Chapter 19. Orthopedics

Clinical Summary

Fractures are caused by high-energy forces on bones and may result from blunt or penetrating trauma. Fracture size and shape is determined by the amount of energy absorbed, the focus of energy, and mass and resistance of the affected bone. Obvious deformities may or may not be present, depending on the degree of fracture angulation and the presence of associated joint dislocation. Patients present with swelling and tenderness. If mental status is intact and there is no associated nerve damage, patients will complain of pain on palpation. Ecchymosis may not be present for minutes to hours and is dependent on associated tissue damage, thickness and integrity of overlying skin, and the degree of vascular injury.

Emergency Department Treatment and Disposition

Obtain plain films that ensure the entire injured area is evaluated at various angles, as fractures are often present on one view but not another. Provide analgesia, elevate the fractured bone, and apply cold compresses after more serious, associated injuries have been ruled out. Provide intravenous (IV) antibiotics for all patients with open fractures to prevent osteomyelitis. Consult orthopedics for all fractures, emergently in the case of open fractures, which may require wound irrigation by the consultant in the operating room. After adequate immobilization and consultation, most patients with isolated closed extremity fracture can be discharged with expeditious follow-up. Admit all patients with open fractures for observation and continued parenteral antibiotics.

Pearls

1. Treat any fracture with an open wound as an open fracture until proven otherwise.

2. Use a radiologic marker in the area of the laceration or puncture to aid in identifying possible foreign bodies.

3. Exploration and irrigation should be done by someone with expertise in open-wound care.

4. Maintain a high suspicion for child abuse when mechanisms of injury do not fit the injury pattern, particularly spiral long bone fractures.

5. Immobilize occult fractures, and if they are in the area of the physis treat these as Salter-Harris type I fractures.

Clinical Summary

The tuft or the distal portion of the distal phalange is located directly beneath the nail bed and fractures to this area are most often caused by a crush injury. Most tuft fractures do not involve the distal interphalangeal (DIP) joint space. Patients present with swelling, pain, and erythema, and there is often a subungual hematoma. Differential diagnosis includes felon, paronychia, cellulitis foreign body, and onychomycosis.

Emergency Department Treatment and Disposition

Obtain x-rays of the digit and consider x-rays of the hand and wrist if there is tenderness in those areas. Subungual hematomas are extremely painful and may act as a distracting injury. Refer all patients for orthopedic follow-up and consult orthopedics emergently for open fractures and phalanx fractures with extension into the joint space, and extensor or flexor tendon rupture. Fractures involving the joint space should have orthopedic follow-up in 48 to 72 hours. Perform cautery drainage for subungual hematoma of 50% or more or as necessary for pain control.

Pearls

1. Apply hairpin aluminum splints without putting pressure on the distal phalanx to provide protection against inadvertent contact.

2. Axial loading of the finger will always elicit pain.

3. Always evaluate the other digits and the wrist, with attention to scaphoid tenderness.

Clinical Summary

Phalangeal fractures often occur from a fall on an outstretched hand, although they can also occur from a crush injury. Distal phalangeal fractures are most often secondary to crush injuries. Osteomyelitis is often associated with open fractures, including nail plate lacerations and fractures associated with drained subungual hematomas. Swan-neck deformity results from an intra-articular avulsion fracture or tendon tear of the dorsal surface of the distal phalanx. If not treated properly, hyperextension deformity of the proximal interphalangeal (PIP) joint with simultaneous flexion of the distal interphalangeal (DIP) joint may occur. The resultant swan-neck appearance of the finger is the reason for its name.

Emergency Department Treatment and Disposition

Obtain x-rays with special attention to chip or avulsion fractures that do not produce a great degree of swelling and may go undetected. If subungual hematoma is present, it may be drained for pain control, especially if more than 50% of the nail is involved. Use cautery through the nail or careful drilling with an 18-gauge needle. Repair any nail bed lacerations with removal of the entire nail after digital block. Consult orthopedics or a hand specialist for all open fractures, comminuted fractures, fractures involving the joint space, and fractures with any degree of digit rotation or any significant degree of angulation. In general, because of the increased mobility from the second to the third to the fourth to the fifth metacarpal bones, a higher degree of angulation is tolerated with greater mobility. Angulation of 30 to 40 degrees can be tolerated for the fifth metacarpal, 30 degrees for the fourth metacarpal, 20 degrees for the third metacarpal, and 10 degrees for the second metacarpal.

Pearls

1. Bony tenderness can often be elicited by applying axial loading with the finger in the extended position.

2. Although degrees of angulation deformities can be tolerated, a rotational deformity of the digit, however slight, is not acceptable.

3. Detect rotational deformities by having the patient flex all 5 digits as in making a fist. All digits should point to the center of the palm.

4. Thoroughly scrutinize lacerations over any joints on the dorsum of the hand to ensure the dorsal hood is not violated, which would mean it is an open joint, necessitating emergent consultation.

Clinical Summary

Mallet fractures result from dorsal avulsion fractures in which the extensor mechanism of the DIP joint is destroyed, leaving the DIP joint in partial flexion. Mallet fractures may occur if there is forced flexion of the distal phalanx when the finger is in taut extension. This is often seen after playing basketball or baseball when the ball hits and creates axial loading of an outstretched finger. Patients present with the inability to fully extend the DIP joint.

Emergency Department Treatment and Disposition

Obtain standard x-rays of the digit. Avulsion fracture may not be apparent on x-ray. Splint the digit with the DIP in hyperextension and the PIP in 45 degrees of flexion using an aluminum splint on the dorsal aspect of the digit. This will keep the avulsed tendon in contact with its area of origin. If not properly treated, a swan-neck deformity may occur. Discharge patients with orthopedic or hand specialist follow-up in 72 to 96 hours.

Pearls

1. The injury is relatively painless unless there is an associated phalanx fracture.

2. Mallet finger is a clinical diagnosis, with the inability to fully extend the DIP joint being pathognomonic.

Clinical Summary

Bennett fracture is a transverse fracture of the first metacarpal base extending into the joint and associated with metacarpal dislocation. In Rolando fracture, the metacarpal fracture is comminuted. These are usually seen with a fall on an outstretched hand and are often associated with high-impact sports such as skiing. Patients present with a significant amount of pain.

Emergency Department Treatment and Disposition

Obtain standard x-rays of the hand, thumb, and wrist and consider scaphoid x-rays. Missed fractures are associated with a significant amount of morbidity. Nonunion is a common complication if not treated in a timely and proper manner.

Pearls

1. Consult orthopedics or hand surgery immediately; these fractures require open reduction internal fixation.

2. Often these injuries will require computed tomographic (CT) scan for evaluation of the carpal bones and to facilitate repair by the orthopedic surgeon.

3. Arthritis, limited range of motion, and decreased grip strength are fairly common complications.

Clinical Summary

Fracture of the fourth or the fifth metacarpal neck is called Boxer’s fracture and are the most common metacarpal fractures. Volar angulation of the distal bone is almost always present. Most commonly, this results from hitting a wall with the fist rather than from boxing injuries. Patients present with swelling and tenderness over the distal fifth metacarpal. Comminution of the anterior cortex is common, resulting in volar angulation of the metacarpal head. Often the neutral position of the pinky will be normal unless there is extreme volar angulation or any rotational component. Fractures isolated to the metacarpal neck have few complications. Because of the mobility of the fifth metacarpal-carpal joint, angulation up to 40 degrees is well tolerated. Angulation of greater than 40 degrees or any rotational deformity if not reduced will result in an inability to maintain the normal tucked-in position of a clenched hand. This will lead to further vulnerability to injury of the fifth digit.

Emergency Department Treatment and Disposition

Obtain standard x-rays of the hand, including anteroposterior (AP) and lateral views. The lateral view is essential to determine the amount of volar angulation. Consult orthopedics for all open fractures, intra-articular fractures, fractures with a rotational component, and those associated with human bites for evaluation in the emergency department (ED). Splint closed fractures with an ulna gutter splint and discharge with instructions for orthopedic/hand specialist follow-up within a week.

Pearls

1. Consult orthopedics for evaluation in the ED if there is angulation greater than 40 degrees for the fifth or 30 degrees for the fourth digit, or any rotational deformity.

2. Clinched fist-to-mouth injuries resulting in a puncture/laceration over the fourth or fifth metacarpophalangeal (MCP) joints need, at minimum, antibiotics in the ED, scrutiny for involvement of the MCP joint, and admission when associated with a fracture.

Clinical Summary

Scaphoid or navicular fractures are the most common carpal fractures and occur by falling on an outstretched hand or after seemingly minor trauma.

Emergency Department Treatment and Disposition

Perform a physical examination including snuffbox tenderness, axial loading, and forced supination to rule out a scaphoid fracture. To assess snuffbox tenderness, have the patient fully flex the thumb into the palm with the second through fifth digits flexed over it, and actively flex the wrist medially into ulnar deviation and palpate the snuffbox. Assess axial loading by keeping the thumb in the extended position while the examiner holds it by the distal phalanx and gently pushes into its origin. The proximal phalanx sits on the scaphoid and with injury this will elicit pain. To assess supination, ask the patient to shake hands with the examiner and resist attempts to force the hand into supination. If any of these tests elicit pain, scaphoid fracture should be suspected. Obtain standard x-rays of the wrist, including scaphoid or navicular views. Consult orthopedics emergently for all radiologically apparent injuries of the carpal bone or dislocations.

Pearls

1. Nonunion is the most common complication of a scaphoid/navicular fracture, and this requires open pinning with subsequent decreased mobility.

2. Radiologically apparent carpal fractures or dislocations require a long arm thumb spica splint or cylindrical cast.

3. Blood supply to the scaphoid is paradoxical, coming from the palmar arch and the dominant ulnar artery. Therefore, distal scaphoid fractures heal better than proximal scaphoid fractures.

4. X-rays may not detect a scaphoid fracture for weeks.

Clinical Summary

Wrist fractures often occur from a fall on an outstretched hand, and to a much lesser extent from a crush injury and are the most common upper extremity injury. Distal radius fractures are often referred to as a “dinner fork” deformity. Colles fracture occurs when there is angulation posteriorly and Smith fracture occurs when there is angulation anteriorly. Simultaneous ulnar styloid fracture is often present. Complications are infrequent, including tendon damage and subsequent arthritis, which occurs much more frequently when the articular surface of the distal radius is involved. Injuries of the epiphysis may result in growth arrest with subsequent instability of the radioulnar joint.

Emergency Department Treatment and Disposition

Consult orthopedics emergently for displaced or angulated fractures involving the articular surface. Splint torus fractures and nondisplaced, nonangulated fractures not involving the articular surface and discharge patients with expeditious orthopedic referral.

Pearls

1. Definitive treatment for all displaced distal radius fractures is closed reduction.

2. Must test for median nerve injury.

Clinical Summary

Galeazzi fracture dislocation is fracture of the distal radial shaft associated with a distal radioulnar dislocation. Monteggia fracture dislocation is fracture of the proximal third of the ulna with a radial head dislocation. The most common mechanism of injury is a fall on the arm. Tenderness on palpation is always present, but swelling and deformity may be minimal.

Emergency Department Treatment and Disposition

Obtain complete x-rays of the radius and ulna as well as the wrist. Consult orthopedics for evaluation and treatment in the ED, and immobilize, elevate, and ice the injury while awaiting consultation.

Pearls

1. Both Galeazzi fracture dislocation and Monteggia fracture dislocation require open reduction and internal fixation in the operating room.

2. Neurovascular complications with Galeazzi fracture dislocations are uncommon.

3. Monteggia fracture dislocations are associated with radial nerve injury.

Clinical Summary

Olecranon fractures are usually due to a direct blow to the elbow. Patients present with tenderness and swelling over the posterior elbow and pain on flexion and extension.

Emergency Department Treatment and Disposition

Obtain x-rays of the elbow including AP and lateral views. Splint nondisplaced fractures with the elbow in 90 degrees of flexion and referral to orthopedics in the next several days.

Pearls

1. Olecranon fracture is associated with ulnar nerve injury.

2. Consult orthopedics for evaluation and treatment in the ED for fractures with greater than 2 mm of displacement.

3. When caused by a direct blow, consider child abuse.

Clinical Summary

Radial head fractures usually result from falls onto an outstretched hand. Type I fractures involve less than one-third of the articular surface with displacement of less than 1 mm (nondisplaced or marginal fractures). Type II have displacement of more than 1 mm or depression of more than 3 mm, with greater than one-third of the articular surface involved. Patients present with tenderness on radial head palpation and pain is worse with supination of the arm.

Emergency Department Treatment and Disposition

Evaluate for point tenderness of the lateral distal elbow over the radial head. Obtain standard x-rays of the elbow, although fractures may not be apparent on x-ray and fat pad signs are often the only evidence of a fracture. A small anterior fat pad may be normal. A “sail sign” or a large anterior fat pad is abnormal. A posterior fat pad suggests a fracture. Immobilize fractures and refer patient to follow up within several days with orthopedics. Splint nondisplaced fractures place the arm in a sling, and refer patient to follow up with orthopedics within several days. For comminuted or displaced fractures, ice, elevate, and immobilize the limb while awaiting emergent evaluation by orthopedics.

Pearls

1. Neurovascular complications are rare in minimally displaced radial head fractures.

2. Myositis ossificans in this area can occur when radial head or neck fractures are accompanied by elbow dislocation.

3. Radial neck fractures, which are also common in children, are usually buckle fractures that can easily be overlooked on x-rays.

Clinical Summary

Supracondylar fractures are caused by falls onto an outstretched hand, typically in children from 3 to 15 years of age. Patients present with a swollen elbow and tenderness over both the lateral and medial epicondyles.

Emergency Department Treatment and Disposition

Obtain 4 views of the elbow, including AP and lateral views of both the forearm and humerus. X-rays may show the fracture line, an anterior fat pad sign (displaced anterior fat pad), a posterior fat pad, or an abnormal anterior humeral line. The anterior humeral line is drawn down the anterior cortex of the humerus on the lateral x-ray of the elbow and should pass through the center of the ossification center of the capitellum. Consult orthopedics while the patient is in the ED, with degree of displacement, the reliability of outpatient observation, and the availability of urgent follow-up determining the urgency of the consultation. Splint nondisplaced fractures discharge patient, if and only if at-home neurovascular observation and early orthopedic referral is possible. Admit patients with displaced fractures for early reduction.

Pearls

1. Nerve injury occurs in 7% of supracondylar fractures. The median nerve and the radial nerve are most often injured.

2. A positive “OK” sign indicates injury to anterior interosseous nerve. There is loss of strength of the thumb interphalangeal joint in flexion as well as the index DIP joint in flexion. This injury renders the patient unable to perform the “OK sign,” with the thumb and index finger apposed against resistance.

3. Brachial artery compromise can lead to Volkmann contracture (compartment syndrome of the forearm), which will lead to muscle and nerve fibrosis and drastic loss of function.

Clinical Summary

Humerus fractures may be due to a fall or a direct blow, the latter of which should alert the clinician to the possibility of abuse. Patients present with decreased movement of the extremity and localized swelling.

Emergency Department Treatment and Disposition

Obtain perpendicular AP and lateral views of the entire humerus and consult orthopedics for evaluation in the ED for anything greater than one-part fractures or fractures with significant displacement. Immobilize the shoulder and refer urgently to orthopedics.

Pearls

1. Adhesive capsulitis (frozen shoulder) can occur with proximal fracture, and raises the possibility of neglect.

2. Brachial plexus injuries and axillary nerve and artery injuries are associated.

3. Avascular necrosis can occur with medical conditions that cause decreased perfusion, such as sickle cell anemia, or circulatory compromise.

4. Humeral shaft fractures typically involve the middle third, and 10% to 20% have radial nerve injury. The brachial artery can also be injured.

5. Myositis ossificans can be avoided by active routine exercise rather than just simple passive stretching in the recuperatory phase.

6. Young children have open epiphyses and usually suffer epiphyseal separation rather than fractures.

7. Displacement is significant if there is separation of greater than 1 cm or angulation of greater than 45 degrees.

Clinical Summary

Clavicle fractures are the most common fracture in children and are commonly caused by a direct blow or fall on the shoulder. Patients present with pain on clavicular palpation. Swelling is usually minor and usually occurs directly over the fracture. If there is significant distraction of the clavicle, injury to the subclavicular artery or vein may occur.

Emergency Department Treatment and Disposition

Provide a sling, which is proven as effective as the traditional sling and swathe. If there is suspicion of vascular injury, consult orthopedics. Discharge the patient and educate the caregivers that fractures heal with the formation of a lump that may take months to resolve.

Pearl

1. Eighty percent of clavicle fractures involve the middle third of the clavicle.

Clinical Summary

Scapular fractures are caused by a direct blow to the scapular area. Patients present with local pain, swelling, and decreased and painful abduction of the arm.

Emergency Department Treatment and Disposition

Obtain scapular x-rays and search for associated injuries, which are almost always present because of the great force necessary to produce a scapular fracture. Complications are always related to associated injuries and thus identification and treatment of those injuries is paramount. Consult orthopedics as needed for those injuries. In rare cases when the mechanism of injury is localized and other injuries ruled out, immobilize the shoulder with a sling and discharge the patient with instructions to begin limited exercise after 2 weeks.

Pearls

1. Scapular fractures are rare in childhood.

2. Scapular fractures necessitate investigation for other injuries (rib fractures, pneumothoraces, and vertebral fractures).

Clinical Summary

Femur fractures are most commonly associated with motor vehicle accidents and falls from significant heights. In toddlers, child abuse should always be suspected. Patients present with swelling and tenderness on palpation though deformity may or may not be present.

Emergency Department Treatment and Disposition

Obtain x-rays include AP and internal and external rotation views. Consider obtaining hip and knee views as well because there is a high incidence of associated injuries. Consult orthopedics emergently. Immobilize the hip, and assess and document neurovascular status. Provide adequate analgesia and admit patients expeditiously. Ultimate treatment in children less than 6 years of age is more complex. Depending on the fracture, definitive treatment may be external splinting, open reduction or internal fixation.

Pearls

1. Hemorrhage is the most serious complication. Large adolescents can extravasate 1.5 L of blood into the thigh after a femur fracture.

2. Neurovascular injury and avascular necrosis of the femoral head may also occur, especially with fractures of the base of the femoral neck.

3. Midshaft femur fractures, especially spiral fractures, should alert the clinician to the possibility of child abuse (see Figure 1.10 and Figure 19.6).

Clinical Summary

Patellar fractures usually result from a direct blow to the patella or a fall directly on the anterior knee. Patients present with a tender swollen prepatellar area, and if there is a complete transverse fracture they are unable to maintain the leg extended against gravity.

Emergency Department Treatment and Disposition

Obtain patella x-rays including a sunrise view, which are diagnostic. Treat nontransverse/complete fractures with immobilization. Consult orthopedics emergently for transverse or displaced fractures for evaluation in the ED. For all other fractures, refer the patient for orthopedic follow-up. Without treatment, nonunion of the patella can occur, especially in displaced fractures.

Pearl

1. Complete transverse fractures, especially if displaced, need surgical open reduction internal fixation.

Clinical Summary

Maisonneuve fracture is a proximal fibular fracture with disruption of the tibiofibular syndesmosis. External rotation of the ankle is a common mechanism. Patients present with an obvious ankle fracture, although the ankle may appear to be without deformity and pain on palpitation of the proximal calf.

Emergency Department Treatment and Disposition

Ankle studies may be negative, but may also show a widened mortise. When x-rays include the proximal fibula, fractures are usually obvious. Complications include significant arthritic changes and future difficulty in ambulation if left untreated. Nonunion of the tibiofibular syndesmosis can also occur. Although most patients with these injuries can eventually be discharged from the ED, they should not do so without orthopedic consultation.

Pearls

1. When evaluating an injured ankle, always squeeze the calf and anterior lower extremity and look for tenderness.

2. Maisonneuve fracture is usually associated with deltoid ligament rupture and ankle fractures; evaluate the proximal lower leg when these are diagnosed.

Clinical Summary

Ankle fractures and sprains are most commonly caused by inversion. Patients present with swelling that is most pronounced over the lateral malleolus, and joint instability because of a third-degree sprain or a fracture can usually be seen with laxity on manipulation, as with the drawer sign. Epiphyseal injuries that are usually caused by sheering and avulsion forces have no adult counterpart, because they occur at the epiphyseal growth plates. Distal fibular physeal fractures are the most common types of pediatric ankle fractures and are associated with a relatively low risk for long-term complications. The medial malleolus is shorter than the lateral malleolus, which allows the talus to invert more than evert. The deltoid ligament stabilizes the medial aspect of the ankle joint and offers stronger support than the thinner lateral ligaments. As a result, the ankle is more stable and resistant to eversion injury than it is to inversion injury. Differential diagnosis includes Maisonneuve fracture and proximal metatarsal fracture. Complications include arthritis and chronic pain with undiagnosed proximal metatarsal fractures.

Emergency Department Treatment and Disposition

Obtain ankle radiographs though they are usually negative with sprains, and soft tissue swelling is the most common finding. Avulsion off the distal fibula in anterior talofibular tears is occasionally seen. If there is no documented fracture or neurovascular deficit, orthopedic consultation in the ED is not indicated and for such patients (without joint instability), ice, elevation, and splinting are appropriate with a follow-up with orthopedics. Nonfractures with clinical ligamentous injury (or sprains in which ligamentous injury is indeterminate) need telephone orthopedic consultation, and urgent orthopedic follow-up (within 1 week) after adequate immobilization in the ED. Consult orthopedics emergently in the ED for any gross ligamentous deformities (laxity on examination) or any neurovascular deficits or any ankle fracture or any open ankle fracture.

Pearls

1. Twisting injuries that cause fractures in children are usually minimally displaced, but with involvement of the articular surface, they may require open reduction and internal fixation.

2. The ankle joint usually adheres to the ring or pretzel axiom. A fracture in one part of the ring is often associated with a second injury. Always look for an associated medial malleolar fracture when a spiral fracture of the fibula proximal to the ankle mortise is seen.

3. A vertical fracture of the medial malleolus is also associated with either a lateral malleolar fracture or a fracture of the lateral ligaments.

4. Ninety percent of ankle sprains involve the lateral ligaments.

5. Ligamentous injuries occur in the following order of frequency: anterior talofibular, calcaneofibular followed by posterior talofibular.

Clinical Summary

Calcaneal fractures are caused by compression, usually resulting from a fall from a height. Böhler angle (normally 20 to 40 degrees) may be decreased. Böhler angle is formed by the intersection of the 2 lines between the superior margin of the posterior tuberosity of the calcaneus, through the superior tip of the posterior facet, and the superior margin of the posterior tuberosity through the superior tip of the anterior process.

Emergency Department Treatment and Disposition

Obtain standard foot x-rays (PA, lateral, and axial) with the addition of a calcaneal view and a CT scan for displaced fractures. Consult orthopedics or podiatry urgently for displaced fractures that may require open reduction. Immobilize the ankle in a compression dressing and instruct patient to ice and elevate the ankle and avoid weight bearing. Refer the patient to orthopedics or podiatry within several days. Complications include, acutely, compartment syndrome and disruption of the subtalar joint. Chronic complications include arthritis, heel spurs, and plantar fasciitis.

Pearls

1. Most commonly, the tarsal bone is also fractured.

2. Injury of the calcaneus should warrant evaluation of the lumbar sacral spine, which has a high rate of associated injury.

3. Both feet have calcaneal fractures 10% of the time.

Clinical Summary

Jones fractures are caused when a forceful load is placed on the ball of the foot or there is forced oblique lateral plantar flexion. Patients present with mild swelling and point tenderness over the base of the fifth metatarsal. Complications are uncommon and may include chronic pain.

Emergency Department Treatment and Disposition

Obtain standard x-rays of the foot. For true Jones fractures with minimal pain, refer the patient for urgent orthopedic or podiatric consultation within several days. If severe pain is present or there is a proximal shaft transverse fracture, consult orthopedics emergently for placement of a cylindrical cast. Treat with a bulky dressing, analgesics, and weight bearing as tolerated. Consider a walking cast for 3 weeks for patients with severe pain.

Pearl

1. Transverse proximal fifth metatarsal fractures have a completely different prognosis, require urgent/emergent orthopedic or podiatric consultation and have a high incidence of delayed union or nonunion.

Clinical Summary

Lisfranc fractures are tarsometatarsal dislocations or fractures and are most commonly seen with strong blunt or compression force, as in a motor vehicle accident. Severe rotational stress may also produce this type of dislocation. Patients present with significant midfoot swelling and tenderness and inability to bear weight. Degenerative arthritis and decreased circulation to the distal foot are occasional complications.

Emergency Department Treatment and Disposition

Obtain AP, lateral, and oblique views of the foot and consider ordering a foot CT, which is useful in identifying occult injuries. Consult orthopedics emergently, as these cases most commonly require open reduction and internal fixation. Provide ice, immobilization, elevation, and analgesics and admit patients for open reduction and internal fixation.

Pearls

1. Lisfranc fracture is the most common midfoot fracture.

2. Fracture of the base (proximal) of the second metatarsal is nearly pathognomonic.

3. Dislocations may involve one or several tarsometatarsal joints.

4. Separation of the base of the first and second metatarsals is highly suggestive.

Clinical Summary

Stress fractures are almost always secondary to overtraining. Patients present with pain on ambulation, and in particular exertion. Erythema, swelling, and pain on palpation are all rare. Arthritis and chronic pain may occur if the stress fractures are not treated appropriately.

Emergency Department Treatment and Disposition

Order x-rays though these are usually negative. No labs are needed as stress fractures are mechanical problems and do not cause laboratory abnormalities. Consider a bone scan, which may be positive. Instruct patients on appropriate rest and nonsteroidal anti-inflammatory drugs (NSAIDs) as needed. Refer athletes to an orthopedic sports medicine specialist.

Pearls

1. Stress fractures are the second most common fracture after metatarsal fractures.

2. The main differential diagnosis is shin splints, which are usually bilateral; stress fractures are usually unilateral.

Clinical Summary

Interphalangeal joint dislocation usually results from a pull and twist of an isolated finger or a fall on a hand with the fingers locked in extension. The mechanism is often a hyperextension of the proximal or DIP joint. Patients present with obvious angulation of proximal or DIP joint and inability to flex the affected joint.

Emergency Department Treatment and Disposition

Obtain x-rays of the digit in at least 2 views and look for articular surface fractures as well as ligamentous tears. If there is an overlying laceration, examine for the possibility of an open joint that may require exploration of the wound after applying a digital block. Consult a hand/orthopedic specialist on any suspicion of an open joint or in dislocations associated with fractures. Initiate IV antibiotics and admit patients with open joints for wound irrigation in the operating room and continued antibiotics. Reduce isolated dislocations without an associated fracture or open joint, splint with a commercial aluminum splint, and the interphalangeal joint at 15 to 20 degrees of flexion. Obtain a postreduction x-ray to ensure proper alignment. Discharge patients with expeditious follow-up by orthopedics.

Pearl

1. One attempt at axial traction of the distal phalanx can be made without digital block in very young children who have a simple dislocation without phalangeal overlap. All other dislocations should be reduced with the same axial traction after appropriate anesthesia (digital block).

Clinical Summary

Lunate and perilunate dislocations are usually caused by extreme hyperextension of the wrist, and perilunate dislocation is the most common wrist dislocation. Patients present with a protruding deformity on the dorsum of the wrist (dorsal dislocations) or a concavity over the dorsum of the wrist (volar dislocations). With a perilunate dislocation, the lunate remains in anatomic position. The remainder of the hand is displaced either volar or dorsally. With lunate dislocation, x-rays show that the capitate is aligned and the lunate is displaced, resembling a spilled tea cup.

Emergency Department Treatment and Disposition

Obtain standard x-rays, especially a lateral view that will show misalignment of (proximally to distally) the distal radius, the proximal border of the lunate, and the proximal border of the capitate. Consult orthopedics emergently for all wrist dislocations for treatment in the ED.

Pearls

1. Undiagnosed wrist dislocations could result in neurologic or vascular compromise as well as severe mobility limitations. Median nerve injury and scaphoid fractures are also common complications.

2. The lunate usually dislocates volarly.

Clinical Summary

Elbow dislocations are most commonly associated with a fall on an extended, abducted arm. Patients present with the elbow held in flexion. The olecranon process may be palpated posteriorly.

Emergency Department Treatment and Disposition

Obtain lateral x-ray of the elbow, which is usually diagnostic. Reduce the dislocation immediately in the ED and refer the patient to orthopedics. If there is associated fracture or the reduction is not successful as demonstrated on the postreduction lateral elbow x-ray, have orthopedics see the patient in the ED.

Pearls

1. Medial epicondyle fractures are often associated with elbow dislocations, at a rate that may be as high as 30% to 40%.

2. Ulnar nerve injuries have an association with elbow dislocation.

3. Brachial artery injuries have an association with elbow dislocation.

Clinical Summary

Anterior shoulder dislocations are the most common (95%) and usually the humeral head is in the subcoracoid position. Abduction with external rotation of the arm is a common mechanism of injury, such as with a fall, a seizure, or an electric shock. Patients present with the arm held in abduction with internal rotation, unable to abduct or externally rotate the shoulder; the normal contour of the shoulder is lost. Axillary nerve injury occurs approximately 12% of the time. Hill-Sachs lesion (compression fracture of the posterolateral humeral head) and Bankart lesions (fracture of the glenoid rim) are associated, and detachment or tear of the rotator cuff may occur.

Emergency Department Treatment and Disposition

Obtain standard “trauma series” x-rays including AP, lateral, and axillary views. The axillary view is difficult to obtain in a patient with a posterior dislocation and is diagnostic and helpful in differentiating anterior and posterior dislocations. Attempt reduction in the ED and, if successful, immobilize the limb with a sling and swathe, and discharge the patient with instructions for follow-up by orthopedics in a few days. If reduction attempts are not successful, consult orthopedics emergently.

Pearls

1. Anterior shoulder dislocations usually displace the humeral head inferiorly, which when minimal is easily missed on x-ray, including the “Y” view. Thus, the axillary view is definitive for ruling out a shoulder dislocation.

2. Check sensation over the deltoid muscle to test the function of the axillary nerve.

3. If there is an isolated fracture of the lesser tuberosity of the humerus, maintain a high suspicion of index for posterior dislocation, which may not be immediately radiologically apparent.

Clinical Summary

Posterior hip dislocations result from a direct blow along the femoral axis and often occur in front-end motor vehicle accident when the patient is thrown forward and hits the dashboard with the knee. Anterior dislocations result from forced abduction, as with external blunt trauma such as an automobile striking a pedestrian. In posterior dislocations, patients present with the leg adducted, flexed, and internally rotated. In anterior dislocations, the leg is abducted, flexed, and externally rotated at the hip.

Emergency Department Treatment and Disposition

Obtain routine hip and pelvic x-rays and consult orthopedics emergently. Assess and document neurovascular status on arrival and before and after reduction attempts. For posterior dislocations, provide adequate sedation and analgesia. Place the patient in a supine position and have one caretaker or clinician apply steady pressure on both superior iliac crests to stabilize the pelvis. Straddle the patient, flex the knee to 90 degrees, and pull the leg toward the ceiling. For anterior dislocation reduction, provide spinal or general anesthesia. Place the patient supine and flex the hip to convert the anterior dislocation to a posterior dislocation. Then reduce the posterior dislocation as described above. Assess and document neurovascular status after each reduction attempt. Admit all patients to the orthopedic service.

Pearls

1. Posterior dislocations account for 90% of hip dislocations.

2. Acetabular fractures can be difficult to diagnose and can often need the expertise of an orthopedic surgeon who specializes in acetabular fractures. These fractures are usually not associated with immediate complications, but need to be recognized in the ED for ultimate referral to a subspecialist.

3. Twenty-five percent of hip dislocations are associated with knee injuries and almost 5% are associated with ipsilateral femur fractures.

4. Avascular necrosis of the femoral head is a particularly worrisome complication, which is a reason for 100% follow-up.

5. Sciatic nerve injury may occur with posterior dislocations.

Clinical Summary

Knee dislocation results from a direct blow to the knee as in a motor vehicle accident or significant fall. Dislocations are classified by tibial displacement relative to the femur. Anterior and posterior dislocations are most common, but medial, lateral, and rotary dislocations can occur. Patients present with an obvious deformity and tenderness on palpation. Distal pulses may be diminished.

Emergency Department Treatment and Disposition

Obtain standard x-rays of the knee including AP and lateral views and sunrise view of the patella. Consult orthopedics emergently as there is a high incidence of neurovascular injury and reduction should take place promptly in the ED. If orthopedic consultation is not immediately available, provide sedation analgesia and reduce the dislocation with longitudinal traction and pressure toward the normal knee position. Perform angiography to exclude popliteal artery injury. Admit any patient with a suspicion of popliteal artery injuries.

Pearls

1. Complications are very common and include popliteal artery injury (up to 40%), especially with anterior dislocation and peroneal nerve injury in 25% to 35%.

2. Peroneal nerve injury will produce paresthesias over the dorsum of the foot, diminished dorsiflexion of the foot, and/or decreased sensation between the first and second toes.

Clinical Summary

Ankle dislocation may be caused by forced inversion or eversion or by direct external force. Patients usually present with obvious deformity. In order of frequency, ankle dislocations are lateral, posterior, and anterior. With lateral dislocation, the foot is usually obviously displaced laterally and the skin on the medial side will be tense. Avascular necrosis and reflex sympathetic dystrophy are worrisome complications.

Emergency Department Treatment and Disposition

Obtain standard 3-view x-rays, including the AP, lateral, and mortise views and consult orthopedics emergently. If consultation is not immediately available, check vascular integrity and then perform reduction with inline traction by grasping the calcaneus and the forefoot. Check vascular integrity after reduction. Open ankle dislocations require urgent surgery.

Pearls

1. Fifty percent of ankle dislocations are open.

2. Ankle dislocations are often associated with malleolar fractures.

3. If pulses are not present, reduce the dislocation prior to x-ray evaluation; otherwise x-rays should always be taken before reduction.

4. Lateral dislocations are almost always associated with fractures of the malleolus or distal fibula.

Clinical Summary

Patellar twisting injury to an extended knee is a frequent mechanism of dislocation. Patients present with obvious deformity and limited movement of the knee secondary to pain and tenderness on palpation. Differential diagnosis of patella dislocation includes anterior cruciate or other ligamentous tear, patella fracture or contusion or sprain.

Emergency Department Treatment and Disposition

Obtain standard x-rays including AP and lateral of the knee and sunrise view of the patella. Reduce the dislocation by applying mild pressure toward the normal position of the knee. If the first attempt is not successful, provide sedation analgesia for subsequent attempts. After successful reduction immobilize the knee in a dynamic splint and refer the patient for orthopedic consultation. Few complications are associated with a patella dislocation. Orthopedic consultation is rarely emergent and can be made in several days to a week after successful reduction.

Pearl

1. More than 90% of patella dislocations are lateral.

Clinical Summary

Gamekeeper’s thumb is a tear of the ulnar collateral ligament of the MCP thumb joint originally named because gamekeepers who killed fowl by snapping the birds’ necks with their hands were prone to the injury. Today, this injury is more often associated with falling on an outstretched hand and referred to as skier’s thumb. Patients present with laxity of greater than 20 degrees of the ulnar collateral ligament with the thumb in full extension. There is decreased range of motion of the thumb and functionality of the hand with a decreased strength of the pincer grip.

Emergency Department Treatment and Disposition

Obtain x-rays and provide analgesia with 2% lidocaine without epinephrine before checking laxity of the ligament with the thumb in full extension. The injury may not be apparent on x-ray, or may appear as an avulsion fracture of the proximal phalanx base on the medial side. Immobilize the injury with splinting. After immobilization, patients with closed injuries can be sent home with orthopedic or hand specialist follow-up in 48 to 72 hours.

Pearl

1. The inability to hold the pincer grip, “OK,” with the thumb and index finger is key to diagnosing this injury.

Clinical Summary

Sudden traction of the hand or the forearm as when a caretaker pulls a child by the arm to safety results in the annular ligament being pulled over the radial head and becoming displaced between the radial head and the capitellum. This is also known as radial head subluxation or “temper-tantrum elbow” or “pulled elbow.” Patients usually refuse to move the arm, holding it in pronation at the side and flexed at the elbow. Supination elicits pain. Occasionally, a deformity is seen with prominence and displacement of the radial head. Complications are extremely rare with simple subluxation of the radial head or its reduction procedure.

Emergency Department Treatment and Disposition

Radiographs are often unnecessary and may not be helpful, as the radial head and lateral humeral condyle may not be ossified in a young child. When radiographs are obtained, they may serve as the treatment as well because the radiology technician will supinate and flex the elbow to 90 degrees (the procedure used for reduction of the subluxation) to obtain a proper lateral x-ray of the elbow. Reduce the subluxation unless there are external signs of trauma (eg, swelling, extreme tenderness, ecchymosis), suspicion of elbow or forearm fracture or dislocation, or known mechanism of injury unlikely to result in radial head subluxation. Reduction is done by supination and flexion (traditional reduction technique) or hyperpronation technique (pronation and flexion). The latter requires fewer attempts and has greater succus. In supination and flexion, grasp the palm of the involved hand as if to shake it, and encircle the elbow with the other hand with the thumb placed over the radial head. Fully supinate the arm in one quick deliberate motion while applying gentle longitudinal traction and in a continuous motion flex the elbow to the shoulder. For hyperpronation, apply gentle longitudinal traction, and place the forearm in hyperpronation and then flex the elbow. Most often an audible or palpable pop or click is felt by the thumb lying over the radial head as the annular ligament is freed from the joint and this signals successful reduction. If no click is heard or felt, attempt reduction again in 15 minutes. After a successful reduction, no treatment, radiographs, or immobilization is required.

Pearls

1. Indications for radiography include either unsuccessful attempts at reduction or the presence of swelling or significant tenderness, suggesting another diagnosis, or when there is question or doubt about the mechanism of injury.

2. Let the child sit comfortably in the caregiver’s lap for reduction. Gentle examination of the uninvolved arm first may make the examination of the injured arm easier. Exclude any point tenderness before attempting reduction.

3. With successful reduction, movement usually returns in 5 to 15 minutes though may take longer if subluxation has been present for several hours.

4. If there are recurrent subluxations, consider posterior immobilization with the elbow flexed to 90 degrees and the forearm in supination.

5. The strength of the annular ligament and the size of the radial head increase with age, making this subluxation uncommon after the age of 5 years.

Clinical Summary

Acromioclavicular injuries are caused by direct blow to the lateral arm or to the acromion itself. These injuries are common in hockey players, who often hit the boards with their shoulders. Shoulder appearance is usually normal and patients present with pain on gravity traction of the arm. First-degree injuries have incomplete tear of the AC ligament, with no subluxation. Second-degree injuries have subluxation of the AC joint and distal clavicular separation less than 50% of the clavicular diameter in relation to the acromion. In third-degree injuries the clavicular separation is more than 50% of its diameter in relation to the acromion.

Emergency Department Treatment and Disposition

Obtain acromioclavicular x-rays including weight-bearing views. In first degree injuries, x-rays including stress views are negative. In second- and third-degree injures, subluxation may be seen with stress views. For third-degree injuries, consult orthopedics for evaluation in the ED. For first- and second-degree injuries, immobilize the limb with a sling and swathe, and discharge the patient with a referral for orthopedic follow-up. The sling should be worn for 4 to 6 weeks. Future contact sport activity is limited. Neurovascular complications are extremely rare.

Pearls

1. Acromioclavicular injuries are fairly common among athletes in contact sports.

2. Acromioclavicular stress test is performed by bringing the arm across the body, approximating the elbow with the contralateral shoulder. A positive test produces pain in the area.

Clinical Summary

Slipped capital femoral epiphysis (SCFE) occurs when the femoral epiphysis becomes misaligned. Patients complain of fatigue when doing strenuous activities, increasing to pain in the hip or the knee with even mild exertion. As time passes, a classic limp becomes apparent. Because of the rapid bone growth and activity level in prepubescent children, the femoral epiphysis is displaced. Differential diagnosis of slipped capital femoral epiphysis includes transient synovitis of the hip, septic arthritis, degenerative arthritis, and bursitis.

Emergency Department Treatment and Disposition

Obtain AP and lateral frog-leg views of both hips, which will show a widened and displaced capital epiphysis, which is also displaced posteriorly and inferiorly. Complications include avascular necrosis, chondrolysis, further slippage, and degenerative arthritis of the hip. Consult orthopedics emergently. Depending on the degree of slippage, treatment may be conservative or may require internal fixation with application of screws.

Pearls

1. SCFE occurs in children from ages 10 to 16 years (years of rapid bone growth) and boys predominate over girls.

2. There is a higher association with children who are overweight.

3. In 25% of cases both hips are involved.

4. There is a peak incidence in the summer months, when there is increased outdoor physical activity.

5. The history may include minor trauma, but it usually has an insidious onset of symptoms.

Clinical Summary

Legg-Calvé-Perthes disease, or avascular necrosis of the femoral head, results from an ill-defined etiology and is not secondary to any injury and is also known as osteochondrosis of the femoral head. Onset is usually insidious and may progress from months to years. The problem is most often seen in children aged 5 to 7 years and is usually a self-limiting disorder. It is seen more commonly in boys and is usually unilateral. Patients usually present with a limp and a vague complaint of pain in the groin, inner thigh, or hip and have limited abduction of the hip and internal rotation on flexion or extension. Symptoms are exaggerated during times of excessive activity or exertion. Acute complications are unusual and long-term complications include arthritis and limited mobility.

Emergency Department Treatment and Disposition

Obtain x-rays (a pelvic view), which early on may demonstrate only joint-space widening. Later findings are a flattening of the femoral head known as coxa plana. Refer patients for orthopedic consultation, which does not need to take place in the ED.

Pearl

1. Legg-Calvé-Perthes disease is fairly rare in African Americans.

Clinical Summary

Anterior cruciate ligament (ACL) tears are caused by direct force to the knee, most commonly in contact sports. Patients present with a swollen, diffusely tender knee within 1 hour of injury, and the anterior drawer sign and positive Lachman test are fairly sensitive for diagnosis. Complications include arthritis, chronic pain, and limited range of motion.

Emergency Department Treatment and Disposition

Obtain standard x-rays including AP and lateral films of the knee, which usually demonstrate joint effusion and soft tissue swelling but no bony abnormalities. Refer patients with stable knee joints without fracture or dislocation for outpatient orthopedic follow-up within 48 hours. Immobilize the knee and provide crutches for avoidance of weight bearing. Definitive treatment is surgical repair by orthopedics.

Pearls

1. ACL tears are the most common serious ligament injury of the knee.

2. Seventy-five percent of anterior cruciate ligament tears will present with hemarthrosis.

3. A tense hemarthrosis may decrease the sensitivity of the anterior drawer sign and Lachman test.

4. All tender, swollen knees should be immobilized and weight bearing avoided until orthopedic follow-up.

Clinical Summary

Osgood-Schlatter disease is microtrauma to the tibial tubercle tuberosity apophysis and occurs during a normal or slightly advanced activity level for normal adolescents. Patients present with a tender swollen tibial tuberosity and pain. Erythema over the tibial tuberosity may be present. There is usually no direct injury associated with the pain. The only complication is a lack of participation in the routine activities of an adolescent. There are no significant long-term complications of diagnosed Osgood-Schlatter disease.

Emergency Department Treatment and Disposition

Osgood-Schlatter disease is not an acute infectious/inflammatory process; thus, no laboratory values or imaging studies contribute to the diagnosis. Consultations are not necessary unless the patient is a high-functioning individual. When the diagnosis is made, only rarely is there a reason for a consultant to see the patient in the ED. Treatment is rest and NSAIDs.

Pearls

1. Extremely common.

2. The activity level of the patient and point tenderness are key to its diagnosis.

3. If systemic signs or symptoms are present, another diagnosis is likely.

Clinical Summary

Achilles tendon ruptures result from forced dorsiflexion of the ankle, usually related to strenuous athletic activity. Direct trauma to a taut tendon is a secondary cause. Patients present with a tender distal calf and there is a palpable defect in the tendon 1½ to 2 inches (narrowest point) proximal to the calcaneus. On squeezing the calf (Thompson test), there is no plantar flexion. Complete tears are rarely undiagnosed but lead to a difficult surgical repair. Partial tears that are undiagnosed could lead to complete tears.

Emergency Department Treatment and Disposition

Obtain tibia/fibula and ankle films though these are usually negative. Apply a posterior splint in a neutral position and instruct the patient to avoid weight bearing with crutches. Consult orthopedics for definitive follow-up. In closed injuries, it is not necessary for orthopedics to see the patient in the ED. Partial tears should also have orthopedic referral for extended immobilization.

Pearls

1. Most common in the adolescent athlete in the pediatric population.

2. Normally the posterior splints are applied with the ankle at 90 degrees, but in this case the ankle should be splinted in gravity equinus position, in which the ankle lies in when the leg is hanging off the examination table.

3. The Achilles tendon is able to regenerate when partially sectioned, and heals well with immobilization.

4. Partial tears can be missed in 25% of cases.

Clinical Summary

Foreign bodies and penetrating injuries are most often seen on the plantar aspect of the foot or the palmar surface of the hand. Less commonly, these result from falling objects or projectiles. Patients present with a nearby puncture wound, which may be subtle when on the plantar foot. Pain is usually present, especially if there is associated bony involvement. Complications may include cellulitis, and osteomyelitis is common after inoculation into the bony matrix. Septic arthritis, either from direct penetration of the joint capsule, or via direct spread from a focus of osteomyelitis may occur. Retained foreign body, fibrosis, and chronic pain can also occur.

Emergency Department Treatment and Disposition

Obtain x-rays of the appropriate anatomy whenever there is suspicion of a penetrating injury, with foreign bodies of higher density that are radiopaque. Note that the ability to see glass on x-ray is dependent on its lead content, with fine crystal having a high content and bottles a lower content. Order ultrasound to detect subcutaneous foreign bodies. Whether a foreign body is seen on imaging or not, if there is a high suspicion, consult orthopedics and provide parenteral antibiotics in the ED. Admit patients with penetrating foreign bodies for definitive removal when indicated, or an initial course of parenteral antibiotics given when removal is not indicated.

Pearl

1. Of particular concern is a plantar puncture wound of the foot through sneakers, which are often colonized by pseudomonas. Often a small piece of material from the sneaker is left in the puncture cavity and this is very difficult to locate. Infection is inevitable if it is not found and removed.

Clinical Summary

Paronychia is an infection involving the nail fold of the nail and patients present with swelling, tenderness, and fluctuance at the nail base. Paronychia is associated with nail biting, but can also be caused by any penetrating injury at the base of the nail. Spread of infection can occur proximally. A felon (infection of the volar surface of the distal phalanx pulp space), is also a complication of an untreated paronychia. Differential diagnosis of a paronychia includes contusion, retained foreign body, tuft fracture and hair-tourniquet syndrome.

Emergency Department Treatment and Disposition

Radiographic evaluation is not necessary unless there is a recent history of significant trauma. Provide adequate anesthesia with a digital block, and incise and drain with a no. 11 blade scalpel sliding up the nail proximally. This will usually produce purulent material.

Pearls

1. Place a gauze wick to allow for additional drainage.

2. Administer tetanus vaccination as indicated; antibiotics are usually not indicated.

Clinical Summary

Flexor tenosynovitis usually results from puncture wounds along the volar aspect of the digit. Patients present with Kanavel signs:

1. Symmetrical swelling of the finger.

2. Tenderness over the flexor tendon sheath.

3. Pain with passive extension.

4. Finger held in a flexed position.

The most common pathogens causing tenosynovitis include Staphylococcus aureus, and Streptococcus spp, followed by Pseudomonas spp.

Emergency Department Treatment and Disposition

Obtain x-rays of the digit to rule out occult fracture or foreign body and investigate for osteomyelitis. Septic arthritis, ascending cellulitis, joint fibrosis, and limited mobility are complications of tenosynovitis. Consult orthopedics emergently and admit patients for continuous elevation of the infected limb and IV antibiotics (such as oxacillin or clindamycin for patients who are allergic to penicillin). Severe cases and cases that do not respond to antibiotic therapy may require incision and drainage in the operating room.

Pearls

1. Not all cases of tenosynovitis are dramatic on presentation. When there is a question, consult a physician with more experience with ailments of the hand.

2. With no barriers to the spread of infection, the entire tendon sheath usually becomes involved.

Clinical Features

Osteomyelitis is an infection of the bone seen at the junction of metaphysis and epiphysis. Half of all cases occur in children less than 5 years of age, and one quarter by 2 years of age. Clinical presentation varies with the age. Younger children are more likely to have external findings of edema, tenderness, erythema, and warmth at the involved site. Toddlers will present with refusal to use the affected limb and tenderness on examination. Older children may only report mild symptoms with point tenderness. The most common sites are long bones such as the tibia, femur, and humerus. Fever and a history of other nonspecific symptoms such as irritability and poor appetite are helpful clues but are not always present.

Acute osteomyelitis usually occurs by hematogenous seeding from a prior bacteremia and thus there is typically a single offending organism (Table 19.5). Vaccination has dramatically decreased the incidence of Haemophilus influenzae type b–associated osteomyelitis; however, it should be considered in underimmunized populations. Infection of the bone can also occur as a result of direct inoculation of pathogens, as in penetrating injury or extension from local infection.

Differential diagnosis includes septic arthritis, bony tumors (eg, osteogenic sarcoma), metastatic bony lesions (eg, leukemia, neuroblastoma), cellulitis, hemoglobinopathies (bone infarction), and fracture.

Emergency Department Treatment and Disposition

Evaluate any healthy child presenting with focal skeletal pain or decreased limb function for osteomyelitis. Obtain bone aspirate culture or bone biopsy dependent on the lesion found. Blood culture results are variable (positive in 36% to 74% of cases), and other laboratory tests may be helpful, but not diagnostic, including elevated white blood cell (WBC) count with a neutrophil predominance and elevated inflammatory markers (eg, erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]). Order x-rays, noting that these will not show evidence of bone destruction until 10 to 14 days after the onset of infection but can be used to exclude trauma. Order MRI or bone scan, both of which have high sensitivity (>95%) for diagnosis. MRI is preferable as it better outlines collections for drainage and does not expose the child to ionizing radiation. If multifocal disease is considered a bone scan is preferred.

Prescribe antibiotics according to pathogen(s) found in culture specimens (most commonly anti-staphylococcal β-lactam antibiotics such as oxacillin or ceftriaxone). Consider clindamycin or vancomycin, if local antibiograms suggest a high prevalence of methicillin-resistant S aureus. Different antibiotic regimens may be necessary if the clinical history points toward an atypical pathogen (Table 19.5). Consult orthopedics and infectious disease services to develop a management plan including hospitalization. Drainage of bone collections may be both diagnostic and therapeutic. Also, provide adequate analgesia.

Pearls

1. Consider acute osteomyelitis in any child with fever and decreased use of an extremity.

2. Osteomyelitis may be associated with septic arthritis in young children.

3. Radiographic findings will be delayed; MRI or bone scan are preferred for making the diagnosis.

4. Obtain cultures prior to initiation of antibiotics.

Clinical Summary

Although there is some debate over the definition of chronic osteomyelitis, most patients have symptoms for greater than 2 to 3 weeks. Typically, patients have waxing and waning symptoms for months. Often there is a prior history of inadequately or untreated acute osteomyelitis, a surgical procedure or major trauma. Fever and other nonspecific signs of infection may be present intermittently or not at all. A painful and poorly functioning extremity and the presence of draining sinuses and necrotic tissue are important clues to diagnosis. Chronic osteomyelitis is often seen in children with peripheral neuropathy when a lesion on the extremity is not noticed and subsequently becomes infected. Lesions are most commonly polymicrobial (eg, S aureus, Pseudomonas aeruginosa, coagulase-negative Staphylococcus, anaerobes, fungi) but occasionally are due to a single organism. Children without adequate access to health care may present late in the course of illness with chronic osteomyelitis.

Emergency Department Treatment and Disposition

Obtain WBC count, ESR, and CRP, which may be elevated but are often normal. Consult orthopedics and infectious disease for appropriate work-up and management including hospitalization. Order radiographs and CT with contrast and MRI to delineate the extent of disease and find sinus tracts. Obtain blood and/or bone cultures (preferable) before initiating antibiotic therapy. Do not use surface cultures from draining sinuses or skin ulcers as these are not representative of the offending organism. Diagnosis is ultimately made from biopsy histopathology and culture. The primary treatment is adequate debridement of dead tissue and removal of sinus tracts by a specialist trained in such procedures. Antibiotics are a supplement to these procedures and will be continued for at least 3 months and often longer depending on the clinical presentation. Antibiotic choice and duration should be made in conjunction with an infectious disease specialist.

Pearls

1. Patients with chronic osteomyelitis often are symptomatic for weeks to several months.

2. Draining sinuses are a hallmark of this disease.

3. Debridement of dead tissue is crucial to treatment.

Clinical Features

Osteomyelitis is the second most common infection (after pneumonia) in patients with sickle cell disease (SCD). Patients present with fever and pain of the affected area. Signs and symptoms are similar to those described in acute osteomyelitis; however patients with SCD may be ill appearing with a more acute onset and may have multiple boney foci. The most common pathogen is Salmonella species followed by S aureus, Streptococcus pyogenes, Streptococcus pneumoniae and other gram-negative organisms (eg, Shigella species, Escherichia coli). It is difficult to differentiate osteomyelitis from vaso-occlusive crisis in these patients. Both diagnoses can present with fever, leukocytosis, and elevation of inflammatory markers. The persistence of symptoms despite adequate hydration and pain control should prompt further work-up for osteomyelitis.