HPI: Young male presents after feeling a pop in his finger after he dropped a case of bottled water causing his middle finger to get caught in the wrapping. PE: Ulnar deviation of affected digit and a popping sensation and pain when flexing his fingers. Imaging:
Anatomy:
Treatment Options:
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Case: 13 y/o obese AA male presents with left leg pain after stepping in a hole during football training with his brothers. States he felt a pop during this incident and has since been unable to move his leg secondary to pain. Physical exam notable for normal vital signs, edema and tenderness to palpation proximal to left knee. Sensation intact to light touch throughout, 2+ pulses, 5/5 strength of ankle/great toe dorsi/plantar flexion. Diagnosis: Plain films including 2 view femur, 3 view knee, and 2 view tibia/fibula MRI (now gold standard) or ultrasound when plain films not diagnostic and suspicion still high ![]() Case: 27 year old Male s/p MVC with multiple open RLE fractures. Complains of severe pain at the BL ankles, unwilling to allow any further testing in the trauma bay. Plain films of single ankle below: ![]() Calcaneal Fractures: - Mechanism: Generally result from an axial load to the lower extremity. Typically either a fall from height while landing on one’s feet –or- from an MVC. - Presentation: Patients may have a shortened and widened heel with varus deformity. Patients also may have “Mondor’s sign” which is ecchymoses of the foot extending into the heel. Diagnosis:
CT Scans:
Classification: There are multiple levels of classification, but the most important delineation is between intra-articular and extra-articular fractures.
As stated before -> Calcaneal fractures are associated with significant axial load so always consider other injuries including hip/pelvis, or lumbar spine fractures.
Treatment: o For most extra-articular and type I intra-articular fractures: Immobilization with short-leg splint, strict non weight-bearing status, elevation, pain control. Patient will need ortho follow-up ASAP. o For more severe fractures: Surgical fixation, if pursued, will vary depending on the patient’s comorbidities and the preference of the surgeon. Important complications: o Poor wound healing (particularly in smokers and diabetics) o Compartment syndrome o Arthritis HPI: Middle-aged male s/p MCC. PE: Ecchymoses, swelling, and tenderness about ankle. Tender over proximal fibula and pain with squeezing of calf. Figure 1: Mortise view of ankle showing widened mortise mediallyFigure 2: Leg film showing proximal fibular fractureAnkle Sprains: - Divided into grades o I: Minor, no significant ligamentous damage. Able to bear weight. o II: Associated with partial ligamentous tear. Significant ecchymoses/swelling. Difficulty bearing weight. o III: Associated with complete ligamentous tear. Significant functional loss and universal inability to bear weight. - When should we obtain radiographs?: o If pretest clinical suspicion is high based on mechanism of injury or patient cannot be ruled out for fracture based on Ottawa ankle rules: Syndesmotic injuries (AKA “high” ankle sprains):
o PE and mechanism:
o Treatment:
- Otherwise patient needs syndesmotic screw fixation. Patient can be immobilized and follow-up as an outpatient for surgical fixation HPI: 7 y/o fall from monkey bars. Landed on extended shoulder + outstretched arm. Physical exam: Obvious arm deformity. Ecchymosis over distal/medial arm. Inability to flex thumb IP joint and DIP of index finger (AIN neuropraxia). Palpable pulses. Warm extremity. AP showing mild varus angulation Lateral film showing significant posterior displacement of distal portion of fracture Normal lateral film Normal AP flim showing Baumann's angle: angle btw humerus and capitellar physis. This measures amount of varus/valgus deformity Supracondylar Humerus Fractures:
Two categories: · Extension: Distal fragment displaced anteriorly (95% of cases). · Flexion: Distal fragment displaced posteriorly (5% of cases). Four Types: · I: Nondisplaced: look for posterior fat pad · II: Displaced. Posterior cortex intact · III: Completely displaced · IV: Complete periosteal disruption with instability on flexion and extension. Presentation: · Usually from fall on outstretched hand. · Frequently will have neurologic findings: · Anterior Interosseus Neuropraxia: · Most common neurologic finding. Particularly with extension-type fractures. · AIN is a branch of Median nerve. · Patient's cannot flex thumb IP joint or index DIP joint (Can't make an “OK” sign). Almost all will resolve with conservative management. Also have vascular compromise in approximately 1% Usually brachial artery compromise High collateral flow, so patient may have a pink, but pulseless extremity. Still requires emergent reduction. Treatment: Type I: Immobilization at 90 degrees and ortho follow-up. Type II: Closed reduction unless displacement is minimal. Adequate reduction: Baumann's angle wnl, anterior humeral line transects capitellum Type III: High-risk for neurovascular complications. Get ortho involved. Almost always require closed reduction + pinning vs. open reduction Type IV: Open surgical reduction and fixation Indications for open reduction: 1.) Inadequate reduction with closed techniques 2.) Vascular injury 3.) open fracture 4.) Type iv fracture HPI: Patient punched a wall Physical exam: Right hand with significant soft tissue swelling dorsally and TTP over third metacarpal. Metacarpal Fractures: General Principles
Acceptable AngulationTreatment:
Immobilization: Indications for non-operative immobilization are 1.) Stable fracture pattern 2.) Acceptable angulation 3.) no rotational deformity 4.) Shortening of less than 5mm Splinting: • Fracture splints should be forearm-based and should allow for motion of the interphalangeal (IP) joints. • Splints should extend over the dorsal and palmar aspect of the entire metacarpal being treated. • Generally, the wrist should be placed in 20-30° of extension; the metacarpophalangeal (MCP) joints should be immobilized in 70-90° of flexion, with the dorsal aspect of the splint extending to the IP joints; and the volar aspect should end at the distal palmar crease. • Buddy taping the fingers of the involved metacarpal can aid in maintaining rotational control. HPI: Patient 1: Restrained passenger of a head on MVC. Patient 2: Elderly patient with fall from standing. Physical Exam: Patient 1: Hip flexed and internally rotated. Unable to straighten the leg. Unable to walk. Patient 2: Hip flexed and externally rotated. Unable to straighten the leg. Unable to walk. Imaging: Patient 1: Posterior hip dislocation of native hip. Patient 2: Superolateral hip dislocation of prosthetic hip. Posterior Hip DislocationProsthetic Hip DislocationTreatment:
****Don't forgot you can find the ED Policy for Deep Sedation on the Top 20 Page. Anesthesia must be present for intubation. Click here to read more. HPI: Patient 1: Restrained MVC. Presented with knee pain and swelling. Patient 2: Fall from height and chief complaint of shoulder and knee pain. Physical Exam: Patient 1: Swollen left knee with tenderness to palpation. Patient 2: Knee visibly deformed, swollen, and bruised. Small open deformity w/ active bleeding. High risk for compartment syndrome. Imaging: Patient 1: Schatzker type 2 fracture (see table below for classifications of Schatzker fracture) Patient 2: Schatzker type 6 fracture Dispo: Patient 1: Admitted. Splinted w/ ORIF as inpatient. Patient 2: Admitted. Splinted w/ closed reduction and external fixation. Plan for definitive repair in ~2 weeks after soft tissue swelling has subsided. Treatment: 1) Hinged knee brace w/ passive ROM - for patients w/ minimally displaced or split depressed fractures or minimal baseline mobility. 2) External fixation - for patient w/ open or comminuted fractures or significant soft tissue swelling. 3) ORIF - for >3mm articular step off or varus/valgus instability. Types of Schatzker Fractures:
HPI: Patient presents with a grossly deformed right upper extremity.
PE: Gross deformity of humerus, no open fracture. Unable to extend wrist. Unable to hyper-extend MP joints of fingers and unable to flex IP joint of thumb. Radial and ulnar pulses intact. IMAGING: Multi-factorial fracture along the mid third of humerus along the expected course of the radial nerve. DISPO (if at free standing ED): Transfer patient to ED with on-call orthopedics for definitive fixation. Reduce and splint prior to transfer. TREATMENT: Nonoperative managment. Splinted and cast at bedside. Follow radial nerve palsy clinically for improvement. |
Orthopedics BlogAuthorCMC ER Residents Archives
June 2018
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Disclaimer: All images and x-rays included on this blog are the sole property of CMC EM Residency and cannot be used or reproduced without written permission. Patient identifiers have been redacted/changed or patient consent has been obtained. Information contained in this blog is the opinion of the author and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.
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