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.
A 15 yr old female right hand dominant with no significant past medical history presents with left shoulder pain after sustaining injury while playing basketball. States she can not clearly recall the events but remembers extending her arm for the ball and having sudden onset of pain. Describes generalized constant aching pain to the left shoulder only. She has been unable to range her left shoulder since the event stating “it hurts too much”. She denies any numbness or tingling. No other complaints. Last PO intake approximately 6 hours ago.
General: adolescent female sitting upright in bed with left arm flexed and adducted, moderate distress
LUE: left arm held flexed and adducted against her body. Square-like appearance to the shoulder compared to the right which appears rounded. No erythema, abrasions, lacerations, or ecchymosis. Unable to flex, extend, or abduct left shoulder due to pain. Full flexion and extension of elbow and wrist. She can make thumbs up, okay sign, cross fingers, touch thumb to pinky, and keep fingers spread against resistance. Sensation intact in the median, ulnar and radial nerve distributions. Sensation intact in the axillary nerve distribution. 2+ radial pulse
diagnosis and treatment
Anterior left shoulder dislocation. She was given intranasal fentanyl, intraarticular lidocaine and nitrous oxide. Left shoulder was then reduced by external rotation with elbow at patient’s side. No complications. Post reduction films obtained show successful reduction with no fractures
Anterior shoulder dislocations are the most common shoulder dislocation, accounting for approximately 95%. Majority of these occur in patients younger than 30 years old. Posterior dislocations account for about 5%, and inferior dislocations (luxation erecta) are extremely rare.
Anterior shoulder dislocations occur secondary to a “hyper” external rotation. The glenoid dislocates to the position of either subcoracoid (90%), subclavicular, or sublenoid. Usually the patient holds arms by their side. In a thin patient, the acromion appears prominent giving the classic “squared off” appearance the shoulder. In larger patients, the effected shoulder may appear more round instead of its normal square shape.
Intra-articular lidocaine can be used for pain relief prior to reduction as shown below.
Nitrous oxide is also a common and effective means for pain relief. A full neurovascular exam is crucial, approximately 13.5% will have neurologic injury. Axillary nerve is the most commonly effected. This nerve is tested by assessing pinprick sensation over the lateral aspect of the arm. You can also test by motor abduction of the deltoid.
Films must be obtained prior to reduction if: first time dislocation, age over 40, presence of humeral ecchymosis, or traumatic mechanism. The scapular Y view will demonstrate anterior dislocation of the humeral head from the glenoid. Associated injuries to look for include Hill sachs defect, bankart lesions, fractures of the greater tuberosity, soft tissue injuries, and rotator cuff tears.
While we will not discuss in depth associated injuries, it is important to be aware particularly of hill sachs and rotator cuff tears. Hill sachs defect presents in up to 40% of anterior dislocations; this defined by a radiographic defect in the posterior lateral portion of the humeral head. Rotator cuff tears, also common, present more commonly in older patients. It is estimated between 35-86% of anterior dislocations in patients over 40 years old have a rotator cuff tear.
Shown below includes image of anterior shoulder dislocation with hill-sachs deformity on the left; and anterior shoulder dislocation with bankart lesion on the right.
There are several techniques for reduction, none of which have proven more efficient or effective over the other. A common technique, used in this patient, is the external rotation method. Patient sits up, straight back. Examiner holds the elbow at the patients side and with forearm in 90 degree angle, slowly externally rotates the arm. After successfully reduction, the arm is immobilized with splint and post reduction films obtained. Immobilization should be for 3 weeks if younger than 30 yrs old, and for 7-10 days if over 30 yrs old.
This is a 13 yr old Caucasian male with no significant past medical history who is presenting with 2 week history of right hip pain. He describes a vague pain localized around the right hip worsened with movement mostly flexion and extension of the hip. No known alleviating factors. No history of trauma, fever, chills, nausea or vomiting, recent weight loss or night sweats. No other joints involved. No family history of rheumatologic or bone disorders.
General: Obese male, laying flat on bed in no distress.
RLE: Right lower extremity is slightly externally rotated compared to left. No thigh or calf atrophy. No erythema, swelling, or warmth to touch. No abrasions, lacerations or ecchymosis. 2+ dorsalis pedis pulse. Sensation intact in all dermatomes. Full active range of motion of right hip. Passive range of motion however is significant for slight external rotation with flexion of the hip. No patellar or fibular head tenderness. Full active and passive range of motion of knee. Noted to have slight external rotation of right lower extremity with gait.
GU: Normal male genitalia. No erythema, swelling, or tenderness of penis or scrotum. No urethral discharge.
LLE: No erythema, swelling, or warmth to touch. No abrasions, lacerations or ecchymosis. 2+ dorsalis pedis pulse. Sensation intact in all dermatomes. Full active and passive range of motion of hip. No patellar or fibular head tenderness. Full active and passive range of motion of knee.
Diagnosis and treatment
Isolated right slipped capital femoral epiphysis. No involvement of the left side. Patient was taken to the operating room the following day and underwent percutaneous in situ fixation with two cannulated screws. TSH and free T4 obtained, normal. Counseling on weight loss provided.
Slipped capital femoral epiphysis (SCFE) is a disorder where the femoral epiphysis displaces from the femoral neck through the physeal plate. It is a common hip disorder in adolescents affecting approximately 10 per 100,000. Note however, about 15% will present with no description of hip pain but rather knee or thigh discomfort. Thus it is important to maintain a high degree of suspicion to diagnose and treat early.
SCFE is more commonly seen in obese children; obesity is the single greatest risk factor. It more commonly affects males, African Americans, and Pacific islanders. Often it occurs during periods of rapid growth (the average age for boys 13 yrs old, females 12 yrs old). It can be associated with endocrine disorders including hypothyroidism, osteodystrophy of chronic renal failure and growth hormone treatment. If SCFE is diagnosed in a child who is <10 yrs old or whose weight is <50th percentile, an endocrine workup is warranted.
The displacement of the epiphysis occurs secondary to mechanical forces. Through the hypertrophic zone of the physis, slippage can occur. Cartilage within the perichondral ring acts as a weak point and with mechanical forces causes displacement. With displacement, the epiphysis remains within the acetabulum. The neck slips anteriorly and rotates externally.
The most common presenting complains are pain and altered gait. Classically, an obese child presents with dull pain either in the hip, groin, thigh or knee without any history of trauma. Symptoms can be present anywhere from week to several months. Often an abnormal coxalgic gait is noted. The child may have decreased hip motion with obligatory external rotation during passive flexion of the hip. There may also be abnormal leg alignment with the foot slightly externally rotated and thigh atrophy.
Diagnosis is made by radiographs. It is recommended that both an AP and frog-leg lateral of the right and left hip is obtained. 17-50% of SCFE are bilateral. On the AP pelvis, Klein’s line can be drawn to help diagnose. This line is drawn along the superior border of the femoral neck. In a normal hip, the line will intersect the femoral head. In SCFE, Klein’s line does not intersect the femoral head.
PIf the child is able to ambulate, it is termed stable. Unstable SCFE occur in children unable to ambulate or if the epiphysis is displaced from the metaphysis. Each is treated by making the child non-weightbearing until orthopedic consultation and treatment. The importance in the difference is children with unstable SCFE may have further displacement with any manipulation; thus it is extremely important to immediately place child on stretch and instruct to not ambulate.
Children with SCFE should be referred to orthopedics promptly. Non-weightbearing is required until treatment. Treatment is surgical by either percutaneous in situ fixation or open reduction with the capital realignment.
1. SCFE is where the femoral epiphysis displaces from the femoral neck
2. More common in obesity, males, African American, and Pacific islanders
3. Can be associated with endocrine disorders
4. Order AP and frog-leg views bilaterally to diagnose, assess Klein's line
5. Urgent orthopedic consultation for surgical treatment
45 year old male right hand dominant with no significant past medical history presents by EMS after low mechanism motor vehicle crash complaining of left thumb pain. States his left hand “jammed into the steering wheel” during the crash causing deformity to the left thumb. He denies any numbness or tingling but is unable to fully range due to pain. No prior left hand injuries. Non-smoker.
Swelling and deformity to the left thumb metacarpophalangeal joint. No abrasions, laceration or ecchymosis. 2+ radial pulse. Significantly limited flexion and extension of the left thumb at the MCP. Intact flexion and extension at the PIP. 2-point sensation intact. Good capillary refill.
Dorsal dislocation of the left thumb metacarpophalangeal joint
Diagnosis and plan
Simple metacarpophalangeal joint dislocation of the left thumb.
Patient was given pain medication through an IV and a radial and median nerve block was done for anesthesia. The joint was then reduced successfully at bedside with initial attempt. Post-op exam essentially unchanged except significant improvement in flexion and extension at MCP. There did not seem to be any significant instability. Regardless patient was placed in a thumb spica splint and follow-up with hand clinic in 1 week.
Dislocation of digits are common. Dorsal MCP dislocations follow hyperextension of the affected joint with rupture of the volar plate. They are classified by direction as dorsal, volar, or lateral.
Dorsal: distal digit displaced toward back of hand
Volar: distal digit displaced toward palm of hand
Lateral: distal digit displaced ulnar or radial direction
The most frequent direction of dislocation is a dorsal displacement.
Metacarpophalangeal dislocations are further classified by volar plate involvement. For MCP dislocations other than the thumb this is simple (volar plate not interposed in the joint) or complex (volar plate entrapped in the joint). For MCP dislocations of the thumb, classify as incomplete (volar plate ruptured, collateral ligament intact), simple (volar plate and collateral ligament ruptured), or complex (dislocated phalanx entrapped in intrinsic hand muscles and volar plate entrapped). Simple thumb MCP joint dislocation are in extension and reducible whereas complex dislocations are in bayonet apposition and not easily reducible. It is extremely important to obtain radiographs prior to attempting reduction to clarify whether the reduction should be attempted or referral to hand surgeon.
Emergency medicine physician should reduce the dislocation once confirmed a simple dislocation without associated open joint, fracture or entrapped volar plate.
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.