A 42-year-old patient is brought in by EMS after jumping off of a two-story building. The primary survey is intact and the secondary survey demonstrates swelling, ecchymosis, and tenderness to the right heel. You obtain foot x-rays and see the following images (Image 1. Lateral view of the right foot. Author’s own images).
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 28-year-old man presents to the emergency department after a snow blower accident while at work. The patient was performing maintenance and he placed his hand into a clogged snow blower while the machine was still on. His hand subsequently got jammed in the snow blower, catching his second and third digits. The patient has an obvious amputation of the right third digit with the stump still connected to the hand via the flexor tendon, which is attached to the distal phalanx. He has pain in the right hand and lack of sensation to the distal phalanx.
Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series, where bedside ultrasound changed the management or aided in a diagnosis. In this case, an 18-year-old man presents with acute shoulder pain after an injury.
An 18-year-old male with no past medical history presents to the ED with acute-onset left shoulder pain that occurred just prior to arrival. The patient was involved in a physical altercation in which his left arm was pulled. He felt a “pop” followed by pain in the shoulder. The patient reports that his arm was pulled again a second time, further worsening the pain. He complains of persistent limited and painful range of motion (ROM) of the left shoulder. He has no history of prior shoulder dislocations, fractures, or other musculoskeletal injuries.
On physical examination, the patient’s left shoulder has limited active ROM due to pain but is able to perform abduction of more than 90 degrees, and internal and external rotation of the affected joint. There is tenderness to palpation of the anterolateral aspect of the left shoulder but no redness, significant swelling, or any obvious deformities.
Upon physical examination, there was a low clinical suspicion for shoulder dislocation, given the patient’s decent ROM. The clinical presentation suggested a shoulder sprain versus a partial tear of the rotator cuff muscles versus GHJ instability or subluxation, which may be secondary to above.
While an x-ray would be the usual initial imaging modality of choice in a patient presenting to the ED with a musculoskeletal injury, there can be delays in obtaining imaging depending on patient volumes, staffing, and resources. Given this, a bedside POCUS of the shoulder was performed using a posterior approach in order to quickly rule out a shoulder dislocation and expedite patient care.
The patient was placed in a shoulder sling and discharged home with instructions to take ibuprofen as needed for pain. He was instructed to rest the shoulder for the next few days and follow up with his primary care physician with consideration of physical therapy for shoulder strengthening exercises. Lastly, he was referred for outpatient orthopedic followup, as he may need further imaging (i.e. shoulder CT scan or MRI) and potential surgical intervention, if the symptoms persist.
Edited by Dr. Jeffrey Shih, Ultrasound For The Win (US4TW) Series Editor
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.