Authored by: Blake Bauer, MD
The Ankle and Lower Leg
Authored by Dr. Javier Andrade
Authored by Dr. Jessica Hoglund
1. Differential (categorized based on gait pattern)
A. Antalgic gait
B. Non-antalgic gait
1. Transient synovitis
A. Most common cause of hip pain/limp in children <10 yrs
B. Aseptic inflammation of the hip (postviral etiology)
i. Physical exam:
2. Antalgic gait
i. Imaging performed when considering other differentials
ii. Ultrasound may be performed to confirm the presence of a joint effusion
2. Septic arthritis
i. Bacterial infection of joint
ii. Most commonly s. aureus
iii. Consider E. coli or GBS in children < 2 months
iv. Consider gonococcal arthritis in adolescents, sexually active patients, and in polyarticular arthritis
v. Consider salmonella in sickle cell disease
B. Clinical features
i. Neonates often do not appear ill and may not have fever in 50% of cases
ii. Older infants, toddlers, children may localize, limp, or refuse to walk
i. Physical exam1. Limb externally rotated, flexed, and abducted
ii. Labs1. CBC, ESR, possibly blood cultures
iii. Kocher criteria (septic arthritis vs transient synovitis, >3 predictors high risk for septic arthritis)
1. Non weight-bearing
2. Temp > 101.3oF (38.5oC)
3. ESR > 40 mm/hr
4. WBC > 12,000 cells/mm3
1. Ultrasound guided or fluoro guided for hip
2. Synovial fluid with >50,000 WBC’s, >75% PMN’s, positive gram stain and culture
i. IV antibiotics (vanc, rocephin or cefoxatime if < 2 months)
ii. Surgical drainage
i. Avascular necrosis
ii. Capsule damage
iii. Chronic arthritis
A. MCC of hip disability in adolescents
B. Obese adolescents whose hips are exposed to repetitive minimal trauma
i. Physical exam
1. Decreased internal rotation
2. Antalgic or Trendelenburg gait
3. Determine if pt is able to ambulate with or without crutches (determines prognosis)
1. Any adolescent with chronic groin, hip, thigh, or knee pain deserves bilateral hip XR (AP and lateral)
2. High incidence of bilateral disease
3. Use Klein’s lines to aid in diagnosis.
A and C below are abnormal. B and D are normal (line drawn from superior aspect of femoral neck transects lateral aspect of femoral head).
i. Non weight bearing (important to prevent further slippage)
ii. Operative management with possible prophylactic pinning of contralateral hip
i. Avascular necrosis
ii. Premature closure of physis
iii. Limited ROM
5. Legg-calve-perthes disease
A. Idiopathic avascular necrosis of proximal femoral epiphysis
B. Usually unilateral (10-15% bilateral)
C. Clinical features
i. Insidious onset of mild hip or knee pain, possible limp
ii. Repeated episodes of ischemia of femoral head à infarction and necrosis à subchondral stress fracture
i. Physical exam
1. Decreased abduction and internal rotation
2. Possible thigh atrophy on affected side
3. Limb shortening (advanced cases)
1. Early radiographs may be normal, but MRI will show edema in femoral epiphysis with T1 weighted
2. Radiographic progression of disease
i. Symptomatic tx
ii. Non weight bearing
iii. Operative management may prevent early osteoarthritis
can be managed non-operatively with spontaneous revascularization of femoral head
ii. Coxa magna deformity (short, broad femoral head and column)
Flynn, John M, and Roger F Widmann. “The Limping Child: Evaluation and Diagnosis.” Journal of the American Academy of Orthopaedic Surgeons, vol. 9, no. 2, Apr. 2001.Horowitz, Diane Lewis, et al. “Approach to Septic Arthritis.” American Family Physician, 15 Sept. 2011, www.aafp.org/afp/2011/0915/p653.html.“Imaging in Slipped Capital Femoral Epiphysis .” Imaging in Slipped Capital Femoral Epiphysis: Practice Essentials, Radiography, Computed Tomography, 6 May 2017, emedicine.medscape.com/article/413810-overview.“Legg-Calve-Perthes.” Legg-Calve-Perthes - Orthopedics - Medbullets Step 2/3, step2.medbullets.com/orthopedics/120519/legg-calve-perthes.Radiology In Ped Emerg Med, Vol 4, Case 17, www.hawaii.edu/medicine/pediatrics/pemxray/v4c17.htmlSwaminathan, Anand. “Pediatric Septic Hip.” Core EM, coreem.net/core/pediatric-septic-hip/.Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e; 2011 Available at:http://accessmedicine.mhmedical.com/content.aspx?bookid=348§ionid=40381606 Accessed: February 12, 2018
In order to begin an appropriate assessment of the ankle, it is necessary to review the significant anatomical structures.
First, we have the two long bones that form the proximal portion of the joint – the tibia and the fibula. At the ankle joint, the tibia extends as the lateral malleolus and posterior malleolus while the fibula forms the medial malleolus. The distal boney structure of the joint is formed by the talus.
A majority of the articular surface is formed by the horizontal portion of the distal tibia (the tibial plafond) which extends parallel to the dome of the talus; taken with the medial and lateral malleoli, it forms a rectangular socket known as the ankle mortise. Being a synovial joint, the ankle joint (between the ankle mortise and talar dome) is surrounded by a joint capsule. Like the knee joint capsule, the ankle capsule has an additional cranial extension at the syndesmosis.
The lateral and medial malleoli have ligamentous attachments to the talus and calcaneus that contribute to stability of the joint.
A patient presenting with a suspected ankle injury should undergo the following assessment:
Our initial evaluation is important because it helps utilize the following decision tool:
Ottawa Ankle Rule
The Ottawa Ankle Rule helps us screen for patients that will benefit from ankle imaging. Ankle Imaging is warranted in those who have ankle pain and:
Tips from the creators at University of Ottawa:
Palpate the entire distal 6cm of the fibula and tibia;
Do not neglect the importance of medial malleolar tenderness;
“Bearing weight” counts even if the patient limps;
Be caution in patients under age 18.
When imaging the ankle obtain 3 views to appropriately evaluate the joint: AP, Lateral and the Mortise study.
Begin with the AP and Lateral views. Trace the entire length of the tibia and fibula paying special attention to the fibula on the lateral view, for oblique fractures may be difficult to see.
Next, proceed to the mortise view. Trace around the mortise and Talar dome, evaluate for joint space uniformity. The ring structure of the ankle is made up of three bones (tibia, fibula and talus) and three ligaments (medial and lateral collateral ligaments and interosseous ligament) if there is one break in the ring, look for a second.
To evaluate the integrity of the syndesmosis use the following measurements:
•Tibiofibular overlap < 1mm
•Increased medial clear space: less than or equal to 4 mm
•Increased Tibiofibular clear space: < 6 mm
Additional radiographic measurements
Talo-crural angle : The angle is formed by drawing a line parallel to the tibial plafond, a line perpendicular to the tibail plafond, and a line connecting the lateral and medial malleoli. This angle should be between 75 – 87 degrees and should be within 2-5 degrees of contralateral side. Deviation from these measurements is indicative of fibula shortening.
Typical Fracture Patterns
Isolated Medial Malleolus Fracture
Isolated Lateral Malleolus Fracture
Isolated Posterior Malleolus Fracture
Bimalleolar fracture / equivalent
*Notice how there are two breaks to the ring structure, therefore this injury pattern is consistent with an unstable joint (increased medial clear space, distal fibula fracture). These unstable injuries convey a higher need for orthopedic intervention.
Associated syndesmotic injuries
This following fracture pattern is often confused for an ankle fracture, however the presence of a pilon fracture conveys a different mechanism and prognosis.
A Pilon fracture, French for mortar and pestle, occurs due to an axial loading mechanism and is defined by articular impaction and comminution of the distal tibia. When you see a pilon fracture it is important to evaluate for other injuries typical of axial loading (i.e. lumbar spine, calcaneus, ect.)
BY: DR. ETHEN ELLINGTON M.D.
Systematic Approach to Adult Knee Films:
1) Know your anatomy!
2) Check for an effusion
7) Don’t forget the fabella! It’s a normal sesamoid bone of the lateral head of gastrocnemius tendon - NOT to be mistaken for a fracture or loose body
Resources and Images:
By: Dr. jeremy driscoll M.D.
-Hand and Wrist injures (NOT distal radius or ulna fractures, can still supinate and pronate)
-2nd-5th metacarpal head fracture
-Extends along volar forearm from metacarpal heads to just proximal to radial head
-Allow flexion of elbow
-Wrist at 20 degrees of extension
-Can add dorsal "sandwich" for stability
Ulnar Gutter Splint
-4th and 5th phalanges and metacarpals
-Extends from 5th DIP to proximal forearm
-Wrist at 20 degrees of extension
-Flex MCPs at 50-70 degrees, PIP and DIPs in slight flexion
Thumb Spica Splint
-Scaphoid and lunate fractures
-1st metacarpal fracture
-De Quervain tenosynovitis
-Extends from tip of thumb to proximal forearm
-Wrist at 20 degrees of extension
-Thumb slightly flexed
Long Arm Splint
-Proximal forearm and elbow fractures
-Intraarticular fractures of distal humerus and olecranon
-Elbow at 90 degrees of flexion
-Neutral forearm and wrist
Sugar Tong Splint
-Wrist and distal forearm fractures
-Extends from MCPs on dorsum, around elbow, to volar midpalmar crease
-Elbow at 90 degrees of flexion
-Neutral forearm and wrist
-Double sugar tong for complex or unstable forearm and elbow fractures
Michael T Fitch, MD. Basic Splinting Techniques. New England Journal of Medicine. 2008; 359:e32.
HPI: 23 yo male s/p MCC. Patient reports that he swerved to avoid hitting a vehicle in front of him that stopped abruptly and layed down his bike, landing on his right shoulder. He was helmeted and did not lose consciousness. Ambulatory after the event, hemodynamically stable, and complaining of right shoulder pain.
Management: Middle Third (80-85%)
Lateral Third (10-15%)
Medial Third (5-8%)
HPI: 22 yo otherwise healthy male presents s/p head on MVC vs tree. Patient is awake and alert, hemodynamically stable, complaining of right hip pain.
Physical Exam: No external signs of trauma. Right lower extremity is shortened compared to the left and internal rotated. No numbness, 2+ DP pulse.
- Simple: pure dislocation
- Complex: with associated fracture of acetabulum or proximal femur
- Axial load on femur while hip flexed and adducted or through flexed knee (dashboard injury such as this patient)
Requires emergent reduction (within 6 hours!) due to risk of vascular compromise to hip and osteonecrosis
Examine femoral neck closely on XR to rule out fracture prior to attempting closed reduction.
With ipsilateral femoral neck fracture, closed reduction is contraindicated!
Patient must be adequately sedated for procedure. Propofol helps with tissue relaxation!
Post reduction CT must be performed to evaluate for:
- femoral head fractures
- loose bodies
- acetabular fractures
Commonly associated with ipsilateral knee injuries (up to 25%)
Dispo: For simple dislocation, protected weight bearing for 4-6 weeks
1. Serna, Fernando MD, Corczyca, John MD. Hip Dislocations and Femoral Head Fractures. University of Rochester Medical Center. March 2004.
An otherwise healthy 39-year-old female presents to the emergency department complaining of right shoulder pain.
She had a fall the night previous where she fell directly onto the point of her right shoulder. She had dull, moderate pain but went to sleep after the fall as it was late and she had been drinking. She woke up on the morning of presentation with excruciating shoulder pain, inability to move her arm secondary to pain and a visible of the right shoulder deformity. No other traumatic injuries, no other complaints. She is not able to move her shoulder but can move her elbow and hand okay. No paresthesias, no weakness in the right arm.
On physical exam,
Her right shoulder is held against body, flexed at elbow. There is exquisite point tenderness over the AC joint. Appears deformed on visualization, with down-sloping of the anterior shoulder. Skin is intact. Palpation of the long bones and hands does not elicit tenderness or crepitus. The clavicle is neither tender nor deformed. Active/passive elbow and wrist range of motion is full and painless. Passive ROM of the right shoulder is not tolerated well secondary to pain. Patient can give a thumbs up, make an okay sign, and cross his index and long fingers without issue. Sensation to light touch is intact in the radial, median, and ulnar nerve distributions in the hand. Radial pulse is palpable.
Right shoulder XRs were performed and are shown below.
What is the diagnosis? Should you prepare the patient for shoulder reduction?
AC separation of the shoulder usually results from direct trauma to the AC joint, when the arm is in an adducted position. Support of the AC joint is through the acromioclavicular and coracoclavicular ligaments. Tenderness and deformity at the AC joint is diagnostic of this clinically. XRs are performed to confirm the diagnosis and also rule out underlying fracture.
There are six types of AC separation.
Involvement of the AC and CC ligaments determine the severity of acromio-clavicular injury. The types increasingly worsening in severity.
Must have True AP, Axillary and Scapular Y views to diagnose (to rule out associated dislocation or fracture).
The normal AC joint space is 3mm and the normal coracoclavicular distance is 13 mm.
Anything larger than these are pathologic.
Treatment of type I and II injuries consists of rest, ice, analgesics, and immobilization (sling), followed by early range-of-motion exercises (7 to 14 days).
Orthopedic consultation for Types III through VI.
Operative management is ORIF or ligament reconstruction: Type III in elite athletes, Types IV-VI.
By: Dr. Michael Mollo M.D.
1. Rudzinski J Pittman L Uehara D: Injuries to Bones and Joints, in Tintinalli J., et al (eds): Tintinallis Emergency Medicine: A Comprehensive Study Guide, ed 7., (Sec) 22 (Ch) 268:p 1832-1834.
3. Northwestern Orthopedics
A 43 y.o. male presents after a knee injury while playing basketball. Patient states he stopped suddenly and twisted his right knee as he fell to the ground. He complains of right knee pain and swelling. Denies any other injuries after this fall.
On exam, the patient has significant right knee swelling. His right knee is diffusely tender to palpation. ROM testing is limited by pain, especially during flexion. Anterior drawer test is positive for laxity without a firm end point. Lachmen test is also positive for anterior laxity without a firm end point.
DIAGNOSIS AND TREATMENT
Based on the physical exam and the above radiograph, the patient was diagnosed with an anterior cruciate ligament (ACL) tear and a Segond fracture.
Patient was treated with a knee immobilizer and crutches for the immediate post-injury period. He was given outpatient referral for possible later surgical intervention.
This fracture was first described by Dr. Paul Segond in 1879 after experiments on cadavers.
A Segond fracture is a small bone avulsion from the lateral aspect of the tibia. This fracture is significant because it has a strong association with ACL injuries. Approximately 75% of patients with this fracture pattern with have an ACL injury. The associated exists because the stresses needed to produce this fracture also frequently produce ACL injuries. The exact mechanism of this fracture is unclear. It has been thought to be the result of an avulsion of the middle third of the lateral capsular ligament, however other theories exist. The iliotibial band or anterior oblique band may instead be involved.
A Segond fracture is a clue to the clinician to perform a thorough ligamentous exam of the knee to search for other injuries. A medial meniscus injury is also commonly seen.
A “reverse” Segond fracture also exists and is a small medial avulsion fracture of the tibia. This mirror fracture is rare, but is associated with injuries to the medial collateral ligament and the posterior cruciate ligament (PCL).
Segond fracture = small bone avulsion from lateral aspect of tibia.
ACL injury seen in 75% of these patients.
Perform a thorough ligamentous exam if this fracture pattern is seen.
CMC ER Residents
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.