Maryland ACEP Chapter Educational Conference & Annual Meeting - - PDF document

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Maryland ACEP Chapter Educational Conference & Annual Meeting - - PDF document

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Maryland ACEP Chapter Educational Conference & Annual Meeting March 12, 2020 FACULTY: Eric R. Friedman, MD PRESENTATION The State of the Nonunion DESCRIPTION This presentation will discuss commonly mismanaged orthopedic injuries in the

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Maryland ACEP Chapter Educational Conference & Annual Meeting March 12, 2020

FACULTY: Eric R. Friedman, MD PRESENTATION The State of the Nonunion DESCRIPTION This presentation will discuss commonly mismanaged orthopedic injuries in the emergency department. You will learn to be comfortable with multiple different ankle injuries. Be knowledgeable about knee injuries and how to perform a femoral nerve block. OBJECTIVES

  • High ankle sprains: the different ligaments that get injured, XRAY findings, and management
  • Fibula fractures: Weber criteria
  • ACL tears: Different PE maneuverers to evaluate
  • Knee dislocation and management
  • Management of a commonly missed wrist injury: Hook of hamate fx and diagnosis

DISCLOSURE No significant financial relationships to disclose.

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The State of the Nonunion

By Eric Friedman

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Facts

  • 206 bones in the human body
  • All of them are capable of breaking
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High Ankle Sprain

  • 25k ankle sprain per day in EDs (including low ankle sprain)
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High Ankle Sprains

  • Syndesmotic membrane injury
  • Symptoms
  • Anterolateral ankle pain proximal to AITFL
  • May have medial sided ankle tenderness/swelling
  • More difficulty bearing weight than normal lateral ankle sprains
  • Physical Exam
  • Syndesmosis Tenderness (best predictor of return to play)
  • Squeeze Test
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Maisonneuve Fracture

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Case

  • Volleyball player landed and rolled

ankle

  • TTP of lateral malleolus
  • XRAY: Fibular Fracture
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Weber Criteria

  • Isolated distal fibular fractures
  • Weber A: below the level of the syndesmosis
  • Weber B at level of the syndesmosis, need stress view to determine stability
  • Weber C: above the level of the syndesmosis, unstable
  • Any bimalleolar (or trimalleolar) fracture is unstable
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Weber A

  • Non-op
  • Stable
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Weber B

  • Need to do a stress view and look for medial widening
  • >4-5 mm of medial clear space widening→surgery
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Weber C

  • Unstable and needs surgery
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Case

  • 25 yo M presents with right

knee pain

  • He planted and twisted to

cut and felt pain

  • Exam: rt knee edema
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  • Segund Fracture
  • Fracture of the lateral

tibial condyle of the knee

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ACL tears

  • Acute hemarthrosis
  • More common in females
  • ACL is the most commonly injured ligament in the body for which surgery is

frequently performed

  • MCL is most common ligament torn
  • Usually noncontact when cutting and pivoting
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Physical Exam

  • Lachman test: Place the patient's knee in about 20-30 degrees flexion, stabilize femur and anteriorly translate

tibia.

  • Positive test: >2mm of anterior translation compared to the uninvolved knee and/or 10mm of anterior translation.
  • Sensitivity: ~84% Specificity: ~94%
  • Anterior Drawer test: knees flexed to 90 degrees and feet flat, grab the proximal lower leg, just below the

tibiofemoral joint line, and translate the lower leg anteriorly

  • Positive test: lack of end feel or excessive anterior translation relative to the contralateral side
  • Sensitivity: ~73% Specificity: 93%
  • Lelli test/Lever sign
  • Sensitivity: 100% Specificity 100%
  • Repeat study Sensitivity: 63% Specificity 90% (worse than Lachman and anterior drawer in study)
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Why Does All This Matter in the ED?

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Another Case

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Nurse Calls

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Relocated

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Another Case

  • Golfer with rt.

wrist pain

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Exam

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Hook of Hamate Fracture

  • Seen in golfers and baseball players
  • Physical Exam:
  • TTP of the hamate bone in the hypothenar eminence
  • Decreased grip strength
  • Hook of hamate pull test: hand held in ulnar deviation as patient flexes DIP joints of 4th and 5th digits
  • Treatment
  • Splint (short arm splint)
  • Surgical Removal (quicker return to play)
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References

  • https://www.orthobullets.com/trauma/1037/femoral-neck-fractures
  • https://www.ncbi.nlm.nih.gov/pubmed/28759316
  • https://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain-and-

syndesmosis-injury

  • https://coreem.net/core/ankle-stress-views/
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5639970/
  • https://www.ncbi.nlm.nih.gov/pubmed/25536951
  • https://www.rch.org.au/clinicalguide/guideline_index/Femoral_Nerve_Block/