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ice if available, and NSAIDs (see Joint Pain section). Always check for allergies prior to giving medications.
Injecting bursae as above may provide long lasting pain relief.
C. Fractures: Apply traction splint, give IV fluids (see Shock: Fluid Resuscitation) and evacuate urgently.
D. Herniated disc: Use rest (48 hours max), ice, NSAIDs (see Joint Pain section). Later use heat, stretching
and ROM exercises.
F. Aseptic Necrosis: Apply splint, allow no weight bearing, give NSAIDs (see Joint Pain section) and ROM
exercises, evacuate.
G. Septic arthritis: Do not aspirate hip joint. Start antibiotics as below and evacuate urgently:
H. If suspected (most common in young adults) or demonstrated gonorrhea (Gram stain), treat as for PID
(see STDs chapter).
I. Otherwise give nafcillin 1-2 gm q 4h IV or IM, or oxacillin 1-2 gm q 4h IV, or cloxacillin 0.25-0.5 gm
q 6h ac (use higher doses if gram stain positive for staphylococcus); or alternate: cephazolin 0.25 gm q
8h - 2.0 gm q 6h IV or IM, or ciprofloxacin 750 mg po + Rifampin 300 mg po bid. For Gram negative
organisms: ceftriaxone 1 gm qd IV or cefotaxime 1 gm q8h IV, or ceftizoxime 1 gm q8h IV
Patient Education
General: If a fracture is suspected, inform patient of probable need for surgical treatment.
Activity: If a femoral neck stress fracture is suspected, allow no further weight bearing to prevent complete
fracture that may necessitate surgical correction. Recommend crutches and total non-weightbearing on that
hip until x-rays and/or bone scan or MRI can be obtained.
Diet: Additional calcium if suspect stress fracture
Medications: All medications may produce allergic reactions. Long-term use of anti-inflammatories may
produce GI bleeds or kidney problems.
Prevention and Hygiene: Proper training may prevent development of stress fractures.
Follow-up Actions
Return evaluation: If pain persists, reconsider diagnosis and consult specialist or evacuate patient.
Evacuation/Consultation Criteria: Evacuate cases of joint infection, fracture or suspected fracture, and
aseptic necrosis. Also, evacuate any unstable patient or any team member unable to complete the mission
without burdening the team. Consult orthopedics for any patient to be evacuated, and for others as needed.
Symptom: Joint Pain: Knee Pain
CDR Scott Flinn, MC, USNIntroduction: Knee pain is a very common complaint with a broad differential diagnosis. Narrow the
diagnostic possibilities based on the mechanism of injury (acute/trauma vs. chronic/overuse) and signs and
symptoms. Acute knee pain, within minutes to hours, is usually due to trauma or infection. Chronic knee pain
occurs without a specific initiating event, but may be preceded by a long history of minor complaints.
Anterior knee pain is usually due to an overuse condition such as patellofemoral syndrome (PFS) or patellar
tendinitis. Posterior knee pain may be due to a Baker’s cyst. Pain from injuries to the collateral ligaments
or menisci are referred to the side of injury. In addition to local causes, knee pain may result from referred
pain such as femoral shaft stress fracture. Risk Factors: Malformations or variations in anatomic structures
may predispose to overuse injuries.
Subjective: Symptoms
Constitutional: Limp or inability to walk; fever (suggests an acute single joint septic arthritis caused by
gonorrhea until proven otherwise).
Local: Swelling, grinding or popping noises, buckling or giving way, ecchymosis.
Focused History: Can you show or tell me your position when the injury occurred? (direct trauma suggests
structural injury; overuse syndromes suggest tendinitis or PFS) Did it swell immediately? (suggests cruciate
ligament tear or fracture) Did it swell within 12-24 hours? (suggests meniscal tear, osteochondral defect, or
capsule tear with patellar dislocation) Did you feel or hear a “pop”? (suggests anterior cruciate ligament (ACL)
tear) Does the knee give way or buckle due to pain or is it unstable? (instability suggests ACL tear or