Orthopedic Urgencies and Emergencies:

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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

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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.

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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.

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Acute Compartment Syndrome
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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.

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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

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Clinical Anatomy

• Each limb contains a number of compartments at
  risk for CS.
• Upper arm anterior(biceps-brachialis) and
  posterior(triceps).
• Forearm volar(flexors) and dorsal(extensors)
• 3 gluteal, 2 thigh, 4 in the lower leg.

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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.

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Radiographic Findings

• Common fractures associated with ACS
• tibial fractures
• supracondylar fractures of the humerus
• humeral shaft
• forearm fractures
• multiple metacarpal or metatarsal fractures
• Lisfranc fractures
• calcaneal fractures

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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.

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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.

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Case 1 Follow-up

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

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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.

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Cauda Equina Syndrome
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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

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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

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Mechanism of Injury

• Usually secondary to extrinsic pressure from a
  massive central HNP
• Other causes include
• epidural abscess
• epidural tumor
• epidural hematoma
• trauma

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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.

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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

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Imaging

• Plain films
• MRI imaging
  of the entire spine

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Treatment

• Neurosurgical consultation
• High dose systemic corticosteroids
• Emergent surgical decompression

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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.

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Perilunate Injury
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Epidemiology

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

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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.

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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

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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

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Diagnosis

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

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Imaging

• PA and lateral radiographs
• PA view
• constant 2 mm intercarpal
  joint space
• 3 arcs
• Lateral view
• four Cs
• capitolunate angle 0-15 degrees
• scapholunate 30-60 degrees
• Stress views

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Treatment

• Consultation with a hand surgeon to discuss
  management

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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.

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Lisfranc Fracture
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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.

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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.

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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.

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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.

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Diagnosis

• High index of suspicion in ankle and foot
  injuries
• Proper radiographic interpretation

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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

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Treatment

• Orthopedic consultation for possible ORIF
• Identify and manage compartment syndrome

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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.

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Syndesmotic Ankle Sprain
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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.

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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

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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.

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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

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Diagnosis

• Clinical diagnosis
• mechanism of injury
• correlative physical examination
• Radiographic imaging assists in risk stratifying

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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 Radiographic Criterion
• Mortise medial clear space gt 4mm
• AP tibiofibular overlap lt 10 mm

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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.

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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.

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Fifth Metatarsal Fracture
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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.

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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.

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Mechanism of Injury

• Tuberosity fractures have a mechanism of injury
  comparable to an ankle sprain
• An acute fracture of the metaphyseal-diaphyseal
  junction (Jones) occurs with a forceful adduction
  force while the foot is plantarflexed e.g.
  stumbling and catching oneself

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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

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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

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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

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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.

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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.

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PIP InjuriesThe Jammed Finger
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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.

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Clinical Anatomy

• The PIP joint is a concentric bicondylar hinge
  joint
• Primary stabilizers of the PIP joint
• collateral ligaments
• volar plate

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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

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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

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Diagnosis

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

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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

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Treatment

• Stable dorsal dislocation
• Splint for 3 weeks in 30 degrees of flexion,
  followed by buddy taping
• refer fracture over 30 articular surface
• Collateral ligament injury
• buddy taping for 3 to 4 weeks
• refer large avulsion fractures, displaced gt 2 mm
  or articular surface gt 30
• Extensor mechanism injury
• PIP splint full extension for 6 to 8 weeks

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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.

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Skiers Thumb
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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.

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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

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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

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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.

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Imaging

• Thumb PA, lateral and oblique radiographs
• Stress radiographs in equivocal cases
• MRI may r/o Stener lesion

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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

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Treatment

• Conservative vs. Surgical
• Treatment 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

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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!