Ortho Peds & Other

Open intraarticular wound:

  • Use a 30 ml syringe with an 18 gauge needle.
  • Select a site for arthrocentesis away from the wound tract.
  • Sterilly aspirate the joint. Blood return signifies hemarthrosis likely from intraarticular extension of the wound.
  • If no blood is aspirated, inject normal saline with a few drops of sterile fluorescein or methylene blue until the joint is fully distended.
  • Observe for extravasation of the dye from the wound, which would confirm intraarticular involvement.

If confirmed, pt needs OR for joint washout, Tdap, and iv abx.

Wound FB

If a WFB is small, in a harmless location, deep, asymptomatic, and an inert material (i.e. glass, metal), than it may be more damaging to attempt removal than to leave it in place. A WFB that is causing symptoms, soiled, in a location likely to cause future problems (i.e. sole of foot), or a reactive material (i.e. wood) is more likely to require removal. WFBs such as wood, plastic, clothing and vegetative matter can be detected by ultrasound however. Not all WFBs can be removed by irrigation or exploration in the ED. In these cases, the area should be padded and the patient should be referred to the appropriate consultant for removal. Consider antibiotics for retained WFBs. Give good disx instructions as this is a huge source of litigation.

Fight bite:
-appropriate antibiotics include ampicillin/sulbactam, piperacillin/tazobactam, ceftriaxone with metronidazole, or ciprofloxacin with metronidazole or clindamycin. Clindamycin does not cover Eikenella so it should NOT be used as a sole agent. The joint should be splinted.
-if NO infection present and pt can f/u for re-exam in 24h, outpt abx ok
-if infection present OR tendon/bone/joint capsule involved, admit for iv abx

Flexor tenosynovitis
-injury may be minor or even remote. Course may be fulminant or indolent
-may lead to tendon rupture, loss of function, and sepsis
-need Staph and Strep coverage +/- MRSA, GNR, or anaerobic coverage depending on risk factors
-Cover for Pseudomonas if the patient is diabetic and for Pasteurella multocida if the patient was bitten by an animal
-Kanavel signs:
1. Exquisite tenderness over the flexor tendon
2. Finger held in flexion at rest
3. Exquisite pain upon passive extension of the finger
4. Fusiform swelling of the finger
-consult ortho & hand surgeon ASAP; this is a surgical emergency requiring I&D in the OR

Septic olecranon bursitis
-history of local trauma (laceration, puncture) or preceding infection should raise suspicion. However, the absence of trauma or a wound does not rule out the possibility
exam should differentiate swelling of the olecranon bursa (increased pain in terminal flexion) from joint effusion (increased pain at terminal extension)
-look for erythema or warmth over the olecranon bursa, which would raise the suspicion for septic bursitis
-septic bursitis is ruled out if there is no warmth or erythema.  If the diagnosis is unclear, fluid can be aspirated and sent for cell count, gram stain, culture, and crystal analysis
-septic bursitis may lead to bacteremia, sepsis, and permanent bursa damage
-tx with antiStaph abx +/- MRSA coverage depending on risk factors

Gout
-tx: Relief should begin at 24 hours after NSAID therapy and NSAIDs should be continued for 24 hours after symptoms resolve. Colchicine is dosed at 0.5-0.6mg PO q1-2h until pain is controlled, 3 tabs have been taken within 3 hours, or 10 tablets within 24 hours.

Fracture blisters
= from the initial shearing injury, not from the cast
-fracture blisters should prompt contact with the treating orthopedist because they frequently overlie sites of planned internal fixation or surgical incisions
-for any pt presenting with pain in a casted or splinted limb, must remove it to examine the limb

Subungual hematoma
-usu due to nailbed laceration
-do NOT confuse subungual hematoma with Kaposi sarcoma or melanoma (verify a history of trauma)
-wipe with chlorhexidine and trephinate with cautery to relieve pain and prevent pressure necrosis
-underlying fracture is not a contraindication to trephination

Compartment syndrome
pain with passive stretch of a muscle in the suspected compartment, which is more sensitive and specific than the other findings. The affected area will be exquisitely tender and may be tense, hard, or firm
-levels >30mmHg or within 30mmHg of the diastolic blood pressure are suggestive of compartment syndrome.

Open fracture
-If the wound is >10cm with loss of bone coverage and severe soft tissue injury, an aminoglycoside should be added to cover for gram-negative organisms.
-Significant contamination of the wound, either by dirt, soil, gravel, or any other outside material warrants anaerobic coverage (specifically clostridium perfringens) with a penicillin (other options include metronidazole or clindamycin if PCN allergic)

Peds

Iliac avulsion fracture – Advise rest, ice, and NSAIDS. When in bed, a position that avoids tension on the affected muscle should be advised. The patient can bear weight as tolerated with crutches for additional comfort. Refer for a routine orthopaedics follow-up. Athletic activities can resume when the patient is able to participate without pain.

Torus fracture (ex: distal radius) consists of immobilization in a short arm cast for 2-3 weeks with orthopedic evaluation one week

Be wary of diagnosing sprains in children with tenderness near a growth plate. Rather, immobilize with a splint and refer to orthopedics for repeat films in 7-10 days to ensure you don’t miss a Salter-Harris type I or V fracture (esp if history of axial load).

Osteochondritis Dissecans (rare) = a subchondral bony lesion of an articular surface. A piece of cartilage with attached subchondral bone becomes detached, either partially or completely, resulting in a loose body in the joint space. Pts are young and athletic (children age 11-13 or adults age <30) with knee, elbow, or ankle pain. Leads to significant morbidity. Pts have intermittent clicking, locking, and pain and swelling; it is a repetitive use injury and may be exacerbated by trauma. May have a positive Wilson’s test in which the knee is internally rotated and extended from 90 degrees. A positive test is increased pain at 30 degrees or if pain is relieved by external rotation. Wilson’s sign (walking with the knee externally rotated to avoid impingment of the fragment on the condyle) may also be present. Comparison views of the opposite knee are suggested, both to ensure that the lesion seen isn’t an anomalous ossification center (also may be bilateral). Knee immobilizer, NWB, f/u with ortho.
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Fractures of distal radial and ulnar shafts (“both bone” fracture)
-look for tense compartments and skin breaks (open fractures common)
-eval for supracondylar humerus fractures, which creates a ‘floating elbow’ requiring surgical management
-assess radial head alignment to prevent a ‘missed Monteggia’ fracture pattern
-Incomplete (greenstick)* and complete fractures with minimal or no displacement/angulation can be managed with a sugar-tong or long-arm splint.
-If using a long-arm splint, hand positioning depends on location of the fractures.

  • Fractures of the distal third should be splinted in with the hand pronated, midshaft fractures with the hand in neutral, and proximal third fractures with the hand in supination to reduce rotational deformity.

Those with significant angulation (greater than 10 degrees), displacement, or shortening require closed reduction performed in the emergency department. Reduction is performed in a similar manner to that of Colles fractures; finger traps are applied and gravity used to distract the fracture fragments, followed by closed reduction and immediate splinting (same rules as above). Older children typically require only hematoma block, while younger children will require conscious sedation. Due to their excellent remodeling abilities and functional outcomes, children rarely require surgical intervention for uncomplicated forearm shaft fractures

*greenstick/incomplete fx = cortical disruption and periosteal tearing on the convex side of angulation with plastic deformation and intact periosteum on the concave side
-in isolated ulnar shaft fx, evaluate for Monteggia fracture by checking for radial head tenderness which may indicate that the radial head has spontaneously reduced
-In infants, up to 30 degrees of angulation is acceptable. In children less than 10 years old, no reduction is needed for angulation less than 10 degrees.
-For volarly angulated fracture, the fracture is manipulated with the forearm in pronation. In a dorsally angulated fracture, it is manipulated with the forearm in supination. Place ulnar greenstick fractures in a long arm splint

Metaphyseal corner fractures (bucket-handle fractures) of femur (Type II Salter-Harris) – suspect child abuse! (esp if infants & toddlers)
-exam: unable to bear weight. The knee is often held in flexion secondary to hamstring spasm. May be knee effusions and soft tissue swelling
-other fractures suspicious for child abuse: rib fractures, humeral fractures and skull fractures
-place in long leg splint, NWB, with prompt orthopedic referral for operative repair (esp if displaced)
child abuse: long bone fractures in nonambulatory infants, scapula fractures, rib fractures (normally very pliable and resistant to breaks unless large force applied), sternal fractures, skull fracture, and multiple fractures in various stages of healing

Spiral fracture of distal tibia (Toddler fracture)
-NOT child abuse (unless proximal tibia involved)
-weak force fracture due to rotational component in mechanism of injury
-may not be seen initially on xray – consider ultrasound
-NWB, long leg cast

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