EM1Orthopedics Disorders of the Lower Extremities

1.      Regarding the anatomy and biomechanics of the pelvis, identify the following:

         a.            5 parts of the pelvis

         b.            Where fractures occur first when traumatized

Zen Seeker Tinitinalli EM Fifth Edition

The major posterior stabilizing structures of the pelvic ring, that is, the posterior tension band of the pelvis, include the iliolumbar ligament, the posterior sacroiliac ligaments, the sacrospinous ligaments, and the sacrotuberous ligaments. (From Tile M. Anatomy. In: Fractures of the Pelvis and Acetabulum. Baltimore: Williams & Wilkins, 1984, p 11. Used with permission.)

Sagittal section of the male pelvis showing the relation of the full bladder. [From Kane WJ: Fractures of the pelvis, in Rockwood CA Jr, Green DP (eds): Fractures, Vol. 2. Philadelphia, Lippincott, 1975, pp 916, 917. Used with permission.]

Anatomy and Biomechanics

The major functions of the pelvis are protection, support, and hematopoiesis. The pelvis consists of the two innominate bones, which are made up of the ilium, ischium, and pubis; the sacrum; and the coccyx. The two innominate bones and sacrum form a ring structure, which is the basis of pelvic stability. This stability is dependent on the strong posterior sacroiliac, sacrotuberous, and sacrospinous ligaments (Fig. 265-1).3 Any single break in the ring will yield a stable injury without significant risk of displacement. An injury with two breaks in the ring is unstable with the risk of displacement. The iliopectineal, or arcuate, line divides the pelvis into the upper, or false, pelvis, which is part of the abdomen, and the lower, true pelvis. In addition, this line constitutes the major portion of the femorosacral arch, which, along with the subsidiary tie arch (bodies of pubic bones and superior rami), supports the body in the erect position. In the sitting position, the weight-bearing forces are transmitted by the ischiosacral arch augmented by its tie arch, the pubic bones, inferior pubic rami, and ischial rami. When traumatized, the tie arches fracture first, especially at the symphysis pubis, pubic rami, and just lateral to the sacroiliac (SI) joints. Incorporated in the pelvic structure are five joints that allow some movement in the bony ring. The lumbosacral, SI, and sacrococcygeal joints, and the symphysis pubis allow little movement. The acetabulum is a ball-and-socket joint that is divided into three portions: the iliac portion, or superior dome, is the chief weight-bearing surface; the inner wall consists of the pubis, and is thin and easily fractured; and the posterior acetabulum is derived from the thick ischium.

The pelvis is extremely vascular, a fact that is significant in pelvic fractures. The nerve supply through the pelvis is derived from the lumbar and sacral plexuses. Injury to the pelvis may produce deficits at any level from the nerve root to small peripheral branches.

The lower urinary tract is contained in the pelvis (Fig. 265-2). In the adult, the bladder lies behind the symphysis and pubic bones, and the peritoneum covers the dome and base posteriorly. The location of the bladder and the degree of peritoneal reflection are determined by urine content. The lower gastrointestinal tract housed in the pelvis includes a small portion of the descending colon, the pelvic, or sigmoid, colon, the rectum, and the anus. In women, the uterus and vagina are also housed in the bony pelvis.

Fassil  Tintinalli  1801

1. 5 parts of the pelvis: ilium, ischium, pubis, the sacrum and coccyx

2. Where fractures occur first when traumatized: when traumatized, the tie arches fracture first, especially at symphysis pubis, pubic rami and just lateral to the sacroiliac joints.

Anonymous  tint 1801

5 parts of the pelvis – They are the ilium, ischium, pubis, sacrum and coccyx.  The ilium and ischium are innominate bones and form a ring The bodies of pubic bones and superior rami form the tie arch

Where fractures occur first when traumatized.

The tie arches fracture first, especially at the symphis pubis pubic rami and just lateral to the sacroiliac joints.  Incorporated in the pelvic structure are 5 joints that allow some movement in the bony ring.  The lumbosacral, SI and sacrococcygeal joints, and the symphysis pubis allows little movement.  The acetabulum is a ball-and socket joint that is divided into three portions: the iliac portion, or superior dome, is the chief weight bearing surface; the inner wall consists of the pubis, and is thin and easily fractured

Anonymous Tintinalli 1801

5 parts of the pelvis – They are the ilium, ischium, pubis, sacrum and coccyx.  The ilium and ischium are innominate bones and form a ring. The bodies of pubic bones and superior rami form the tie arch

Where fractures occur first when traumatized – The tie arches fracture first, especially at the symphysis pubis pubic rami and just lateral to the sacroiliac joints.  Incorporated in the pelvic structure are 5 joints that allow some movement in the bony ring.  The lumbosacral, SI and sacrococcygeal joints, and the symphysis pubis allows little movement.  The acetabulum is a ball-and socket joint that is divided into three portions: the iliac portion, or superior dome, is the chief weight bearing surface; the inner wall consists of the pubis, and is thin and easily fractured

Anonymous Tintinalli 1801

a)  5 parts of the pelvis- ilium, ischium and pubis (all fuse to form the hip bone, or coxa), sacrum, and coccyx

b) Where fractures occur first when traumatized- When traumatized, the tie arches (bodies of pubic bones and superior rami) fracture first, especially at the symphysis pubis , pubic rami, and just lateral to the sacroiliac (SI) joints.

2.      Describe the clinical presentation of coccyx fractures and how they are treated.

Zen Seeker Tinitinalli EM Fifth Edition

Coccyx Fractures

Coccygeal fractures are more frequent in women and are generally caused by direct violence or a fall in the sitting position. Symptoms and signs include pain, tenderness, and swelling and ecchymoses over the lower sacral region. There may be pain on getting up from a sitting position or straining at stool. The rectal examination reveals pain with movement of the coccyx. A roentgenogram is not needed if physical examination verifies that this is the only fracture, but AP and lateral views with sharp flexion of the thighs may demonstrate the fracture. Treatment consists of bedrest, sitz baths, stool softeners, and sitting on a donut-ring cushion. Primary care or orthopedic follow-up within 2–3 weeks is recommended. Surgical excision of the distal fracture fragment is rarely indicated if symptoms become chronic

Fassil   Tintinalli  1806

•  Coccyx fractures are more frequent in women and generally caused by direct violence or fall in the sitting position.

•  S/S include pain, tenderness, and swelling and ecchymoses over the lower sacral region. There may be pain on getting up from sitting position or straining at stool. The rectal exam reveals pain with movement of coccyx.

•  Treatment consists of bedrest, sitz baths, stool softners, sitting on a donut-shaped cushion.

Anonymous

Generally caused by direct violence or a fall in the sitting position; symptoms and signs include pain, tenderness, and selling and ecchymoses over the lower sacral region.  There may be pain on getting up from a sitting position or straining at stool.  Rectal exam reveals pain with movement of the coccyx.  Treatment consists of bedrest, sitz baths, stool softeners, and sitting on a donut-ring cushion.  Primary care or orthopedic follow-up within 2-3 weeks is recommended.  Surgical excision of the distal fracture fragment is rarely indicated if symptoms become chronic

Tint 1806.

Anonymous Tintinalli 1806

Presentation – More frequently occur in women as a result of direct violence or a fall in the sitting position.  

•   S/S include pain, tenderness, swelling, and ecchymosis over the lower sacral region.  

•   There may be pain when rising from a sitting position or upon straining with a bowel movement.

•   A rectal exam will reveal pain with movement of the coccyx.

Treatment – consists of bedrest, sitz baths, stool softeners, and sitting on a donut-ring cushion.

•   Primary care or orthopedic follow-up within 2-3 weeks is recommended.

•   Surgical excision of the distal fracture fragment is rarely indicated if symptoms become chronic.

Anonymous Tintinalli 1806

Presentation: coccygeal fractures are more frequent in women and are generally caused by direct violence or a fall in the sitting position.  Signs and symptoms include pain, tenderness, and swilling and ecchmosies over the lower sacral region.  There may be pain on getting up from a sitting position or straining at stool.

Treatment: consists of bedrest, sitz baths, stool softeners, and sitting on a donut-ring cushion.  Primary care or orthopedic follow-up within 2-3 weeks is recommended.

3.      Identify the most serious complication of pelvic fractures, accounting for 50% of fatalities.

Zen Seeker Tinitinalli EM Fifth Edition

Complications of Pelvic Fractures

It is imperative to recognize associated injuries. Acute complications include hemorrhage, urogynecologic injury, rectal injury, ruptured diaphragm, and nerve root injury.

HEMORRHAGE

Hemorrhage is estimated to be the cause of death in about 50 percent of total pelvic injuries.18 Retroperitoneal bleeding is an inevitable complication, and up to 4 L of blood can be accommodated in this space until vascular pressure is overcome and tamponade occurs. It is thought that approximately 90 percent of pelvic bleeding is from the fractures and low pressure venous plexus. Both small and large vessels, especially the superior gluteal and internal pudendal branches of the internal iliac artery, can also be disrupted, with hemorrhage dissecting from the back to the buttocks.

General resuscitative measures include massive crystalloid, colloid, and blood replacement. In one series of high-energy pelvic fractures, patients on average required about six units of blood transfused.19 The average transfusion requirement for APC injuries was about 15 units, VS injuries 9 units, and LC injuries about 3.5 units. Aggressive resuscitation of these patients along with treatment of extrapelvic injuries and early or delayed open reduction and internal fixation of the fractures may reduce mortality.20  

The use of the antishock garment is controversial. It may be helpful in controlling bleeding sites by immobilizing fractures and compressing the pelvis. Disadvantages include decreased visibility and access to the abdomen and lower extremities and the risk of compartment syndrome with prolonged application. This garment is generally only recommended for pelvic stabilization in the pre- hospital and ED setting. Early orthopedic consultation should be considered for placement of external fixator device to help control hemorrhage in patients with persistent hemodynamic instability.

If the patient is exsanguinating, angiography can be done and small arterial bleeding sites controlled by transarterial embolization. Most authorities agree that aggressive fluid and blood replacement is the best initial therapy along with correction of hypothermia and coagulopathy. Placement of an external fixator and laparotomy should also be considered prior to angiography.21 Overall, only about two percent of patients with pelvic fracture require embolization and efficacy approaches 100 percent when utilized.22 Younger age, shorter time from injury to embolization, and hemodynamic stability are associated with improved survival.

Fassil   Tintinalli  1807

•        Hemorrhage is estimated to be the cause of death in about 50% of total pelvic injuries.

Anonymous Tint 1807

Hemorrhage is the most serious complication and accounts for about 50% of fatalities retroperitoneal bleeding is inevitable and up to 4L of blood can be accommodated in this space.  Other complications – urogynecologic injury, rectal injuries, ruptured diaphragm and nerve root injury.  

Anonymous Tintinalli 1807

            Hemorrhage is estimated to be the cause of death in about 50% of total pelvic fractures making it the most serious complication.  Retroperitoneal bleeding is an inevitable complication and up to 4L of blood can be accommodated in this space until vascular pressure is overcome and tamponade occurs.

Anonymous Tintinalli 1807

Acute complications include hemorrhage, urogynecologic injury, rectal injury, ruptured diaphragm, and nerve root injury. Hemorrahage is estimated to be the cause of death in about 50% of total pelvic injuries.  Retroperitioneal bleeding is an inevitable complication, and up to 4 L of blood can be accommodated in this space until vascular pressure is overcome and tamponade occurs.

4.      Describe the clinical presentation of nondisplaced and displaced femoral neck fractures and how they are treated.

Zen Seeker Tinitinalli EM Fifth Edition

FEMORAL NECK FRACTURES

Femoral neck fractures are commonly seen among older adults, due to osteoporosis, and occur more frequently in women than in men. These fractures are rare among the younger population. The cause of such fractures is usually minor trauma secondary to falls (90 percent) or torsion in the patient with osteoporosis or osteomalacia. In younger patients, the high kinetic energy sustained in the major trauma causes a fracture through normal bone with marked soft tissue disruption and comminution.

The classification of femoral neck fractures is by fragment displacement. The symptoms seen with femoral neck fractures range from complaints of mild pain in the groin or inner thigh in patients with an incomplete fracture to moderate to severe pain in patients with displaced fractures.

Patients who have sustained a fracture without displacement may walk with some limping rather than being completely unable to bear weight. Their only physical findings are minor pain with movement and minimal muscle spasm limiting range of motion. In contrast, displaced fractures cause severe pain, inability to ambulate, limited range of motion, and no palpable movement of the extracapsular head. The patient lies with the extremity in slight external rotation, abduction, and shortening.

Radiographic evaluation is essential in any patient suspected of having a femoral neck fracture. Stress fractures, however, may not show up on x-ray for days or weeks, so repeat films or bone scans in symptomatic patients are necessary. The standard AP view should have the patient maximally internally rotated to best demonstrate the femoral neck. The AP view should be inspected for a fracture line starting on the superior surface of the neck. These fracture lines routinely become complete within 10 to 14 days. Also, disruption of Shenton´s line may be appreciated on the AP view in some instances. If there is any concern that the patient has sustained a fracture that is not visible on the initial x-ray examination, the patient should be conservatively treated and x-ray films should be made again in 10 to 14 days; or the physician may order a CT or MRI, which demonstrates the fracture in most instances. In contrast, displaced fractures are obvious on the AP film, but a lateral view should also be done to ascertain the exact position.

Orthopedic consultation should be obtained in the emergency department for these fractures. The orthopedic surgeon´s goal of treatment for femoral neck fractures is anatomic reduction and stability. Treatment for nondisplaced or impacted fractures is somewhat controversial but usually involves a form of internal fixation. This is due in part because up to 15 percent of impacted fractures can develop secondary displacement without surgery. Conservative treatment is generally only considered if the patient is medically unfit for surgery or the fracture is several weeks old and the patient is walking without pain.22 Displaced fractures definitely require emergency surgery for fixation. Prosthetic hip replacements may be required in certain instances, particularly in those patients over age 70.27 The timing of surgery remains controversial. Early surgery (<72 h) is indicated in fit patients, whereas surgery should be delayed if correctable comorbidities are present. Special note should be made of stress fractures because some are treated in a conservative manner and others are treated with internal fixation, depending on the type of fracture and the patient´s cooperation. Skeletal traction is contraindicated with femoral neck fractures because it may further compromise femoral head blood flow.

The complications of femoral neck fractures are significant. They include infections, emboli, and avascular necrosis, which is the most feared early complication. Avascular necrosis has an incidence of 15 percent in nondisplaced fractures and rises to near 90 percent with untreated, completely displaced fractures. A higher incidence is also associated with more severe fractures or fractures that are not surgically reduced to anatomic position within 48 h. Nonunion in nondisplaced fractures is rare but occurs in approximately 20 to 30 percent of patients with displaced fractures.22

Fassil   Tintinalli 1809

•        The classification of femoral neck fractures is by fragment displacement. Patient who sustained a fracture without displacement may walk with some limping rather than being completely un able to bear weight. Their only physical findings are minor pain with movement and minimal muscle spasm limiting ROM.

•        In contrast, displaced Fx cause severe pain, inability to ambulate, limited ROM, and no palpable movements of the extracapsular head. The patient lies with the extremity in slight external rotation, abduction, and shortening.

•        Orthopedic consultation should be obtained in the emergency department for these Fx. The orthopedic surgeon’s goal of treatment for femoral neck Fx is anatomic reduction and stability.

1.      Tx for non-displaced or impacted Fx is somewhat controversial but usually involves a form of internal fixation.

2.      Displaced Fx definitely require emergency surgery for fixation.

Anonymous Nondisplaced- may walk with some limping rather than being completely unable to bear weight. Only physical findings are minor pain with movement and minimal muscle spasm limiting ROM.

Displaced- cause severe pain, inability to ambulate, limited range of motion and no palpable movement of the extracapsular head. Patient lies with the extremity in slight external rotation, abduction and shortening. Tintinalli, p1809

Anonymous Tintinalli 1809-1810

            Femoral neck fractures are commonly seen in the older adults due to osteoporosis and occur more frequently in women than men.

            Non-displaced Femoral Neck Fracture

•      Presentation – May walk with some limping rather than completely unable to bear weight.  Only physical findings are minor pain with movement and muscle spasm limiting range of motion.

•      Treatment – An orthopedic consult should be obtained in the ER.  Treatment usually involves some form of internal fixation.  The goal of treatment is reduction and stability.  Conservative treatment in generally only considered if the fracture is several weeks old and the patient is walking without pain.  The non-displaced impacted fracture runs the risk of becoming displaced without surgery.

            Displaced Femoral Neck Fracture

•      Presentation – severe pain, inability to ambulate, limited range of motion and no palpable movement of the extracapsular head.  The patient lies with the extremity in slight external rotation, abduction, and shortening.

•      Treatment – Displaced fracture definitely require emergency surgery for fixation.  In some cases a prosthetic hip may be necessary, particularly in the over 70 patient.

Anonymous Tintinalli 1809

Radiographic evaluation is essential in any patient suspected of having a femoral neck fracture.  The standard AP view should have the patient maximally internally rotated to best demonstrate the femoral neck.  The AP view should be inspected for a fracture line starting on the superior surface of the neck. If there is any concern that the patient has sustained a fracture that is not visible on the initial x-ray examination, the patient should be conservatively treated and x-ray films should be made again in 10 to 14 days; or the physician may order a CT or MRI, which demonstrated the fracture in most instances.  Orthopedic consultation should be obtained in the ED for these fractures.  The orthopedic surgeon’s goal of treatment for femoral neck fractures is anatomic reduction and stability.

Nondisplaced:

Presentation-  Patients who have sustained a fracture without displacement may walk with some limping rather than being completely unable to bear weight.  Their only physical findings are minor pain with movement and minimal muscle spasm limiting range of motion.  

Treatment- treatment for nondisplaced or impacted fractures is somewhat controversial but usually involves a form of internal fixation.  This is due in part because up to 15% of impacted fractures can develop secondary displacement without surgery.  Conservative treatment is generally only considered if the patient is medically unfit for surgery or the fracture is several weeks old and the patient is walking without pain.

Displaced:

Presentation- displaced fractures cause severe pain, inability to ambulate, limited range of motion, and no palpable movement of the extracapsular head.  The patient lies with the extremity in slight external rotation, abduction, and shortening.

Treatment- displaced fractures definitely require emergency surgery for fixation.  Prosthetic hip replacements may be required in certain instances, particularly in those patients over age 70.  Displaced fractures are obvious on AP film, but a lateral view should also be done to ascertain the exact position.

5.      Describe the most common causes of femoral shaft fracture and how they are treated.

Zen Seeker Tinitinalli EM Fifth Edition

Femoral Shaft Fractures

Fractures of the shaft of the femur most often occur in men during their most active period in life. Falls, industrial and automobile accidents, and gunshot wounds account for the majority of these fractures.36 Severe, direct trauma may result in transverse fractures (most common) with displacement, oblique or spiral oblique fractures, or badly comminuted segments. Pathologic fractures are uncommon but can occur secondary to metastases (breast, lung, or prostate most common) or rarely secondary to primary bone tumors such as osteogenic sarcoma.

Spiral midshaft femur fractures can occur in toddlers who are running and trip with a twisting motion.37 Midshaft femur fractures in children are often the result of neglect or abuse; however, up to 80 percent of fractures during the first year of life are possibly due to abuse.38 The suspicion of abuse should be greater if the fracture occurs in an infant, child with preexisting brain damage, child with bilateral femur fractures, subtrochanteric femur fractures, or fractures occurring in children with other concomitant trauma. Distal metaphyseal chip fractures and delays in the family seeking medical care for the child should also raise the clinical suspicion for abuse. A femoral fracture in a young child with no history suggestive of abuse or significant trauma should suggest the possibility of osteogenesis imperfecta.

The femur is surrounded by large muscle groups with a rich vascular supply. Therefore, femoral fractures may result in a loss of 1 L or more of blood into the soft tissue of the thigh, producing clinical shock. The initial evaluation should always include careful neurovascular examination of the extremity. Vascular occlusion or disruption can occur, but nerve damage is rare.

Femoral shaft fractures are generally evident in the field to prehospital personnel because of the shortening, deformity and associated swelling. Initially, basic stabilization of the patient should take place in the field, along with spinal assessment and immobilization. External hemorrhage should be controlled by direct pressure, open wounds covered with a sterile dressing and then neurovascular examination of the extremities performed. It is best to splint the affected extremity with a traction splint at the time of injury. Hare (Dyna-Med, Carlsbad, CA) or Sager (Minto Research & Development, Redding, CA) traction splints can be placed over the trousers, applying traction to a sling around the ankle and forefoot. Traction splints are relatively contraindicated in cases of open fracture with grossly contaminated exposed bone ends or when sciatic nerve injury is probable because traction can exacerbate nerve injury. For the latter, splint placement without application of traction is indicated.

Emergency Department management includes basic stabilization of the patient followed by careful neurovascular examination of the affected extremity. Open fractures require broad spectrum antibiotics, debridement, and copious irrigation, generally in the operating room. Radiographs of the femur are generally lower priority in the acute resuscitation phase and parenteral analgesics are generally required if there is no contraindication to their use. Orthopedic consultation should be obtained early and most patients require hospitalization and surgical intervention.

Definitive management options include traction, external fixation, pins and plaster, and internal fixation. In infants and in children up to 2 years of age or 30 pounds, fractures of the shaft of the femur are treated by direct overhead traction applied to both legs (Bryant´s traction) followed by spica casting. Spica casting is also used for children up to age six. In an older child or young adult, the Fisk-type of traction by means of a half-Thomas ring and Pearson attachment, to allow flexion of the knee, is satisfactory for unstable fractures followed by spica casting or cast bracing. External fixation and flexible intramedullary rod fixation are being employed more frequently in this age group.39 The intermedullary interlocking nailing is the method of choice for the treatment of uncomplicated fractures of the mid shaft and junction of the upper and middle third of the femur in adults, except where comminution is so extensive that stability with the rod cannot be maintained. In cases where comminution is severe, either dual-plating or the use of a compression plate device can result in excellent fixation. Open femur fractures require early orthopedic consultation for copious irrigation and debridement in the operating room. These injuries can generally be nailed immediately.40 In severely contaminated open fractures, external fixation may be the preferred method of treatment.

The overall prognosis of midshaft femur fractures is very good, with most patients being able to return to work within six months. Union rates approach 100 percent, with non-union being very uncommon. Mild degrees of limb shortening or malalignment can result in limp and posttraumatic arthritis.

Patients with preexisting internal hardware may suffer recurrent fractures with trauma. These fractures tend to be very severe and comminuted because the bone is weaker than the hardware. Evaluation and treatment principles are the same as without hardware. Hardware migration, loosening and rarely breakage can occur. Pain at the site and radiographic changes compared to old films are present. Infection, suggested by pain at the fracture site and fever, may also occur, but is uncommon with closed procedures.

Fassil   Tintinalli  1811-12

•        Fx of the shaft of the femur most often occur in men during their most active period in life. Falls, industrial and automobile accidents, and gunshot wounds account for the majority of these fractures.

•        Initial Tx include basic stabilization of the patient should take place in the field, along with spinal assessment and immobilization. Definitive management options include traction, external fixation, pins and plaster, and internal fixation.

Anonymous Tintinalli, pp 1811-1812

Often occur in men during their most active period in life. Falls, industrial and automobile accidents, and gunshot wounds account for the majority of these fractures.

Treatment- ED management includes basic stabilization of the patient followed by careful neurovascular examination of the affected extremity. Open fractures require broad spectrum antibiotics, debridement and copious irrigation, generally in the OR. Parenteral analgesics generally required if not contraindicated. Orthopedic consult should be obtained early. Definitive management options include traction, external fixation, pins and plaster, and internal fixation.

Anonymous Tintinalli 1811-1813

            These fractures most often occur in men during their most active period in life.  

            Common causes of femoral shaft fractures include:

                        Falls

                        Industrial accidents

                        Automobile accidents

                        GSW

            Treatment – In the field

•      initial basic stabilization of patient and spinal assessment (usually done in field)

•      External hemorrhage control

•      Splint injury at time of injury with a traction splint (Hare Splint or Sager).  Traction splints are contraindicated in open fractures

            Treatment – in the ER

•      Basic stabilization of pt

•      Careful neurovascular exam of the extremity

•      Broad spectrum antibiotics, debridement, and copious irrigation generally done in surgery for open wound.

•      Orthopedic consultation should be obtained early as patient will need hospitalization and surgery.

•      Definitive management options include traction, external fixation, pins, and plaster, and internal fixation.

Anonymous Tintinalli 1811-13

Causes- Fractures of the shaft of the femur most often occur in men during their most active period in life.  Falls, industrial and automobile accidents, and gunshot wounds account for the majority of these fractures.

Treatment- Initially, basic stabilization of the patient should take place in the field, along with spinal assessment and immobilization.  External hemorrhage should be controlled by direct pressure, open wounds covered with a sterile dressing and then neurovascular examination of the extremities performed.  It is best to splint the affected extremity with a traction splint at the time of injury.  ED management includes basic stabilization of the patient followed by careful neurovascular examination of the affected extremity.  Open fractures require broad spectrum antibiotics, debridement, and copious irrigation, generally in the operating room.  Radiographs of the femur are generally lower priority in the acute resusitation phase and parenteral analgesics are generally required if there is no contraindication to their use.  Orthopedic consultation should be obtained early and most patients require hospitalization and surgical intervention. Definitive management options include traction, external fixation, pins and plaster, and internal fixation.

6.      Discuss the following regarding patella fractures:

         a.            Most common type of fracture

         b.            How they present

         c.            How they are treated

Zen Seeker Tinitinalli EM Fifth Edition

Classification of patellar fractures. (From Hohl M, Johnson EE, Wiss DA. Fractures of the knee, in Rockwood CA Jr, Green DP, Bucholz RW (eds): Fractures in Adults, 3d ed, vol. 2. Philadelphia, Lippincott, 1991, p. 1765. Used with permission.)

FRACTURES

Fractures of the Patella

Fractures of the patella occur from a direct blow such as with the knee striking a car dashboard in an MVA, a fall on the flexed knee, or forceful contraction of the quadriceps muscles, which can occur with falling or stumbling. Fractures may be transverse, comminuted, or of the avulsion type, when the quadriceps or patellar tendon pulls off a small portion of the patella (Fig. 266-1).

Transverse fractures of the patella are most common, followed by stellate and comminuted fractures.7 Patients with nondisplaced fractures may be ambulatory. Physical examination reveals focal patellar tenderness, swelling, and effusion. It is imperative that the integrity of the extensor mechanism of the knee be checked by having the patient perform a straight-leg raise against gravity. Transverse fractures are more likely to be displaced and have a disrupted extensor mechanism. Differential diagnosis of patellar fractures radiographically includes bipartite patella. This condition involves the superior lateral corner of the patella, is typically bilateral, and is differentiated from fracture by its smooth cortical margins.

A nondisplaced fracture of the patella with an intact extensor mechanism is initially treated in the emergency department with a knee immobilizer, ice, elevation, and nonsteroidal anti- inflammatory drugs and/or opioid analgesics. Such fractures are generally treated in a long leg cast for a total of six weeks of immobilization.7 During this period the patient should be encouraged to walk on crutches initially, with partial weight- bearing progressing to full weight-bearing as tolerated. Fractures that are displaced greater than 3 mm, or that are associated with the disruption of the extensor mechanism, require early referral to orthopedics for open reduction and internal fixation.7 This generally consists of tension-band wiring of the patella and suturing of the retinaculum. Severely comminuted fractures may be treated surgically by removal of smaller fragments (or all fragments if they are small) and suturing of the quadriceps and patellar tendons. All open fractures must be debrided and irrigated by orthopedics in the operating room and antistaphylococcal antibiotics should be administered. The overall prognosis for patellar fractures is good.7

Anonymous Tintinalli, pp 1815-1816

Most common type of fracture- Transverse fractures of the patella.

How they present- Nondisplaced may be ambulatory. PE (for displaced and nondisplaced) shows focal patellar tenderness, swelling and effusion. Need to check integrity of extensor mechanism with straight leg raise.

How they are treated- Nondisplaced with an intact extensor mechanism initially treated in ED with knee immobilizer, ice, elevation and NSAIDS or opiods. Definitive treatment is generally long leg cast for six weeks. Displaced >3mm require early referral to orthopedics for open reduction and internal fixation.

Anonymous Tintinalli 1815-1816        

• Most common type of fracture – transverse fractures of the patella are the most common followed by stellate and comminuted.

• How they present – Exam reveals focal patellar tenderness, swelling, and effusion.

• How they are treated – The most common patellar fracture is transverse and most of these are displaced and treatment consists of an early referral to ortho for open reduction and internal fixation.  If the fracture is non-displaced and the extensor mechanism is intact it is initially treated in the ER with a knee immobilizer, ice, elevation, and NSAID’s or opioid analgesics.  Such fractures are generally treated in a long leg cast for a total of 6 weeks immobilization.

KIM R   Titinalli pg 1816

a.  Most common—is the transverse FX.  Transverse fxs are more likely to be displaced and have a disrupted extensor mechanism.

            Other types of patella fx are comminuted or avulsion.

b.  presentation—PE reveals focal patellar tenderness, swelling, and effusion.

c.  treatment--  Displaced  if > 3mm, or those associated with the disruption of the extensor mechanism, require early referral to orthopedics for open reduction and internal fixation.

                        Nondisplaced  with intact extensor mechanism is initially treated in the ED with a knee immobilizer, ice, elevation, and NSAIDs or opiod analgesics.

                        Severely comminuted  may be treated surgically by removal of smaller fragments and suturing of the quadriceps and patellar tendon.

Kate   Tintin 1816

1. Transverse fracture of the patella are most common

2. Patellar fx s are due to direct blow typically from striking dashboard in  MVC.

If nondisplaced, pt. may be ambulatory.  Phys. Exam reveals focal patellar tenderness, swelling, and effusion.  If displaced, fragments may disrupt extensor mechanism so check ability to perform active straight leg raise against gravity.

3. Nondisplaced, intact extensor mechanism fractures should me treated with knee immobilizer, ice, elevation, NSAIDS and/or opiod analgesics.  If displaced or extensor mechanism disruption, need early referral to orhto for reduction and/or surgery.

Anonymous Tintinalli 1815-16

a) Most common type of fracture- Transverse fractures of the patella are most common, followed by stellate and comminuted fractures.

b) How they present- Fractures of the patella occur from a direct blow such as with the knee striking a care dashboard in an MVA, a fall on the flexed knee, or forceful contraction of the quadriceps muscles, which can occur with falling or stumbling.

Nondisplaced- patients may be ambulatory and PE reveals focal patellar tenderness, swelling, and effusion.

Transverse-  more likely to be displaced and have a disrupted extensor mechanism

c) How they are treated

Nondisplaced- knee immobilizer, ice, elevation, and nonsteroidal anti-inflammatory drugs and/or opioid analgesics (in ED). Such fractures are generally treated in a long leg cast for a total of six weeks of immobilization.

Displaced- fractures that are displaced >3mm, or that are associated with the disruption of the extensor mechanism, require early referral to orthopedics for open reduction and internal fixation.

Comminuted – may be treated surgically by removal of smaller fragments (or all fragments if they are small) and suturing of the quadriceps and patellar tendons.

All open fractures must be debrided and irrigated by orthopedics in the operating room and antistaphylococcal antibiotics should be administered.

7.      Discuss the following regarding ligamentous knee injuries:

         a.            Physical exam findings in medial or lateral collateral ligament disorders

   b.            Common presentation of anterior cruciate ligament (ACL) tears

         c.            Two tests used to diagnose ACL tears

         d.            Usual mechanism of injury in posterior cruciate ligament (PCL) tears

         e.            A test to assess a PCL tear

         f.             General treatment

Zen Seeker Tinitinalli EM Fifth Edition

Ligaments of the right knee joint. The articular capsule and the patella have been removed. (From Spencer AP, Mason EB: Human Anatomy and Physiology. Menlo Park, Benjamin/Cummings, 1979, p 174. Used by permission.)

Valgus stress in full extension (A) and in 30° of flexion (B). (From Scott WN. Ligament and Extensor Mechanism Injuries of the Knee: Diagnosis and Treatment. St. Louis, Mosby-Year Book, 1991, p 91. Used with permission.)

The Lachman test is performed with the knee flexed between 15° and 30°. (From Scott WN. Ligament and Extensor Mechanism Injuries of the Knee: Diagnosis and Treatment. St. Louis, Mosby-Year Book, 1991, p 94. Used with
permission.)

Anterior drawer test. (From Scott WN. Ligament and Extensor Mechanism Injuries of the Knee: Diagnosis and Treatment. St. Louis, Mosby-Year Book, 1991, p 95. Used with permission.)

In the pivot shift of Galway and MacIntosh, the test is done with the knee in full extension with application of a valgus and internal rotation stress. The “clunk” of reduction is felt in the first 20° to 30° of flexion. (From Scott WN. Ligament and
Extensor Mechanism Injuries of the Knee: Diagnosis and Treatment. St. Louis, Mosby-Year Book, 1991, p 95. Used with permission.)

Posterior drawer test. (From Scott WN. Ligament and Extensor Mechanism Injuries of the Knee: Diagnosis and Treatment. St. Louis, Mosby-Year Book, 1991, p 97. Used with permission.)

LIGAMENTOUS AND MENISCAL INJURIES

The knee joint depends on ligaments and muscles for support (Fig. 266-3). It is frequently subjected to injuries from traumatic forces while extended or in various stages of flexion. These traumatic forces include abduction, flexion, and internal rotation of the femur on the tibia; adduction, flexion, and external rotation of the femur on the tibia; hyperextension; and anteroposterior displacement. By far the most common are abduction, flexion, and internal rotation of the femur on the tibia, which produce injuries to the medial side of the knee. Injuries to the lateral side of the knee are produced by adduction, flexion, and external rotation. Such forces may result in a strain or rupture of the medial or lateral collateral ligaments, the anterior or posterior cruciate ligaments, the capsular structures, or a tear in the medial or lateral meniscus, singularly or in combination. Functional instability of the knee is determined by stress testing, which will demonstrate abnormal laxity when properly done.

Initial stress testing is an abduction or valgus deformity (Fig. 266-4) applied to the knee, which is in approximately 30° of flexion, to determine the integrity of the medial capsular and ligamentous structures. The medial collateral ligament supplies the majority of restraint to valgus deformities of the knee in all stages of flexion. A varus or adduction force is then applied to the lateral aspect of the knee, again with approximately 30° of flexion, to ascertain the integrity of the lateral structures. The lateral collateral ligament, similar to the medial collateral ligament, is the major restraint to varus laxity on the knee at all positions of flexion. If there is a demonstrated laxity of greater than 1 cm without a firm end-point as compared to the other knee, there is a complete rupture of the medial or lateral collateral ligament.10 If there is laxity with a firm end-point or a laxity of less than 1 cm, an incomplete or partial tear is present. If there is no demonstrated instability but there is pain, the patient has suffered a strain in the ligamentous structures tested. The patient who is unstable with the varus or valgus test performed with 30° of flexion should be brought into full extension, if possible, and similar maneuvers carried out. Medial instability in full extension indicates a severe lesion involving the cruciate ligaments and posterior capsule along with the medial ligaments. Lateral instability in extension likewise indicates a severe injury that may involve the posterolateral corner of the knee as well as the cruciate ligaments. Peroneal nerve injuries may also occur in lateral injuries.

Injury to the anterior cruciate ligament may be the most common ligamentous injury today.10 The mechanism of injury is usually noncontact; a deceleration, hyperextension, or marked internal rotation of the tibia on the femur results in an injury to the cruciate. This injury is often associated with a “pop” and swelling that develops within hours. This pop is considered pathognomonic for anterior cruciate injury.11 There may be an associated medial meniscal tear as well. Such a mechanism of injury combined with the presence of a traumatic effusion is very suggestive of a disruption of the anterior cruciate ligament.

The diagnosis of the anterior cruciate ligament injury is ascertained by using the Lachman test (Fig. 266-5), the anterior drawer sign, (Fig. 266-6) and the pivot shift (Fig. 266-7).12 Although the anterior drawer sign has been used for a long time, it is not very sensitive. The maneuver is done with 45° flexion at the hip and 90° flexion at the knee. The physician then attempts to forwardly displace the tibia from the femur. A displacement of greater than 6 mm as compared to the normal, opposite knee indicates that there has been an injury to the anterior cruciate ligament. There are false-negatives associated with this maneuver. The Lachman test is a much more sensitive test.10 The examiner places the knee in 20° of flexion by resting it on a pillow and stabilizes the femur above the knee with his or her nondominant hand. The dominant hand is placed behind the leg at the level of the tibial tubercle, and the examiner introduces an anterior force, attempting to displace the tibia forward. If a displacement of greater than 5 mm as compared to the opposite knee occurs, or if there is a soft, mushy end-point, then a tear in the anterior cruciate ligament has occurred. Although this examination is more sensitive than the anterior drawer and able to identify partial tears in the anterior cruciate ligament when the examiner is skilled, it is difficult on patients who have large legs. The pivot shift is the third maneuver by which the examiner can determine the integrity of the anterior cruciate ligament. The pivot shift is easily performed once the examiner is familiar with it, but it may be somewhat painful to the patient. While the patient is supine and relaxed, the examiner lifts the heel of the foot to approximately 45° of hip flexion with the knee fully extended. The opposite hand grasps the knee with the thumb behind the fibular head. The examiner then internally rotates the ankle and knee, applies a valgus force to the knee, and flexes the knee. If an anterior subluxation of the tibia is present, a sudden visible, audible, and palpable reduction of the subluxation occurs at about 20 to 40° of flexion. This indicates a deficit in the anterior cruciate ligament, which is required to stabilize the knee in this position. There are other tests described in the literature to determine the integrity of the anterior cruciate ligament, including the jerk test and dynamic extension testing.

The posterior cruciate ligament can also suffer an isolated injury or be injured in combination with other ligamentous structures of the knee. In contrast to anterior cruciate injuries, isolated posterior cruciate injuries are seen much less frequently. The posterior cruciate ligament provides initial resistance to posterior translation at all angles of flexion of the knee. The mechanism of injury then is usually an anterior to posterior force applied to the tibia or lower leg. Posterior cruciate injuries are seen in association with other ligamentous injuries when a serious injury has occurred to the knee. A deficit in this ligament is determined by the posterior drawer test (Fig. 266-8). The knee is examined with flexion at the hip and at the knee as described for the anterior drawer sign. The physician applies a posterior force to the tibial tubercle. If there is displacement posteriorly, then the examiner can diagnose an injury to this ligament. The physician might also notice a posterior sag or drop back of the tibial tubercle due to loss of integrity of the posterior cruciate when observing the knee with 45° flexion at the hip and 90° flexion at the knee. This test can be misleading, however, if there is a straight anterior instability resulting in a subluxation of the knee forward. This abnormal position would give the physician the false impression of too much posterior play when performing the posterior drawer test because the knee would be reduced to its normal anatomic alignment from the forwardly subluxed position. 

Combined instabilities of the knee are often seen, especially in athletes. Anteromedial and anterolateral instability are the two that occur most frequently. They result from external rotation and abduction or adduction forces placed on the knee. Virtually any combination of medial and lateral instabilities of the knee can occur, however.

One knee injury that is especially difficult to detect is injury to the posterolateral structures. Posterolateral instability usually involves a tear of the popliteus-arcuate complex, which may occur in combination with lateral ligament injury and possible anterior or posterior cruciate ligament injury. Isolated injuries to the popliteus-arcuate complex can occur themselves but are rare. Isolated posterolateral instability is demonstrated by testing at 0 to 30° of flexion for maximal posterior translation, and at 90° of flexion for maximal external rotation as compared to the normal opposite knee. Further testing to determine the integrity of the lateral collateral ligament and anterior or posterior cruciates must be done as well.

Most ligamentous injuries of the knee present with hemarthroses. In fact, approximately 75 percent of all hemarthroses are due to disruption of the anterior cruciate ligament.10 Serious ligament injuries, however, may present with minimal pain and no hemarthrosis due to complete disruption of the ligamentous and capsular fibers, allowing leakage of the blood into the soft tissue spaces. Hemarthrosis can also be due to osteochondral fractures or fractures that extend into the joint line or peripheral meniscal tears. Traumatic hemarthroses usually occur within minutes to hours of injury, in contrast to chronic effusions of the knee due to synovial inflammation, which occur one to two days after strenuous use of the joint.

Plain radiographs in ligamentous injuries are typically normal or only reveal an effusion. An avulsion fracture at the site of attachment of the lateral capsular ligament on the laterial tibial condyle (Segond fracture) is a marker for anterior cruciate ligament rupture.13 Cortical avulsion of the medial tibial plateau (very uncommon) is associated with tears of the posterior cruciate ligament and medial meniscus.14 Continued refinements in MRI have resulted in high-quality images of the ligamentous and meniscal structures of the knee resulting in an accuracy rate of close to 90 percent for meniscal and cruciate ligament disruption.7 The ordering of this examination, however, is typically done by the patient´s primary care provider or orthopedist in follow-up.

Stable injuries involving a single ligament with minor strain can be managed with a knee immobilizer, ice packs, elevation, nonsteroidal anti-inflammatory agents, and ambulation as soon as is comfortable for the patient.15 When knee immobilizers are placed, the patient must be instructed to perform daily range of motion exercises to avoid contracture and maintain mobility. These complications are more common in the elderly and can occur after only a few days of immobilization. While there is no universally accepted regimen for range of motion exercise, one regimen is to apply ice first to relieve pain, and then perform 10–20 knee flexion-extensions (no weights should be added) three or four times a day. These injuries should be referred to an orthopedic surgeon or the patient´s primary care provider within the next few days to a week for follow-up examination. Complete rupture of an isolated ligament can generally be treated conservatively in the same fashion with quadriceps strengthening, range of motion exercises, and functional bracing being part of the follow-up care.11 Professional athletes with single ligament ruptures or patients with more than one ligament torn and an unstable knee necessitate immediate orthopedic consultation so that definitive surgical management can be planned.

Arthrocentesis may be of therapeutic benefit in patients with large, tense effusions of the knee. Recurrence of the effusion following aspiration, however, is common. Arthrocentesis may also be of assistance diagnostically if the etiology of the effusion is not clearly due to trauma. The presence of blood and glistening fat globules is pathognomonic of lipohemarthrosis, which indicates intra-articular knee fracture. The major complication of arthrocentesis is septic arthritis.

Anonymous Tintinalli Ch.266 p.1817

Physical exam findings in medial or lateral collateral ligament disorders: laxity on stress testing w/ knee flexed 30º valgus stress (medial) +/or varus stress (lateral) >1 cm w/o firm end point indicates a complete rupture or tear; laxity of <1cm w/ a firm end point indicates a partial rupture. If there is pain, but no instability found on flexion, there is a collateral ligament strain. The same testing should be performed if instability is found w/ the knee extended to determine severity + involvement of other structures.

Common presentation of anterior cruciate ligament (ACL) tears: Usually associated w/ a “pop” + swelling within hours.

Two tests used to diagnose ACL tears: (1) Lachman test (2) anterior drawer test

Usual mechanism of injury in posterior cruciate ligament (PCL) tears: Usual mechanism is anterior to posterior force applied to tibia or lower leg.

A test to assess a PCL tear: posterior drawer test

General treatment: Stable single ligament strains or rupture/knee immobilizer, ice packs, elevation, NSAIDs followed by ambulation as soon as is comfortable. Pt. should also be instructed to do daily ROM exercises to avoid contracture + maintain mobility. Refer to ortho surgeon or PCP within the next few days to a week for follow-up. Pro athletes, multiple ligament involvement or instability require immediate ortho consult to plan definitive surgical management.

Anonymous Tintinalli 1817-1819

•         Physical exam findings in medial or lateral collateral ligament disorders – Review BCS exam cards to remember those MCL and LCL stability tests.  

•      If there is laxity of greater than 1 cm without a firm end-points compared to the other knee, there is a complete rupture of the ligament.

•      If there is laxity with a firm end-point or a laxity of less than 1 cm an incomplete or partial tear is present.

•      If there is pain without laxity, then the patient has suffered a strain in the ligamentous structures.

•         Common presentation of anterior cruciate ligament (ACL) tears – This may be the most common ligamentous injury today.  Injury is usually non-contact; a deceleration, hyperextension, or marked internal rotation of the tibia or femur results in this injury.

•      The injury is associated with “pop” and swelling that develops within hours.  The “pop” is considered pathognomonic for ACL injury.  

•         Two tests used to diagnose ACL tears – The two tests for diagnosis are the Lachman (more sensitive) and the anterior drawer sign.  ( We may want to refer to Bates if we forgot what these tests are)

•         Usual mechanism of injury in posterior cruciate ligament (PCL) tears – for this injury to occur the mechanism is usually an anterior to posterior force applied to the tibia or lower leg.

•         A test to assess a PCL tear – The posterior drawer test will assess for a PCL injury

•         General treatment  - Is somewhat dependent upon type of injury

•      Stable injuries involving a single ligament with minor strain can be managed with a knee immobilizer, ice packs, elevation, NSAID’s, and ambulation as soon as is comfortable for patient.  When knee immobilizers are place the patient is given instructions to perform daily ROM exercises.

•      Referral to ortho or PCP is necessary for follow-up

•      Complete rupture of an isolated ligament can generally be treated conservatively in the same fashion as a strain.

•      Arthrocentesis may be of therapeutic benefit in patients with large tense effusions of the knee.

KIM R  Titinalli pg 1817-18

a.  PE finding in medial or lateral collateral ligament disorders.  

            - initial stress testing is an abductor or valgus pressure applied to the knee, approx 30 degree of flexion, to determine the integrity of the medial capsular structures.

            - A varus or adduction force is then applied to the lateral aspect of the knee, again with approx 30 degree of flexion to determine the integrity of the lateral capsular structures.

            ** if there is demonstrated laxity of > 1 cm without a firm end-point as compared to the other knee, there is a COMPLETE rupture of the medial collateral ligament.

            ** if there is laxity with a firm end-point or a laxity of < 1c, an INCOMPLETE or PARTIAL tear is present.  

            ** if there is demonstrated instability but there is pain, the pt has suffered a strain.

            - the pt who is unstable with the varus or valgus maneuver should be brought to full extension, if possible, and similar maneuvers carried out.

            -Medial instability-in full extension indicated severe lesion involving the cruciate ligaments and posterior capsule along with the medial ligaments.

            -Lateral instability- in full extension likewise indicates a severe injury that may involve the posterolateral corner of the knee as well as the cruciate ligaments.  Peroneal nerve injuries may also occur in lateral injuries.

b. Common presentation if anterior collateral ligament (ACL) tears

            *most common ligament injury of the knee

            *mechanism of injury is usually NON-Contact in nature, usually as a deceleration, hyperextention, or marked internal rotation of the tibia on the femur results in an injury to the cruciate.

            * this injury is associated with a “POP” and swelling.  The pop is considered pathognomonic for ACL injuries.

c.  Two tests used to diagnose ACL tears

            - Lachman test (we already know about)

            -anterior drawer test (again, we know about this one)

            -Pivot shift—may be painful to the pt.  Pt lying spine and relaxed, examiner lift the heel of the foot approx. 45 degree of hip flexion with the knee fully extended.  The opposite hand grasps the knee with the thumb behind the fibular head  The examiner then internally rotates the ankle and knee, applies a valgus force to the knee, and flexes the knee.   SEE picture on page 1818 of Titinalli.

4. Usual mechanism of injury in posterior cruciate ligament (PCL) tears

* is usually an anterior-to-posterior force applied to the tibia or lower leg.  PCL injuries are seen in association with other ligamentous injuries when a serious injury had occurred to the knee.

e.  A test to assess a PCL tear

            -the posterior drawer test.  Same as anterior drawer.

f.  General treatment

            - Stable injuries—involing a single ligament with minor strain can be managed with a knee immobilizer, ice, elevation, NSAIDs, and ambulation as soon as comfortable for the pt.  The pt MUST be instructed to perform daily ROM exercises to avoid contracture and maintain mobility.

            Complete ruptures—of an isolated ligament can generally be treated conservatively in the same fashion with quadriceps strengthening, ROM excecises, and functional bracing being part of the follow-up care.

Kate Tintin 1817

1. If there is a demonstrated laxity of greater than 1 cm without a firm end-point as compared to the other knee in the valgus/varus, lachman or anterior drawer test, there disorder of the medial or lateral collateral ligament.

2. Pt. reports “pop” then traumatic effusion within 1 hour of injury

3. Lachman and Anterior Drawer test

4. Posterior Drawer test

5. Complete rupture can be treated conservatively  with knee immobilizer, ice packs, elevation, NSAIDS, and ambulation as soon as is comfortable for the patient.  Refer to orthopedic surgeon or pt.’s PCP within days.  If pt. is a professional athlete or pt’s with more than one ruptured ligament should get immediate consultation.  Arthrocentesis may be therapeutic for pt’s with large, tense effusions of the knee.

Anonymous Tintinalli 1817-18

a) Physical exam findings in medial or lateral collaeral ligament disorders

If there is demonstrated laxity of >1cm without a firm end-point as compared to the other knee, there is a complete rupture of the medial or lateral collateral ligament.  If there is laxity with a firm end-point or a laxity of < 1 cm, an incomplete or partial tear is present.  If there is no demonstrated instability but there is pain, the patient has suffered a strain in the ligamentous structures tested.

b)      Common presentation of anterior cruciate ligament (ACL) tears Goroll 4^th Ed. 860

Typically, it occurs in the setting of sudden noncontact deceleration that causes valgus twisting of the knee.  A “pop” is heard, and marked swelling ensues within a few hours because of intraarticular bleeding.  The resulting subluxation of the tibia compresses the meniscus between the tibia and femur and may cause the cartilage to tear.  Initially after an ACL tear, the knee may function reasonably well, but instability develops on resumption of sports activity

c)      Two tests used to diagnose ACL tears- anterior drawer and Lachman test (more sensitive)

d)      Usual mechanism of injury in posterior cruciate ligament (PCL) tears- the mechanism of injury is usually an anterior to posterior force applied to the tibia or lower leg

e)      A test to assess a PCL tear- posterior drawer test

f)        General treatment- Stable injuries involving a single ligament with minor strain can be managed with a knee immobilizer, ice packs, elevation, NSAIDS, and ambulation as soon as is comfortable for the patient.  When knee immobilizers are place, the patient must be instructed to perform daily ROM exercises to avoid contracture and maintain mobility.

8.      Discuss the following regarding meniscal injuries:

         a.            Usual presentation

         b.            How they are diagnosed

         c.            General treatment

Zen Seeker Tinitinalli EM Fifth Edition

Meniscal Injuries

Meniscal injuries of the knee occur by themselves or in combination with ligamentous injuries. For example, anterior cruciate injuries are commonly associated with meniscal injuries. Cutting, squatting, or twisting maneuvers may cause injury to the meniscus. The medial meniscus is approximately twice as likely as the lateral meniscus to be injured. Four-fifths of the tears involve the peripheral posterior aspect of the meniscus.16 Many maneuvers have been described in the literature to determine whether a meniscus has been injured. Most of these tests, however, have an unacceptable specificity and sensitivity. Although the diagnosis of a meniscal tear is difficult to make in certain patients, a combination of a suggestive history and physical findings on examination should lead the emergency physician to consider the diagnosis. On questioning the patient, the physician should ask if the patient experiences locking of the knee joint on either flexion or extension that is painful and limits further activity. This sign clearly points to the diagnosis of a torn meniscus. Effusions that occur after activity; a sensation of popping, clicking, or snapping; a feeling of an unstable joint, especially with activity; or tenderness in the anterior joint space after excessive activity suggests the diagnosis of a meniscal tear. When performing a physical examination, a physician should attempt to identify atrophy of the quadriceps muscle due to disuse, and joint line tenderness, which is very suggestive. Various maneuvers, such as McMurray´s test or the grind test, are useful but, as mentioned earlier, are positive only about 50 percent of the time.17 If a tentative diagnosis of a meniscal tear is considered, referral to an orthopedic surgeon or the patient´s primary care provider is warranted. Nonsteroidal anti- inflammatory agents and partial weight-bearing are advised pending follow-up. Definitive diagnosis can be made by MRI or arthroscopy with the latter having the advantage of allowing for definitive surgical treatment (usually partial meniscectomy or meniscal repair).

The patient who presents to the emergency department with a locked knee can experience a great deal of pain along with loss of mobility. Following conscious sedation, one can attempt to unlock the knee by positioning the patient with the leg hanging over the edge of the table with the knee in 90° or greater of flexion. After a period of relaxation, the physician can apply longitudinal traction to the knee with internal and external rotation in an attempt to unlock the joint. If this maneuver is unsuccessful, consultation with the orthopedic surgeon is recommended.

Anonymous

Usual presentation: Pain, locking, popping, clicking, effusions after activity, feeling of joint instability, tenderness in the anterior joint space after excessive activity suggests a tear.

How they are diagnosed: MRI is definitive. Positive McMurray’s test or grind test may be helpful.

General treatment: Partial wt.bearing + NSAIDs pending ortho follow-up.

Anonymous Tintinalli, pg 1819

•        Usual presentation - Occur by themselves or with a ligamentous injury . ACL injuries are commonly associated with meniscal injuries. Cutting, squatting, or twisting maneuvers may cause injury to meniscus. Medial meniscus is twice as likely as lateral meniscus to be injured. Four-fifths of tears involve peripheral posterior aspect of meniscus.

•        How they are diagnosed - Most of  the maneuvers have unacceptable specificity and sensitivity. Combination of history and physical findings should lead examiner to consider diagnosis. Does patient experience locking of the knee joint on either flexion or extension that is painful and limits further activity? This sign clearly points to a torn meniscus. Effusions that occur with activity; a sensation of popping, clicking, or snapping; feeling of an unstable joint, esp. with activity; or tenderness in the anterior joint space after excessive activity suggests meniscal tear. On PE, attempt to identify quad atrophy and joint line tenderness which is very suggestive. Mcmurray’s test and grind test are useful but are only positive 50% of the time.

•        General treatment - If a tentative diagnosis of a meniscal tear is made is considered, referral to an orthopedic surgeon or patient’s PCP is warranted. NSAIDS and partial weight bearing are advised pending followup.  Patient’s presenting to the ED with a locked knee can experience a great deal of pain along with loss of mobility. Following conscious sedation, one can attempt to unlock the knee by positioning the patient with the leg hanging over the edge of the table with the knee in 90 degrees or greater flexion. After period of relaxation, physician can apply longitudinal traction to the knee with internal and external rotation in an attempt to unlock the joint. If maneuver unsuccessful, consultation with an orthopedic surgeon is recommended.

KIM R   Titinalli pg 1819

a. usual presentation—presents with a locked knee, pain, and loss of mobility.

b.  diagnosed by—effusions that occur after activity, a sensation of popping, clicking, or snapping; feeling of an unstable joint, especially with activity; or tenderness in the anterior joint space after excessive activity.

c. General treatment—

            -NSAIDs

            -Partial weight-bearing are adviced pending follow-up

            -referral to ortho

Kate Tintin 1819

a.       meniscal injuries of the knee occur by themselves or in combination with ligamentous injuries.  Pt may experience locking of the  knee joint on  either flexion  or extension that is painful and limiting.  Effusions after activity, sensation of popping, clicking or snapping, feeling of unstable joint, tenderness in the anterior joint space after excessive activity suggests the dx of meniscal tear.  Provider may  identify atrophy of the quads due to disuse, and joint line tenderness.

b.      McMurray’s and grind test are useful but are positive only about 50% of the time, definitive dx can be made by MRI or arthroscopy.

c.       Referral to an orthopedic surgeon or the pt’s PCP , if pt. presents with locked knee, can give conscious sedation and attempt to unlock the knee by position the pt with the leg hanging at 90 degrees, allow for relaxation and apply longitudinal traction to the knee with internal/external rotation.

Anonymous Tintinalli 1819

a)      Usual presentation- Meniscal injuries of the knee occur by themselves or in combination with ligamentous injuries.  For example, ACL injuries are commonly associated with meniscal injuries.  Cutting, squatting, or twisting maneuvers may cause injury to the meniscus.

b)       How they are diagnosed- by a H&P (imagine that)

 if the patient experiences locking of the knee joint on either flexion of extension that is painful and limits further activity, then this clearly points to the diagnosis of a torn meniscus.  Effusions that occur after activity; a sensation of popping, clicking, or snapping; a feeling of an unstable joint, especially with activity; suggests the dx of a meniscal tear.  When performing a PE, the identification of atrophy of the quadriceps muscle d/t disuse, and joint line tenderness, is very suggestive of a torn meniscus. The McMurray’s test or the grind test are useful, but are positive only about 50% of the time. Definitive diagnosis can be made by MRI or arthroscopy.

c)      General treatment-NSAIDS and partial weight bearing are advised pending f/u. Surgical treatment is usually a partial meniscectomy or meniscal repair. If the patient has a locked knee, after conscious sedation, one can attempt to unlock the knee by positioning the patient with the leg hanging over the edge of the table with the knee in 90 degree or greater flexion.  After a period of relaxation, the physician can apply longitudinal traction to the knee with internal and external rotation in an attempt to unlock the joint.

9.      Explain how a dislocated patella presents and how it can be reduced.

Zen Seeker Tinitinalli EM Fifth Edition

Patella Dislocation

Dislocation of the patella usually occurs from a twisting injury on the extended knee and is more common in women. The patella is displaced laterally over the lateral condyle, resulting in pain and deformity of the knee (Fig. 266-10). Tearing of the medial knee joint capsule often occurs. Reduction is accomplished following conscious sedation by flexing the hip, hyperextending the knee, and sliding the patella back into place. This results in immediate relief of pain, but further soreness from capsular injury persists for a period of time. The patella and knee should be x-rayed to rule out a fracture, and the knee should be immobilized after reduction. Follow-up with a primary care provider or orthopedist within one to two weeks is suggested. Partial weight-bearing progressing to full weight-bearing, nonsteroidal anti- inflammatory agents, and isometric quadriceps strengthening exercises are also indicated. Recurrent lateral dislocation of the patella occurs in about 15 percent of patients, and superior, horizontal, and intercondylar dislocations require referral to an orthopedic surgeon for possible surgical intervention.

Anonymous

Patella creates deformity on affected side (usually lateral). After conscious sedation, the hip is flexed + the knee is hyperextended. The patella is then slid back into place. X-ray + immobilization should follow.

Anonymous Tintinalli, pg 1820)

Usually occurs from a twisting injury on the extended knee and is more common in women. Patella is displaced laterally over the lateral condyle, resulting in pain and deformity. Tearing of medial joint capsule often involved. Reduction is accomplished following conscious sedation by flexing the hip, hyperextending the knee, and sliding the patella back into place. This results in immediate pain relief, but soreness may persist for a period of time. Patella and knee should be xrayed to rule out fracture and knee immobilized after reduction. Followup with PCP or orthopedist within 2 weeks. Partial progressing to full weight bearing, NSAIDS, & quad strengthening indicated.

KIM R  Titinalli pg 1820          

n      due to twisting injury on the extended knee.  The patella is displaced laterally over the lateral condyle, resulting in pain and deformity of the knee.

n      reduction is accomplished under conscious sedation by flexing the hip, hyperextending the knee, and sliding the patella back into place.

n      Xray the knee and patella to rule out fx, and place knee in an immobilizer after reduction

Kate Tintin 1820

            The patella is displaced laterally over the lateral condyle, resulting in pain and deformity of the knee.  Tearing of the medial knee joint capsule often occurs.  Reduction is accomplished following conscious sedation by flexing the hip, hyperxtending the knee and sliding the patella back into place.

Anonymous Tintinalli 1820

Presentation- dislocation of the patella usually occurs from a twisting injury on the extended knee and is more common in women.  The patella is displaced laterally over the lateral condyle, resulting in pain and deformity of the knee.  Tearing of the medial knee capsule often occurs.

Reduction- reduction is accomplished following conscious sedation by flexing the hip, hyperextending the knee, and sliding the patella back into place.

10.    Describe the presentation of a quadriceps or patella tendon ruptures and how they are treated.

Zen Seeker Tinitinalli EM Fifth Edition

Quadriceps/Patellar Tendon Rupture

Rupture of the quadriceps or patellar tendons can occur from forceful contraction of the quadriceps muscle or falling on a flexed knee. Patellar tendon rupture occurs most commonly in individuals under age 40 with a history of tendinitis or past steroid injections. Quadriceps tendon rupture is most frequent in the over 40 age group.7 There is significant pain, diffuse swelling, and the patient is unable to extend a flexed knee against mild resistance in both instances. Depending on the tendon ruptured, a defect may be palpable above or below the patella. A “high-riding patella” may be seen on the lateral x-ray of the knee with patellar tendon rupture (Fig. 266-11). The treatment is surgical repair of the involved tendon22 within the first 7 to 10 days following rupture to achieve the best results. Orthopedic consultation in the emergency department is indicated.

Anonymous Tintinalli Handbook pg 894

Quadriceps: SX include sharp pain at the proximal knee on ambulating.  Pt unable to extend leg from knee flexion although may straight-leg raise if complete tear.  Palpable defect may be present with tenderness, swelling at the suprapatellar region and patella baja (low riding).  TX is x-ray to r/o patellar or femoral avulsion fracture, treated similarly to quadriceps muscle tear or if complete, orthopedic consultation for surgery.

Patella: SX include pain inferior to the patella.  On exam, a defect inferior to the patella with inability to extend the knee will be seen.  Patella alta (high riding) or patella baja (low riding.  TX is x-ray to r/o patella fx or avulsion, knee immobilization and ortho consult for surgery within 7-10 days.

Anonymous Tintinalli, pg 1820

Can occur from forceful contraction of the quads or falling on flexed knee. Patellar most common in individuals under 40 and hx of tendonitis or steroid injections. Quads most frequent in over age 40 group. There is significant pain, diffuse swelling, and unable to extend flexed knee against mild resistance. Depending on rupture, may be palpable above or below the patella. A “high riding” patella may be seen on lateral x-ray with patellar tendon rupture. Treatment is surgical repair of involved tendon within first 7-10 days to achieve best results. Ortho consult in ED indicated.

KIM R  Titnalli pg 1820

            -- occur from forceful contraction of the quadriceps muscle or falling on a flexed knee.

            ** pt presents with significant pain, diffuse swelling, and pt is unable to extend a flexed knee against resistance.

            Treatment—surgical repair of the involved tendon within the first 7 to 10 days following rupture to achieve the best results.

Kate Tintin 1820

            With quad or patella tendon rupture there is significant pain, diffuse swelling and the pt is unable to extend a flexed knee against mild resistance.  May be palpable defect above or bellow the patella.  A “high-riding” patella may be seen on lateral x-ray of knee with patellar tendon rupture.  Treatment is surgical repair fo the involved tendon within the first 7-10 days, requires ortho consult in the ED.

Anonymous Tintinalli 1820

Presentation- Rupture of the quadriceps or patellar tendons can occur from forceful contraction of the quadriceps muscle or falling on a flexed knee.  Patellar tendon rupture occurs most commonly in individuals under age 40 with a history of tendonitis or past steroid injections.  Quadriceps tendon rupture is most frequent in the over 40 age group.  There is significant pain, diffuse swelling, and the patient is unable to extend a flexed knee against mild resistance in both instances.

Treatment- the treatment is surgical repair of the involved tendon within the first

7-10 days following rupture to achieve the best results. Ortho. consultation in the ED is indicated.

11.    Discuss chondromalacia patellae as to how it presents, how it is diagnosed, and treatment.

Zen Seeker Tinitinalli EM Fifth Edition

Chondromalacia Patellae

Chondromalacia patellae is an overuse syndrome of the articular cartilage of the patella. The condition is caused by patellofemoral malalignment, which leads to a tracking abnormality of the patella, placing excessive lateral pressure on the articular cartilage. It is most common in young, active women and the pain is generally localized to the region of the anterior knee. Stair climbing and rising from a chair exacerbate the pain.

Two tests may aid in the diagnosis. The patellar compression test is performed by pushing the patella distal in the trochlear groove with the knee extended and quadriceps muscles tightened. This maneuver illicits pain. The apprehension test is performed on a relaxed leg. When the patella is pushed laterally, the quadriceps muscles contract in anticipation of pain. Treatment of this condition consists of rest, nonsteroidal anti- inflammatory medication, and quadriceps strengthening exercises.25

Anonymous Tintinalli Handbook pg 895

Chondromalacia patellae is caused by patellofemoral malalignment which places lateral stress on the articular cartilage.  Presentation is anterior knee pain that worsens with climbing stairs or rising from a sitting position.  Diagnosis is assisted using the patellar compression test and the apprehension test.  Treatment includes non-steroidal anti-inflammatory drugs, rest and quadriceps-strengthening exercises.

Anonymous Tintinalli, pg 1821

Overuse syndrome of articular cartilage of the patella. Caused by patellofemoral malaignment which leads to tracking abnormality of patella placing excessive pressure on articular cartilage. Most common in young active women localized in anterior knee. Stair climbing and rising from chair exacerbate pain. Patellar compression test performed pushing patella in trochlear groove with knee extended and quads tightened, maneuver illicits pain. Apprehension test performed on relaxed knee by pushing patella laterally, quad muscles contract in anticipation of pain. Treatment is rest, NSAIDS, and quad strengthening.

Suzy Tintinalli 1821

Overuse syndrome of the articular cartilage of the patella, caused by patellofemoral malalignment, which leads to a tracking abnormality of the patella, placing excessive lateral pressure on the articular cartilage.

Presents: Most common in young, active women and the pain is generally localized to the region of the anterior knee.  Stair climbing and rising from a chair exacerbate the pain.

Diagnosed:  

•        Patellar compression test-push the patella distal with the knee extended and quadriceps tightened=Pain

•        Apprehension test-Push the patella laterally on a relaxed leg=quadriceps contract in anticipation of pain.  

Treatment:  Rest, NSAIDS, quadriceps strengthening exercises.

Tim Tintinalli, pg 1821

            Chondromalacia patellae is an overuse symdrome of the articular cartilage of the patella caused by patellafemoral malalignment, which leads to a tracking abnormality of the patella, placing excessive lateral pressure on the articular cartlilage.  Commonly seen in young active women and the pain is localized to the anterior knee.  Stair climbing and raising from a chair exasterbate px.  Dx is supported by positive (painful) compression test and positive apprehension test.

Anonymous Tintinalli 1821

Presentation- the condition is caused by patellofemoral malalignment, which leads to a tracking abnormality of the patella, placing excessive lateral pressure on the articular cartilage.  It is most common in young, active women and the pain is generally localized to the region of the anterior knee. Stair climbing and rising from a chair exacerbate the pain.

Diagnosis- two tests may aid in the diagnosis, the patellar compression test (performed by pushing the patella distal in the trochlear groove with the knee extended and quadriceps muscles tightened—this will illicit pain) and the patellar apprehension test (I think we all remember this one).

Treatment- rest, NSAIDS, and quadriceps strengthening exercises

12.    Discuss the following regarding fibula and tibia fractures:

         a.            Isolated fibula fractures

         b.            Tibia fracture with an intact fibula

         c.            Treatment of tibia fractures

Zen Seeker Tinitinalli EM Fifth Edition

SPECIFIC INJURIES

Fibula Fractures

Isolated fibula fractures usually result from a direct blow. They are relatively uncommon. Since this bone only bears 15 percent of the body weight, patients are often able to walk despite the fracture. Proximal fibular fractures are often the result of external rotation, whereas distal fractures usually result from internal rotation. Repetitive trauma, particularly in runners beginning their training, may result in stress fracture of the distal fibula. A mild soreness caused by a low-velocity injury and a fibula fracture can be treated with immobilization using an elastic wrap (distal fibula) or a knee immobilizer (proximal fibula). More impressive pain and disability can be treated with crutches and casting or Robert Jones splinting. Nonunion is uncommon. Pain medication, cessation of the activity that caused the activity, and the use of ice and elevation are also recommended.

Tibia Fractures

A low-energy event such as a skier falling down and suffering a boot-top “tib/fib” fracture will have a more benign course than a motorcyclist who shatters a tibial shaft. In the setting of a tibial fracture, an intact fibula is a welcome finding in that this suggests that less energy was involved. The fibula may also help support or splint the fractured tibia. The extent and type of soft tissue damage incurred may determine the method used to immobilize the tibia. The majority of fractures of the tibia will require a prompt evaluation by an orthopedist while the patient is in the emergency department. Information that will assist the orthopedist includes (1) the general health of the patient and the presence of other injuries, (2) location of the fracture, (3) the pattern of the fracture lines, (4) the number of fracture fragments, (5) whether the fibular shaft is also fractured, and (6) the extent of soft tissue damage, including vascular compromise, soilage, and the possible presence of compartment syndromes.

Anonymous Tintinalli Handbook pg 892-893.  

Isolated fibula fractures-commonly distal fibula and usually occur from direct trauma.  TX is usually immobiliztion, crutches, elevation and analgesics.

Tibia fracture with an intact fibula- a welcome finding in that this suggests that less energy was involved. The fibula may also help support or splint the fractured tibia.

Treatment of tibia fractures-displacement requires ORIF, depressed fx are treated operatively with elevation of fragments, most tibial shaft fx require urgent orthopedic evaluation.  Indications for emergent surgery include open fx, vascular compromise and compartment syndrome.

Anonymous Tintinalli, pg 1824

•        Isolated fibula fractures - Usually result from direct blow and relatively uncommon. Patients are able to walk despite break since bone bears only 15% of body weight. Proximal fx’s from external rotation and distal fx’s from internal rotation. Repetitve trauma can lead to stress fx of distal fibula (athletes, runners).  Mild soreness caused by low-velocity injury  and fib fx treated with immobilization using elastic wrap (distal fib) or knee immobilizer (proximal fib). Impressive pain and disability can be treated with crutches and casting or Robert Jones splinting. Nonunion is uncommon. Pain meds, cessation of activity, ice & elevation are recommended.

•        Tibia fracture with an intact fibula - Less energy was involved in injury. Fibula may splint or help support the fx tibia.

•        Treatment of tibia fractures - Extent and type of soft tissue damage incurred may determine method used to immobilize tibia. Majority of fractures will require prompt ortho eval in ED. Info that will help ortho includes 1) pt’s general health status and presence of other injuries, 2) location of fracture, 3) pattern of fx lines, 4) # of fx fragments, 5) whether fibia was fx’d, 6) extent of soft tissue damage including vascular compromise, soilage, and possible presence of compartment syndromes.

Suzy Tintinalli 1824

a.                   Isolated fibula fractures usually result from a direct blow.  Uncommon. The bone bears only 15% of the body weight, patients are often able to walk despite the fracture.

a.                   Tibia fracture with an intact fibula is a welcome finding in that this suggests that less energy was involved.  The fibular may also help support or splint the fractured tibia.

c.       Treatment of tibia fractures depends on the extend and type of soft tissue damaged incurred may determine the method used to immobilize the tibia.

      Majority: Orthopedist evaluation considers

•        General health of the patient and the presence of other injuries

•        Location of the fracture

•        Pattern of the fracture lines

•        Number of fracture fragments

•        Whether the fibular shaft is also fractured

•        Extent of soft tissue damage, including vascular compromise, soilage, and possible presence of compartment syndromes

Tim Tintinalli, pg. 1824

1. Isolated fibula fractures can result from a direct blow but may be also be result of internal (distal fib fxs) or external (prox fib fxs) rotation.  

2. Tibia fracture with an intact fibula is a welcome finding because this suggests low energy injury. The fibula may also help support or splint the fractured tibia.

3. Treatment of tibia fractures: Majority of tibia fxs will require a prompt eval by an orthopod while the pt is in the ED.  Extent and type of soft tissue damage incurred may determine the method used to immobilize the tibia. Info that will help ortho includes 1) pt’s general health status and presence of other injuries, 2) location of fracture, 3) pattern of fx lines, 4) # of fx fragments, 5) whether fibular shaft was fx’d, 6) extent of soft tissue damage including vascular compromise, contamination, and possible presence of compartment syndromes.

Anonymous Tintinalli 1824

a) Isolated fibula fractures- usually result from a direct blow.

They are relatively uncommon.  Since this bone only bears 15% of the body weight, patients are often able to walk despite the fracture.

b) Tibia fracture with an intact fibula- in the setting of a tibial fracture, an intact fibula is a welcome finding in that this suggests that less energy was involved.  The fibula may also help support or splint the fractured tibia.  

 c) Treatment of tibia fractures- the majority of fractures of the tibia will

require a prompt evaluation by an orthopedist while the patient is in the ED.  Information that will assist the orthopedist includes: 1) the general health of the patient and the presence of other injuries, 2) location of the fracture, 3) the pattern of the fracture lines, 4) the number of fracture fragments, 5) whether the fibular shaft is also fractured, and 6) the extent of soft tissue damage, including vascular compromise, soilage, and the possible presence of compartment syndromes.

13.    Explain how an Achilles tendon can rupture, how it is diagnosed, and treatment.

Zen Seeker Tinitinalli EM Fifth Edition

Achilles Tendon Rupture

When the soleus and gastrocnemius muscles contract, the Achilles tendon pulls up the calcaneous, plantar flexing the foot. Rupture often occurs in sports settings, especially in poorly conditioned players. Forceful plantar flexion results in rupture of the tendon. A popping sound is heard by the patient, who then has difficulty ambulating. This injury is also likely to occur in individuals who have rheumatoid arthritis, lupus erythematosus, or prior steroid injection of the tendon. It frequently ruptures 2 to 6 cm above its attachment to the calcaneous, where it has its poorest vascular supply. A gap may be palpated at this point, and a dent may be visible. The Thompson-Doherty test is performed by squeezing the midportion of the calf of the patient lying in the prone position. An intact Achilles tendon is demonstrated by a plantar flexion of the foot. Another test is to have the patient walk on his or her toes. The diagnosis does not usually require imaging, but computed tomography or magnetic resonance imaging can be helpful in ambiguous cases. In the emergency department, the patient should be splinted in neutral position with a Robert Jones splint, with prompt referral to an orthopedist. Crutches will be needed for ambulation.

Anonymous Tintinalli, p. 1824

How it happens- Rupture often occurs in sports settings, especially in poorly conditioned players. Forceful plantar flexion results in rupture of the tendon.

How it is diagnosed- A gap may be palpated at a point 2-6cm above the attachment point of the Achilles to the calcaneous and a dent may be visible. Thompson-Doherty test is performed by squeezing the midportion of the calf of the patient lying in the prone position. An intact Achilles tendon is demonstrated by plantar flexion of the foot. Another test is to have the patient walk on his/her toes. Dx usually does not require imaging, but CT or MRI can be helpful in ambiguous cases.

Treatment- In the ED, patient should be splinted in neutral position with a Robert Jones splint, with prompt referral to an orthopedist. Crutches will be needed to ambulate.

Anonymous Tintinalli, pg 1824

Often occurs in sports settings, esp in poorly conditioned players. Forceful plantar flexion results in rupture. A popping sound is heard, and then difficulty ambulating. Also likely to occurs in those with rheumatoid arthritis, lupus erythematosus, or prior steroid injection of tendon; ruptures 2-6cm above attachment to calcaneous where it has poor vascular supply. A gap may be palpated and dent visible. Thompson-Doherty test can be performed by squeezing midportion of calf with patient in prone position- intact Achilles demonstrated by plantar flexion of foot. Another test is having patient walk on toes. Diagnosis does not usually require imaging but CT or MRI may be helpful in ambiguous cases. Patient should be splinted in ED in neutral position with Robert jones splint and prompt referral to orthopedist. Crutches for ambulation needed.

Suzy Tintinalli 1824

Ruptures:  Forceful plantar flexion.  The soleus and gastrocnemius muscles contract, the Achilles tendon pulls up the calcaneous, plantar flexing the foot.  Often in poor conditioned sports players, individuals who have rheumatoid arthritis, lupus, or prior steroid injection of the tendon.

Diagnosed:    

•        A gap may be palpated 2 to 6cm above the attachment to the calcaneous, and a dent may be visible.  Patient heard a pop, then had difficulty ambulating.

•        Thompson-Doherty test-squeeze the midportion of the calf of the patient lying in the prone position. Intact demonstrated by plantar flexion of the foot.

•        Patient walks on their toes, if they can not-it is ruptured.

Tim Tintinalli, pg 1824

            Occurs with forceful planar flexion of the foot often in sports settings, especially in poorly conditioned players, pts w/ RA, SLE and pts who have had prior achillies tendon injection.  Pt may hear a popping sound that is felt in the back of ankle.  An indentation to palpation can be felt at the point of rupture and Thomas-Doherty test (squeezing the calf w/ pt prone, abnormal = no plantar flexion of the ankle) will confirm Dx.  Pt should be splinted and referred to ortho with crutches and non-weight bearing status.

Anonymous Tintinalli 1824

Rupture often occurs in sports settings, especially in poorly conditioned player.  Forceful plantar flexion results in rupture of the tendon.  A popping sound is heard by the patient, who then has difficulty ambulating.

Diagnosis- the Thompson-Doherty test is performed by squeezing the midportion of the calf of the patient lying in the prone position. An intact Achilles tendon is demonstrated by a plantar flexion of the foot.  Another test is to have the patient walk on his/her toes. Imaging is not usually required but an MRI or CT can be helpful in ambiguous cases

Treatment- the patient should be splinted in a neutral position with a Robert Jones splint, with prompt referral to an orthopedist.  Crutches will be needed for ambulation.

14.    Explain how a gastrocnemius can rupture, how it is diagnosed, and treatment.

Zen Seeker Tinitinalli EM Fifth Edition

Gastrocnemius Rupture

The medial head of the gastrocnemius is frequently injured during athletic events. A forceful plantar flexion of the foot, often with an extended knee, results in partial tear or rupture of the medial head of the gastrocnemius near its origin on the distal femur. This may be the result of a fall on a plantar-flexed foot or the sudden plantar flexion that occurs in the back leg of an athlete serving a tennis ball. Predisposing factors include inadequate stretching, prior muscle injury, and advanced age.

The athlete feels a sudden sharp pain on the medial aspect of the proximal gastrocnemius. It is painful to ambulate and plantar flexion is uncomfortable. On exam, the proximal medial calf is tender, and may be swollen and bruised. Walking on tiptoes is possible, but uncomfortable. The history is similar to that of Achilles tendon rupture, but the pain and tenderness are more proximal, and the Thompson test is negative in patients with gastrocnemius muscle rupture. Rupture of a Baker cyst should also be considered in the diagnosis, along with deep vein thrombosis.

Treatment typically consists of immobilization with a posterior splint, crutches for ambulation, ice, and pain medications. A mild rupture may be treated simply with rest and non-weight bearing.

Anonymous Tin, pg. 1824

            The medial head of the gastrocnemius is frequently injured during athletic events.  A forceful plantar flexion of the foot, often with an extended knee, results in partial tear or rupture of the medial head of the gastrocnemius near its origin on the distal femur.  This may be the result of a fall on a plantar-flexed foot or the sudden plantar flexion that occurs in the back leg of an athlete serving a tennis ball.  Predisposing factors include inadequate stretching, prior muscle injury, and advanced age.

            The athlete feels a sudden sharp pain on the medial aspect of the proximal gastrocnemius.  It is painful to ambulate and plantar flexion is uncomfortable.  On exam, the proximal medial calf is tender, and may be swollen and bruised.  Walking on tiptoes is possible, but uncomfortable.  The history is similar to that of Achilles tendon rupture, but the pain and tenderness are more proximal, and the Thompson test is negative in patients with gastrocnemius muscle rupture.  Rupture of a Baker cyst should also be considered in the diagnosis, along with DVT.

            Treatment typically consists of immobilization with a posterior splint, crutches for ambulation, ice, and pain medications.  A mild rupture may be treated simply with rest and non-weight bearing.

Anonymous Tintinalli, p.1824

•        Injury to the medial head of the gastrocnemius typically occurs during athletic events with predisposing factors that may include inadequate stretching, prior muscle injury, and advanced age.  A forceful plantar flexion of the foot, often with an extended knee, results in partial tear or rupture of the medial head of the gastrocnemius near its origin on the distal femur.  

•        Diagnosis is based on history similar to that of Achilles rupture, but pain and tenderness are more proximal, Thompson’s test is negative.  PE reveals proximal calf tenderness, may be swollen and bruised, and may present with discomfort while walking on tiptoes.  Differential Dx- DVT and ruptured Baker cyst.

•        Treatment of gastrocnemius rupture typically consists of immobilization with posterior splint, crutches for ambulation, ice and pain meds.  Mild ruptures may only require rest and non-weight bearing.

Suzy Tintinalli 1824

Ruptures:  Forceful plantar flexion of the foot, often with an extended knee, results in partial tear or rupture of the medial head of the gastrocnemius near its origin on the distal femur.  Happens during a fall on a plantar-flexed foot or the sudden plantar flexion that occurs in the back leg of an athlete serving a tennis ball.  Predisposing factors include inadequate stretching, prior muscle injury, and advanced age.

Diagnosed:  On exam, the proximal medial calf is tender, and may be swollen and bruised.  Walking on tiptoes is possible, but uncomfortable.  Thompson test is negative.  Rupture of a Baker cyst should also be considered in the diagnosis, along with deep vein thrombosis.

Treatment:  Immobilization with a posterior splint, crutches for ambulation, ice, and pain medications.  Mild rupture may be treated with rest, and non-weight bearing.

Tim Tintinalli, pg. 1824

Forceful plantar flexion of the foot w/ the knee extended often in athletic events frequently tears the medial gastroc head near it’s origin of the distal femur.  Pt will feel sudden sharp pain in the prox gastroc area that is accentuated with ambulation or plantar flexion.  Dx is made by pain to palpation with bruising over prox gastroc area, and patient complains of pain with tiptoe walking.  Thompson test for achillies will be normal. DVT and baker’s cyst should be differentials.  Tx= immobilization w/ posterior splint, crutches for ambulation, ice and px meds.  Mild tear tx=rest + nonweightbearing.

Anonymous Tintinalli 1824

A forceful plantar flexion of the foot, often with an extended knee, results in partial tear or rupture of the medial head of the gastrocnemius near its origin on the distal femur.  This may be the result of a fall on a plantar-flexed foot or the sudden plantar flexion that occurs in the back leg of an athlete serving a tennis ball.  Predisposing factors include inadequate stretching, prior muscle injury, and advanced age.

Diagnosis- on exam, the proximal medial calf is tender, and may be swollen and bruised.  Walking on tiptoes is possible, but uncomfortable.  The history is similar to that of Achilles tendon rupture, but the pain and tenderness are more proximal, and the Thompson test is negative in patients with gastrocnemius muscle rupture.  Rupture of a Baker cyst should also be considered in the diagnosis, along with deep vein thrombosis.

Treatment- immobilization with a posterior splint, crutches for ambulation, ice, and pain medications.  A mild rupture may be treated simply with rest and non-weight bearing.

15.    Discuss the usual mechanism causing shin splints and how it is treated.

Zen Seeker Tinitinalli EM Fifth Edition

Shin Splints

The term shin splints describes pain over the lateral and anterior tibia that occurs with exertion and is relieved by rest. Athletes may suffer this early in their training, particularly when running on a hard surface. The only physical finding may be tenderness to the anterior or lateral tibia. Radiographs may be useful to detect a stress fracture of the tibia, but a bone scan is more sensitive. Treatment consists of cessation of the offending activity, usually for several weeks.

Anonymous Tintinalli, pg. 1824

            The term shin splints describes pain over the lateral and anterior tibia that occurs with exertion and is relieved by rest.  Athletes may suffer this early in their training, particularly when running on a hard surface.  The only physical finding may be tenderness to the anterior or lateral tibia.  Radiographs may be useful to detect a stress fracture of the tibia, but a bone scan is more sensitive.  Treatment consists of cessation of the offending activity, usually for several weeks.

Anonymous Tintinalli, p. 1824

•        Shin splints are pain over the lateral and anterior tibia that occurs with exertion and is relieved by rest.  It may occur early in an athletes training, particularly when running on hard surfaces.

•        Treatment consists of cessation of offending activity, usually for several weeks.

Suzy Tintinalli 1824

Pain over the lateral and anterior tibia that occur with exertion and is relieved by rest.

Cause:  Running on a hard surface.

Treatment:  Cessation of the offending activity, usually for several weeks.

Tim,Tintinalli pg. 1824

Shin splints describes pain over the lateral and anterior tibia that occurs with exertion and is relieved by rest.  Athletes may suffer this early in their training particularly when running on a hard surface.  The only physical finding may be tenderness to the anterior or lateral tibia.  Radiographs may be useful to detect a stress fracture of the tibia but a bone scan is more sensitive.  Treatment consists of cessation of the offending activity usually for several weeks.

Anonymous Tintinalli 1824

Shin splints describe pain over the lateral and anterior tibia that occurs with exertion and is relieved by rest.  Athletes may suffer this early in their training, particularly when running on a hard surface. The only physical finding may be tenderness to the anterior or lateral tibia.

Treatment- consists of cessation of the offending activity, usually for several weeks

16.    Explain the following for Osgood-Schlatter disease:

         a.            Anatomic lesion

         b.            Who typically gets it

         c.            How it is diagnosed

         d.            Treatment

Zen Seeker Tinitinalli EM Fifth Edition

Osgood-Schlatter Disease

This lesion is typically seen in athletic teenagers. Girl and boy athletes are both affected. Football, soccer, basketball, gymnastics, and ballet can cause this injury. The anatomic lesion is the partial separation of the tibial tuberosity at the insertion of the patellar tendon. In about one-fourth of cases, it is a bilateral process. Palpation of the tibial tuberosity reveals tenderness and induration. A lateral x-ray of the proximal tibia with the knee flexed 30 degrees reveals an elevation of the distal portion of the tubercle off of the tibia. Alternatively, ultrasound can be used. Cold compresses, anti-inflammatory drugs, and stopping the offending activity is standard treatment. Follow-up with an orthopedist is advisable for this sometimes chronic condition

Anonymous Tintinalli, pg. 1824

a. Anatomic lesions.  The anatomic lesion is the partial separation of the tibial tuberosity at the insertion of the patellar tendon.  In about one-fourth of cases, it is a bilateral process.

b. Who typically gets it.  This lesion is typically seen in athletic teenagers.  Girl and boy athletes are both affected.  Football, soccer, basketball, gymnastics, and ballet can cause this injury.

c. How it is diagnosed.  Palpation of the tibial tuberosity reveals tenderness and induration.  A lateral x-ray of the proximal tibia with the knee flexed 30 degrees reveals an elevation of the distal portion of the tubercle off of the tibia.  Alternatively, ultrasound can be used.

d. Treatment.  Cold compresses, anti-inflammatory drugs, and stopping the offending activity is standard treatment.  Follow-up with an orthopedist is advisable for this sometimes chronic condition.

Anonymous Tintinalli, p. 1824

•        Anatomic lesion- Osgood-Schlatter disease is a partial separation of the tibial tuberosity at the insertion of the patellar tendon.

•        Who typically gets it- Athletic teenagers

•        How it is diagnosed- Lateral radiologic views of the proximal tibia with the knee flexed at 30 degrees reveals an elevation of the distal portion of the tibial tubercle off of the tibia.  US may also be used.

•        Treatment- Treatment includes symptomatic and supportive treatment for lesions, including cold compresses, anti-inflammatory drugs, discontinuing the offending activity and follow-up with and orthopedist if needed (for chronic condition).

Ky.  Up to date & Tintinali p1824

a.  Anatomic lesion:  avulsion of developing ossificaiton center & overlying hyaline cartilage of tibial tuberosity. Bilateral in 25% of cases.

b.  Who typically gets it:  athletic teenagers.  13-14 y/o boys & 11-12 y/o girls

c.  How it is diagnosed:  tenderness to palpation of TT.  Up to date says no x-ray but Tintinali z-rays it.  Reproduce pain on extension with resistance or stressing quads.

d.  Treatment: cold compresses, anti-inflammatories, Tin says stop offending activity.  Up to date says that may not be entirely necessary.

Anonymous Tininalli 1824

a) Anatomic lesion- the lesion is the partial separation of the tibial tuberosity at the insertion of the patellar tendon

b) Who typically gets it- the lesion is typically seen in athletic teenagers.  Girl and boy athletes are both affected.  Football, soccer, basketball, gymnastics, and ballet can cause this injury.

c) How it is diagnosed- a lateral x-ray of the proximal tibia with the knee flexed 30 degrees reveals an elevation of the distal portion of the tubercle off of the tibia.  Alternatively, ultrasound can be used.

d) Treatment- cold compresses, anti-inflammatory drugs, and stopping the offending activity is standard treatment. Consult an orthopedist if it is a chronic condition.

17.    From Tintinalli Fig. 268-2, list the Ottawa Ankle Rules for ankle injuries.

Zen Seeker Tinitinalli EM Fifth Edition

The Ottawa Ankle Rules for ankle and midfoot injuries.

IMAGING

The Ottawa Ankle Rules have provided a significant advance in the evaluation of ankle injuries in the ED. Previous studies suggested that not all patients who presented to the ED needed radiographs.3 The Ottawa Ankle Rules were derived from an initial series of studies4 –6 and then were prospectively validated.1,7,8 These studies involved over 9000 patient encounters and 200 emergency physicians. Two further studies by the same group found the implementation of the rules to be cost effective and that, once taught, emergency physicians continued to use them.9,10 Although these studies were carried out in eight academic and community emergency departments in Canada, other studies at independent sites in the United States,11,12 the United Kingdom,13 and France2 have further validated their use. Additionally, it has been demonstrated that nurses at triage can apply the rules successfully.11,13 Only two studies have failed to replicate these results,14,15 but these studies were found to have either a flawed methodology or did not accurately assess the rules as developed.

The rules are simple to apply and are illustrated in Fig. 268-2. The rules can be used on patients with an injury to the ankle, which is clinically broadly defined as the area of the distal leg and the midfoot subject to twisting injuries. Mechanisms of injury include twisting, direct blunt trauma, and falls. The rules were not developed for patients under the age of 18. Clinical judgment should prevail if the examination is unreliable due to lack of cooperation, intoxication, distracting injuries, or a diminished sensation in the leg. To assess the ability to bear weight, ask the patient to take four steps. If the patient can complete two transfers to the injured ankle, the patient passes the test.

Various objections that have been raised in the United States to applying these rules include, but are not limited to, the malpractice potential of missing any fracture, however insignificant; the patient´s expectation of a radiograph and perception of a full assessment; and the physician´s perception that the proportion of patients with fractures who present with ankle injuries is higher in the United States. Communication with the patient, such as an explanation of the thoroughness of the clinical examination, and the fact that a chip fracture, if missed, is treated like a sprain, is often effective. The saving of time and money for the patients should help them to accept the completeness of the evaluation. Additionally, studies done in the United States show a similar 15 percent fracture rate as demonstrated in Canada, the United Kingdom, France, and Scandinavia.

An excellent review of radiologic subtleties in the diagnosis of extremity injuries is found in Weissman.16 Utilization of computed tomography and magnetic resonance imaging in the assessment of ankle injuries, although useful, is not appropriate for the ED

Anonymous

Ankle X-rays are only required of there is pain in the malleolar zone, and any of these concurrent findings. 1-Bone tenderness at the posterior edge or tip of the lateral or medial malleolus. 2-An inability to bear weight both immediately and in the ED.

Anonymous. Tintinalli, p. 1828  See page 1828 for diagram.

Ky Tintinali p1828

This table lists the 1 or more criteria that must be met in determining whether or not to X-ray a foot/ankle injury:

Anonymous

18.    For lateral ligament injuries, explain the three grades of injury, and general treatment in patients who are unable to bear weight and in patients who can easily bear weight.

Zen Seeker Tinitinalli EM Fifth Edition

INJURIES, TREATMENT, AND PROGNOSIS

Soft Tissue LIGAMENTOUS SPRAINS

Lateral Ligament Complex

Sprains of the lateral ankle are the most common ankle injury, and the great majority are minor. The classification systems for ligamentous injuries to the lateral ankle are quite confusing. Older texts describe a purely anatomic classification scheme: A grade 1 injury is described as a complete rupture of one ligament and a grade 3 injury is a complete disruption of the three-ligament complex. More recent articles describe a more functional system: In this scheme, patients with grade 1 injuries have microscopic tears of the ligament, minimal swelling, normal findings on stress testing, and the ability to bear weight. Grade 2 injuries have a partial disruption of the ligament, significant swelling, indeterminant results on stress testing, and difficulty bearing weight. The ankle with a grade 3 injury has a ruptured ligament, swelling and ecchymosis, abnormal results on stress testing, and the inability to bear weight. These two classification systems are probably of little value to emergency physicians. A much more useful approach divides the injuries into two groups: stable, and potentially unstable or unstable.17 If stress testing can be accomplished in the ED and the findings are normal, then the patient has a stable lateral ankle sprain and can be so treated. If results on stress testing are clearly abnormal or are indeterminate because of excessive swelling or pain, then the sprain should be treated as unstable.

Treatment of lateral ankle sprains has been equally controversial. A recent review of the English-language medical literature yielded 84 articles dealing primarily with soft tissue injuries of the ankle for a 30-year period.18 The authors categorized the data to compare pharmacotherapy, surgical repair, active immobilization, cryotherapy, and diathermy. Although the average quality of the studies on a 10-point scale was 4 and no statistical analysis was performed, they made the following conclusions. Nonsteroidal anti-inflammatory drugs (NSAIDs) were associated with quicker recovery and less pain, active mobilization was the treatment of choice, and cryotherapy was useful. Unfortunately, only seven of the studies classified the degree of injury, and NSAIDs were compared with placebo rather than to acetaminophen. A review of more recent literature includes some fairly well performed prospective studies.19 –21 Most of these studies treated patients with grade 2 or 3 ankle sprains with compression, rest, and cryotherapy for 24 to 72 h. They then usually compared two treatment groups: (1) weight bearing with an ankle brace that allows plantar-dorsiflexion while resisting inversion and (2) eversion and plaster immobilization for up to 6 weeks. Patients in the early-mobilization groups returned to work or sport earlier than the immobilization groups, but at late follow-up there were no differences in outcomes. Additionally, direct comparisons of operative repair with cast, cast alone, and early controlled mobilization of acute grade 3 ankle sprains suggest that there is no difference in long-term outcome.22  

The data indicate that individuals with stable and unstable ankle sprains, who are unable to bear weight easily, should be treated with rest, ice, compression, and elevation (RICE) for 24 to 72 h, depending on the amount of swelling and degree of pain. Individuals who can easily bear weight and have a stable joint probably need no more than simple analgesics and an elastic bandage, near normal activity with no sports involvement or prolonged walking, and follow-up in 1 week if they still have discomfort. Patients who are unable to bear weight in the ED but appear to have a stable joint can be given an ankle brace and be told to apply it in 24 to 72 h and to follow with their primary care physician or orthopedist within 1 week for a repeat evaluation. Patients who clearly have an unstable joint should be referred to an orthopedic surgeon, with consideration of a posterior mold. Timing of consultation depends on local preferences, but it would be prudent to establish communication early, as the ultimate decision on the method of treatment lies with the orthopedic surgeon.

Anonymous

Grade I injuries have microscopic tears of the ligament, minimal swelling, normal findings on stress testing, and the ability to bear weight.

Grade II injuries have a partial disruption of the ligament, significant swelling, indeterminate results on stress testing, and difficulty bearing weight.

Grade III injuries have a ruptured ligament, swelling and ecchymosis, abnormal results in stress testing, and the inability to bear weight. Per the book, this and a prior grading system are probably of little value to emergency physicians. Individuals with stable and unstable ankle sprains, who are unable to bear weight easily, should be treated with RICE, (rest, ice, compression, and elevation) for 24-72 hours depending on swelling and pain. Those individuals who easily bear weight and have a stable joint probably need no more than simple analgesics and an elastic bandage, near normal activity with no sports or prolonged walking. Follow-up in one week.

Anonymous Tintinalli, p. 1827-28

•        Grade I- microscopic tears of ligament with minimal swelling, normal findings on stress testing and ability to bear weight.

•        Grade II- injuries that have a partial disruption of the ligament and significant swelling, indeterminate results on stress testing and difficulty bearing weight.

•        Grade III- ruptured ligament, swelling and ecchymosis, abnormal results on stress testing and inability to bear weight.

•        Persons that are unable to bear weight should be treated with RICE (rest, ice, compression, elevation) for 24 to 72 hours, depending on swelling and degree of pain.  If they appear to have joint stability, they can be given a brace for 24 to 72 hours and to follow with their PCP or ortho within a week for eval.  Those with clearly unstable joints should be referred to an orthoapaedic surgeon, for consideration of a posterior mold.

•        Persons that are able to bear  weight can be treated with analgesics, an elastic bandage, near normal activity, with no sports involvement or prolonged walking, and follow-up in one week if they still have discomfort.

Ky.  Tintinali p1827-28

Grade I:  microscopic tears of ligament with minimal swelling, normal findings on stress testing and ability to bear weight.

Grade II:  injuries that have a partial disruption of the ligament and significant swelling, indeterminate results on stress testing and difficulty bearing weight.

Grade III:  ruptured ligament, swelling and ecchymosis, abnormal results on stress testing and inability to bear weight.

To quote Tintinali, this grading system is probably “useless” for the ER clinician.  Better to think of injuries in 2 categories:  stable/potentially unstable AND stable.  Use stress testing to classify.

TX:

Unable to bear weight:  RICE (rest, ice, compression, elevation) for 24 to 72 hours, depending on swelling and degree of pain.  If joint stable, then give a brace for 24 to 72 hours and f/up with PCP or ortho within a week.  Clearly unstable joints should be referred to an orthoapaedic surgeon, for consideration of a posterior mold.

Able to bear weight:  Analgesics, an elastic bandage, near normal activity, with no sports involvement or prolonged walking, and f/up in one week if they still have discomfort.

Anonymous Tintinalli 1828

Grade 1 microscopic tears of the ligament, minimal swelling, normal findings on stress testing, and the ability to bear weight

Grade 2 partial disruption of the ligament, significant swelling, indeterminant results on stress testing, and difficulty bearing weight

Grade 3 ruptured ligament, swelling and ecchymosis, abnormal results on stress testing, and the inability to bear weight.

Treatment:                

Non-weight bearing

Stable and unstable sprains- RICE for 24-72h, depending on the amount of swelling and degree of pain.

Stable joint- ankle brace and f/u with PCP in one wk for reevaluation

Unstable joint- patients should be referred to an orthopedic surgeon with consideration of a posterior mold

Weight bearing

Stable joint-simple analgesics and an elastic bandage, near normal activity with no sports improvement or prolonged walking, and f/u in 1 wk if they still have discomfort.

19.    Discuss the treatment of ankle fractures.

Zen Seeker Tinitinalli EM Fifth Edition

TREATMENT

All fractures of the ankle, with the exception of fibular avulsion fractures, require immobilization by cast alone or surgical reduction with subsequent casting. Avulsion fractures are treated as stable ankle sprains if they are minimally displaced, less than 3 mm in diameter, and there is no indication of a medial ligamentous injury. The treatment goal with all other ankle fractures is to restore the anatomic relationship of the ankle, maintain reduction during the healing process, and institute early mobilization of the ankle. To ensure this, the talus has to be anatomically positioned in the mortise, the joint line has to be parallel to the ground, and the articular surface has to be smooth. The means to attain this goal is not only dependent on the type of fracture but also on the age and athletic expectations of the patient. Local preferences may also play a role in this decision. Most fractures, with the exception of unimalleolar injuries, require open reduction and fixation. The Maisonneuve fracture (AO type C2-3), although considered an unstable injury, can generally be treated with cast immobilization for 6 to 8 weeks, depending on the stability of the syndesmosis.15 The Bosworth fracture, a rare variation of the Maisonneuve fracture where the proximal fibula gets trapped behind the tibia, usually requires operative reduction. The debate over the necessity of operative treatment for unimalleolar fractures with associated syndesmosis and deltoid ligamentous injuries is complex and beyond the scope of this text. Stable fibular fractures are treated with a short leg-walking cast for 6 weeks. 

The timing of consultation is discussed below. In the interim, fractures should be splinted with a posterior mold and kept non-weight-bearing in all cases and elevated with application of ice in many. The analgesic need of the patient should be addressed. There is absolutely no basis for the practice of withholding analgesics until operative consent is obtained.

Anonymous Tintinalli, p. 1829

In ED- fractures should be splinted with a posterior mold and kept non-weight-bearing in all cases and elevated with application of ice in many. The analgesic need of the patient should be addressed. There is absolutely no basis for the practice of withholding analgesics until operative consent is obtained.

Overall- All fractures of the ankle, with the exception of fibular avulsion fractures, require immobilization by cast alone or surgical reduction with subsequent casting. Avulsion fractures are treated as stable ankle sprains if they are minimally displaced, less than 3mm in diameter and there is no indication of a medial ligamentous injury. Treatment goal w/ all ankle fractures is to restore the anatomic relationship of the ankle, maintain reduction during the healing process and institute early mobilization of the ankle.

Anonymous Tintinalli, p. 1829

• All fractures of the ankle, with the exception of fibular avulsion fractures, require immobilization by cast alone or surgical reduction with subsequent casting.  Avulsion fx’s are treated as stable ankle sprains if minimally displaced, < 3mm in diameter.  Treatment goal of all other fractures is to restore anatomical relationship of ankle, maintain reduction during healing process and early mobilization of ankle by positioning the talus anatomically in the mortise, ensure joint line is parallel to ground, and articular surface is smooth.  Most fractures, with the exception of unimalleolar fractures, require ORIF.  Stable fibular fractures are treated with short leg-walking cast x 6 weeks.  There are no set guidelines for timing of orthopedic consult for each type of ankle injury.

• Maisonneuve fracture-can generally be tx’d with cast immobilization for 6 to 8 weeks, depending on stability of the syndesmosis.

• Bosworth fracture- (a rare variation of the Maisonneuve fracture where the proximal fibula gets trapped behind the tibia) usually requires operative reduction.

• Osteochondral fractures-(deformation of cartilage overlying talar dome to a free-floating avulsion fracture). Requires ortho eval. Treatment may involve excision or cast immobilization of for up to 6 weeks.

• Fracture-dislocations/Open fractures-Under most circumstances, the reduction of fracture-dislocations is left to an orthopedic surgeon.  However, if there is vascular compromise indicated by absent pulses and a cool dusky foot or tenting of the skin caused by fractured bone, the emergency physician should perform the reduction.  It can typically be done with the patient sitting on a stretcher, with the affected leg hanging over the edge.  Adequate IV analgesia and cardiorespiratory monitoring should be performed.  Reduction is done by downward traction and rotation applied in the opposite direction of the mechanism of injury.  A splint is applied once distal perfusion is restored and the foot is again elevated.  Irreducible fractures require open reduction.  

• Protect open fractures from further contamination by applying a wet, sterile dressing over the wound with a gauze roll and a splint until radiographs or definitive treatment are available.  Td toxoid is given as necessary and tetanus immunoglobulin considered if wound is grossly contaminated.  Antibiotics such as cephalexin and an aminoglycoside are added if the wound is grossly contaminated. Consider clindamycin in pts with PCN allergies.

• Pediatric Injuries-  Salter type I and II fibular fractures can be treated with closed reduction and a walking cast x 4 weeks.

  • Salter type II tibial fractures- closed reduction with a short or long leg cast x 6 weeks.

  • Salter type III and IV fractures of distal tibia with an associated fibular shaft fracture often require ORIF.

  • Salter type V fractures are rare and treated with closed reduction and non-weight bearing, and can lead to bone growth retardation.

Ky.  Tintinali p1829

General idea:  All fractures of the ankle, with the exception of fibular avulsion fractures, require immobilization by cast alone or surgical reduction with subsequent casting.

Avulsion fractures:  treat as stable ankle sprains if they are minimally displaced (<3mm) and there is no indication of a medial ligamentous injury.  Treatment goal:  restore the anatomic relationship of the ankle, maintain reduction during the healing process and institute early mobilization of the ankle

There is more info re:  specific fx’s.

Anonymous Tintinalli 1829

All fractures of the ankle, with the exception of fibular avulsion fractures, require immobilization by cast alone or surgical reduction with subsequent casting.  Avulsion fractures are treated as stable ankle sprains if they are minimally displaced, less than 3 mm in diameter, and there is no indication of a medial ligamentous injury.  The treatment goal with all other ankle fractures is to restore the anatomic relationship of the ankle, maintain reduction during the healing process, and institute early mobilization of the ankle.  

20.    From Tintinalli Table 268-2 list the type of ankle injuries that require immediate orthopedic consultation.

Zen Seeker Tinitinalli EM Fifth Edition

TABLE 268-2         Timing of Consultation

*Implies that communication is established at time of diagnosis and specific time of consultation has been set.

†Consultation can be delayed in the emergency department in fractures without neurovascular compromise and appropriate splinting.

TIMING OF CONSULTATION

No set of rigid rules for the timing of orthopedic consultation exists to guide emergency physicians for each specific ankle injury. Although it may be reasonable to request an in-person orthopedic consultation in an academic center at 3 o´clock in the morning for a stable ankle fracture, this will not endear a community-based emergency physician to his orthopedic colleagues. Although it may be perfectly acceptable for an emergency physician in some countries to apply a circular short leg cast to an AO type A1 or a Salter type I or II fibular fracture and arrange follow-up, this approach would not be common practice in other locales (Table 268-2).

Anonymous Tintinalli pg  1828

a. An ankle XR series is only required if:  there is any pain in the malleolar zone and any of these findings occur:

-bone tenderness at posterior edge or tip of later malleolus

-bone tenderness to posterior edge or tip of medial malleolus

-inability to bear weight both immediately and in ED

b. A foot XR series is only required if:  there is any pain in midfoot zone and any of these findings occur:

-bone tenderness to the base of the 5^th metatarsal

-bone tenderness to the navicular

-inability to bear weight both immediately and in the ED

Anonymous Tintinalli pg 1832

Immediate                              Deferred                                 Within 1 week

All open fractures                     Stable unimalleolar fx                Potentially unstable sprains

All fracture dislocations             Unstable Ligamentous injuries

All dislocations                         Acute peroneal dislocations

All trimalleolar fractures                        Pediatric Salter I, II

All bimalleolar fractures

Unstable unimalleolar fractures

Pediatric Salter III, IV, V

Maisonneuve fractures

Ky. Tintinali p1832

Anonymous 1832

1. All open fractures

2. All fracture dislocations

3. All dislocations

4. All trimalleolar fractures

5. All bimalleolar fractures

6. Unstable unimalleolar fractures

7. Pediatric Salter III, IV,V

8. Maisonneuve fratures

21.    Identify the following:

         a.            Components of the hindfoot, midfoot, and forefoot

         b.            Which metatarsal bears the most weight

         c.            Injuries complicated by avascular necrosis

Zen Seeker Tinitinalli EM Fifth Edition

Bony anatomy of the foot.

ANATOMY

Chopart and Lisfranc joints divide the foot into three regions. The talus and the calcaneum comprise the hindfoot. The midfoot contains the cuneiforms, the cuboid, and the navicular. The metatarsals and the phalanges make up the forefoot (Fig. 269- 1). There are a total of 28 bones and 57 articular surfaces. Numerous intrinsic muscles and ligaments contribute to the integrity of the foot´s structure. The biomechanical specifics of the foot involved in ambulation are extremely complex. In general, eversion and inversion occur about the subtalar and calcaneotarsal joints, whereas adduction-abduction and flexion- extension occur about the metatarsophalangeal and interphalangeal joints.

The body weight when standing is distributed about the heel to the rear and the five metatarsal heads to the front. The curved shape of the foot is held in position by three arches. The shape of the bones, the arrangement of the ligaments, and the tone of the muscles maintain the position of the arches. The plantar aponeurosis covers the sole of the foot and is a strong band of fascia that originates on the medial side of the calcaneum and fuses with the fibrous sheaths of the phalanges.

The blood supply of the foot comes from branches of the popliteal artery. The anterior tibial artery serves the dorsum of the foot, and its branch, the dorsalis pedis, can be palpated over the dorsum of the midfoot. Branches of the posterior tibial and the peroneal arteries serve the sole. The motor and sensory nerves of the foot include branches of both the femoral and sciatic nerves and include branches of the saphenous, sural (sensory), and deep and superficial peroneal nerves (both sensory and motor).

The essential parts of the anatomy of concern include, but are not limited to, the following. The first metatarsal bears twice the weight as any other metatarsal, and injuries to this bone require a more conservative approach. The blood supply to the foot is tenuous, and major fractures of the talus and subtalar dislocations are complicated by avascular necrosis. The base of the second metatarsal is the “keystone” of the Lisfranc complex, and any injury to this area has to be treated with caution.

Anonymous

components of the hindfoot, midfoot, and forefoot.

Hindfoot—comprised of calcaneum and talus.

Midfoot—comprised of cuneiforms, the cuboid, and the navicular.

Forefoot—comprised of the metatarsals and the phalanges

which metatarsal bears the most weight?

The 1^st metatarsal bears twice the weight as any other metatarsal, and injuries to this bone require a more conservative approach.

Injuries complicated by avascular necrosis.

The blood supply to the foot is tenuous, and major fractures of the talus and subtalar dislocations are complicated by avascular necrosis.  The base of the second metatarsal is the ‘key-stone’ of the Lisfranc complex, and any injury to this area has to be treated with caution.

Anonymous Tintinalli pg 1833-4

•        Components of the hindfoot, midfoot, and forefoot.

• Hindfoot—talus and the calcaneum

• Midfoot—cuneiforms, the cuboid, and the navicular

• Forefoot—metatarsals and the phalanges

•        Which metatarsal bears the most weight

• The first metatarsal bears twice the weight as any other metatarsal, and injuries to this bone require a more conservative approach.

•        Injuries complicated by avascular necrosis

• Major fractures of the talus and subtalar dislocations are complicated by avascular necrosis.

Dustin, Tintinalli pg. 1833

A   Hindfoot: talus and calcaneous

Midfoot:  medial cuneiform bone, middle cuneiform bone, lateral cuneiform bone, navicular bone, cuboid bone.

Forefoot:  proximal, middle, distal phalanges, and metatarsal bones.

B.  The first metatarsal bears twice the weight as any other metatarsal.

C.  Major fractures of the talus and subtalar dislocations are complicated by avascular necrosis.

L.H. Tintinalli pg. 1833

Hindfoot—talus and the calcaneous

Midfoot—cuneiforms, cuboid, navicular

Forefoot—metatarsals, phalanges

The first metatarsal bears twice the wt of any other.

Major fx of the talus and subtalar dislocations are complicated by AVN.

Anonymous Tintinalli 1833

a)      Components of the hindfoot, midfoot, and forefoot  

Hindfoot- the talus and calcaneum

Midfoot-  the cuneiforms, the cuboid, and the navicular

Forefoot- metatarsals and phalanges

b)      Which metatarsal bears the most weight

The first metatarsal bears twice the weight as any other metatarsal

c)      Injuries complicated by avascular necrosis

The blood supply to the foot is tenuous, and major fractures of the talus and subtalar dislocations are complicated by avascular necrosis

22.    Explain what is meant by “turf toe” and how it is treated.

Zen Seeker Tinitinalli EM Fifth Edition

TURF TOE

Forced hyperextension of the the first metatarsophalangeal causes a sprain or tear of the joint capsule. The injury is usually associated with a push-off mechanism from a hard surface. The treatment is conservative, with analgesics and with a supportive shoe to prevent further dorsiflexion.

Anonymous

Forced hyperextension of the first metatarsophalangeal causes a sprain or tear of the joint capsule.  The injury is usually associated with a push-off mechanism from a hard surface.  The treatment is conservative, with analgesics and with a supportive shoe to prevent further dorsiflexion.

Anonymous Tintinalli pg 1834

Forced hyperextension of the first metatarsophalangeal causes a sprain or tear of the joint capsule.  The injury is usually associated with a push-off mechanism from a hard surface.  Treatment is conservative, with analgesics and with a supportive shoe to prevent further dorsiflexion.

Dustin, Tintinalli pg. 1834

Turf toe:  Forced hyperextension of the first metatarsophalangeal causes a sprain or a tear of the joint capsule.  The injury is usually associated with a push-off mechanism from a hard surface.  Treatment is conservative, with analgesics and with a supportive shoe to prevent further dorsiflexion.

L.H. Tintinalli pg. 1834

Forced hyperextension of the first metatarsophalangeal causes a sprain or tear of the joint

capsule.  Injury is usually assoc. with a push off mechanism from a hard surface.  Tx is

conservative:  analgesics and supportive shoe to prevent further forsiflexion.

Anonymous Tintinalli 1834

Forced hyperextension of the first metatarsophalangeal causes a sprain or tear of the joint capsule.  The injury is usually associated with a push-off mechanism from a hard surface.

Treatment- treatment is conservative, with analgesics and with a supportive shoe to prevent further dorsiflexion

23.    From Tintinalli Table 269-1, identify the diagnosis, etiology, and treatment for:

         a.            Plantar fasciitis

         b.            Morton neuroma

         c.            Metatarsal stress fractures

Zen Seeker Tinitinalli EM Fifth Edition

TABLE 269-1         Differential Diagnosis of Subacute and Chronic Foot Pain

Abbreviations: DIP/IP, distal interphalangeal/interphalangeal joint; MT, metatarsal; MTP, metatarsophalangeal; NSAIDs, nonsteroidal anti-inflammatory drugs.

DIFFERENTIAL DIAGNOSIS OF SUBACUTE AND CHRONIC FOOT PAIN

Patients frequently present to the ED with the complaint of foot pain of varying duration. Although several disorders that cause pain are obvious on inspection, including bunions, ingrown toenails, corns, hammertoes and blisters, other problems require a directed physical examination of the foot. The diagnosis and treatment of these disorders is described in Table 269-1.

Anonymous Tintinalli, pp. 1835

Anonymous Tintinalli pg 1835

Plantar fasciitis

            DX—Tenderness over plantar fascia of medial foot, increases with dorsiflexion of toes.

            ETIOLOGY—inflammation caused by prolonged standing or overuse

            TX—Rest, NSAIDS, orthotics

Morton neuroma

            DX—Episodes of lancinating pain in the 3^rd or 4^th MT interspace, relieved by shoe removal; reproduced by compression of interspace of MT heads.

            ETIOLOGY—impingement of the interdigital nerve, caused by perineural fibrosis

            TX—NSAIDS, nerve block, surgical release

Metatarsal stress fractures

            DX—insidious onset of aching pain, with tenderness over the affected MT shaft; confirmed by bone scan

            ETIOLOGY—repetitive stress in runners, usually affecting MT 2 or 3

            TX—analgesics, rest, reevaluation of training method

Dustin, Tintinalli pg. 1835

1. Plantar fasciitis:  Diagnosis:  Tenderness over plantar fascia of medial foot, increased with dorsiflexion of the toes.  Etiology:  Inflammation caused by prolonged standing or overuse.  Treatment:  Rest, NSAIDS, orthotics.

2. Morton Neuroma:  Diagnosis:  Episodes of lancinating pain in the 3^rd or 4^th MT interspace, relieved by shoe removal; reproduced by compression of interspace or MT heads.  Etiology:  Impingement of the interdigital nerve, caused by perineural fibrosis.  Treatment:  NSAIDS, Nerve block, surgical release.

3. Metatarsal Stress fractures:  Diagnosis:  Insidious onset of aching pain, with tenderness over the affected MT shaft; confirmed by bone scan.  Etiology:  Repetitive stress in runners, usually affecting MT 2 or 3.  Treatment:  Analgesics, rest, reevaluation of training program.

L.H. Tintinalli pg. 1835

Plantar fascitis—tenderness over plantar fascia of medial foot, increased with dorsiflexion of toes.  Etiology:  inflammation caused by prolonged standing or overuse.  Tx:  Rest, NSAIDS, orthotics.

Morton Neuroma—episodes of lancinating pain in the 3^rd or 4^th metatarsal interspace (relieved by shoe removal, reproduced by compression of interspace or MT heads).

Etiology:  impingement of the interdigital nerve, caused by perineural fibrosis.          

 TX:  NSAIDS, nerve block, surgical release.

Metatarsal stress fractures—insidious onset of aching pain, with tenderness over the affected MT shaft, confirmed by bone scan.  Etiology:  repetitive stress in runners, usually affecting MT 2 or 3.  TX:  rest, analgesics, reevaluation of training method.

Anonymous Tintinalli 1835

Plantar fascitis:

Diagnosis- Tenderness over plantar fascia of medial foot, increased with dorsiflexion of toes

Etiology- Inflammation caused by prolonged standing overuse

Treatment- Rest, NSAIDS, orthotics

Morton Neuroma:

Diagnosis- Episodes of lancinating pain in the 3^rd or 4^th MT interspace, relieved by shoe removal; reproduced by compression of interspace or MT heads

Etiology- Impingement of the interdigital nerve, caused by perineural fibrosis

Treatment- NSAIDs, nerve block, surgical release

Metatarsal stress fractures:

Diagnosis- Insidious onset of aching pain, with tenderness over the affected MT shaft; confirmed by bone scan

Etiology- Repetitive stress in runners, usually affecting MT 2 or 3

Treatment- Analgesics, rest reevaluation of training method

24.    Identify the usual mechanism causing calcaneal fractures and other associated injuries that often accompany them.

Zen Seeker Tinitinalli EM Fifth Edition

Fractures and Dislocations

HINDFOOT

Talar fractures are uncommon. Minor avulsion fractures of the neck, body, and lateral process are usually treated with a posterior slab, crutches, and orthopedic follow-up. Os trigonum and transchondral talar dome fractures are difficult to identify in the ED and are sometimes diagnosed in the follow-up of “ankle sprains.” Major fractures of the talar neck and body are associated with severe dorsiflexion and axial forces. These injuries often require open reduction and merit immediate orthopedic consultation. These fractures are frequently complicated by avascular necrosis.

Peritalar or subtalar dislocations are rare. In this injury, the calcaneotalar and talonavicular joints are disrupted while the tibiotalar joint remains intact. Although the dislocation can occur in any direction, medial dislocation is by far the most common and is the result of a severe rotational-inversion force. These injuries require immediate orthopedic consultation and emergent reduction. Closed reduction can sometimes be accomplished using conscious sedation in the ED, although frequently a general or regional anaesthetic in the operating room is required.

An axial load to the heel, caused by a fall from a height, is the mechanism associated with most fractures of the calcaneum. These injuries are frequently associated with other injuries, most commonly vertebral column, forearm, and other lower extremity fractures. Fractures should be categorized as intraarticular or extraarticular.

Although the more common subtalar, intraarticular fractures are usually obvious on the lateral foot radiograph, some compression fractures may be subtle. When this injury is suspected by mechanism or examination, carefully examine the radiograph utilizing the measurement of Boehler´s angle. If the angle is less than 20°, suspect a fracture (Fig. 269-3). The criterion for open reduction of these fractures is controversial, with CT scanning playing an important diagnostic and preoperative planning role. Seek immediate orthopedic consultation. In the interim, apply a well-padded posterior splint, elevate the foot, and address analgesic needs. Comminuted fractures of the calcaneum can be extremely painful. The incidence of compartment syndrome with these fractures is high.

Extraarticular fractures are less common and usually are associated with a rotational mechanism as well as an axial load. Included are fractures of the tuberosity, the sustentaculum tali, anterior process avulsion, and extraarticular oblique body fractures. Most nondisplaced fractures can be treated conservatively with a posterior slab, crutches, and early orthopedic consultation

Anonymous Tintinalli, pp. 1835

The usual mechanism causing calcaneal fractures is an axial load to the heel caused by a fall from a height.  Frequently associated injuries are vertebral column, forearm, and other lower extremity fractures.  Fx should be categorized as intraarticular or extraarticular.

Anonymous Tintinalli pg  1835

An axial load to the heel, caused by a fall from a height, is the mechanism associated with most fractures of the calcaneum.  Frequently associated with vertebral column, forearm, and other lower extremity fractures.  

Dustin, Tintinalli pg. 1835

An axial load to the heel, caused by a fall from a height is the mechanism associated with most fractures of the calcaneum.  These injuries are frequently associated with other injuries, most commonly vertebral column, forearm, and other lower extremity fractures.

L.H. Tintinalli pg. 1835

Axial load to the heel, caused by a fall from ht.  Injury usually assoc. with injuries of the

vertebral column, forearm, and other lower extremity fx’s.

Anonymous Tintinalli 1835

An axial load to the heel, caused by a fall from a height, is the mechanism associated with most fractures of the calcaneum.  These injuries are frequently associated with other injuries, most commonly vertebral column, forearm, and other lower extremity fractures.

25.    Discuss the nature of injures to the Lisfranc joint and how they are diagnosed on x-ray.

Zen Seeker Tinitinalli EM Fifth Edition

Fracture of the base of the second metatarsal.

MIDFOOT

Isolated fractures of the navicular, cuboid, and cuneiforms are uncommon and are difficult to identify on radiograph. Fractures of the navicular are most common and can involve the tuberosity, the dorsal surface, and the body. Isolated fractures of the cuboid and cuneiforms are extremely rare, and an associated injury to the Lisfranc joint should be sought. Most isolated injuries of the tarsal bones are treated conservatively.

The six-bone tarsometatarsal complex is known as the Lisfranc joint. Injuries to this joint are not uncommon, and unfortunately up to 20 percent of these injuries are missed in the ED.6 The force required and the mechanism of injury are varied and can range from a seemingly minor rotational force to severe axial load as seen in an automobile accident. The great majority of injuries to the Lisfranc joint are associated with fractures, usually of the metatarsals, the cuboid, or the cuneiforms. A fracture of the base of the second metatarsal is pathognomonic of a disruption of the ligamentous complex (Fig. 269-4). The Lisfranc injury is classified by the direction of the dislocation. A divergent dislocation describes metatarsals splayed in both medial and lateral directions, usually between the first and second metatarsals. In isolated dislocations, one or more metatarsals are displaced from the rest. In homolateral dislocations, all five metatarsals are displaced in the same direction, either laterally or medially. Suspect this injury if there is point tenderness over the midfoot or when there is laxity between the first and second metatarsals in a dorsal-plantar direction. Diagnosis is made radiographically on the AP view when there is more then a 1-mm gap between the bases of the first and second metatarsals. Weight-bearing radiographs may be required to make the diagnosis. Injuries to the Lisfranc joint frequently require open reduction and fixation or percutaneous placement of Kirschner wires and non-weight-bearing for several weeks. These injuries are complicated by pedal artery damage in the short term and degenerative arthritis and chronic pain in the long term.

Anonymous Tintinalli Handbook pg 900

Lisfanc joint injuries are fractures of the cuboid or cuneiform metatarsals (tarsometatarsal complex).  Injuries to this joint are rare and frequently missed.    X-rays should include AP, lateral and Oblique

Anonymous Tintinalli pg 1836

•        The six-bone tarsometatarsal complex is known as the Lisfranc joint.  Injuries to this joint are not uncommon, and unfortunately up to 20 % of these injuries are missed.  

•        The force required and the mechanism of injury are varied and can range from a seemingly minor rotational force to severe axial load as seen in an automobile accident

•        The great majority of injuries to the Lisfranc joint are associated with fractures, usually of the metatarsals, the cuboid, or the cuneiforms.

•        Suspect this injury if there is point tenderness over the midfoot or when there is laxity between the 1^st and 2^nd metatarsals in a dorsal-plantar direction.  

•        DX—is made radiographically on the AP view when there is more than 1 mm gap between the

•        bases of the 1^st and 2^nd metatarsals.  Weight-bearing radiographs may be required to make the diagnosis

Dustin, Tintinalli pg 1836

The six-bone tarsometatarsal complex is known as the Lisfranc Joint.  Injuries to this joint are not uncommon.  The force required and the mechanism of injury are varied and can range from a seemingly minor rotational force to severe axial load as seen in an automobile accident.  The great majority of injuries to the Lisfranc joint are associated with fractures, usually of the metatarsals, the cuboid, or the cuneiforms.  Diagnosis is made radiographically on the AP view when there is more than a 1mm gap between the bases of the first and second metatarsals.

L.H. Tintinalli pg. 1836

The 6 bone tarsometatarsal complex is known as the lisfranc joint.

The force required and the mechanism of injury are varied and can range from a

seeminglyh minor rotational force to severe axial load as seen in MVC’s.  The great

 majority of injuries are assoc. with fx’s, usually of the metatarsals, the cuboid, or the

cuneiforms.  

Lisfranc injury is classified by the direction of the dislocation:

1)  Divergent dislocation—metatarsals slayed in both medial and lateral directions, usually between first and second metatarsals.

2)  isolated dislocations—one or more metatarsals displaced from the rest.

3)  hemolateral dislocations—all five metatarsals are displaced in the same direction, either laterally or medially.

Diagnosis is made radiographically on the AP view when there is more than 1 mm gap between the bases of the 1^st and 2^nd metatarsals.  Wt. bearing films may be required to make the diagnosis.

Anonymous Tintinalli 1836

The six- bone tarsometatarsal complex is known as the Lisfranc joint. The force required and the mechanixm of injury are varied and can range from a seemingly minor retational force to severe axial load as seen in an automobile accident.  The great majority of injuries to the Lisfranc joint are associated with fractures, usually of the metatarsals, the cuboid, or the cuneiforms.

Diagnosis is made radiographically on the AP view when there is more then a 1 mm gap between the bases of the first and second metatarsals.  Weight-bearing radiographs may be required to make the diagnosis.

26.    Discuss forefoot fractures regarding the following:

         a.            Treatment of nondisplaced metatarsal shaft fractures

         b.            Jones fractures

         c.            Treatment of nondisplaced phalangeal fractures

Zen Seeker Tinitinalli EM Fifth Edition

Fractures of the fifth metatarsal.

FOREFOOT

Metatarsal fractures are most often associated with a crush or more occasionally with a twisting injury. Metatarsal fractures are divided into shaft and neck fractures. Nondisplaced shaft injuries are usually treated conservatively with either a walking cast or an orthopedic shoe. An exception is a fracture of the first metatarsal shaft. Keep this injury non-weight-bearing. Likewise, displaced shaft fractures of the middle metatarsals can be treated with closed reduction, followed by immobilization in a cast and non-weight-bearing for 6 weeks. A displaced first metatarsal fracture will often require an open reduction and fixation. Metatarsal neck fractures generally follow the treatment of shaft fractures, but postreduction instability of displaced neck fractures is not uncommon and open fixation is sometimes required.

Fifth metatarsal fractures are the most common of the metatarsal fractures. Shaft fractures usually can be treated conservatively, as above. The Jones fracture is described as a transverse fracture through the base of the fifth metatarsal 15 to 31 mm distal to the proximal part of the metatarsal. This fracture is frequently complicated by nonunion or malunion and should be treated with a non-weight-bearing cast for 6 weeks. The “pseudo-Jones” is an avulsion fracture of the tuberosity of the base and can be treated with a cast shoe. (Fig. 269-5).

Most nondisplaced phalangeal fractures can be treated conservatively with “buddy taping” and, occasionally, a cast shoe. Address the patient's analgesic need and arrange orthopedic consultation on a prn basis. Advise against prolonged ambulation or standing in the first week. Displaced fractures can be manipulated into position by using a digital block and manual traction. Some authors advocate open reduction of some displaced fractures, especially of the big toe.

Most dislocations of the forefoot involve the the distal interphalangeal and posterior interphalangeal joints of the second through fifth toes. These injuries can be easily reduced by manual traction and treated with buddy taping as needed. Dislocations of the big toe are rare, occasionally difficult to reduce, and require walking-cast immobilization for 3 weeks.

Anonymous Tintinalli Handbook pg 900

Treatment of non-displaced metatarsal shaft fractures-conservative treatment.

Jones fractures-transverse fx through the base of the fifth metatarsal is subject to complications and must be with a non-wt bearing cast and close orthopedic follow up.

Treatment of non-displaced phalangeal fractures-conservative tx including buddy taping or cast shoe.

Anonymous Tintinalli 1836-37:

•         Treatment of nondisplaced metatarsal shaft fractures – conservative tx with either a walking cast or an orthopedic shoe; an exception is a fracture of the first metatarsal shaft which should be non-weight bearing

•         Treatment of displaced shaft fractures of middle metatarsals – closed reduction, followed by immobilization in a cast and no weight bearing X 6 weeks; these will often require ORIF

•         Jones fractures – transverse fracture through the base of the 5^th metatarsal 15-31mm distal to the proximal part of the metatarsal

o       Frequently complicated by nonunion or malunion and should be treated with a non-weight bearing cast for 6 weeks

o       The “pseudo-Jones” is an avulsion fracture of the tuberosity of the base and can be treated with a cast shoe

•         Treatment of nondisplaced phalangeal fractures – conservatively with “buddy-taping”, and occasionally a cast shoe; advise against prolonged standing or ambulation in the first week

o       Displaced fractures can be manipulated into position by using a digital block and manual traction

Sung K, Tintinalli p.1836-7

a) Treatment of nondisplaced metatarsal shaft fractures – treated conservatively with either a walking cast or an orthopedic shoe. An exception is a fracture of the 1^st metatarsal shaft which should be non-weight-bearing.

b) Jones fractures – a transverse fracture through the base of the 5^th metatarsal 15 to 31 mm distal to the proximal part of the metatarsal. This fracture is frequently complicated by nonunion or malunion and should be treated with a non-weight-bearing cast for 6 weeks.

c)  Treatment of nondisplaced phalangeal fractures – treated conservatively with “buddy taping” and occasionally a cast shoe. Address need for analgesics and arrange prn orthopedic consult. Advise against prolonged ambulation or standing in the first week.

Michelle Tintinalli Pg. 1836-37

a)      Treatment of nondisplaced metatarsal shaft fractures – treated conservatively with either a walking cast or an orthopedic shoe. An exception is a fracture of the 1^st metatarsal shaft which should be non-weight-bearing.

b) Jones fractures – a transverse fracture through the base of the 5^th metatarsal 15 to 31 mm distal to the proximal part of the metatarsal. This fracture is frequently complicated by nonunion or malunion and should be treated with a non-weight-bearing cast for 6 weeks.

c)   Treatment of nondisplaced phalangeal fractures – treated conservatively with      “buddy taping” and occasionally a cast shoe. Address need for analgesics and arrange prn orthopedic consult. Advise against prolonged ambulation or standing in the first week.

Anonymous Tintinalli 1836-37

a)      Treatment of nondisplaced metatarsal shaft fractures

Nondisplaced shaft injuries are usually treated conservatively with either a walking cast or an orthopedic shoe.  An exception is a fracture of the first metatarsal shaft.  Keep this injury non-weight bearing.

b)      Jones fractures

The Jones fracure is described as a transverse fracture through the base of the fifth metatarsal 15-31 mm distal to the proximal part of the metatarsal.  This fracture is frequenetly complicated by nonunion or malunion and should be treated with a non-weight bearing cast for 6 wks.

c)      Treatment of nondiplaced phalangeal fractures

Most nondisplaced phalangeal fractures can be treated conservatively with “buddy taping” and occasionally, a cast shoe.  Address the patient’s analgesic need and arrange orthopedic consulation on a prn basis.  Advise against prolonged ambulation or standing in the first week.

27.    Explain what is meant by compartment syndrome, which tissue is most sensitive to ischemia, signs and symptoms, and what can cause it.

Zen Seeker Tinitinalli EM Fifth Edition

Compartment syndromes are serious and often insidious problems that must be considered in the emergency department (ED) on a frequent basis. The incidence of compartment syndromes overall is unknown, but the conditions that can cause it are myriad and common. Early diagnosis and treatment are curative, whereas delay results in permanent and severe disability. An understanding of the pathophysiology and the early signs of the process is crucial if an emergency physician is to intercede appropriately. Compartment syndromes occurring in the limbs are the subject of this chapter.

PATHOPHYSIOLOGY

Compartment syndromes are due to increased pressure within closed tissue spaces that compromises the flow of blood through nutrient capillaries in muscles and nerves. The complex relationships between time, Starling forces, systemic and venous pressure, and reperfusion injury are not completely understood. The clinical variables of each case make a definitive explanation of how capillary blood flow is compromised a difficult exercise. However, a common factor is elevated tissue pressure. Normal tissue pressure is about zero and usually less than 10 mmHg. Capillary blood flow within the compartment is compromised at pressures greater than about 20 mmHg, and muscle and nerves are at risk for ischemic necrosis at pressures greater than about 30 to 40 mmHg. Of the tissues within the compartments, nerve is most sensitive, followed by muscle tissue. Blood flow through arteries, arterioles, and collaterals is not compromised significantly at these pressures. Nevertheless, tissues within the compartment that are dependent on the nutrient capillaries become ischemic and then necrotic if the compartment pressure is not reduced promptly. By the time that distal pulses are reduced, muscle necrosis has occurred. Ischemic muscles hurt, and this pain is exacerbated by active muscle contraction and by passive stretching of the muscle.

An increase in compartmental pressure can be caused by (1) compression of the compartment, for example, by burn eschar, a circumferential cast, or a pneumatic pressure garment; and (2) by a volume increase within the compartment due to hematoma and edema. Direct trauma with resulting bleeding and edema is probably the most common cause, but overexertion (shin splints) and limb compression during recumbency as a result of alcohol or drug overdose are also common causes. Mubarak and Hargens1 developed a classification of the acute compartment syndromes (Table 270-1) listing the myriad of possible causes. Their text is highly recommended for readers wishing to learn more about this topic.

TABLE 270-1      Classification of Acute Compartment Syndromes

Decreased compartment size

    Constrictive dressings and casts

    Closure of fascial defects

    Thermal injuries and frostbite

Increased compartment contents

    Primarily edematous accumulation

          Postischemic swelling

                Arterial injuries

                Arterial thrombosis or embolism

                Reconstructive vascular and bypass surgery

                Replantation

                Prolonged tourniquet time

                Arterial spasm

                Cardiac catheterization and angiography

                Ergotamine ingestion

          Prolonged immobilization with limb compression

                Drug overdose with limb compression

                General anesthesia with knee-chest position

          Thermal injuries and frostbite

          Exertion

          Venous disease

          Venomous snakebite

    Primarily hemorrhagic accumulation

          Hereditary bleeding disorders, (e.g., hemophilia)

          Anticoagulant therapy

    Vessel laceration

    Combination of edematous and hemorrhagic accumulation

          Fractures

                Tibia

                Forearm

                Elbow (e.g., supracondylar)

                Femur

          Soft tissue injury

          Osteotomies (e.g., tibia)

    Miscellaneous

          Intravenous infiltration (e.g., blood or saline)

          Popliteal cyst

          Long leg brace

Source:  From Mubarak and Hargens, 1 with permission.

Anonymous Tintinalli, pp 1839-1840

Definition- Compartment syndromes are due to increased pressure within closed tissue spaces that compromises the flow of blood through nutrient capillaries in muscles and nerves.

Most sensitive to ischemia- nerves, followed by muscle tissue.

S/Sx- Symptoms: pain exacerbated by active muscle contraction and passive stretching of muscle, diminished distal pulses, hypoesthesia of affected compartment. Signs: palpation of the compartments in question may or may not reveal tenseness and swelling. When in doubt, provider should measure tissue pressure.

Causes- compression of the compartment (burn eschar, circumferential cast, pneumatic pressure garment, etc.), or volume increase within the compartment due to hematoma and edema. Direct trauma with resulting bleeding and edema is probably the most common cause.

Sung K, Tintinalli p.1838, Stedman’s Medical Dictionary

a)  Definition: condition in which increased intramuscular pressure in a confined anatomical space brought on by overactivity or trauma impedes blood flow and function of tissues within that space.

b) Most sensitive to ischemia– nerve tissue

c)  Signs and Sx – generally pain with active contraction and passive stretching, hypoesthesia, decreased distal pulses

d) Causes: compression of compartment (e.g. burn eschar, circumferential cast) or volume increase in compartment (e.g. hematoma, edema)

Michelle Tintinalli Pg 1838

Definition- Compartment syndromes are due to increased pressure within closed tissue spaces that compromises the flow of blood through nutrient capillaries in muscles and nerves.

Signs and Symptoms: pain exacerbated by active muscle contraction and passive stretching of muscle, diminished distal pulses, hypoesthesia of affected compartment. Signs: palpation of the compartments in question may or may not reveal tenseness and swelling. When in doubt, provider should measure tissue pressure.

Causes- compression of the compartment (burn eschar, circumferential cast, pneumatic pressure garment, etc.), or volume increase within the compartment due to hematoma and edema. Direct trauma with resulting bleeding and edema is probably the most common cause

Anonymous Tintinalli 1838

Compartment syndromes are due to increased pressure within closed tissue spaces that compromised the flow of blood through nutrient capillaries in muscles and nerves.

Capillary blood flow within the compartment is compromised at pressures greater than about 20 mmHg, and muscle and nerves are at risk for ischemic necrosis at pressures greater than about 30-40 mm Hg. Of the tissues within the compartments, nerve is most sensitive, followed by muscle tissue.

Causes:

1. compression of the compartment, for example, by burn eschar, a circumferential cast, or a pneumatic pressure garment

2. by a volume increase within the compartment due to hematoma and edema.

Direct trauma with resulting bleeding and edema is probably the most common cause, but overexertion (shin splints) and limb compression during recumbency as a result of alcohol or drug overdose are also common causes.

28.    Identify the compartment of the leg, which is the most at risk for compartment syndrome.

Zen Seeker Tinitinalli EM Fifth Edition

The four compartments of the leg.

Lower Extremity

There are three gluteal compartments of the buttocks. One contains the tensor muscle of the fascia lata, another the gluteus medius and minimus, and the third the gluteus maximus. The sciatic nerve lies adjacent to the gluteus maximus and can be compressed by it.

The thigh has three compartments: the anterior, medial, and posterior. The anterior compartment contains the vastus lateralis, the vastus intermedius, and the vastus medialis muscles, as well as the sartorius and rectus femoris muscles. The femoral artery and nerve also traverse the anterior thigh compartment. The medial compartment contains the adductor longus, the adductor brevis, and the adductor magnus muscles, plus the gracilis muscle. The posterior compartment contains the semimembranosus, the semitendinosus, and the biceps femoris muscles. The sciatic nerve also traverses the posterior compartment. 

The leg has four compartments (Fig. 270-4). The anterior compartment, the compartment most frequently involved by this syndrome, contains the tibialis anterior muscle and the extensor muscles of the toes—the extensor hallucis longus and the extensor digitorum longus muscles. The anterior tibial artery and the deep peroneal nerve are also located in this compartment. The lateral compartment, which is frequently involved when the anterior compartment is involved, contains the peroneous longus and brevis muscles, as well as the superficial peroneal nerve. The deep posterior compartment contains the tibialis posterior muscle, the flexor digitorum longus muscle, and the flexor hallucis longus muscle. It also contains the posterior tibial artery and the tibial nerve. The superficial posterior compartment contains the gastrocnemius muscle, the soleus muscle, and the sural nerve

Anonymous Tintinalli, p. 1839:  

The anterior leg compartment (one of four compartments in the leg) is the compartment most

frequently involved by this syndrome.

Anonymous  Tint.  1838-1841

            Compartment syndromes are due to increased pressure within closed tissue spaces that compromises the flow of blood through nutrient capillaries in muscles and nerves.  The complex relationships between time, Starling forces, systemic and venous pressure, and reperfusion injury are not completely understood.  A common factor is elevated tissue pressure.  Normal tissue pressure is about zero and usually less than 10mgHg.  Capillary blood flow within the compartment is compromised at pressures greater than 20mgHg, and muscle and nerves are at greatest risk for ischemic necrosis at pressures greater than about 30-40mgHg.  Of the tissues within the compartments, nerve is most sensitive, followed by muscle tissue.  Blood flow through arterioles, arteries, and collaterals is not compromised significantly at these pressures.  Nevertheless, tissues within the compartment that are dependent on the nutrient capillaries become ischemic and then necrotic if the compartment pressure is not reduced promptly.  By the time that distal pulses are reduced, muscle necrosis has occurred.  Ischemic muscles hurt, and this pain is exacerbated by active muscle contraction and by passive stretching of the muscle.  Virtually any muscle mass invested in fascia is at risk, given the right conditions.

Causes include:

• Constrictive dressing and casts

• Closure of fascial defects

• Thermal injuries and frostbite

•        Primary edematous accumulation

• arterial injuries, thrombosis, or embolism, spasm

• Reconstructive vascular and bypass surgery

• Replantation

• Prolonged tourniquet time

• Cardiac catheritization and angiography

• Ergotamine ingestion (A crystalline alkaloid that can stimulate smooth muscle of blood vessels and the uterus-used in treatment of migraines).

• Prolonged immobilization with limb compression

• Drug overdose with limb compression

• General anesthesia with knee-chest position

• Exertion

• Venous Disease

• Venomous snake bite

• Primarily hemorrhagic accumulation

  • Hereditary bleeding disorders

  • Anticoagulant therapy

  • Vessel laceration

• Combination of edematous and hemorrhagic accumulation

  • Fractures

    • Tibia

    • Forearm

    • Elbow (supracondylar)

    • Femur

  • Soft tissue injury

  • Osteotomies (tibia)

• Miscellaneous

  • IV infiltration (blood, saline)

  • Popliteal cyst

  • Long leg brace

Sung K, Tintinalli p.1839

        The anterior compartment is most at risk. It contains the tibialis anterior muscle and the extensor muscles of the toes – the extensor hallucis longus and the extensor digitorum longus muscles. The anterior tibial artery and the deep peroneal nerve are also located in this compartment.

Michelle Tintinalli Pg 1839

            The anterior compartment of the lower leg is most at risk of developing compartment syndrome. It contains the tibialis anterior muscle and the extensor muscles of the toes – the extensor hallucis longus and the extensor digitorum longus muscles. The anterior tibial artery and the deep peroneal nerve are also located in this compartment.

Anonymous Tintinalli 1839

The leg has four compartments. The anterior compartment, the compartment most frequently involved by this syndrome, contains the tibialis anterior muscle and the extensor muscles of the toes (the extensor hallucis longus and the extensor digitorum longus muscles).

29.    Identify the common presentation of compartment syndrome in the alert patient.  

Zen Seeker Tinitinalli EM Fifth Edition

DIAGNOSIS

The history, including mechanism of injury, is very important, since many patients at risk for the syndrome are severely ill or injured and cannot relate whether they are experiencing pain. Palpation of the compartments in question may or may not reveal tenseness and swelling; when in doubt, the resuscitating physician should measure tissue pressure.

Alert and intact patients will virtually always relate that they are experiencing severe and constant pain over the involved compartment. Palpation of the compartment will also elicit pain. Active contraction of the involved muscles will increase the pain, as will passive stretching of the muscles (Table 270-2). Hypoesthesia resulting from compromise of nerves traversing the involved compartment appears at about the same time as muscle weakness and pain. 

Possible compartment syndromes associated with injuries such as fractures or penetrating wounds should prompt an immediate surgical consultation, since the presence of a compartment syndrome may influence subsequent treatment choices.

Anonymous Tintinalli, p. 1840:

Alert and intact patients will virtually always relate that they are experiencing severe and constant pain over the involved compartment.  Active contraction of the involved muscles will increase the pain, as will passive stretching of the muscles.  

Anonymous Tint. 1840

            The history, including mechanism of injury, is very important, since many patients at risk for the syndrome are severely ill or injured and cannot relate whether they are experiencing pain.  Alert and intact patients will virtually always relate that they are experiencing severe and constant pain over the involved compartment.  Palpation of the compartment will also elicit pain.  Active contraction of the involved muscles will increase the pain, as will passive stretching of the muscles.  Hypoesthesia resulting from compromise of nerves traversing the involved compartment appears at about the same time as muscle weakness and pain.  

Sung K, Tintinalli p.1840

        Virtually always experience severe and constant pain over the involved compartment. Palpation of the compartment will also elicit pain. Active contraction and passive stretching of the involved muscle will elicit pain.

Michelle Tintinalli Pg 1840

Alert and intact patients will virtually always relate that they are experiencing severe and constant pain over the involved compartment.  Palpation of the compartment will also elicit pain.  Active contraction of the involved muscles will increase the pain, as will passive stretching of the muscles.

Anonymous Tintinalli 1840; see Table 270-2

Alert and intact patients will virtually always relate that they are experiencing severe and constant pain over the involved compartment.  Palpation of the compartment will also elicit pain.  Active contraction of the involved muscles will increase the pain, as will passive stretching of the muscles.  Hypoesthesia resulting from compromise of nerves traversing the involved compartment appears at about the same time as muscle weakness and pain.

30.    From Tintinalli Table 270-2, identify signs of anterior compartment syndrome in the leg.

Zen Seeker Tinitinalli EM Fifth Edition

TABLE 270-2         Symptomatology of Acute Compartment Syndromes

Anonymous Tintinalli pg. 1840

-Pain on active and passive dorsiflexion and plantar flexion of the foot.  Hypoesthesia of the first web space.

Anonymous Tint. 1840 table 270-2  

Sung K, Tintinalli p.1840

        a)  Pain on active and passive dorsiflexion and plantar flexion of the foot

        b) Hypoesthesia of the 1^st web space

Michelle Tintinalli Pg 1840 Table 270-2

Pain on active and passive dorsiflexion and plantar flexion of the foot.  Hypoesthesia of the first web space.

Anonymous

Pain on active and passive dorsiflexion and plantar flexion of the foot

Hyperesthesia of the first web space

31.    For treatment of compartment syndrome, discuss the following:

         a.            Treatment of high pressures

         b.            What should not be done

         c.            Conservative treatment measures

Zen Seeker Tinitinalli EM Fifth Edition

MANAGEMENT

Compartment pressures between 15 and 20 mmHg are problematic. If the problem is acute and the patient is reliable, the patient can be told to return for repeat measurement if symptoms do not improve. A pressure of 20 mmHg can be damaging if it persists for several hours; therefore, admission or surgical consultation will be needed for unreliable patients. Pressures greater than 20 mmHg demand admission and surgical consultation. A pressure of 30 to 40 mmHg is generally considered grounds for emergent fasciotomy in the operating room. Fasciotomy is accomplished by making a longitudinal skin incision over the compartment. The underlying fascia is then split the length of the compartment, allowing the contained muscle to expand. Do not recommend ice cooling, because muscle perfusion may be decreased by it. Do not recommend elevation of the limb, because the resulting decrease in arterial perfusion pressure may also decrease muscle perfusion. Bed rest would provide the best chances for improvement when conservative management seems to be in order.

Anonymous Tintinalli pg. 1841

a. Treatment of high pressures:  A pressure of 30-40 mmHg is considered grounds for emergent fasciotomy in the OR.

b. What should NOT be done:  Do not recommend ICE COOLING!!  Because muscle perfusion may be decreased by it.  Do not recommend ELEVATION OF THE LIMB!!  Because the resulting decrease in arterial perfusion pressure may also decrease muscle perfusion.

c. Conservative treatment measures: Bed rest.

Anonymous

Treatment of high pressures- A pressure of 20mmHg can be damaging if it persists for several hours; therefore; admission or surgical consultation will be needed for unreliable patients who do not return for repeat measurements if symptoms do not improve.  

What should be done- pressures greater than 20-mmHg-demand admission and surgical consultation.  A pressure of 30-40 mmHg is generally considered grounds for emergent fasciotomy in the OR.  

Conservative treatment measures- Compartment pressures between 15-20 mmHg are problematic.  If the problem is acute and the patient is reliable, the patient can be told to return for repeat measurement if symptoms do not improve.  Do not recommend ice cooling, because muscle perfusion may be decreased by it.  Do not recommend elevation of the limb, because the resulting decrease in arterial perfusion pressure may also decrease muscle perfusion.  Bed rest would provide the best chances for improvement when conservative management seems to be in order.

Janelisa, Tintinalli 1841

a.       Treatment of high pressures – pressures above 20 mmHg require admission and surgical consultation; pressures above 30 mmHg are considered grounds for emergent fasciotomy in the OR. A longitudinal skin incision is made over the compartment, and the underlying fascia is then split the entire length to allow the contained muscle to expand

b.      What should not be done – ice cooling and limb elevation may decrease muscle perfusion

c.       Conservative treatment measures – bed rest

Brent- Tintinalli 1841

a.  Pressure>20mmHg requires admission and a surgical consult.  Pressures of 30-40 mmHg are generally grounds for emergent fasciotomy in the OR.

b.  DO NOT:

         -Ice because muscle perfusion may decrease

         -Elevate the limb because it results in a decrease of arterial pressure, subsequently

          decreasing muscle perfusion.

c.  Conservative management:

         -Pressures between 15-20:  If the problem is acute and the pt. is reliable, pt. can bed

          sent home on bed rest and to return for repeat measurements if sx’s persist.

         -Pressure of 20mmHg for unreliable pt. require admission and surgery consult.

Anonymous Tintinalli 1841

a)      Treatment of high pressures

20 mmHg- can be damaging if it persists for several hrs., so, admission or surgical consultation will be needed for unreliable patients.

>20mmHg- admission and surgical consultation

30-40 mmHg- emergent fasciotomy in the operating room, which is accomplished by making a longitudinal skin incision over the compartment.  The underlying fascia is then split the length of the compartment, allowing the contained muscle to expand.

b)      What should not be done- Do not recommend ice cooling, because muscle perfusion may be decreased by it. Do not recommend elevation of the limb, because the resulting decrease in arterial perfusion pressure may also decrease muscle perfusion.

c)      Conservative treatment measures- Bed rest would provide the best chances for improvement when conservative management seems to be in order.

32.    Be able to explain under what circumstances the CT would be a better imaging technique than the MRI for pelvic trauma and vice versa.

Zen Seeker Tinitinalli EM Fifth Edition

Janelisa, Squires 362-3 CT can show fracture lines better than plain films and can identify the subtle cortical abnormalities of nondisplaced fractures. CT can show the fracture lines in greater detail and the position and orientation of fracture fragments better than any imaging procedure. MRI can’t show fracture lines or fragments as well as CT because there is no MR signal from cortical bone. It is better at showing bone bruises which produce hemorrhage and edema within the marrow space.

Brent- Squire’s 363

CT shows fracture lines and fragments better than MR.  MR is more beneficial when looking for bony injuries, such as bone bruises, that don’t involve cortical bone disruption but produce hemorrhage and edema within the marrow space.

Anonymous

CT- for a diplacement of the cortex

MRI- soft tissue injuries

33.    Be able to identify the most appropriate imaging technique for the “occult” hip fracture.

Zen Seeker Tinitinalli EM Fifth Edition

RADIOLOGIC EVALUATION

Roentgenographic evaluation of the pelvis and hips is a must in all unconscious patients who have sustained multiple injuries. The threshold for obtaining radiographs in demented elderly patients who have sustained minor falls should also be relatively low because those patients may be particularly difficult to evaluate.23 Lower extremity long bone fractures, as well as pelvic symptoms or signs, are also indications for these x-ray examinations. The x-ray evaluation should include a standard AP and a lateral view of the pelvis. If further studies are needed, AP views of either hemipelvis, internal and external oblique views of the hemipelvis as described by Judet and colleagues, or “inlet” and “tilt” views may be done. In certain instances, such views allow better identification and detail of the acetabulum and femoral head and neck. Always inspect not only the hip joint but also the femur and knee when evaluating hip disorders on x-ray films. Disorders to the knee and the femoral shaft often occur with hip injuries. Significant hip pain with weight-bearing following trauma and normal radiographs suggest the possibility of occult fracture, especially at the femoral neck or acetabulum.24 The patient should be prescribed protected weight-bearing and the emergency physician should communicate with the patient´s primary care provider or orthopedist regarding close follow-up for possible CT or MR hip imaging to rule out occult fracture.25,26 MR is reliable in detecting occult fractures within 24 h of injury.

Janelisa, Tintinalli 1808 Occult fractures are suggested when there is significant hip pain with weight-bearing following trauma and normal x-ray. The fracture is often at the femoral neck or acetabulum and is detected by CT or MRI. MRI is reliable in detecting occult fractures within 24 hours of injury.

Brent- Tintinalli 1808

CT or MR for occult hip fx’s but only MR for fx’s within 24 h. of injury.

Anonymous Essentials of MS Care, 310

An AP radiograph of the pelvis identifies most fractures.  Special views, CT, and /or MRI may be needed to define the extent of injury or identify an occult fracture.

lecture:

Bone scan

MRI

34.    Be able to identify the imaging technique of choice for soft tissue injuries of the lower extremity.

Zen Seeker Tinitinalli EM Fifth Edition

Janelisa, Squires 403-405 MR is the best method for soft-tissue musculoskeletal imaging because it can produce sectional views in almost any plane – coronal, sagittal, axial, and oblique – and because it can individually depict tendons, ligaments, blood vessels, nerves, hyaline cartilage, and fibrocartilage. MR is the best method for imaging joints as well.

Brent- Squires’s 403

MR is the imaging method of choice. With its superior tissue differentiation, it can depict tendons, ligaments, blood vessels, nerves, hyaline cartilage, and fibrocartilage.

Anonymous

MRI