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 

 

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

The Foot

• Basic Bony Anatomy

​The Ankle and Lower Leg

​The Knee

​The Hip

Authored by Dr. Javier Andrade

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)
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

​          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).

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 

                  2. Radiographic progression of disease

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)

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

​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.

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.

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. 

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. 

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

​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  

 
*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
​

​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.)

​ 
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:
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

 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

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

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:

Radiology:

Management:  Middle Third (80-85%)

Lateral Third (10-15%)

Medial Third (5-8%)

Treatment:

Nonop

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

Operative

• ​ORIF

Resources:
​Orthobullets.com

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.

​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!

 
​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