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Orthopedic Trauma

Orthopedic Trauma. Landon C. Bartlett, MHS,PA-C, EMCAQ ER Physician Assistant St. Joseph Mercy Livingston Emergency Dept Brighton Emergency Department St. Joseph Mercy Ann Arbor ED EMPG, PC August 2012. Initial Management. ABCDEs of Trauma Evaluation Primary Survey

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Orthopedic Trauma

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  1. Orthopedic Trauma Landon C. Bartlett, MHS,PA-C, EMCAQ ER Physician Assistant St. Joseph Mercy Livingston Emergency Dept Brighton Emergency Department St. Joseph Mercy Ann Arbor ED EMPG, PC August 2012

  2. Initial Management • ABCDEs of Trauma Evaluation • Primary Survey • Airway, Breathing, Circulation, Disability, Exposure • Secondary Survey • Head to toe examination, maintain C-spine immobilization • Reduce orthopedic emergencies: Vascular Compromise • Manage Limb Threatening Injures • Traumatic Amputation • Compartment Syndrome

  3. Manage Limb Threatening Injures • Traumatic Amputation • Guillotine best for reimplantation • Crush injuries less successful • X-ray: • help establish precise location of injury • Treatment: • Moist saline dressing of stump and amputated part • Place amputated part in plastic bag on ice • Do not allow to freeze • Viability 6-8 hours, 12-24 with cooling • Antibiotics and Tetanus • Disposition • Admit limb amputation to appropriate service • Digit amputation: Specialty eval. In ER or close follow up

  4. Compartment Syndrome • Lower extremities, but can occur anywhere (hand, forearm, abdomen) • Crush Injury, fractures, surgery, etc. • Neurovascular compromise due to swelling in compartment • 5 P’s • Pallor, Pulselessness (late), Pain, Paresthesias and Poikilothermia • Early findings • Pain out of proportion with passive ROM • Sensory hypoesthesia • Measure intracompartmental pressure • Stryker or Arterial Line Pressure Monitor • Above 30 mmHg ABnormal • Decompression Fasciotomy within 4-8 hours

  5. General Considerations • Fractures and Dislocations • Terminology: open/closed, proximal/distal, transverse/oblique, displaced anterior/posterior/medial/lateral, angulated • Describe relative to distal structures relation to proximal portion • Type of Injury (Special Names) • Salter Harris • Lisfranc

  6. Describe This Fracture

  7. Salter Harris Fractures • Type I • Through physis • Excellent prognosis • Type II • Most common • Through physis with oblique Metaphyseal fracture • Excellent prognosis • Type III • Epiphysial fracture through physis • Common in distal tibia • Requires appropriate reduction to prevent growth plate arrest • Good prognosis • Type IV • Through Metaphysis, Epiphysis and physis • Surgical Repair to prevent growth plate arrest • High risk for growth plate arrest • Type V • Rare, usually distal tibia and knee • Crushing forces • No fracture visible = frequently missed • Shortening and angular deformity due to growth plate arrest

  8. Sprains & Strains • Can be associated with fracture • Grades I-III • I: incomplete tear, conservative care • II: Significant incomplete tear, joint laxity, splint with follow-up • III: Complete disruption, unstable joint, splint with follow-up • RICE, NSAIDS, APAP • When in doubt splint and follow-up

  9. Splinting • Stabilize injury, pain relief, prevent further injury • Splint one joint above and one joint below the injury • Check neurovascular prior to discharge, after splint • Fiberglass, plaster, premolded

  10. Procedural Sedation • Goal: Analgesia, amnesia and relaxation without general anesthesia • Policy • Requirements: • Functioning IV, Supplemental Oxygen, Pulse Oximeter, Suction, Intubation Equipment, BVM • Etomidate, Versed/Opiate, Ketamine, Propofol • Discharge when ambulatory and tolerating PO fluid • Hematoma Block • Local anesthetic injection into fracture site

  11. Shoulder Girdle Injuries • Sternoclavicular Joint Dislocation • Clavicle Fracture • Acromioclavicular Joint Injury • Scapula Fractures • Rotator Cuff Injury • Shoulder Dislocation

  12. Shoulder Girdle Injuries • Sternoclavicular Joint Dislocation • Anterior most common • Immobilize (sling/swath) after reduction, analgesia, ortho follow-up • Posterior result of crushing forces to chest • 25% superior mediastinal injuries • CT all posterior dislocation • Specialty consultation, many require surgical repair • Usually require admission • Graded I-III • I: Mild sprain, analgesia and sling • II: Subluxation, rupture of ligament, analgesia, sling/swath • III: Complete Dislocation • Tender SCJ • X-rays: Chest, Clavicle and Sternal

  13. Shoulder Girdle Injuries • Clavicle Fracture • Fall onto shoulder, direct blow • Tender clavicle, possible deformity • X-ray: Clavicular • Closed fractures • Analgesia, sling or sling/swath, f/u ortho • Open Fractures • Antibiotics, Td, ortho consultation

  14. Shoulder Girdle Injuries • Acromioclavicular Joint Injury • 25% of shoulder girdle dislocations • Fall onto shoulder with point tender AC Joint • Grade I-III • I: Sprain, minimal tear, Ice, sling, analgesia • II: Small tear, no change with weight, Ice, sling, analgesia • III: Complete AC ligament disruption, coracoclavicular ligament and muscular attachments. Ortho referral with conservative or surgical treatment.

  15. Shoulder Girdle Injuries • Scapula Fractures • Uncommon, 1% of all fractures, well protected • Direct blow (high force) – other injuries i.e.. Rib fracture, lung contusion, pneumothorax, humerus fracture • Type I-IV • I: Coracoid process, acromion process or scapular spine • II: Scapular neck • III: Glenoid fossa, intra-articular • IV: Body, most common, risk of pulmonary contusion • Sling and swath, analgesia for isolated fractures

  16. Shoulder Girdle Injuries • Rotator Cuff Injury • Falls • SITS muscles (subscapularis, infraspinatus, teres minor and supraspinatus. • Positive “Drop Arm Test” • X-ray to rule out fracture • MRI, as outpatient • Sling, analgesia, ortho follow-up

  17. Shoulder Girdle Injuries • Shoulder Dislocation • Most common major joint dislocation • 95% Anterior Dislocations • Posterior dislocation -- seizures or electrocution • Neurovascular exam -- axillary nerve at lateral aspect of shoulder • Neurologic deficit - - contact ortho • X-rays: Y-view reveals anterior or posterior dislocation • Hill-Sachs deformity – Impacted post/lat. humeral head • Bankart Fracture – ant/inferior glenoid rim fracture, assoc. with anterior dislocation, may only be seen on CT • Reduction • Adequate sedation • Method: Scapular Manipulation, Traction-Counter traction • Sling/Swath, analgesia, Ortho follow-up 2-3 days

  18. Upper Extremity Injuries • Humerus Fracture • Supracondylar Fracture • Elbow Injures • Olecranon Fracture • Radial Head Fracture • Elbow Dislocation • Radial Head Subluxation (Nursemaid’s Elbow) • Forearm Fracture • Wrist & Hand Injuries • Lunate/Perilunate dislocation • Scapholunate Dislocation • Carpal Bone Fractures • Metacarpal Fractures • Phalanx Fracture/Dislocation • Ulnar collateral ligament rupture

  19. Upper Extremity Injuries • Humerus Fracture • Frequent in elderly, FOOSH • Neurovascular • Brachial artery • Radial nerve -- Wrist drop • Easily seen on x-ray • Conservative management • Sling & Swath or coaptation splint, analgesia, Orthopedic follow-up, contact while in ED. • Nearly 100% rate of union

  20. Upper Extremity Injuries • Supracondylar Fracture • Children predominantly • Risk for serious morbidity • Volkmann Contracture: Ischemic muscle damage • Neurovascular exam • Ulnar nerve most commonly injured (ABduction of fingers) • X-ray • Fracture, displacement • Anterior and Posterior Fat Pads • Orthopedic Referral for all! • Don’t reduce yourself. • Posterior long arm splint • Nondisplaced fractures can be discharged home with prompt ortho evaluation

  21. Upper Extremity Injuries • Olecranon Fracture • Direct trauma or avulsion • X-ray: AP, lateral • Acute orthopedic consult • Ulnar nerve injury • Displaced >2 mm • Posterior long arm and sling • Analgesia

  22. Upper Extremity Injuries • Radial Head Fracture • FOOSH or Direct Trauma • Pain with supination/pronation • X-rays • Occult fracture common • Posterior Fat: Never normal • Anterior Sail Sign • Simple nondisplaced • Splint, sling, analgesia, follow-up • Comminuted • Call orthopedist

  23. Upper Extremity Injuries(Radial Head Fracture)

  24. Upper Extremity Injuries • Elbow Dislocation • 2nd most common dislocated major joint • Posterior most common • Ulna posterior to humerus • Fractures common • Deformity visible at olecranon • Neurovascular (brachial artery and median nerve • Reduce immediately if neurovascular compromise • Reduction • Sedation • Traction (1-3 person) • Posterior long arm splint, sling, analgesia, Ortho follow-up

  25. Upper Extremity Injuries • Radial Head Subluxation (Nursemaid’s Elbow) • Children < 5 yo, 25% of elbow injuries in children • Traction injury, with slipping of annular ligament proximally • Child will not use arm, held in slight flexion and pronation forearm • Radial head tender, child resists supination • X-rays • Not needed if excellent story. Obtain if not. • Normal x-rays • Reduction (all with thumb on radial head) • Supination • Supination with flexion • Pronation with flexion • Successful if child resume usage in several minutes • “Positive sucker sign”

  26. Upper Extremity Injuries • Forearm Fractures • FOOSH injuries • Assess nerve injury • 6 Common Fractures • Colles’- transverse distal radius with dorsal angulation • Smith - transverse distal radius with volar angulation • Barton– oblique, intra-articular of distal radius with dorsal displacement of distal fragment along with dorsal carpus subluxation • Chauffeur’s – intra-articular distal radial styloid • Monteggia – Ulnar fracture with radial head dislocation • Galeazzi – Distal 1/3 radius fracture with dislocation of distal radioulnar joint • GRUM/MUGR • Galeazzi=radial fracture • Ulna=Monteggia

  27. Upper Extremity Injuries • Forearm Fractures • Nondisplaced • Volar or sugar-tong splint to metacarpals • Ortho follow-up • Displaced • Reduction • Hematoma block, traction, analgesia • Sugar-tong splint • Orthopedic referral

  28. Colles’ Fracture • Transverse distal radius with dorsal angulation • SMITH Fracture • “Reverse Colles” • Transverse distal radius with volar angulation

  29. Smith Fracture • “Reverse Colles” • Transverse distal radius with volar angulation

  30. Barton Fracture • oblique, intra-articular of distal radius with dorsal displacement of distal fragment along with dorsal carpus subluxation

  31. Chauffeur’s Fracture • Intra-articular distal radial styloid

  32. Monteggia Fracture • Ulnar fracture with radial head dislocation • Need good lateral x-ray • Proximal Radial Line bisects Anterior Humeral line • Open Reduction if prolonged dislocation • Loss of range of motion

  33. Monteggia Fracture

  34. Galeazzi Fracture • Distal 1/3 radius fracture with dislocation of distal radioulnar joint

  35. Upper Extremity Injuries • Hand and Wrist Injuries • Anatomy • Carpal bones • “Sally Left The Party To Take Connie Home” • Tenuous blood supply • Avascular Necrosis • When in doubt: Splint and refer to Ortho

  36. Upper Extremity Injuries • Perilunate/Lunate Dislocation • FOOSH • Severe pain, swelling, decreased ROM • Median nerve injury possible • Lateral Wrist X-ray (most important) • Spilled tea cup • Line through center of radius and capitate with lunate either dorsal or volar displaced • Urgent reduction in the ER • Surgery likely due to extensive ligamentous injury even if reduction successful

  37. Perilunate/Lunate Dislocation

  38. Upper Extremity Injuries • Scapholunate Dislocation • Frequently missed as sprain • FOOSH • AP Wrist x-ray • “Terry Thomas Sign” • Space between scaphoid and lunate more than 3mm • Splint, analgesia • Refer to orthopedist for repair

  39. Upper Extremity Injuries • Carpal Bone Fracture • FOOSH • Kienbock Disease • AVN of Scaphoid and/or Lunate • Scaphoid Fracture • Snuff Box tenderness • splint with ortho follow-up • Risk of AVN • Treatment • Thumb Spica: Scaphoid • Ulnar Gutter: Triquetral • Repeat x-rays in 1-2 weeks for occult fractures • Orthopedic follow up

  40. Upper Extremity Injuries • Metacarpal Fractures • Boxer’s Fracture (5th Metacarpal) • Most common • Punching • Angulation Indicates Reduction: 10/20/30/40 • Laceration of 4th/5th MCPJ = “Fight Bite” (human bite) • Infection and tendon injury – HIGH RISK • Antibiotic - Augmentin • No wound closure • Splint in position of function • Hand Surgeon

  41. Upper Extremity Injuries • Metacarpal Fractures • Bennet Fracture • Intra-articular base of 1st metacarpal • Require operative repair as outpatient • X-rays • Displacement and Angulation • 10,20,30,40 rule • Reduction • Hematoma Block, traction and manipulation • Splint • Volar Splint for 2nd-4th Metacarpal Fractures • Ulnar Gutter for Boxer’s Fracture • Thumb Spica Splint for Bennet Fracture

  42. Upper Extremity Injuries • Phalanx Fractures and dislocations • Neurovascular • Rotational injury • X-ray • Reduction • Digital Block with Bupivacaine • Finger splint with Hand Surgeon Follow-up

  43. Distal Extensor Tendon Injuries • Mallet Finger • Extensor tendon laceration/avulsion at distal phalanx insertion • Unable to straighten finger tip (DIPJ) • Possible avulsion fracture • Splint at DIPJ for 6 weeks • Open wounds • Antibiotics • Hand surgeon follow up

  44. Distal Extensor Tendon Injuries • Boutonniere Deformity (Button Hole) • Rupture of central portion of extensor tendon at insertion of middle phalanx • Trauma i.e.. Jammed finger • Pain, swelling dorsal PIPJ • Insidious onset 7-21 days • X-rays usually normal • Splint in extension for 6 weeks, leave DIP alone • Open injury– Hand surgeon

  45. Pelvic Girdle Injuries • Pelvic Fractures • Hip Injures • Hip Fractures • Hip Dislocations

  46. Pelvic Girdle Injuries • Pelvic Fractures • Stable • Ground level fall • Unilateral super/inf. Rami fracture • Analgesia, weight bare as tolerated, DVT prophylaxis • Unstable • High impact injury • Multisystem trauma • 50% mortality if Shock • Bilateral ring disruption • Rami + Sacrum or Ilium • Symphysis pubis + sacral fracture/sacroiliac ligament disruption • Assoc. with genitourinary injury • High riding prostate/meatal blood • Retrograde cystogram • Blood loss of 1-5 liters • ABCs, Resuscitation • Operative Treatment

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