UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: Apprehension test for shoulder dislocation

Keywords: shoulder dislocation, apprehension (PubMed Search)

Posted: 8/25/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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Apprehension test for shoulder dislocation


Tests for chronic shoulder dislocation                                                       

Similar to the patellar apprehension test

Designed to place the humeral head in a position of imminent subluxation or dislocation


ABduct and externally rotate arm to a position where the shoulder may dislocate

If the shoulder is about to dislocate, the patient will experience apprehension due to the familiar pattern of dislocation, report the laxity and resist further motion.

Category: Orthopedics

Title: Synovial Fluid Analysis

Keywords: lactate, synovial fluid, (PubMed Search)

Posted: 8/18/2012 by Michael Bond, MD (Updated: 6/13/2024)
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The Analysis of Synovial Fluid Analysis

When trying to diagnosis a septic joint, it is common to order the following labs on the synovial fluid:

  • Synovial WBC count
  • Glucose
  • Protein
  • Gram Stain
  • Culture

Unfortunately, there is no value of glucose or protein that has enough sensitivity and specificity to make the tests diagnostically helpful.  Gram stains are only postive in culture positive septic joints in approximately 50% of the cases.  Cultures take too long to be helpful in the ED.  The synovial WBC count can be helpful if very high, but a low value does not ensure that the patient does not have a septic joint.

The one test that has been shown to have a Positive Likelihood ratio of Infinity is a synovial lactate level >10.  A synovial lactate should be sent on all synovial fluid as a level of 10 and greater makes the diagnosis of septic arthritis, regardless of the gram stain or synovial WBC level.


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Category: Orthopedics

Title: Humerus Fractures

Keywords: Humerus Fractures (PubMed Search)

Posted: 7/21/2012 by Michael Bond, MD (Updated: 8/28/2014)
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Humerus Fractures, Proximal

  • Proximal fractures of the humerus only account for about 5% of all fractures but account for 45% of all humeral fractures.
  • We should be familar with the Neer Classication System for Humeral fractures, which can also be seen at
  • The classification system classifies fractures based on
    • 1-part
    • 2-part
    • 3-part
    • 4-part
  • The bony segments that make up the parts are
    • Greater Tuberosity (GT)
    • Lesser Tuberosity (LT)
    • Humeral Head
    • Humeral Surgical Neck (SN)
  • A part is defined as displaced if >1 cm of fracture displacement or >45 degrees of angulation.
  • The greater the number of parts the more likely the patient will require surgery or have increased complications.
    • 3 and 4 part fractures are often fixed surgical due to the increased risk of vascualr compromise to the humeral head.


Category: Orthopedics

Title: Ulnar nerve compression neuropathy

Keywords: Ulnar nerve, compression, neuropathy, wrist (PubMed Search)

Posted: 7/14/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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The median nerve is not the only compression neuropathy of the wrist

The ulnar nerve can become compressed at the level of the wrist as it 1) enters Guyon's canal or 2) or as the deep branch curves around the hook of the hamate

Compression can occur due to carpal bone fractures, local inflammation, ganglias, lipomas, anatomic abnormalities, etc

In sports medicine, the most common mechanism is injury is seen in cyclists (cyclist/handlebar palsy)

Also seen in those who participate in racquet sports, baseball, and golf

Symptoms can be isolated motor (claw hand = rare), sensory or both

Can be associated w/ median nerve compression

Tx: Activity modification such as wearing padded gloves, padding the object, or changing hand position on the handlebars

If above fails, surgical decompression is very effective.

Category: Orthopedics

Title: First Metacarpal Fractures

Keywords: Bennett, Rolando, fracture (PubMed Search)

Posted: 6/30/2012 by Michael Bond, MD (Updated: 6/13/2024)
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First Metacarpal Fractures:

There are two types of fractures that commonly occur at the base of the 1st metacarpal.  They are:

Bennett Fracture:  This is an intraarticular fracture at the base of the 1st metacarpal that always involves some degree of subluxation or dislocation of the 1st carpometacarpal joint. 

Bennett Fracture

Image from Wikipedia Commons

  • This is the most common fracture of the thumb. 
  • This fracture is typically caused by axial loading the thumb while the metacarpal is partially flexed.  A common mechanism is when a person punches a wall or hard object with their thumb take the brunt of the force.
  • Most of these fractures will require surgical repair but can be treated in the ED with a Thumb Spica Splint.

Rolando Fracture:  This is a communited intraarticular fracture at the base of the first metacarpal that typically has a T or Y shaped configuration with 3 fragments.

Rolando Fx

Image courtesy of WikiPedia Commons

  • Less common then Bennett Fractures
  • Associated with a worse prognosis
  • Requires surgical repair but can be splinted in the ED with a thumb spica splint.

Category: Orthopedics

Title: "Is exercise bad for my knees doc?"

Keywords: knee, cartilage, physical activity (PubMed Search)

Posted: 6/23/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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I am often asked whether physical activity has a positive or negative effect on the overall health of knee cartilage. The answer is unclear. Published data are conflicting.

What is known and generally agreed on:

1) Physical activity has been shown to facilitate cartilage development in children

2) Forced immobility (spinal cord injury) results in rapid cartilage loss

3) The medial knee compartment experiences significant mechanical loads during weight-bearing activity and is often the primary site of knee OA

A recent study attempted to answer whether 1) long-term (10yrs) participation in vigorous physical activity would benefit knee cartilage in healthy adults and 2) whether there were certain subgroups with asymptomatic preexisting structural knee changes which predict a harmful cartilage response to long-term physical activity.

Vigorous = activity generating sweating or SOB at least 20min 1/wk

Healthy older adults (mean age 57.8 yr) performing persistent vigorous physical activity had an increased risk (odds ratio 1.5) of worsening medial knee cartilage defects but not of a change in cartilage volume

In those w/ asymptomatic preexisting structural knee changes, there was worsening of cartilage defects (odds ratio 3.4) and a trend toward increased rate of loss of cartilage volume (again in the medial knee compartment)

Long-term effects of vigorous physical activity may depend on the preexisting health of the joint

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Category: Orthopedics

Title: Thoracolumbar fractures

Keywords: back, vertebae, fracture (PubMed Search)

Posted: 6/9/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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Wedge compression fractures

  • Account for 50 – 70% of all thoracolumbar compression fractures
  • Usually results from motor vehicle collisions and falls where an axial load is applied to the spine in flexion causing injury to the anterior column without posterior column injury
  • Best seen on the lateral radiograph
  • Simple wedge fractures are stable and have no associated neurologic injury
  • Instability is present if
    • There is severe compression (>50%)
    • Kyphosis greater than 20 degrees
    • Multilevel compression fractures



Category: Orthopedics

Title: Hamate Fractures

Keywords: hamate, wrist, fracture (PubMed Search)

Posted: 5/26/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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Hamate Fractures

Occur in two locations: the body of the hamate and the hook (hamular process) of the hamate

Fractures are present in 2 to 4% of carpal bone fractures

Body fractures are less common and are associated with dislocation of the fourth and fifth metacarpals

                Axial force transmitted down the metacarpal shaft (a fall or fist strike)

Hook fractures occur from a direct force from an object strikes the palm such as that from a bat, golf club or racket

Have increased suspicion in these athletes who present w/ ulnar sided wrist pain

Diagnosis is frequently missed;  chronic fractures are associated w/ flexor tendon rupture and ulnar neuropathy

PE:  Tenderness localized over the hamate (in the hypothenar eminence) and over the dorsal ulnar aspect of the wrist. Swelling may be present. Look for resisted flexion of the 5th digit when the wrist is held in ulnar deviation. May note sensory changes in ulnar nerve distribution

Imaging: PA and lateral views of the wrist will show a body fracture but will frequently MISS a fracture of the hook of the hamate. In those with a clinical suspicion for this entity, order a “carpal tunnel view.”  In the proper clinical setting, CT imaging is excellent for those with high suspicion and normal plain films.,%208th%20ed./HTML/f4-u1.0-B978-1-4160-3285-4..10044-0..gr2.jpg

Category: Orthopedics

Title: Panner's disease

Keywords: Elbow, osteochondritis, capitellum (PubMed Search)

Posted: 5/12/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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Panner's disease refers to osteochondrosis of the capitellum.

Affects the dominant elbow of boys between the ages of 5 and 10

Associated with the repetitive trauma of throwing

Must be differentiated from osteochondrosis dissicans (occurs in the older child >13yo)

Hx: Intermittent pain and stiffness of the elbow. Better w rest, worse w activity.

PE: tenderness over capitellum w/ slight effusion. Loss of 20 degrees full extension

The articular surface of the capitellum appears irregular with areas of radiolucency.

Tx: Symptomatic treatment with rest. In severe cases a long arm splint/cast may be applied for 2-3 weeks.


Category: Orthopedics

Title: Luxatio Erecta

Keywords: Inferior shoulder dislocation (PubMed Search)

Posted: 4/28/2012 by Brian Corwell, MD
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Luxatio erecta, aka inferior shoulder dislocation, is an uncommon form of shoulder dislocation (0.5-2%)

2 Mechanisms: 1) Forceful, direct axial loading of an ABducted arm.

2) Hyperabduction of the arm leads to impingement of the humeral head against the acromion, If forceful enough, this leverage can rupture the capsule and drive the humeral head downward, resulting in an inferior dislocation. This mechanism is more common.

Classic presentation: Arm locked in marked ABduction with the flexed forearm lying above the head.

One may palpate the humeral head against the lateral chest wall

Bony injuries include fractures to surrounding structures such as the coracoid process, acromion, glenoid rim, clavicle, greater tuberosity and humeral head.

Nerve injuries include damage to the brachial plexus/axillary nerve (usually reversed with reduction)

Vascular injuries: Axillary artery thrombosis

Some quick board review pearls.  Remember these fractures/dislocations and the neurologic injury that is associated with them

  • Acetabular fracture – sciatic nerve
  • Anterior shoulder dislocation – axillary and musculocutaneous nerve
  • Elbow dislocation – ulnar or median nerve
  • Hip dislocation
    • Anterior – femoral nerve
    • Posterior – sciatic nerve
  • Humerus – radial nerve
  • Knee Dislocation – peroneal or tibial nerve
  • Olecranon fracture – ulnar nerve
  • Supracondylar fracture – median, radial or ulnar nerve
  • Tibia plateau fracture – peroneal nerve

Category: Orthopedics

Title: Medial Tibial Stress Syndrome

Keywords: stress fracture, shin splints (PubMed Search)

Posted: 4/7/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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Exertional leg pain in the athlete carries a wide range of possible etiologies. In a recent review article, etiologies included, stress fracture (25%), exertional compartment syndrome (33%), medial tibial stress syndrome (13%), nerve entrapment (10%), and popliteal artery entrapment syndrome.


Medial Tibial Stress Syndrome (MTSS) is also known as shin splints. It is a repetitive-stress overuse injury.

Risk factors include: hyperpronation, higher BMI, increased hip internal rotation, and hyperplantar flexion.

While MTSS may be on a stress reaction spectrum that includes fracture, the causes are likely to also include tendinopathy and muscle dysfunction (tibialis anterior, posterior and soleus).

Radiographs will be normal with this condition. MRI and bone scan may show signal abnormality along the posterior medial tibial surface.

Treatment: In most cases participation in sports may continue. Also consider, rest/activity modification, ice, NSAIDs, physical therapy for calf stretching and strengthening,  and rigid orthotics (to correct foot hyperpronation). Semi rigid and neoprene orthotics may be considered for prevention in those with a prior history.

Category: Orthopedics

Title: Cardiac risks during a marathon

Keywords: cardiac arrest, exercise, marathon (PubMed Search)

Posted: 3/24/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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A recent study looked at the risk of sudden cardiac death during a marathon.

Many isolated reports of sudden death make headlines in the national news.

However, of nearly 11 million runners, only 59 went into cardiac arrest during a race. This equates to an incidence rate of 0.54 per 100,000 participants,

This rate appears to be on par with sudden death from other athletic endeavors such as triathlons and college athletics.

Median age was 42. Men affected more than women (men also more likely to die from the event).

71% of events were fatal.

Further, risk is greater for both cardiac arrest and sudden death for full marathons than half marathons.

Interestingly, older patients fared better (increased survival in those >40yo), thought to be due to an increased incidence of hypertrophic cardiomyopathy in younger aged runners.

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Category: Orthopedics

Title: plantar Fasciitis

Keywords: foot, plantar fasciitis (PubMed Search)

Posted: 3/10/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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The plantar fascia arises from the medial tuberosity of the calcaneous and extends to the proximal phalanges of the toes.

Pkantar Fasciitis is the most common cause of heel pain in adults.

Etiology is thought to be from a degenerative tear at the fascial origin followed by a tendinosis type reaction and .

Affects women 2x> men

More common in overweight patients.

Onset is insidious and not related to trauma.

Hx: Pain and tenderness directly over the medial calcaneal tuberosity and 1-2cm distally along the plantar fascia.

Pain is worse with prolonged standing/walking. Pain is most intense however when rising from a resting position such as first thing in the morning.

PE: Pain is increased with passive dorsiflexion of the toes. Tenderness to palaption over the medial calcaneal tuberosity and 1-2cm distally along the plantar fascia.(At times, one may have to apply increased pressure to approximate weight bearing type stress)

XR: Usually not necessary with a good history and exam. Heel spurs are seen in up to 50% with the disease (and in up to 20% without it!)

DDx: Tarsal tunnel syndrome. Calcaneal stress fracture. Fat pad atrophy. traumatic rupture of planter fascia.




Category: Orthopedics

Title: Severs disease

Keywords: Heel, overuse injury, apophysis (PubMed Search)

Posted: 2/25/2012 by Brian Corwell, MD (Updated: 6/13/2024)
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Severs disease

- Perhaps the most common overuse injury

-Pain is due to inflammation of the calcaneal apophysis growth plate

- Caused by repetitive microtrauma from the pull of the Achilles tendon on the apophysis.

- Occurs in young athletes ages 7-14

Sx’s bilateral in >50%

Hx – Gradual onset of posterior heel pain, worse with activity, better with rest.

PE – Tenderness at the insertion of the Achilles tendon onto the calcaneous. Swelling is mild.

This is a self limited condition because as the adolescent ages, the physis closes

Tx – Rest (no running or jumping), ice, NSAIDs, heel lifts/arch supports. Outpatient physical therapy for stretching and strengthening exercises.

Category: Orthopedics

Title: Morton's Neuroma

Keywords: Morton, neuroma (PubMed Search)

Posted: 2/18/2012 by Michael Bond, MD (Updated: 6/13/2024)
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Morton's Neuroma

  1. A benign perineural fibroma of an intermetatarsal plantar nerve.
  2. Most commonly affects the third and fourth intermetatarsal space
  3. Patient's will often complain of pain and/or numbness in the ball of their foot and toes when the metatarsal heads are compressed together as in when wearing shoes. Pain is often described as burning or shooting.  Some patients report that it feels like they are standing on a pebble.
  4. On physical exam you can reproduce the pain by squeezing the metatarsal heads together. (Mulder's sign)
  5. Diagnosis can be confirmed with MRI though clearly this does not need to be done in the ED.
  6. Treatment includes NSAIDs and referral for orthotics, corticosteroid injection, or surgical removal.

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Category: Orthopedics

Title: Herbs & supplements for pain

Keywords: herbal, supplements, complementary medicine (PubMed Search)

Posted: 2/11/2012 by Brian Corwell, MD
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Common herbs and supplements used to treat pain

1) Turmeric root - used for arthritis pain. Little evidence to support its use. May slow blood clotting/enhance anticoagulant/antiplatelet effects.

2) Boswellia - used for OA and RA pain. Little evidence to support its use.May interfere with anticoagulant drugs and leukotreine inhibitors.

3) St. John's Wort - used for HA, migraine, neuralgia, muscle pain, sciatica, fibromyalgia. Little to no evidence to support its use.May interfere with numerous medications including anticoagulants, digoxin and SZ medications.

4) Glucosamine and Chondroitin - used for OA, knee pain, back pain. The glucosamine/chondroitin arthritis intervention trial found that "the dietary supplements Glucosamine and Chondroitin, taken alone or in combination are generally ineffective for OA pain of the knee." May increase the effect of Warfarin.

5) KavaKava - used for HA, muscle pain. Insufficient evidence demonstrating effectiveness for treatment of painful conditions. May cause severe liver damage and potentiate drowsiness side effects of other medications.

6) Echinacea - used for pain, migraines, arthritis. Little evidence to support its use. May exacerbate symptoms of autoimmune disorders.

7) Valerian root – used for joint and muscle pain. Insufficient evidence to support its use. May potentiate sedative side effects of barbiturates and benzos.

8) Chinese Thunder God Vine – used for arthritis. There is some evidence to suggest that this agent has anti-inflammatory properties. Long term this agent may decrease bone mineral density in women, decrease fertility in men, and may produce GI side effects.

9) Feverfew – used for muscle pain, arthritis. Some evidence to suggest that may reduce frequency of migraine headaches. No evidence for benefit in RA. May enhance effects of anticoagulants and some drugs that undergo hepatic metabolism.

10) Cat’s claw – used for herpes zoster, bone pain, arthritis. Possible benefit for OA and RA in small studies in humans but no large study has shown benefit. May interact with clotting agents, BP meds and cyclosporine.

11) Black Cohosh – used for muscle pain and arthritis. Insufficient evidence demonstrating benefit. May be associated with severe liver side effects.

12) Bromelain – used for muscle pain, arthritis, knee pain. The NIH reports that bromelain may be effective for arthritis when used in combination with trypsin and rutin. May interact with amoxicillin and other antibiotics, anticoagulants and antiplatelet drugs.

13) Devil’s claw – used for muscle pain, back pain, arthritis, migraine. The NIH reports that “taking devil’s claw alone or with NSAIDs seems to help decrease OA related pain.” May increase effects of warfarin.

Category: Orthopedics

Title: Hip Dislocation? Page a drunken pirate

Keywords: Hip dislocation, technique, reduction (PubMed Search)

Posted: 1/28/2012 by Brian Corwell, MD
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Our old friend Captain Morgan (the rum pirate) may now be able to assist us during a shift, not just afterwards.

In a small case series in last months Annals of Emergency Medicine, a new reduction maneuver was described as an alternative to the traditional Aliis's maneuver.

The maneuver is named after the pirate spokesperson for the similarities in body positioning.

The patient is placed supine on a stretcher. The pelvis is fixed to a backboard with a strap. The patient's hip and knee are flexed to 90 degrees. The physician places one foot on the back board with the same knee behind the patient's knee. By holding the patient's ankle down, the patient's knee is kept in flexion. The physician then lifts his/her calf, thereby applying an upward force to the hip while gently rotating the lower leg from side to side.

with a slight variation

The success rate was 12 of 13 cases. The single failure occurred in a patient with an acetabular fracture with an intra-articular fragment requiring open reduction. There were no described neurovascular complications or injuries to the knee. The technique limits the physician's risk of back strain and of falling from the stretcher.

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Category: Orthopedics

Title: Flexor Tenosynovitis

Keywords: Flexor, Tenosynovitis (PubMed Search)

Posted: 1/21/2012 by Michael Bond, MD
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Flexor Tenosynovitis

  • This is a rapidly spreading infection of the finger and hand.
  • Often starts as an infection in the finger that then spreads into the hand due to the flexor sheaths.
  • The flexor tendon sheaths of the long, index, and ring finger extend from the distal phalanx to the superficial palmar arch, and some even extend to the wrist.
  • Most patient will need to be admitted for IV antibiotics and a hand consult for probable operative I&D
  • You can diagnosis flexor tenosynovitis by documenting the four Kanavel signs:
    1. Fusiform swelling of the finger
    2. Finger held in partial flexion (position of comfort)
    3. Percussion tenderness along the flexor tendon
    4. Increased pain with passive extension of the finger

You can follow this link,  , to see the physical exam findings of flexor tenosynovitis

Category: Orthopedics

Title: Lidocaine for shoulder discloations

Keywords: intra-articular lidocaine, shoulder dislocation (PubMed Search)

Posted: 1/15/2012 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Approximately 48% of shoulder dislocations occur during sports and recreation.

These are usually first managed in the clinic and sideline setting.

In 6 reviewed studies, 5 used 20mL of 1% lidocaine and 1 used 4 mg/kg of 1% lidocaine.

    Patients incurred significantly reduced cost compared to IV sedation

There were no infections, neurovascular damage or systemic effects of the lidocaine.

No significant differences were noted in pain control, success rate or ease of reduction between intra-articular lidocaine and systemic sedation.

The risk of chondrolysis increases with higher concentration and longer duration of exposure to local anesthetics.

There is scant research about the effects of a single exposure of cartilage to lidocaine.

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