� Foot Fractures

Non displaced fractures of the navicular and cuboid bones

require a short leg splint. Calcaneus fractures require a

bulky compressive dressing and a posterior splint. The

patient will remain non-weight-bearing for 6-8 weeks.

Metatarsal fractures should be immobilized in a posterior

leg splint and treated nonoperatively, unless there is an

associated Lisfranc dislocation, a displacement of more

than 3-4 mm, or angulation of more than 10 degrees, all of

which are managed operatively. Because of a tenuous

blood supply, a Jones fracture requires a posterior leg splint

and non-weight-bearing status for proper healing. Finally,

phalangeal fractures are treated with buddy taping the

injured toe to an adjacent toe and a hard-soled shoe.

DISPOSITION

� Admission

Admission is required for patients with hemodynamic

instability (from acute blood loss) and fractures that are

open, associated with multiorgan trauma, or require early

ORIF (eg, hip fractures).

� Discharge

Most patients with nondisplaced fractures, ligamentous

injury, or meniscus tears can be splinted and sent home

with referral to orthopedics for further management (ie,

cast or surgical repair). If non-weight-bearing status is

required, patients must be able to ambulate with crutches

or have home assistance with activities of daily living.

SUGGESTED READING

Newton EJ, Love J. Emergency department management of

selected orthopedic injuries. Emerg Med Clin North Am.

2007;25:763-793.

Perron AD, Brady WJ. Evaluation and management of the highrisk orthopedic emergency. Emerg Med Clin North Am.

2003;21:159-204.

Menkes JS. Initial evaluation and management of orthopedic

injuries. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHlill, 20 1 1, pp. 1 783-1 796.

Low Back Pain

Pa ul E. Casey, MD

Key Points

• The diag nostic approach to lower back pain is

facil itated by classifying back pain into (1 ) nonspecific low back pain, (2) back pain associated with

radiculopathy, and (3) back pain due to a serious

underlyi ng cause.

INTRODUCTION

Acute low back pain may be due to a variety of conditions

ranging from benign ( eg, muscle strain) to devastating

( eg, spinal cord compression from malignancy or abscess).

For the clinician in the emergency department (ED), it is

critical to develop a systematic approach that will allow

one to differentiate and manage the minority of patients

with conditions that threaten neurologic function from

those with benign, self-limited etiologies. This chapter

focuses primarily on the evaluation and management of

acute ( <4 weeks) low back pain.

An estimated 60-70% of adults in the United States will

experience low back pain in their lifetime, and although

only 25-30% will seek medical care, low back pain is an

exceedingly common reason for ED visits in the United

States. The economic impact of low back pain is s ubstantial, estimated to account for $26.3 billion of direct health

care costs in the United States in 1998.

The pathophysiology of nonspecific low back pain is

usually indeterminate, as pain may arise from a number of

sites including the vertebral column, surrounding muscles,

tendons, ligaments, and fascia. The mechanism of injury to

these structures varies from stretching, tearing, or contusion as a result of heavy lifting or torsion of the spinal column. In contrast, the pathophysiology of radicular low back

pain is more clearly defined. Herniation of the nucleus

• It is critical to screen for risk factors associated with

serious back pathology as well as identify the presence

of neurologic deficits.

• Imaging is indicated in select patients with significant

risk factors and/ or neurologic deficits.

pulposus through the annulus fibrosis causes compression

of the dural lining around the spinal nerve root, resulting in

radicular pain.

CLINICAL PRESENTATION

The history and physical examination serve as cornerstones

in the evaluation of back pain. To facilitate a rational

diagnostic approach, an attempt is made to classify low

back pain into 1 of 3 categories:

1. Nonspecific low back pain: pain with no signs or

symptoms of a serious underlying condition

2. Radicular back pain: pain with nerve root dysfunction

associated with pain, sensory impairment, weakness, or

impaired deep tendon reflexes in a specific nerve root

distribution

3. Serious underlying etiology: pain with neurologic

deficits or underlying conditions requiring prompt

evaluation (eg, tumor, infection, fracture, cauda equina

syndrome)

...... History

The history should focus on the location of pain (including

radiation of pain), frequency and duration of symptoms,

and exacerbating and alleviating factors, as well as any

403

CHAPTER 92

Table 92-1. Risk factors for serious pathology

in back pain.

Risk factors for underlying malignancy

• Prior history of malignancy

• Age >50 years

• unexplained weight loss

• Failure to improve after 4 weeks

Risk factors for vertebral infection

• Fever

• Intravenous drug use

• Recent infection

Risk factors for vertebral compression fracture

• Old age

• History of osteoporosis

• Corticosteroid use

previous episodes or treatments of back pain. Pain that radiates down the leg, usually past the knee, suggests a radiculopathy. Pain from a herniated disk is worse with movement,

sitting, or Valsalva maneuver (eg, coughing). Pain worse at

night or rest suggests malignancy or spinal infection. A past

medical history of malignancy or immunocomprornise is

determined. Inquire about recent weight loss or fevers.

Patients should also be asked about severe or progressive

neurologic deficits including motor deficits, fecal inconti ­

nence, and bladder dysfunction. Bilateral leg pain and

bowel/bladder dysfunction suggests cauda equina syndrome.

Other warning signs of serious disease underlying low back

pain are listed in Table 92- 1.

� Physical Examination

The musculoskeletal exam should include percussion of

the spinous processes of the back. Pain with percussion

suggests spinal infection, vertebral malignancy, or com ­

pression fracture. Tenderness and spasm of the paraspinal

muscles frequently heralds muscle strain, but can also be

seen in secondary condition (eg, epidural abscess). As a

result, when other signs and symptoms for a serious back

pain etiology are present, don't dismiss them just because

the pain is reproduced by palpation of the paraspinal

muscles.

Patients should also undergo a complete neurologic

assessment. Neurologic deficits that suggest spinal cord

compression include spasticity, bilateral weakness,

positive Babinski sign, multiple dermatomes, and

bilateral reflex abnormalities. Findings consistent with

cauda equina syndrome are decreased sensation to light

touch and pinprick in the inner thighs and perineum

(saddle anesthesia), decreased rectal tone, and urinary

retention with a post-void residual over 100 mL. Saddle

anesthesia is seen in 75% of cases of cauda equina syndrome, whereas an elevated postvoid residual is present

in 90%.