Key Concepts The Ottawa Ankle and Foot Rules should be used to evaluate the need for x-rays in ankle and foot injuries. CT scans are indicated for negative x-rays of the ankle and foot when a high clinical concern of fracture exists. Ankle dislocations with obvious vascular compromise should be reduced promptly, before radiographs are obtained. The entire fibula should be examined if a medial malleolar…
Key Concepts Knee dislocation often causes vascular injury to the popliteal artery. Early revascularization is crucial. Hard signs of vascular injury include absent pedal pulses, cool mottled foot, expanding popliteal hematoma, or popliteal hemorrhage. When any of these are present, angiography or emergent surgical exploration is indicated. Soft signs of popliteal artery injury include asymmetric pedal pulses and foot or leg paresthesias. Computed tomography (CT) angiography…
Key Concepts A hip dislocation is an orthopedic emergency. The likelihood of avascular necrosis (AVN) is related to both the initial degree of trauma and the amount of time the femoral head remains out of joint. Reduction of the hip within 6 h after dislocation significantly decreases the incidence of AVN. When a painful hip makes ambulation difficult and plain radiographs do not reveal a fracture,…
Key Concepts The most serious pelvic ring injuries caused by high-energy impact are (1) anteroposterior compression fractures (“open-book” fracture), (2) vertical shear fractures, and (3) fractures involving significant displacement. These injuries are associated with major blood loss and transfusion requirements. Pelvic fractures are a marker for serious injury to other organ systems. The vast majority of patients who die after sustaining a pelvic fracture have multiple…
Key Concepts Axillary nerve function is best evaluated by testing the motor function of the deltoid muscle. The three-view trauma series of the shoulder (true anteroposterior, scapular Y, and axillary views) leads to an accurate radiographic diagnosis of most fractures and dislocations, although specialized views are sometimes necessary. Consider the presence of unfused epiphyses in adolescents and young adults. Most shoulder girdle fractures can be treated…
Key Concepts Clinical decision rules for the elbow joint have not been validated. Radiographs should be obtained when there is limitation in range of motion, moderate to severe pain, obvious deformity, joint effusion, or significant tenderness or crepitus over any of the bony prominences or the radial head. The threshold for radiographic imaging should be lower in pediatric patients (with the exception of radial head subluxations),…
Acknowledgment We would like to thank David Williams, Karen G.H. Woolfrey, Michael Woolfrey, and Mary A. Eisenhauer for their contributions to previous versions of this chapter. Key Concepts On plain radiographs of the wrist, three distinct arcs, known as Gilula’s lines , and equal spacing between carpus bones (1–2 mm), known as parallelism , assist in the radiographic diagnosis of carpal injuries. In the setting of…
Acknowledgments The authors would like to acknowledge the assistance of Ronald Barry, MD, FACS in the preparation of this chapter, including providing many of the images. Key Concepts For general testing of the motor nerve function of the hand, have the patient make an “OK” sign with their thumb and index finger (testing the median nerve), while spreading/abducting the third, fourth, and fifth fingers (ulnar nerve)…
Key Concepts Many orthopedic injuries can be stabilized and treated definitively by the emergency clinician. Consultation with an orthopedist should be sought for the treatment of some long bone fractures, open fractures, injuries with joint violation, tendon injuries, and injuries with neurovascular compromise. A careful history and physical examination can predict radiographic findings in orthopedic injuries with a high degree of accuracy. Open fracture management should…
Key Concepts The overall condition of the patient with an acute peripheral vascular injury determines the extent of emergency department (ED) evaluation and stabilization. Critically injured patients may require immediate surgery, which should not be delayed for confirmatory studies of obvious vascular injury. Arterial injury may be readily apparent or clinically occult. In patients with high-energy blunt mechanisms, computed tomography angiography (CTA) should be the initial…
Key Concepts Microscopic or gross hematuria is suggestive of genitourinary trauma; however, the degree of hematuria does not correlate well with either the severity or anatomy location of injury. The kidney is the most frequently injured genitourinary organ, and imaging should be considered in patients with gross hematuria or microscopic hematuria with hemodynamic instability. Most noniatrogenic ureteral injuries are due to penetrating mechanisms and are unilateral;…
Key Concepts The accuracy of a physical examination is limited in cases of abdominal trauma. It is rendered less reliable by distracting injury, altered sensorium (e.g., head trauma, alcohol or drug intoxication, developmental delay, psychiatric illness), and spinal cord injury. Stab and gunshot wounds frequently violate the lung parenchyma, diaphragm, mediastinum, intraperitoneal cavity, and retroperitoneum in some combination. Physical examination with extended focused assessment with sonography…
Key Concepts Even relatively minor chest wall injuries, such as rib fractures, may result in serious complications in elderly patients and patients with preexisting pulmonary disease if adequate analgesia and close follow-up care are not provided. Unless there are abnormalities on the electrocardiogram (ECG) or an elevated serum troponin level, there is no need to pursue the diagnosis of myocardial contusion with more sophisticated testing. Many…
Key Concepts Significant injuries to the cerebral vessels can occur as a result of blunt or penetrating trauma to the neck. Blunt trauma to the neck can lead to immediate or delayed ischemic strokes, and a low threshold for imaging vessels when neurologic findings or risk factors for cervical vessel injury exist is recommended. A no-zone approach to penetrating neck trauma is becoming widely accepted as…
Key Concepts NEXUS or CCR decision rules may be used to determine the need for radiographic imaging in the awake, evaluable trauma patient. CT scanning is preferred over plain radiography in the evaluation of the trauma patient with potential spinal injury, especially if axial imaging is needed for evaluation of other injuries. Suspicion for an anterior cord syndrome warrants prompt neurosurgical consultation because it is a…
Key Concepts The face is central to the patient’s ability to breathe, eat, and communicate. Injuries to the face can have serious psychological and psychosocial consequences. Facial injuries may be prevented by the appropriate use of safety devices including motor vehicular seat belts, child restraints, air bags, helmets, and mouth and face guards. The epidemiology of facial injury is changing, with an increasing proportion of injuries…
Key Concepts Head trauma is a broad term describing an external trauma to the craniofacial area of the body from blunt, penetrating, blast, rotational, or acceleration-deceleration forces. The term head injury refers to a clinically evident injury on physical examination, and the term brain injury indicates an injury to the brain itself. Traumatic brain injury (TBI) is often categorized into mild (Glasgow Coma Scale score, 13–15),…
Key Concepts Immediately after a trauma patient arrives the emergency department (ED), the primary survey should be performed in a standardized fashion. The goal of the primary survey is to rapidly identify and initiate the treatment of critical, and life-threatening injuries. The extended Focused Assessment with Sonography for Trauma (eFAST) examination should be performed early in the evaluation of the trauma patient (ideally as part of…
Acknowledgments The authors would like to thank Roy Hatch for his invaluable assistance in preparing this chapter. Key Concepts Acute low back pain is a common, costly, recurring and painful condition that often has no recognizable or dangerous cause. While most cases of back pain are non-specific and improve without laboratory evaluation or imaging, the aim of the emergency department (ED) assessment is to identify those…
Key Concepts Pregnancy status is the single most important determination to make in evaluating a patient with vaginal bleeding. The use of the term dysfunctional uterine bleeding is no longer recommended, and the term abnormal uterine bleeding is preferred. The etiologies of abnormal uterine bleeding can be divided into structural and nonstructural causes using the PALM-COEIN classification. Structural causes include p olyps, a denomyosis, l eiomyomas,…