Orthopedic Urgencies and Emergencies:

1. Orthopedic Urgencies and Emergencies: Problems You Don’t Want to Miss! Francis G. O’Connor, MD, FACSM Director, Primary Care Sports Medicine Uniformed Services University

2. Objectives • Discuss common orthopedic urgencies and emergencies that are not uncommonly misdiagnosed and/or initially mismanaged. • Detail pertinent diagnostic features and clinical criteria for referral to an orthopedic colleague.

3. Case 1 • Patient is a 16 y/o soccer player who presents to the ER with a painful forearm after a FOOSH injury. He is quite tender to palpation over the proximal forearm and has visible deformity. The skin is intact. Neurovascular examination is normal. • Radiographs. • Patient is placed in a long arm splint. • Prior to discharge from the ED for Ortho f/u in the am, the patient complains of thumb numbness.

5. Acute Compartment Syndrome

6. Epidemiology • Compartment Syndrome(CS) is a serious life and limb-threatening complication of extremity trauma. • Fractures, burns, crush injuries and arterial injuries can all result in CS. • Three quarters of cases are associated with fractures; tibia most common. • Other sites include: hand; forearm; arm; shoulder; back; buttocks; thigh; foot.

7. Pathophysiology • CS develops when there is increased pressure within a closed tissue space e.g. muscle compartments bound by fascial sheaths. • Increased pressure compromises the flow of blood through vessels supplying contained muscles and nerves. • External: circumferential cast or burn eschar • Internal: edema or soft tissue hematoma formation

8. Clinical Anatomy • Each limb contains a number of compartments at risk for CS. • Upper arm: anterior(biceps-brachialis) and posterior(triceps). • Forearm: volar(flexors) and dorsal(extensors) • 3 gluteal, 2 thigh, 4 in the lower leg.

9. Diagnosis • High index of clinical suspicion, with pain out of proportion to the mechanism of injury being the hallmark symptom. • Five Ps: pain; paresthesia; paresis; pallor; pulses. • Loss of normal sensation is the most reliable sign. • Diagnosis is based on the compartment pressure.

10. Radiographic Findings • Common fractures associated with ACS: • tibial fractures • supracondylar fractures of the humerus • humeral shaft • forearm fractures • multiple metacarpal or metatarsal fractures • Lisfranc fractures • calcaneal fractures

11. Pressure Monitoring • Normal tissue pressure ranges between 0 and 10mmHg. • Capillary blood flow is compromised at 20 mmHg, while the muscles and nerves are at risk for ischemic necrosis at pressures greater than 30 to 40 mmHg.

12. Treatment • Acute CS is a surgical emergency. • Delays over 24 hrs can result in myoglobinuria, renal failure, metabolic acidosis, hyperkalemia, ischemic contracture. • Indications for fasciotomy: • clinical signs of CS • tissue pressure over 30 mmHg with clinical picture of CS • interrupted arterial circulation over 4 hours.

13. Case 1 Follow-up • Clinical diagnosis of ACS made. • Taken to the OR for ORIF and compartment fasciotomy. • Delayed skin closure.

14. Case 2 • Pt is a 45 y/o male with a history of colon CA, who presents with a history of low back pain and a history of new onset bladder incontinence.

15. Cauda Equina Syndrome

16. Epidemiology • 80% of the population experiences back pain at some point in their lives. • 90% of low back pain resolves in 6 -12 weeks • “Red Flag” symptoms include: age over 50, trauma, fever, incontinence, night pain, weight loss, progressive weakness. • Cauda Equina Syndrome (CES) is a rare disorder, representing only 0.0004% of all back pain patients

17. Clinical Anatomy • Three joint motion complex consisting of the facets and the intervertebral disc. • The spinal cord extends from the foramen magnum to the L1-L2 disk where the cauda equina continues to the coccygeal region

18. Mechanism of Injury • Usually secondary to extrinsic pressure from a massive central HNP • Other causes include: • epidural abscess • epidural tumor • epidural hematoma • trauma

19. Clinical Presentation • Bilateral leg symptoms that include sciatica, weakness, sensory changes and gait disturbance. • Physical examination demonstrates bilateral weakness as well as decreased sensation, in particular in the “saddle” region. • Sphincter tone is decreased in 60 to 80% of patients • All patients who complain of urinary or fecal incontinence should be considered to have CES until proven otherwise.

20. Diagnosis • Clinical diagnosis: • loss of bladder control; perianal numbness; pain and weakness involving both legs • Evaluation of the urinary post-void residual volume assists with diagnosis: • the absence of a post-void residual volume of over 100ml, essentially excludes a diagnosis of CES, with a negative predictive value of 99.99%

21. Imaging • Plain films • MRI imaging of the entire spine

22. Treatment • Neurosurgical consultation • High dose systemic corticosteroids • Emergent surgical decompression

23. Case #3 • Pt is a professional football player, wide receiver, who presents to with wrist pain. He describes a FOOSH mechanism of injury and complains of numbness in the distribution of the median nerve.

24. Perilunate Injury

25. Epidemiology • Wrist injuries account for 2.5% of all ED visits. • Lunate and perilunate injuries are thought to represent 10% of all carpal injuries.

26. Clinical Anatomy • There are 8 carpal bones comprising two carpal rows; the scaphoid bridges both rows. • With radial deviation the scaphoid and lunate palmar flex • Intrinsic and extrinsic ligaments maintain carpal stability.

27. Mechanism of Injury • Perilunate and lunate dislocations result from hyperextension injuries. • Most common mechanism of injury is a FOOSH, followed by an MVA. • Progressive Injuries: • Stage I: scapholunate dissociation • Stage II: perilunate dislocation • Stage III: dislocation of the triquetrem • Stage IV: lunate dislocation

28. Clinical Presentation • History of high energy mechanism of hyperextension • Palpable pain over the dorsum of the wrist • Tenderness distal to Lister’s tubercle in the area of the scapholunate ligament

29. Diagnosis • High index of suspicion • Palpation over the dorsum of the wrist • Watson Click Test • Radiographs

30. Imaging • PA and lateral radiographs • PA view: • constant 2 mm intercarpal joint space • 3 arcs • Lateral view: • four Cs • capitolunate angle 0-15 degrees • scapholunate 30-60 degrees • Stress views

31. Treatment • Consultation with a hand surgeon to discuss management

32. Case #4 • Pt is a 23 y/o active duty special operations soldier who presents with persistent dorsal foot pain. He stepped in a hole over a week ago, and has not improved with self-care.

33. Lisfranc Fracture

34. Epidemiology • The articulation between the tarsal and metatarsal bones in the foot is named after Jaques Lisfranc, a field surgeon in Napoleon's Army. • Lisfranc injuries may represent 1% of all orthopedic trauma, but 20% are missed on initial presentation.

35. Clinical anatomy • The second metatarsal is the keystone to the Lisfranc joint. • Transverse ligaments join the metatarsals, excluding the first and second. • Soft tissue support is abundant on the plantar surface, leaving the dorsal surface relatively vulnerable.

36. Mechanism of Injury • Lisfranc injuries are caused by either direct or indirect trauma. • Indirect injuries account for the majority of injuries: either a rotational force to the forefoot, or axial loading on a plantar flexed, fixed foot. • Common source of trauma: falls from a height; motor vehicle accidents; equestrian and athletic injuries.

37. Clinical Presentation • Presentation varies from a mild undetectable subluxation to an obvious fracture dislocation • Midfoot pain, swelling and difficulty bearing weight are clinical clues • Pain with passive pronation and abduction of the forefoot with the hindfoot supported • Tense swelling may indicate a CS.

38. Diagnosis • High index of suspicion in ankle and foot injuries • Proper radiographic interpretation

39. Imaging • AP, lateral and oblique views • On AP and obliques the 2nd met medial border should align with the middle cuneiform • On the lateral the metatarsal shaft should not be more dorsal than the respective tarsal bone • Contralateral foot films • Weight-bearing views

40. Treatment • Orthopedic consultation for possible ORIF • Identify and manage compartment syndrome

41. Case #5 • Pt is an 18 y/o football player who presents with an ankle sprain. • Pt has considerable swelling and demonstrates more tenderness proximal to the ATFL in the area of the AITF ligament. • Radiographs are negative for fracture.

42. Syndesmotic Ankle Sprain

43. Epidemiology • Ankle sprains are the most common lower extremity injury in sports medicine, and constitute 25% of all sports injuries. • In one series, syndesmotic injuries constituted 17 % of ankle sprains. • Syndesmotic injuries result in longer periods of disability than standard lateral ankle sprains. • Syndesmotic injuries are not uncommonly associated with fractures.

44. Clinical Anatomy • The syndesmotic ligaments maintain stability between the distal tibia and fibula • Anterior tibiofibular ligament • Posterior tibiofibular ligament • Transverse tibiofibular ligament • interosseous ligament • interosseous membrane

45. Mechanism of Injury • Injuries to the syndesmosis occur as a result of a forced external rotation of the foot, or during internal rotation of the tibia on a planted foot. • Common in soccer, skiing, motocross and football. • Syndesmosis injuries are commonly associated with ankle fractures (Weber B &C) and deltoid ligament ruptures.

46. Clinical Presentation • Usually the patient cannot put weight upon the leg. • Pain is located anteriorly along the syndesmosis. • Active movement of external rotation of the foot is painful. • Positive Squeeze Test • Positive External Rotation Stress Test

47. Diagnosis • Clinical diagnosis • mechanism of injury • correlative physical examination • Radiographic imaging assists in risk stratifying

48. Imaging • Ottawa Ankle Rules: AP, lateral and mortise views should be obtained: • tenderness over the lateral and medial malleolus • unable to bear weight for four steps immediately or in the ED • Syndesmosis Radiographic Criterion • Mortise: medial clear space > 4mm • AP: tibiofibular overlap < 10 mm

49. Treatment • Ligamentous injuries without fracture or gross widening can be treated conservatively • Fractures or radiographic evidence of syndesmotic widening warrant orthopedic consultation for operative repair.

50. Case #6 • Pt is a 35 y/o physician/mother who while running up the stairs, noted a painful pop involving the lateral foot. • On palpation, she has considerable tenderness over the proximal fifth metatarsal.