Introduction

• Usually from a high-impact injury (tackle while leg planted); 
• Outside of sports medicine, we typically see in trauma setting with dashboard injuries
• Nearly 75% of ligaments will be disrupted 
• Associated Injuries:
  • Vascular
    • 5-15% in all dislocation with nearly have occurring in A/P dislocations
  • Nerve
    • Common peroneal nerve injury in 25% of cases!
      • S: Decreased sensation over dorsum of foot sparing the lateral most portion
      • M: loss of dorsiflexion/eversion of the ankle; Loss of EHL -> Foot drop
  • Fractures presenting 60% of cases with femur and tibia being most common 

 
Signs & Symptoms

• Symptoms = Knee pain/instability (brought to knees)
• PE:
  • No deformity!
    • 50% of knee dislocations will spontaneously reduce prior to arrival; very deceptive
  • Swelling, effusion, abrasions
  • Obvious deformity
    • Reduce immediately!!!
• Make sure you assess all ligaments (ACL, PCL, MCL, LCL)
• Vascular exam is key!
  • Number one priority
  • Need to do both BEFORE and AFTER reduction
  • DP/PT pulses 
    • If pulses present/normal àDoes NOT rule-out arterial injury; collateral circulation can mask complete popliteal artery occlusion
    • ABI time!
      • >0.9 = serial examinations
      • <0.9 = CT angiography; consult vascular surgery if needed
    • Diminished/Absent Pulses:
      • Make sure knee is reduced!
      • Time = Muscle
      • IMMEDIATE surgical consult if pulses are still absent following reduction or hard signs of vascular compromise (expanding hematoma, distal ischemia, thrill)
      • Ischemia >8 hours has amputation rate ~85%
  • Pulses present after reduction àABIs àObservation vs angiography

 
Classification

• Kennedy classification for direction of displacement of tibia on femur; Schenck for ligaments
• Anterior
  • Most common (30-50%)
  • Hyperextension injury and usually requires PCL to tear
• Posterior
  • 2ndmost common (25%)
  • Due to axial load on a flex knee
  • *Highest rate of vascular injury, i.e. complete popliteal artery tear
• Lateral and Medical
  • Due to varus/valgus force
  • Lateral dislocation has highest change of peroneal nerve injury

 
Diagnostics:

• XR ànormal if spontaneous reduction
• Look for other fractures (Segond)
• Non-emergent MRI
• CT angiography as above

Treatment:

• Reduce and re-exam!

• This is an ORTHOPEDIC/SPORTS EMERGENCY
• There is one situation where reduction of the knee should not take place.  The “dimple sign” represents buttonholing of the medial femoral condyle through the anterior medial joint capsule.  The sign indicates an irreducible dislocation and closed reduction is contraindicated for the risk of skin necrosis.
• Posterior:
  • Someone holds distal femur, provider pulls longitudinally then anteriorly
  • Be careful; too much force can cause popliteal injury
• Anterior:
  • Counter-traction on proximal tibia
• Once reduced, splint in 20-30 (deg) flexion and re-shoot films
• Most cases require surgical stabilization, consult your orthopedic surgeons
• If ABI >0.9 with strong pulses and normal doppler -> Admit for observation
• ABI <0.9 with asymmetric pulses or abnormal doppler -> consult vascular surgery, obtain CTA

Background

• Secondary to shoulder trauma (not as much direct clavicle trauma)
  • Tackled to ground
  • FOOSH
  • Direct impact to lateral shoulder
• Majority of fractures involves the middle third (75-80%); Distal third (15%); Medial third (5%)
• Distal third associated with AC joint injury and/or coracoclavicular ligament rupture
• Medial fracture àintrathoracic injuries

 
Clinical Features

• Swelling, deformity, tenderness, pain over anterior shoulder
• Patient may be supporting affected arm with the contralateral arm
• Displaced fractures
  • Medial fragment displaced posteriorly and superiorly (SCM pulls)
  • Lateral fragment displaced inferiorly and medically (Pectoralis and weight of arm pulls)
  • Open fractures usually result from medial fragment buttonholing through platysma

 
Evaluation

• Assess distal pulses, motor, and sensation
• XR (CXR, SXR, Dedicated clavicle films)
  • Associated injuries are rare, but can see rib fractures, PTX, neurovascular injuries
  • Additional XR view = ZANCA view (15-degree cephalic tilt)
    • Determines superior/inferior displacement
    • Have patient hold 5-10 lbs weight in affected hand
• Consider CT for further eval and possible vascular injury

 
Classification

• Neer, Allman, Craig, Robinson

• AO Classification:
  • Type A, B, C (A = Simple; B = Wedge; C = Complex)

 
Management

• Non-operative
  • Sling or figure-of-eight immobilization with early ROM exercises at 2-4 weeks; start strength training at 6-10 weeks
  • Best for minimally displaced, <2 cm shortening, no neuro deficits
  • Nonunion rate = 1-5 %
    • Most often in elderly and females
• Operative
  • ORIF
    • Open fractures
    • Displaced fracture with skin tenting
    • Neurovascular injury
    • Risk of need for future procedures, implant removal or debridement for infection
• Pain control
  • Chang AK, Bijur PE, Esses D, et al. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA2017;318:1661-7

 
Disposition

• Discharge with ortho/sports follow-up
• Possible surgical intervention for comminuted fractures, significant displacement or >2 cm of shortening
• Consult orthopedics in the ED if patient has an open fracture, Neurovascular compromise or skin tenting

Incidence

• Rare
• Distal biceps tendon rupture represents about 10% of biceps ruptures, with majority being proximal
• Ruptures tend to occur in the dominant elbow (86%) of men (93%) in their 40s

Risk factors

• Your muscle builders with their anabolic steroids
• Smoking has 7.5x greater risk than nonsmokers
• Typically, patients will report a snap or pop as the elbow is eccentrically loaded from flexion to extension

• Weakness and pain, primarily in supination, are hallmarks of this injury
• May produce mid-arm "ball", also be referred to as the reverse “Popeye’s sign” = change in contour of the muscle
• Motor exam often shows loss of supination and flexion, with mostly loss of supination
• Distal swelling and tenderness over antecubital fossa
  • For most complete tears, there will be an Inability to palpate distal biceps tendon in antecubital fossa
  • However, there is a great provocative test you can perform called the Hook test. This was a technique first described in 2007 in an article published in the AJSM (Dr. Shawn O’Driscoll), which was found to be ~100% sensitive and specific
    • Performed by asking the patient to actively flex the elbow to 90° and to fully supinate the forearm. Using you index finger, attempt to hook the lateral edge of the biceps tendon.
    • With an intact / partially torn tendon, finger can be inserted 1 cm beneath the tendon
  • Follow-up study using the Hook test has shown once again near 100& specificity, however lower sensitivity at 82%, but overall a great physical exam maneuver if you have high suspicion!
• The biggest challenge is going to be distinguishing between complete tear and partial tears
• Biceps tendon is absent in complete rupture and palpable in partial rupture (otherwise they have a very similar clinical picture)

Evaluation

• Obtain radiographs to rule-out avulsion fracture (Usually normal)
  •  However, occasionally shows a small fleck or avulsion of bone from the radial tuberosity
• Ultrasound can help with diagnosis--> Use linear probe (high frequency probe) to assess for tendon defects
• Ideally, outpatient MRI will often be used to distinguish between complete tear vs. partial tear or muscle substance vs. tendon tear

Management

• Proximal rupture
  • Sling, ice, NSAIDS, physical therapy, referral to ortho
• Distal
  • Nonoperative
    • Supportive treatment followed by physical therapy
    • Older, low-demand or sedentary patients who are willing to sacrifice function. Most becoming asymptomatic at 4-6 weeks
  • Operative
    • Surgical repair of by fixation of tendon to tuberosity 
    • Indications
      • Young healthy patients who do not want to sacrifice function 
      • Partial tears that do not respond to nonoperative management
      • Surgical treatment should occur within a few weeks from the date of injury
      • Further delay may preclude a straightforward, primary repair

Background:

• Associated with fluoroquinolone use
• Sudden, severe pain typically with rapid acceleration or pivoting. Sports like football, track and field (sprinting), basketball, soccer
• May hear a "pop"
• Inability to run, stand on toes, or climb stairs
• Most frequently ruptures 2-6cm above calcaneus (where blood supply is weakest)

 
Dx:

• Clinical diagnosis
• Ultrasound can be used in equivocal cases:
  • Use linear probe (high frequency probe)
  • Place probe in longitudinal plane over suspect tendon:
  • Achilles 2-6cm above calcaneus
  • Fan and slide side to side to optimize your view
  • Slide distal to proximal to find defect
  • Turn probe 90° to assess for tendon body defects
  • Positive Findings
    • Discontinuity in longitudinal view of ligament
    • Collection of fluid in longitudinal or transverse view suggests injury
  • Look at other limb for "normal" anatomy
  • Have patient range attempt plantar/dorsi-flexion and view in real time
  • Be aware of partial tears!
• Comparing to normal ankle can reveal smaller defects or tears
  • Kankle
• Thompson test (SN 96% and SP 93%)
  • Lay patient prone with knee bent at 90°
  • In normal patient, squeezing calf results in plantar-flexion; Patient’s with tendon rupture will likely have lack of plantar flexion with calf squeeze
• Palpable defect in Achilles tendon 2-6 cm proximal to calcaneus, however the data on this finding isn’t very strong and wouldn’t base your diagnosis solely on this fact

 
Tx:

• Short leg posterior splint in plantarflexion
• ~25% of ruptures will have some amount of active plantar flexion or be able to walk
• Even if partial tear, splint! Can evolve into a complete tear
• Outpatient orthopedic referral 

 

​Background:

• Usually caused by a traumatic impaction blow (i.e. sudden forced flexion) to the tip of the finger in the extended position. Often seen in ball sport like basketball, volleyball, and baseball. Commonly, I’ve seen this mostly in basketball players who present after “jamming” their finger when going for a rebound. Essentially, this blow forces the DIP joint into forced flexion, which the DIP doesn’t like. So in response, you get a rupture of extensor tendon in area of distal phalanx distal to DIP joint

 
PE:

• DIP joint flexed to ~45°, lack of active DIP extension

 
Dx:

• Clinical diagnosis
• Consider finger x-ray (PA and lateral) to evaluate for avulsion fracture
• Now I’m sure you all know about Doyle’s classification of mallet finger injuries? Uh, yeah, of course. Yeah, me either. Let’s leave that to the hand surgeons. 

 
Tx:

• Now, most importantly… If left untreated, a mallet finger can lead to a swan neck deformity (PIP extension with DIP flexion; FDP unopposed)
• For ED treatment, Splint DIP joint in continuous slight hyperextension, but don’t overextend x 6-8 weeks
• Splinting of the PIP joint is not necessary and should be avoided; Let that PIP flow free!
  • Inadvertently splinting PIP for 6 weeks results in collateral ligamentous overgrowth and functional disability
• Discharge with hand surgery follow-up in 7-10 days

 
 
Aluminum and Foam strips
Advantages:

• Light weight and readily available

Disadvantages:

• Must be taped in place
• Patient cannot readily wash their hands while wearing
• The foam will degrade over time
• Skin can get macerated from lack of air getting to the skin

• Splint limits finger use

 
Stax Splint
Advantages:

• Lightweight and holds the fingertip straight

 Disadvantages:

• Must be taped on
• Covers the fingertip so patient’s finger cannot be used
• Difficult to wash hands while wearing
• Skin gets macerated

• Can be difficult to fit

 
Oval-8® Finger Splint
Advantages:

• One or two Oval-8 Finger Splints may be used to hold the DIP joint in extension while still allowing flexion of the proximal interphalangeal (PIP) joint
• Lightweight-- the fingertip is open for function
• Open design eliminates skin maceration
• Size adjustability designed into the Oval-8 accommodates changes in swelling
• Patient can wash hands easily by removing the splint

• Easy to slide on and off for skin care

Disadvantages:

• Professional adjustments may be needed for a custom fit

• May fall off if weather is cold or swelling decreases