Compartment Syndrome

Risk Factors:

• Fractures (especially tibia and forearm)
• Crush injuries
• Vascular injuries with reperfusion

Presentation:

• 6 P’s (pain, pallor, paresthesia, paralysis, pulselessness, poilikothermia)
• Escalating analgesia requirements

Diagnosis: Centurion needle is stocked at ULH. Pressure >30 mmHg is diagnostic for compartment syndrome.

Dispo: admit to surgical service for fasciotomy

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Septic Arthritis

Risk Factors:

• Recent joint instrumentation
• Joint damage
• Other infection

Presentation:

• Red, warm, swollen, painful joint with decreased ROM

Workup: CBC, ESR, CRP, STI urine/swabs, arthrocentesis

Diagnosis: WBC >/= 50k, PMNs 90%

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Cervical Spine Injuries & Clearance

Jefferson Bit Off a Hangman’s Thumb

Spinal Cord Injuries

• Central cord
• Anterior cord
• Brown-Sequard
• Posterior cord

NEXUS: sens 99-99.6%, spec ~12%

Canadian: sens ~100%, spec ~42%

• Stiell et al., NEJM 2023 Canadian missed less injuries compared to NEXUS

MRI after negative CT in awake, neuro intact patients with midline tenderness very rarely identifies an unstable injury requiring acute management.

• West Trauma study does not recommend MRI

PECARN 2024: sens ~94%, NPV ~99.9%

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Low Back Pain Emergencies

Red Flags:

• Fever
• h/o malignancy
• IVDU
• Incontinence
• Recent instrumentation
• Weight loss
• Age >50
• Immunocompromise
• Anticoagulation

Broad Diagnostic Categories:

1. Vascular – AAA, aortic dissection, spinal epidural hematoma
2. Infectious – epidural abscess, osteomyelitis/discitis
3. Malignancy – pathologic fx, bony metastatic disease
4. Anatomic

Imaging: MRI with contrast of the C/T/L Spine

Lightning Lecture – Rhabdomyolysis

Classic triad is rare unless severe.

Diagnosis: CK 5X upper limit of normal + causative factor OR characteristic signs/symptoms OR UA with myoglobinuria

Lightning Lecture – Crystal Arthropathy

Synovial fluid aspiration is gold standard for diagnosis, but not always necessary if the presentation is straightforward with infection unlikely.

• Negatively birefringent = gout
• Positively birefringent = pseudogout
• Presence of crystals does not exclude septic arthritis.

Workup: CBC, CMP, ESR//CRP, uric acid

• Uric acid is not reliable for diagnosis on its own

PEM – Ortho Injuries & Child Abuse

Reference developmental milestones when assessing viability of reported mechanism of injury (ex. 2 mo is unlikely to roll off of a bed on their own).

TEN-4-FACESp Rule for <4 yo – signs concerning for abuse

• Torso, ears, or neck
• Any bruising in 4 months and youngers
• Frenulum, angle of jaw, cheeks, eyelids, or subconjunctivae
• Patterned bruising

Workup: CBC, PT/PTT, CMP (or AST/ALT), amylase (or lipase), UA, tox screen, skeletal survey

• Consider CT Head if concern for head injury

Concerning Fractures:

• Bucket handle fracture
• Posterior rib fractures
• Spiral fracture of long bone
• Skull fracture

Non-Concerning Fractures:

• Buckle fracture
• Toddler’s fracture
• Nursemaid’s elbow
• SCFE

Gonorrhea/Chlamydia Arthopathy

Likely underdiagnosed. Think about this in your young patient with unexplained arthritis.

Consider incorporating GC/chlamydia, HIV, and syphilis testing on select patients who may benefit from testing from a public health standpoint.