Varsha Aravindabose, OMS-IV at Kansas City University College of Osteopathic Medicine

Acute orthopedic complaints comprise a significant number of Emergency Department (ED) visits every year. Yet, studies show that many Emergency Medicine physicians are not confident in their diagnosis and management of musculoskeletal complaints. In fact, musculoskeletal injuries are a common cause of litigation and misdiagnosis for physicians. How can this be? Perhaps it is a combination of difficulty identifying severe cases, assumption of low acuity, or incorrectly assuming a negative radiograph implies soft tissue injury. The nature of the ED is to expedite care and limit wasted wait times. As a result, oftentimes, imaging has already been ordered and completed before a physician’s initial examination. Unfortunately, this can lead to a major pitfall in the management of orthopedic cases: reviewing radiographs prior to assessing the patient. Following a step by step guide to managing orthopedic cases in the ED leads to improved detection of pathology and appropriate intervention. Current physicians and aspiring students can benefit from becoming more adept in the approach to orthopedic injuries.

Dr. Arun Sayal MD CCFP (EM) provides a detailed work-up of orthopedic cases in his article “Emergency Medicine Orthopedic Assessment: Pearls and Pitfalls”. He emphasizes the necessity of a thorough history and physical exam, which is integral to all EM complaints, but often haphazardly completed for musculoskeletal conditions. A focused history for musculoskeletal complaints must include:

1. Age
2. Hand dominance, if applicable
3. Trauma, if applicable
4. Reason for fall, if applicable
5. Forces involved
6. Mechanism of injury
7. Events after injury
8. Quality of the bone to which the force was applied
9. Previous injuries to that joint or the comparison
10. Past medical history
11. Medications
12. Occupation/recreation demands

Let’s take a closer look at some of these key elements. Understandably, knowing the age of the patient is useful as the strength of bone is largely determined by age. It would be easy to assume that children are at higher risk for fracture but, their open growth plates actually lead to more soft tissue injuries. On the other end of the spectrum, elderly patients tend to have structurally weaker bones due to osteoporosis and other underlying medical conditions. As such, similar forces on various ages results in vastly different outcomes.

Trauma accompanies most fractures in the emergency department. In fact, the absence of significant trauma makes fracture much less likely. However, it is important to consider pathologic mechanisms especially in the elderly population. Sometimes, even simple, normal movements can result in pathologic fractures. EM physicians should have a lower threshold when it comes to obtaining radiographs in this patient population. When it comes to falls, it is important for the EM physician to consider all factors that may have resulted in the fall, including self-injury.

With regard to forces involved in the injury, why might it be useful to know this information? For low or medium energy forces, the weakest link in the chain tends to be the most commonly injured. This information can help focus consideration and examination to the most likely impacted area even prior to imaging. The mechanism of injury is another key detail that can help predict injury patterns and guide your clinical attention. For example, a sudden deceleration or change in direction is typical of anterior cruciate ligament injuries, whereas a twisting motion is more commonly associated with meniscal injury.

Previous injuries to that joint, past medical history, and medications can help to predict likelihood of fracture and may alter the pretest probability and presentation of illness. Consider a patient with Stage IV cancer vs. a patient on long-term bisphosphonates, both complaining of bone pain. In the former patient, we are most likely concerned for metastatic disease. In the patient on long-term bisphosphonates, your differential diagnosis would most likely include an atypical femur fracture. It bears repeating that a thorough history is immensely useful in directing the management of musculoskeletal injuries.

Once a complete history has been taken, it is time for the physical examination. In general, Emergency Medicine physicians should ignore obvious deformities and search for life-threatening conditions when presented with orthopedic injuries. Once emergent conditions are ruled out in the other parts of the body, the injured extremity should be examined for limb-threatening conditions and neurovascular compromise. A clinical pearl offered by Dr. Sayal is to always get in the habit of assessing the joint above and below the injured area. Doing so will allow the EM physician to gauge for other subtle injuries.

Dr. Sayal offers a methodical manner to assessing MSK complaints. Consider: Look, Palpate and Move.

Look for alignment, swelling, redness, erythema, signs of infection or inflammation

• Remember to disrobe the patient and pre-hospital splints

Palpate and localize the pain

• Start the physical examination by examining the opposite side or away from the injury first
• If a positive finding is noted, compare with the opposite side to know whether it is a true finding
• Find the point of maximal tenderness
• Assess and document neurovascular status
• Assess for warmth
• Palpate the compartments

Move the joints and assess for active and passive range of motion

Once the physician has adequately and thoroughly conducted the physical examination, decisions can be made regarding management. Consider radiographs, laboratory studies if infection is suspected, and joint aspiration if there is any suspicion of a septic joint or crystal-induced arthritis. Clinical decision making rules such as the Ottawa Ankle Rules and Pittsburgh Knee Rules can be easily accessed through MDCalc.com and aid in management, especially if there is an unclear clinical picture. However, the clinical decision making rules should not supersede the findings gained from the history and physical. It would be beneficial to keep the following suggestions in mind when ordering appropriate radiographs for orthopedic injuries.

1. Wider ≠better
   1. For example, if both the elbow and wrist are areas of concern, do not order a forearm series to cover both joints
   2. Order separate views to properly analyze each joint
2. A minimum of 2 views at 90 degrees is required
3. The lateral view is most important and must be obtained correctly
4. Consider location-specific views for certain bones such as the scaphoid, distal radius and tibial plateau
5. If you see one fracture, take extra care in searching for a second fracture
6. Be aware of normal variants and accessory ossicles

Remember, the ED physicians can help catch orthopedic injuries that radiologists may miss because we are equipped with the underlying history and physical. Therefore, it is of utmost importance to look at the plain films when available as to not rely solely on the radiologist’s interpretation alone.

It can be overwhelming when presented with an orthopedic case during a busy shift in the ED. As discussed above, proper management of these cases require a methodical and exhaustive approach to obtaining a history and conducting a physical examination. With the clinical pearls outlined by Dr. Sayal, EM physicians have a step-by-step approach to most orthopedic cases. Hopefully, with proper implementation and practice, this will result in an increased number of accurate diagnoses, fewer missed injuries and better overall management of orthopedic injuries.

References:

Sayal, Arun. “Emergency Medicine Orthopedic Assessment.” Emergency Medicine Clinics of North America, vol. 38, no. 1, 2020, pp. 1–13., doi:10.1016/j.emc.2019.09.001.