EM E2: Ortho

What should be included on XR of a broken bone?

joint above/below

T/F: A report of negative findings does not rule out significant injury

True

What needs to be included when describing fxs?

open vs closed, location, orientation of fx line, displacement or separation, shortening, angulation, rotation, subluxation

Label each type of long bone/shaft fx

A) Transverse B) Oblique

C) Spiral D) Comminuted

E) Segmental F) Torus

G) Greenstick

What is shortening?

bone’s length has been reduced

What is angulation?

amount bone bent, must describe which direction the short terminal or distal fragment is pointing

Review Salter-Harris fxs

🙂

Why should control of pain and swelling of fx be done early?

swelling can delay immobilization dressing

Should you withhold analgesics for fxs in order to get a more accurate PE?

NO -have virtually no effect on the pain of movement or manipulation of an injury

What is important to ask about when obtaining pt hx regard hand/digit injury?

time/cause of injury, MOA, pt occupation, handedness (R vs L handed)

What needs to be done before anesthesia is given for injuries?

test sensation and ROM (+against resistance)

What are the minimum view you should get for a hand/digit injury?

PA, lateral, oblique

What is the MCC of injury to flexor tendons?

laceration

What is the tx for flexor tendon lacerations?

primary repair w/in 12 hr, secondary up to 4 weeks after

What is a common injury to the flexor tendons?

Jersy finger (avulsion of FDP from its insertion)

What is the MC site of tendon injury?

extensor tendons

What might blunt trauma to the extensor tendon cause?

“mallet finger” may develop into swan-neck deformity

What is the MC ligamentous injury to the hand?

axial load and hyperextension of PIP

What is gamekeeper’s or skier’s thumb?

rupture of ulnar collateral ligament

*refer to surg if weak pincer function

What splint is needed for gamekeeper’s thumb?

thumb spica splint

What cause distal phalanx fxs?

crush or shearing forces

*tx as soft tissue injury w/ splinting

What is a Bennett fx?

intraarticular fx w/ subluxation or dislocation of CMC

What is a Rolando fx?

intraarticular comminuted fx at base of metacarpal

*thumb spica splint & surg consult

What hand injury might cause compartment syndrome?

crush injury → pain/paresthesias early → paralysis and pulselessness

*measure pressure

What is the tx for compartment syndrome?

fasciotomy

What causes most wrist injuries?

FOOSH

What does anatomic snuffbox tenderness indicate?

scaphoid fx

What is the best way to evaluate wrist injuries?

radiography

What are the splints used for a scaphoid fx?

long-arm vs short-arm thumb spica cast

What is the tx for scapholunate ligament instability?

radial gutter spint or short arm volar posterior mold, ortho referral

What is the tx for triquetrolunate ligament instability?

ulnar gutter splint, short arm posterior mold, ortho f/u

What is the tx for perilunate and lunate dislocations?

ALL get emergent ortho consult

What is the MC missed wrist injury?

carpal bone fx

What complication can arise from a scaphoid fx?

AVN

What is the tx for triquetrum fx?

*twisting motion of hand is suddenly resisted

sx: wrist splint x 1-2 weeks

asx: 6 wk cast, may need internal fixation

What is the tx for a lunate or trapezium fx?

thumb spica splint

*displaced → surgery

What is a Colles fx?

distal radial metaphysis fx, dorsally angulated, displaced proximally

What is a Smith fx?

“reverse Colles”, volar angulated fracture of distal radius

What is the tx for Colles or Smith fx?

stable: compression and splint → ortho, or closed reduction

may require casting w/ pinning, external fixation, or ORIF

What is a Barton fx?

wrist fx involving distal radius, dislocation of radiocarpal joint

*Dorsal: fx extends through dorsal radius

*Volar: fx extends through the volar aspect

What is the tx for a radial styloid fx?

ORIF

What is the tx for an ulnar styloid fx?

ulnar gutter splint in slight ulnar deviation

What is the MC elbow dislocation?

posterior

What is the tx for an elbow dislocation?

sedation, closed reduction, plaster splint from axilla to fingers

Who are intercondylar elbow fxs more common in?

adults (assoc w/ soft-tissue injury)

What should you watch for w/ supracondylar elbow fxs?

*extension-type MC

acute vascular injury

What do you need to assess for with elbow fxs?

nerve injury (ulnar nerve common)

What splint is used for radial head fx?

sugar tong splint

What sign on an XR indicates an elbow fx?

Fat pad sign

How do biceps tendon ruptures present?

flexion of forearm → pain, mid arm ball “Popeye”

What is the tx for a biceps tendon rupture?

sling, ice, pain meds, surgical repair

How do sternoclavicular dislocations present/

uncommon (MVA or sports), severe pain worsened by arm movement

*CT = TOC; closed reduction

Where do most clavicle fxs occur?

middle third

*d/t blow to the shoulder

What is the tx for a clavicle fx?

immobilize w/ sling: figure-of-eight brace

What is a complication of reducing a shoulder dislocation?

rotator cuff tear or recurrent dislocation

What is the MC type of should dislocation?

anterior

Who is more likely to get a proximal humerus fx?

elderly osteoporotic pts

What is common w/ humeral shaft fx?

neurovascular injury, displacement, distal 1/3 prone to entrap radial nerve

What makes up the brachial plexus?

C4-T1 nerve roots

*injury: arm pain, constant, burning

What needs to be done if you suspect spine injury?

immobilize → long spine board, cervical spine collar

Which C-spine fx are considered VERY unstable?

atlanto-occipital or atlanto-axial dislocation ± odontoid fx

What is a Jefferson fx?

axial load, burst fx of lateral masses of C1

How does an odontoid (dens) fx present?

immediate, severe, high cervical pain, muscle spasm, can cause quadriplegia

*3 types

What is a Hangman’s fx?

traumatic spondylolysis of C2 (most often result of head-on collision)

How does a simple wedge fx present?

dec ht, inc concavity of anterior vertebral body/ inc density of vertebral body/ soft-tissue swelling

What is a teardrop fx?

wedge-shaped fragment of anteroinferior vertebral body displaced anteriorly; commonly involves ligamentous injury

What is a Clay-Shoveler’s fx?

oblique fx of base of spinous processes of lower cervical vertebrae, stable, usually no neuro involvement

What is a burst fx?

occurs in C & L-spine, vertebral body shattered outwards from within, stable, may impinge on spinal cord

What is subluxation?

rupture of ligamentous complexes w/o bony injury → widening of interspinous space + gaping of intervertebral space posteriorly

*flexion/extension views necessary

What is a wedge compression fx?

compression of anterior vertebra (osteoporosis)

What is the tx for cervical sprain/strain?

NSAIDs, muscle relaxers (Naproxen, Tylenol, Toradol IM, skelaxin, etc)

What causes a break in the pelvic ring?

MVA or ped vs MVA → complex urogenital and vascular injury, hemorrhage

What cause acetabular fx?

MVAs, usually knee vs dashboard

*reduce and internal fixation

What do femoral head fxs usually occur with?

dislocations of the hip

Who are femoral neck fxs commonly seen in?

older adults (osteoporosis)

What is the tx for trochanteric fx?

conservative w/ protect weight-bearing, outpt ortho referral; may need screw fixation if there is displacement

What is the tx for an anterior hip dislocation?

true ortho EMERGENCY, early closed reduction

What is the MC type of hip dislocation?

posterior

What is the tx for a posterior hip dislocation?

closed reduction

*comp: sciatic nerve injury, AVN

What causes femoral shaft fx?

direct trauma → obvious shortening, deformity, swelling

What is the tx for a femoral shaft fx?

careful neurovascular exam, most need surgical intervention, open = abx, debridement

What is the concern w/ femoral condyle fx?

popliteal artery injury

*other comps: DVT, fat embolus syndrome

What is the tx for a femur fx?

cast immobilization; ORIF as necessary

What is the MC type of patella fx?

transverse

What is the tx for a patella fx?

nondisplaced: immobilizer, ice, elevation, NSAIDs

displace: early ortho referral for ORIF

What XR view is needed for patella fx?

sunrise view

What is the MC ligamentous injury?

ACL

(+Lachman, + anterior drawer)

What is the tx for ligamentous and meniscal injuries?

often require surgical correction

What is the tx for tibia fx?

admit for pain control, observation for compartment syndrome (requires significant force); open → ortho

What is the tx for a fibula fx?

*seen w/ tibia fx or stress

pain meds, cessation of activity, immobilization, ice, elevation

What is the ED tx for an achilles tendon rupture?

*have pt walk on toes to help dx

splinted in neutral position w/ posterior splint, prompt ortho referral, crutches

What is the tx for a gastrocnemius rupture?

(calf is tender, swollen, bruised)

immobilization w/ posterior splint, crutches, ice, pain meds

What is the MC ankle injury?

lateral ligament complex sprain

What is the tx for an ankle sprain?

RICE, ankle brace, f/u

What is the tx for ankle strain/contusion?

analgesics, rest, rehab

What do all fx of the ankle require?

immobilization by cast alone or surgical reduction w/ casting

What is turf toe?

forced hyperextension of first proximal phalanx d/t repetitive push-off mechanism on hard surface

What is the tx for a talar fx?

immediate ortho → open reduction

What is the tx for fx of the calcaneous?

posterior slab, crutches, ortho

What is the tx for injuries to the Lisfranc joint?

ORIF