Fracture and Dislocation Management

• tuning fork

• compression

• distraction

• percussion

fracture assessment tools/techniques

• deformity

• open wounds

• tenderness

• swelling

DOTS acronym for head-to-toe assessment

transverse fracture

fracture that is perpendicular to the shaft of the bone

linear (longitudinal) fracture

fracture that splits down the length of the bone

oblique fracture

fracture with a spiral shape; occurs when one end of the bone is fixed and the other end is twisted

spiral fracture

fracture with an s-shaped separation; occurs when ends of bone are twisted in opposite directions

greenstick fracture

incomplete break of bone that has not fully ossified (children under 10)

comminuted fracture

fracture that consists of >3 fragments at the fracture site; often caused by a hard blow or fall

avulsion fracture

fracture where a ligament or tendon pulls off a piece of bone

impacted/compression fracture

fracture caused by a fall from height causing the bone to be compressed

serrated fracture

fracture where bony fragments have sawtooth fracture line

stress fracture

fracture caused by repetitive microtrauma that exceeds the stress bearing capacity of the bone

Type I

Salter-Harris fracture with complete separation of the physis with no fracture to the bone

Type II

Salter-Harris fracture with separation of the growth plate occurring along with a small portion of the metaphysis

Type III

Salter-Harris fracture that is an epiphysis fracture

Type IV

Salter-Harris fracture where portions of both the epiphysis and metaphysis fracture

Type V

Salter-Harris fracture where a crushing force causes a gross deformity without displacing the physis

• signs of fracture

• low chance of successful reduction

• concomitant injury

• 1st attempt unsuccessful

• children aged 6-12

• suspected growth plate involvement

joint reduction contraindications

• distract

• disengage/recreate deformity

• reposition

general steps for reducing joint

shoulder

most commonly dislocated joint

95%

% of shoulder dislocations that are anterior

anterior shoulder dislocation

shoulder dislocation that presents with abducted and externally rotated position

inferior shoulder dislocation

shoulder dislocation that presents with limited abduction

posterior shoulder dislocation

shoulder dislocation that presents in an internally rotated and adducted position

axillary artery and nerve

adjacent structures that can be damaged during shoulder dislocation

Boss-Holzach-Matter Maneuver (Davos) Technique

shoulder self-reduction technique where patient grabs their knee and leans back

77-86%

Boss-Holzach-Matter Maneuver (Davos) Technique success rate

External rotation maneuver

shoulder reduction technique where patient is supine with elbow flexed to 90 and longitudinal traction is applied while gently externally rotating

Stimson technique

shoulder reduction technique where patient lies prone with affected shoulder hanging off table in 90 forward flexion and a 5-15lb weight is attached to the wrist

28-96%

Stimson Technique success rate

~90 seconds

Boss-Holzach-Matter Maneuver (Davos) Technique relocation time

8-20 minutes

Stimson technique reduction time

spaso technique

shoulder relocation technique where patient lies supine with arm straight up, distraction force is applied while externally rotating the arm and can be aided by a second clinician stabilizing the scapula

traction-countertraction/matsen technique

shoulder relocation technique where patient lies supine; one provider provides traction on humerus while a second provider provides a counterforce along the patient’s chest

scapular manipulation technique

shoulder relocation technique where patient lies prone and longitudinal traction is applied to the humerus and another clinician applied a medial glide on the scapula

Milch maneuve

shoulder relocation technique where patient is supine with scapula fixated and longitudinal traction is applied while the arm is externally rotated and abducted

FARES method

shoulder relocation technique where patient is supine with elbow extended and forearm in neutral. Wrist is grasped with both hands and a gentle longitudinal traction is applied while oscillating the arm and slowly abducting.

Cunningham Technique

Shoulder relocation technique where patient is seated and has arm in adducted position next to the body with the elbow flexed to 90; clinician places hand between the patient’s forearm and body with the wrist/hand resting on clinician’s upper arm and gentle traction is applied while massaging the trapezius, deltoid, and biceps with the other hand.

elbow

second most commonly dislocated joint8

80%

percent of elbow dislocations that are posterior

• 10-19 y/o

• male

• wrestling, football, and gymnastics

elbow dislocation risk factors

• patient seated or supine

• inline traction

• forearm supination

• elbow flexion while placing direct pressure on tip of olecranon

elbow reduction technique

extension and valgus stress

post-reduction elbow unstable positions

dorsal DIP joint

most common finger dislocation

• fracture

• tendon rupture

• rings present

• growth plate

• 6-12 y/o

finger relocation contraindications

apply direct pressure over dorsal aspect of proximal phalanx with wrist in flexion

dorsal finger dislocation reduction method

apply direct pressure over volar aspect of proximal phalanx with MCP in flexion

volar finger dislocation reduction method

• stabilize phalange proximal to dislocated joint and grasp dislocated segment

• apply longitudinal traction and force to exaggerate dislocation

• apply force to base of dislocated segment in direct opposire direction

exaggerated finger reduction method

• stabilize phalange proximal to dislocated joint and grasp dislocated segment

• apply axial traction to dislocated segment while pushing bone in opposite direction of dislocation

traction finger reduction method

flexed and adducted hip with axial load through flexed knee

hip dislocation MOI

90%

% of hip dislocations that are posterior

hyperextension or pivot shift mechanism

knee dislocation MOI

50%

% of knee dislocations that self reduce

• male (4:1)

• football

• MVC

• extreme sports

knee dislocation risk factors

• one clinician stabilize distal femur, other grasps tibia

• apply longitudinal traction to tibia

• if unsuccessful, reverse dislocation of tibia

knee dislocation reduction method

30 degrees

degree to lock TROM after knee reduction

lateral

most common patellar dislocation

foot planted and internal twist while knee in valgus

patellar dislocation MOI

• hip flexed

• slowly extend knee while applying pressure to lateral patella

patellar dislocation reduction

31%

% of ankle dislocations that occur is ports

forceful landing on or into surface; contact

ankle dislocation MOI

posterior

most common ankle dislocation

posterior

ankle dislocation where talus is posterior to tibia; associated with fracture to lateral malleolus

anterior

ankle dislocation where talus is anterior to tibia

lateral

ankle dislocation where talus is lateral to tibia; associated with bimalleolar fracture or distal fibular fracture

superior or diastasis injury

ankle dislocation where talus is superiorly located within the mortise (separation of syndesmosis)

• anatomical splint

• rigid splint

• soft splints

• traction splints

types of splints/imobilization

anatomical splint

splint using another part of the body

soft splints

splints that do not limit as much motion and conform better to extreme injuries (ie towel, cervical collar, pillow, etc)

rigid splints

splint that limits further movement such as SAM splints, ortho-glass, and aluminum finger splints

air splints

clear, inflatable plastic splints that are inflated and provide uniform compressive force around the injured extremity; can NOT be used with displaced or open fractures

PneuSplint

splint that is held in place with quick open and close straps; work for non-displaced and angulated injuries

vaccum splint

splint composed of strong, tough plastic containing polystyrene beads

• open fracture

• excessive bleeding

vaccum splint potential contraindications

• stabilize fracture

• reduce blood loss

• reduce muscle spasm

• maintain distal vascular supply

traction splint benefits

2

number of people required to place traction splint

clavicle sling

sling type

desault bandage

sling type

soft splint with sling and swathe

sling type

posterior elbow splint

sling type

dorsolateral rigid splint elbow dislocation

sling type

sugar tong splint

sling type

Volar SAM splint

sling type

rigid volar splint

sling type

ulnar gutter splint

sling type

dorsal finger splint

sling type

SAM splint/ankle stirrup

sling type

SAM splint: cadillac

sling type

ankle soft splint

sling type

lower leg/anatomic soft splint

sling type

lower leg rigid splint

sling type

knee anatomic/soft splint

sling type

rigid straight leg splint

sling type

6 inches

distance crutches should be in front of body when fitting

2 inches

distance crutches should be at the side when fitting

~1inch (2-3 fingers)

distance between top of crutch and underarm

12-18 inches

distance crutches should be placed in front of body when moving in tripod method