Orthopaedic & Rheumatological Emergencies

Finals Countdown 7th February 2012 Alex Cornish & Pomme Knowles

Outline
History and Examination 8 Key Conditions
Presentation Investigation Basic Management

These are things you should already know We want you to test your own knowledge

Key points
Orthopaedic management is not for an FY1... but basic management is! Your role should be Prompt recognition Getting senior help.

History 2min task

Thinking of an orthopaedic/rheumatological Hx.........
Presenting complaint History of presenting complaint PMH Social and FH Drug HX and Allergies

Write down your basic Hx questions & specifics related to ortho/rheum

Our specific questions (not exhaustive)!

Presenting complaint Pain history - SOCRATES, stiffness, swelling, trauma, MOI, time of injury, systemic symptoms, recent infections if a limb ?able to weight bear, any previous episodes Past medical history Previous fractures/falls. Osteoporosis, Malignancy DM, immunodeficiency, arthritis, trauma Past Surgery Drug history and allergies. Osteoporotic drugs/NSAIDs/opiates/steroids/benzos/alcohol/etc Social/family history. Occupation/handedness, GUM, IVDU, Travel

Examination
Look
Swelling, deformity, skin changes, muscle wasting

Feel
Swelling, tenderness, temperature

Move
Active and passive, ROM and pain

Special tests And dont forget the joints above and below

Name the 2 finger deformities

What is the diagnosis

Write down the features of an OA vs RA Xray

What is the diagnosis?

Case 1
22 year old Caucasian male. 1 day history of pain and swelling in left knee joint. No trauma Came on gradually. Feeling feverish. Analgesia ineffective. FBC: Hb 15.1, WCC 22

On Examination
Describe what you see Differentials Likely pathogen Immediate management

Differential Diagnosis
Septic Arthritis Crystal Arthropathies Bursitis Seronegative (Reiters, psoriasis) Haemarthroses (haemophilia, fracture, ACL)

Septic Arthritis
Medical emergency
Functional joint loss within 48 hours. Appreciable mortality.

Can affect any joint Commonly fever, pain and reduced ROM. Can present subclinically in elderly. Clinical picture can indicate pathogen.

Presentation
Site
Knee (50%), hip (20%), shoulder/ankle/wrists (8% each) Sacroiliac and sternoclavicular: think IVDU.

Pathogen
Staphylococcus aureus: most common, early PJI. Neisseria gonorrhoea: 75% in young people. Streptococci, coag ve staph: IVDU, late PJI. Haemophilus influenzae in young children.

Investigation
ABC Bloods & blood cultures X-ray (useful?) Swabs (pharynx, anal, GU) Joint aspiration turbid synovial fluid (as in gout/pseudo gout)
Diagnosis Analgesia

Joint Aspiration
Appearance Send for polarised microscopy, WCC, MC+S. WCC
Normal Inflamed (gout/RA) Gonococcal Non-gonococcal <200 ~14,000 ~16,000 ~65,000

Predominant neutrophilia with NGSA.

Management
ABC and admit to hospital. IV antibiotics (LTHT guidelines). Refer to orthopaedics for further aspiration +/- washout. Strict bed rest +/- splinting and physio. Analgesia.
(risk AVN, if in a prosthesis may need joint removal)

Crystal arthropathys
1. Provide 2 differentials 2. Which condition would demonstrate:
i - +ve birefringent rhomboid crystals ii -ve birefringent needle shaped crystals

3. Acute management

GOUT
Sodium monourate crystals, mainly 1st MTP

Precipitants: trauma, starvation, drugs, surgery.

Classically: obese males, alcohol, high purine food.

Negatively birefringent crystals & neutrophils.

Acute Mx NSAIDS (not aspirin), colchicine,

(steroids).
Prevention lifestyle, allopurinol/probenacid.

Pseudogout
Calcium pyrophosphate crystals. Weakly positively birefringent crystals in wrist, knee. NSAIDs help, often need steroids. Hydroxychloroquine for prophylaxis.

Case 2
Dear Doctor, thank you for seeing this 73 year old lady who presented three weeks ago with back pain. Mobility worsening and now off legs

What important things are there to consider in your Hx? List back pain red flags Consider Investigations & Management

History
Pain - SOCRATES Sensory loss Weakness Sphincter dysfunction Fever/autonomic dysfunction/respiratory compromise. Past medical & surgical history, symptoms of malignancy Drugs, allergies, social and family. Consider psychosocial factors (yellow flags)

Red (or pink) flags!

First onset <20, >55years Non mechanical pain (no variation on movement) Pain at night, not relieved by simple analgesia Suspected spinal fractures
Thoracic pain, Prolonged steroid use, trauma, osteoporosis
Fever, unexplained wt loss, recent bact infection, IVDU, immunosupression, pain worse when supine, thoracic pain, structural deformity, severe or progressive weakness in lower limbs

Suspected (or previous) cancer or infection

Cauda equina specifically

saddle anaesthesia, sphincter dysfunction, limb weakness, urinary retention, sexual dysfunction, severe or progressive neuro deficit in lower extremities, major weakness

The GP Letter tells you his examination findings...

Power 3/5 left leg, 4/5 right leg. Reflexes absent. Sensation absent below T10. Radicular pain at T9. Anal tone reduced. Apyrexial, obs stable.
Name 3 differentials for causes of this presentation...

Acute cord syndrome

1. Malignancy
Myeloma. Primary CNS. Cord/vertebral metastases

2. Inflammatory or infective. 3. Trauma & degenerative disc lesions 4. Haemorrhage or haematoma.

Do you know your cancers?

Name 5 cancers which famously metastasise to bone. Name 2 cancers with secondary bony involvement. Which of the cancers you have named would develop lytic lesions?

 Which of these could be secondaries from Prostate Ca

Investigation

Investigation
MRI whole spine Bloods Neurosurgery review +/- further imaging

Management ABC Neurosurgeons/oncologists!

Case 3 - Long Bone #

37yo Male on orthopaedic ward 36hrs after RTA with closed fracture of right femur, tibia and fibula. You are phoned by the nurse to tells you he is has become drowsy with a reduced UOP. Earlier in the day he c/o a vague CP & difficulty breathing WHAT ORTHOPAEDIC EMERGENCIES DO YOU WANT TO CONSIDER?

Complications of fracture (inc long bone)

Early
Bleeding. Infection. Neurological/vascular injury. Compartment syndrome. Fat Embolism/thromboembolism AVN

Late
Non-union or malunion. Chronic pain. Reflex sympathetic dystrophy.

Case continued......
Following a successful recovery, the nurse asks you to please come and prescribe some analgesia. He is complaining of increasing pain in his cast (closed, NV intact fracture disclocation mid-radius) Pain 10/10 in last hour, cast feels tight and tingling of his newly pale fingers.

What is the diagnosis?

Compartment Syndrome
Increased pressure in a compartment. Ischaemia and necrosis due to decreased perfusion. Higher risk if in cast. 6 Ps Anterior tibial most common. Remove cast, observe 30-60 minutes, surgical review. Consider fasciotomy What are the 6Ps?

Case 4.....
Nelly 93yrs RH resident Attended her weekly ZUMBA Class held at the NH Nelly tripped over her feet with the complicated steps and landed on her left side
What is your immediate concern? What might Nelly be complaining of? What may you notice on immediate inspection?

Fractured neck of femur.

Common injury. High index of suspicion. Shortened, externally rotated leg. Pain, inability to weight bear (usually). High mortality within a year.

Intracapsular vs Extracapsular.
Femoral head receives blood via femoral neck (retinacular blood supply) & ligamentum teres. Displacement damages these vessels, leads to avascular necrosis. Capsule from just above base of femoral neck. Extracapsular
Intratrochanteric, basal cervical.

Intracapsular
Transcervical, subcapital.

Garden Classification

II

III

IV

Increasing AVN risk

One, two, use a screw; three, four, Austin Moore

(hip replacement).

1.

2.

3.

4.

5.

6.

Wrist fractures
Colles fracture
Fall onto outstretched hand. Posteriorly angulated, posteriorly displaced fracture of distal radius. Dinner fork deformity. +/- Ulnar styloid #.

Smiths Fracture
Opposite of a Colles. Anteriorly angulated and displaced. Garden spade deformity.

Next Case........
76 yr old man General malaise at least 3 months, 6kg weight loss. Now complaining of
Throbbing left temporal headache for last 2 weeks Pain when shaving his face and intermittent jaw pain during meals especially with tough food like steaks. Generalised aching over shoulders, hip and knees. Generally getting quite down about things now that it is dragging on and seems to be getting worse.

Differentials and Investigations

Differentials Headaches: Migraine/Tension/medication overuse/sinister Trigeminal neuralgia facial pain Polymyositis proximal limb weakness/ache Polymyalgia Rheumatica (and fibromyalgia) Investigations Acute phase reactants - inc CRP, ESR/PV. Temporal artery biopsy (NB skip lesions) Duplex USS temporal artery

Temporal/Giant Cell Arteritis

Headache severe frontal/occipital Jaw claudication Visual disturbance visual loss Systemic symptoms (wt loss, anorexia, fever, sweats, malaise, fatigue and depression) PMR features proximal stiffness, soreness and pain

Diagnosis of Temporal Arteritis

Age >50 years New headache Abnormalities of the temporal arteries ESR >50 mm/hour Positive temporal artery biopsy

Treatment and complications

Treatment Steroids (>/= 40mg pred) Aspirin 75mg (+ gastro protection) Complications: Visual loss (irreversible) 15-20% Relapse (<60%) taper steroids slowly, average duration 2 years). NB SE steroids

Conclusions
A red, swollen knee is septic arthritis until proven otherwise. Back pain and leg weakness is cord compression until proven otherwise. Pulseless and paralysed youve missed the boat. Dont panic, describe what you see.

Thankyou
Any Questions? References
Wheeless Textbook of Orthopaedics online. Kumar and Clark. ATLS Course Manual. Oxford Handbook of Acute Medicine. eMedicine website.

Recommended Books
PasTest: Surgical Finals, short cases with structured answers PasTest: Medical Finals. Short cases with structured answers PasTest: EMQs for medical students, practise papers. Volumes 1-3