Musculoskeletal and Soft-Tissue Disorders
Core approach
Orthopedic and soft-tissue emergencies require recognition of threats to limb, joint, and life. Core diagnoses include fractures, dislocations, open fractures, compartment syndrome, necrotizing soft-tissue infection, septic arthritis, flexor tenosynovitis, and cauda equina syndrome. Assess neurovascular status before and after reduction, splint appropriately, and provide analgesia. Open fractures need antibiotics, tetanus assessment, and urgent debridement. Suspect necrotizing fasciitis when pain is severe, skin findings evolve, or systemic toxicity is present; surgical consultation is immediate.
Traps
Compartment syndrome can occur with palpable pulses and a normal radiograph. Pain out of proportion and pain with passive stretch are early clues; pulselessness is late and unreliable. Necrotizing fasciitis may lack crepitus and may have misleading laboratory values. Do not miss open joint injuries or retained foreign bodies. In back pain, screen for red flags: urinary retention, saddle anesthesia, bilateral weakness, fever, cancer history, and anticoagulation.
Worked example
A patient with a tibial fracture has worsening anterior leg pain, tense swelling, and pain with passive toe extension. Pulses remain palpable. Do not wait for pulselessness; measure compartment pressures if needed and call surgery urgently for fasciotomy. Rule of thumb: compartment syndrome is a clinical diagnosis, and pulselessness is a late finding.
Key concepts
Reduce dislocations promptly and reassess neurovascular status. Septic arthritis requires joint aspiration and antibiotics. Cauda equina syndrome is a surgical emergency.