Extremity

Rapid Review

• Differentials
  • Anterior
    • Anterior capsule strain
    • Biceps tendinopathy
    • Gout
    • Intra-articular loose body
    • Osteoarthritis
    • Pronator syndrome
    • Rheumatoid arthritis
  • Lateral
    • Lateral epicondylitis
    • Osteochondral defect
    • Plica
    • Posterolateral rotatory instability
    • Radial Tunnel Syndrome
  • Medial
    • Medial epicondylitis
    • Ulnar collateral ligament injury
    • Cubital tunnel syndrome
  • Posterior
    • Olecranon bursitis
    • Olecranon stress fracture
    • Osteoarthritis
    • Triceps tendinopathy
    • Posterior impingement
• History
  • Exact location of most pain
    • Narrow differentials based on location
  • Recent trauma
    • Consider fracture, dislocation, etc.
  • Play sports (tennis, golf, etc.)
    • Consider lateral/medial epicondylitis
  • Prolonged resting on the elbow
    • Consider olecranon bursitis
  • Fever/Chills
    • Consider septic arthritis
• Physical Exam
  • (+) Elbow abduction stress test or Milking maneuver
    • Suggests ulnar collateral ligament injury
  • (+) Hook test
    • Suggests distal biceps tendon rupture
  • (+) Middle finger test
    • Suggests posterior interosseous nerve compression syndrome
  • (+) Tinel test
    • Suggests cubital tunnel syndrome
• Work-Up
  • Labs
    • CBC, BMP, ESR, CRP
  • Procedures
    • Arthrocentesis (cell count, culture, gram stain, crystals, protein, glucose, lactate)
  • Imaging
    • Elbow X-ray series

Pearls

• Beware the “fat pad” or “sail” sign on X-ray, suggesting an occult condylar fracture or radial head fracture that is otherwise not visible. 
• Fractures in pediatric patients often occur through unossified cartilage. This makes X-rays difficult to interpret.

Deep Dive

• Elbow Injuries: Ten Pitfalls in Diagnosis and Management (EM Cases)

Rapid Review

• Differentials
  • Orthopedic/Trauma
    • Bursitis
    • Osteoarthritis
    • Hemarthrosis
    • Ligament tear (ACL, PCL, MCL, LCL)
    • Meniscus injury
    • Fracture
    • Dislocation
  • Infectious
    • Septic joint
    • Reactive arthritis
    • Osteomyelitis
    • Septic bursitis
  • Crystalline
    • Gout
    • Pseudogout
  • Other
    • Tumor
    • Deep Venous Thrombosis
    • Baker’s Cyst
• History
  • Recent injury
    • Consider traumatic process
  • Hear a pop or snap
    • Consider fractures or ligament/meniscal injury
  • Fever/Chills
    • Consider infectious process
  • History of smoking, OCP’s, prolonged immobility
    • Consider DVT
• Physical Exam
  • Recent injury
    • Likely traumatic process
  • Warm, swollen, erythematous
    • Gout vs septic joint
  • Recurrent knee effusion
    • Suggests meniscus injury
  • (+) Anterior drawer or (+) Lachman
    • Suggests ACL injury
  • (+) Posterior sag sign
    • Suggests PCL injury
  • Pain w/ Varus stress
    • Suggests LCL injury
  • Pain w/ Valgus stress
    • Suggests MCL injury
• Work-Up
  • Labs
    • CBC, BMP, ESR, CRP
  • Procedures
    • Arthrocentesis (cell count, culture, gram stain, crystals, protein, glucose, lactate)
  • Imaging
    • Knee X-rays (2-3 view)

Pearls

• Knee pain can often be referred pain from the hip. Be sure to do a thorough exam across the entire extremity. 
• Maintain a high index of suspicion for popliteral artery injuries following knee dislocations. Consider Ankle-Brachial Index (ABI) measurements and/or CT angiography.

Deep Dive

• Occult Knee Injuries: Pearls and Pitfalls (EM Cases)

Rapid Review

• Differentials
  • Vascular
    • Deep vein thrombosis
    • Peripheral artery disease
    • Arterial occlusion 
    • Thrombophlebitis
  • Infectious
    • Necrotizing fasciitis
    • Septic joint
    • Osteomyelitis
  • Musculoskeletal
    • Compartment syndrome
    • Fracture/sprain
    • Spinal stenosis (pseudoclaudication)
  • Cardiac
    • Congestive heart failure (venous stasis, edema)
• History
  • Pain w/ exertion
    • Suggest PAD
  • Sudden onset pain
    • Suggests arterial occlusion
  • History of trauma
    • Consider fracture or compartment syndrome
  • Fever/chills
    • Consider necrotizing fasciitis, osteomyelitis, septic joint
  • Shortness of breath
    • Consider pulmonary embolism secondary to DVT
• Physical Exam
  • Homan Sign
    • Suggests DVT
  • Absent pulses
    • Consider arterial occlusion
  • Overlying warmth, erythema
    • Consider cellulitis/necrotizing fasciitis
  • Non-healing ulcers
    • Suggests peripheral vascular disease
  • Swelling/deformity
    • Consider fracture/compartment syndrome
• Work-up
  • Labs
    • CBC, BMP, CPK, lactate
  • Procedures
    • ABI measurement
      • If suspect vascular etiology
    • Compartment pressure measurement
      • If suspect compartment syndrome
  • Imaging
    • Ultrasound (DVT)

Pearls

• Tibial plateau fractures on commonly missed on plain film. Perform a CT scan if you have high clinical suspicion for this injury. 
• Remember the 6 P’s for acuter limb ischemia (pain, pallor, paresthesias, poikilothermia, pulselessness, and paralysis). 

Deep Dive

• Basics of EM – Leg Pain (REBEL EM)

Rapid Review

• Differentials
  • Non-traumatic/chronic
    • Subacromial bursitis
    • Biceps tendinitis
    • Adhesive capsulitis
    • Impingement syndrome
    • Calcific tendinitis
  • Traumatic/acute
    • Shoulder dislocation
    • Clavicle fracture
    • Humerus fracture
    • Scapula fracture
    • Acromioclavicular joint injury
    • Rotator cuff tear
    • Biceps/triceps tendon rupture
    • Septic Joint
  • Referred Pain/Non-orthopedic
    • Brachial plexus injury
    • Thoracic outlet syndrome
    • Myocardial infarction
    • Pulmonary embolism
    • Axillary artery thrombosis
    • Subclavian Steal Syndrome
• History
  • Recent injury
    • Likely acute process
  • Hear a pop/snap
    • Consider fracture
  • Recent seizure
    • Consider dislocation
  • Pain radiate to the elbow
    • Consider cervical disc disease
  • Clunking sound w/ overhead motion
    • Labral disorder
• Physical Exam
  • Deformity
    • Suggests dislocation/fracture
  • Apley scratch test
    • Suggests rotator cuff problem
  • Neer’s Sign
    • Suggests subacromial impingement
  • Hawkin’s test
    • Suggests supraspinatus tendon impingement
  • Drop arm test
    • Suggests rotator cuff injury
• Work-Up
  • Labs
    • CBC, BMP, ESR, CRP
  • Procedures
    • Arthrocentesis (cell count culture, crystals, gram stain)
  • Imaging
    • Shoulder X-rays (2-3 view)

Pearls

• Consider acute coronary syndrome as a source of shoulder pain if the patient does not have a clear history of overuse or injury.
• A CT scan is usually not needed unless there is a suspicion for intrathoracic injuries as well. 

Deep Dive

• Shoulder Pain in the Urgent Care (JUCM)

Rapid Review

• Differentials
  • Traumatic
    • Scaphoid fracture
    • Hook of hamate fracture
    • Distal radius fracture
    • Scapholunate ligament tear
    • Perilunate dislocation
  • Non-traumatic
    • Carpal tunnel syndrome
    • De Quervain tenosynovitis
    • Ulnar neuropathy
    • Radial neuropathy
• History
  • Fall forward on hands
    • Consider distal radius or scaphoid fracture
  • Fall backward on hands
    • Consider injury to distal ulna, ulnar stylus, triquetrum, or lunate
  • Occupational activity
    • Computer based activities suggestive of carpal tunnel
    • Child-care activities may cause De Quervain tenosynovitis (from lifting children repeatedly) 
• Physical Exam
  • Snuffbox tenderness
    • Scaphoid fracture until proven otherwise
  • Neurosensory deficit
    • Warrants orthopedic consultation
  • Tinnel or Phalen sign
    • Suggests carpal tunnel syndrome
  • Finklestein test
    • Suggests De Quervain tenosynovitis
• Work-up
  • Labs
    • None usually needed
  • Imaging
    • Wrist X-ray

Pearls

• Plain films miss approximately 40% of all scaphoid fractures. If you suspect this injury, the patient must be splinted (thumb spica) and referred to orthopedics.
• Scapholunate dissocations are the most commonly missed ligament injury of the wrist. The “Watson test” on physical exam and “clenched fist” views on X-ray can help make the diagnosis. 

Deep Dive

• Can’t Miss Adult Wrist Injuries (ALiEM)