Ortho EM Pearls

Tolerate More Than Pain

Achilles Heel - Kager’s Fat Pad

A 25-year-old male with no medical history presents with left foot pain after a soccer injury yesterday. He states he was running when he felt a sudden “pop” to the posterior aspect of the left ankle and thought someone had kicked him. He is complaining of mild pain localized to the posterior ankle though has been ambulating with pain.

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February 05, 2025

Achilles Heel - Kager’s Fat Pad

January 29, 2025

Calf-inated

A 45-year-old male presents with pain in the posterior right calf after falling forward while skiing. He now has pain with ambulation. He has pain with passive dorsiflexion of the ankle, pain with resisted plantar flexion, but preserved plantar flexion with squeeze of calf muscles.

January 27, 2025

Regional Anesthesia Interscalene Block

A 27-year-old male presents with left shoulder pain after falling down a flight of stairs and trying to grab onto a railing to catch himself. He has an obvious deformity to his left shoulder, and is holding his arm in abduction and internal rotation.

January 22, 2025

Too much send

An 18-year-old male presents with left ankle pain after overshooting the landing of a large jump while snowboarding.

January 15, 2025

I declare a thumb war

A 39-year-old female presents to the emergency department with right thumb pain after falling in a skiing accident. On exam, there is mild swelling, tenderness on the ulnar aspect of the 1st MCP joint. Additionally, there is laxity with valgus stressing of the 1st MCP joint.

January 08, 2025

The Heel Deal

A 57-year-old male with a history of alcohol induced cirrhosis presents to the ED w/ 10 days of reported L foot pain after fall from 6 foot ladder, landing directly onto his left foot. Since his injury, he has noticed increasing redness and swelling to the posterior aspect of the foot beginning approximately 4 days after the fall. He has been using a walker that he borrowed from his friend to assist in ambulation. He denies any knee pain or back pain.

December 28, 2024

Regional Anesthesia Upper Extremity

A 24-year-old male presents after a high-energy ATV rollover. He presents with a gross deformity to his forearm.

December 25, 2024

Foosh there it is

A 72-year-old woman presents to the emergency department with right wrist pain and swelling. She states that she was crossing the street when she fell and attempted to brace herself with her right hand.

December 18, 2024

Red Hot Wrist

The patient is a 74-year-old male with a PMH of diabetes, and hypersensitivity pneumonitis on chronic prednisone who presented with fevers and right wrist pain. He had a cortisone injection in his right wrist 4 days prior. The patient reports pain, swelling, and erythema of the right wrist. Pain is worse with movement. He denies trauma to the wrist. His distal neurovasculature is intact. He is febrile to 38.5C, tachycardic (HR:130), tachypnic (RR: 25), and hypoxic requiring oxygen (85% room air).

December 04, 2024

To Immobilize or Not to Immobilize: That is the Question

A patient presents to the Emergency Department after sustaining a twisting knee injury while skiing. She felt a pop and was unable to bear weight afterwards secondary to pain and instability. Shortly after the injury, she noted increased swelling and pain. On examination, she has a moderate effusion and a positive Lachman test.

To Immobilize or Not to Immobilize: That is the Question

November 27, 2024

Pain in the Butt

A 48-year-old female with no pertinent past medical conditions presents for ongoing pain in the gluteal region which is worse on the right compared to the left. Pain is dull/aching in nature but at times describes it as a burning sensation. She denies any recent trauma. She states it is worse when lying on her side, when she goes for a jog, and when she squats. She has been taking non-steroidal anti-inflammatories (NSAIDs) but states the pain has been getting more and more prominent. On exam, she has point tenderness along the right lateral hip. She has a negative straight leg test, and a positive FABER. X-ray of the hip seen below in Image 1 was obtained which was unremarkable.

November 23, 2024

Regional Anesthesia Lower Extremity Part 1

A 67-year-old male with diabetes stepped on a metal object and is complaining of ongoing heel pain. You obtain the below X-ray.

Regional Anesthesia Lower Extremity Part 1

November 20, 2024

Foot Doesn’t Work Right

A 35-year-old male felt a painful “pop” in his posterior left lower leg while playing football. Afterwards his “foot didn’t work right anymore.” X-ray of the left ankle and tib/fib are normal but he is unable to ambulate. You place an ultrasound over the area of maximal tenderness and discover the following:

November 13, 2024

Knee Deep

A 40 year-old male with no medical history presented for right knee pain after his knee was struck by a skylight while at work. He has had pain for three days, unrelieved with home medications, however has been ambulating with steady gait. He ultimately presented to the Emergency Department for ongoing pain.

November 06, 2024

Let the Feet Drop

A 72-year-old male with history of diabetes and rheumatoid arthritis presents with inability to dorsiflex his left foot after relaxing with his feet on his desk and hearing a “pop” upon standing. On exam, he has swelling and a palpable mass of the anterior ankle.

October 30, 2024

In a Jam

A 20 year old soccer player with left great toe pain, swelling, and bruising after a kick in a game the previous night where he stated “I jammed my toe.”

October 26, 2024

Regional Anesthesia Hip

An 83-year-old female from a nursing home had a witnessed fall. She is brought in with severe R hip pain, and her leg is shortened and externally rotated. She is found to have a R femoral neck fracture. You decide to perform a fascia iliaca block for pain control.

October 23, 2024

Only sort of broken

A 9-year old male soccer goalie presented to the emergency department with a complaint of forearm pain following a fall on outstretched arm during practice. Pain was located in the mid-distal radius, proximal to the wrist. There was minimal pain with wrist flexion and extension. No pain with movement of the elbow. There is significant tenderness to palpation in a small area of the mid-distal radius without any tenderness proximal or distal to this area. No deformity of the forearm noted. Bedside ultrasound (Image 1) of the area of tenderness is shown below.

October 16, 2024

The Other Type of Pediatric Knee Pain

A 9-year-old previously healthy male presented to the emergency department with anterior knee pain after kicking a ball at school. Patient was ambulatory at the school and in the ED although limping due to pain. Patient is an avid soccer player and has not had any previous knee injuries or issues related to knee pain. Physical exam showed a normal appearing knee with point tenderness at the inferior pole of the patella and proximal patellar tendon, painful but intact knee extension and painful ambulation with some mild limping. Distal neurovascular exam intact.

October 09, 2024

Shouldering Too Much of the Load

A 13-year-old male with no PmHx presents with 3 weeks of progressive shoulder pain. No direct trauma or injury was reported, but the patient reports that the pain began after pitching in a game in which he threw more pitches than usual and during which he exceeded his pitch count. Physical examination was remarkable for significant tenderness to palpation on the lateral aspect of the proximal humerus. Intact ROM and strength, no clavicular or acromial tenderness.

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