An 18-year-old football player presents to the Emergency Department after an episode of transient numbness, tingling, and inability to move his right upper extremity after making a tackle. He continued playing without recurrence. The above imaging was obtained (Figure 1. Lateral cervical spine x-ray. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 32505).
A 17 year-old female who recently started training for a marathon presents with progressively severe pain over her midfoot, notable for point tenderness over the 2nd metatarsal shaft. The above image was obtained (Image 1. X-ray of the left foot. Image courtesy of Matthew Negaard, MD). (more…)
A 20-year-old male presents with right posterior thigh pain and difficulty walking after he felt a “pop” while sprinting in a race. An ultrasound of the right posterior thigh is performed and the above image is seen on the transverse view without compression (Image 1. ST- semitendinosus; BF – bicep femoris; H – hematoma. Courtesy of Matthew Negaard, MD).
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.
