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

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: Lateral view: Stress views
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 Contralateral foot films
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

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 Collateral ligament injury
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!