuries.

Clinical Presentation
Presentation

varies from a mild undetectable


subluxation to an obvious fracture dislocation
Midfoot pain, swelling and difficulty bearing
weight are clinical clues
Pain with passive pronation and abduction of
the forefoot with the hindfoot supported
Tense swelling may indicate a CS.

Diagnosis
High

index of
suspicion in ankle
and foot injuries
Proper radiographic
interpretation

Imaging
AP, lateral

and oblique views

On

AP and obliques the 2nd met


medial border should align with the
middle cuneiform
On the lateral the metatarsal shaft
should not be more dorsal than the
respective tarsal bone
Contralateral

foot films
Weight-bearing views

Treatment
Orthopedic

consultation for
possible ORIF
Identify and manage
compartment
syndrome

Case #5
Pt

is an 18 y/o football player who presents


with an ankle sprain.
Pt has considerable swelling and
demonstrates more tenderness proximal to
the ATFL in the area of the AITF ligament.
Radiographs are negative for fracture.

Syndesmotic Ankle
Sprain

Epidemiology
Ankle

sprains are the most common lower extremity


injury in sports medicine, and constitute 25% of all
sports injuries.
In one series, syndesmotic injuries constituted 17 % of
ankle sprains.
Syndesmotic injuries result in longer periods of
disability than standard lateral ankle sprains.
Syndesmotic injuries are not uncommonly associated
with fractures.

Clinical Anatomy
The

syndesmotic ligaments maintain


stability between the distal tibia and fibula
Anterior

tibiofibular ligament
Posterior tibiofibular ligament
Transverse tibiofibular ligament
interosseous ligament
interosseous membrane

Mechanism of Injury
Injuries

to the syndesmosis occur as a result of


a forced external rotation of the foot, or during
internal rotation of the tibia on a planted foot.
Common in soccer, skiing, motocross and
football.
Syndesmosis injuries are commonly associated
with ankle fractures (Weber B &C) and deltoid
ligament ruptures.

Clinical Presentation
Usually

the patient cannot put weight upon the

leg.
Pain is located anteriorly along the
syndesmosis.
Active movement of external rotation of the
foot is painful.
Positive Squeeze Test
Positive External Rotation Stress Test

Diagnosis
Clinical

diagnosis

mechanism

of injury
correlative physical
examination
Radiographic

imaging
assists in risk stratifying

Imaging
Ottawa Ankle

Rules: AP, lateral and mortise


views should be obtained:
tenderness

over the lateral and medial malleolus


unable to bear weight for four steps immediately
or in the ED
Syndesmosis
Mortise:

Radiographic Criterion

medial clear space > 4mm


AP: tibiofibular overlap < 10 mm

Treatment
Ligamentous injuries
without fracture or gross
widening can be treated
conservatively
Fractures or radiographic
evidence of syndesmotic
widening warrant
orthopedic consultation for
operative repair.

Case #6
Pt

is a 35 y/o physician/mother who while


running up the stairs, noted a painful pop
involving the lateral foot.
On palpation, she has considerable
tenderness over the proximal fifth
metatarsal.

Fifth Metatarsal
Fracture

Epidemiology
The

most commonly fractured metatarsal is


the fifth.
These fractures may result from direct or
indirect trauma.
Proximal fifth metatarsal fractures,
however, have been the subject of
considerable debate and controversy.

Clinical Anatomy
The

proximal fifth metatarsal consists of the


tuberosity, base, and proximal shaft.
Tuberosity

is the site of attachment of the peroneus


brevis and lateral band of the plantar fascia.
The metaphyseal-diaphyseal junction is a vascular
watershed
The

metaphyseal-diaphyseal junction includes


the joint between the base of the 4th and 5th
metatarsals.

Mechanism of Injury
Tuberosity

fractures have a mechanism of


injury comparable to an ankle sprain
An acute fracture of the metaphysealdiaphyseal junction (Jones) occurs with a
forceful adduction force while the foot is
plantarflexed e.g. stumbling and catching
oneself

Clinical Presentation
Pain,

swelling and an inability to bear weight similar


to a moderate ankle sprain.
In a tuberosity fracture there is pinpoint pain over the
base of the fifth metatarsal
In an acute Jones fracture the pain is distal to the
tuberosity at the fracture site
History of prodromal symptoms is important to r/o
stress fracture

Diagnosis
Torg

Classification

A.

Tuberosity avulsion fracture


B. Fractures within 1.5 cm of the tuberosity

Acute Jones Fracture

Type 1: early
Type 2: delayed union
Type 3: nonunion

Stress Fractures

Type 1: early
Type 2: delayed union
Type 3: nonunion

Imaging
AP, lateral

and oblique radiographs


Avulsion fractures are almost
always transverse
In a Jones fracture the fracture line
is transverse and extends into the
joint between the bases of the 4th
and 5th metatarsals

Treatment
Tuberosity

fractures rarely need referral,


unless displaced over 3mm. Initially treated
in a firm-soled shoe, and transitioned to a
SLWC or fracture boot as needed.
Jones fracture: treated in a posterior splint
and referred for either a SLNWBC or
operative fixation.

Case #7
Pt

is a 17 y/o football player who comes


into the urgent care center complaining of
persistent pain after jamming his finger on a
tackle.
He has pain over the dorsum of the middle
phalynx of the middle finger.

PIP Injuries
The Jammed Finger

Epidemiology
Potentially

serious PIP joint injuries are


commonly misdiagnosed as a simple sprain
or jammed finger
PIP dorsal joint dislocations are the most
common ligamentous injuries of the hand
Hyperextension is the most common
mechanism, but axial loading and
hyperflexion are can also occur.

Clinical Anatomy
The

PIP joint is a
concentric
bicondylar hinge
joint
Primary stabilizers
of the PIP joint:
collateral

ligaments
volar plate

Mechanism of Injury
Hyperextension

stress with longitudinal


compression results in a dislocation
Forced hyperflexion injury to extended
finger can rupture the extensor tendon
Dorsal dislocations result in injury to the
volar plate
Volar dislocations injure the central slip

Clinical Presentation
High

index of suspicion
Mechanism of injury
Observation
Careful palpation
Stability testing after
radiographs; active and
passive
Assess active and passive
range of motion

Diagnosis
Avulsion

of the central
slip of the extensor
tendon
Collateral ligament injury
Volar plate injury
PIP dislocation
Jammed finger

Imaging
Radiographs

should be obtained
prior to attempting a reduction
True lateral and AP views
after

a reduction; there should be a


concentric reduction of the middle
phalynx on the proximal phalynx

Treatment

Stable dorsal dislocation

Collateral ligament injury

Splint for 3 weeks in 30 degrees of flexion, followed by


buddy taping
refer fracture over 30% articular surface
buddy taping for 3 to 4 weeks
refer large avulsion fractures, displaced > 2 mm or
articular surface > 30 %

Extensor mechanism injury

PIP splint full extension for 6 to 8 weeks

Case #8
Pt

is a 30 y/o female who presents to your


urgent care center with pain over the
proximal thumb, on the ulnar aspect of the
base.
She had a fall while skiing the day before.

Skiers Thumb

Epidemiology
Skiers thumb,

also called Gamekeepers


thumb, is a UCL rupture of the thumb MCP
joint.
Often underdiagnosed or mismanaged
resulting in recurrent pain and or disability.

Clinical Anatomy
The

thumb has a volar plate and well


defined collateral ligaments.
The unique feature of this joint is the
relationship of the UCL to the adductor
aponeurosis (AA), with the adductor
tightly overlying the UCL

Mechanism of Injury
FOOSH

causing a forced abduction of the


thumb,such as occurs from a fall during
skiing while holding a ski pole.
If the UCL ligament ruptures distal to the
joint line, the UCL ligament can become
trapped outside the adductor aponeurosis
creating a Stener lesion

Clinical Presentation
Accurate

diagnosis requires a high index of suspicion


Pain is principally felt over the ulnar MCP; nodule of
Stener lesion may be present
PA, lateral and oblique radiographs should be
obtained prior to stressing the involved joint
Stress testing should be performed in 30 degrees of
flexion to relax the volar plate; a digital block may be
required.

Imaging
Thumb

PA, lateral and


oblique radiographs
Stress radiographs in
equivocal cases
MRI may r/o Stener lesion

Diagnosis
Stable

or unstable?

A fracture

is unstable if it is displaced more


than 2 mm, or involves more than 25% of the
articular surface
The ligament is considered unstable if the
joint opens more than 35 degrees on stress
testing

Treatment
Conservative
Treatment

vs. Surgical

in a thumb spica cast/splint for 4 to 6

weeks:
nondisplaced fracture of proximal phalynx
no fracture; joint stable

Surgical

Consultation

displaced or unstable fracture of proximal phalynx


unstable joint; Stener lesion

Conclusion
Orthopedic

injuries are commonly


encountered in urgent and emergent care
settings!
Common presentations can masquerade
serious conditions.
A high index of suspicion is always
required!