Ortho EM Pearls

Tolerate More Than Pain

Arcuate Sign

A 50-year-old female patient presents to the ED with left knee pain after suffering a hyperextension injury to the left knee. She was walking down steps and reports she internally rotated and hyperextended the knee with immediate pain.

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October 02, 2024

Arcuate Sign

September 28, 2024

Anterior Knee

A 71-year-old female presents with right knee pain after falling and landing directly on her knee. She has swelling over her knee. You obtain an ultrasound image over the area of most concern.

September 25, 2024

Not So Typical Hip Dislocation

A 20-year-old female presents to the ED after MVC with left hip pain. Notably her leg was up on the dash of the car when the accident occurred. Unable to ambulate since the accident and her pain is constant and worse with attempted movement. She notes muscle spasms around her left hip region. She was lying on the stretcher with the affected lower extremity abducted, slightly flexed and externally rotated without obvious shortening. On log roll testing she reported significant pain especially in the anterior groin region.

September 19, 2024

Time is Tissue

A previously healthy 14-year-old right-handed male presented to the children’s emergency department with acute onset swelling of the left hand. He awoke in the morning with left palmar swelling and purple discoloration. Over a few hours, the patient’s swelling spread to the distal fingertips and proximally to the left distal forearm. He denied any IV drug use, use of steroids, or recent trauma. Upon arrival at the ED, the patient was hemodynamically stable and afebrile, but his left wrist and fingers were in a flexed position and held upright against the gurney at rest (Image 1). The patient had prominent circumferential swelling from his distal forearm to the fingertip with diffuse tenderness to palpation along the volar forearm, wrist, and hand. He was unable to actively extend his left wrist and digits due to pain. With passive wrist and finger extension, he reported excruciating pain.

September 11, 2024

Bent my bars and my wrist

A 32-year-old female presents to the ED for right wrist pain after a crash in a rock garden during a downhill mountain biking race. She has significant pain in her right wrist but denies any other pain or symptoms including numbness or tingling.

September 04, 2024

Not So Simple Ankle Dislocation - Sub Talar Trauma

A 45-year-old male was involved in a high-speed interstate MVC rollover accident. Left lower extremity with obvious deformity and open injury.

Not So Simple Ankle Dislocation - Sub Talar Trauma

August 28, 2024

Back it Up - Addressing Low Back Pain

A 58-year-old male presents to the Emergency Department complaining of low back pain, progressively worse over the last few days. He states that he first noticed the pain after work about two weeks ago and seems to be worse with movement. He has tried heating pads and tylenol with little improvement.

August 24, 2024

Anterior Elbow

A 67-year-old male is complaining of left upper arm swelling after lifting a heavy object. He has noted a deformity to his upper arm. You obtain an ultrasound image over the area of most concern.

August 21, 2024

Cutting Edge Blade Encounters: A Review on Hand Anatomy

A 56-year-old male patient presented to the ED after sustaining a circular saw injury to his left hand. He is right hand dominant. The saw lacerated the palmar/volar surface from the wrist joint to the proximal phalanx of the thumb. On exam he is able to extend against resistance with his thumb at the IP joint, is able to cross-fingers/abduct fingers against resistance, but is unable to initiate palmar abduction of the thumb as well as flexion of the thumb IP and index DIP (“A-OK sign”). He also reports decreased sensation throughout the thumb.

Cutting Edge Blade Encounters: A Review on Hand Anatomy

August 14, 2024

Ditch Dislocation

A 46-year-old male fell into a ditch at a height of approximately 6-7 ft per EMS. He presented to the ED with obvious left ankle deformity seen below.

July 31, 2024

Snap and Shift: The Hip Avulsion Saga

A 15-year-old male presented to the emergency department with acute left hip pain after playing basketball. The patient experienced a sharp pain in the left anterior hip after making an abrupt twisting movement while trying to take the ball from his opponent and is now unable to bear weight. He denies numbness, tingling, or other traumas, but reports left leg weakness and pain.

July 27, 2024

Procedure Knee

A 63-year-old male with a history of R total knee replacement is complaining of knee pain, redness, and swelling. His knee started swelling a few days ago and has pain with flexion. You perform an ultrasound and notice a large effusion. To assist with diagnosis, you opt to perform a knee arthrocentesis.

July 24, 2024

Could You Lend Me a Hand?

An 18-year-old presents with R hand pain and swelling after a tackle resulted in him landing on his hand with his full weight during a rugby match. His x-ray is below.

July 17, 2024

Twist and Shout: A Stressed Out Ankle

A 20-year-old female presents with right ankle pain after a ground level mechanical fall. She has tenderness to palpation of her right lateral malleolus with associated swelling. She was unable to ambulate after her fall.

July 10, 2024

Behind the Knee Pain

A 44 year old male with a PMHx of hypertension, presents to the emergency department with a 3 month history of right knee pain and swelling. Patient installs carpet for a living. Pain is worse when kneeling, better with rest. Patient has taken ibuprofen intermittently for symptomatic relief. Patient tried to see his primary care provider but they did not have any openings.

July 03, 2024

Notch Your Average Sign

A 37-year-old female presented to the ED for left knee swelling and pain after a ground level mechanical fall with possible twisting injury. Patient states she was pushed to the ground and struck her left knee on the concrete, feeling immediate pain and swelling.

June 26, 2024

Popeye’s Peril: The Biceps Blowout

A 38 year male with no significant past medical history presents for right elbow pain after a skydiving injury. He states that while he was trying to adjust his chute, a gust of wind caught his chute and his arm was jerked straight and he thinks he heard a pop. He has pain and weakness with opening jars. He denies numbness or tingling. On exam his arm appears like Image 1. He has ecchymosis on the medial aspect of his arm. Motor strength reveals 4 / 5 flexion and 3 /5 supination with pain. When his arm is flexed to 90 and he supinates against resistance, there is no cord-like structure on palpation. Radiographic imaging is normal.

June 22, 2024

Procedure Ankle

A 45-year-old male with a history of gout is complaining of ankle pain and swelling. His right ankle started swelling a few days ago and has pain with movement. You perform an ultrasound.

June 19, 2024

MCP, are you with me?

A 50-year-old right-handed male presented to the emergency department with finger pain in his right hand following a fall. The incident occurred as he was disembarking from a cruise ship and tripped while descending an escalator, resulting in a tumble. The patient's sole complaint is pain and deformity in his finger.

June 12, 2024

The Forgotten Joint

A 51-year-old man complains of right-sided lower neck/chest pain and deformity after a trip and fall onto his right shoulder while playing basketball. The patient is otherwise asymptomatic. Examination reveals a palpable bump right of the sternum with tenderness to palpation.

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