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Thread: Alarm Bells in Orthopaedics

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    Smile Alarm Bells in Orthopaedics

    01 Acute swelling of a single joint think of septic arthritis.
    02 A painful, swollen finger could be septic flexor tenosynovitis a surgical emergency.
    03 Paediatric trauma may be due to child abuse.
    04 An adolescent with a limp, hip or knee pain could have slipped upper femoral epiphysis.
    05 Uncontrollable limb pain after injury may be compartment syndrome.
    06 Wrist pain after injury do not miss scaphoid fracture.
    07 A skin break overlying any fracture means an open fracture until proved otherwise.
    08 A cut on the knuckle is a fight bite until proved otherwise.
    09 Not all acute back pains are mechanical.
    10 Unexplained bone pain, especially at night, is ominous.










    Notes




    1 Septic arthritis

    Septic arthritis is serious and difficult to diagnose in the early stages. Typically, the patient presents with fever and an acutely painful, inflamed joint with restricted active and passive range of motion. Atypical presentations can occur in infants and the immunocompromised. Consider the diagnosis in children who refuse to walk or use a limb. In young, sexually active patients with fever and rash, suspect gonococcal arthritis. Antibiotics should be withheld until after joint aspiration and blood cultures are performed. The differential includes crystal disease (gout, pseudogout).

    Action: Refer immediately to orthopaedics.




    2 Septic flexor tenosynovitis

    Flexor tenosynovitis is infection in the flexor sheath, often due to a puncture wound. It is a hand surgery emergency, and so needs to be differentiated from other benign causes of swollen, painful finger. The four cardinal features are: finger held in slight flexion; fusiform swelling of the whole digit; tenderness along the entire flexor tendon sheath; and intense pain with passive extension of the digit. The process can rapidly destroy the flexor tendon sheath and result in loss of function. Staphylococcus aureus is the most common organism isolated.

    Action: Refer immediately. Keep the patient nil by mouth. Check FBC, ESR, CRP and do blood cultures. Commence IV antibiotics.




    3 Child abuse

    Failure to recognise child abuse can be ethically and legally catastrophic. In any paediatric trauma, features on history that should raise suspicion include delay in seeking care, implausible or inconsistent history, failure to thrive, prior unusual injury, and repeated accidents, especially if treated at different places. Worrying signs include multiple bruises in infants, head and facial injuries, and cigarette burns. Spiral fractures of the shaft of long bones in children under 2 years, old fractures, rib and skull fractures may have a non-accidental cause. However, differential diagnoses should not be forgotten (coagulopathies, osteogenesis imperfecta, copper deficiency and neuromuscular diseases). The case is handled best by specialists.

    Action: Refer immediately to paediatrics with orthopaedic involvement. The child will need a thorough assessment by a clinician experienced in child abuse.




    4 Slipped upper femoral epiphysis (SUFE)

    SUFE is the most common non-traumatic hip problem in adolescents. Delay in treatment may lead to avascular necrosis of the head of the femur and permanent disability. Diagnosis is often delayed because it can present without hip pain, misleading the unwary. It should be considered in any adolescent with hip, knee or distal thigh pain, limp, or limited range of hip movement. It is more common in overweight, adolescent boys, and is bilateral in about 30%. Presentation is either gradual or acute.

    Action: Refer immediately to orthopaedics. In acute cases, do not manipulate the hip, and do not let the patient weight-bear, until assessed by orthopaedics.




    5 Compartment syndrome

    Fractures and other limb injuries may be complicated by compartment syndrome. This occurs when pressure within closed, fascial compartments exceeds perfusion pressure resulting in muscle ischaemia. The most important feature is unrelenting pain despite opiates, which increases on passive stretch of the fingers or toes whose tendons travel in the compartment(s) affected. The limb may also feel cold, have sensory deficit and be pulseless, but these are often late signs. Causes include trauma, both fractures and soft tissue crush injuries, and constricting casts or bandages. A high index of suspicion is the key to the diagnosis. Surgical fasciotomy may be needed.

    Action: Refer immediately to orthopaedics. Keep patient nil by mouth. Split any constricting cast or bandage down to the skin.




    6 Scaphoid fracture

    A missed scaphoid fracture can lead to long-term patient disability and loss of occupation. It is a common medicolegal case. If there is clinical suspicion due to tenderness over the scaphoid and painful restriction of wrist movement, it is safer to assume that there may be a scaphoid fracture. Initial radiographs may not show evidence of a fracture.

    Action: Refer urgently to orthopaedics. Splint the wrist in a backslab while awaiting orthopaedic review.




    7 Open fracture

    In open fractures, inspection may not reveal exposed bone. A break in the skin near to the fracture could be all there is to see. The most frequent error is to assume the skin disruption does not communicate with the fracture itself. About one-third of patients sustaining an open fracture also have other lifethreatening injuries.

    Action: Refer immediately to orthopaedics. In the interim, dress the wound, splint the limb and give tetanus prophylaxis. Do not close the wound primarily.




    8 Fight bite

    A clenched fist injury that results from striking another persons mouth is termed a fight bite. There is typically a small transverse or oblique cut overlying the metacarpophalangeal joint. Though the appearance is deceptively benign, if tooth has penetrated skin, it has also invariably entered the joint capsule. Such injuries require formal debridement by a hand surgeon. Patients often deny the mechanism of injury so the clinician must have a high index of suspicion.

    Action: Refer immediately to orthopaedics. Give appropriate antibiotics. Do not close the wound primarily.




    9 Medical causes of acute back pain

    Most acute back pain is due to a self-limiting mechanical condition, reflecting degenerative spine processes. However, other serious, medical causes should not be forgotten: dissecting aortic aneurysm, pyelonephritis and ectopic pregnancy.

    Action: Consider non-orthopaedic causes of acute back pain.



    10 Osteomyelitis and musculoskeletal tumours

    Unrelenting bone pain, especially night pain, is ominous. Osteomyelitis is more common in children and often involves the ends of long bones. It often presents with toxaemia, pain and loss of function. However, atypical presentations are not uncommon. Musculoskeletal tumours are rare but can present at any age and can involve any region. Pain is often the first symptom. There may be a firm or ill-defined swelling. Loss of limb function, decreased range of motion or pathological fracture occurs in some patients. Immediate treatment is required for pathological or impending fractures, impending or existing neurological deficits and uncontrollable pain.

    Action: Refer urgently to orthopaedics, immediately in situations described above.
    " VALUE HAS A VALUE ONLY IF ITS VALUE IS VALUED "
    Never Let Student Die In Your Heart When It Dies You Want Remain A Doctor But You Will Be A Technician

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    ***EDIT***you copy paste this from ***EDIT*** from the real author Dr.Aymn without any referral to that ***EDIT**
    Last edited by CMa; 05-09-2008 at 03:29 PM. Reason: Deleting external links!

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    Dear DR.Shaher,

    First, Dont abuse any member ever in our forum, Next If the original author is someone esle, Ok Fine. But afterall knowledge is for sharing, nothing is wrong in sharing it here! It doesn't deserve such a post from u!

    Grow up!, Don't act like a child!!

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    thanks i want to convey the same massage to Dr.Shaher that we all are here to share our knowledge & other stuff which we got to share here so it can be helpful to other
    Last edited by jamesmayur; 05-10-2008 at 10:14 PM.
    " VALUE HAS A VALUE ONLY IF ITS VALUE IS VALUED "
    Never Let Student Die In Your Heart When It Dies You Want Remain A Doctor But You Will Be A Technician

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    tttttttttttttaaaaaaanxxxxxxxxxxxxxxxxxxxx

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