MVC/MCC

Assaults

Penetrating: GSW, shotgun

Industrial/work related

crush

falls

-low level: fall from stand, fall from sitting heigh

high energy: fall from height

These are all examples of what?

type: fracture pattern

comminution: number of fragments (non-comminuted, mildly ≤3, severely >3)

location: anatomic location, bone divided into thirds- intra-articular: fracture involved the joint space

displacement

Displacement:

non-displaced: fragments in anatomic alignment

Displaced: loss of position along the axis of alignment. Measured in percentrage of bone width

Angulated: fragments of bone at angles to each other

Relationship to surrounding tissue

Closed:

soft tissue and skin intact

no communication of fracture with environment

not orthopedic emergency UNLESS neurovasc compromise

Open

• skin has been violated
• caused by fragment penetrating skin
• fracture skite is contaminated
• may be only pinprick- THOROUGH EXAM KEY
• Grade I-III classficiate- damage to soft tissue
• OR urgent: washout, debridement, stabilization
• IV abx: first dose in ED, typically Ancef
• Flagyl or Unasyn for anaerobic coverage

specific to peds

Type I: physis fracture

Type II: metaphysis and physis fracture

Type III: epiphysis and physis fracture

Type IV: epiphysis to metaphysis fracture

Type V: crush fracture

What is a Salter Harris I fracture?

fracture line transverses longitudinally thru epiphyseal plate (physis)

Clinical dx: x-ray (-) may not see

point tenderness at epiphyseal plate

+/- joint effusion

non-surgical

immobilization

complications rare

Eg: slipped capital femoral epiphysis

fracture splits partially thru epiphyseal plate

includes triangular bone fragment of metaphysis: called the Thurson Holland fragment or "corner" sign

Most common of all SHF

Immobilization most common treatment

Complications rare: type II distal femur and tibia may result in growth deformity

fracture partially involved the growth plate, extends thru the epiphysis into joint

potential to disrupt joint space

requires early surgical reduction

Tillaux fracture of anterolateral tibial epiphysis

-common in adolescents

-baseball slide/skateboarding

-prone to chronic disability

-surgery if displaced

fracture runs obliquely thru the metaphysis, transverses thru epiphyseal plate, epiphysis and enters joint

Thurston Holland sign seen

Potential to disrput joint

Requires surgery

Complication: growth disturbance (premature focal effusion causing deformity)

What is a Salter V?

fracture is a compression or crushing injury of epiphyseal plate

No associated epiphyseal or metaphyseal fracture

Intial dx: difficult, commonly made after growth disturbance occurs

Rare: ≤1% all SHF

MOI: severe axial load

Worst prognosis

Requires surgery

S:slipped growth plate

A: Above; fracture lies above growth plate

L: Fracture is lower/below growth plate

T: Through; fracture is thur 3 bones: growth plate, metaphysis, epiphysis

R: growth plate has been rammed/ruined due to compression

how many liters of retro-peritoneal blood loss can there be before shock?

How many liters does the thigh hold in a femur fracture?

Pelvis: 4L

femur fracture: 2.5L

1. Inspection: deformity, ecchymosis/discoloration, swelling/joint effusion, skin integrity

2. Passive and Active ROM: Joints above and below injury

3. Palpation: Tenderness, crepitus, deformity, compartment pressure, assess ligaments and tendons to rule out injury or rupture as indicated

4. Neurovascular status: motor/sensory function, capillary refill, pulses, assess before/after fracture reduction and splinting

Extend wrist, "ok" sign, digits 3-5 spread out

what does this tell you?

Wrist extension and thumbs up

-fully bend/extend index PIP/DIP

-Sensation dorsum first 3 digits

What are you testing?

Peace sign/cross fingers

spread/adduct all digits

sensation volar aspect palm, ulna side, 4th/5th digits

What does that test?

"O" with them"/pinky

adduct/pinch thumb and pinky

sensation volar aspect palm thumb to ring ringer

What are you testing?

Common injury patterns:

Anterior Shoulder dislocation and _____ nerve injury

Distal humerus fracture and ____ nerve injury

Displaced wrist fracture and ____ nerve injury

Hip dislocation and ___ nerve injury

Knee dislocation and ____ nerve injury

Anterior Shoulder dislocation and axillary nerve injury

Distal humerus fracture and radial nerve injury

Displaced wrist fracture and median nerve injury

Hip dislocation and sciatic nerve injury

Knee dislocation and peroneal nerve injury

active pulsatile bleeding

expanding hematoma

bruit or palpable thrill

diminished or absent pulse compared to other limb-not due to shock

signs of distal ischemia: cold pale, insensate limb

• CXR, pelvis, c-spine as indicated
• Limb specific: above and below fracture
• Special views if needed: eg scaphoid view
• CT scans indicated for certain fractures
• CT angiogram or angiogram
• CT scans as indicated to assess injuries head, neck, chest, abdomen/pelvis

• RICE (rest, ice, compress, elevation)
• splint injuries
• IV abx for open fractures
• Update tetanus with open fractures
• ortho consult: stat consult vs outpatient follow up

•Open Fractures

•Hip Dislocations

•Most large joint dislocations

•Compartment Syndrome

•NeuroVascular injury due to fracture

•Hemorrhagic Shock due to pelvic/long bone fractures

•Amputations

•Crush injuries

•Certain fracture patterns

–Open book pelvic fracture

•Poly-Trauma pt with orthopedic injury

•Cauda Equina

•Acute infections

–Deep space hands/feet/joint, septic joint, osteomyelits

Site of injury: what bones are fractured?

Location of fracture

Angulation present? spiral, angulated?

Displacement? what %?

Open or closed fracture

(+) neurvascular status

Splinting:

what do most ED's use?

What are goals?

splinting depends on fracture

Most ED's use Ortho-Glass or OCL

Goals:

relieve pain

augment healing

stabilize fracture in anatomic alignment

prevent injury to soft tissue, vessels, nerves

Indications: fractures, suspect fractures with neg xray, deep lacerations over or near joint, tendon lacerations, deep space infections

Splinting Complications: ischemia/compartment syndrome, plaster burn, dermatitis, joint stiffness, infection underlying wounds

What are fracture discharge instructions?

(6)

• rest and elevation
• ice x 48 hrs
• keep splint dry
• pain control
• When to see orthopedist: arrange appt if able; most injuries 3-7 days
• Explain when pt should return to ED

• RICE
• Ace Wrap, Splint, Immobilizer eg "air cast"
• Crutches, walker
• Pain control
• follow up instructions

-high grade sprains with orthopedist 7 days

-mild injury or sprains with PCP in 1 week

Compartment syndrome:

what is it?

irreversible damage after how long?

What is Whiteside's theory?

Emergency?

•Perfusion pressure falls below tissue pressure in a closed anatomic space

•Venous Pressure < Capillary Perfusion Pressure

•Irreversible damage after 6hrs

•Compartment pressure > 30 requires fasciotomy

•Whiteside’s Theory: 10-30mmHg of DBP

•Orthopedic Emergency!

•Fractures

–Minimally displaced pediatric elbow fx

–Minimally displaced tibia fx

–Displaced long bone fractures

•Crush injuries without fracture

•Burns

•GSW

•Massive IVF resuscitation

•Splint/cast/tight dressings

•Exertional

•Rhabdomyolysis

•Anticoagulation

•“Found down”

•Compartment fluid injection

–Eg: extravasation IV CT contrast dye

•Any injured extremity in pt unable to give reliable exam!

Clinical findings:

Pain out of proportion to injury and/or PE

Firm, tensely swollen muscle compartment

can occur in ANY muscle compartment

what is most common?

Compartment syndrome

tibia and forearms: most common

gluteal, hands, feet more common than you think

•Paresthesias: First finding

•Pain on passive stretch of involved muscle

–Out of proportion to exam

–Deep, unrelenting, throbbing pressure

•Paralysis

•Pallor: late finding

•Pulselessness: Very late finding

•Poikilothermia: cold limb=limb loss

What is the difference btw a dislocation and a subluxations?

What are most common sites of dislocatins?

•Dislocation: complete loss of contact between 2 opposing joint surfaces

•Subluxation: partial loss of contact

•Dislocation most extreme form of subluxation

•Most common dislocations:

–Anterior Shoulder dislocation (95-98%)

–Posterior Hip dislocation

What would the following look like:

anterior shoulder dislocation

post shoulder dislocation

posterior hip dislocation

Anterior shoulder

– Arm held in ABDuction, external rotation

•Posterior shoulder: seizure or electric shock

•Posterior Hip: Orthopedic Emergency

–Leg ADDucted, internally rotated

•Strain: injury to muscle or tendon usually from overuse or strecthing

•Sprain: injury to ligament when joint goes thru a ROM > than normal

–No fracture or dislocation

–Grade I-III

What is a grade I sprain?

Mechanical instability?

Joint Laxity

X-rays

•Partial tear of ligament

•Mild localized tenderness/swelling

•No or slight functional loss

–Pt can bear weight and ambulate

•No mechanical instability

•No joint laxity

–Anterior drawer

–Talar tilt

•X-rays: normal

What is a grade II sprain?

instability/joint laxity?

x-rays?

•Incomplete tear of ligament with moderate functional impairment

•Significant tenderness

•Moderate edema and ecchymosis

•Some loss of motion and function

–Pain with weight bearing and ambulation

•Mild-moderate instability/joint laxity

•X-rays: joint effusion or avulsion fx tip of fibula

What is a grade III sprain?

instability

joint laxity

x-ray

•Complete tear/rupture of ligament with loss of integrity of ligament

•Severe pain and tenderness

•Marked ecchymosis and edema

•Severe loss of ROM and ability to bear weight

•Mechanical instability present

•Joint laxity present

•X-ray: joint effusion, avulsion fx, disrupted mortise

•RICE

•Analgesia: NSAID’s and/or narcotics

•Splint

–Pre-made, air cast, posterior splint

•Non-weight bearing (NWB)

•Crutches

•Ortho referral for Grade II/III sprains

•Physical Therapy:

–improves pain, functional recovery and soft tissue damage

Pt presents after running or jumping.

They are weekend warrios 30-40

They say they heard an audible "snap" and then they were unable to walk on tiptoes.

what could it be?

Thompson Test

what is it?

•RICE

•Analgesia/NSAID’s

•Non-weight bearing

•Posterior splint

•Crutches

•Ortho evaluation within 72hrs

what is a stress fracture?

where is it common?

What population typically gets?

•Over-use or “fatigue” fx

•Common in lower extremity

•Repetitive stress fatigues bone

•Evolves into fx

•Common in military recruits and pts with sudden increase in training or new exercise program

Pt presents stating they have mild diffuse pain during activity.

It improves with rest-progression of fracture pain persists at rest

Night pain present.

Localized swelling.

What are you thinking?

If you suspect pt has stress fracture:

what test can you do on PE?

What radiographs do you order?

What treatment?

•“Hop” test may reproduce pain

•Plain x-rays: may be (-)

–t/c bone scan

•Dx: history and PE

Treatment:

•Rest 4-12 weeks

•Physical therapy for strengthening

•NSAID’s

•ICE

Pathologic fractures:

Where does it occur?

what is most common?

what bone disease are associated?

•Fracture occurs through bone weakened by underlying, pre-existent pathologic bone lesion

•Metastatic bone tumors most common

•Other bone diseases: osteoporosis, osteomalacia and Paget’s

•Traumatic event “trivial”

–May be spontaneous: vertebral compression fx

•Clinical findings same as any fracture

•Need to work-up/find underlying cause