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

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(biceps-brachialis) 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 fractures associated with ACS: tibial 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 Lister’s 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: Lateral view: Stress views constant 2 mm intercarpal joint space 3 arcs Lateral view: four Cs capitolunate angle 0-15 degrees scapholunate 30-60 degrees Stress views

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 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

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 Radiographic Criterion Mortise: 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 metaphyseal-diaphyseal 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

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 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

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.

Skier’s Thumb

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.

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 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

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!