muscle & joint disorders - dr. adrian mo

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Objective To better identify these Orthopaedic emergencies when

there isn’t an obvious trauma related injury

Discuss certain procedures that ER physicians will need to be able to perform

Give the appropriate treatment and disposition for the patient

Table of Contents Hand

Joints

Muscle

Pediatric Hip

What is this?

Versus this?

Versus this?

So what’s the difference?Paronychia Felon

Infection of the lateral nail fold Infection of the pulp space of fingertip

S. aureus or Streptococcus S. aureus

If early, can treat with Keflex and warm compresses

Treatment: I&D, splint, antibiotic

If late and with pus, will need I&D plus above

What is the proper way to incise and drain a felon?

So should I cut into this?

Herpetic Whitlow HSV-1 or HSV-2 (PROTECT YOURSELF FROM

EXPOSURE)

Usually only 1 finger is involved

Treatment:

Acyclovir

Splinting

Pain control

Case:

Flexor Tenosynovitis S. aureus or Streptococcus

Kanavel’s Sign

Treatment:

Emergent Hand Consultation

IV antibiotics

Ancef, Rocephin

Tetanus

Splinting

Always beware of those fingers…

Symmetric polyarticular joint pain

RA

SLE

Rheumatic Fever

Bacterial endocarditis

Hepatits B

Rubella

Asymmetric polyarticular joint pain

Reiter’s “can’t see, can’t pee, can’t climb a tree”

Gonococcal Arthritis Associated rash accompanies arthritis

Treat with ceftriaxone

Henoch-Schonlein Purpura Usually in children

Triad of migratory arthritis, palpable purpuric rash, and abdominal pain

Lyme Disease Usually affects the knees

Stage III – months to years after initial infection

Treat with doxycycline

Case: 58 year old male presents to ED with fever and left knee

pain x 2 days. Knee is swollen, warm, and tender on exam with decreased range of motion. Labs show an elevated ESR. Athrocentesis show > 100,000 WBC with predominance of PMNs and low glucose. What is the diagnosis?

Septic Joint S. aureus

Knee most commonly affected joint

Diagnosis: arthrocentesis

Treatment: surgical consultation, IV antibiotics

Arthrocentesis

Synovial Fluid C – cell count, crystals

Crystals for gout, pseudogout

WBC

< 200 with < 25% PMNs is normal

200-2000 with < 25% PMNs is osteoarthritis

2000-5000 with > 50-75% PMNs is inflammatory

> 50,000 with > 75% PMNs is septic joint

A – appearance

P – protein

S – sugar, stain (gram) Sugar usually low in septic joint and RA

Gout/Pseudogout

Compartment Syndrome Usually from trauma but

can be from prolonged exercise

Pain, decreased 2 point sensory discrimination, paresthesia, palpable tenderness, pallor of skin, pulselessness

STAT orthopedic consultation

Measure compartment pressure and fasciotomy if pressure is > 30 mmHg

Rhabdomyolysis Causes:

Trauma – crush injuries

Exertion – exercise

Seizures

Body temperature changes – malignant hyperthermia, heat stroke

Drugs – cocaine, alcohol

Labs: CK > 5x normal

Myoglobinuria

FLUIDS, FLUIDS, FLUIDS 200-1000 mL per hour

Target urine output is 3 mL/kg/hr

Does type of fluid help?

May need dialysis

Pediatric Hip Disorders

Case: “You are in the newborn nursery on your pediatrics

rotation as a third year. You’re doing the Ortolanimaneuver on a newborn and you hear a click. What is going on?”

Congenital Hip Dislocation

Asymmetry seen to skin folds

Needs orthopedics for a Pavlik Harness

Case: “You are working in the Children’s ER when a 5 year old

presents with fever and a limp on gait exam. The affected leg is flexed, abducted, and externally rotated. What is going on?”

Septic arthritis of the hip

Same findings on synovial fluid as described above

Usually S. aureus but sickle cell patients can have salmonella (osteomyelitis)

Case: “You are examining a 8 year old male who appears well

and non-toxic but has pain to the hip and knee with a limp and inability to bear weight. What is going on?”

Transient toxic synovitis

Sometimes related to a recent viral infection (URI)

Diagnosis of exclusion

Self-limiting - 1 week

Still need joint aspiration to rule out septic joint

Case: “You are examining a 10

year old male who presents with a limp. There is hip pain, knee pain, and thigh pain. There is limited range of motion to hip with no fevers, normal WBC, and normal ESR. Hip XR shows (picture). What is going on?”

Legg-Calve-PerthesDisease Non-weight bearing

Pain control

Case: “You meet an overweight

13 year old boy who is eating a cheeseburger in your ER. He has not been really able to walk recently. He complains of hip pain that radiates down to knee. Here is his pelvis XR. What is going on?”

Slipped capital femoral epiphysis Orthopedic consult

Admit if bilateral

No weight bearing

The End

References:1. http://lifeinthefastlane.com

2. http://emedicine.medscape.com

3. http://www.orthobullets.com/hand/6102/felon

4. http://www.wheelessonline.com/ortho/infectious_flexor_tenosynovitis

5. http://www.aafp.org/afp/2002/1015/p1497.html

6. http://www.surgicalcriticalcare.net/Guidelines/rhabdomyolysis%202009.pdf

7. http://orthoinfo.aaos.org/topic.cfm?topic=a00070

8. UpToDate

9. Pepid

10. MedComic

11. Dr. Dustin Williams