Musculoskeletal

Rapid Review

• Background
  • Involves puncture of elbow joint and aspiration of synovial fluid for therapeutic or diagnostic purposes. 
• Indications
  • Suspicion for septic arthritis or inflammatory causes such as gout, pseudogout, or rheumatologic disorders. May also be used to relieve pain and improve mobility. 
• Contraindications
  • No absolute contraindications. Relative contraindications include overlying skin infection, joint prosthesis, bacteremia, or anticoagulant use. Do not inject steroids into joint if infection is suspected.
• Complications
  • Infection (rare), hemarthrosis, allergic reaction to anesthetic.

Pearls

• The target for elbow arthrocentesis is the “triangle” (radial head, lateral epicondyle, oclecranon tip)
• The ideal position for the patient is elbow flexed at 90 degrees and forearm pronated (palm down)

Deep Dive

• Elbow Arthrocentesis (StatPearls)

Rapid Review

• Background
  • Involves puncture of knee joint and aspiration of synovial fluid for therapeutic or diagnostic purposes. 
• Indications
  • Suspicion for septic arthritis or inflammatory causes such as gout, pseudogout, or rheumatologic disorders. May also be used to relieve pain and improve mobility. 
• Contraindications
  • No absolute contraindications. Relative contraindications include overlying skin infection, joint prosthesis, bacteremia, or anticoagulant use. Do not inject steroids into joint if infection is suspected.
• Complications
  • Damage to cartilage if place improperly, infection (rare), small hemarthrosis

Pearls

• You may compress or “milk” both sides of the knee joint to help facilitate fluid aspiration.
• Once you are able to aspirate fluid, do not advance the needle any further. This may cause damage to the cartilage.

Deep Dive

• Is There Water on the Knee? Arthrocentesis in the ED (emDocs)

Rapid Review

• Background
  • Puncture of the radiocarpal joint with needle aspiration of synovial fluid for therapeutic or diagnostic purposes
• Indications
  • Suspicion for septic arthritis or inflammatory causes such as gout, pseudogout, or rheumatologic disorders. May also be used to relieve pain and improve mobility. 
• Contraindications
  • No absolute contraindications. Relative contraindications include overlying skin infection, joint prosthesis, bacteremia, or anticoagulant use. Do not inject steroids into the joint if infection is suspected.
• Complications
  • Infection (rare), hemarthrosis, allergic reaction to anesthetic.

Pearls

• Do not inject into the anatomic snuffbox! This may cause neurovascular damage. Our target is just beyond this landmark, ulnar to the EPL and distal from the Lister tubercle. 
• If you hit bone initially, pull the needle back redirect carefully towards the thumb

Deep Dive

• How To Do Wrist Arthrocentesis (Merck Manual)

Rapid Review

• Background
  • Procedure used to assess for compartment syndrome. 
• Indications
  • Pain or paresthesia following fractures, crush injury, snake bites, burns, prolonged tourniquet, or infection.
• Contraindications
  • No absolute contraindications. Avoid sites with overlying infection.
• Complications
  • Pain, low risk of infection

Pearls

• For the most accurate results, measure pressure at sites that have the most amount of palpable tension.
• The number to look out for is 30. If the pressure is above 30, then this is suggestive of compartment syndrome.  Alternatively, if the difference between the diastolic BP and the compartment pressure is less than 30, this is also suggestive of compartment syndrome.

Deep Dive

• Compartment Pressure Measurement (WikEM)

Rapid Review

• Background
  • Reduction of a dislocated elbow joint. Far majority of dislocations are posterior (90%) and typically occur as a result of a FOOSH (fall on outstretched hand) injury.
  • Reduction techniques include the prone approach and the supine approach
• Indications
  • Posterior elbow dislocation. 
  • Immediate reduction warranted if neurovascular compromise present
• Contraindications
  • Fractures present
  • Multiple prior attempts at reduction
• Complications
  • Injury to brachial artery or median/ulnar nerve

Pearls

• Although nerve injury is rare, pre/post-reduction neurovascular examination is key.  Especially if X-ray shows significant widening between the distal humerus and the olecranon.  
• Following a successful reduction, the elbow should be immobilized in a neutral position or pronation with 90 degrees of flexion. 

Deep Dive

• Elbow Dislocation (Core EM)

Rapid Review

Pearls

Deep Dive

Rapid Reviews

• Background
  • Reduction of a hip dislocation. Far majority of dislocations are posterior (90%). Reduction of native hip should be performed within 6 hours to reduce risk of osteonecrosis.
  • Techniques include the Allis maneuver, Captain Morgan maneuver, Waddell maneuver, Whistler maneuver, and Rocket Launcher maneuver.
• Indications
  • Closed dislocations w/o fractures. 
  • Urgent reduction warranted if signs of neurovascular compromise
• Contraindications
  • Open dislocations or presence of fractures
  • Multiple failed reduction attempts.
• Complications 
  • Fracture, irreducibility.

Pearls

• Most reduction techniques are designed for posterior dislocations. Anterior dislocations are best reduced by simple in-line traction and external rotation. 
• Do not wait too long. A delay in reduction > 6 hours significantly increases risk for femoral head avascular necrosis. 

Deep Dive

• Hip Dislocation (Core EM)

Rapid Review

• Background
  • Reduction of the knee joint. These dislocations typically occur from MVCs, fall from heights, and sports injuries.
  • Reduction technique depends on anterior vs posterior dislocation
• Indications
  • Tibiofemoral dislocation. Immediate reduction required before radiographs if neurovascular compromise exists.
• Contraindications
  • “Pucker sign” during knee extension is an indication that dislocation is not reducible by closed reduction.
• Complications
  • Worsening neurovascular injury. 
  • Knee dislocations commonly associated with popliteal artery injury. 

Pearls

• Reduction involves longitudinal traction with lifting of the distal femur (anterior dislocations) or lifting of the proximal tibia (posterior dislocations).
• A “Pucker” sign is a sign of a posterolateral dislocation, which will require open reduction in the OR.

Deep Dive

• Knee Dislocation (Maimonides Emergency Medicine)

Rapid Review

• Background
  • Reduction of patellar dislocation; common in athletes and adolescent women. Dislocation may be lateral (most common), horizontal, vertical, or intercondylar
• Indications
  • Lateral/medial dislocations, especially if associated with vascular compromise.
• Contraindications
  • Presence of proximal tibia or distal femur fracture.
• Complications
  • Osteochondral fractures (rare)

Pearls

• Raising the head of the bed helps to flex the hip and allow for relaxation of the quadriceps muscle prior to reduction.
• A knee immobilizer should be worn for at least 3 weeks following a successful reduction. 

Deep Dive

• Patellar Dislocation (Life in the Fast Lane)

Rapid Review

• Background
  • Reduction of anterior (most common), posterior, or inferior (rare) shoulder dislocation.
• Indications
  • Uncomplicated, low force shoulder dislocations
• Contraindications
  • Associated fractures of humeral neck or subclavicular/intrathoracic dislocations. Avoid multiple attempts in those with suspected nerve injuries or other common fractures (Hill-sachs deformity, bankart fracture, 
• Complications
  • Rare, but include fractures, neurovascular injuries, or rotator cuff injuries (rare)

Pearls

• Allowing the muscles to relax prior to attempting reduction is key to a successful procedure.
• Do not delay immobilizing a joint after a sucessful reduction. Joints can spontanously dislocate shortly following the procedure.

Deep Dive

• Shoulder Reduction Techniques (emDocs)

Rapid Review

• Background
  • Reduction of a radial head subluxation (nursemaid’s elbow). Most subluxations occur in patients 1-5 years old and are caused by excessive longitudinal traction on the arm.
  • Reduction is accomplished using a hyper-pronation or supination-flexion technique.
• Indications
  • Radial head subluxation (diagnosis can be made clinically in most pediatric patients).
• Contraindications
  • Deformities, evidence of infection, or distal neurovascular compromise (indicates injury beyond subluxation)
• Complications
  • Complications are rare. May cause further injury.

Pearls

• The hyper-pronation technique has a 94% first-time success rate compared to supination-flexion at 69%
• If using the supination reduction technique, applying pressure to the radial head throughout may improve success rates.

Deep Dive

• How To Reduce a Radial Head Subluxation (Merck Manual)

Rapid Review

• Background
  • Dynamic splinting of injured finger to an adjacent, unaffected finger
• Indications
  • Nondisplaced, stable fracture of middle or proximal phalanx
  • Minor strains or PIP dislocations (after reduction)
• Contraindications
  • Unstable fractures or dislocations
  • Tendon injuries (boutonniere injury, mallet finger)
• Complications
  • Skin breakdown/necrosis
  • Vascular compromise

Pearls

• Gauze or cotton padding should be placed between the fingers to prevent skin maceration
• Avoid taping too tightly to prevent restriction of circulation

Deep Dive

• How To Buddy-Tape Fingers (Merck Manual)

Rapid Review

• Background
  • Application of splinting device to injured phalanx. More stable than the buddy tape method.
  • Several commercial splints exist (ex. padded aluminum, frog legs, et.)
• Indications
  • Distal phalanx fracture, DIP dislocations
  • Tendon injuries (mallet finger, jersey finger, boutonniere injury)
• Contraindications
  • Open fractures
• Complications
  • Vascular compromise from taping too tight

Pearls

• For mallet finger, the DIP must be kept in continuous extension for 6-8 weeks,  even during splint changes.
• Full finger immobilization isn’t always needed. Only splint the joints necessary for the specific injury. 

Deep Dive

• How To Apply a Fixed Finger Splint (Merck Manual)

Rapid Review

• Background
  • Type of splint for mid-upper arm for stabilization of the humerus. Modified versions exist for non-cooperative patients.
• Indications
  • Mid-shaft or proximal third humeral shaft fracture
• Contraindications
  • No absolute contraindications
• Complications
  • Skin breakdown, vascular compromise

Pearls

• A coaptation splint should always be paired with a sling as well.
• After 1-2 weeks of coaptation splinting, patients are typically transitioned to functional bracing for minimum of 8 weeks

Deep Dive

• Coaptation Splint (WikEM)

Rapid Review

• Background
  • Application of splinting device for immobilization of the hand and wrist.
• Indications
  • Soft tissue hand/wrist injuries, fractures of 2nd-4th metacarpals
  • Isolated distal radius fracture injuries
• Contraindications
  • No absolute contraindications
  • Relative contraindications include complex or open fractures.
• Complications
  • Pressure injuries, dermatitis, ischemia

Pearls

• The wrist should be maintained in extension between 10-20 to achieve neutral positioning. Having the patient hold a bandage wrap can help ensure this.
• Unfortunately, the volar splint does not prevent supination or pronation. If this type of immobilization is needed (ex. distal radius/ulna fracture) , a sugar tong splint should be used instead.

Deep Dive

• Forearm Volar Splint (WikEm)

Rapid Review

• Background
  • Splint applied to the radial aspect of the wrist to prevent flexion or extension of the 2nd/3rd metacarpals or phalanges.
• Indications
  • Soft tissue injuries or fractures of the 2nd and 3rd metacarpals
  • Soft tissue injuries or fractures of the 2nd and 3rd phalanges
• Contraindications
  • Complex or open fractures
  • Injuries with neurovascular compromise
• Complications
  • Dermatitis, pressure injuries, vascular compromise

Pearls

• Positioning is key. The wrist should be in slight extension (20 degrees), MCP flexed (50-70 degrees), and DIP/PIP in slight flexion (5-10 degrees)
• Leave an adequate amount of space for the thumb when applying.

Deep Dive

• Radial Gutter Splint (WikEM)

Rapid Review

• Background
  • Splint applied to the thumb and forearm to prevent movement of the thumb and limit flexion/extension of the wrist.
• Indications
  • Scaphoid fracture, lunate injuries, first metacarpal fracture
  • Gamekeeper’s/Skier’s thumb, positioning for de Quervain tenosynovitis 
• Contraindications
  • Complex or open fractures
• Complications
  • Neurovascular compromise, dermatitis, pressure injuries

Pearls

• Anybody with a suspected scaphoid fracture should be immobilized with thumb spica splint.
• Be generous with the padding over the radial styloid to maximize comfort.

Deep Dive

• Thumb Spica Splint (WikEM)

Rapid Review

• Background
  • Splint applied to the forearm and 4th/5th phalanges to limit flexion/extension of the wrist and 4th and 5th fingers.
• Indications
  • 4th/5th metacarpal fractures
  • Fractures and soft tissue injuries of the 4th/5th phalanges
• Contraindications
  • None
• Complications
  • Pressure injuries, dermatitis, compartment syndrome

Pearls

• Be thorough in checking for lacerations prior to splinting, as these  injuries are frequently associated with “fight bite” wounds.
• To prevent maceration, apply padding between th 4th and 5th digits.

Deep Dive

• How To Apply an Ulnar Gutter Splint (Merck Manual)

Rapid Review

• Background
  • Splint applied to the forearm to prevent wrist flexion, extension, supination, and pronation.
• Indications
  • Distal radius or distal ulna fracture
• Contraindications
  • No absolute contraindications
• Complications
  • Dermatitis, compartment syndrome, pressure injuries

Pearls

• Maintain the elbow at 90 degrees flexion and the wrist at 10-20 degrees extension while molding the splint.
• A reverse sugar tong splint avoids splint buckling at the elbow while simultaneously accomplishing the same degree of immobilization as a classic sugar tong splint.

Deep Dive

• Trick of the Trade: Reverse Sugar Tong Splint (ALiEM)

Rapid Review

• Background
  • Splint applied to upper/lower arm to limit elbow flexion/extension, wrist flexion/extension, and pronation/supination
• Indications
  • Complex/unstable elbow and forearm fractures
• Contraindications
  • None
• Complications
  • Pressure injuries, dermatitis, compartment syndrome

Pearls

• Apply the forearm splint first, then the upper arm splint after.
• Forearm should remain neutral with the thumb up and the elbow flexed at 90 degrees.

Deep Dive

• Double Sugar Tong Splint (WikEM)

Rapid Review

• Background
  • Splinting application for immobilization of the elbow and proximal forearm
  • Does not limit forearm supination and pronation like a double sugar tong splint.
• Indications
  • Fracture of the olecranon, proximal radius/ulna, or distal humerus
  • Severe ligamentous injuries of the elbow
• Contraindications
  • Complex/open fractures or injuries with neurovascular compromise
• Complications
  • Pressure injuries, compartment syndrome, dermatitis, neurovascular compromise

Pearls

• Complex or unstable fractures that require limiting pronation/supination should be immobilized with a double sugar tong splint instead
• The elbow must remain in 90 degrees flexion during the hardening of the splint. An assistant can help ensure this.

Deep Dive

• How To Apply a Long Arm Splint (Merck Manual)

Rapid Review

• Background
  • Shoulder sling to support the weight of the arm and limit movement. A swathe can be added to further restrict internal/external rotation.
• Indications
  • Humerus fractures (after splinting), clavicle fractures, AC joint injuries
  • Shoulder dislocation (after reduction)
• Contraindications
  • No absolute contraindications
• Complications
  • Ulnar nerve compression (if sling is too short and wrist is hanging out)

Pearls

• If the sling is too short, the wrist will not be supported by the sling, causing a ulnar nerve compression.
• Unless contraindicated by proximal humerus fractures, encourage the patient to perform shoulder ROM exercises at home to prevent adhesive capsulitis. 

Deep Dive

• How To Apply a Shoulder Sling and Swathe (Merck Manual)

Rapid Review

• Background
  • Splint extending from the sole of the foot to the upper thigh to prevent plantar flexion and dorsiflexion of the ankle, as well as flexion/extension/rotation of the knee.
• Indications
  • Fractures of the knee, distal femur, or tibial plateau
  • Maisonneuve fracture
• Contraindications
  • Complex or open fractures
• Complications
  • Dermatitis, compartment syndrome, pressure injuries

Pearls

• Pre-fabricated knee immobilizers can be useful alternatives to posterior long leg splinting. However, formal splinting should still be applied to angulated fractures or pediatric femoral shaft fractures.
• Immobilize with the knee at 5 degrees flexion and the foot in slight plantarflexion

Deep Dive

• Long Leg Posterior Splint (WikEM)

Rapid Review

• Background
  • Splint applied to the lower leg/ankle to prevent plantar flexion, dorsiflexion, eversion, and inversion of the ankle.
  • Provides more medial-lateral stability than the posterior ankle splint
• Indications
  • Distal tibia/fibula fracture
  • Severe ankle sprain or ankle dislocation (after reduction)
• Contraindications
  • Complex or open fractures
• Complications
  • Dermatitis, pressure injuries, neurovascular compromise

Pearls

• Add a posterior ankle splint to the ankle stirrup splint for unstable ankle injuries
• The foot should remain at 90 degrees flexion while the splint hardens

Deep Dive

• Stirrup Splint (WikEM)

Rapid Review

• Background
  • Splint applied to the lower leg to limit plantar flexion, dorsiflexion, eversion, and inversion of the ankle
  • Provides more anterior-posterior stability than the ankle stirrup splint
• Indications
  • Distal tibia/fibula fracture
  • Severe ankle sprain or ankle dislocation (after reduction)
• Contraindications
  • Complex or open fractures
• Complications
  • Pressure injuries, dermatitis, neurovascular compromise

Pearls

• If using this splint to immobilize the Achilles tendon, the ankle should be in the equine position as opposed to 90 degrees flexion.
• Unstable ankle injuries should have a sugar tong splint (ankle stirrup) added to the posterior ankle splint.

Deep Dive

• How to Apply a Posterior Ankle Splint (Merck Manual)