UMEM Educational Pearls - Orthopedics

Category: Orthopedics

Title: Retroperitoneal hemorrhage presenting as an orthopedic complaint

Keywords: Back pain, groin pain (PubMed Search)

Posted: 9/22/2016 by Brian Corwell, MD (Emailed: 9/24/2016) (Updated: 9/24/2016)
Click here to contact Brian Corwell, MD

Retroperitoneal hemorrhage

The pathophysiology is unknown. Some hypothesize that occult vasculopathy and arteriosclerosis of the small vessels in the retroperitoneum may render them friable and therefore prone to rupture. This can be seen in minor trauma in sports and forceful vomiting or coughing. Spontaneous bleeding starts at the microvascular level, and large vessels become disrupted or stretched as the hematoma enlarges.

Retroperitoneal hemorrhage occurs in a variety of clinical circumstances, including spontaneous hemorrhage into a pre-existing benign adrenal cyst or bleeding from a left inferior phrenic artery, tumors of the adrenal gland and kidney, rupture of any blood vessel (most commonly infrarenal aorta); percutaneous interventions (such as cardiac catheterization), trauma, and polycythemia vera,

It is most commonly seen in association with patients with bleeding abnormalities, in HD patients and with anticoagulation therapy,. Risk is much greater with unfractionated heparin therapy than with warfarin. In most of the heparin patients studied, their coagulation parameters were in the therapeutic range.

Patients may present to the non acute area of the ED with back, lower abdominal or groin discomfort, Over time, this may progress to hemodynamic instability, and a fall in hemoglobin, Early identification is crucial to improving patient morbidity and mortality. Early symptoms depend on the location of the bleeding.

Hematoma near or within the iliopsoas muscle usually presents as femoral neuropathy (groin pain or leg weakness).

Femoral neuropathy caused by retroperitoneal hematoma can present with sudden onset severe pain in the affected groin and hip, with radiation to the anterior thigh and the lumbar region. This can easily be missed as the presentation is similar to a pulled msucle or strained hip/back. Iliopsoas muscle spasm often results in the characteristic flexion and external rotation of the hip, and any attempt to extend the hip will result in severe pain. Over time, pain and parasthesia in the antero-medial thigh and leg is seen.

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Category: Orthopedics

Title: PatelloFemoral Syndrome Treatment

Keywords: Patellofemoral Syndrome (PubMed Search)

Posted: 9/10/2016 by Michael Bond, MD (Emailed: 9/17/2016) (Updated: 9/17/2016)
Click here to contact Michael Bond, MD

Patellofemoral Syndrome Treatment options

Patients do best with a combined intervention (ie, exercise therapy, education, manual therapy and taping)  plan or patellofemoral bracing may improve outcomes for people with patellofemoral syndrome and the subtype of patellofemoral osteoarthritis.

For for the ED, we can start NSAIDs, and then have them follow up with Physical Therapy, A sports trainer if in organized sports, or with a sports medicine physician/PCP.  Physical therapy is targeted at strengthening the quadricep muscle particularly vastus medialis, which improves the patella’s tracking with knee flexion.

Young athletes, especially around the age of puberty, are at higher risk for pelvic avulsion fractures

Often seen in sports that require sprinting, rapid changes in movement or jumping

Caused by sudden, forceful contraction of the muscles of the abdominal, the hip and thigh or the hamstring

Avulsion fractures can occur at many areas of the pelvis.

A mnemonic is: Alabama’s stoned rappers got ill hunting armadillos

·  Iliac crest: Abdominal muscles

·  Anterior superior iliac crest: Sartorius

·  Anterior inferior iliac crest: Rectus femoris

·  Greater trochanter: Gluteal muscles

·  Lesser trochanter: Iliopsoas **(rare in adults)

·  Ischial tuberosity: Hamstrings

·  Pubic symphysis: Adductor group

** Isolated nontraumatic avulsion fractures of the lesser trochanter in adults is a pathognomonic sign of metastatic disease

This site has some good images of common injury patterns

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Category: Orthopedics

Title: PatelloFemoral Syndrome

Keywords: Patellofermoral Syndrome (PubMed Search)

Posted: 8/20/2016 by Michael Bond, MD (Updated: 6/17/2024)
Click here to contact Michael Bond, MD

According to the 4th International Patellofemoral Pain Research Retreat recently published in British Journal of Sports Medicine, the core criterion required to define Patelofemoral Pain (PFP) syndrome is pain around or behind the patella, which is aggravated by at least one activity that loads the patellofemoral joint during weight bearing on a flexed knee (eg, squatting, stair ambulation, jogging/running, hopping/jumping).

Additional criteria (not essential):

  1. Crepitus or grinding sensation emanating from the patellofemoral joint during knee flexion movement
  2. Tenderness on patellar facet palpation
  3. Small effusion
  4. Pain on sitting, rising on sitting, or straightening the knee following sitting

PFP is common in young adolescents, with a prevalence of 7–28%, and incidence of 9.2%.

Stay tuned for recommendations on treatment and diagnosis.

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Category: Orthopedics

Title: Collar Button Abscess

Keywords: Hand infection (PubMed Search)

Posted: 8/13/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

47yo M chef presents to your ED with 2 days of worsening left hand pain after sustaining a puncture wound to hand at work. The hand is red and swollen and he complains of pain. Interestingly, his index and middle digits are in an ABducted position at rest.

Collar Button Abscess

Web space infection of the palmer AND dorsal hand

The Palmer aponeurosis prevents volar extension (but promotes dorsal encroachment)

The pus spreads between the MC bones and erupts dorsally....creating a DORSAL abscess.

Loss of palmer concavity is seen.

ABduction of the adjacent digits, resulting in a "V" configuration with the apex pointing to the site of infection. This would not happen from simple pus in the dorsal space!

Can be missed if only focused on the dorsal hand. The palm will show the original injury (splinter, cut, foreign body)

Treatment is urgent surgical drainage.

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Category: Orthopedics

Title: Pectoralis Major Rupture

Keywords: Chest, muscle injury (PubMed Search)

Posted: 7/24/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

30yo male weight lifter who 10 days ago had a painful left shoulder injury after bench press. The next morning his left anterior chest wall and left upper arm were bruised and swollen. He went to see his PCP who diagnosed him with a muscle strain. 8 days later the bruising and swelling have resolved but he still cant move his shoulder and comes to the ED.

The pec major attaches to the humerus and originates from the sternum and clavicle

Injury is usually due to tendon rupture off the humerus but can also occur at the muscle tendon junction or within the muscle belly itself.

Injury is becoming increasingly common due to the popularity in power lifting sports.

Mechanism: excessive tension on a maximally eccentrically contracted muscle.

Patients will complain of pain and weakness of the shoulder.

PE: Swelling and bruising to anterior medial arm. Palpable defect and deformity or anterior axially fold (may be hidden by swelling).

Weakness and pain with adduction and internal rotation and forward flexion

Chronic presentations can be challenging to diagnose. Consider ultrasound

Non operative treatment may be indicated for partial tears (sling, ice, NSAIDs)

Operative repair of tendon avulsions is very successful. Patients age, occupation/activity level and location of injury and condition of tear are considered.

Category: Orthopedics

Title: Foot Sesamoid injuries

Keywords: Foot injury, bipartate (PubMed Search)

Posted: 7/10/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Sesamoid Injuries

Unlike other bones in the human body that are connected to each other at joints, sesamoid bones are only connected via tendons (or are imbedded in muscle).

The largest sesamoid bone is the patella.

2 small sesamoid bones lie on the plantar foot near the great toe

Sesamoid bones can fracture and the surrounding tendons can become inflamed (sesamoiditis)

Traumatic injury is usually due to hyperextension and axial loading

Sx: Pain located under the great toe on the ball of the foot (Gradual with sesamoiditis and acutely with a fracture).

There may be associated swelling and bruising. Pain with palpation, flexion and extension.

The medial/tibial sesamoid is larger, has great weight bearing status and is more commonly injured that its lateral counterpart.

In many people (10 - 25%) the medial sesamoid of the foot has two parts (bipartite). This finding is bilateral in 25% of people.

This may confuse some providers as it may appear to be a fracture

Look for a smooth contour to the bones and clinically correlate (bruising, soft tissue swelling, etc.) if it is an incidental finding.

Other radiographic clues include

1) The fractured sesamoid is usually slightly larger than the lateral sesamoid while the bipartite sesamoid has a much larger medial sesamoid than lateral sesamoid

2) The fractured sesamoid shows a sharp, radiolucent, uncorticated line between the two fragments while the bipartite sesamoid has two corticated components

3) The fractured sesamoid fragments often fit together like pieces of a puzzle while the bipartite sesamoid has two components that do not fit together snugly

4) Other means to differentiate the two involve MRI and bone scanning

Treatment involves a stiff-soled shoe or applying a cushioning pad or J-shaped pad around the area to relieve pressure.

It may take months for the pain to subside.

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Plain films are commonly used to screen children for pelvic fractures or dislocations following blunt torso trauma

The sensitivity of this common screening practice is unknown

A recent study looked at this question.

Of 451 patients with pelvic fractures or dislocations, 382 had AP radiographs. Injury was correctly identified in 297 patients (sensitivity 78%).

The sensitivity was greater in the sicker subgroups :92% for those requiring operative intervention and 82% for those with hypotension

Plain AP pelvic radiographs should have a limited role in the sole evaluation of children with blunt torso trauma.

They should be incorporated in the assessment of hemodynamically unstable children and those in whom the clinician is not planning on otherwise obtaining an abdominal/pelvis CT.

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Medication-overuse headache (MOH) is one of the most common chronic headache disorders

Worldwide prevalence of 1 2%

Characterized by chronic headache and overuse of different headache medications

Withdrawal of the overused medication is the treatment of choice

A 2014 study looked at adolescent patients treated in a headache clinic with chronic post traumatic headaches (concussion headaches)

77 had chronic post-traumatic headache of 3-12 months' duration

54 of 77 (70.1%) met criteria for probable medication-overuse headache.

After the OTC medicine was stopped 68.5% had resolution or improvement !!

Excessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents.

Sometimes the advise of "just keep taking the motrin and it'll get better" isnt the answer

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Category: Orthopedics

Title: Sacrum and Coccyx Imaging

Keywords: X-ray, radiographs (PubMed Search)

Posted: 5/4/2016 by Brian Corwell, MD (Emailed: 5/28/2016) (Updated: 5/28/2016)
Click here to contact Brian Corwell, MD

Radiographs of the sacrum and coccyx in the emergency department (ED) have no quantifiable clinical impact, according to a study published in the American Journal of Roentgenology.  

Researchers from Emory University Midtown Hospital and Morehouse School of Medicine in Atlanta, GA, sought to determine the yield and clinical impact of sacrum and coccyx radiographs performed in the ED.

Sacrum and coccyx X-rays performed on 687 consecutive patients over a six-year period in level-1 and level-2 trauma centers (4 total hospitals). The patients’ mean age was 48.1, 61.6% were women. The images were categorized as positive for acute fracture or dislocation, negative, or other.


The researchers then analyzed:

• Follow-up advanced imaging in the same ED visit

• Follow-up advanced imaging within 30 days

 New analgesic prescriptions

• Clinic follow-up

 Surgical intervention within 60 days


The researchers found positive results in 58 of the 687 patients, a positivity rate of 8.4%.

None of the 58 positive cases had surgical intervention.

There was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical follow-up among the patients evaluated at the level-1 trauma centers.

However at the level-2 trauma centers, 34 (97.1%) of 35 patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals. Negative cases were at 82.9%.

Of all cases, 39 patients (5.7%) underwent advanced imaging in the same ED visit and 29 patients (4.3%) underwent imaging within 30 days.

“Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit,” the authors wrote. “There was no significant difference in 30-day advanced imaging at the level-1 trauma centers, but there was at the level-2 trauma centers.”

The researchers concluded that routine sacrum and coccyx radiography should not be part of ED practice and that patients should be treated conservatively based on clinical parameters.

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What is their risk of MI???

Anger outbursts are bad for your heart. Out of 300 patients with an acute MI, just over 2% reported losing their temper within 2 hours of the event. A review of nine studies of rage and cardiovascular events all found an increase in cardiovascular events in the 2 hours preceding an anger outburst. Examples included arguments at home, at work or by road rage. Compared with their usual anger levels, the relative risk of heart attack from a fit of rage was 8.5.

What about those of us who are just fanatics, I mean fans....A recent study of World Cup soccer found that the intense strain and excitement of viewing a dramatic soccer match more than doubles the risk of acute heart attack, particularly in men with known coronary heart disease. This was regardless of the outcome of the match!

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Category: Orthopedics

Title: Exercise and the heart

Keywords: Sudden cardiac death, physical activity (PubMed Search)

Posted: 4/23/2016 by Brian Corwell, MD (Updated: 6/17/2024)
Click here to contact Brian Corwell, MD

Exercise and the heart

Exercise increases the risk of sudden cardiac death (SCD) acutely.

Exercise decreases the risk of SCD in the long term.

Regular physical activity (even as little as 15 mins/day) reduces the risk of cardiovascular disease (CVD). 

Up to 15% of MIs occur during or soon after vigorous physical exercise. This is typically in sedentary men with coronary risk factors.

In a 1993 study, in the first hour after heavy exertion, risk of heart attack rose more than 100-fold from baseline for habitually inactive persons. However, for frequent exercisers, this risk rose less than three-fold. Think of snow shoveling after a winter storm.

Both the Physicians’ Health Study and the Nurses’ Health Study show that the risk of SCD during exertion is reduced by habitual exercise.

If you are physically active, stay active. If you are not active, you should be because exercise has innumerable personal benefits. However, it is important to start gradually Some individuals at higher risk need to start under the guidance of a physician.

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Orthopedic documentation

1) Document location with specificity and laterality.

2) Document the location with as much specificity as possible

-Name of specific bone and specific site on bone (Shaft, head, neck, distal, proximal, styloid)

3) Document fractures as open/closed, displaced vs. non-displaced, routine or delayed healing,

-Orientation of fractures, such as transverse, oblique, spiral

- Document intra-articular or extra-articular involvement

4) For a particular injury, a complete note will include mention of the following

The joint above (e.g. for shoulder injuries this would be the neck, for hip injuries - the back)

The joint below

Motor (e.g. for arm injuries document the distal median, radial and ulnar motor innervation)



Skin (for all fractures document intact overlying skin esp. when covering with a splint)

Compartments (a simple mention of compartments are grossly soft/not tense will suffice)

*Especially relevant for forearm and tib/fib injuries

Category: Orthopedics

Title: Metacarpal Fractures

Keywords: Metacarpal Fractures (PubMed Search)

Posted: 3/26/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Metacarpal Fractures

* Localize fracture to head, neck or shaft (neck most common)

5th metacarpal most commonly fractured

* Note amount of angulation, shortening and the presence of malrotation

*Treatment is based on which metacarpal is fractured and the location of the fracture

*The amount of acceptable angulation varies by the digit involved

For example for index and long finger - acceptable angulation of the shaft is 10-20 degrees and neck is 10 to 15 degrees

Whereas for the 5th digit - acceptable angulation for the shaft is 40 degrees and neck is 50 degrees


No degree of malrotation is acceptable (document the absence of this!)

Strongly suspect fight bite injury with abrasions/lacerations overlying metacarpal heads

Highly prone to infection given the proximity to the joint capsule

Consider lacerations over metacarpal fractures as open fractures (do not close/discuss management with hand surgery re timing of washout. Many prefer delayed fixation for suspected infections )

Document integrity of the extensor tendon (can be lacerated and retracted)

Category: Orthopedics

Title: NSAIDs and Osteoarthriits

Keywords: osteoarthritis, nsaids (PubMed Search)

Posted: 3/20/2016 by Michael Bond, MD (Updated: 6/17/2024)
Click here to contact Michael Bond, MD

A meta-analysis of 74 randomized trials with a total of 58,556 patients was recently published in the Lancet that looked at the effectiveness of NSAIDs in the treatment of osteoarthritis (OA) pain.

Briefly, their conclusion was that:

  1. Acetaminophen is ineffective as a single-agent in the treatment of OA.
  2. Diclofenac 150 mg/day had best evidence to support it as the most effective NSAID available presently with respective to its effectiveness in relieving pain and improving function.
  3. They found no evidence that treatment effects varied over the duration of treatment ( no tolerance)

You can find the article here

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Category: Orthopedics

Title: Femoral neck fractures

Keywords: X-ray, Hip pain (PubMed Search)

Posted: 3/12/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Femoral neck fracture

  • The most commonly missed hip fracture

We typically think of the presentation of the displaced fracture severe pain, writhing in the bed, unable to ambulate, limited ROM

* However, patients with nondisplaced fractures (15 20%) may walk with a limp

* Occurs primarily in the elderly & osteoporotic population after a fall directly onto the hip

* Look for a cortical step-off in the femoral neck (w/ foreshortening)

* A patient with a minimally displaced fracture may only complain of hip, knee, or groin pain and may be able to walk (albeit with a limp)

* Almost 9% of hip fractures are radiographically normal (Nondisplaced or impacted fractures)

* Fractures which were initially nondisplaced, may become displaced upon re-presentation

* Remember the limitations of plain x-ray in the evaluation of femoral neck fractures!

* Because of the significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip

Category: Orthopedics

Title: Achilles tendon rupture

Keywords: Achilles tendon rupture (PubMed Search)

Posted: 2/27/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Achilles tendon rupture

More common in

men, ages 30 - 40yo, s/p steroid injections, fluoroquinolone use, and episodic athletes "weekend warriors

Mechanism: usually during an athletic endeavor, sudden forced planar flexion or violent dorsiflexion of a plantar flexed foot

Location: Usually occurs 4 to 6 cm ABOVE the Achilles calcaneal insertion (hypovascular region)

Patient will report a sudden pop, gunshot like sound

History: Will report heel and calf pain and weakness/inability to walk

Physical examination: Palpable gap, weakness with plantar flexion, + Thompsons test

Consult orthopedics and splint in resting equinus

Category: Orthopedics

Title: Spondylolysis

Keywords: back pain, sports injury (PubMed Search)

Posted: 2/14/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD


Prevalence 3-6% in the general population (Higher in athletes)

Location: L4 (5-15% of cases) & L5 (85-95% of cases)

Population: More likely in the skeletally immature athlete due to the vulnerability of the immature pars interarticularis to repeated stress

Symptoms: Lumbar pain worse with extension

Higher risk sports: Gymnastics, diving, weightlifting, wrestling

Treatment: Bracing and activity modification, physical therapy

- Good results in 80% with conservative management allowing return to play.

- Those who fail benefit from iliac crest bone grafting and posterolateral fusion.

-Return to play is controversial in this group

Please review th images below for anaomy and imaging appearence

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Recommended follow-up for common orthopedic injuries

Initial follow up within a 5-7 days. If surgery needed, usually wait until swelling has decreased and surgery performed after 7 days.

Within 5-7 days. Regardless of reduction, often needs surgery due to high risk of collapse. Again surgery can wait into 2nd week.

Barton (volar and dorsal tilt)
Same as Smith for both
Scapholunate dissociation
Within 5-7 days for 1st visit. Needs to be operated on within 3-4 weeks otherwise window for "repair" is gone.
Lunate dislocation
Within 3-5 days to assess reduction and neurovascular status. Higher risk of Carpal tunnel syndrome.
Perilunate dislocation
Within 3-5 days to assess stability, reduction, and neuro status.
Galeazzi (or any DRUJ injury)
Within 3-5 days as will need surgery ASAP.
Scaphoid fx seen on film
Within 5-7 days for X-ray and casting.
Scaphoid fx suspected
Within 7 days for evaluation. Usually followed 2 weeks later for X-rays.
Triquetral fracture
Within 5-7 days.

Category: Orthopedics

Title: Pediatric Fractures and the Salter Harris System

Keywords: Salter Harris, pediatric, fracture (PubMed Search)

Posted: 1/16/2016 by Michael Bond, MD (Updated: 1/19/2016)
Click here to contact Michael Bond, MD

The Salter Harris Classification System is used in pediatric epiphyseal fractures. The higher the type of fracture the greater the risk of complications and growth disturbance.

Some common exam facts about Salter Harris Fractures are:

  • The type II fracture is the most common.
  • The small metaphyseal fragment in Salter Harris type II and IV fractures is called the Thurston Holland Sign.
  • Type III and IV fractures often require open reduction and internal fixation due to the fracture extending into the joint.
  • Type V fractures may appear normal, but the epiphyseal plate is crushed and the blood supply is interrupted.

The Classification system as listed by Type:

  • Type I: A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened or displaced..
  • Type II: A fracture through the physeal growth plate and metaphysis.
  • Type III: A fracture through the physeal growth plate and epiphysis.
  • Type IV: A fracture through the epiphysis, physeal growth plate and metaphysis.
  • Type V: A crush injury of the physeal growth plate.

For Maite, a helpful mnemonic is SALTR , Slipped (Type I), Above (Type II), Lower (Type III), Through (Type IV), and Ruined or Rammed (Type V)

A image of the fractures can be found on FP Notebook at