Dr. Adrian Mo's Senior Grand Rounds on Muscle and Joint Disorders.

2. Objective
 To better identify these Orthopaedic emergencies when
there isn’t an obvious trauma related injury
 Discuss certain procedures that ER physicians will need to
be able to perform
 Give the appropriate treatment and disposition for the
patient

3. Table of Contents
 Hand
 Joints
 Muscle
 Pediatric Hip

4. What is this?

5. Versus this?

6. Versus this?

7. So what’s the difference?
Paronychia Felon
Infection of the lateral nail fold Infection of the pulp space of fingertip
S. aureus or Streptococcus S. aureus
If early, can treat with Keflex and warm
compresses
Treatment: I&D, splint, antibiotic
If late and with pus, will need I&D plus
above
 What is the proper way to incise and
drain a felon?

9. So should I cut into this?

10. HerpeticWhitlow
 HSV-1 or HSV-2 (PROTECTYOURSELF FROM
EXPOSURE)
 Usually only 1 finger is involved
 Treatment:
 Acyclovir
 Splinting
 Pain control

11. Case:

12. FlexorTenosynovitis
 S. aureus or Streptococcus
 Kanavel’s Sign
 Treatment:
 Emergent Hand Consultation
 IV antibiotics
 Ancef, Rocephin
 Tetanus
 Splinting

13. Always beware of those fingers…

14. Symmetric polyarticular joint pain
 RA
 SLE
 Rheumatic Fever
 Bacterial endocarditis
 Hepatits B
 Rubella

15. Asymmetric polyarticular joint
pain
 Reiter’s
 “can’t see, can’t pee, can’t climb a tree”
 GonococcalArthritis
 Associated rash accompanies arthritis
 Treat with ceftriaxone
 Henoch-Schonlein Purpura
 Usually in children
 Triad of migratory arthritis, palpable purpuric rash, and abdominal pain
 Lyme Disease
 Usually affects the knees
 Stage III – months to years after initial infection
 Treat with doxycycline

16. Case:
 58 year old male presents to ED with fever and left knee
pain x 2 days. Knee is swollen, warm, and tender on exam
with decreased range of motion. Labs show an elevated
ESR. Athrocentesis show > 100,000WBC with
predominance of PMNs and low glucose.What is the
diagnosis?

17. Septic Joint
 S. aureus
 Knee most commonly
affected joint
 Diagnosis: arthrocentesis
 Treatment: surgical
consultation, IV
antibiotics

18. Arthrocentesis

19. Synovial Fluid
 C – cell count, crystals
 Crystals for gout, pseudogout
 WBC
 < 200 with < 25% PMNs is normal
 200-2000 with < 25% PMNs is osteoarthritis
 2000-5000 with > 50-75% PMNs is inflammatory
 > 50,000 with > 75% PMNs is septic joint
 A – appearance
 P – protein
 S – sugar, stain (gram)
 Sugar usually low in septic joint and RA

20. Gout/Pseudogout

22. Compartment Syndrome
 Usually from trauma but
can be from prolonged
exercise 
 Pain, decreased 2 point
sensory discrimination,
paresthesia, palpable
tenderness, pallor of skin,
pulselessness
 STAT orthopedic
consultation
 Measure compartment
pressure and fasciotomy if
pressure is > 30 mmHg

23. Rhabdomyolysis
 Causes:
 Trauma – crush injuries
 Exertion – exercise
 Seizures
 Body temperature changes – malignant hyperthermia, heat stroke
 Drugs – cocaine, alcohol
 Labs: CK
 > 5x normal
 Myoglobinuria
 FLUIDS, FLUIDS, FLUIDS
 200-1000 mL per hour
 Target urine output is 3 mL/kg/hr
 Does type of fluid help?
 May need dialysis

24. Pediatric Hip Disorders

25. Case:
 “You are in the newborn nursery on your pediatrics
rotation as a third year.You’re doing the Ortolani
maneuver on a newborn and you hear a click.What is
going on?”
 Congenital Hip Dislocation
 Asymmetry seen to skin folds
 Needs orthopedics for a Pavlik Harness

27. Case:
 “You are working in the Children’s ER when a 5 year old
presents with fever and a limp on gait exam.The affected
leg is flexed, abducted, and externally rotated.What is
going on?”
 Septic arthritis of the hip
 Same findings on synovial fluid as described above
 Usually S. aureus but sickle cell patients can have salmonella
(osteomyelitis)

28. Case:
 “You are examining a 8 year old male who appears well
and non-toxic but has pain to the hip and knee with a limp
and inability to bear weight. What is going on?”
 Transient toxic synovitis
 Sometimes related to a recent viral infection (URI)
 Diagnosis of exclusion
 Self-limiting - 1 week
 Still need joint aspiration to rule out septic joint

29. Case:
 “You are examining a 10
year old male who presents
with a limp.There is hip
pain, knee pain, and thigh
pain.There is limited range
of motion to hip with no
fevers, normalWBC, and
normal ESR. Hip XR shows
(picture). What is going
on?”
 Legg-Calve-Perthes
Disease
 Non-weight bearing
 Pain control

30. Case:
 “You meet an overweight
13 year old boy who is
eating a cheeseburger in
your ER. He has not been
really able to walk recently.
He complains of hip pain
that radiates down to knee.
Here is his pelvis XR.What
is going on?”
 Slipped capital femoral
epiphysis
 Orthopedic consult
 Admit if bilateral
 No weight bearing

32. The End

33. References:
1. http://lifeinthefastlane.com
2. http://emedicine.medscape.com
3. http://www.orthobullets.com/hand/6102/felon
4. http://www.wheelessonline.com/ortho/infectious_flexor_tenosynovitis
5. http://www.aafp.org/afp/2002/1015/p1497.html
6. http://www.surgicalcriticalcare.net/Guidelines/rhabdomyolysis%202009.pdf
7. http://orthoinfo.aaos.org/topic.cfm?topic=a00070
8. UpToDate
9. Pepid
10. MedComic
11. Dr. DustinWilliams