INTERNS’ SURVIVAL GUIDE TO ED ORTHOPEDICS

Table of Contents

BASIC WOUND CARE 3

DOCUMENTATION OF YOUR PROCEDURES 3

ORTHOPEDIC EMERGENCIES 4

JOINT FLUID ANALYSIS 5

HAND 6
PHYSICAL EXAM 6
BASIC ANATOMY 6
COMMON FRACTURES 7
OTHER COMMON HAND DIAGNOSES 8

WRIST & FOREARM 10

BASIC ANATOMY 10
COMMON FRACTURES 10

ELBOW 12
BASIC ANATOMY 12
READING ELBOW XRAYS 12
COMMON DIAGNOSES 13

SHOULDER 14
BASIC ANATOMY 14
PHYSICAL EXAM 14
COMMON DIAGNOSES 15

PELVIS 17
BASIC ANATOMY 17
PHYSICAL EXAM 17
READING PELVIC FILMS 18
FRACTURES 18

HIP 19
BASIC ANATOMY 19
COMMON DIAGNOSES 20

KNEE 22
BASIC ANATOMY 22
PHYSICAL EXAM 22
1
 COMMON DIAGNOSES 22

ANKLE 25
BASIC ANATOMY 25
COMMON DIAGNOSES 25

FOOT 27
BASIC ANATOMY 27
COMMON DIAGNOSES 27

2
 BASIC WOUND CARE
Irrigation: rule of thumb is 60 mL of NS for every 1 cm of wound

Sutures:
Deep or SQ: rapid absorbing (Vicryl)
Skin closure: nylon or prolene
Face: 6.0
Hand/finger: 5.0
Trunk/extremities: 4.0
Scalp, sole of foot, anything under high tension: 3.0
Suture removal: face 3-5 days, hand 5-7 days, non-face 7-10 days, joints 10-14 days

DOCUMENTATION OF YOUR PROCEDURES

Wound checks:
Location, size/length of wound. Note whether the sutures/staples are intact. Are there any signs of
infection? – erythema, warmth, soft tissue swelling, discharge, healed edges, granulation tissue.
Neurovascular exam: e.g., sensation, CR < 2 sec. Motor function.

Suture note:
Location, size and length
Anesthesia: lido + epi, %, how many cc’s, method – SQ, block, directly into wound
Exploration: how deep did you explore, did you find any foreign bodies?, exposed fasica, muscle,
tendons, bone? “explored in a bloodless field”
Irrigation: “copious irrigation” with type of solution “under high pressure”
Closure: deep, SQ, dermal, simple interrupted vs continuous vs mattress, type of suture, number of
sutures
Dressing: dry, ointment, splint
“Wound hemodynamically stable and patient tolerated procedure without complications.”

I&D:
Location, size __x__ cm for area of fluctuance, induration and erythema
Pre-medication?
Anesthesia: lido + epi, %, how many cc’s
Length of incision
Discharge: __ mL of pus, serosanguinous, bloody
Cultures sent?
Irrigation: “copious irrigation” with type of solution “under high pressure”
Packing with iodoform gauze
Dressing
“Wound hemodynamically stable and patient tolerated procedure without complications.”

3
 ORTHOPEDIC EMERGENCIES

Exam Rx/Dispo
FLEXOR Kanavel signs: IV Cefazolin 1g IV q8.
TENOSYNOVITIS 1. Fusiform digit Emergent ortho consult –
2. Finger is held requires I&D in the OR
Infection of the passively in flexion Admit
flexor tendon 3. Passive extension of
sheath distal phalanx causes
pain
4. Pain that tracks along
flexor sheath

COMPARTMENT Risk factors: open Pain out of proportion Emergent ortho consult,
SYNDROME fracture, crush injury, is the most reliable and admit.
cast  bleeding, earliest sign. Pain w/
edema passive ROM, TTP, Fasciotomy.
tense compartment, tight
shiny skin. Late sy =
anesthesia,
pulselessness,
paresis.
Compartment
pressures >40 mmHg
suggestive of dx but
often an unreliable
measurement. Can
also use DBP: if DBP
– compartment
pressure <30mmHg,
this is also suggestive
of dx.
Order a CK and UA!
OPEN Grades I-III: based on ALL require emergent
FRACTURE degree of soft tissue ortho consult, IVF, broad
injury (Gustillo spectrum antibiotics –
classification). ceftriaxone and
gentamicin, update
tetanus, keep NPO.
Depending on the grade,
possible admit.
KNEE Limb-threatening 2/2 Most present w/ Emergent vascular and
DISLOCATION potential for popliteal spontaneous ortho consults. Admit.
artery rupture. Rare. reduction. If w/ gross
Req’s rupture of 3 of knee deformity 
4 major ligaments immediate reduction!
4
 (ACL+PCL most Do not wait for XRs!
common, and MCL, Make sure to do
LCL). thorough NV exam
Classification based before and after
on displacement of reduction. Presence
proximal tibia in of pulses does not
relation to distal exclude popliteal injury
femur.  do ABIs. If <0.9,
get an angiogram.
NECROTIZING Streptoccoccus, Soft tissue crepitance Emergent consult – requires
FASCIITIS Clostridia, may be only early immediate surgical I&D.
polymicrobial. sign. Rapidly Admit
progressive pain,
swelling and fever.
Late sy: hemorrhagic
bullae, skin necrosis,
fluctuance.
SEPTIC JOINT Risk factors: old, *Severe pain on IV abx – usually Vanco +
young, prosthetics, passive ROM  Zosyn. Emergent ortho
IVDU, immuno- irritable joint. Joint consult. Admit. These will
compromised, RA may have significant require washout in the OR.
effusion, erythema,
and warmth. Dx can
be confirmed by
arthocentesis – see
table below. Do NOT
tap through cellulitic
areas.

JOINT FLUID ANALYSIS

Non-
Normal Inflammatory Septic
inflammatory
WBC <200 mm3 <2000 <50,0000 5000 – 50,000
PMNs <25% <25% >75% >90%
Crystals None None Maybe None, but if
present, does
not R/O dx
Glucose 95-100% 95-100% 80-100% <50%
Gram stain Negative Negative Negative Positive or
negative
Culture* (>90% Negative Negative Negative Positive
sensitive)

5
HAND
PHYSICAL EXAM
Date of injury, hand dominance and occupation. H/o previous injury to that same extremity.
Edema – ecchymosis – erythema – obvious deformities – skin intact
Focal TTP
TTP at joint above/below
ROM and laxity of involved joint, if applicable, and joints above/below
SILT in FDWS/SF/IF
Motor: TU/OK/X 2-3/F&E 1-5
Compartments soft
RP palpable, CR < 2 sec

If hand injury, especially in setting of penetrating trauma, document this:

IF MF RF SF Thumb
FDS EPL
FDP EPB
Extension FPL
RDN APL
UDN RDN
CR/O2 sat UDN
2 pt discrim CR

BASIC ANATOMY
SENSORY MOTOR
Ulnar Volar tip SF Finger AB- and AD-duction
Median Volar tip IF OK, thumb to pinky
Wrist/finger extension off
Radial FDWS
table

6
ZONES OF THE HAND
Important to note for your consultant, especially if complex laceration.

Extensors Flexors

EPL x4, EPB x4. FDP x4, FDS x 4.

In the thumb, EPL + In the thumb, FPL.

EPB + APL = anatomic
snuff box

COMMON FRACTURES
Exam Imaging Rx Dispo Considerations
FINGER Document pre- Pre- and post- Reduce. Hand in
DISLOCATION and post-reduction reduction films Finger splint 1-2
NVM function or buddy weeks
tape
PHALANX Note digital Splint with Hand in Emergent or
FRACTURE cascade – elicits outrigger. 1-2 next day referral
malrotation weeks. if open fx,
comminuted
intra-articular or
malrotation.

METACARPAL If simple, Hand in Degrees of

FRACTURE splint. 1-2 angulation:
weeks. #2-3 up to 20
If @ neck w/ #4 up to 30°
volar If #5 up to 40°
displaceme requires Anything
nt of head reduction greater, or with
(BOXER’S or post- severe rotation,
FX), splint reduction will require
w/ outrigger. in ED, reduction.
next day
referral.

7
BENNETT’S Reduction. Likely
FRACTURE Thumb Needs
spica splint. surgery.
Next day
referral.

Fracture +
Dislocation at CMC
joint in thumb. Will
still have small
fragment articulating
with trapezium.

ROLANDO’S Reduce. Needs *Note: these are

FRACTURE Thumb surgery. often difficult to
spica splint. Next day differentiate
referral. from Bennett’s.
Just know that
they both need
to be seen by
an orthopaedist
sooner than
Comminuted intra- later.
articular fx at the
base of thumb.

OTHER COMMON HAND DIAGNOSES

Exam Imaging Rx Dispo Considerations
CARPAL Tinel’s sign: None. Wrist splint, esp PMD in 2-4 Can be bilateral
TUNNEL percussion of at night. weeks. in 50%.
SYNDROME median n. over NSAIDs.
volar wrist that
Compression of reproduces
median n. paresthesias/pain
secondary to in median n.
repetitive distribution.
motion.
Phalen’s sign:
flexion of wrists to
90 reproduces
paresthesias/pain
in median n.
distribution.
EXTENSOR Isolate each joint If fracture End to end If repaired,
TENDON and evaluate suspected. repair with non- Hand 1
INJURY ability to extend absorbable week. If not,

8
 suture. Splint. then splint
and next day
referral.

Splint finger in
full extension,
will likely need
immobilization
for 1 month.
FLEXOR Isolate each joint If fracture Thorough wash Needs
TENDON and evaluate suspected. out. Leave operative
INJURY ability to flex. wound open – repair so
do not close. emergent or
next day
referral,
dependent
on severity.
CLOSED FIST Thorough hand Hand 3V Copious Admit for IV Concern is for
INJURY exam! irrigation, abx infection –
update tetanus, (Augmentin mixed flora from
leave wound or Unasyn) fist striking
OPEN, dry vs discharge tooth.
dressing. with PO
Emergent ortho Augmentin
consult for with next day
possible follow up.
washout.
FELON Infection of closed I&D and place a UADC in 5-7 Caution: these
pulp space in wick. days for can progress to
distal phalanx. wound OM, FTS, or
check. abscess.
PARONYCHIA Infection of the I&D and wick. UADC in 5-7
distal phalanx If there is days for
along the nail bed. cellulitis, PO wound
abx. check.
HIGH HPI shoulld XR, update Admit. Caution: these
PRESSURE include what tetanus, start IV injuries are at
INJECTION substance was abx (cefazolin + high risk for
WOUND injected – oil vs gentamicin). compartment
water-based paint, Emergent ortho syndrome 2/2
grease gun, etc. consult – needs rapidly
operative progressing
debridement. edema.
NAIL BED Remove nail if UADC in 5-7
LACERATION needed. days for
Repair with 6.0 wound
absorbable and check.
if possible,
replace nail on

9
 top. If not
possible, dress
with dry gauze.
SUBUNGUAL Always get If not clotted,
HEMATOMA an XR to r/o trephination to
fracture. relieve the
hematoma. If
clotted, then
NTD.
If there is a
fracture, and
more than 50%
of the nail is
hematoma,
remove the nail
and assess for
nail bed injury.
MALLET Avulsion of the Splint in PMD in 4-6
FINGER extensor digitorum extension full weeks.
over the DIP. time x 4-6
Patient will not be weeks.
able to fully extend
distal phalanx.
BOUTONNIER Loss of active Full time PMD in 4-6
ES extension at PIP extension splint weeeks.
with x 4-6 weeks
hyperextension of
DIP.
JERSEY FDP tendon Splint x 4-6 Need
FINGER avulsion at the weeks. surgical
DIP. Cannot fully repair, so
flex @ DIP. next day
referral.

WRIST & FOREARM

BASIC ANATOMY

COMMON FRACTURES
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 Exam Imaging Rx Dispo Considerations
DISTAL Make sure to Hand, wrist and FA XR. Sugartong If non-displaced, Check the ulnar
RADIUS examine and Radial inclination ~22. splint and non- styloid – this is
document Volar tilt 11-22. angulated, ortho often an
function of UE in 1 week. associated
median nerve. COLLES FX: distal If displaced, fracture, but
fragment is dorsally angulated, or doesn’t change
displaced. intra-articular, management.
SMITH FX: volarly next day
displaced. referral.
BARTON’S FX: intra-
articular and extends into
the radio-carpal joint 
req’s ORIF.
SCAPHOID If (+) snuff box Navicular series. Thumb Hand 1 week Must have high
tenderness and Can try shooting an spica splint. clinical suspicion
a negative XR, AP/lateral with the patient for these b/c if not
may take up to in a clenched fist with treated, there is
7-10 days for ulnar deviation to high incidence of
this fx to appear elucidate the fracture. non-union and
radiographically. AVN.
CARPAL 18% of all hand
BONES fractures.  Gilulas lines: 3 arcs

LUNATE FOOSH injuries. Volar splint. Next day Must have high
If missed and referral. These clinical suspicion.
not treated, can will require
lead to osteo- surgical repair.
necrosis.

PERILUNATE FOOSH injuries. Volar splint. Next day Must have high
DISLOCATIO referral. These clinical suspicion.
N will require
surgical repair.

MID-SHAFT Reduce if Next day

RADIUS displaced. referral for eval
Long arm for possible
splint. ORIF,
regardless of
angulation or
displacement.
MID-SHAFT Aka nightstick fx Reduce if Ortho UE 1
ULNA displaced. week.

11
 Long arm
splint.

ELBOW

BASIC ANATOMY
BONY ANATOMY LIGAMENTOUS ANATOMY

READING ELBOW XRAYS

Radiologic Finding Significance

Figure of 8, distal humerus
Anterior fat pad
Posterior fat pad
Check the alignment
Check the olecranon
If not present, this is an inadequate
lateral.
May be present in normal anatomy
but should be small and adherent to
humerus. If large, protruding, sail-
shaped fat pad  intra-articular
fracture.
If present, this is ALWAYS abnormal
 intra-articular fracture.
Anterior humeral line and radio-
capitellum line should intersect in
the middle 1/3 of the capitellum.

All intra-articular fractures need to be dispo’ed to the OET the next day for possible
operative fixation.

Keep in mind that the ulnar nerve runs posterior to the medial condyle  make sure to document a
good neurovascular exam.

On your exam, include degree of supination and pronation.

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COMMON DIAGNOSES
Exam Imaging Rx Dispo Considerations
OLECRANON Posterior Next day Always an intra-
FX splint in referral articular fx
extension for ORIF.
SUPRACONDY Usually in kids. Posterior Next day
LAR FX splint in referral.
extension
GALEAZZI = distal radius fx + Next day
radial-ulnar referral.
dislocation
MONTEGGIA = mid-shaft ulnar Next day
fx + radial head referral.
dislocation
NURSEMAID’S Affected arm held Reduction: Home.
ELBOW in passive flexion. supination
Refusal by patient of FA and
to move the arm. flexion at
Point tenderness the elbow,
at elbow. with gentle
pressure at
the radial
head.
OLECRANON Bursae are fluid- XR only if h/o NSAIDs Home.
BURSITIS filled cavities near trauma. PMD
joints where referral.
tendons or
muscles pass over
bony projections.
They assist
movement and
reduce friction
between moving
parts.

Causes: chronic
overuse, trauma,
RA, gout, or
infection.
ELBOW Elbow 3V Procedural Next day **MUST do a
DISLOCATION sedation referral. stability exam
and after reduction –
reduction. fully range the
Posterior joint and
long arm evaluate for
splint. Get instability. If
post- any concern,
reduction emergent
films. consult for
fluoroscopic
13
 eval.

SHOULDER

BASIC ANATOMY

PHYSICAL EXAM
Do your complete UE exam, as well as these specific exam findings:

ABDUCTION Note the angle at which the patient can no longer actively range. Then
allow them to use their other arm to help range. Motor strength.
FORWARD Note the angle at which the patient can no longer actively range. Then
FLEXION allow them to use their other arm to help range. Motor strength.
EXTERNAL Primarily by infraspinatus. Elbow flexed 90 and held stationary,
ROTATION patient moves distal arm away from abdomen. To test strength, patient
places hand, palm-side out, onto back, and moves it away from back.
INTERNAL Primarily by subscapularis. Elbow flexed 90 and held stationary,
ROTATION patient moves distal arm towards abdomen. To test strength, BELLY

14
 PRESS: patient places hand, palm-side down, on belly with arm flexed
and resists as you push the elbow posteriorly.
JOBE TEST Shoulder is 90° abduction with 30° forward flexion, thumbs down
(internally rotated). If weak, (+) and suggests supraspinatus is injured.
DROP ARM Raise patient’s arm 90° abduction and ask them to slowly lower their
arm. If it drops, (+) and suggests supraspinatus injury.
HAWKINS Place patient’s arm in 90° forward flexion and then internally rotate. If
pain, (+) impingement.
NEER Passive forward flexion >90° while stabilizing scapula. If pain, (+)
IMPINGEMENT impingement.

These films are always a must with any shoulder injury.

AP LATERAL AXILLARY

** If patient is unable to AB-duct the arm for the axillary view, ask for a VELPEAU view.

COMMON DIAGNOSES
Exam Imaging Rx Dispo Considerations

ROTATOR Document a MRI, which will not PMD for If documented

CUFF INJURY thorough shoulder happen in the ED referral to injury (e.g.,
exam. MRI and patient has MRI in
rehab. hand), then send
to Ortho Sports
clinic.
GLENOHUME MC anterior. Procedural Ortho UE CAUTION: if
RAL sedation and 1 week. dislocation is
DISLOCATION reduction. inferior to the
Make sure to do and Post-reduction films Shoulder glenoid, consider
document post- should include immobilizer – a Hill-Sachs
reduction exam. Velpeau. make sure fracture – where
elbow is the glenoid is
anterior to impacted into the
mid-axillary head of the
line. humerus and
locks it in place,
making reduction

15
 difficult.

HUMERUS 3 types:
FRACTURE
PROXIMAL: If only 1 part, Ortho UE If anatomic neck
depends on number non- 1 week fx (uncommon),
of PARTS (Neer’s displaced, poor prognosis
classification), where sling for secondary to risk
a part = >1cm comfort and of AVN 
displacement or early emergent ortho
>45° angulation mobilization consult.
with
Codman’s
exercises.
If > 2 parts, Next day
sling. referral for
ORIF.

MIDSHAFT: 90% Reduction Ortho UE

heal w/o surgery. and 1 week
Pay attn for radial coaptation
nerve injury. splint (these
use weight of
the arm to
facilitate
reduction).
DISTAL: uncommon If non- Ortho UE
in adults. Do a good displaced  1 week.
neurovascular exam: long arm
fractured fragment posterior If
can damage the splint in 90 displaced,
brachial artery, degrees of NV injury
median nerve, or flexion. or open,
radial nerve. emergent
ortho
consult.
CLAVICLE Affected arm is Middle 1/3: No Sling x 4-6 Ortho UE Always emergent
FRACTURE adducted across the disruption of ligaments weeks. 1-2 weeks consult if 1) open
chest and supported fx, 2) skin tenting,
by the other hand to Distal 1/3: Fx is medial Sling x 4-6 Next day or 3) NV
offload the injured to coraco-clavicular weeks. referral for compromise.
shoulder. ligaments. possible
MC = middle 1/3. ORIF.
Proximal 1/3: MC Sling x 4-6 Ortho UE
assoc’d with brachial weeks. 1-2
plexus injuries. weeks.

16
ACROMIO- AP, scapular Y, Rest x 7-10 PMD in 1- There are actually
CLAVICULAR axillary days, ice, 2 weeks. 6 grades,
DISLOCATION sling x 2 however, what
weeks, early you need to know
mobilization. is that anything
more than a
Grade III requires
ortho evaluation
for possible
surgical repair.
Grade 1: no
disruption of
ligaments.

Grade 2: disruption AC joint widening, Rest, ice, Ortho UE

of AC ligaments but stress films will show sling. in 1-2
coracoclavicular normal weeks.
ligaments are intact. coracoclavicular space
compared to
contralateral space.

Grade 3: both AC Distal clavicle is Rest, ice, Next day

and CC ligaments superior to medial sling. referral for
are disrupted, border of acromion, ORIF.
deltoid and trapezius stress views with (+)
muscles are widened
detached from distal coracoclavicular space
clavicle. compared to
contralateral side.

PELVIS

BASIC ANATOMY

PHYSICAL EXAM
17
 1. Because the pelvis is a ring, it MUST fracture (or dislocate) in TWO places in order for
there to be any displacement.
2. Apply gentle internal and external rotation along the iliac crests (always check internal
first in case there is an open book fracture).
3. Apply vertical load and traction to the femur to detect axial instability.
4. Always do a rectal exam to look for colon injury or palpable fracture line.
5. Look for blood at the urethral meatus.

READING PELVIC FILMS

Lines of the pelvis that you should check for:

1) Shenton’s line: actually a curve that traces the

arc from obturator foramen to medial fermoral
neck. It should be continuous and smooth. If
broken  subluxation or dislocation.
2) Perkin’s line: runs vertically thru lateral aspect
of bony acetabulum and is perpendicular to
Hilgenreiner’s line
3) Higlenreiner’s line: horizontal line thru superior
aspects of the triradiate cartilage. Use this to
create a quadrant with Perkin’s line. If hip is
dislocated, the femoral head will be in the
upper outer quadrant. If hip is subluxed, the
femoral head will be in the lower outer
quadrant.
4) Acetabular index: angle formed by acetabular roof and Hilgenreiner’s line. Should
be <10° in adults, varies in kids depending on age.

FRACTURES

YOUNG & BURGESS CLASSIFICATION OF PELVIC FRACTURES Rx/Dispo

ANTERIOR- Anteriorly applied force from direct impact or Pelvic binder.
POSTERIOR transferred from lower extremities  results in Consult trauma and
18
COMPRESSION external rotation injuries, symphyseal ortho.
diastasis, or longitudinal pubic rami fractures. Admit.

If symphyseal diastasis is >2.5cm, disruption

of all anterior ligaments is likely, and this is an
OPEN BOOK FRACTURE  think of
massive hemorrhage from venous plexus, up
to 4L can accumulate.

If < 2.5 cm, likely that posterior ligaments will

be intact.
LATERAL Implosion of pelvis 2/2 laterally applied force
COMPRESSION  oblique fx’s of pubic rami. Pelvic
hemorrhage tends to be tamponaded by intact
anterior ligaments.
VERTICAL SHEAR Aka Malgaigne. Axial force caused by falls Trauma and ortho
onto extended lower extremity  complete consults. Admit.
disruption of symphysis, anterior ligaments,
high incidence of neurovascular injury and
hemorrhage. This is a very unstable fracture!

HIP

BASIC ANATOMY

Normal femoral shaft-neck angle = 120-130°

19
COMMON DIAGNOSES

Exam Imaging Rx/Dispo Considerations

HIP Most common is AP pelvis, XR hip Reduction. NWB. Caution: Risk of
DISLOCATION posterior (95%). and femur. Admit. Ortho and AVN rate
Assoc’ed with trauma consults. increases to
inferior femoral Get a CT after 50% if reduction
head fractures, reduction, whether does not occur
sciatic nerve successful or within 6h of
injury, acetabular unsuccessful, or if injury.
fracture, or you suspect a neck
ipsilateral lower fracture.
extremity injury.

If anterior, hip is
externally rotated,
and depending on
location of
fracture, can be
extended or
flexed. Assoc’ed
with superior
femoral head
fractures, arterial
injury, and venous
thrombosis.
ACETABULAR Most often from AP + Judet views. NWB. Admit. Ortho
FRACTURE high-energy Likely also and trauma consults.
impact so look for inlet/outlet.
other injuries.
FEMORAL Almost all are AP + Judet views. NWB. Admit. Ortho
HEAD assoc’d w/ Likely also and trauma consults.
FRACTURE dislocations from inlet/outlet.
high-energy
impact transmitted
thru the femur.

20
FEMORAL Occur in elderly, NWB. Admit. Ortho High risk of AVN
NECK F>M. Present consult. – disruption of
FRACTURE non-ambulatory, circumflex
with leg shortening femoral artery at
and external the femoral
rotation. neck, the most
important of 3
vascular
supplies.
Prognosis
depends on
degree of
AP pelvis, hip + displacement:
femur XR. non-displaced
up to 20% risk
of AVN; if
displaced, risk
increases to
35%.
INTER- 50% of proximal NWB. Admit. Ortho Caution: high
TROCHANTER femur fxs. Elderly, consult for likely surgical rate of mortality
IC FRACTURE F>M. Non- repair. and DVT.
ambulatory,
shortened,
externally rotated.

AP pelvis, hip +
femur XR.

TROCHANTER GREATER: rare. NWB.

IC FRACTURE
If non-displaced 
NWB, crutche, ortho LE
clinic in 1 week.

If displaced >1 cm 
ortho consult.

LESSER: MC in NWB.
adolescents. If in
elderly, think If non-displaced 
pathological fx. NWB, crutches and
ortho LE clinic in 1
week.

If displaced >2 cm, 

ortho consult for ORIF.

21
FEMORAL Results from high- NWB. Admit. Ortho Complications:
SHAFT FX energy trauma. consult for ORIF. major blood loss
– up to 1.5L.
DISTAL MC result from Make sure to NWB. If stable, non- Caution: risk of
FEMUR FX severe axial evaluate displaced fx  popliteal vessel
loading. neurovascular fxn mobilization in hinged rupture!
distal to fx and do knee brace and PWB. If
ABI’s  <0.9 is displaced  ortho
concerning for consult for ORIF.
arterial injury, get an
angiogram.

KNEE

BASIC ANATOMY

PHYSICAL EXAM
1) Inspection: effusion, obvious deformities, trauma, erythema
2) Palpation: along the joint line, medial/lateral lines, popliteal region, patella
3) ROM: normal ROM = 10° extension to 140° flexion, gait, ability to weight bear
4) Stability: varus/valgus stress, drawer signs
5) Neurovascular status

Ottawa knee rule: age > 18, sensitivity 98.5%, specificity 48.6%. Obtain knee radiographs if:
1) age >55
2) Unable to flex to 90 degrees
3) Unable to take 4 steps immediately after injury and in the ER
4) Isolated patellar or fibular head tenderness

COMMON DIAGNOSES

Exam Imaging Rx/Dispo Considerations

22
TIBIAL NWB. Ortho consult. MC d/t AVP.
PLATEAU FX Lateral >
medial. If
medial, more
commonly have
assoc’ed soft
tissue injuries.
Often assoc’ed
with meniscal
and ligamentous
injuries, NV
damage, and
arterial injuries.

Segond sign:
lateral capsular
avulsion of fibular
head on XR 
ligamentous injury.
PATELLAR FX Active straight leg AP, lateral, axial Emergent ortho eval.
raise  if unable, (sunrise) views.
MC in 20-50yo. patella, patellar If displacement > 3mm,
MC is tendon, quads articular disruption
transverse. and/or tibia >2mm, or open fx, rx =
tuberosity tendon ORIF.
insertion is
interrupted. If intact extension, non-
displaced fx with no
articular disruption, rx =
knee immobilizer and
next day referral.
PATELLAR Usually laterally. AP + lateral views. To reduce, extend knee
DISLOCATION P/w hemarthrosis, with slight hip flexion,
inability to flex, and apply medial force.
displaced patella. Rx = casting/bracing in
knee extension, WBAT.
Next day referral.
MENISCAL Medial > lateral. XR but these are Knee immobilizer, NWB.
INJURY “Pop” or tearing often negative. MRI Refer to PMD for MRI
sensation, is definitive. for definitive dx.
followed by pain +
locking w/ delayed
swelling.

McMurray’s test:
w/ hip and knee
flexed,
varus/valgus
stress reproduces
pain on affected

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 side.
LIGAMENTOU “Pop” or tearing XR but these are NWB. Knee
S INJURY sensation, often negative. MRI immobilizer. RICE.
followed by pain is definitive. PMD referral.
+ locking with
immediate
swelling, and
difficulty
ambulating.

Varus and valgus

stress @ 30°
flexion and then
0° flexion.
SEPTIC Infection of the I&D + packing. Needle
BURSITIS prepatellar bursa aspiration if diagnosis is
 warm, red, unclear.
swollen knee.

POPLITEAL Expansion of Do not aspirate. Rule out

(BAKER’S) semimembranous popliteal artery
CYST bursa due to aneurysm.
excess synovial Rupture can
fluid can cause cause soft
outpouching into tissue swelling
the popliteal fossa. that appears
similar to DVT.
TIBIA-FIBULA MC long bone fx. If isolated, closed, Always look for
FRACTURE minimal displacement compartment
and comminution, rx = syndrome.
reduction, long leg cast
w/ 5° flexion, WBAT.
Dispo = ortho LE in 1
week.

If open, displaced, or
comminuted, rx/dispo =
ortho consult.

If isolated fibula shaft fx,

WBAT. Immobilization
is not required. Dispo =
ortho LE in 1 week.

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 ANKLE

BASIC ANATOMY

Exam: always palpate all the way up to the knee in any ankle injury.

Ottawa ankle rules: Only obtain knee radiographs if (+) pain in the malleolar zone + 1 of the
following:
1) Bone TTP along distal 6cm of posterior edge of fibula or tip of lateral malleolus
2) Bone TTP along distal 6cm of posterior edge of tibia or tip of medial malleolus
3) Inability to bear weight for 4 steps both immediately after injury and in the ED
* If there is obvious dislocation, reduce and splint immediately, before XR.

AP view Oblique view

*If you see a medial malleolus fracture, make sure you have a tibia-fibula XR.

COMMON DIAGNOSES

Exam Rx/Dispo Considerations

ANKLE MC ATF ligament. For all grades, Rx =
SPRAIN RICE and pain
Grade I: partial tear with mild TTP and control. Dispo =
swelling. No mechanical instability. PMD. Referral to
Grade II: incomplete tear with rehab/PT if no
moderate fxnal impairment, pain, improvement.
swelling.
Grade III: complete tear with severe
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 pain, swelling, ecchymosis and
instability.
ANKLE Two classification schemes:
FRACTURE
WEBER: classification based on location
of fracture relative to plafond.

Type A: posterior
Type A: horizontal avulsion fx below short leg splint. Ortho
mortise. Stable. LE in 1 week.
Type B: spiral fibular fx that starts at Type B:
the level of the mortise. Occurs
secondary to external rotational
forces. Can be stable or unstable
depending on ligamentous injury or
associated fx on medial side.
Type C: posterior +
Type C: above mortise and disrupts sugartong splint.
the ligamentous attachments distal to Next day referral for
fx. Unstable. ORIF.
LAUGE-HANSEN: classification based Splint, next day
on 1) position of foot at time of injury, referral.
and 2) direction of injuring force.

 Supination-Adduction
 Supination-External Rotation
 Pronation-Abduction
 Pronation-External Rotation

BI / TRI - Posterior + sugartong

MALLEOLAR splint. Next day
FX referral for ORIF.
MAISONNEUV Medial malleolus fx + fx of proximal 1/3 Long leg posterior
E FX fibula. Results from external rotational splint. Next day
injury.
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 referral for ORIF.
TALUS FX Make sure to get both ankle and foot XR. ORIF. Ortho consult.
Consider CT if high suspicion b/c XR may
not show comminution, displacement or
step offs.
ACHILLES Usually from jumping/pushing off of Posterior splint in
TENDON forefoot. Patient may hear a “pop” and is plantar flexion. Next
RUPTURE unable to walk on toes or plantar flex. day referral.
Thompson test: (+) if squeezing GSC
does NOT cause plantar flexion. Make
sure to check both GSC.
Can use ultrasound to identify rupture.

FOOT
BASIC ANATOMY

COMMON DIAGNOSES

If simple shaft fx of MT 2-4, then hard sole shoe, WBAT. For both, dispo = ortho LE in
1 week.
If 5th MT, depends on location – proximal base vs distal spiral:
 Jones: MOI is adduction or inversion of forefoot. XR: fx @ base, located within
1.5cm distal to tuberosity of 5th MT. Concern for non-union. Rx = NWB, SLC.
Dispo = ortho LE in 1 week.
 Dancer’s: on XR – spiral oblique fx, MOI is rotational force on plantar flexed
foot. Rx = hard sole shoe, WBAT. Dispo = ortho LE in 1 week.

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 Jones Avulsion Dancer’s

PHALANX FX Hard sole shoe for comfort, WBAT. Ortho LE in 2 weeks.

CALCANEAL Usually from axial loading.
FRACTURE XRs: AP, lateral , Harris axial and
complete ankle series.
If intra-articular, obtain CT.
Normal Bohler’s 25-40.

TARSO- Rare, often misdiagnosed. MC MOI – twisting, axial loading, crush injury. MC fx is 2nd
METATARSAL MT, but also cuneiforms and cuboid fx. XR: foot 3V + WB lateral. Classified according
(LISFRANC) to pattern of injury:
FX-DL  Homolateral: all 5 MT are displaced in same direction
 Isolated: 1-2 MT displaced from others
 Divergent: usually medial displacement of 1st MT and lateral
displacement of 2nd-5th MTs
What to look for on XR: 1) loss of in-line arrangement of lateral 1st MT with lateral 1st
cuneiform, 2) loss of in-line arrangement of medial 2nd MT with the medial 2nd
cuneiform, 3) (+) fleck sign – small avulsed fragments from rupture of Lisfranc ligament
, 4) step off on lateral XR at proximal 2nd MT-cuneiform joint.

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