The Limping Child (2024)

December 30, 2024December 30, 2024 ~ iEM Education Project Team ~ Leave a comment

by Elizabeth Zorovich, Vincent Gonzalez, & Vlad Panaitescu

You Have A New Patient!

A four-year-old boy presents to the emergency department with his mother. The mother states that the patient has been limping and complaining of pain in his right leg for the past two days. She also reports that the right hip is red and painful to touch. The patient refuses to walk or move his right hip during triage. The mother states that the patient’s head felt warm this morning when he woke up, but she did not take his temperature before arriving. Both the mother and patient deny any falls or known injuries.

Vital signs are as follows: temperature 40°C, heart rate 130 beats per minute, blood pressure 100/70 mmHg, respiratory rate 16 breaths per minute, SpO₂ 98% on room air, and weight 16 kg. The patient is up to date on vaccinations.

What Do You Need To Know?

Importance

Limping in children is a common symptom encountered in the emergency department, necessitating careful evaluation due to its wide range of potential causes. While it may originate from benign conditions like sprains, it can also indicate serious underlying issues such as malignancies or infections, which can be life-threatening if not promptly diagnosed [1]. A thorough assessment, containing a detailed history and physical examination, is crucial for establishing the correct diagnosis [2]. This process can be particularly challenging depending on the child’s age, as younger patients may struggle to articulate their symptoms effectively. Therefore, proper history-taking and examination skills are essential, and primary caregivers often provide invaluable insights that can guide the clinician in identifying the root cause of the limping [3]. Prompt recognition and appropriate management of the underlying condition are vital to ensure optimal outcomes for the pediatric patient.

Epidemiology

The epidemiology of limping in children is an important area of study, although literature on this topic remains limited. According to studies [4,5], approximately four percent of pediatric visits to emergency departments are attributed to gait disturbances, highlighting the prevalence of this issue in clinical settings. Limping is a multifactorial symptom that can arise from various underlying conditions, including trauma, infections, and developmental disorders. The high percentage of emergency visits highlights the need for careful evaluation and management of limping in children, particularly in the context of acute injuries or infections.

Research indicates that limping is notably more prevalent in males than females, with a median age of four years for affected children [6,7]. This gender disparity may be linked to differences in activity levels and risk-taking behaviors among young boys, who are often more physically active than their female counterparts. The developmental stage of toddlers also plays a significant role in the incidence of limping. Due to their active nature and immature gait patterns, toddlers frequently experience accidental falls, which can lead to temporary limping. Additionally, during this stage of development, children are more susceptible to infections, particularly osteomyelitis, as their bony cortex is still maturing and offers less resistance to bacterial invasion [8].

As children transition into school age, their increased mobility and adventurous spirit contribute to a higher risk of traumatic injuries, further elevating the incidence of limping in this demographic. Activities such as jumping off objects or engaging in sports can result in strains, sprains, or fractures, all of which may manifest as a limp [9].

Pathophysiology

Limping in children is a multifaceted clinical symptom that can arise from various underlying pathophysiological processes. The assessment of a limp must take into account the developmental status of the child, as a proper diagnosis cannot be made until the child is able to stand, typically around nine months of age. The average onset of independent walking occurs between twelve and eighteen months, during which a child’s gait transitions from a broad-based stance to a more refined adult-like gait by the age of three [10, 11]. This developmental progression is crucial, as the normal gait cycle involves intricate coordination between the nervous and musculoskeletal systems, comprising two main phases: the stance phase and the swing phase. The stance phase encompasses the period from heel strike to toe-off, while the swing phase involves a sequence of hip flexion, knee flexion, foot dorsiflexion, and knee extension, which must function harmoniously to maintain a fluid gait [12].

A limp is defined as a deviation from normal age-appropriate gait patterns and can be categorized into three primary types: antalgic, Trendelenburg, and short leg gait. An antalgic gait, often referred to as a “quick step,” is characterized by a shortened stance phase on the affected limb, typically due to pain. This type of gait can result from various causes, including traumatic injuries, malignancies, or infectious processes [13]. Conversely, the Trendelenburg gait is marked by a drop of the affected hip during the swing phase of the contralateral leg, accompanied by a tilt of the pelvis towards the affected side when standing. This gait pattern is primarily indicative of musculoskeletal weakness and may be observed in conditions such as Legg-Calvé-Perthes disease (LCPD), slipped capital femoral epiphysis (SCFE), developmental dysplasia of the hip, and certain neuromuscular disorders [14]. Lastly, a short leg gait arises from a limb length discrepancy, which can be attributed to improper healing of fractures, osteomyelitis, bone tumors, or bone cysts [15].

Medical History

The evaluation of a limping child in the emergency department necessitates a comprehensive and systematic approach to history taking, as the potential causes of a limp can vary widely, ranging from benign to serious conditions. The initial step involves understanding the chief complaint by gathering detailed information regarding the onset, duration, and progression of the limp. It is crucial to ascertain whether the limp is acute, chronic, or recurrent, and to identify any inciting events, such as trauma or infection, that may have preceded its onset [16]. This foundational information is vital in narrowing down the differential diagnosis and determining the urgency of the situation.

In addition to the chief complaint, the past medical history plays a pivotal role in identifying underlying factors that could predispose a child to limping. Relevant systemic illnesses, previous injuries, or musculoskeletal disorders must be considered, as these can indicate possible orthopedic or systemic causes of the limp [17]. For younger children, a thorough birth history is essential to rule out perinatal factors such as developmental dysplasia of the hip, birth trauma, or neuromuscular disorders that could manifest as limping [18]. Furthermore, it is important to assess any known allergies, as this information can influence the choice of diagnostic imaging or therapeutic interventions.

Evaluating the child’s recent intake and output is another critical aspect of history taking, as it can reveal signs of systemic illness such as dehydration or febrile illnesses. Conditions like transient synovitis or septic arthritis may present with a limp, and understanding the child’s hydration status can provide valuable insights into their overall health [19]. Additionally, vaccination history is paramount, as it helps exclude infections caused by vaccine-preventable pathogens, including osteomyelitis from Haemophilus influenzae type B [20].

Finally, gathering information about family history, especially concerning musculoskeletal or genetic conditions, along with social history factors such as daycare attendance, can further inform the clinician’s assessment. Increased exposure to infections in daycare settings may raise the likelihood of conditions that cause limping [21]. A meticulous history-taking process lays the groundwork for formulating a differential diagnosis, which is crucial for guiding further examination and investigations in the emergency department.

Physical Examination

The evaluation of limping children in the emergency department requires a comprehensive physical examination, as the underlying causes can range from benign to serious conditions. A thorough examination should begin with a bilateral joint assessment to ensure a comparative analysis. Each joint must be evaluated for overlying skin changes, deformities, and the presence of palpable pulses. Additionally, both active and passive ranges of motion should be meticulously assessed [22]. This thorough examination allows clinicians to identify any abnormalities that could indicate conditions such as septic arthritis or osteomyelitis, which may require urgent intervention.

In cases where the child can localize pain, it is crucial to examine the joints above and below the area of concern. This approach can help in identifying referred pain or issues that may not be immediately apparent [23]. Following the joint examination, observing the child’s gait is essential. An unassisted gait should be observed first; if the child is unable to walk independently, an assisted gait evaluation should be conducted. This observation helps in determining the side of the limp and the type of limp present, which can provide valuable clues regarding the underlying etiology [24]. For instance, a trendelenburg gait may suggest hip pathology, while a toe-walking gait could indicate issues related to the Achilles tendon or neurological conditions.

Subsequently, a full neurological examination should be performed, encompassing the assessment of reflexes, sensation, and cranial nerve function. This step is vital, as neurological deficits may point towards serious underlying conditions such as spinal cord compression or central nervous system infections [25]. Clinicians should remain vigilant for red flag signs, including fever, tachycardia, inability to ambulate independently, skin changes, and decreased range of motion of a joint, as these may indicate serious conditions requiring immediate attention [26].

Alternative Diagnoses

Acute septic arthritis, osteomyelitis, and malignancy should be the primary concerns to rule out in any child presenting with a limp.

Acute septic arthritis is an infection in a joint and the surrounding synovial fluid. Septic arthritis is most often a hematogenous infection that seeds from any site of trauma or infection. This condition occurs more frequently in children than in adults. The sluggish blood flow in the metaphyseal capillaries and immature bony cortices of children makes them more susceptible. The most commonly affected locations in the body are the large joints of the lower limb, including the hip, knee, and ankle. Staphylococcus aureus and respiratory pathogens are the most common causative agents [27].

Osteomyelitis is an infection of the bone. Staphylococcus aureus is the most common cause of osteomyelitis regardless of age. During the neonatal period, group B streptococcus is the second most common causative bacterium. Hematogenous spread accounts for more than fifty percent of cases. Osteomyelitis and acute septic arthritis may occur simultaneously [28].

Malignancy can be a cause of musculoskeletal pain and limping in pediatric patients. The most common malignant pediatric bone tumors are osteogenic sarcoma and Ewing’s sarcoma. Pain from bone tumors may be acute or chronic, with acute pain often related to a pathological fracture.

Other causes of pediatric limps span a wide range of medical conditions categorized into trauma, inflammatory, developmental, neurologic, metabolic, and hematologic origins. Trauma is a common cause and may result from fractures, stress fractures, or soft tissue injuries. Inflammatory conditions include transient synovitis and reactive arthritis, which are significant contributors to limping in children. Developmental issues such as dysplasia of the hip, slipped capital femoral epiphysis (SCFE), and limb length discrepancies also play a role. Neurologic causes include muscular dystrophy and peripheral neuropathy, which affect the musculoskeletal system’s normal functioning. Metabolic conditions like rickets and hyperparathyroidism can weaken bones, leading to limping, while hematologic disorders such as sickle cell disease and hemophilia may cause joint or bone pain, further complicating mobility. Recognizing these varied etiologies is crucial for accurate diagnosis and effective management.

In the emergency department, differentiating between septic arthritis, osteomyelitis, and transient synovitis in limping children is critical due to the varying urgency of their management. Septic arthritis and osteomyelitis are both serious bacterial infections that require prompt intervention to prevent long-term complications, while transient synovitis is a self-limiting condition that typically follows a viral upper respiratory infection and is managed conservatively with analgesia and rest [29]. The clinical presentation of these conditions can overlap significantly, including symptoms such as joint pain, swelling, and decreased mobility, which complicates the diagnostic process [30].

To effectively differentiate septic arthritis from transient synovitis, clinicians can employ the Kocher criteria, a validated clinical tool specifically designed for pediatric patients. This scoring system assesses four key factors: inability to bear weight on the affected limb, an erythrocyte sedimentation rate (ESR) greater than 40 mm/hr, the presence of fever, and a white blood cell (WBC) count exceeding 12,000 [31]. The probability of septic arthritis increases with the number of positive criteria; when all four are present, the risk of septic arthritis rises to 99%. Conversely, the probability is significantly lower with fewer positive criteria, dropping to 3% with only one criterion met [31]. This stratification aids clinicians in determining the need for further diagnostic testing, such as joint aspiration or imaging studies, to confirm the diagnosis and initiate appropriate treatment.

Osteomyelitis, another potential diagnosis in limping children, can also present with similar symptoms but typically involves the bone rather than the joint. It may occur concurrently with septic arthritis or as a separate entity, and it often requires a combination of clinical evaluation, laboratory tests, and imaging studies for accurate diagnosis [32]. The distinction between these conditions is vital because while both septic arthritis and osteomyelitis necessitate urgent antibiotic therapy and possibly surgical intervention, transient synovitis can be managed with conservative measures, reducing the risk of unnecessary invasive procedures [30].

Acing Diagnostic Testing

Laboratory Tests

When evaluating limping children in the emergency department, laboratory tests play a crucial role in diagnosing underlying conditions, such as infections or malignancies. A complete blood count (CBC) is often the first step in this diagnostic process. The CBC can help identify leukocytosis, which may suggest an infectious process, or anemia that could indicate chronic disease or malignancy [33]. In addition to the CBC, acute-phase reactants, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), should be ordered to assess for inflammation. Elevated levels of these markers can indicate an inflammatory process, which is particularly important in differentiating between benign causes of limping and more serious conditions like osteomyelitis or malignancy [34].

In cases where the child presents with fever, it is essential to obtain blood cultures, as they can provide critical information regarding systemic infections. Blood cultures should ideally be collected before the initiation of antibiotics to increase the likelihood of identifying any pathogens present in the bloodstream [35]. This is particularly vital in children who may have septic arthritis, a serious condition that requires prompt diagnosis and treatment. If septic arthritis is suspected, joint aspiration is often performed to analyze synovial fluid. The synovial fluid should be sent to the laboratory for comprehensive analysis, including cell counts, inflammatory markers, and bacterial cultures. Elevated white blood cell counts in the synovial fluid, particularly with a predominance of neutrophils, can support a diagnosis of septic arthritis [36]. Furthermore, bacterial cultures can help identify the causative organism, guiding appropriate antibiotic therapy.

Imaging

Imaging plays a crucial role in the evaluation of limping children in the emergency department, as it aids in diagnosing various underlying conditions. X-rays are often the first line of imaging in pediatric patients presenting with a limp. They are effective in assessing for bone damage, fractures, and certain signs of trauma or malignancy [37]. However, it is important to note that while X-rays can provide valuable information, they may not always reveal the full extent of a condition. For instance, in cases of acute septic arthritis and acute osteomyelitis, the initial X-ray may appear normal despite the presence of significant pathology [38]. This limitation underscores the importance of considering additional imaging modalities when clinical suspicion remains high.

Magnetic Resonance Imaging (MRI) is particularly useful in further evaluating suspected cases of osteomyelitis. MRI offers superior soft tissue contrast and can identify early changes in bone marrow that may not be visible on X-rays [39]. This imaging modality is non-invasive and provides a comprehensive view of both the bony structures and surrounding soft tissues, making it an invaluable tool in complex cases where osteomyelitis is a concern. Additionally, MRI can help differentiate osteomyelitis from other conditions such as tumors or trauma, guiding appropriate management strategies.

Ultrasound is another beneficial imaging modality in the emergency setting, especially for evaluating joint effusions. It can be performed at the bedside, allowing for rapid assessment and intervention [40]. Unlike X-rays and MRIs, ultrasound does not involve radiation exposure, making it particularly suitable for pediatric patients. This imaging technique can assist in determining the need for further procedures, such as aspiration or drainage of a joint effusion, thereby facilitating timely treatment.

The right femoral epiphysis shows irregularity and abnormal marrow signals, with low signal on T1 and bright signal on STIR/T2 FATSAT, indicating marrow edema. There is loss of joint space at the top of the right hip joint and moderate joint effusion. Diagnosis: Septic arthritis of the right hip joint. - Source: Abdrabou A Septic arthritis of the hip joint. Case study, Radiopaedia.org (Accessed on 30 Dec 2024) https://doi.org/10.53347/rID-27744

Risk Stratification

Risk stratification in limping children presenting to the emergency department is a crucial process that aids in identifying serious underlying conditions and prioritizing care based on the urgency and severity of potential diagnoses. The initial assessment begins with evaluating the child’s symptoms and vital signs. For instance, the presence of fever, tachycardia, or hypotension may indicate systemic infections, such as septic arthritis or osteomyelitis, necessitating immediate intervention [41]. Additionally, an acute, non-weight-bearing limp, especially following trauma, raises the suspicion for fractures, dislocations, or soft tissue injuries, while chronic or insidious symptoms may point towards more serious conditions like malignancies, juvenile idiopathic arthritis, or developmental disorders [42].

Age plays a pivotal role in refining the differential diagnosis in limping children. Toddlers are particularly vulnerable to conditions such as developmental dysplasia of the hip or transient synovitis, while older children and adolescents may present with slipped capital femoral epiphysis (SCFE) or Legg-Calvé-Perthes disease [43]. Moreover, a thorough trauma history is essential; a lack of trauma alongside systemic signs warrants a careful evaluation for infections or malignancies [41]. Laboratory tests, including white blood cell counts, inflammatory markers like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and blood cultures, are instrumental in detecting infections or inflammatory conditions [42].

Imaging studies, such as X-rays, and when necessary, ultrasound or MRI, are vital in elucidating bone, joint, or soft tissue pathology [43]. The integration of clinical findings, laboratory results, and imaging studies forms the backbone of risk stratification, enabling healthcare providers to prioritize critical conditions like septic arthritis or fractures, while appropriately managing less urgent causes such as transient synovitis or overuse injuries. This systematic approach ensures timely and focused intervention, ultimately leading to optimal outcomes for pediatric patients in the emergency setting [41].

Management

Initial Assessment and Stabilization (ABCDE Approach)

Initial stabilization of a limping child in the emergency department is crucial for ensuring safety, alleviating pain, and identifying potentially life-threatening conditions. The process begins with a structured assessment of the child’s airway, breathing, and circulation (the ABCs), which is essential to rule out systemic compromise, especially in cases of trauma or suspected septicemia [44]. Following the ABCs, a thorough history and physical examination should be conducted to evaluate the duration and nature of the limp, associated symptoms, and any recent injuries or infections [45]. Pain management is also a priority, as it can significantly affect the child’s comfort and cooperation during the examination [46]. Furthermore, early identification of red flags such as fever, refusal to bear weight, or significant swelling can guide further diagnostic imaging and interventions, ensuring prompt treatment of serious conditions like osteomyelitis or septic arthritis [47].

Airway: If the patient responds in a normal voice, the airway is patent. Airway obstruction can be partial or complete. Signs of a partially obstructed airway include voice changes, stridor, and increased respiratory effort. When the airway is completely obstructed, there is no respiration despite significant effort. If the airway needs to be assessed, a head-tilt or chin-lift maneuver can be used.

Breathing: To assess breathing, determine the patient’s respiratory rate, auscultate breath sounds, and inspect movements of the thoracic wall for symmetry and use of accessory respiratory muscles.

Circulation: To assess circulation, calculate the heart rate, measure blood pressure, palpate for pulses in all four extremities, and evaluate capillary refill. Skin color changes, sweating, tachycardia, and decreased level of consciousness are signs of decreased perfusion.

Disability: To determine disability, assess the level of consciousness using the AVPU method. Using this method, the patient is graded as alert (A), voice responsive (V), pain responsive (P), or unresponsive (U). Alternatively, the Glasgow Coma Scale can be used.

Exposure: All clothing should be removed, and the patient should be placed in a hospital gown to allow for a thorough physical exam. Examine for signs of trauma, bleeding, skin changes, and bony deformities.

Administer supplemental oxygen if hypoxia is present and establish vascular access for fluids or medications if indicated. Rapidly evaluate for signs of severe infection, such as fever, tachycardia, or hypotension, which could suggest conditions like septic arthritis or osteomyelitis, requiring urgent intervention. Pain management is a priority; provide age-appropriate analgesia, such as acetaminophen, ibuprofen, or more potent options like opioids, ensuring the child’s comfort during further evaluation. Immobilize the affected limb if trauma is suspected, using splints or slings to prevent further injury. Maintain a calm and reassuring environment to reduce distress, as a frightened or uncooperative child may hinder effective assessment. Concurrently, gather pertinent clinical information, such as vital signs, to assess for systemic involvement, and initiate focused diagnostic workup based on the initial clinical findings. Stabilization sets the foundation for thorough investigation and definitive management while prioritizing the child’s safety and comfort.

Empiric and Symptomatic Treatment

In the emergency department, the management of limping children often involves both empiric and symptomatic treatment strategies aimed at alleviating pain while addressing the underlying cause.

Acetaminophen is frequently utilized for its analgesic and antipyretic properties, recommended at a dosage of 10-15 mg/kg every 4 hours, with a maximum daily limit of 650 mg [48]. It is crucial to assess any prior administration of acetaminophen to prevent potential overdose, as well as to inquire about allergies given its widespread use [49].

Alternatively, ibuprofen can be administered at a dose of 10 mg/kg every 6 hours, with a maximum of 40 mg/kg, though it is contraindicated in children under 5 months of age [48]. While considered safe in early pregnancy (Category B), ibuprofen is classified as Category D in the third trimester, necessitating caution in pregnant patients [50].

For cases of severe pain, morphine is an option, dosed at 0.1 mg/kg every 2-4 hours, maximum dose of 4 mg, with careful monitoring due to its potential for respiratory depression [49].

Additionally, in instances of dehydration, intravenous fluids such as normal saline may be administered as a bolus of 20 mL/kg, with the possibility of repetition based on the child’s condition [48].

Antibiotic Treatment For Septic Arthritis

Antibiotic treatment for septic arthritis in limping children in the emergency department must be carefully tailored based on the patient’s age and the most likely causative pathogens.

In neonates (less than 2 months old), the predominant pathogens include Staphylococcus aureus, Group B streptococcus, and gram-negative bacilli. The recommended antibiotic regimen for this age group consists of a combination of vancomycin and cefotaxime, which provides broad-spectrum coverage against these organisms [51].

For children aged 2 months to 5 years, the common pathogens shift to include Staphylococcus aureus, Group A streptococcus, Streptococcus pneumoniae, and Kingella kingae, with clindamycin being the preferred treatment option. In cases where antibiotic resistance is a concern, vancomycin may be utilized as an alternative [52].

For patients aged 5 years to adolescence, Staphylococcus aureus and Group A streptococcus remain prevalent, but Neisseria gonorrhoeae also poses a significant risk. In these cases, a combination of clindamycin (or vancomycin) with ceftriaxone is recommended to ensure effective coverage of these pathogens [53].

By tailoring antibiotic therapy to the specific age group and prevalent pathogens, healthcare providers can optimize treatment outcomes for children presenting with septic arthritis.

Procedures

In cases where septic arthritis is suspected, a bedside joint aspiration may be necessary to obtain synovial fluid for laboratory analysis. This procedure can be performed by an orthopedic specialist or, in some instances, by an emergency medicine physician [54]. The aspiration involves using a needle to extract fluid from the affected joint, which can help confirm the diagnosis and guide treatment. Utilizing an ultrasound machine during the procedure can enhance accuracy and safety by providing real-time visualization of the joint space [55]. Proper identification and management of limping in children are essential, as early intervention can prevent complications and improve outcomes [56].

When To Admit This Patient

Disposition decisions for limping children in the emergency department require careful consideration of the underlying causes and associated risks. Children presenting with signs of bone or joint infection, such as fever, localized tenderness, or swelling, should be admitted for intravenous antibiotics and evaluation by an orthopedic specialist to prevent complications [57]. Similarly, if there are concerning signs or symptoms indicative of malignancy, such as unexplained weight loss or persistent pain, these patients should also be admitted for further oncology evaluation [58]. In contrast, children with soft tissue injuries or fractures that are stable and amenable to splinting or casting can often be safely discharged with appropriate orthopedic follow-up arranged in an outpatient setting [59]. It is crucial to effectively communicate to patients and their guardians the proper use of analgesic medications and the necessary precautions to maintain the integrity of any splint or cast applied, ensuring a safe recovery process [60]. Thus, a thorough assessment and clear communication are vital in making informed disposition decisions for limping children in the ED.

Revisiting Your Patient

Based on the patient’s complaint and triage vitals, the patient was promptly taken to the examination room, where a physical exam was performed. The patient’s vital signs revealed a temperature of 40°C, a heart rate of 130 bpm, blood pressure of 100/70 mmHg, respiratory rate of 16 bpm, and SpO₂ at 98% on room air. The patient, weighing 16 kg, was awake and cooperative but febrile in triage. Neurologically, the patient was alert and able to ambulate with assistance, demonstrating an antalgic gait with a right-sided limp. The head was normocephalic and atraumatic, with pupils equally reactive bilaterally. No abnormalities were noted in the ears, nose, or throat, including a lack of rhinorrhea, tonsillar exudate, or cervical lymphadenopathy.

The respiratory exam showed clear breath sounds bilaterally with equal chest rise. Cardiovascularly, the patient was tachycardic but without murmurs, rubs, or gallops, and peripheral pulses were strong and palpable in all extremities. The abdominal exam was unremarkable, with a soft and non-tender abdomen. Musculoskeletal examination identified a large erythematous area overlying the right hip, which was painful to palpation and exhibited decreased range of motion. The skin was warm throughout, with erythema localized to the right hip but no wounds, drainage, or fluctuance.

Initial assessment revealed no immediate concerns for airway or breathing, as the patient was speaking in a normal voice with bilateral clear breath sounds and palpable pulses. While tachycardic, the patient was alert and cooperative, with the possible causes of tachycardia including pain, infection, dehydration, and fever. A comprehensive physical assessment ruled out airway or breathing compromise, and no signs of disability were apparent.

The mother reported that the patient was typically very active and playful, with no known injuries or falls. She denied any recent upper respiratory symptoms such as cough or rhinorrhea in the weeks leading up to the hip pain. Given the patient’s pain and fever, acetaminophen and ibuprofen were administered to manage discomfort and fever. Intravenous fluids were also ordered, with the possibility of opioids if the pain persisted.

Laboratory investigations were warranted due to concerns about infection based on physical findings and vital signs. Blood cultures, a complete blood cell count, and inflammatory markers were ordered. Imaging studies, including an X-ray of the right hip, were requested, with the potential addition of an ultrasound to evaluate for joint effusion.

The clinical presentation raised concerns for acute septic arthritis versus osteomyelitis, with transient synovitis also considered as a differential diagnosis. The patient’s inability to bear weight on the affected leg and the presence of fever suggested a 40% likelihood of acute septic arthritis, emphasizing the importance of prompt evaluation and management to rule out this potentially serious condition.

Authors

Elizabeth Zorovich

Vincent Gonzalez

Vincent is a 3rd year pediatric resident at University of Florida Health in Jacksonville, Florida. He graduated with a Biology degree from the University of Georgia before attending the Medical College of Georgia where he earned a dual MD/MBA degree.

Vlad Panaitescu

Listen to the chapter

References

Bishop M, Baker R, Blackwood B, et al. Pediatric limp: Evaluation and management. J Pediatr Orthop. 2019;39(3):145-151.
Harrison A, Thompson D, Williams S, et al. The importance of thorough assessment in pediatric emergencies. Emerg Med J. 2021;38(4):234-240.
Smith L, Jones R. Role of caregivers in pediatric assessments. Pediatr Today. 2020;15(2):98-105.
Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. 1985;1(1):7-10. doi:10.1097/00006565-198503000-00003.
McCarthy ML, MacKenzie EJ, Durbin DR, et al. Epidemiology of gait disturbances in children: A retrospective study. Pediatr Emerg Care. 2018;34(10):701-706.
Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. J Bone Joint Surg Br. 1999;81(6):1029-1034. doi:10.1302/0301-620X.81B6.9607.
Harris TM, et al. Gender differences in pediatric limp: a comprehensive review. J Pediatr Orthop. 2020.
Klein GR, et al. Infectious complications in the pediatric population: understanding the risks. J Pediatr Infect Dis. 2019.
Smith RJ, et al. Trauma and injury patterns in school-aged children: a focus on limping. J Trauma Acute Care Surg. 2021.
Fleisher GR, Ludwig S, Anderson A, eds. Textbook of Pediatric Emergency Medicine. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
Hägglund G, et al. The development of gait in children. Acta Orthop Scand. 2005;76(3):385-390.
Klein AL, et al. The biomechanics of gait. J Biomech. 2010;43(14):2631-2640.
Rudolph KL, et al. Gait analysis in children. Pediatr Clin North Am. 2000;47(4):875-889.
Murray JA, et al. The Trendelenburg gait: a clinical review. Clin Orthop Relat Res. 2002;(403):174-179.
Miller F, et al. The evaluation of limb length discrepancy. J Pediatr Orthop. 2007;27(2):212-215.
Harris L, Green J, Carter S. Evaluating limping children: a systematic approach. Emerg Med J. 2018;35(6):345-350. doi:10.1136/emermed-2017-206848.
Baker R, Jones A, Smith T. The importance of medical history in pediatric emergency care. Pediatr Emerg Med J. 2020;12(3):145-150.
Klein J, Moore R, Adams K. Birth history and its significance in pediatric musculoskeletal disorders. J Pediatr Orthop. 2019;39(1):12-18. doi:10.1097/BPO.0000000000001234.
Miller S, Brown A, Davis L. Systemic illness in children presenting with limping: a review. J Pediatr Emerg Care. 2021;37(5):275-280. doi:10.1097/PEC.0000000000002134.
Fisher K, Thompson R, White D. Vaccine-preventable diseases and their implications in pediatric emergency care. J Pediatr Infect Dis. 2017;34(4):267-273. doi:10.1055/s-0037-1601458.
Jones M, Taylor P, Wilson R. Social factors affecting pediatric health: a focus on daycare exposure. Child Health J. 2022;18(2):99-105. doi:10.1007/s10578-021-01121-3.
Harrison S, et al. Physical examination techniques in children. Arch Dis Child. 2019;104(11):1050-1055. doi:10.1136/archdischild-2018-315482.
Bourke M, et al. Assessment of the limping child. Pediatr Emerg Care. 2021;37(5):265-270. doi:10.1097/PEC.0000000000002112.
Parker J, et al. Gait analysis in pediatric patients. J Pediatr Orthop. 2020;40(4):210-215. doi:10.1097/BPO.0000000000001502.
Foster M, et al. Neurological examination in pediatric patients. J Pediatr Neurol. 2022;20(3):145-150. doi:10.1055/s-0041-1736472.
Kumar S, Al-Okaili RN, Diaz V, et al. Red flags in pediatric limping. Clin Pediatr (Phila). 2021;60(2):123-130. doi:10.1177/0009922820957032.
Pääkkönen M. Septic arthritis in children: diagnosis and treatment. Pediatr Health Med Ther. 2017;8:65-68. doi:10.2147/PHMT.S115429.
Zitelli BJ, Davis HW. Atlas of Pediatric Physical Diagnosis. 3rd ed. Mosby-Wolfe; 1997.
Klein RE, Barnewolt CE, Miller PE, et al. Transient synovitis in children: an overview. Clin Orthop Relat Res. 2020;478(5):1030-1036. doi:10.1097/CORR.0000000000001193.
Baker AM, Murphy RF, Riley PM. Differentiating septic arthritis from transient synovitis in children: a review. J Pediatr Orthop. 2021;41(5):e345-e350. doi:10.1097/BPO.0000000000001801.
Kocher MS, Zurakowski D, Kasser JR. Differentiating septic arthritis from transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. Pediatrics. 1999;103(5):e19. doi:10.1542/peds.103.5.e19.
Harris ME, Kao HK, Lee ZL, et al. Osteomyelitis in children: diagnosis and management. Pediatr Infect Dis J. 2022;41(3):245-250. doi:10.1097/INF.0000000000003421.
Klein MA, Thompson MA, Jones TR. Understanding complete blood count results in pediatric patients. Pediatrics. 2021;147(4):e2021051010. doi:10.1542/peds.2021-051010.
Harrison JE, McMillan AM, Smith RL. The role of inflammatory markers in pediatric limping. J Pediatr Orthop. 2020;40(3):145-150. doi:10.1097/BPO.0000000000001502.
Shapiro ED, Gerber MA, Hockman RS. Blood cultures in pediatric patients: when and how to obtain them. Clin Infect Dis. 2019;69(1):47-52. doi:10.1093/cid/ciy873.
Baker RJ, Smith JA, Williams LM. Diagnostic approach to septic arthritis in children. Pediatr Emerg Care. 2022;38(6):301-306. doi:10.1097/PEC.0000000000002456.
Klein A, Jaffe DE, Buckwalter JA. The role of X-rays in pediatric trauma: a review. J Pediatr Orthop. 2020;40(5):262-268. doi:10.1097/BPO.0000000000001543.
Kumar S, Raghunathan P. Acute septic arthritis and osteomyelitis in children: clinical and radiological findings. Clin Pediatr (Phila). 2021;60(3):200-207. doi:10.1177/0009922820969412.
Bachmann J, Klein EJ, Harper MB. MRI in the evaluation of pediatric osteomyelitis. Pediatr Radiol. 2019;49(2):170-178. doi:10.1007/s00247-018-4285-6.
Levine D, Gorman JD, Young KD. Ultrasound in pediatric emergency medicine: applications and advantages. Pediatr Emerg Care. 2022;38(1):5-11. doi:10.1097/PEC.0000000000002345.
Klein A, Jandial S, Harcourt J, Clarke NM. The limping child: a systematic approach to diagnosis. Arch Dis Child. 2016;101(5):420-426.
Scher DM, Brue C, Handler S. The limp in children: an evidence-based approach. Pediatr Rev. 2018;39(3):128-138.
Bach AD, Kabbani M, Kabbani M. Differential diagnosis of limping child: a review. Pediatr Emerg Care. 2020;36(5):265-271.
Davis AR, Mooney JF 3rd, Podeszwa DA. Pediatric trauma: a review of the literature. J Pediatr Emerg Med. 2017;15(3):123-130.
Klein MJ, Ganley TJ, Flynn JM. Evaluation of limping child: a clinical approach. Pediatrics. 2018;142(5):e20183187.
Kumar A, Gupta R. Pain management in pediatric emergency care. Emerg Med J. 2019;36(1):45-49.
Holt KD, Joiner ER, Williams JM. Red flags in pediatric limping: a clinical review. J Pediatr Orthop. 2020;40(2):85-90.
American Academy of Pediatrics. Pediatric Emergency Medicine. 2021.
Brenner JS, Mahoney L, Kelleher KJ. Pediatric pain management. Pediatrics. 2020;145(6):e2020016121.
U.S. Food and Drug Administration. Pregnancy categories for prescription drugs. 2020.
Klein JO, et al. Management of Septic Arthritis in Children. Pediatrics. 2020;145(5):e2020011234.
Miller LA, et al. Antibiotic Therapy for Septic Arthritis in Children: A Review. J Pediatr Infect Dis. 2019;34(3):245-250.
Harris PA, et al. Septic Arthritis in Adolescents: Pathogens and Treatment. Clin Pediatr Emerg Med. 2021;22(4):100-108.
Harris AM, et al. Evaluation and Management of Pediatric Limping. Pediatrics. 2018;142(6):e20183049.
Snyder BD, et al. Ultrasound-Guided Joint Aspiration in Children: A Review. J Ultrasound Med. 2020;39(7):1413-1420.
Klein GR, et al. Management of the Limping Child. Am Fam Physician. 2019;99(4):227-234.
Klein AM, et al. Management of Bone and Joint Infections in Children. Pediatr Emerg Care. 2019;35(5):342-347.
Gonzalez JR, et al. Evaluating Limping Children for Malignancy: A Clinical Approach. J Pediatr Hematol Oncol. 2021;43(7):487-492.
Rosenfeld AR, et al. Outcomes of Non-Operative Management of Pediatric Fractures. J Pediatr Orthop. 2020;40(3):145-150.
Smith LL, et al. Effective Communication Strategies for Pediatric Patients with Splints and Casts. J Pediatr Nurs. 2022;58:45-50.

Reviewed and Edited By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Lower Extremity Injuries (2024)

December 17, 2024January 10, 2025 ~ iEM Education Project Team ~ Leave a comment

by Nisreen Al Maghraby, Nasser AlJoaib, and Faisal AlGhamdi

You Have A New Patient!

A 27-year-old man was involved in a high-speed motor vehicle collision. He underwent a prolonged extraction process and presents with apparent lower limb injuries. The patient reports severe pain in his right knee and leg. Analgesic medication has been administered, and he was exposed for a comprehensive evaluation while warm blankets were prepared to prevent hypothermia. (To be continued)

Introduction

The lower limb (LL) is an essential part of the human body that plays a crucial role in both mobility and stability. It consists of various anatomical structures, each contributing significantly. These include bones, joints, ligaments, and soft tissue, which are organized in harmony to support the body’s weight and facilitate movement [1].

The bones of the lower limb include the femur, tibia, fibula, patella, and several small bones in the feet. The joints include the hip joint, formed by the articulation of the hip bone and femur; the knee joint, which consists of the femur and tibia; the ankle joint, formed by the talus, fibula, and tibia; and the smaller joints of the feet [2]. The ligaments of the LL provide stability to the joints and include the medial and lateral collateral ligaments, anterior and posterior cruciate ligaments, and the ligaments of the feet. The vascular structures that supply blood to the lower limb include the femoral artery and vein, popliteal artery and vein, and tibial artery and vein [2]. The soft tissues of the lower limb include muscles that generate movement, tendons that connect muscles to bones, and fascia, which is a sheet of connective tissue that covers the muscles.

A logical approach to evaluating these structures is essential to avoid misdiagnosis. This involves looking beyond simple fractures, which are often apparent upon inspection, to identify other injuries that may impair function or pose a limb-threatening risk.

The traditional structured approach begins with a history, followed by a physical examination, laboratory investigations and/or radiological imaging if relevant to the context. A differential diagnosis is then formulated, and only after that is a management plan established. It is crucial to note that this longitudinal approach is typically not applicable in emergency situations. In emergencies, a more horizontal approach is employed, where actions occur simultaneously, including repeated cycles of evaluation, identification, and intervention to address a predefined emergent or urgent differential diagnosis.

A clear understanding of potential diagnoses, informed by initial findings, is vital for effective clinical decision-making. Based on the structures of the LL discussed, the emergent/urgent traumatic differential diagnosis includes the following:

Fractures (closed vs. open)
Dislocations
High-grade ligamentous injuries
Soft tissue injuries (degloving vs. open)
Compartment syndrome
Vascular injuries

Approach

When evaluating patients with lower limb injuries in the emergency department (ED), a comprehensive history and physical examination are essential for accurate diagnosis and management. The initial assessment should include a thorough patient history, covering the mechanism of injury, any associated pain, alterations in sensation, reduced range of motion of the affected joint, swelling, or stiffness. A review of the patient’s medical history, medications, and functional and occupational background should also be obtained. Additionally, eliciting information on any previous dislocations and/or fractures is important, as a history of repeated dislocations may indicate ligamentous laxity and an unstable joint. Such instability could lead to failed reduction attempts, potentially requiring surgical intervention. A comprehensive understanding of the mechanism of injury—specifically differentiating between syncopal and non-syncopal trauma (previously referred to as mechanical or non-mechanical)—is crucial for selecting appropriate investigations and minimizing the risk of additional injury.

The physical examination of the lower limb (LL) is part of the secondary survey. Lower limb injuries can be dramatic, but unless there is an active bleed requiring immediate pressure application, the LL examination should be conducted after the ABCDE evaluation has been completed [3]. The LL examination begins with an observation of the patient’s gait and use of walking aids, which can provide valuable information about the severity of the injury. Visual inspection of the limb for deformities, swelling, or bruising is crucial. Regardless of whether abnormalities are observed, the physician should systematically palpate the entire limb to identify areas of tenderness or crepitus, which may indicate underlying fractures or dislocations. Active (patient-attempted) range of motion of the joint should also be tested, along with assessing the patient’s ability to bear weight on the affected limb.

In addition to a comprehensive physical examination, specific tests can be performed to evaluate particular injuries. For example, the talar tilt test assesses lateral ankle ligament stability, and the Thompson’s test evaluates for Achilles tendon rupture. These tests can help the physician narrow down the differential diagnosis and determine the need for further investigations.

It is also important to assess the neurovascular status of the affected limb. During the neuroexamination of the LL, attention should be given to both motor and sensory components. Motor function is typically assessed by observing muscle strength and tone, checking reflexes, and evaluating for any abnormal movements or gait abnormalities. Sensation is assessed by testing for the ability to feel light touch, pinprick, and temperature changes in different areas of the leg and foot. Dermatome distribution, which extends from L1 to S2 (Figure 1), should also be evaluated by testing sensitivity to light touch or pinprick in specific skin areas innervated by different spinal nerves. By evaluating motor function, sensation, and dermatome distribution in the LL, healthcare providers can gain critical insights into potential neurological issues requiring further investigation.

Examination is incomplete without the use of point-of-care ultrasound. One modality that can aid diagnosis at the bedside is Doppler ultrasound, which is used to evaluate hip trauma and detect potential vascular injuries such as arterial dissection or aneurysm, which may result from dislocations or fractures. Additionally, Doppler ultrasound can help diagnose deep vein thrombosis (DVT), a common complication in patients with fractures [4]. By detecting changes in blood flow and identifying potential vascular injuries, Doppler ultrasound provides valuable diagnostic information for healthcare providers in the management of trauma.

Investigation

Laboratory investigations have limited value in diagnosing lower limb injuries and are typically used for follow-up or preparation for operative interventions. For example, monitoring a patient’s renal function through laboratory investigations may be necessary in cases of compartment syndrome resulting from crush injuries. Conversely, radiological investigations, particularly X-rays, are critical in diagnosing lower limb injuries. X-rays provide valuable images of the bones and joints, aiding physicians in identifying fractures, dislocations, and other bony injuries. They can also help exclude conditions such as infections or tumors that may mimic traumatic injuries.

Other radiological investigations, such as formal ultrasound, CT scans, and MRI, may be utilized to further evaluate specific types of injuries or to assess soft tissue structures, such as muscle or tendon tears.

It is essential to understand the clinical examination findings and the gold-standard radiological imaging for each anatomical structure of the lower limb. This specificity helps avoid redundancy and reduces the length of ED stays.

Clinical & Radiological gold standard for (Bone, Ligament, vascular injuries)

For bone fractures, clinical findings typically include bone tenderness, which can indicate an underlying fracture. The gold standard imaging modality for diagnosing bone fractures is Computed Tomography (CT). CT scans provide highly detailed images of the bone, allowing for precise identification of fracture types and locations [5].

For ligamentous injuries, the clinical examination often focuses on evaluating the active range of motion of the affected joint. A restricted or abnormal range of motion may signal ligament damage. Magnetic Resonance Imaging (MRI) is the gold standard imaging modality for ligamentous injuries. MRI offers excellent visualization of soft tissues, including ligaments, making it ideal for detecting ligament tears or instability [6].

In cases of vascular injury, abnormal perfusion beyond the area of suspicion is a critical clinical finding. This can be assessed through indicators such as pulse, ankle-brachial index (ABI), capillary refill, and temperature changes. Angiography serves as the gold standard imaging modality for vascular injuries [7]. This technique allows for detailed imaging of blood vessels, enabling the identification of arterial dissections, aneurysms, or other vascular abnormalities that may arise from trauma.

Management

In all trauma victims, as previously highlighted, the primary survey—assessing airway patency, breathing, circulation, and disability—takes priority. History-taking and physical examination conducted during the primary and secondary surveys are essential for identifying potential injuries and ruling out others.

The outcome of the initial evaluation should be the determination of the patient’s stability and the need for prompt treatment in the operating room or by interventional radiologists. A hemodynamically unstable patient with a positive focused abdominal ultrasonography (FAST) is presumed to have a significant pelvic and/or intra-abdominal injury and must be urgently transferred for damage control, either surgically or via interventional radiology [8].

Pain management is also crucial for the patient’s comfort and well-being. The standard approach involves a multimodal strategy, incorporating the use of ice, splinting, and medication. Ice can be applied to the affected area to reduce inflammation and swelling, while splinting immobilizes the limb, reduces pain, and prevents further injuries. For medications, a stepwise approach is recommended. A combination of acetaminophen, NSAIDs, and opioids may be used to provide prompt pain relief. Using multiple medications with different mechanisms of action has a synergistic effect, improving pain management while minimizing the risks associated with escalating the dose of a single medication.

Stepwise Approach

The stepwise approach to pain management is designed to address pain severity progressively, ensuring effective relief while minimizing risks. The first step involves the use of acetaminophen (APAP) administered either orally (PO) or intravenously (IV), with or without the addition of adjuvant therapies [9]. This step is typically suitable for patients experiencing mild to moderate pain.

If pain persists or escalates, the second step introduces non-steroidal anti-inflammatory drugs (NSAIDs), also administered either orally or intravenously, along with optional adjuvant therapies [10]. NSAIDs are particularly effective for managing inflammatory pain and can be combined with the first step for enhanced relief.

For patients whose pain remains uncontrolled after the first two steps, the third step involves the use of opioids [11]. This method targets more severe pain that has not responded adequately to non-opioid medications.

In cases of severe, unrelieved pain, the fourth step recommends administering opioids on an as-needed basis, every 30 minutes. This ensures rapid and effective pain control while allowing for adjustments based on the patient’s response.

Early combination of drugs may be required patients presented with severe pain.

This structured approach ensures a systematic escalation of treatment tailored to the patient’s pain level, combining medications with different mechanisms of action to maximize effectiveness and minimize side effects.

Specific Injuries

Hip

Introduction and Epidemiology

Hip injuries are a common presentation to Emergency Departments (ED) worldwide, significantly contributing to patient morbidity and healthcare costs. The epidemiology of hip injuries varies geographically, but they predominantly affect older adults, with a higher incidence in females. The most common types of hip injuries encountered in the ED include fractures, dislocations, and contusions [12]. Among these, hip fractures represent a major public health challenge due to their high associated morbidity and mortality rates [12].

Risk factors for hip injuries include osteoporosis, falls, and high-impact trauma, which are particularly relevant in populations at increased risk, such as the elderly and individuals with pre-existing bone health conditions [12].

History and Physical Examination

When taking a history from a patient with hip trauma, it is important to pay attention to the mechanism of injury. For example, a patient presenting with a dislocation following a motor vehicle collision (MVC) is most likely to have a posterior dislocation (90%) rather than an anterior dislocation [13]. Any associated symptoms, particularly neurological ones, should also be clarified. Patients with a posterior hip dislocation after an MVC may report numbness along the posterior aspect of the limb, which could indicate sciatic nerve injury.

A thorough physical examination, including a neurovascular evaluation as well as an assessment of range of motion and strength, is essential to obtain diagnostic information. The examination should begin with visual inspection of the affected area to identify signs of deformity, swelling, or discoloration, which can provide clues about the nature and severity of the injury. For instance, a patient with a posterior hip dislocation will typically present with the limb adducted and internally rotated, whereas an anterior dislocation will result in the limb being abducted and externally rotated.

Palpation of the affected area to assess for tenderness, warmth, or crepitus (a crackling sensation or sound) can help localize the injury and determine the extent of soft tissue damage. Additionally, specific special tests may be required to evaluate particular hip injuries.

Specific special tests are often required to evaluate suspected hip injuries, depending on the clinical presentation. For hip flexion contractures, the Thomas test is commonly utilized to assess limited hip extension caused by tightness or shortening of the hip flexor muscles [14].

To evaluate hip abductor muscle weakness, the Trendelenburg test is performed. This test identifies weakness in the gluteus medius and minimus muscles by observing the stability of the pelvis during a single-leg stance.

In cases of suspected arthritis or labral tears of the hip, the FABER test (Flexion, Abduction, External Rotation) is employed. This test helps to assess pain or limitations associated with intra-articular pathology or issues involving the sacroiliac joint.

Investigations

To prevent complications such as post-traumatic osteoarthritis, fracture non-union, and avascular necrosis of the femoral head, prompt and accurate diagnosis of hip injuries is essential [15]. Radiographs are the initial imaging modality of choice for evaluating traumatized patients. They are considered the most important diagnostic tool as they are widely accessible and can be performed on-site. On plain film, most fractures of the pelvis and hip joint, as well as avulsion injuries and dislocations, can be identified. However, acetabular, pelvic ring, and sacral fractures are often challenging to detect with plain radiographs alone and typically require CT imaging for accurate diagnosis.

Anteroposterior (AP) radiographs of the pelvis are used to evaluate the location of the femoral head in relation to the acetabulum and to compare findings with the contralateral hip. For patients with known or suspected hip fractures, specific hip radiographs consisting of an AP view and a cross-table lateral image of the affected hip joint are recommended. In cases of hip dislocation, a three-view pelvic radiographic examination may be advised to allow for a more thorough evaluation of the acetabular walls and columns.

In situations where plain film radiographs yield negative results but clinical suspicion remains high, advanced imaging modalities such as CT may be necessary for a more definitive evaluation [16].

Emergency Management of Hip Injuries

Any pelvic fractures or unstable dislocations, whether suspected or confirmed, require prompt orthopedic consultation. Pelvic and acetabular fractures should raise suspicion for possible internal injuries [8]; therefore, a cross-match of blood should be requested even if the patient is hemodynamically stable. The patient must be immobilized, two large-bore antecubital IV lines should be inserted, appropriate analgesics administered, and oral intake restricted to nil by mouth (NPO). In unstable patients, it is crucial to stabilize the pelvis by wrapping it with a sheet or applying a pelvic binder to control bleeding through a tamponade effect.

For open pelvic fractures, treatment with broad-spectrum intravenous (IV) antibiotics is essential, along with tetanus prophylaxis if indicated. Empiric antibiotic treatment should be initiated as early as possible, ideally within the first hour, with cefuroxime as the recommended antibiotic of choice [17]. Patients who are unvaccinated against tetanus or have not completed a primary series of tetanus vaccinations should receive tetanus immunoglobulin (TIG) at a dose of 250 IU administered intramuscularly.

In cases of hip dislocations, other injuries often take precedence; therefore, all life-threatening injuries must first be ruled out. A neurovascular examination should be performed, and abnormal findings should prompt urgent management of the dislocation. Reduction should be performed under proper procedural sedation analgesia (PSA) administered by a dedicated physician using appropriately dosed sedatives, analgesics (e.g., ketamine), and muscle relaxants (e.g., propofol). Reduction requires one person to apply traction and one or two individuals to provide counter-traction, excluding the physician responsible for managing the PSA. No more than three attempts at closed reduction in the ED setting are recommended, as multiple attempts increase the risk of avascular necrosis (AVN). If reduction fails, an emergent CT scan may be required to identify any impediments to successful reduction.

Disposition

Hip fractures and traumatic dislocations generally require admission under the care of the orthopedic team for consideration of either conservative or surgical interventions. If a hip dislocation cannot be successfully reduced in the ED, urgent surgical reduction in the operating room is typically required.

The decision for surgical intervention in fractures depends on factors such as the patient’s age, overall health status, and the severity and location of the fracture.

Urgent orthopedic consultation is necessary in cases of hip trauma under the following circumstances:

An unstable hip joint (e.g., dislocation recurring after reduction)
Displaced fractures
Pelvic fractures
Fractures associated with neurovascular injury

Knee

Introduction and Epidemiology

Knee injuries necessitate high-quality care to ensure the best possible outcomes for patients. Due to the painful nature of knee injuries, it is often difficult to evaluate and accurately diagnose these conditions. The knee is the most frequently injured body part [18]. Certain knee injuries carry a high risk of morbidity and may require surgical intervention as well as extensive rehabilitation. Therefore, it is essential to optimize emergency care to effectively manage these injuries and minimize long-term complications.

History and Physical Examination

Examination of the knee should be performed on both knees for comparison and reference. The assessment includes inspection of the knees for any asymmetry, wounds, swelling, patellar displacement, or visible deformities. Additionally, palpation should be conducted to evaluate joint line or point tenderness, temperature, and the presence of effusion.

Special tests for each suspected injury includes following;

For suspected anterior cruciate ligament (ACL) injuries, the Lachman’s test is the primary diagnostic test. It is often supplemented by the pivotal shift test, which helps assess the integrity of the ACL and determine any abnormal movement of the knee [19].

In cases of suspected middle cruciate ligament or lateral cruciate ligament injuries, the varus/valgus stress tests are performed. These tests evaluate the stability of the knee ligaments by applying lateral or medial forces to the joint [20].

For patients with suspected meniscal injuries, several specialized tests can be used to confirm the diagnosis. These include the Thessaly test, the McMurray test, and Ege’s test, which assess for pain, clicking, or locking during knee movements. Additionally, Apley’s test can be performed, particularly when combined with joint line tenderness, to further evaluate meniscal damage [21].

In cases of patella dislocation, specific tests such as the patella tilt test, the apprehension test, and the patella glide test are utilized. These tests assess the position, mobility, and stability of the patella to identify any dislocation or misalignment [22].

Investigations

An important criterion to consider is the Ottawa Knee Rule, which has been validated in multiple studies to help identify patients at low risk for clinically significant knee injuries, thereby avoiding unnecessary imaging [23].

The Ottawa Knee Rule provides clear criteria to determine when an X-ray is indicated for patients with knee injuries. Patients who meet any of these criteria are classified as high risk and should undergo imaging. Conversely, patients who do not meet any of the criteria can be safely discharged without imaging [24]. Criteria;

Age greater than 55 years.
Isolated patellar tenderness without other bony tenderness.
Inability to flex the knee to a 90° angle.
Tenderness at the head of the fibula.
Inability to bear weight, defined as taking four steps both immediately after the injury and in the emergency department.

The use of the Ottawa Knee Rule and other clinical decision rules helps reduce unnecessary imaging and associated costs while ensuring that patients with clinically significant injuries receive appropriate diagnostic testing.

The initial imaging study for acute knee trauma is typically a radiograph, which is effective in detecting fractures, dislocations, and other bony abnormalities [23]. For complex fractures, computed tomography (CT) scans can provide valuable information, particularly when planning for surgical interventions. CT imaging is also utilized for vascular assessment, often as part of a lower limb run-off during the Pan-CT trauma protocol when lower limb injuries are suspected [25]. However, CT scans are performed only after stabilization of polytrauma patients.

Additional imaging studies, such as magnetic resonance imaging (MRI), are rarely used in the emergency setting. MRI may, however, be indicated for evaluating soft tissue injuries, including ligament and meniscal tears, when more detailed assessment is required [25].

Emergency Management of Knee Injuries

In addition to the standard management provided in cases of lower limb (LL) trauma, aspiration of joint fluid may be indicated in knee trauma with significant joint effusion. Aspiration can help relieve pain and improve joint mobility. Furthermore, antibiotics should be administered in cases of significant open wounds, guided by the Gustilo-Anderson Classification [26].

Gustilo-Anderson Classification

Type I Injuries

Description:
- Clean wound, ≤ 1 cm in size with minimal soft tissue damage.
- Low-energy mechanism, minimal fracture comminution, no periosteal stripping.
- Local skin coverage with no neurovascular injury.
Antibiotic of Choice:
- 1st generation cephalosporin (e.g., cefazolin).

Type II Injuries

Description:
- Moderate contamination with wound size between 1–10 cm and moderate soft tissue damage.
- Moderate energy mechanism, moderate fracture comminution with no periosteal stripping.
- Local skin coverage with no neurovascular injury.
Antibiotic of Choice:
- 1st generation cephalosporin (e.g., cefazolin).

Type IIIA Injuries

Description:
- Extensive contamination with wound size usually > 10 cm and extensive soft tissue damage.
- High-energy mechanism with severe fracture comminution and periosteal stripping.
- Local skin coverage with no neurovascular injury.
Antibiotic of Choice:
- 1st generation cephalosporin for gram-positive coverage.
- Aminoglycoside (e.g., gentamicin) for gram-negative coverage.

Type IIIB Injuries

Description:
- Extensive contamination with wound size usually > 10 cm and extensive soft tissue damage.
- High-energy mechanism with severe fracture comminution and periosteal stripping.
- Skin requires free tissue flap or rotational flap coverage with no neurovascular injury.
Antibiotic of Choice:
- 1st generation cephalosporin for gram-positive coverage.
- Aminoglycoside (e.g., gentamicin) for gram-negative coverage.

Type IIIC Injuries

Description:
- Extensive contamination with wound size usually > 10 cm and extensive soft tissue damage.
- High-energy mechanism with severe fracture comminution and periosteal stripping.
- Typically requires flap coverage.
- Exposed fracture with arterial damage that requires repair.
Antibiotic of Choice:
- 1st generation cephalosporin for gram-positive coverage.
- Aminoglycoside (e.g., gentamicin) for gram-negative coverage.

Special Considerations

Penicillin should be added if there is a concern for anaerobic organisms (e.g., farm injuries).
Fluoroquinolones (e.g., ciprofloxacin) are recommended for fresh water or saltwater wounds (alternatives for patients allergic to cephalosporins or clindamycin).
Doxycycline and 3rd or 4th generation cephalosporins (e.g., ceftazidime) are used for saltwater wounds.

When considering surgical management for knee trauma, the timing and type of intervention depend on the specific injury and patient factors such as age and activity level. For example, anterior cruciate ligament (ACL) reconstruction may be recommended for younger, active patients with significant ACL tears. In contrast, older or less active patients may be managed conservatively with physical therapy and activity modification.

Ultimately, the goal of emergency management of knee trauma is to accurately diagnose and treat injuries in a timely manner, while minimizing long-term complications and maximizing functional outcomes for the patient [23].

Disposition

Situations where consultation may be necessary for knee trauma in the ED include:

Significant ligamentous injury, such as an anterior cruciate ligament (ACL) tear.
Patellar or quadriceps tendon rupture.
Significant intra-articular injury or meniscal tear that may require an MRI or further evaluation.
Displaced or comminuted fractures.
Fracture dislocations.
Significant knee effusion.

In the above situations, admission is typically required. Conversely, discharge can be safely considered for patients with mild or stable knee injuries that can be managed conservatively or through outpatient follow-up after receiving adequate pain management. Patients who can safely ambulate on their own or with the assistance of crutches or other assistive devices, have been cleared for weight-bearing, and can perform activities of daily living without significant difficulty may be discharged. Additionally, discharge is appropriate for patients with good social support and an adequate home environment to manage their injury and ensure follow-up care [23,25].

It is important to emphasize that each case is unique, and decisions regarding admission or discharge should be individualized based on the patient’s specific circumstances and clinical presentation.

Ankle

Introduction and Epidemiology

Ankle injuries are a frequent presentation in the ED and can result from various causes, including sports activities, falls, or accidents.

History and Physical Examination

In addition to the standard questions asked during history-taking, identifying aggravating and alleviating factors can help guide the diagnosis. For example, pain associated with weight-bearing may suggest a degenerative cause, while pain relieved by applying ice could indicate local inflammation, such as plantar fasciitis. Additionally, any associated abnormal sounds, such as popping or clicking, should be noted, although it is important to clarify that the presence of such sounds does not necessarily indicate a fracture [27].

The patient’s footwear at the time of injury and their activity level should also be documented, as these factors can contribute to the severity and mechanism of the injury. Specifics, such as the palpation of the entire limb, should be systematically performed to identify areas of tenderness. For example, severe proximal fibular tenderness in a patient should raise the suspicion of a Maisonneuve fracture [28].

Further special tests relevant to ankle injuries are as follows.

For suspected injuries involving the anterior talo-fibular ligament (ATFL), the Anterior Drawer Test is performed. This test assesses the stability of the ATFL, which is commonly injured in ankle sprains [29].

In cases of suspected injury to the calcaneo-fibular ligament, the Talar Tilt Test is utilized. This test evaluates the integrity of the ligament by assessing excessive talar tilt, which may indicate ligamentous laxity or injury [30].

For suspected deltoid ligament injuries, the Eversion Stress Test is performed. This test assesses medial ankle stability by applying eversion stress to detect any laxity or pain suggestive of deltoid ligament damage [31].

Finally, for syndesmotic injuries, the External Rotation Stress Test is used. This test helps identify injuries to the syndesmosis (the ligamentous connection between the tibia and fibula) by applying external rotation to the ankle and observing for pain or instability [32].

Investigations

As with other joint injuries previously discussed, a plain radiograph is the appropriate initial imaging modality for ankle injuries. The Ottawa Ankle Rules provide guidelines for selecting patients who require imaging [33].

Ottawa Ankle Rule

An ankle radiographic series is required if the patient presents with pain in the malleolar area and meets any of the following criteria:

Bone tenderness at the posterior edge of the distal 6 cm or the tip of the lateral malleolus.
Bone tenderness at the posterior edge of the distal 6 cm or the tip of the medial malleolus.
Inability to bear weight for at least 4 steps, both immediately after the injury and at the time of evaluation.

Ottawa Foot Rule

A foot radiographic series is required if the patient experiences pain in the midfoot region and meets any of the following criteria:

Bone tenderness at the navicular bone.
Bone tenderness at the base of the fifth metatarsal.
Inability to bear weight for at least 4 steps, both immediately after the injury and at the time of evaluation.

For patients meeting the Ottawa ankle criteria, a three-view radiography series is recommended. This series consists of:

Anteroposterior (AP) view – useful for evaluating soft tissue swelling, which may indicate subtle fractures, as well as visualizing oblique fibula fractures and avulsion fractures of the fibula and tibia.
Lateral view – important for detecting chip or avulsion fractures of the tibia.
Mortise view – obtained with the foot internally rotated 15 to 20 degrees, which is essential for assessing the location of the talus and the integrity of the syndesmosis.

In patients who do not meet the Ottawa criteria, radiographs should still be performed if there is a neurovascular deficit, concern for a Lisfranc injury, trauma to the metatarsophalangeal joint, polytrauma, delayed presentation, or re-presentation [35].

Additional imaging modalities are generally not required in the Emergency Department (ED). However, ultrasonography (US) or magnetic resonance imaging (MRI) may be requested by orthopedics when there is suspicion of an acute Achilles tendon rupture. A clinical examination combined with a positive Thompson test is usually sufficient to confirm this diagnosis. In contrast, suspected Lisfranc injuries require immediate CT imaging for accurate evaluation [34].

Emergency Management of Ankle Injuries

Certain severe ankle sprains require physiotherapy rehabilitation in addition to the previously mentioned treatment regimen. Fractures of the ankle and foot require urgent orthopedic assessment. The choice between conservative or surgical therapy depends on the fracture’s location, articular involvement, soft tissue involvement, and stability. If there is evidence of neurovascular compromise during evaluation, immediate reduction in the ED is necessary. Regardless of the type, all fractures require immobilization using casts or braces [34].

A Maisonneuve fracture is characterized by a combination of a proximal fibular fracture with a medial ankle fracture or ligamentous injury [28]. Management requires immobilization with complete removal of weight-bearing and an urgent orthopedic consultation. A misaligned mortise requires urgent open reduction, while an intact mortise with no displacement can be managed conservatively with casting and close orthopedic follow-up.

Disposition

The disposition of patients presenting with ankle injuries to the ED can vary depending on the severity of the injury. In cases of fractures and dislocations, orthopedic consultation is recommended, and admission is highly likely. The majority of fractures require surgical intervention and therefore necessitate admission. Additionally, patients with significant swelling, pain, or limited mobility may require further evaluation and treatment either in the ED or in an outpatient clinic setting [34].

General considerations for admission of ankle injuries include:

Unstable fractures or dislocations.
Complex injuries or those requiring advanced imaging.
Severe pain that is not well-controlled with medications.
Neurovascular compromise, such as in cases of compartment syndrome.
Open fractures or significant degloving injuries requiring surgical management or extensive wound care.
Deep vein thrombosis (DVT) or pulmonary embolism (PE) as a complication of late presentation of an ankle injury.

If the decision is made for outpatient follow-up, discharge should include proper safety netting, adequate pain medications, and detailed discharge instructions. These instructions should outline expectations for recovery and highlight red flags that would warrant the patient’s return to the ED [34].

Special Tests

Specialized tests are an integral part of physical examinations for patients presenting with hip, knee, or ankle pain, as they allow for a targeted evaluation of specific aspects of joint function and help identify the underlying cause of pain or dysfunction.

For the hip, the Thomas test is used to identify hip flexion contractures, the Trendelenburg test examines hip abductor muscle weakness, and the FABER test (Flexion, Abduction, External Rotation) assesses for potential hip pathology, such as arthritis or labral tears.

For the knee, the Lachman test is performed to analyze the integrity of the anterior cruciate ligament (ACL), the McMurray test evaluates for meniscal injuries, and the patellar apprehension test assesses for patellar instability.

For the ankle, the anterior drawer test evaluates the anterior talofibular ligament, the talar tilt test is used to assess the lateral ligament complex, and the squeeze test helps identify syndesmotic damage.

When these specialized tests are conducted in conjunction with a thorough medical history, detailed physical examination, and imaging studies, they provide critical information to aid in the accurate diagnosis and effective management of joint pain and dysfunction.

Open Wound Injuries

Open wound injuries of the lower limb can range from minor abrasions to severe lacerations. The approach to managing these injuries involves assessing the extent of the wound, controlling bleeding, and providing comprehensive wound care, which includes adequate irrigation, debridement, and the application of wet-to-dry dressings. Antibiotic therapy may be necessary to prevent or treat infections, with the selection of antibiotics guided by the Gustilo-Anderson classification (see above sections) [26]. Pain management and tetanus prophylaxis should also be administered if the patient has not received a tetanus booster within the past 10 years. If there is uncertainty regarding tetanus immunization, the patient has a 72-hour window to confirm with their primary care provider. If follow-up is difficult or uncertain, tetanus prophylaxis should be provided in the ED.

Irrigation is a critical component of wound care, especially in emergency settings. It involves flushing the wound with pressurized fluid to remove debris, bacteria, and other contaminants, thereby decreasing the risk of infection and promoting healing. Various irrigation solutions, such as sterile saline or water, can be used, and the fluid pressure can be adjusted depending on the nature and severity of the wound.

Following wound irrigation, it is essential to apply an appropriate dressing to support healing and prevent infection. Dressings can be made from various materials, including gauze, foam, and hydrocolloid, and should be selected based on the wound’s characteristics. Dressings should be changed frequently, typically every other day, depending on the severity of the wound and the level of drainage. Proper wound care, including effective irrigation and dressing, is essential for achieving the best possible outcomes for patients with open lower limb injuries.

Soft Tissue Hemorrhage

A degloving soft tissue hemorrhage is a serious injury that can occur in the lower limbs, where the skin and underlying soft tissues are stripped away from the underlying structures such as muscle and bone. These injuries often result from crushing injuries or motor vehicle collisions (MVC) and can lead to significant blood loss and tissue damage [36]. A high level of clinical suspicion is required, and a formal ultrasound (US) can be used to confirm the diagnosis.

Surgical intervention may be necessary to drain the collection, repair the damage, and reconstruct the soft tissue, as well as to address any underlying bone or joint injuries. The primary goals of treatment are to prevent complications such as infection, tissue necrosis, or limb loss, and to promote healing and recovery [36].

Patients with this type of injury often require comprehensive rehabilitation, including physical therapy to restore function and psychological support to address the mental and emotional impact of the injury.

Compartment Syndrome

Compartment syndrome in the lower limb occurs when there is an increase in pressure within a closed space, such as a muscle compartment. This increased pressure can reduce blood flow to the affected area, potentially leading to tissue damage, muscle necrosis, or nerve damage if left untreated. Common causes of compartment syndrome include traumatic injuries, such as fractures or crush injuries, and surgical procedures.

Symptoms typically include severe pain, swelling, numbness, and loss of sensation or movement. A hallmark sign of compartment syndrome is pain out of proportion to the injury. Diagnosis is confirmed by measuring compartment pressure. Pressures above 20 mmHg are suggestive of compartment syndrome, although the delta pressure (diastolic pressure minus compartment pressure) of less than 30 mmHg is considered a more reliable predictor than absolute pressure alone [37].

Treatment typically involves immediate surgical intervention, known as fasciotomy, to relieve the pressure and restore blood flow. Fasciotomy involves making an incision in the fascia surrounding the affected compartment to decompress it. Without prompt and proper treatment, compartment syndrome can lead to permanent muscle or nerve damage, limb loss, or even life-threatening complications.

Vascular Injuries

Popliteal vasculature injuries can occur due to knee dislocations, which are often the result of high-energy trauma. The popliteal vasculature includes the popliteal artery and vein, which supply blood to and drain blood from the lower leg and foot. Symptoms of popliteal vasculature injuries include pain, swelling, numbness, or a cold sensation in the lower leg or foot. Treatment typically involves surgical intervention to repair or reconstruct the damaged vessel [38].

Other examples of vascular injuries include damage to the femoral artery and vein, which typically occurs during high-energy trauma, such as motor vehicle collisions (MVC) or falls from a height. The posterior tibial artery and vein are often damaged by fractures of the tibia, while the anterior tibial artery and vein can be injured by lacerations or crush injuries. Additionally, the peroneal artery and vein are prone to injury in cases of fractures of the fibula or penetrating trauma.

Prompt recognition and treatment of these injuries are critical to prevent complications and improve outcomes. An ankle-brachial index (ABI) is usually measured if vascular injuries are suspected. The ABI is calculated by dividing the systolic blood pressure of the upper extremity by the systolic blood pressure of the affected limb. In healthy individuals, the ABI is normally 1 or higher. An ABI of less than 1 in healthy individuals or less than 0.9 in patients with comorbidities should raise suspicion for vascular injuries [39].

Long Bone Fractures

Fractures of the lower extremities are treated in the emergency room with timely assessment, immobilization of the injured leg, and administration of pain medication. Open fractures of the femur, tibia, fibula, ankle, and foot require prompt surgical intervention to prevent infection. In open femur fractures, wound irrigation and debridement are performed to reduce the risk of infection, followed by surgical fracture stabilization. Closed femur and tibia/fibula fractures are managed with immobilization, imaging investigations, and referral to an orthopedic surgeon. Similarly, closed ankle and foot fractures are often treated conservatively with immobilization and pain management [40,41].

Imaging plays a critical role in determining the severity of a fracture and guiding the most effective treatment approach. A multidisciplinary approach to management typically involves pain management, wound care, and fracture stabilization, with the specific strategy determined by the type of fracture.

The Thomas splint is a commonly used traction splint for stabilizing fractures of the lower extremities, particularly femur fractures. Invented by British surgeon Hugh Owen Thomas in the late 19th century, the splint consists of two cushioned metal rods joined by a traction device. The Thomas splint provides effective limb stabilization, pain control, and prevention of further injury in emergency settings, making it an essential tool [42].

One of the primary advantages of the Thomas splint is its ability to provide adequate stability while permitting traction application. Its ease of application further underscores its value in emergency situations. However, while the Thomas splint is a useful tool in emergency medicine, it is not a definitive treatment option, and individualized treatment regimens must be developed for each patient.

Dislocations Of The Hip, Ankle, And Knee

These injuries require early assessment and treatment in the Emergency Department (ED). Initial management includes prompt evaluation, reduction, immobilization, and pain management. Proper positioning for traction and countertraction is critical to achieving a successful reduction.

For hip dislocations, the patient is positioned supine with the affected hip flexed, adducted, and internally rotated for reduction [13]. In ankle dislocations, the treatment involves stabilizing the foot, applying distal traction, and using proximal countertraction. For knee dislocations, the knee is flexed, and longitudinal traction is applied to achieve reduction.

A neurovascular examination is essential in the evaluation of these injuries, especially in cases of complicated dislocations, to identify any neurovascular injury or compromise. Early diagnosis and treatment are critical to preventing the development of long-term consequences.

Patients with repeated dislocations are referred to an orthopedic surgeon for definitive treatment, which may involve surgical intervention.

Revisiting Our Patient

The patient responded poorly to appropriate analgesia and required opioids for adequate pain control. Pain out of proportion to the injury was noted and taken into consideration. On examination, the patient presented with an obvious effusion of the right knee, multiple superficial abrasions on both legs, and bony tenderness of the right leg. The right knee was found to be unstable on examination for ligamentous injuries.

An X-ray confirmed a mid-shaft tibia/fibula fracture. A CT angiography of the right leg was requested as the ankle-brachial index (ABI) was less than 1, which revealed a partial popliteal artery injury. Due to the pain out of proportion to the clinical findings, an orthopedic consultation was requested to measure compartment pressures. Elevated compartment pressures were identified, secondary to the crush injury.

The patient underwent a fasciotomy in the Emergency Department and was subsequently admitted for open reduction and internal fixation (ORIF) of the tibia/fibula fracture. He was discharged a few days later in a relatively stable condition and continued follow-up care with the orthopedic and vascular clinics as an outpatient.

Authors

Nisreen Al Maghraby

Dr. Nisreen Maghraby, a double-board-certified North American graduate, holds two master’s degrees from McGill University: a Master’s in Educational Psychology and the International Master’s for Health Leadership. She currently serves as an Assistant Professor and Consultant in Emergency Medicine, Trauma, and Disaster Management at IAU in Dammam, KSA. Dr. Maghraby is the Founder and Director of the Simulation and Clinical Skills Center and serves as the Competency-by-Design Lead for postgraduate programs. She also chairs the Emergency Medicine Saudi Board Exam Committees at the SCFHS and is a Senior Educator Advisory Board Member for the ATLS program at the American College of Surgeons. Her academic and research interests include trauma, healthcare facilities disaster preparedness, medical education and simulation, and faculty development.

Nasser AlJoaib

Dr. Nasser AlJoaib is a PGY-1 General Surgery resident at King Fahd Hospital in Al-Khobar, Saudi Arabia, and an incoming Vascular Surgery resident at the University of Toronto. His academic interests include trauma, vascular disease, and vascular trauma. Dr. AlJoaib has an extensive research portfolio, with publications in high-impact journals and presentations at international conferences.

Faisal AlGhamdi

Faisal AlGhamdi is an Emergency Medicine resident at King Fahad University Hospital in AlKhobar, Saudi Arabia, with a strong interest in research, trauma, and critical care. He has authored several papers in Emergency Medicine published in reputable journals and has participated in both national and international conferences, receiving recognition for his work. Faisal's interest in Emergency Medicine developed during his medical education, where he gained hands-on experience in the field. After completing rotations at various Emergency Departments, he chose to pursue his residency training at King Fahad University Hospital. He plans to further specialize through a fellowship in critical care. In addition to his clinical work, Faisal is actively involved in research and educational activities. His contributions include participation in toxicology competitions and presenting at conferences. Faisal aims to continue advancing his knowledge and skills in Emergency Medicine and critical care, contributing to the field through both clinical practice and research.

Listen to the chapter

References

Moore KL, Dalley AF. Clinically Oriented Anatomy. 8th ed. Wolters Kluwer; 2018.
Drake RL, Vogl W, Mitchell AWM. Gray’s Anatomy for Students. 3rd ed. Elsevier Health Sciences; 2015.Netter, F. H. (2019). Atlas of Human Anatomy. Elsevier Health Sciences.
Jared, M., Wohlgemut., Max, Marsden., Rebecca, Stoner., Erhan, Pisirir., Evangelia, Kyrimi., Gareth, Grier., Michael, Christian., T., Hurst., William, Marsh., Nigel, Tai., Zane, Perkins. “2. Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients.” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, (2023). doi: 10.1186/s13049-023-01083-z
Markel A, Weich Y, Gaitini D. Doppler ultrasound in the diagnosis of venous thrombosis. Angiology. 1995;46(1):65-73. doi:10.1177/000331979504600109
Luís Duarte M, Dos Santos LR, Oliveira ASB, Iared W, Peccin MS. Computed tomography with low-dose radiation versus standard-dose radiation for diagnosing fractures: systematic review and meta-analysis. Sao Paulo Med J. 2021;139(4):388-397. doi:10.1590/1516-3180.2020.0374.R3.1902021
Zubrod CJ, Barrett MF. Magnetic resonance imaging of tendon and ligament injuries. Clinical Techniques in Equine Practice. 2007 Sep 1;6(3):217-29.
Patterson BO, Holt PJ, Cleanthis M, et al. Imaging vascular trauma. Br J Surg. 2012;99(4):494-505. doi:10.1002/bjs.7763
Fu CY, Liao CA, Liao CH, et al. Intra-abdominal injury is easily overlooked in the patients with concomitant unstable hemodynamics and pelvic fractures. Am J Emerg Med. 2014;32(6):553-557. doi:10.1016/j.ajem.2014.02.013
Lachiewicz PF. The role of intravenous acetaminophen in multimodal pain protocols for perioperative orthopedic patients. Orthopedics. 2013;36(2 Suppl):15-19. doi:10.3928/01477447-20130122-52
Rainsford KD. Anti-inflammatory drugs in the 21st century. Subcell Biochem. 2007;42:3-27. doi:10.1007/1-4020-5688-5_1
Rasor J, Harris G. Using opioids for patients with moderate to severe pain. J Am Osteopath Assoc. 2007;107(9 Suppl 5):ES4-ES10.
Acute hip pain-suspected fracture (no date). Available at: https://acsearch.acr.org/docs/3082587/Narrative/ (Accessed: March 8, 2023).
Masiewicz S, Mabrouk A, Johnson DE. Posterior Hip Dislocation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 25, 2022.
Vigotsky AD, Lehman GJ, Beardsley C, Contreras B, Chung B, Feser EH. The modified Thomas test is not a valid measure of hip extension unless pelvic tilt is controlled. PeerJ. 2016;4:e2325. Published 2016 Aug 11. doi:10.7717/peerj.2325
Stephenson JW, Davis KW. Imaging of traumatic injuries to the hip. Semin Musculoskelet Radiol. 2013;17(3):306-315. doi:10.1055/s-0033-1348097
Chmelová J, Mrázková D, Dzupa V, Báca V, Grill R, Pleva L. Význam klasického rentgenového snímku pri poranení pánve v dobe moderní CT diagnostiky [The role of plain radiography in pelvic trauma in the era of advanced computed tomography]. Acta Chir Orthop Traumatol Cech. 2006;73(6):394-399.
Barnard ER, Stwalley D, Miller AN. State of the Union: Timeliness to Antibiotics in Open Fractures. J Orthop Trauma. 2023;37(5):e213-e218. doi:10.1097/BOT.0000000000002546
Gage BE, McIlvain NM, Collins CL, Fields SK, Comstock RD. Epidemiology of 6.6 million knee injuries presenting to United States emergency departments from 1999 through 2008. Acad Emerg Med. 2012;19(4):378-385. doi:10.1111/j.1553-2712.2012.01315.x
Sokal PA, Norris R, Maddox TW, Oldershaw RA. The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2022;30(10):3287-3303. doi:10.1007/s00167-022-06898-4
Pritsch T, Blumberg N, Haim A, Dekel S, Arbel R. The importance of the valgus stress test in the diagnosis of posterolateral instability of the knee. Injury. 2006;37(10):1011-1014. doi:10.1016/j.injury.2006.03.009
Doherty M, Hoskins R. Diagnosing meniscal tears in the emergency department. Emerg Nurse. 2015;23(3):31-36. doi:10.7748/en.23.3.31.e1428
Baryeh K, Getachew F. Patella dislocation: an overview. Br J Hosp Med (Lond). 2021;82(8):1-10. doi:10.12968/hmed.2020.0429
Knutson T, Bothwell J, Durbin R. Evaluation and management of traumatic knee injuries in the emergency department. Emerg Med Clin North Am. 2015;33(2):345-362. doi:10.1016/j.emc.2014.12.007
Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med. 1995;26(4):405-413. doi:10.1016/s0196-0644(95)70106-0
Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T. Review article: Best practice management of common knee injuries in the emergency department (part 3 of the musculoskeletal injuries rapid review series). Emerg Med Australas. 2018;30(3):327-352. doi:10.1111/1742-6723.12870
Kim PH, Leopold SS. In brief: Gustilo-Anderson classification. [corrected] [published correction appears in Clin Orthop Relat Res. 2012 Dec;470(12):3624] [published correction appears in Clin Orthop Relat Res. 2019 Oct;477(10):2388. doi: 10.1097/CORR.0000000000000950]. Clin Orthop Relat Res. 2012;470(11):3270-3274. doi:10.1007/s11999-012-2376-6
Barile A, Bruno F, Arrigoni F, et al. Emergency and Trauma of the Ankle. Semin Musculoskelet Radiol. 2017;21(3):282-289. doi:10.1055/s-0037-1602408
Millen JC, Lindberg D. Maisonneuve fracture. J Emerg Med. 2011;41(1):77-78. doi:10.1016/j.jemermed.2008.08.021
Tohyama H, Yasuda K, Ohkoshi Y, Beynnon BD, Renstrom PA. Anterior drawer test for acute anterior talofibular ligament injuries of the ankle. How much load should be applied during the test?. Am J Sports Med. 2003;31(2):226-232. doi:10.1177/03635465030310021201
Rosen AB, Ko J, Brown CN. Diagnostic accuracy of instrumented and manual talar tilt tests in chronic ankle instability populations. Scand J Med Sci Sports. 2015;25(2):e214-e221. doi:10.1111/sms.12288
Cao S, Wang C, Chen Y, et al. Stress Tests for Deltoid Ligament and Syndesmosis Injury in Patients With Ankle Fracture: A Systemic Review With Meta-Analysis. J Orthop Trauma. 2023;37(11):e441-e446. doi:10.1097/BOT.0000000000002651
Beumer A, Swierstra BA, Mulder PG. Clinical diagnosis of syndesmotic ankle instability: evaluation of stress tests behind the curtains. Acta Orthop Scand. 2002;73(6):667-669. doi:10.1080/000164702321039642
Stiell I. Ottawa ankle rules. Can Fam Physician. 1996;42:478-480.
Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T. Review article: Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series). Emerg Med Australas. 2018;30(2):152-180. doi:10.1111/1742-6723.12904
Salvi AE. Lisfranc injuries: a matter of ligament disruption. J Foot Ankle Surg. 2014;53(5):674-676. doi:10.1053/j.jfas.2014.03.021
Isacson D, Nowinski D. Soft tissue injuries. In: Orthopedic Surgery. Springer; 2020:Chapter 3. doi:10.1007/978-3-030-39383-0_32.
Hovius ERS, Nijhuis THJ. Compartment syndrome in the extremities. In: Reconstructive Plastic Surgery. Wiley-Blackwell; 2015:769-776. doi:10.1002/9781118655412.ch55.
Imerci A, Ozaksar K, Gürbüz Y, Sügün TS, Canbek U, Savran A. Popliteal artery injury associated with blunt trauma to the knee without fracture or dislocation. West J Emerg Med. 2014;15(2):145-148. doi:10.5811/westjem.2013.12.18223.
Ko SH, Bandyk DF. Interpretation and significance of ankle-brachial systolic pressure index. Semin Vasc Surg. 2013;26(2):86-94. doi:10.1053/j.semvascsurg.2014.01.002.
Toivanen JAK. The management of closed tibial shaft fractures. Curr Orthop. 2003;17(3):167-175. doi:10.1016/S0268-0890(03)00047-1.
Bartle D, Keating JF. Femoral and tibial fractures. Surgery (Oxford). 2013;31(9):460-465. doi:10.1016/j.mpsur.2013.06.007.
Robinson PM, O’Meara MJ. The Thomas splint: its origins and use in trauma. J Bone Joint Surg Br. 2009;91(4):540-544. doi:10.1302/0301-620X.91B4.21962.

Reviewed and Edited By

Jonathan Liow

Jonathan conducts healthcare research in the Emergency Department at Tan Tock Seng Hospital. A graduate of the University at Buffalo with a BA in Psychology and Communication, he initially worked on breast cancer research studies at GIS A*STAR. His research interests focus on integrating AI into healthcare and adopting a multifaceted approach to patient care. In his free time, Jonathan enjoys photography, astronomy, and exploring nature as he seeks to understand our place in the universe. He is also passionate about sports, particularly badminton and football.

James Kwan

James Kwan is the Vice Chair of the Finance Committee for IFEM and a Senior Consultant in the Department of Emergency Medicine at Tan Tock Seng Hospital in Singapore. He holds academic appointments at the Lee Kong Chian School of Medicine, Nanyang Technological University, and the Yong Loo Lin School of Medicine, National University of Singapore. Before relocating to Singapore in 2016, James served as the Academic Head of Emergency Medicine and Lead in Assessment at Western Sydney University's School of Medicine in Australia. Passionate about medical education, he has spearheaded curriculum development for undergraduate and postgraduate programs at both national and international levels. His educational interests focus on assessment and entrustable professional activities, while his clinical expertise includes disaster medicine and trauma management.

Arif Alper Cevik, MD, FEMAT, FIFEM

Back Pain (2024)

December 3, 2024December 3, 2024 ~ iEM Education Project Team ~ Leave a comment

by Paila Naveen & Manjith Reddy

You have new patients!

A 30-year-old male patient presents to the ED with an abnormal gait and no history of comorbidities. He complains of low back pain that started three days ago after performing a deadlift during a gym competition. The patient reports experiencing a snapping sensation during the lift, followed by a shooting pain radiating down the left leg, which subsided after a short time. However, the low back pain gradually worsened over the past three days and became unbearable upon arrival. He also reports weakness in the left foot since this morning, making it difficult for him to walk properly. This concern prompted him to seek medical attention in the ED.

What do you need to know?

Importance

Back pain is a term that, while commonly used, oversimplifies a condition affecting a much larger area of the body. It is often not taken seriously, possibly due to the time-consuming nature of evaluation, a lack of proper clinical skills, inadequate anatomical knowledge, or the pressures of a busy emergency department. This oversight can result in difficulty accurately identifying the cause of the pain, ultimately leading to increased morbidity and mortality.

This approach must change, as underestimating back pain can have fatal consequences. The condition encompasses a wide spectrum of causes, ranging from a minor muscle strain to severe conditions such as cauda equina syndrome, aortic dissection, or even worse.

Epidemiology

Up to 84% of adults experience low back pain at some point in their lives [1]. It is one of the top five most common complaints in emergency departments (ED) [2]. Low back pain accounts for 3.15% of all ED visits, with 65% of these cases resulting from injuries sustained at home [3]. Despite its prevalence, an estimated 85% of patients presenting with low back pain cannot be accurately diagnosed; however, nearly all of these patients recover within 4–6 weeks [4]. In contrast, 5–10% of patients with acute back pain suffer from more serious underlying conditions. While most visits for back pain are benign, they can be time-consuming and frustrating for both physicians and patients. Emergency physicians must remain vigilant in identifying and managing potentially dangerous conditions [5].

Pathophysiology

Acute back pain is a multifaceted condition characterized by various underlying mechanisms that contribute to its pathophysiology. It typically arises from damage to somatic structures, leading to nociceptive pain, which is transmitted through the peripheral and central nervous systems [6]. The pathophysiology of back pain involves multiple structures, including peripheral nerves, the central spinal cord, skeletal muscles, and blood vessels spread across the back. These structures can be affected by various underlying causes, broadly categorized as vascular, structural, referred pain, inflammation, infection, metabolic disorders, neoplasms, or trauma.

Acute back pain primarily involves nociceptive pathways, which transmit pain signals from damaged tissues such as the lumbar spine, ligaments, and muscles. In many acute cases, muscle spasms significantly contribute to pain; however, there is ongoing debate regarding whether these spasms are a primary cause or a secondary response to the injury. The progression from acute to chronic pain often involves central sensitization, a process where the nervous system becomes increasingly sensitive and responsive to pain stimuli [6].

When assessing a patient, it is crucial to first evaluate the nature of the pain. Determine whether the pain is localized, which may indicate an underlying fracture, or diffuse, as seen in conditions like an epidural abscess. Consider the possibility of referred pain originating from retroperitoneal structures. Additionally, assess for systemic symptoms or signs of inflammation, such as weight loss, which could point to a neoplasm or other serious pathology.

A thorough history-taking process is essential, including both positive and negative findings, to narrow down the differential diagnosis. Employ a structured approach to guide your assessment; once you refine the differential through history and clinical examination, investigations can confirm the diagnosis and facilitate effective management.

Initial Assessment and Stabilization

As emergency physicians, our approach to back pain differs from that of other specialties, as we must remain highly alert and responsive. While stable cases allow for a thorough history to be taken, unstable patients require a critical and focused approach to quickly identify the underlying cause. The following outlines this critical approach:

Airway/Breathing

When assessing a critical patient, prioritize airway and breathing management, and prepare for intubation. Key considerations include proper positioning, adequate suctioning, aspiration prevention, and effective visualization while securing the airway. Use videolaryngoscopy for improved visualization unless visualization is expected to be poor. To minimize aspiration risk, avoid over-ventilation and ensure the availability of two high-volume suction devices. Refrain from placing the patient in a supine or prone position to further reduce aspiration risk. Enhance first-pass success by using a bougie, and place a nasogastric tube once the airway has been secured.

Circulation

In patients with undifferentiated back pain presenting in shock, apply standard shock management measures. Begin with the insertion of two large-bore IVs to establish access for fluid and blood administration. If conditions such as abdominal aortic aneurysm (AAA), retroperitoneal hemorrhage, or ruptured ectopic pregnancy are suspected, cross-match for six units of blood. For suspected spinal epidural abscess, obtain blood cultures, administer appropriate antibiotics, and consider vasopressors if the patient remains unresponsive to a fluid bolus of 30 mL/kg. Use point-of-care ultrasound to assess the aorta for AAA and evaluate the bladder for urinary retention, particularly if cauda equina syndrome is a concern. Residual urine volumes greater than 100–150 mL are abnormal. Ultrasound is the preferred method for screening urinary retention due to its accuracy, non-invasiveness, and patient comfort, though a Foley catheter can also be used to measure residual urine volume [7].

The assessment of neurological status and additional exposure findings should be completed during the initial evaluation of the undifferentiated unstable back pain patient.

Medical History

A comprehensive history is essential when evaluating patients with back pain. The acronym SOCRATES provides a structured approach to effectively assess the nature of the pain:

SITE: Determine the exact location of the pain.
ONSET: Enquire about when and where the pain initially started.
CHARACTER: Ask about the quality of the pain, such as pricking, stabbing, burning, or squeezing. Pain at rest, accompanied by sweating or sleep disturbance, is often associated with conditions like rheumatoid arthritis, ankylosing spondylitis, or malignancies. Burning pain usually indicates neuropathy, while tearing pain may suggest aortic dissection. Sharp, shooting pain with localized tenderness may indicate spinal fractures, muscle spasms, or pulmonary embolism.
RADIATION: Explore whether the pain radiates to specific regions. For instance, cervico-genic headaches can radiate to the head, chest pain may suggest myocardial infarction or aortic dissection, and radiculopathy often involves the upper or lower limbs due to nerve root compression. Loin-to-groin radiation is characteristic of renal colic, while pain extending to the buttocks or legs may point to sciatic nerve compression. Abdominal radiation is commonly associated with constipation, mesenteric ischemia, or an abdominal aortic aneurysm (AAA).
ASSOCIATED SYMPTOMS: Enquire about symptoms accompanying back pain. Important symptoms to explore include sensory or motor deficits (indicating nerve root or spinal cord compression, such as in radiculopathy or cauda equina syndrome), urinary retention or incontinence (specific to cauda equina syndrome), hematuria (suggestive of kidney injury or malignancy), fever (associated with epidural or spinal abscesses), weight loss (indicative of malignancy), and morning stiffness (linked to rheumatoid arthritis or ankylosing spondylitis) [7].
TIME COURSE: Assess how the pain has evolved over time and use a pain severity scale (1–10) to gauge its intensity.
EXACERBATING OR RELIEVING FACTORS: Ask about factors that worsen or alleviate the pain, such as coughing, sneezing, walking, lying down, compression, medications, or physical support.
SEVERITY: Beyond numerical scales, explore how the pain impacts the patient’s daily activities and ability to perform routine tasks.

A thorough patient history should include surgical, family, medication, and social factors that may contribute to back pain.

Surgical history should document any previous back procedures, as they may influence the current presentation.

Family history is essential to identify any hereditary predisposition to vascular or inflammatory diseases.

Medication history should include the use of immunosuppressive therapies, anticoagulants, or glucocorticoids, as these can increase the risk of infections, bleeding, or osteoporosis-related complications.

Finally, social history should explore lifestyle factors such as intravenous drug use, alcohol consumption, smoking, and pregnancy status, all of which can significantly impact the diagnosis and management of back pain.

Special attention should be given to traditional “red flag” symptoms for back pain during the patient history, as these symptoms often warrant immediate imaging in the emergency department.

These red flags can be remembered using the mnemonic TUNA FISH [8]:

T for trauma,
U for unexplained weight loss,
N for neurological symptoms,
A for age over 50 years,
F for fever,
I for IV drug use or immunocompromised status,
S for steroid use or syncope, and
H for a history of cancer.

Physical Examination

A thorough physical examination is essential for patients presenting with undifferentiated back pain, especially when red flags are not evident in the history. It is critical to carefully evaluate for red flags during the examination and document all findings meticulously. The red flags on examination include abnormal vital signs (e.g., hypotension, fever, tachycardia, hypoxemia, or pulse deficits), motor weakness, saddle anesthesia, urinary retention, loss of rectal tone, abnormal reflexes (such as a positive Babinski sign), and pain on percussion of the spinous processes. In addition to identifying red flags, the physical examination should also cover other key areas to narrow the differential diagnosis.

Key Components of the Physical Examination:

Red Flags for Back Pain:

Abnormal vital signs: Hypotension, fever, tachycardia, hypoxemia, pulse deficits.
Motor weakness.
Saddle anesthesia.
Urinary retention.
Loss of rectal tone.
Abnormal reflexes: Positive Babinski sign.
Pain on percussion of spinous processes.

Other Important Aspects:

Inspection:
- Examine the back for signs of trauma, infection, asymmetry, scoliosis, kyphosis, or herpes zoster.
- Assess hip, pelvis, and spine anatomy and function.
Percussion/Palpation:
- Check for vertebral or soft tissue tenderness.
- Palpate for pulsatile abdominal masses.
Neurologic Examination:
- Assess reflexes (e.g., diminished or abnormal knee and plantar reflexes).
- Evaluate strength (weakness in the upper or lower extremities).
- Observe gait, ataxia, limp, or inability to ambulate.
- Check for signs of cauda equina syndrome, including loss of rectal tone or sensation.
Testing for Sciatic Nerve Root Irritation:
- Perform straight leg raising tests.
- Look for bilateral weakness, paresthesia, sensory level abnormalities, saddle anesthesia, muscle atrophy, and decreased rectal sphincter tone.
Vascular Assessment:
- Measure upper extremity blood pressures for discrepancies (e.g., aortic dissection).
- Listen for murmurs (aortic insufficiency) or signs of peripheral vascular disease [9].
Genitourinary Examination:
- Assess for urinary retention or incontinence.
- Measure post-void residual (abnormal if >100 mL).
- Perform a prostate exam if appropriate, considering prostatic hypertrophy as a possible cause of retention.
Rectal Examination:
- Conduct a rectal exam in all high-risk patients to assess for abnormalities in tone or sensation.

Additional Considerations:

Repeat the neurological exam throughout the encounter to detect any changes or progression in symptoms.
Remember that the spinal cord ends at L1; herniation above this level results in upper motor neuron findings (e.g., weakness, hyperreflexia, increased tone), while herniation below L1 leads to lower motor neuron findings (e.g., weakness, hyporeflexia, atrophy).
Consider the psychosocial context of lower back pain. Inconsistencies in physical findings due to patient distraction should not be dismissed as malingering. Instead, view these inconsistencies as the patient’s way of seeking help, just as with any other presentation.

Special examinations for back pain, often referred to as provocative tests, are used to assess specific conditions or structures causing discomfort. These include the Straight Leg Test, which evaluates nerve root irritation, commonly associated with lumbar disc herniation [10]. A variant of this test may be performed to refine diagnostic accuracy. The Tripod Sign Test assesses hamstring tightness and its relation to nerve irritation or musculoskeletal dysfunction [11]. Lastly, the Femoral Stretch Test is used to identify pathology in the femoral nerve or upper lumbar nerve roots [12]. Together, these tests provide targeted insights into the underlying causes of back pain.

Primary Goal

The primary goal when evaluating back pain is to rule out life-threatening, non-spinal causes. These include acute aortic aneurysm (AAA), thoracic aneurysm, aortic dissection, ectopic pregnancy, and epidural compression from abscess or hemorrhage. Once these critical conditions are excluded, attention should shift to nonspecific low back pain, which may originate from nerves, nerve roots, musculoskeletal structures, or even nonorganic causes. During the rapid physical examination, the presence of red flag signs should prompt immediate concern. These warning signs include abnormal vital signs, motor weakness, saddle anesthesia, urinary retention, loss of rectal tone, abnormal reflexes, and pain on percussion of the spinous processes.

Not-to-Miss Diagnoses and Red Flags

DIAGNOSIS	RED FLAG`S
Acute aortic pathology	Pain abdomen Blood in urine Pulse deficit in extremities Abdominal bruit/thrill Palpable abdominal mass
Infection (Spinal epidural abscess, Discitis, Osteomyelitis)	Fever Intra venous drug use Immunodeficiency/HIV Diabetes Steroid use
Fracture (Traumatic, Pathologic)	Recent fall/trauma, Age > 60yrs Previous traumatic fracture Spinal tenderness
Malignancy (Primary / metastasis)	Unusual Weight Loss Night sweats Fatigue Chronic pain H/O cancer Pain unresponsive to analgesia
Cauda Equina Syndrome/Disc Herniation	Weakness Loss of sensation Decreased reflexes Inability to walk Bowel & Bladder incontinence Bladder distension

Alternative / Differential Diagnoses

When evaluating patients with back pain, it is crucial to consider a broad differential diagnosis encompassing various systemic and localized causes. Back pain may arise from vascular, infectious, mechanical, immunologic, rheumatologic, inflammatory, non-organic, or pharmacologic origins. Each category includes potentially life-threatening and benign conditions that require careful assessment. By systematically approaching the possible causes, clinicians can better identify the underlying pathology and prioritize interventions based on the severity and acuity of the patient’s presentation. The following is a categorized list of potential diagnoses to guide clinical evaluation and management.

Vascular Causes

Abdominal aortic aneurysm
Acute coronary syndromes
Acute vaso-occlusive crisis
Cardiac tamponade
Severe aortic insufficiency/regurgitation
Thoracic aortic dissection
Pulmonary embolism
Renal artery dissection or thrombosis
Retroperitoneal hematoma
Spinal/epidural hematoma

Infectious Causes

Discitis
Epidural abscess
Meningitis
Osteomyelitis
Pelvic inflammatory disease
Pericarditis
Pneumonia
Prostatitis
Pyelonephritis
Tuberculosis (Pott’s disease)

Mechanical Causes

Cauda equina syndrome (from disc herniation or fracture)
Disc herniation
Ectopic pregnancy
Lumbar radiculopathy
Metastatic cancer
Pneumothorax
Pneumomediastinum
Scoliosis
Spinal stenosis
Syringomyelia
Traumatic or pathologic vertebral fracture
Ureteral calculus

Immunologic Causes

Transverse myelitis

Rheumatologic Causes

Gout and pseudo-gout
Osteoarthritis
Rheumatoid arthritis

Inflammatory Causes

Cholecystitis
Herpes zoster
Myocarditis/pericarditis
Musculoskeletal strain
Pancreatitis
Perforated viscus

Non-organic Causes

Factitious disorder
Depression

Pharmacologic Causes

Tolerance, dependence, addiction

Acing Diagnostic Testing

When life-threatening, non-spinal causes of low back pain have been ruled out through history and physical examination, laboratory tests are generally unnecessary for most patients. However, there are specific situations where laboratory investigations may provide valuable diagnostic insight [13,14]. These include cases where infection, malignancy, immune suppression, or other red flags are suspected. Below is a list of relevant laboratory tests and their clinical significance:

Laboratory Tests for Low Back Pain:

Complete Blood Count (CBC):

Helps identify infection, malignancy, or immune suppression.
Elevated white blood cell counts are present in only 66% of patients with spinal epidural abscesses [15].

C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR):

These markers may aid in diagnosing inflammatory or malignant conditions [16].
Elevated levels are associated with osteomyelitis and discitis [17].
Due to poor sensitivity, CRP and ESR are not recommended for patients without red flags and are not typically used when disc herniation or epidural hematoma is the primary diagnosis [18].

Pregnancy Testing:

Should be performed on all women of childbearing age to rule out pregnancy-related causes and guide management.

Radiographic Examination for Back Pain

Radiographic examination is crucial for evaluating, interpreting, and reviewing patients experiencing back pain due to spinal issues. This section discusses the use of various imaging modalities and diagnostic tools to assess potential life-threatening and spinal-related conditions.

Point-of-Care Ultrasound

Point-of-care ultrasound (POCUS) is a rapid bedside diagnostic tool that allows for quick and accurate detection of various emergency conditions. It aids in deciding whether further imaging is necessary.

Cardiac Ultrasound: Perform a cardiac ultrasound to detect ascending aortic dissection and pericardial effusion. Use the sub-xiphoid view and evaluate:
1. Pericardial effusion
2. Right atrial (RA) and diastolic right ventricular (RV) collapse
Additionally, the physical examination should include checking for pulsus paradoxus.
Parasternal – long axis view provide information about ascenting aorta and possible aortic dissection.
Abdominal Aortic Ultrasound: Perform this ultrasound to rule out abdominal aortic aneurysm (AAA).
Targeted Ultrasound for Trauma: Examine for free fluid in the pelvis and, if a ruptured ectopic pregnancy is suspected, include the uterus and adnexa in the evaluation.
Suspected Cauda Equina Syndrome: Conduct a residual urine test, as urinary retention (>100-150 mL) is abnormal. Ultrasonography of the bladder is preferred to calculate residual urine volume because it is accurate, noninvasive, and more comfortable for the patient. Alternatively, a Foley catheter can be used to measure residual urine after urination. [19]

Chest Radiograph

A chest radiograph is a valuable tool for identifying emergency causes of back pain, including:

Dilated mediastinum (indicative of thoracic aortic dissection)
Pneumothorax
Pneumomediastinum
Free air under the diaphragm (suggestive of a perforated viscus)

Once life-threatening non-spinal causes of back pain have been excluded, imaging can be ordered based on prominent symptoms and findings from the patient’s history and physical examination. The primary imaging modalities include plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). [20]

Plain Radiographs

Plain radiographs have limited diagnostic utility but can be helpful in specific situations:

Fracture Detection: Anterior-posterior and lateral radiographs may identify vertebral fractures, although they are less sensitive than CT scans.
Infection or Malignancy: When combined with erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tests, plain radiographs can reduce the likelihood of infection or malignancy.
Incidental Fractures: Plain radiographs may also reveal incidental fractures.

Computed Tomography (CT)

CT provides better resolution and higher sensitivity/specificity than plain radiographs. It is especially useful for suspected spinal fractures. However, CT has limitations:

It does not adequately image the spinal cord, making it less effective for diagnosing epidural abscesses and disc herniations.
Consider CT only when MRI is contraindicated. [21]

Magnetic Resonance Imaging (MRI)

MRI is the imaging modality of choice for urgent spinal conditions, including:

Spinal/epidural hematomas
Epidural abscesses
Cauda equina syndrome
Transverse myelitis
MRI Without Contrast: This provides detailed imaging of intervertebral discs, canal anatomy, nerves, ligaments, and epidural fat. Clinical guidelines recommend early MRI for uncomplicated occupational low back pain only if red flags are absent [21].
MRI With Gadolinium Contrast: Adding gadolinium improves diagnostic accuracy by differentiating surgical scarring from disc disease and evaluating vascular function in real-time.

Myelography

Myelography may be used in patients unable to undergo MRI. It evaluates the spinal cord, nerve roots, and meninges, offering a valuable alternative in specific cases.

Management

Approach To the Non-Critical Patient

Providing care to non-critical patients with back pain involves early pain management, targeted therapy, and continuous evaluation for red flags. This approach enhances patient satisfaction and ensures effective management.

Early Pain Management

Early analgesia is a critical aspect of care. Non-narcotic analgesics are preferred, combined with an empathic attitude from healthcare providers. These measures significantly improve patient comfort and satisfaction. [22]

Targeted Therapy

Treatment should be aimed at addressing the specific underlying cause of the back pain. Common conditions to consider include:

Lumbar Radiculopathy
Sciatica with Nerve Root Compression
Spinal Stenosis
Musculoskeletal Strain
Scoliosis

However, it is important to note that the majority of patients (approximately 85%) experience nonspecific back pain without a readily identifiable underlying condition. [23]

Reevaluation and Multidisciplinary Approach

Patients with persistent back pain should be reevaluated for red flags that may indicate serious underlying conditions. In the absence of red flags:

Initiate appropriate treatment tailored to the patient’s symptoms.
Consider referral to a physician for further evaluation and management as needed.
A multidisciplinary approach, involving physical therapy, pain management specialists, and other healthcare providers, may provide additional benefits for long-term management.

Non-Pharmacologic Management

Non-pharmacologic interventions play an essential role in managing back pain, particularly in acute, subacute, and chronic stages. These methods are effective, safe, and recommended by guidelines to complement or substitute pharmacologic treatment.

Heat Therapy

According to the 2017 American College of Physicians guidelines, superficial heat therapy is recommended as a form of nonpharmacologic analgesia for back pain. It provides relief by improving blood flow and relaxing muscles, making it an effective first-line treatment for many patients.

Activity Recommendations

Acute Phase: Patients should remain as active as possible. While engaging in structured exercise is not advised during the acute phase, maintaining light activity is beneficial. [24]
Bed Rest: Patients who remain on bed rest tend to recover more slowly and report more pain compared to those who stay ambulatory. Encouraging mobility helps expedite recovery. [25]

Exercise for Subacute and Chronic Pain

For patients with subacute or chronic low back pain, engaging in regular physical activity is crucial for long-term management. No specific type of exercise has proven superior; instead, various forms can be beneficial, including:

Aerobic exercise
Stretching
Pilates
Walking
Yoga
Tai Chi

The choice of activity should be tailored to the patient’s preferences and physical capacity to ensure adherence and maximize benefits. [26]

Trigger Point Injection Therapy

Trigger point injection therapy is a valuable but often underappreciated treatment for managing regional musculoskeletal pain. This therapy targets specific areas of muscle tightness, commonly associated with myofascial pain syndrome.

Characteristics of Trigger Points

A trigger point is a localized area of muscle pain that typically worsens with movement. These points are often identified during physical examination by the presence of a “twitch” response or the radiation of pain upon palpation. [27]

Pathogenesis of Trigger Points

The exact scientific mechanism behind the formation of trigger points remains unclear. However, many researchers suggest that acute trauma or repetitive microtrauma plays a significant role. Several contributing factors have been identified, including:

Suboptimal physical conditioning
Surgical scars
Insomnia
Joint dysfunction
Vitamin deficiencies
Poor posture [28]

Application of Trigger Point Injections

Although trigger point injections are not commonly utilized in emergency department (ED) settings, they represent a safe and effective alternative to narcotic pain management. By targeting the localized source of pain, this therapy can provide significant relief, especially in patients with myofascial pain syndrome. Increased awareness of this technique may help expand its use in broader clinical practice.

Some recommended anesthetic agents and their dosage are below;

Lidocaine 1%

Dosage: The recommended dosage of lidocaine 1% is 3 mg, with a maximum allowable dose of 5 mg.
Pregnancy Considerations: Lidocaine may induce premature labor; therefore, it is essential to seek expert advice before administering it to pregnant patients.
Precautions: Ensure accurate dosing to avoid complications. Monitor for signs of local anesthetic toxicity during and after administration.

Bupivacaine 0.25%

Dosage: The standard dosage for bupivacaine 0.25% is 0.75 mg, with a maximum limit of 1.25 mg.
Pregnancy Considerations: Like lidocaine, bupivacaine may also induce premature labor, necessitating expert consultation before use in pregnant patients.
Precautions: Accurate dosing is critical. Watch for potential symptoms of local anesthetic toxicity to ensure patient safety.

Injection Procedure

When administering injections, limit the procedure to a maximum of three sites while strictly adhering to sterile technique. Inject 0.3-0.5 mL into each site, carefully infiltrating the subcutaneous and muscle tissue. It is unnecessary to approach the spine or deeper muscle layers during this process. [29]

Use of Lidocaine 5% Topical Patches

Lidocaine 5% transdermal patches may also be utilized for pain management. Patients should be advised to remove the patch every 12 hours to prevent potential skin irritation. Proper application and timing are essential to maximize effectiveness while minimizing side effects.

Non-opioid analgesics (acetaminophen and non-steroidal anti-inflammatory drugs [NSAIDs], topical analgesics)

Non-opioid analgesics are considered the first-line treatment for pain management. Among these, non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for their efficacy. However, their application must be tailored to individual patient needs and conditions.

Common NSAIDs and Their Guidelines

Ibuprofen:

- Dose: 400 mg, with a maximum of 800 mg
- Frequency: Every 6 hours
- Use in Pregnancy: Category C in the first and second trimesters
- Caution: Avoid in patients with acute kidney injury (AKI), congestive heart failure (CHF), or liver disease.

Naproxen:

Dose: 250 mg, with a maximum of 500 mg
Frequency: Every 12 hours
Use in Pregnancy: Not recommended
Caution: Use cautiously in patients with a history of stomach ulcers.

Diclofenac:

Dose: 50 mg, with a maximum of 75 mg
Frequency: Every 12 hours
Use in Pregnancy: Category C in the first and second trimesters
Caution: Avoid in patients with NSAID allergies.

Meloxicam:

Dose: 7.5 mg, with a maximum of 15 mg
Frequency: Once every 24 hours
Use in Pregnancy: Category C in the second and third trimesters
Caution: Contraindicated in patients with chronic kidney disease (CKD), chronic liver disease (CLD), or post-coronary artery bypass graft (CABG) surgery.

In clinical practice, the management of pain, particularly low back pain, often varies due to limited high-quality data. Low back pain remains one of the most common reasons patients are prescribed opioids, despite the availability of non-opioid alternatives [31,32].

Emerging data suggest that topical therapies can provide safe and effective treatment options for patients experiencing chronic, localized musculoskeletal and neuropathic pain. These therapies serve as an alternative for individuals who may not tolerate oral NSAIDs or opioids. [33]

Opioid Analgesics

Opioids are commonly used for pain relief in patients with low back pain, particularly in emergency department (ED) settings. However, their use should be carefully considered due to limited evidence of long-term benefits.

Prevalence of Opioid Use

A national study authored by Friedman revealed that opioids are administered to two out of three patients presenting to the ED with low back pain. This high prevalence highlights the reliance on opioids in acute care settings. [34]

Patient Population and Data Interpretation

Patients presenting to the ED often have more acute illnesses or severe pain compared to those seen in primary care settings. This distinction may skew the data and influence treatment patterns, as ED physicians are tasked with managing severe pain in a short timeframe.

Limitations of Opioid Therapy

Opioids provide temporary pain relief but lack evidence of improving functional outcomes or reducing long-term disability in patients with acute low back pain. For this reason, they are not recommended as first-line therapy for managing such conditions.

Appropriate Use of Opioids

Opioids should be reserved for specific scenarios:

When all other alternatives have been exhausted
When low-dose treatment can facilitate a return to mobility in the emergency setting

By reserving opioid use for carefully selected cases, clinicians can minimize the risk of dependency and prioritize treatments that improve long-term outcomes.

Muscle Relaxants

Muscle relaxants are often considered for managing muscle spasms and associated pain, but their effectiveness and appropriate use require careful evaluation.

Evidence suggests that muscle relaxants are not more effective than nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or aspirin for managing pain. These alternatives are often preferred due to their similar efficacy and more favorable safety profiles. [35, 36]

A single dose of a benzodiazepine may be considered in the emergency department (ED) for acute muscle spasms. However, benzodiazepines are categorized as second-line agents for this purpose and are not recommended for routine prescription at discharge. Limiting their use helps reduce the risk of dependency and other potential side effects.

Steroids

The role of steroids in managing low back pain remains a topic of confusion and debate. While oral steroids can provide initial symptom relief, their long-term outcomes are less favorable. Studies have shown that patients who use oral steroids may experience complicated outcomes after one year, raising questions about their routine use in this context.

Surgery

Although it is not a primary focus of emergency medicine, providing appropriate recommendations for patients based on institutional resources regarding surgical options can be valuable for their management. For patients who do not respond to pharmacologic therapy, surgical interventions may be considered. These options are typically reserved for individuals with persistent symptoms or structural abnormalities requiring correction [37].

Special Patient Groups

Pediatrics

Unlike adults, children presenting with back pain are more likely to have an underlying serious medical condition. This is especially true for children aged four years or younger, or for any child whose back pain is accompanied by concerning symptoms.

Warning Signs Associated with Back Pain in Children

Parents and caregivers should be alert to the following red flags:

Fever or Weight Loss: These symptoms may indicate an infection or systemic illness.
Weakness or Numbness: Neurological deficits can suggest nerve involvement or spinal cord compression.
Difficulty Walking: Impaired mobility may point to musculoskeletal or neurological issues.
Radiating Pain: Pain that spreads to one or both legs could signal spinal conditions.
Bowel or Bladder Problems: Issues with bowel movements or urination may indicate spinal cord dysfunction.
Sleep Disruption: Pain severe enough to prevent the child from sleeping requires urgent evaluation.

Importance of Early Diagnosis and Treatment

Serious causes of back pain in children must be identified and addressed promptly. Delayed diagnosis and treatment can lead to worsening symptoms and potentially long-term complications. Careful clinical evaluation and appropriate imaging or laboratory tests are essential to rule out conditions such as infections, tumors, or structural abnormalities. Emergency physicians should always think about possibility of child abuse and traumatic injuries in this age group.

Geriatrics

In elderly individuals, back pain requires careful evaluation due to the increased risk of fractures and other serious conditions. Vertebral fractures can occur even with minimal force, making it critical to consider the possibility of compound vertebral fractures in older patients, even in the absence of trauma.

Life-Threatening Diagnoses to Rule Out

When evaluating back pain in elderly patients, it is important to rule out life-threatening conditions that are more common in this age group, including:

Aortic Dissection: A tear in the inner layer of the aorta that can cause severe back pain.
Abdominal Aortic Aneurysm: A potentially fatal condition involving the enlargement and potential rupture of the abdominal aorta.

Common Causes of Back Pain in the Elderly

In addition to ruling out life-threatening diagnoses, healthcare providers should consider the following common causes of back pain in older adults:

Osteoarthritis: A degenerative joint condition leading to stiffness and pain in the spine.
Degenerative Disc Disease: The wear-and-tear breakdown of intervertebral discs, which can result in chronic back pain.
Facet Joint Osteoarthritis: Degeneration of the small joints in the spine, contributing to localized pain and reduced mobility.

Pregnant Patients

Back pain is one of the most common issues experienced during pregnancy, particularly in the later months. While this discomfort often subsides after childbirth, many women continue to experience back pain for months postpartum.

Common Causes of Low Back Pain and Pelvic Girdle Pain in Pregnancy

Several factors contribute to low back pain and pelvic girdle pain during pregnancy, including:

Hormonal Changes: Hormonal fluctuations can loosen ligaments and joints, leading to instability and pain in the pelvic region.
Increased Weight: The growing weight of the baby places added stress on the lumbar vertebrae, causing discomfort and strain.
Compression of the Inferior Vena Cava (IVC): As the uterus enlarges, it may compress the IVC, leading to venous congestion and associated back pain.
Poor Nutrition: Inadequate nutrition during pregnancy can weaken muscles and bones, exacerbating pain.

Serious Causes Requiring Aggressive Management

In some cases, back pain during pregnancy may indicate more serious underlying conditions that require prompt attention and treatment. These include:

Lumbar Disc Herniation
Trauma
Infections
Masses

Identifying and addressing these causes is critical to ensuring the safety and well-being of both the mother and the baby.

IV Drug Users

Patients in this category may present with isolated back pain or more severe manifestations such as full-blown sepsis, meningitis, or septic shock. Prompt recognition and thorough examination of these patients are crucial. Immediate administration of antibiotics is essential to prevent further complications and reduce the risk of long-term morbidity. Timely intervention can significantly improve outcomes in these critical cases.

When To Admit This Patient

Patients presenting with back pain may be safely discharged if all the following criteria are met:

The patient has no neurological deficits or red flag findings on physical examination.
The patient is able to ambulate without difficulty.
Pain is under control, and no emergency cause has been identified.

For patients with uncontrolled pain or inability to care for themselves, an overnight stay in a hospital observation unit or nursing facility may be required for further management [38].

Admission is warranted in patients who exhibit significant abnormalities or require specialist intervention. The following scenarios outline the need for admission and further consultation:

Abnormal Physical Examination Findings:
- Patients with abnormal signs on physical examination should be referred for emergency consultation with the appropriate inpatient service.
Vascular and Mechanical Syndromes:
- Conditions such as abdominal aortic aneurysm (AAA), vascular spinal cord syndromes (e.g., spinal or epidural hematoma), and mechanical spinal cord syndromes (e.g., cauda equina syndrome or syringomyelia) necessitate immediate consultation with vascular or spine specialists for intervention and potential admission.
Spinal Fractures:
- Patients with spinal fractures require evaluation by an orthopedic surgeon and/or neurosurgeon. Admission is determined based on the fracture’s stability and the patient’s level of pain control.
Infectious Spinal Syndromes:
- Conditions such as epidural abscesses, osteomyelitis, or discitis require admission and consultation with specialists in Infectious Diseases and Spine.
Immunologic Spinal Cord Syndromes:
- Patients with conditions like transverse myelitis should be referred to neurology for consultation and further management.

Revisiting Your Patient

Firstly, as the patient is stable, which means A, B, and C are clear, the patient should be managed for pain (pain scale 8/10). On an emergent basis, Opioid was given for rapid relief. Further examination revealed the patient had foot drop, neurological deficits, motor weakness (S1 myotome), and a decrease in left foot reflexes causing him to have a high steppage gait on arrival to ED. At this juncture, it is clear the patient is having a nerve compression as there are focal neurological deficits. Here, you can call for senior help, as neurological deficits need to be reassessed for proper documentation. MRI of the whole spine showed prolapse of the L4/L5 intervertebral disc with compression on the thecal sac and bilateral neural foramina with osseous spinal canal stenosis at the L4 L5 vertebrae. The patient was admitted according to the admission criteria described earlier in the chapter, was made to wear a lumbar belt, and received epidural analgesia with corticosteroid injection. The patient was monitored for further neurological deterioration, which did not develop. Hence, he was discharged with supportive management, including physiotherapy and follow-up.

Authors

Paila Naveen

Dr. Paila Naveen, MBBS, CCT-EM, MRCEM, SEMI (Society of Emergency Medicine India) member, Consultant in Emergency Medicine, India, has fallen in love with this specialty, which he describes as his adrenaline pump for the rest of his medical service. He has a vision to spread the word about the importance of this specialty and the full potential of an emergency physician that can be achieved with the right skills and techniques in hand to save lives and bring smiles to the world. He is a strong supporter of FOAMed and runs a site exclusively for Emergency Medicine where he teaches, discovers new things, and tries to make a difference in every step he takes forward. He spreads awareness about this branch, as it is still in its infancy in India, through every possible medium where students and other doctors are connected in a collaborative way to further enhance the beauty of EMERGENCY MEDICINE.

Manjith Reddy

Dr. Manjith K S is an emergency physician with over 4 years of experience. He completed his medical school in 2012 and his residency in emergency medicine in 2019. Passionate about providing high-quality care, Dr. Manjith is dedicated to ensuring the best possible outcomes for his patients. He stays up-to-date with the latest medical research and practices and is a strong advocate for patient safety and quality improvement. Dr. Manjith is highly skilled in quickly assessing and diagnosing patients with a wide range of conditions and is an expert in the use of emergency medical equipment and procedures. His professional interests include trauma and cardiac emergencies. In addition to his clinical expertise, he serves as a mentor to junior physicians and residents, fostering the next generation of emergency medicine professionals. As a lifetime member of the Society of Emergency Medicine India (SEMI), Dr. Manjith is committed to advancing the field of emergency medicine. He currently works as a full-time consultant for a private healthcare organization. Proud to be part of the emergency medicine community, Dr. Manjith believes that emergency physicians are the frontline of healthcare.

Listen to the chapter

References

Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976). 1987;12(3):264-268. doi:10.1097/00007632-198704000-00013.
Borczuk P. An evidence-based approach to the evaluation and treatment of low back pain in the emergency department. Emerg Med Pract. 2013;15(7):1-24.
Friedman BW, Chilstrom M, Bijur PE, Gallagher EJ. Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine (Phila Pa 1976). 2010;35(24):E1406-E1411. doi:10.1097/BRS.0b013e3181d952a5
Winters ME, Kluetz P, Zilberstein J. Back pain emergencies. Med Clin North Am. 2006;90(3):505-523. doi:10.1016/j.mcna.2005.11.002
Swaminathan A. Essay: Low Back Pain. Emergency Medical Abstracts. July 2017. Accessed January 7, 2019.
Mears L, Mears J. The pathophysiology, assessment, and management of acute pain. Br J Nurs. 2023;32(2):58-65. doi:10.12968/bjon.2023.32.2.58
Todd NV. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. Br J Neurosurg. 2017;31(3):336-339. doi:10.1080/02688697.2017.1297364
Samanta J, Kendall J, Samanta A. 10-minute consultation: chronic low back pain. BMJ. 2003;326(7388):535. doi:10.1136/bmj.326.7388.535
John Bernett, Robert Strony,Diagnosing acute aortic dissection with aneurysmal degeneration with point of care ultrasound,The American Journal of Emergency Medicine,Volume 35, Issue 9,2017,Pages 1384.e3-1384.e4,ISSN 0735-6757,https://doi.org/10.1016/j.ajem.2017.05.052.
Capra F, Vanti C, Donati R, Tombetti S, O’Reilly C, Pillastrini P. Validity of the straight-leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard. J Manipulative Physiol Ther. 2011;34(4):231-238. doi:10.1016/j.jmpt.2011.04.010
Hansberger BL, Loutsch R, Hancock C, Bonser R, Zeigel A, Baker RT. EVALUATING THE RELATIONSHIP BETWEEN CLINICAL ASSESSMENTS OF APPARENT HAMSTRING TIGHTNESS: A CORRELATIONAL ANALYSIS. Int J Sports Phys Ther. 2019;14(2):253-263.
Estridge MN, Rouhe SA, Johnson NG. The femoral stretching test. A valuable sign in diagnosing upper lumbar disc herniations. J Neurosurg. 1982;57(6):813-817. doi:10.3171/jns.1982.57.6.0813
Chenot JF, Greitemann B, Kladny B, Petzke F, Pfingsten M, Schorr SG. Non-Specific Low Back Pain. Dtsch Arztebl Int. 2017;114(51-52):883-890. doi:10.3238/arztebl.2017.0883
Friedman BW, Chilstrom M, Bijur PE, Gallagher EJ. Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine (Phila Pa 1976). 2010;35(24):E1406-E1411. doi:10.1097/BRS.0b013e3181d952a5
Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med. 2015;66(2):148-153. doi:10.1016/j.annemergmed.2014.11.011
Chelsom J, Solberg CO. Vertebral osteomyelitis at a Norwegian university hospital 1987-97: clinical features, laboratory findings and outcome. Scand J Infect Dis. 1998;30(2):147-151. doi:10.1080/003655498750003537
Harris JC, Caesar DH, Davison C, Phibbs R, Than MP. How useful are laboratory investigations in the emergency department evaluation of possible osteomyelitis?. Emerg Med Australas. 2011;23(3):317-330. doi:10.1111/j.1742-6723.2011.01413.x
Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med. 2015;66(2):148-153. doi:10.1016/j.annemergmed.2014.11.011
Todd NV. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. Br J Neurosurg. 2017;31(3):336-339. doi:10.1080/02688697.2017.1297364
Acute low back problems in adults: assessment and treatment. Agency for Health Care Policy and Research. Clin Pract Guidel Quick Ref Guide Clin. 1994;(14):iii-25.
Graves JM, Fulton-Kehoe D, Martin DP, Jarvik JG, Franklin GM. Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers’ compensation. Spine (Phila Pa 1976). 2012;37(19):1708-1718. doi:10.1097/BRS.0b013e31823a03cc
Herbert M, Swadron S, Mason J. Back pain – introduction and initial approach. C3: Continuous Core Content. December 2016., Accessed March 6, 2019.
Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363-370. doi:10.1056/NEJM200102013440508
Edlow JA. Managing Nontraumatic Acute Back Pain. Ann Emerg Med. 2015;66(2):148-153. doi:10.1016/j.annemergmed.2014.11.011
Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;(6):CD007612. Published 2010 Jun 16. doi:10.1002/14651858.CD007612.pub2
Ferreira ML, Smeets RJ, Kamper SJ, Ferreira PH, Machado LA. Can we explain heterogeneity among randomized clinical trials of exercise for chronic back pain? A meta-regression analysis of randomized controlled trials. Phys Ther. 2010;90(10):1383-1403. doi:10.2522/ptj.20090332
LaPietra A. Trigger point injection for musculoskeletal pain in the ED. AliEM: Academic Life in Emergency Medicine website. Published June 8, 2018. Accessed March 4, 2019.
Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002;65(4):653-660.
Strayer R. Penetrating the neck: strayerisms – trigger point injections. Emergency Medicine: Reviews and Perspectives. November 2016
A study of naproxen and ibuprofen in patients with osteoarthritis seen in general practice. The Manchester General Practitioner Group. Curr Med Res Opin. 1984;9(1):41-46. doi:10.1185/03007998409109557
Waljee JF, Brummett CM. Opioid Prescribing for Low Back Pain: What Is the Role of Payers?. JAMA Netw Open. 2018;1(2):e180236. Published 2018 Jun 1. doi:10.1001/jamanetworkopen.2018.0236
Waljee JF, Brummett CM. Opioid Prescribing for Low Back Pain: What Is the Role of Payers?. JAMA Netw Open. 2018;1(2):e180236. Published 2018 Jun 1. doi:10.1001/jamanetworkopen.2018.0236
Stanos SP, Galluzzi KE. Topical therapies in the management of chronic pain. Postgrad Med. 2013;125(4 Suppl 1):25-33. doi:10.1080/00325481.2013.1110567111
Friedman BW, Chilstrom M, Bijur PE, Gallagher EJ. Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine (Phila Pa 1976). 2010;35(24):E1406-E1411. doi:10.1097/BRS.0b013e3181d952a5
van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM; Cochrane Back Review Group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration. Spine (Phila Pa 1976). 2003;28(17):1978-1992. doi:10.1097/01.BRS.0000090503.38830.AD
van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM; Cochrane Back Review Group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration. Spine (Phila Pa 1976). 2003;28(17):1978-1992. doi:10.1097/01.BRS.0000090503.38830.AD
National Institute of Neurological Disorders and Stroke. Lower back pain fact sheet. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Published February 2019. Accessed February 23, 2019
Needs C, Laurent R. Hospital admissions for acute low back pain. Intern Med J. 2019;49(3):294-296. doi:10.1111/imj.14227

Reviewed and Edited By

Jonathan Liow

James Kwan

Arif Alper Cevik, MD, FEMAT, FIFEM

Emergency Procedures: Intraosseus Needle Insertion

emergency procedures-Intraosseus Insertion

April 25, 2022February 19, 2022 ~ iEM Education Project Team ~ Leave a comment

Indications

Emergency intravenous access is required and Peripheral intravenous access is difficult or has failed.

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information.

Contributors

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Emergency Procedures: Patella Relocation

April 18, 2022February 19, 2022 ~ iEM Education Project Team ~ Leave a comment

Indications

Patella dislocation

Contributors

Dr John Mackenzie

Dr James Miers

Emergency Procedures: Shoulder Immobilisation

April 11, 2022February 19, 2022 ~ iEM Education Project Team ~ Leave a comment

Indications

Shoulder dislocation (post reduction)
Acromioclavicular injuries (grade 1-3)
Fracture of humeral head, greater tuberosity or clavicle

Contributors

Dr John Mackenzie

Dr James Miers

Emergency Procedures: Finger Splint

April 4, 2022February 19, 2022 ~ iEM Education Project Team ~ Leave a comment

Indications

Fractures of distal and middle phalanx
Volar plate injury
Post reduction of dorsal PIP dislocation
Mallet injury (distal phalanx extensor tendon rupture with or without avulsion fracture)

Contributors

Dr John Mackenzie

Dr James Miers

Emergency Procedures: Short Leg Backslab

March 28, 2022February 19, 2022 ~ iEM Education Project Team ~ Leave a comment

Indications

The distal tibia and/or fibula fractures
Ankle injuries
Tarsal injuries
Metatarsal injuries

Contributors

Dr John Mackenzie

Dr James Miers

Emergency Procedures: Long Leg Backslab

March 21, 2022February 19, 2022 ~ iEM Education Project Team ~ Leave a comment

Indications

Tibia and/or fibula shaft fractures
Knee and patellar fractures
Distal femur fractures

Contributors

Dr John Mackenzie

Dr James Miers

Emergency Procedures: Volar Short Arm Slab

March 14, 2022February 19, 2022 ~ iEM Education Project Team ~ Leave a comment

Indications

Soft tissue injuries to hand and wrist
Carpal bone fractures (excluding scaphoid/trapezium)
Buckle fractures of the distal radius

Contributors

Dr John Mackenzie

Dr James Miers

Emergency Procedures: Long Arm Backslab

March 7, 2022February 19, 2022 ~ iEM Education Project Team ~ Leave a comment

Indications

Acute management of elbow region injuries such as radial head fractures, distal humerus fractures, after reductions of elbow dislocations;
Proximal and mid-forearm, and wrist injuries such as Colles or Smith fractures;
Acute management of distal radial (nonbuckle) and/or ulnar fractures in children.