UMEM Educational Pearls - Orthopedics

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: 3/5/2024)
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: 3/5/2024)
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

Sever's disease also known as calcaneal apophysitis, is the most common cause of heel pain in the young adolescent (ages 8 to 12).

It can be thought of as the Achilles tendon equivalent of Osgood-Schlatter's disease (patellar tendon insertion pain).

It is a non inflammatory chronic repetitive injury.

Commonly seen bilaterally in up to two -thirds of cases.

Patients will complain of activity related pain to the heel.

There may be tenderness and local swelling at the Achilles tendon insertion.

Radiographs are not necessary for acute cases.

Treat with activity modification, heel raise, physical therapy.

Category: Orthopedics

Title: Concussion Recovery

Keywords: Adolescent, head injury (PubMed Search)

Posted: 12/26/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Protracted Recovery from Concussion

Age and sex may influence concussion recovery time frame

Methods: 266 adolescent athletes presenting to a sports medicine concussion clinic

Female athletes had a longer recovery course (P=0.002) and required more treatment interventions (p<0.001).

Female athletes were more likely to require academic accommodations (p<0.001), vestibular therapy (P<0.001) and medications (P<0.001).

Be aware that not all concussion patient subgroups with concussions recover in the same manner. Further study is needed to support whether female adolescent athletes require unique management and treatment guidelines.

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Quick pearl for those that are trying to complete their holiday shopping.

Mulder's sign is not a sign that there is an extra-terrestial in your ED, But rather a sign that your patient is suffering from a Morton's Neuroma (see pearl from 2012)

Patients will often complain of pain in 3rd and 4th intermetatarsal space and if you can reproduce the pain by compressing the metatarsal heads together then you have a Positive Mulder's sign. Check out the original pearl at

Parental Knowledge of pediatric concussion

Sample: Parents of children brought to pediatric hospital or outpatient clinics for evaluation of orthopedic injuries.

Participants scored an average of 18.4 (0-25) on knowledge and 63.1 (15-75) on Attitudes toward concussions.

Safest attitudes were seen in white females. Knowledge increased with income and education levels.

Parents from low income or education levels may benefit from additional education in the ED prior to discharge in addition to providing paper information which may not be read or understood.

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Category: Orthopedics

Title: Medial elbow pain and the ulnar collateral ligament

Keywords: Elbow, ligament, throwing athlete (PubMed Search)

Posted: 11/28/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Medial elbow pain is common among baseball pitchers and is also seen in other sports including football, javelin and gymnasts.

More than 97% of elbow pain in pitchers is located medially.

The ulnar collateral ligament of the elbow is an important structure in these patients.

While initially primarily seen in professional throwers, these injuries are now being seen in younger athletes.

Initially, patients may only note changes in stamina or strength of throws.

Later, they will note pain during the acceleration and follow through-phase of throwing

The Valgus stress test for UCL deficiency is similar to the valgus test for the knee

Treatment: splinting, ice, NSAIDs

Surgical indications: Failure of non-operative treatment with desire to return to same or higher level competition.

Hook of Hamate Fracture

Rare (2% of all carpal fractures)

Mechanism usually direct blow from a stick sport (golf, hockey, baseball)

Presents with hypothenar pain and pain with gripping activities

Physical examination - local swelling and tenderness to palpation over hook of hamate

Diagnostic test - Hook of hamate pull test

XR - standard wrist series but add carpal tunnel view

Happy Halloween!! 

I hope you have had a safe and fun Halloween. Thank you to all the people that are staffing the EDs on a Saturday Night Halloween.

Prostate-Selective Alpha Antagonists have been tied to Falls and increased risk of fractues in elderly men.  These medications can lead to syncope and hypotension putting patients at increased risk of falls. A recent canadian study showed that at 90 days of use; individuals on alpha antagonists were at increased risk of hospital visits for falls (1.45% vs. 1.28%) or fractures (0.48% vs. 0.41%). There was also an increased risk of  head trauma.

Please warn patients that are on these medications of the risks, so that injuries can be minimized. They should take specific care when changing postural positions, and report episodes of lightheadedness to their PCPs.

The article can be found at

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