Often times, I get called to triage to help decide whether a patient should be sent to Radiology for an initial x-ray after injuring their knee, ankle, and/or foot. After teaching one of the nurses about the Ottawa rules, she taped a list of these rules on the triage wall.
This installment of the Paucis Verbis (In a Few Words) e-card series reviews Ottawa Knee, Ankle, and Foot Rules.
How do you splint 2nd or 3rd metacarpal fractures? A short arm volar splint is usually applied, because a fracture should be immobilized one joint distal and proximal to the injury. This splint, however, unnecessarily immobilizes the 4th and 5th fingers. It makes gripping things with your hand difficult.
How accurate is the clinical knee exam?
JAMA published a meta-analysis trying to answer this question. Although they include patients with acute and chronic knee pain, it’s a good general review of the knee anatomy, historical clues, and exam elements.
In the ED, the knee exam is challenging because we see very acute injuries where knee pain and swelling often preclude an accurate exam. For patients with an equivocal exam, be sure to refer for orthopedic follow-up. A repeat exam should be performed once the pain and swelling subside.
This installment of the Paucis Verbis (In a Few Words) e-card series reviews the Knee Exam.
I used to be all confused and had a hard time memorizing all the different maneuvers (especially for the meniscus). It is much easier to remember after doing these knee exams routinely. Particularly, the lateral pivot test and McMurray test can be done with several rounds of simultaneous knee flexion-extension, internal-external rotation, and valgus stressing. Looking at diagrams almost makes things more confusing.
Go to ALiEM (PV) Cards for more resources.
Ankle fractures are a common injury diagnosed in the Emergency Department. Being able to speak Ortho-ese (i.e. the language of orthopedists) is invaluable in consulting the orthopedist over the phone. One ankle fracture classification system that our orthopedists like to use is the Lauge-Hansen system.
Go to ALiEM (PV) Cards for more resources.
Find the fracture in this patient with blunt knee trauma.As a general rule, plain films are insensitive in ruling out orthopedic injuries. One particularly tricky area is the knee. This 2-view knee series above is normal.
Did you know that the sensitivity of picking up knee fractures is as low as 79% with a 2-view series and 85% with a 4-view series? With the advent of CT imaging, more and more subtle fractures are being found.
Over the years, I have been frustrated by how inelegant finger nailbed closure is. Nailbed lacerations are often sustained by a major crush injury, resulting in a stellate and irregular laceration pattern. This typically also requires the crushed fingernail to be removed. Cosmesis is never ideal because pieces of the nailbed are often missing, as seen in the photo above.
Occasionally, nailbed lacerations are caused by a cutting rather than a crush mechanism. In these cases, I use a different technique. I leave the fingernail on. In fact, I use the fingernail to help reapproximate the nailbed edges.
A man recently presents with knee pain after pivoting and torquing his knee while falling. He complains of concurrent mild ankle pain. He presents with this tib-fib xray. Realizing that a proximal fibular fracture can present concurrently with a medial malleolus fracture or deltoid ligament rupture, we obtained xrays of the ankle. We were looking for a Maisonneuve fracture.