Transient Synovitis vs Septic Arthritis of the Hip

Limping is a common reason for parents to bring their children to emergency departments. It is known that 77% of acute, atraumatic limp is dealt with in the ED, and 20% do not even complain of pain.¹ Our job as physicians is to complete appropriate assessments to not miss any serious pathology. Specifically, differentiating between transient synovitis (TS) and septic arthritis (SA) of the hip can be difficult and frustrating for everyone. What is your approach?

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By Salim Rezaie, MD|2019-09-10T13:38:27-07:00May 1, 2013|Orthopedic, Pediatrics, Radiology|

Patwari Academy videos: Pediatric head injury – To CT or not?

When would you obtain a CT for a pediatric patient who sustained a head injury? Watch this nice 11-minute video review by Dr. Raul Patwari, discussing the 2009 Lancet PECARN study.

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By Michelle Lin, MD|2019-02-19T18:07:48-08:00Feb 10, 2013|Orthopedic, Patwari Videos, Pediatrics, Radiology|

P-video: Remembering NEXUS criteria

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By Michelle Lin, MD|2019-01-28T22:08:17-08:00Jan 17, 2013|Orthopedic, P-videos, Trauma|

Trick of the Trade: Reducing the metacarpal neck fracture

General principles of fracture reduction involve axially distracting or pulling on a fracture fragment and pushing the piece back into anatomical alignment. This can be seen in the video below (automatically starts at 2:25 for the actual procedure). What if this approach doesn’t work? The fracture fragment remains immobile despite your best efforts.

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By Michelle Lin, MD|2026-06-16T16:02:17-07:00Jan 8, 2013|Orthopedic, Tricks of the Trade|

PV card: Metacarpal fractures

$metacarpal fracture rotationa angulationa=$ Patients with rotation deformities of the fingers from a metacarpal fracture should be reduced. All fingers should normally point towards the patient’s scaphoid bone.

Metacarpal (MC) fractures are common injuries, which often spark discussions about whether they should be reduced in the ED urgently.

What are the criteria for acceptable degrees of angulation? Are these criteria different for the MC neck versus shaft?
Which fractures tend to be unstable and thus require eventual operative repair?
How should I splint the injury?

Here’s a quick-reference card to help guide your management decisions. These recommendations may vary slightly based on what references you use. You may need to tailor your decisions based on your regional practices.

PV Card: Metacarpal Fractures

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Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Nicole Strauss at the UCSF-SFGH Orthopaedic Trauma Institute and my go-to hand expert for her input.

By Michelle Lin, MD|2021-10-08T09:33:03-07:00Dec 13, 2012|ALiEM Cards, Orthopedic|

Poll: How would manage a metacarpal fracture in the ED?

$Metacarpal5fracture$

I am in the process of creating a PV card on metacarpal fractures, divided into anatomical areas (base, shaft, neck, head), and am realizing that the EM and orthopedic literature don’t quite agree. Actually they are quite vague on whether reductions should occur in the ED vs orthopedics clinic in the next few days.

Do you need to close-reduce all angulated fractures in the ED, which are outside of “acceptable” angulations?
What exactly are “acceptable” angulations? Some sources say that angulations of 10, 20, 30, and 40 degrees are acceptable for MC neck fractures and only 10, 10, 20, and 20 degrees are acceptable for MC shaft fractures. These numbers, though, vary from reference to reference.

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By Michelle Lin, MD|2016-11-11T18:43:07-08:00Dec 5, 2012|Orthopedic|

Paucis Verbis: Antibiotics and open fractures

$Fx Tib Fib Open Irrigation open fractures antibiotics$

Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED.

Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides?

Pearl

Once you have significant soft tissue injury, you are automatically have a Type III fracture and should add an aminoglycoside.

PV Card: Open Fractures and Antibiotics

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Hoff W, Bonadies J, Cachecho R, Dorlac W. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011;70(3):751-754. [PubMed]

By Michelle Lin, MD|2021-10-11T15:20:36-07:00Jan 20, 2012|ALiEM Cards, Orthopedic|