muscle & joint disorders - dr. adrian mo
TRANSCRIPT
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
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?
Herpetic Whitlow HSV-1 or HSV-2 (PROTECT YOURSELF FROM
EXPOSURE)
Usually only 1 finger is involved
Treatment:
Acyclovir
Splinting
Pain control
Flexor Tenosynovitis S. aureus or Streptococcus
Kanavel’s Sign
Treatment:
Emergent Hand Consultation
IV antibiotics
Ancef, Rocephin
Tetanus
Splinting
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
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
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
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
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