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Orthopedic Urgencies and Emergencies: Francis G. O’Connor, MD, FACSM Director, Primary Care Sports Medicine Uniformed Services University Problems You.

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Presentation on theme: "Orthopedic Urgencies and Emergencies: Francis G. O’Connor, MD, FACSM Director, Primary Care Sports Medicine Uniformed Services University Problems You."— Presentation transcript:

1 Orthopedic Urgencies and Emergencies: Francis G. O’Connor, MD, FACSM Director, Primary Care Sports Medicine Uniformed Services University Problems You Don’t Want to Miss!

2 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.

3 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.


5 Acute Compartment Syndrome

6 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.

7 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

8 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.

9 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.

10 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

11 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.

12 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.

13 Case 1 Follow-up  Clinical diagnosis of ACS made.  Taken to the OR for ORIF and compartment fasciotomy.  Delayed skin closure.

14 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.

15 Cauda Equina Syndrome

16 Epidemiology  80% of the population experiences back pain at some point in their lives.  90% of low back pain resolves in 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 % of all back pain patients

17 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

18 Mechanism of Injury  Usually secondary to extrinsic pressure from a massive central HNP  Other causes include:  epidural abscess  epidural tumor  epidural hematoma  trauma

19 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.

20 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%

21 Imaging  Plain films  MRI imaging of the entire spine

22 Treatment  Neurosurgical consultation  High dose systemic corticosteroids  Emergent surgical decompression

23 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.

24 Perilunate Injury

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

26 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.

27 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

28 Clinical Presentation  History of high energy mechanism of hyperextension  Palpable pain over the dorsum of the wrist  Tenderness distal to Lister’s tubercle in the area of the scapholunate ligament

29 Diagnosis  High index of suspicion  Palpation over the dorsum of the wrist  Watson Click Test  Radiographs

30 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 degrees  Stress views

31 Treatment  Consultation with a hand surgeon to discuss management

32 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.

33 Lisfranc Fracture

34 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.

35 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.

36 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.

37 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.

38 Diagnosis  High index of suspicion in ankle and foot injuries  Proper radiographic interpretation

39 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

40 Treatment  Orthopedic consultation for possible ORIF  Identify and manage compartment syndrome

41 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.

42 Syndesmotic Ankle Sprain

43 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.

44 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

45 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.

46 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

47 Diagnosis  Clinical diagnosis  mechanism of injury  correlative physical examination  Radiographic imaging assists in risk stratifying

48 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 > 4mm  AP: tibiofibular overlap < 10 mm

49 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.

50 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.

51 Fifth Metatarsal Fracture

52 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.

53 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.

54 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

55 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

56 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

57 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

58 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.

59 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.

60 PIP Injuries “The Jammed Finger”

61 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.

62 Clinical Anatomy  The PIP joint is a concentric bicondylar hinge joint  Primary stabilizers of the PIP joint:  collateral ligaments  volar plate

63 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

64 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

65 Diagnosis  Avulsion of the central slip of the extensor tendon  Collateral ligament injury  Volar plate injury  PIP dislocation  “Jammed finger”

66 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

67 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 > 2 mm or articular surface > 30 %  Extensor mechanism injury  PIP splint full extension for 6 to 8 weeks

68 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.

69 Skier’s Thumb

70 Epidemiology  Skier’s thumb, also called Gamekeeper’s thumb, is a UCL rupture of the thumb MCP joint.  Often underdiagnosed or mismanaged resulting in recurrent pain and or disability.

71 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

72 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

73 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.

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

75 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

76 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

77 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!

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