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COMPARTMENT SYNDROME

6/25/2018

0 Comments

 

Authored by Dr. Angie Rombola

Background:
  • Occurs when high compartment pressure prevent adequate perfusion
  • Irreversible muscle and nerve damage after 4-6 hrs
  • Most commonly: lower leg (40%)
  • Can occur anywhere skeletal muscle is surrounded by fascia (forearm, thigh, hand, foot, buttock)
Mechanism:
  • Fractures (69%)
    • Increased incidence with openfractures
    • Tibial fracture (most common)
  • Soft tissue injury 
    • Crush Injuries
    • Contusions
    • Burns
    • Prolonged limb compression 
  • External compression 
    • Tight casts, dressings
  • Vascular
    • Hemorrhage
  • Ischemic-reperfusion injury 
    • Arterial injury 
 
Clinical Features: 
  • Common
    • Pain out of proportion (earliest)
    • Pain with passive stretch (most sensitive)
    • Rapidly increasing & tense swelling
  • Paresthesias (early)
    • Uncommon
    • Decreased sensation
    • Motor weakness (late)
    • Pulselessness (uncommon)
Diagnosis:
  • Primarily a clinical diagnosis
  • Measure of tissue pressures is confirmatory 
  • Measuring compartment pressure indicated in polytrauma, sedated/AMS patients
Compartment Pressure:
  • Intra-compartment pressure: > 30mm Hg
  • Delta pressure (DBP – compartment p) < 30 mmHg
    • Better measurement
    • Helps avoid unnecessary fasciotomies 
Management:
  • Remove external compressive wrappings
  • Address underlying cause
  • Surgical consult for fasciotomy
  • Supplemental Oxygen
  • Correct hypotension
  • Reverse patients on anticoagulants
4 Compartments of the lower leg
  • Anterior
  • Lateral
  • Superficial posterior
  • Deep posterior 

  • Need to measure all 4 compartments 
 

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The FOot

6/12/2018

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By: DR. AUSTIN COSTA

When to order foot X-rays?:
  • Ottawa midfoot rules
    • Pain with palpation of base of 5thmetatarsal
    • Pain with palpation of navicular
    • Inability to bear weight both at time of injury and in ED
  • Suspected injury with high energy mechanism 
Picture
Anatomy (From proximal to distal):
  • Hindfoot 
    • Calcaneus and talus
  • Chopart joint 
  • Midfoot 
    • Navicular, medial cuneiform, middle cuneiform, lateral cuneiform, and cuboid
  • Lizfranc joint
    • Lizfranc ligament connects medial cuneiform and 2ndMT on plantar aspect of foot
  • Forefoot 
    • Metatarsals, phalanges
Picture
​Standard Views:
  • AP
    • Forefoot 
    • Midfoot
    • Lizfranc injury
      • Alignment of 1stMT and medial cunneaform
      • Alignment of 2ndMT and middle cunneaform
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Oblique
  • Forefoot
  • Midfoot
  • Calcaneus 
  • Alignment for 3rdMT with lateral cuneiform
  • Alignment of 4thMT with cuboid
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  • Lateral
    • Hindfoot 
      • Boehler’s angle
        • upper edge of the calcaneal body posteriorly to the upper edge of the posterior articular facet of the calcaneus (red)
        • upper edge of the posterior articular facet of the calcaneus to the upper edge of the anterior process of the calcaneus (blue)
        • Normal is 25-40 degress ​
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  • Dorsal foot arch
    • Weight bearing films (if able to tolerate)
    • Allows spreading of metatarsals
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  • 1. ​Approach to foot X-rays:
    • Assess cortical disruption for fractures in area of tenderness
      • Forefoot
        • AP, oblique
      • Midfoot
        • AP, oblique
      • Hindfoot
        • Oblique, lateral
        • Boehler’s angle < 25 degress = calcaneal depression fracture
  •  2. Lizfranc Injury
    • Plantar ecchymosis
    • Stress tarso-MT joint
    • Get weight bearing films!
    • Instability ED Ortho consult
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  • 3. Base of 5thMetatarsal 
    • Pseudo-Jone(Zones)
      • Ankle inversion
      • Peroneus brevis insertion
    • Jones (Zone II) 
      • Metaphyseal-diaphyseal junction
      • At level of 4th-5thmetatarsal joint
      • High risk of non-union
    • Diaphyseal Stress Fracture (Zone III)
      • Repetitive microtrauma
Picture
Management:
  • Hindfoot: Splint (Bulky Jones), NWB
    • Boehler’s angle
    • Look for spinal injuries
  • Midfoot: Splint (sugar tong w/ posterior slab), NWB
    • Lizfranc. -> Weight bearing films
  • Forefoot: 
    • Metatarsals: CAM boot, NWB -> WBAT. Except 1stand base of 5th zones 2&3
    • Phylanges: Buddy tape, post op shoe, unless significantly displaced/rotated
References
  1. Londner M, Hammer D, Kelen GD. Foot injuries. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 8 th ed. New York: McGraw-Hill; 2004; (cited 2017, Sep 08)
  2. Smith, M. S., Hatch, R., & Eiff, M. (2012). Calcaneous and Other Tarsal Fractures; Metatarsal Fractures; Toe Fractures; . In Fracture Management for Primary Care (3rd ed., pp. 276-326). Philadelphia, PA: Saunders.
  3. Weatherford, B. (n.d.). 5th Metatarsal Base Fracture. Retrieved September 08, 2017, from http://www.orthobullets.com/foot-and-ankle/7031/5th-metatarsal-base-fracture
  4. Hatch, R. L., & Hacking, S. (2003, December 15). Evaluation and Management of Toe Fractures. Retrieved September 08, 2017, from http://www.aafp.org/afp/2003/1215/p2413.html
  5. Foot Fracture Treatment & Management. (2017, August 03). Retrieved September 08, 2017, from http://emedicine.medscape.com/article/825060-treatment#d10
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Commonly Missed Orthopedic Injuries: Lower Extremity

4/2/2018

1 Comment

 
Authored by: Blake Bauer, MD
  • Missed orthopedic injuries account for 8% of all litigated cases from emergency department visits (Brown, 2010)
    • 28-36% of the time, decision is if favor of plaintiff
    • Not just emergency physicians, includes all specialties sued secondary to patient’s emergency department visit
    • EM physicians 19% off the study data
  • When evaluating all litigated cases against emergency medicine physicians specifically, it is suggested orthopedic injuries account for 19% of litigated cases (Kachalla, 2007)
    • 96% of cases could be attributed to not ordering the right plain film, or incorrect interpretation
  • As 3rd year residents are getting ready to depart on their own to community ED’s where orthopedics rarely comes into the hospital, it’s important to know what subtle fractures are frequently missed, both for patients’ and pocketbooks benefit
The Foot
  • Basic Bony Anatomy
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  • Lisfranc injury is commonly misnomer-ed as a “Lisfranc Fracture”, incorrectly reassuring the EM physician who sees no cortical defect on plain film
    • In general, this is any sort of injury, fracture or ligamentous, that leads to midfoot instability
    • This is typically axial loading on a hyper-plantar-flexed foot
    • Most commonly seen in MVCs, falls from height onto feet, or in wide receivers/basketball players
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  • Important to obtain oblique ankle films to evaluate for metatarsal-cuneiform alignment
  • In the AP view, alignment of 2nd and 1st metatarsals most easily visualized, and 3rd/4th most easily visualized on oblique
  • Lateral view can help identify dorsal misalignment
  • Important to obtain weight-bearing films if you suspect subtle articular widening; this will identify any instability and subsequent need for surgical intervention
  • From EM perspective, this patient will need a short leg splint and non-weight-bearing status with Ortho follow up for surgery
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  • Calcaneal fractures can be blatantly obvious or obscenely subtle. Reassuringly, the tradition surgical fractures are obvious
  • The subtle fractures can mean the difference between walker boot and weight bearing as tolerated, and a cast for up to 6 weeks
  • Stress fractures, posterior facet compression fractures, and anterior process fractures are classically missed
  • Stress fractures are subtle fracture patterns in the posterior aspect of the calcaneus, difficult to truly identify a clean fracture line
  • Key for diagnosis is a keen eye, a good lateral, and a good story (runner, pain getting worse, etc.)
  • For the posterior facet compression, this is the classic utility of Bohler’s angle.
  • If the fracture is occult, flattening of this angle can be your only clue; it is made by creating an imaginary line from anterior process through tip of posterior facet. This line should create and angle 20-40 degrees with another imaginary line between posterior facet and insertion of Achilles tendon
  • This is technically an intraarticular fracture, so severity will delineate management; typically, the subtle fractures are Sanders I (not displaced), and not managed surgically
  • Remember to evaluate the spine if there is a calcaneal compression fracture!
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  • Anterior process fractures are very difficult to identify due to many overlapping osseous structures in the area
  • This makes identifying an abnormal fracture line difficult to separate from articular surfaces
  • This fracture is typically from a rotational ankle injury, as opposed to axial force like the previous fractures
  • Remember to get the foot film on the patient with an “ankle” injury! This fracture is easy to miss if you aren’t actively looking!
  • Calcaneal fractures as mentioned above typically are not surgical, but be sure to identify them for appropriate casting and weight-bearing status
    • Short leg cast and non-weight-bearing for 6(stress)-12(anterior/posterior) weeks
​The Ankle and Lower Leg
Picture
Picture
  • The majority of ankle fractures are very visible, but the two “French” injury complexes of the ankle and lower leg can be missed if not suspected
  • Maisonneuve fracture is a torsional fracture of the proximal fibula with an associated ankle instability from a syndesmosis injury + a medial malleolus fracture or deltoid ligament injury
Picture
  • In general, either the ankle instability is missed while the fibular fracture is found, or vice versa
  • Patient may have twisted ankle and only be complaining of knee pain, or only notice their ankle pain without noting tenderness at their proximal fibula
  • Remember to always exam a bone/joint above and below area of concern/complaint
  • Measure the syndesmosis (tibiofibular clear space) 1cm above the ankle mortise; the distance between tibia and fibular here should be less than 6mm if syndesmosis intact
  • Similarly, if no medial malleolus fracture is noted, obtain weight bearing films to make sure medial clear space does not widen, suggesting a deltoid ligament injury
  • This requires a short leg splint (fibula does not need stabilizing typically), with Ortho follow up for operative fixation of ankle + fibula
  • Tillaux fracture is a fracture of adolescents, typically an external rotational injury of the ankle leading to avulsion of the lateral distal tibia
    • This is a Salter Harris III fracture, as it is the physis and epiphysis that are avulsed by the talofibular ligament
  • The anterolateral tibia is the last portion for growth plate closure, leading to vulnerability of this injury as an adolescent
  • The fracture fragment can sometime be subtle and “hide” behind the fibula, making it difficult to identify
  • Keys to identification are high suspicion and diligence; adolescent with external rotational force to ankle/foot (i.e. foot stuck with forced internal rotation of lower leg)
  • Management is typically a long leg splint in the emergency department, and likely outpatient operative fixation
  • If the story is good, child will not bear weight, but you do not see a fracture, CT scan can be utilized to rule out/rule in fracture, and serves as preoperative planning if present
Picture
​The Knee
Picture
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  • Similar to the ankle, most knee fractures that we see are not subtle. However, some tibial plateau fractures can be small and fracture line can be difficult to distinguish.
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  • As with all fractures, scrutinize the cortex for any irregularities
  • Tibial plateau fractures are intraarticular fractures, leading to lipohemarthrosis
  • Evaluate the lateral film for the “FBI” or fat-blood-interface, where the blood displaces the fat pad anteriorly
  • Fractures can be split predominate, compression predominate, or a combination
  • Subtle compression fractures can “push” the tibia more laterally as it is flattened.
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  • If you draw an imaginary line, in a true AP, down the lateral condyle and the medial fibular cortex, there should be less than 5mm of tibia lateral to this line
  • Tibial plateau fractures are intraarticular fractures, leading to lipohemarthrosis
  • Evaluate the lateral film for the “FBI” or fat-blood- interface, where the blood displaces the fat pad anteriorly
  • Treatment is a hinged knee brace for stability and crutch for partial weight bearing
  • If you can evaluate joint for instability, do so, but patient will likely need follow up outpatient with orthopedics to determine joint stability and need for surgery after swelling decreased
​The Hip
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  • Occult femoral neck fractures are very frequent in the emergency department setting. Anywhere from 2-10% of femoral neck fractures that present to the emergency department are occult on initial plain film imaging
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  • This is dangerous because a previously nondisplaced femoral neck fracture can subsequently move, leading to AVN, malunion, and increased morbidity/mortality
  • Initial step can be an extra set of eyeballs; when patient has hip pain and will not bear weight (or even difficulty bearing weight), the search needs to continue
  • This is especially true in the elderly population, who can have very deceiving exam; have a heightened suspicion for occult fracture
  • Traditionally, gold standard was MRI, with CT reported as missing up to 33% of occult fractures
  • Newer studies with newer CT scanners show near equivalence with MRI in sensitivity, but many are not satisfied with study design and MRI remains gold standard in the literature
  • This can obviously be an issue in the flow of an emergency department, so other methods can be considered before waiting hours for an MRI
  • Judet and “Bristol” views can give you more angles of the femoral neck for better visualization. Quick plain films, if they show the fracture, can save plenty of time and further testing
  • Further consideration on disposition of patient can then play into CT vs MRI if plain films do not show the fracture. Vast majority of EM providers are confident with modern day CT imaging
  • Treatment is hemiarthroplasty versus pinning, depending on patient’s clinical status and comorbidities
1 Comment

The Wrist

3/5/2018

0 Comments

 
Authored by Dr. Javier Andrade
  • With any orthopedic injury, it is important to understand the normal bony anatomy of the injured area you are examining:
    • The Wrist is a complex area with multiples bones and joint.
    • It is composed of the more proximal ulna and radius which anchor the wrist and help create the supination and pronation needed for complex hand movements
    • The distal portion of the wrist is made up of the 8 carpal bones arranged in two rows.
Picture
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  • Now that we now what bones make up the wrist, we can talk a bit more about the alignment and tricks we can use to see if there is an injury to the wrist.
    • One such trick we can use for the PA view are Gilula’s Line. It is a technique which uses 3 curved lines to check the alignment of the carpal bone rows.
      • Proximal row, proximal portion (pink)
      • Proximal row, distal portion (blue)
      • Distal row, proximal portion (red)
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  • Also, as with any ortho injury, remember to assess that the patient is neurovascularly intact!
    • Vascular: Can use the doppler probe to assess
      • Ulnar artery
      • Radial Artery
      • Palmar arch
    • Nerves:
      • Radial n: Test the extensor pollicus longus using “thumbs up”
      • Median n: Test using the “OK sign”
        • Make sure patient flexes at the DIP joint
      • Ulnar n: Test using pinky abduction
  • Pathology:
    • Scaphoid Fx
      • Most commonly injured carpal bone and can be easily missed. If you have clinical exam findings but no radiologic findings, treat this as a fracture!
      • Tx: Thumb spica cast and reimage in 12 days.
    • Lunate and Perilunate dislocation
      • Associated with high-energy mechanism of injury as it has to tear through multiple ligaments that hold the hand together. Be on the lookout for other injuries in the wrist.
        • Associated with median n injury in 25% of patients
      • Notice the anatomy on the normal image (left). We can use the lines on the lateral XR view to assess for injury
Picture
Picture
  • Hamate fracture:
    • Body: Clenched fist against solid object
      • Typically requires surgical intervention
    • Hook: Associated with injuries that require swinging equipment (baseball, tennis, etc.)
      • Can cause ulnar n. injury or impingement
  • Distal Radius Fractures:
    • Colle’s: Fx with posterior displacement
    • Smith’s: Fx with anterior displacement
  • Distal Radial-Ulnar joint (DRUJ) injuries
    • Normally, the ulna sits on a small groove on the distal radius known as the sigmoid notch.
      • Any spacing here is abnormal
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  • Management:
    • If purely ligamentous closed immobilization and outpatient follow-up
    • If associated with fracture then operative repair is necessary
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Evaluation of the pediatric limp

3/4/2018

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Authored by Dr. Jessica Hoglund
1.   Differential (categorized based on gait pattern)
​A.     Antalgic gait
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B.     Non-antalgic gait
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1.   Transient synovitis
A.     Most common cause of hip pain/limp in children <10 yrs
B.     Aseptic inflammation of the hip (postviral etiology)
C.     Diagnosis
        i.  Physical exam:
            1.     Non-toxic
            2.     Antalgic gait    
                   i.         Imaging performed when considering other differentials   
                  ii.         Ultrasound may be performed to confirm the presence of a joint effusion
D.     Management      
        i.         Rest    
​        ii.         Analgesics 

2.   Septic arthritis
A.     Causes      
        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
C.     Diagnosis     
        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   
        iv.         Imaging
Picture
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​          v.        Arthrocentesis
                    1.     Ultrasound guided or fluoro guided for hip
                    2.     Synovial fluid with >50,000 WBC’s, >75% PMN’s, positive gram stain and culture
D.     Management      
          i.         IV antibiotics (vanc, rocephin or cefoxatime if < 2 months)    
          ii.         Surgical drainage
E.     Complications      
         i.         Avascular necrosis    
         ii.         Capsule damage   
         iii.         Chronic arthritis   
         iv.         Osteomyelitis    
​         v.         Sepsis
​
​4.   SCFE
A.     MCC of hip disability in adolescents
B.     Obese adolescents whose hips are exposed to repetitive minimal trauma
C.     Diagnosis      
         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)    
        ii.         Imaging
                   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).
Picture
Picture
D.     Management      
        i.         Non weight bearing (important to prevent further slippage)    
        ii.         Operative management with possible prophylactic pinning of contralateral hip
E.     Complications      
        i.         Avascular necrosis    
        ii.         Premature closure of physis     
        iii.         Limited ROM   
        iv.         Osteoarthritis

​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
D.    Diagnosis      
        i.         Physical exam
                  1.     Decreased abduction and internal rotation
                  2.     Possible thigh atrophy on affected side
                  3.     Limb shortening (advanced cases)    
       ii.         Imaging
                  1.     Early radiographs may be normal, but MRI will show edema in femoral epiphysis with T1 weighted 
Picture
                  2. Radiographic progression of disease
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E.     Management      
        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
F.     Complications      
        i.         Osteoarthritis    
​        ii.         Coxa magna deformity (short, broad femoral head and column)
Picture

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&sectionid=40381606 Accessed: February 12, 2018
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The Adult Ankle

10/15/2017

2 Comments

 
​In order to begin an appropriate assessment of the ankle, it is necessary to review the significant anatomical structures.
 
Bony Anatomy
 
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.
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Joint Anatomy
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.
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Ligament Anatomy
The lateral and medial malleoli have ligamentous attachments to the talus and calcaneus that contribute to stability of the joint.
  • The lateral ligamentous complex is composed of the posterior talofibular ligament (PTFL), anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). The ATFL is the first or only ligament to be injured in the majority of ankle sprains. Specifically, injuries that result from inversion mechanisms. 
Picture
Picture
  • The medial malleolus is anchored by 3 ligaments collectively referred to as the deltoid ligament. Injury to the deltoid ligament is much less common and disruption of this ligamentous complex conveys a high mechanism of injury. 
Picture
  • Cranially the tibia and fibula are anchored to each other by the fibrous joint of the syndesmosis (along the interosseous membrane).
Picture
Initial Evaluation
A patient presenting with a suspected ankle injury should undergo the following assessment:
  1. Inspection – the joint should be inspected for any signs of ecchymosis, swelling, or skin tenting that could represent injury. Also, be sure to remove any dressing or bandages – you don’t want to miss an open fracture
  2. Palpate – Palpate the entire length of the fibula because syndesmotic injuries can be associated with proximal fibula fracture. Palpate the distal tibia, the bony portions of the foot, and the Achilles tendon. If tenderness of the Achilles is present, squeeze the calf muscles to perform a Thompson test.
  3. Range of Motion -  Check for pain on gentle passive inversion and eversion of the ankle that can indicate a ligament injury. Assess the patient’s ability to plantar and dorsiflex
  4. Deficits – Use 2-point discrimination to test for nerve deficits. An important testing location is between the webbing of the first two digits to assess the deep peroneal nerve. Assess for pulse deficits, make use of the Doppler if you are having difficulty with palpation.   
  5. Joints above and below – Perform an assessment on the joints above and below to detect for any additional injuries.
 
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:
  • tenderness over the posterior 6 cm or tip of the posterior or lateral malleolus -  ankle-ray is indicated.
  • patient is unable to take four steps both immediately and in the emergency department -  x-ray of the painful area is indicated
Sensitivities for the Ottawa ankle rule range from the high 90%-100% range for “clinically significant” ankle and midfoot fractures. This is defined as a fracture or an avulsion greater than 3 mm. Specificities for the Ottawa ankle rules are approximately 41% so while it is a good screening tool, we cannot use it to rule in pathology.
 
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.
 
Imaging Studies
When imaging the ankle obtain 3 views to appropriately evaluate the joint: AP, Lateral and the Mortise study. 
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Radiographic Evaluation
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
Picture
​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.
 
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​Typical Fracture Patterns
Isolated Medial Malleolus Fracture  
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Isolated Lateral Malleolus Fracture
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Isolated Posterior Malleolus Fracture
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Bimalleolar fracture / equivalent
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*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
​
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​Pilon Fracture
 
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.)
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Picture
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Sources
 
https://radiopaedia.org/articles/ankle-radiograph-an-approach
 
http://www.orthobullets.com/trauma/1047/ankle-fractures
 
http://www.orthobullets.com/trauma/1046/tibial-plafond-fractures?expandLeftMenu=true
 
https://radiopaedia.org/search?utf8=✓&q=pilon+fracture&scope=all
 
https://meds.queensu.ca/central/assets/modules/ts-ankle-radiograph/isolated_medial_malleolus_fracture.html
 

BY: DR. ETHEN ELLINGTON M.D.
2 Comments

The adult knee

9/19/2017

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​When are knee films indicated?
  • Trauma
  • Bony tenderness at the head of the fibula
  • Isolated patella tenderness
  • Patient unable to flex the knee to 90 degrees
  • If the patient is unable to weight bear
  • Suspected osteoarthritis
  • Detecting joint effusions
  • Infection
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Standard Views:
  • AP View
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  • Lateral Horizontal Beam
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  • Skyline View
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​ 
Systematic Approach to Adult Knee Films:
1) Know your anatomy!
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Picture
​2) Check for an effusion
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3) Check the main bones (tibia, femur, fibular head, and patella)

4) Check the tibio-femoral alignment -- The tibia should be within 0.5 cm of this line, otherwise it suggests a lateral tibial plateau fracture.
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​▪ 5) Look at the tibial plateaus -- Fractures most commonly happen on the lateral tibial plateau
*Check for a tibial plateau avulsion from the lateral edge (Segond fracture)
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6) Look for patellar tendon disruption
  - In a normal knee, the ratio is between 0.8 - 1.2 (mean value = 1)
  • If the ratio is < 0.8, the patella lies low (=patella baja)
  • If the ratio is > 1.2, the patella lies high (=patella alta)
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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
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​ 
Resources and Images:
https://radiopaedia.org/articles/knee-series
https://radiopaedia.org/articles/knee-radiograph-an-approach
http://dontforgetthebubbles.com/knee-x-ray-interpretation/
http://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/knee_x-ray
http://www.imageinterpretation.co.uk/knee.php

By: Dr. jeremy driscoll M.D.

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Let's Review Upper extremity Splinting

2/28/2016

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 Volar Splint

Indications:
-Hand and Wrist injures (NOT distal radius or ulna fractures, can still supinate and pronate)
-Carpal fractures
-Lunate dislocation
-2nd-5th metacarpal head fracture
​
Application:
-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

Indications:
-4th and 5th phalanges and metacarpals

Application:
-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

Indications:
-Scaphoid and lunate fractures
-1st metacarpal fracture
-Thumb fractures
-De Quervain tenosynovitis

Application:
-Extends from tip of thumb to proximal forearm
-Wrist at 20 degrees of extension
-Thumb slightly flexed
​Long Arm Splint

Indications:
-Proximal forearm and elbow fractures
-Intraarticular fractures of distal humerus and olecranon

Application:
-Elbow at 90 degrees of flexion
-Neutral forearm and wrist
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Sugar Tong Splint

Indications:
-Wrist and distal forearm fractures

Application:
-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
Resources:
Michael T Fitch, MD. Basic Splinting Techniques. New England Journal of Medicine. 2008; 359:e32.
​Wikiem.com
Ortho-teaching.feinberg.northwestern.edu/docs/Splinting.pptx

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Clavicle Fractures

2/21/2016

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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.
​
Exam:
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Radiology:
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Management:  Middle Third (80-85%)
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Lateral Third (10-15%)
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Medial Third (5-8%)
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Treatment:

Nonop
  • sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10 week
Operative
  • ​ORIF



Resources:
​Orthobullets.com
0 Comments

Posterior hip dislocation

2/12/2016

1 Comment

 
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.
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​Classification:
​- Simple: pure dislocation
​- Complex: with associated fracture of acetabulum or proximal femur

​Mechanism:
​- 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

​However...

​Examine femoral neck closely on XR to rule out fracture prior to attempting closed reduction.
​
With ipsilateral femoral neck fracture, closed reduction is contraindicated!

Picture
 
​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
​

Resources:
1. Serna, Fernando MD, Corczyca, John MD. Hip Dislocations and Femoral Head Fractures. University of Rochester Medical Center. March 2004.
2. Orthobullets.com

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