SplintER Series: “Pop in the Posterior Thigh”

transverse view of the hamstring

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).

 

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SplintER Series: My Knee, Again!

posterior tibiofemoral dislocation knee dislocation

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).

 

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SplintER Series: I Think My Knee Popped?

 

patellar subluxation

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.

  • PEARL: Patellar subluxations and dislocations are most commonly seen in the pediatric population [1].
  • PEARL: Patellar subluxation most frequently occurs in the lateral direction. Most commonly secondary to trauma, however, can also be seen in people with hypermobile joints.

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.

Potential complications of patellar subluxations

Image 2. Knee MRI – Sagittal cut showing large knee effusion. Image courtesy of John Kiel, DO.

Potential complications of patellar subluxations

Image 3. Knee MRI – Axial cut showing the osteochondral defect of the patella. Image courtesy of John Kiel, DO.

  • PEARL: In this case, the patient has a large effusion and loose body on the outpatient MRI. The medial constraint of the patella that prevents lateral subluxation, the medial patellofemoral ligament (MFPL), is torn.

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.

  • PEARL: Most common complaints include pain, joint effusion/swelling, lockage, decreased range of motion, joint instability, and/or crepitation [2].

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.

  • PEARL: In about 60% of the pediatric population, the zone of the MFPL injury is the predominant site of patellar insertion, which is an indication for surgical reconstruction [4].

 

References

  1. Chotel, F., Knorr, G., Simian, E., Dubrana, F., & Versier, G. Knee osteochondral fractures in skeletally immature patients: French multicenter study. Orthop Traumatol Surg Res. 2011;97(8). PMID: 22041573
  2. Kramer, D. E., & Pace, J. L. (2012). Acute Traumatic and Sports-Related Osteochondral Injury of the Pediatric Knee. Orthop Clin North Am. 2012;43(2), 227-236. PMID: 22480471
  3. Griffin, J. W., Gilmore, C. J., & Miller, M. D. (2013). Treatment of a Patellar Chondral Defect Using Juvenile Articular Cartilage Allograft Implantation. Arthrosc Tech. 2013;2(4). PMID: 24400181
  4. Dixit, S., & Deu, R. S. Nonoperative Treatment of Patellar Instability. Sports Med Arthrosc Rev. 2017;25(2), 72-77. PMID: 28459749

 

SplintER Series: Punched a Wall

X ray boxer's fracture

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].

  • Pearl: Unlike most hand and wrist fractures, metacarpal fractures are more likely to occur from axial loading than from a fall onto an outstretched hand (FOOSH) [1].

1. Skin:

  • Closely observe for any breaks on the dorsal surface, especially near the MCP joint, as this can indicate an open fracture which would require operative irrigation, debridement, and antibiotics.

2. Angulation:

  • Observe for any obvious malalignment. Dorsal angulation may cause depression of the MCP joint and disappearance of the normally appearing knuckle [1].

3. Neurovascular:

  • As always, any neurovascular deficits should prompt surgical consultation.
  • Pearl: Given the tight fascial layers of the hand, keep compartment syndrome in mind.

4. Rotational Alignment:

  • Observe by having the patient make a fist and checking for proper finger alignment. Extending lines from the fingers should show eventual convergence at the scaphoid. Any degree of malrotation warrants urgent surgical consultation [3].

Image of hand malrotation

Opinions vary, but most agree that any angulation beyond 30 degrees at the metacarpal neck requires reduction [1].

  • PEARL: Anesthesia can be achieved by an ulnar nerve or hematoma block, with reduction accomplished by applying dorsal pressure with the MCP, PIP, and DIP in flexion.

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.

  • Pearl: Studies have shown that patients with less than 60 degrees of angulation can be managed non-operatively and expect a full functional recovery. Cosmetic defects may occur, but are often preferable to surgical intervention if function is kept [4].
  • Pearl: If the fracture is comminuted, significantly angulated, malrotated, or intraarticular, educate the patient the possibility of surgical fixation [4].

References

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.

  1. Malik S, Herron T, Rosenberg N. Fifth Metacarpal Fractures (Boxer’s Fracture). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. PMID: 29261999
  2. Nakashian MN, Pointer L, Owens BD, Wolf JM. Incidence of metacarpal fractures in the US population. Hand (NY). 2012;7(4):426-430. PMID: 24294164
  3. Yang S, Kim JP. Hand Fractures. J Korean Fract Soc. 2018 Apr;31(2):61-70. DOI: 10.12671/jkfs.2018.31.2.61
  4. van Aaken, J, et al. Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial. Archives of Orthopaedic and Trauma Surgery: Including Arthroscopy and Sports Medicine. January 2016 136(1):135-142. PMID: 26559192

SplintER Series: Pain in the Snuff Box

Scaphoid Fracture
 
A 16-year-old male presents to the ED after injuring his wrist during a track meet. The patient was running hurdles when he fell forward, planting his wrist into the ground. The imaging is shown below (courtesy of Dr. Hani Makky ALSALAM, Radiopaedia.org).
Scaphoid fracture (Image 2).

  • Pearl: The scaphoid is the most frequently fractured carpal bone [1,2].
  • Pearl: Fractures occur at the waist, proximal third, and distal portion: 65%, 25%, and 10% respectively [3].

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].

Snuff Box

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.

  • Pearl: There is also a scaphoid view that is recommended if the department technician is trained. This image is a posterior-anterior view of the scaphoid that is obtained with the wrist in ulnar deviation [7].

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].

  • Pearl: Initial imaging can miss 5-20% of fractures [8].

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].

  • Pearl: AVN is of high concern and directly correlated to the site of fracture. The scaphoid receives blood supply via retrograde flow – the more proximal the fracture, the higher the risk of AVN [1-4,6].
  • Pearl: SNAC occurs when the proximal scaphoid remains attached to the lunate and the distal fragment rotates into flexion. This results in early osteoarthritis between the distal scaphoid and radial styloid, leading to pain and decreased functionality [9].

 

References & Resources:

For a review of other causes of traumatic wrist pain check out the SplintER archives.

  1. Tada K, Ikeda K, Okamoto S, Hachinota A, Yamamoto D, Tsuchiya H. Scaphoid Fracture–Overview and Conservative Treatment. Hand Surg. 2015;20(2):204-209. PMID 26051761.
  2. Sabbagh MD, Morsy M, Moran SL. Diagnosis and Management of Acute Scaphoid Fractures. Hand Clin. 2019;35(3):259-269. PMID 31178084.
  3. Gupta V, Rijal L, Jawed A. Managing scaphoid fractures. How we do it?. J Clin Orthop Trauma. 2013;4(1):3-10. PMID 26403769.
  4. Basu A, Lomnassey LM, Demos TC, et al: Your Diagnosis? scaphoid fracture. Orthopedics 28:177, 2005. PMID 15751361
  5. Watson HK, Weinzweig J. Physical examination of the wrist. Hand Clin. 1997;13(1):17-34. PMID 9048180.
  6. Stapczynski, JS, Tintinalli, JE. Wrist injuries. In Tintinalli’s emergency medicine: A comprehensive study guide, 8th Edition. New York, NY: McGraw-Hill Education; 2016: 1853-1854
  7. Cheung GC, Lever CJ, Morris AD. X-ray diagnosis of acute scaphoid fractures. J Hand Surg Br. 2006;31(1):104-109.PMID 16257481.
  8. Ashmead D 4th, Watson HK, Damon C, Herber S, Paly W. Scapholunate advanced collapse wrist salvage. J Hand Surg Am. 1994;19(5):741-750. PMID 7806794.
  9. Moritomo H, Tada K, Yoshida T, Masatomi T. The relationship between the site of nonunion of the scaphoid and scaphoid nonunion advanced collapse (SNAC). J Bone Joint Surg Br. 1999;81(5):871-876. PMID: 10530853.
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