An 80-year-old female presents to the Emergency Department with right shoulder pain, deformity, and decreased range of motion after falling down half a flight of stairs. AP and Y-views of the right shoulder were obtained (Images courtesy of Kenneth Chang, DO).
A 61-year-old F presents to the ED from the orthopedic clinic with acute right knee pain. She endorses that while a physical exam was being performed, she had sudden onset knee pain. Denies any trauma to the knee, radiation of pain, numbness, tingling, or swelling. The above knee radiographs were obtained (Images courtesy of John Kiel, DO).
13-year-old M presents to the ED with acute left knee pain that occurred about 2 hours prior to arrival while playing football. No direct trauma. Reports two audible “pops” followed by knee instability. Radiograph as pictured (Image 1. Plain film of the left knee. Image courtesy of John Kiel, DO).
Patellar subluxation. This patient likely had a spontaneous dislocation and relocation (the two “pops”). There is a very small avulsion fracture noted along the lateral femoral condyle.
It is very important to complete a full neurovascular exam. As well as performing a thorough musculoskeletal exam, assessing the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), lateral cruciate ligament (LCL), medial cruciate ligament (MCL), and patella. View the ALiEM 2 minute knee examination.
If there is an abnormal neurovascular exam or unstable knee examination, pursue further workup such as a CT scan. As an outpatient, further imaging that can be considered is an MRI knee. See below for images from this case.
Image 2. Knee MRI – Sagittal cut showing large knee effusion. Image courtesy of John Kiel, DO.
Image 3. Knee MRI – Axial cut showing the osteochondral defect of the patella. Image courtesy of John Kiel, DO.
This is one of the few times a knee immobilizer is appropriate. However, close follow-up with sports medicine or orthopedics should be stressed as atrophy and contractions can occur if the patient remains in the knee immobilizer for an extended duration. Provide crutches and ask the patient to be non-weight bearing. Anti-inflammatories as needed are appropriate and encourage icing and movement.
An urgent follow-up is needed with sports medicine or orthopedics for further evaluation [3]. In the case of this patient who already had an MRI, he will typically require chondroplasty of the patella and MFPL reconstruction as an outpatient. Post-operatively, he will undergo standard physical therapy with an emphasis on range of motion and quadriceps strengthening.
A 27-year-old male presents to the ED with left hand pain after punching a wall. He has pain and swelling on the ulnar side of the dorsal hand. The above hand radiographs were obtained (image courtesy of Mark Hopkins).
This patient has a fracture of the 5th metacarpal neck, otherwise known as a Boxer’s fracture. It is so named because a majority of these fractures come from punching an object [1].
1. Skin:
2. Angulation:
3. Neurovascular:
4. Rotational Alignment:
Opinions vary, but most agree that any angulation beyond 30 degrees at the metacarpal neck requires reduction [1].
Patients should be placed in an ulnar gutter splint. They can follow up with a hand specialist as determined by institutional policy as an outpatient in 1 week.
Looking to bone up in general? Check out the SplintER archives. Want more information on hand radiographs? Check out SplintER Series: Case of a First Metacarpal Fracture or Trick of the Trade: Reducing the metacarpal neck fracture.
Image 2. Fracture of scaphoid. Case courtesy of Dr. Hani Makky ALSALAM, Radiopaedia.org, rID: 10398 (arrow added by authors).
Occurs when there is an axial load across hyper-dorsiflexed, pronated and ulnar deviated wrists or from a fall on the outstretched hand (FOOSH) [1-3].
Snuff box tenderness, scaphoid tubercle tenderness over the volar aspect of the wrist, and/or positive scaphoid compression test (pain reproduced with an axial load applied through thumb metacarpal) [4-6].
Image 3. Location of scaphoid tubercle (S) at the base of the thenar eminence (left) and the location of the snuffbox (SB) on the radial aspect of the wrist (right). Images by authors.
Plain film imaging with anterior-posterior, oblique, and lateral views to assess for injury.
Abnormal exam: If not neurovascularly intact or if there is an open fracture, consult orthopedics in the ED.
Identified scaphoid fracture: Thumb spica splint and prompt orthopedic follow-up usually within 1-3 days as though some fractures only require immobilization for treatment; surgery may be required for some fracture patterns [1-3,6].
Suspicion for fracture without radiographic evidence: Place in thumb spica splint and repeat imaging in 14 days to evaluate for occult fracture. If negative again at that time with high clinical suspicion, the patient should have an outpatient MRI [1-3,6].
Classic complications include vascular necrosis (AVN), and scaphoid nonunion advanced collapse (SNAC). Associated fractures and dislocation of the surrounding carpal bones, distal radius, ligamentous disruption may be seen as other pathology occurs secondary to a FOOSH [1-4,6].
For a review of other causes of traumatic wrist pain check out the SplintER archives.
29-year-old F presents to ED with acute onset knee pain. Reports hearing an audible “pop” after twisting her leg while running down the stairs at home. She explains that her right knee is stuck, and she can neither flex nor extend it. An image is shown below (courtesy of Andrew Murphy, Radiopaedia.org)
A 17-year-old male baseball catcher presents with right knee pain after an opponent slid into home plate, striking the anteromedial aspect of the patient’s knee while it was in extension trying to block the plate. An x-ray of the tibia and fibula was obtained (courtesy of Dr. Haytham Bedier, Radiopaedia.org).
This is a proximal avulsion fracture of the styloid process of the fibula, indicating injury to the posterolateral corner (PLC) of the knee [1].
This injury usually occurs from varus stress in a hyperextended knee- think a blow to the anteromedial tibia with the knee in extension [2].
The arcuate sign is a horizontal linear lucency through the head of the fibula that represents a fracture of the styloid process [3].
A proximal fibular avulsion fracture is commonly associated with injury to the posterior cruciate ligament, anterior cruciate ligament, popliteus, or meniscus. It is frequently seen with bone contusions and sometimes a tibial plateau fracture [2].
This injury indicates potential significant instability of the knee and requires outpatient follow-up with MRI. Operative management will be dictated on an individual basis, after evaluating MRI results. In the emergency department, place the patient in a knee immobilizer and recommend non-weight-bearing status until further imaging. Follow-up with orthopedics or sports medicine within 1 week.
If diagnosis of this injury is delayed, posterolateral instability may develop. If not recognized and managed appropriately, this may hinder the success of a cruciate ligament reconstruction [1].
Want more information about the knee exam? Check out the SplintER archives.
