dont miss ortho injuries 2

8/10/2019 Dont Miss Ortho Injuries 2

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O"(ecti!es

Disc%ss common orthopedic

%rgencies and emergencies that

are not %ncommon#ymisdiagnosed and)or initia##y

mismanaged.

Detai# pertinent diagnostic

eat%res and c#inica# criteria or

reerra# to an orthopedic

co##eag%e.


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Case *

Patient is a *+ y)o soccer p#ayer ho presents tothe E- ith a pain%# orearm ater a FOOSin(%ry. e is /%ite tender to pa#pation o!er the

pro0ima# orearm and has !isi"#e deormity. 1hes2in is intact. 3e%ro!asc%#ar e0amination isnorma#.

-adiographs.

Patient is p#aced in a #ong arm sp#int. Prior to discharge rom the ED or Ortho )% in the

am, the patient comp#ains o th%m" n%m"ness.


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Epidemio#ogyCompartment Syndrome4CS5 is a serio%s #ie and

#im"6threatening comp#ication o e0tremity tra%ma.

Fract%res, "%rns, cr%sh in(%ries and arteria# in(%ries

can a## res%#t in CS.

1hree /%arters o cases are associated ith

ract%res7 ti"ia most common.

Other sites inc#%de: hand7 orearm7 arm7 sho%#der7"ac27 "%ttoc2s7 thigh7 oot.


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C#inica# AnatomyEach #im" contains a n%m"er o

compartments at ris2 or CS.

Upper arm: anterior4"iceps6"rachia#is5 and posterior4triceps5.

Forearm: !o#ar4#e0ors5 and

dorsa#4e0tensors5

9 g#%tea#, thigh, ; in the #oer#eg.


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Diagnosisigh inde0 o c#inica# s%spicion, ith pain o%t o

proportion to the mechanism o in(%ry "eing the

ha##mar2 symptom.

Fi!e Ps: pain7 paresthesia7 paresis7 pa##or7 p%#ses.


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-adiographic Findings

Common ract%res associated ith ACS: ti"ia# ract%res

s%pracondy#ar ract%res o the h%mer%s h%mera# shat

orearm ract%res

m%#tip#e metacarpa# or metatarsa# ract%res


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Case * Fo##o6%p

C#inica# diagnosis o

ACS made.

1a2en to the O- or

O-8F and compartment

asciotomy.

De#ayed s2in c#os%re.


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Case

Pt is a ;> y)o ma#e ith a

history o co#on CA, ho

presents ith a history o#o "ac2 pain and a

history o ne onset

"#adder incontinence.


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Ca%da E/%inaSyndrome


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Epidemio#ogy

[email protected] o the pop%#ation e0periences "ac2 pain at

some point in their #i!es.

[email protected] o #o "ac2 pain reso#!es in + 6* ee2s B-ed F#ag symptoms inc#%de: age o!er >=, tra%ma,

e!er, incontinence, night pain, eight #oss,

progressi!e ea2ness.

Ca%da E/%ina Syndrome 4CES5 is a rare disorder,

representing on#y =.===;@ o a## "ac2 pain patients


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Mechanism o 8n(%ry

Us%a##y secondary to e0trinsic press%re

rom a massi!e centra# 3P

Other ca%ses inc#%de: epid%ra# a"scess

epid%ra# t%mor

epid%ra# hematoma

tra%ma


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Diagnosis

C#inica# diagnosis: #oss o "#adder contro#7 periana# n%m"ness7 pain

and ea2ness in!o#!ing "oth #egs

E!a#%ation o the %rinary post6!oid resid%a#

!o#%me assists ith diagnosis:

the a"sence o a post6!oid resid%a# !o#%me oo!er *==m#, essentia##y e0c#%des a diagnosis o

CES, ith a negati!e predicti!e !a#%e o

[email protected]


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8maging

P#ain i#msM-8 imaging

o the entire spine


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Case 9

Pt is a proessiona# oot"a## p#ayer, ide

recei!er, ho presents to ith rist pain.

e descri"es a FOOS mechanism oin(%ry and comp#ains o n%m"ness in the

distri"%tion o the median ner!e.


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Peri#%nate 8n(%ry


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Epidemio#ogy

&rist in(%ries acco%nt

or .>@ o a## ED

!isits.


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Mechanism o 8n(%ryPeri#%nate and #%nate dis#ocations res%#t rom

hypere0tension in(%ries.

Most common mechanism o in(%ry is a FOOS,

o##oed "y an MA.Progressi!e 8n(%ries: Stage 8: scapho#%nate dissociation

Stage 88: peri#%nate dis#ocation

Stage 888: dis#ocation o the tri/%etrem

Stage 8: #%nate dis#ocation


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C#inica# Presentationistory o high energy

mechanism o

hypere0tension

Pa#pa"#e pain o!er the

dors%m o the rist

1enderness dista# to


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8magingPA and #atera# radiographs PA !ie:

constant mm intercarpa# (oint space

9 arcs degrees

scapho#%nate 9=6+= degrees

Stress !ies


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1reatment

Cons%#tation ith ahand s%rgeon to

disc%ss management


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Case ;

Pt is a 9 y)o acti!e d%ty specia# operations

so#dier ho presents ith persistent dorsa#

oot pain. e stepped in a ho#e o!er a ee2ago, and has not impro!ed ith se#6care.


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C#inica# anatomy1he second metatarsa# is the

2eystone to the


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Mechanism o 8n(%ry


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C#inica# PresentationPresentation !aries rom a mi#d %ndetecta"#e

s%"#%0ation to an o"!io%s ract%re dis#ocation

Midoot pain, se##ing and diic%#ty "earing

eight are c#inica# c#%es

Pain ith passi!e pronation and a"d%ction o

the oreoot ith the hindoot s%pported

1ense se##ing may indicate a CS.


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Diagnosis

igh inde0 o

s%spicion in an2#eand oot in(%ries

Proper radiographic

interpretation


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1reatment

Orthopedic

cons%#tation orpossi"#e O-8F

8dentiy and manage

compartmentsyndrome
http://www.wramc.amedd.army.mil/MainFrame.cfm


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Case >

Pt is an *? y)o oot"a## p#ayer ho presents

ith an an2#e sprain.

Pt has considera"#e se##ing anddemonstrates more tenderness pro0ima# to

the A1F< in the area o the A81F #igament.

-adiographs are negati!e or ract%re.


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Syndesmotic An2#e

Sprain


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Epidemio#ogyAn2#e sprains are the most common #oer e0tremity

in(%ry in sports medicine, and constit%te >@ o a##

sports in(%ries.

8n one series, syndesmotic in(%ries constit%ted *I @ oan2#e sprains.

Syndesmotic in(%ries res%#t in #onger periods o

disa"i#ity than standard #atera# an2#e sprains.

Syndesmotic in(%ries are not %ncommon#y associated

ith ract%res.


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C#inica# Anatomy

1he syndesmotic #igaments maintain

sta"i#ity "eteen the dista# ti"ia and i"%#a

Anterior ti"ioi"%#ar #igament Posterior ti"ioi"%#ar #igament

1rans!erse ti"ioi"%#ar #igament

interosseo%s #igament interosseo%s mem"rane


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C#inica# PresentationUs%a##y the patient cannot p%t eight %pon the

#eg.

Pain is #ocated anterior#y a#ong thesyndesmosis.

Acti!e mo!ement o e0terna# rotation o the

oot is pain%#.

Positi!e S/%eeKe 1est

Positi!e E0terna# -otation Stress 1est


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Diagnosis

C#inica# diagnosismechanism o in(%ry

corre#ati!e physica#

e0amination

-adiographic imaging

assists in ris2 stratiying


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8magingOttaa An2#e -%#es: AP, #atera# and mortise

!ies sho%#d "e o"tained: tenderness o!er the #atera# and media# ma##eo#%s

%na"#e to "ear eight or o%r steps immediate#y

or in the ED

Syndesmosis -adiographic Criterion

Mortise: media# c#ear space L ;mm

AP: ti"ioi"%#ar o!er#ap *= mm


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1reatment


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Case +

Pt is a 9> y)o physician)mother ho hi#e

r%nning %p the stairs, noted a pain%# pop

in!o#!ing the #atera# oot.

On pa#pation, she has considera"#e

tenderness o!er the pro0ima# ith

metatarsa#.


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Fith Metatarsa#

Fract%re


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Epidemio#ogy

1he most common#y ract%red metatarsa# is

the ith.

1hese ract%res may res%#t rom direct or

indirect tra%ma.

Pro0ima# ith metatarsa# ract%res,

hoe!er, ha!e "een the s%"(ect oconsidera"#e de"ate and contro!ersy.


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C#inica# Anatomy1he pro0ima# ith metatarsa# consists o the

t%"erosity, "ase, and pro0ima# shat.1%"erosity is the site o attachment o the perone%s

"re!is and #atera# "and o the p#antar ascia.1he metaphysea#6diaphysea# (%nction is a !asc%#ar

atershed

1he metaphysea#6diaphysea# (%nction inc#%des

the (oint "eteen the "ase o the ;th and >th

metatarsa#s.


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Mechanism o 8n(%ry

1%"erosity ract%res ha!e a mechanism o

in(%ry compara"#e to an an2#e sprain

An ac%te ract%re o the metaphysea#6

diaphysea# (%nction 4ones5 occ%rs ith a

orce%# add%ction orce hi#e the oot is

p#antar#e0ed e.g. st%m"#ing and catchingonese#


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C#inica# Presentation

Pain, se##ing and an ina"i#ity to "ear eight simi#ar

to a moderate an2#e sprain.

8n a t%"erosity ract%re there is pinpoint pain o!er the

"ase o the ith metatarsa#

8n an ac%te ones ract%re the pain is dista# to the

t%"erosity at the ract%re site

istory o prodroma# symptoms is important to r)o

stress ract%re


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Diagnosis1org C#assiicationA. 1%"erosity a!%#sion ract%re

. Fract%res ithin *.> cm o the t%"erosity

Ac%te ones Fract%re 1ype *: ear#y

1ype : de#ayed %nion

1ype 9: non%nion

Stress Fract%res

1ype *: ear#y 1ype : de#ayed %nion

1ype 9: non%nion


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8maging

AP, #atera# and o"#i/%e radiographs

A!%#sion ract%res are a#most

a#ays trans!erse

8n a ones ract%re the ract%re #ine

is trans!erse and e0tends into the

(oint "eteen the "ases o the ;thand >th metatarsa#s


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1reatment

1%"erosity ract%res rare#y need reerra#,

%n#ess disp#aced o!er 9mm. 8nitia##y treated

in a irm6so#ed shoe, and transitioned to aS


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Case I

Pt is a *I y)o oot"a## p#ayer ho comes

into the %rgent care center comp#aining o

persistent pain ater (amming his inger on atac2#e.

e has pain o!er the dors%m o the midd#e

pha#yn0 o the midd#e inger.


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P8P 8n(%riesB1he ammed Finger


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Epidemio#ogy

Potentia##y serio%s P8P (oint in(%ries are

common#y misdiagnosed as a simp#e sprain

or B(ammed ingerP8P dorsa# (oint dis#ocations are the most

common #igamento%s in(%ries o the hand

ypere0tension is the most commonmechanism, "%t a0ia# #oading and

hyper#e0ion are can a#so occ%r.


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C#inica# Anatomy1he P8P (oint is a

concentric

"icondy#ar hinge

(oint

Primary sta"i#iKers

o the P8P (oint:

co##atera# #igaments

!o#ar p#ate


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Mechanism o 8n(%ry

ypere0tension stress ith #ongit%dina#

compression res%#ts in a dis#ocation

Forced hyper#e0ion in(%ry to e0tended

inger can r%pt%re the e0tensor tendon

Dorsa# dis#ocations res%#t in in(%ry to the

!o#ar p#ate

o#ar dis#ocations in(%re the centra# s#ip


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C#inica# Presentationigh inde0 o s%spicion

Mechanism o in(%ry

O"ser!ation

Care%# pa#pationSta"i#ity testing ater

radiographs7 acti!e and

passi!e

Assess acti!e and passi!e

range o motion


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8maging

-adiographs sho%#d "e o"tained

prior to attempting a red%ction1r%e #atera# and AP !ies ater a red%ction7 there sho%#d "e a

concentric red%ction o the midd#e

pha#yn0 on the pro0ima# pha#yn0


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1reatment Sta"#e dorsa# dis#ocation

Sp#int or 9 ee2s in 9= degrees o #e0ion, o##oed "y"%ddy taping

reer ract%re o!er [email protected] artic%#ar s%race

Co##atera# #igament in(%ry"%ddy taping or 9 to ; ee2s

reer #arge a!%#sion ract%res, disp#aced L mm orartic%#ar s%race L 9= @

E0tensor mechanism in(%ry P8P sp#int %## e0tension or + to ? ee2s


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Case ?

Pt is a 9= y)o ema#e ho presents to yo%r

%rgent care center ith pain o!er the

pro0ima# th%m", on the %#nar aspect o the

"ase.

She had a a## hi#e s2iing the day "eore.


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S2iers 1h%m"


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C#inica# Anatomy

1he th%m" has a !o#ar p#ate and e##

deined co##atera# #igaments.

1he %ni/%e eat%re o this (oint is there#ationship o the UC< to the add%ctor

apone%rosis 4AA5, ith the add%ctor

tight#y o!er#ying the UC degrees on stresstesting


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1reatment

Conser!ati!e !s. S%rgica#1reatment in a th%m" spica cast)sp#int or ; to +

ee2s: nondisp#aced ract%re o pro0ima# pha#yn0

no ract%re7 (oint sta"#e

S%rgica# Cons%#tation disp#aced or %nsta"#e ract%re o pro0ima# pha#yn0

%nsta"#e (oint7 Stener #esion


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dont miss ortho injuries 2

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