Orthopedic Emergencies and Clinical Management

Posted on Jun 21, 2026 in Medicine

1. Red Flags and Emergencies (Do Not Miss)

Cauda Equina Syndrome

  • Back pain and sciatica
  • Saddle anesthesia or reduced perianal sensation
  • Urinary retention leading to late incontinence
  • 👉 Management: Urgent MRI of the spine

Epidural Abscess or Discitis Complication

  • Back pain, fever, and neurological signs
  • Risk factors: Intravenous drug use (IVDU), infective endocarditis
  • Organism: Staphylococcus aureus
  • 👉 Management: MRI; consider echocardiogram if discitis is present

Compartment Syndrome

  • Pain out of proportion to the injury
  • Pain on passive stretch (key clinical sign)
  • Increased analgesia requirement
  • Pulses may be present (do not use their presence to rule out the condition)
  • 👉 Management: Emergency fasciotomy

Spinal Cancer Red Flags

  • Previous history of malignancy
  • Thoracic back pain
  • Progressive neurological deficit


2. Fractures and Trauma

Upper Limb

Scaphoid Fracture

  • Fall on an outstretched hand (FOOSH), snuffbox tenderness, and pain on thumb compression
  • Risk: Avascular necrosis (specifically of the proximal pole)
  • Initial management: Splint or backslab
  • If X-ray is normal: Repeat imaging in 7–10 days
  • Proximal pole involvement: Surgical fixation

Colles’ Fracture

  • FOOSH leading to a dorsally displaced distal radius
  • “Dinner fork” deformity
  • Complication: Median nerve injury

Galeazzi Fracture

  • Radial shaft fracture combined with distal radioulnar joint dislocation

Monteggia Fracture

  • Ulnar fracture combined with proximal radioulnar dislocation

Biceps Rupture

  • “Popeye” deformity

Shoulder Dislocation

  • Anterior (>95%): Often caused by FOOSH
  • Posterior: Associated with seizures or electric shocks
  • Can be reduced without sedation in selected cases


Lower Limb

Ankle Sprain

  • Inversion injury
  • Anterior talofibular ligament (ATFL) is most commonly affected

Weber A Fracture

  • Stable: Managed with a CAM boot and weight-bearing as tolerated

5th Metatarsal Fracture

  • Result of an inversion injury

Stress Fracture

  • The tibia is the most common site

Hip Fractures

  • Intracapsular: Managed with hemiarthroplasty or total hip replacement (THR)
  • Intertrochanteric: Managed with a dynamic hip screw
  • Subtrochanteric: Managed with an intramedullary nail
  • Aim: Early mobilization and weight-bearing

Posterior Hip Dislocation

  • Presents as a shortened and internally rotated leg
  • Risk of sciatic nerve injury


3. Spine and Radiculopathy

Radiculopathy Patterns

L3

  • Anterior thigh sensory loss
  • Weakness in hip flexion and knee extension
  • Decreased knee reflex

L4

  • Medial knee and medial malleolus sensory loss
  • Weakness in knee extension and hip adduction
  • Decreased knee reflex

L5

  • Sensory loss on the dorsum of the foot
  • Foot drop (dorsiflexion weakness)
  • Hip abduction weakness
  • No specific reflex loss

S1

  • Posterolateral leg and lateral foot sensory loss
  • Weakness in plantar flexion
  • Decreased ankle reflex


Spinal Conditions

Spinal Stenosis

  • Neurogenic claudication
  • Symptoms worsen with walking and are relieved by sitting or leaning forward

Cauda Equina

  • Bilateral sciatica and saddle anesthesia
  • Late signs: Urinary incontinence
  • Requires urgent MRI

Discitis

  • Staphylococcus aureus is the most common organism
  • Risk factor: Intravenous drug use (IVDU)
  • Can progress to an epidural abscess

4. Joint and Ligament Conditions

Knee

Meniscal Tear

  • Twisting injury
  • Symptoms include locking and giving way
  • MRI confirms the diagnosis
  • Ligament injuries: MRI is the best imaging modality

ACL Injury

  • Sudden “pop,” swelling, and instability
  • Lachman test is the most sensitive clinical test


Osteochondritis Dissecans

  • Knee pain following exercise
  • Symptoms include locking and clunking

Shoulder

Rotator Cuff Injury

  • Presents with a painful arc
  • Treatment: Analgesia and physiotherapy unless a tear is suspected

Adhesive Capsulitis

  • Risk factor: Diabetes
  • Classic sign: Loss of external rotation

AC Joint Injury (Grade 1–2)

  • Conservative management (sling and rest)

Hand and Wrist

Carpal Tunnel Syndrome

  • Median nerve compression
  • Diagnosis: Prolonged sensory and motor conduction on nerve studies
  • Treatment: Splint or steroid injection as first-line therapy
  • Surgical management: Flexor retinaculum release
  • Rheumatoid Arthritis (RA) is a common cause

De Quervain’s Tenosynovitis

  • Radial wrist pain
  • Inflammation of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendon sheaths
  • Finkelstein test is positive


Dupuytren’s Contracture

  • Risk factors: Phenytoin use and diabetes
  • Metacarpophalangeal (MCP) contracture: Patient cannot place the hand flat

Ganglion Cyst

  • Located on the dorsal wrist; transilluminates

5. Hand Osteoarthritis

  • Heberden’s nodes (located at the DIP joints)
  • Carpometacarpal (CMC) joint involvement
  • Thumb squaring
  • Common pattern in Osteoarthritis (OA) hand disease

6. Hip and Lower Limb Pain

Trochanteric Bursitis

  • Lateral hip pain
  • Tenderness over the greater trochanter

IT Band Syndrome

  • Runner’s knee pain

Plantar Fasciitis

  • Heel pain (medial calcaneus)


Meralgia Paraesthetica

  • Lateral femoral cutaneous nerve compression
  • Burning pain in the lateral thigh
  • Causes: Weight gain or tight clothing

7. Infection and Bone Conditions

Osteomyelitis

  • MRI is the best imaging modality
  • Staphylococcus aureus is the most common organism
  • In children: Typically affects the metaphysis
  • Sickle cell disease: Associated with Salmonella

Psoas Abscess

  • CT of the abdomen is the best imaging modality
  • Drainage is usually successful
  • Staphylococcus is a common organism
  • Presents with fever and back or flank pain

8. Fracture Healing and Special Rules

Scaphoid Fractures

  • Immobilize even if the initial X-ray is normal
  • Repeat imaging in 7–10 days
  • Proximal pole fractures require surgery

Open Fractures

  • Definitive surgery is delayed until soft tissue recovery occurs


Ankle Injury Rule

  • Perform X-ray if there is malleolar tenderness OR the patient cannot weight-bear for 4 steps
  • Neurovascular compromise: Reduce immediately; do not delay for an X-ray

9. Bone Disease and Osteoporosis

Fragility Fracture

  • In older patients (>50): DEXA is not needed if a fragility fracture is already present

QFracture / FRAX

  • Tools used to guide the need for a DEXA scan

Osteoporotic Vertebral Fracture

  • X-ray is the first-line investigation

10. Avascular Necrosis

Risk factors:

  • Steroid use
  • Chemotherapy
  • Trauma

Best imaging:

  • MRI of the hip


11. Other High-Yield Points

  • Rib fractures: Managed conservatively with analgesia (critical for ventilation)
  • Nerve blocks: Used if pain is uncontrolled
  • Achilles rupture: Ultrasound is the first-line investigation
  • Achilles tendonitis: Managed with rest, NSAIDs, and physiotherapy
  • Charcot joint: Risk associated with alcoholic neuropathy
  • Fat embolism: Triad of respiratory distress, neurological signs, and petechial rash
  • Olecranon bursitis: Elbow swelling
  • Baker’s cyst: Asymptomatic posterior knee swelling, often seen in children