TCP Week 7 (Extremity Trauma)

fracture definition

a disruption in the integrity of living bone, involving injury to bone marrow, the periosteum, and adjacent soft tissues

closed fracture

bone breaks without creating a wound in the skin

open fracture

bone breaks through skin (types I - III)

type 1 open fracture

clean,

type 2 open fracture

>1 cm

clean wound

no major soft tissue damage

type 3 open fracture

>1 cm

significant soft tissue disruption

unstable fracture, fragmentation, high impact injury

intra-articular fracture

fracture extends into the joint space

extra articular fracture

a fracture that does not involve a joint surface but is adjacent to the joint

displaced fracture

bone breaks in 2 or more parts, ends move so they do not line up

angulated fracture

fracture fragments at angles to each other

transverse fracture

fracture line at right angle to long axis of bone

oblique fracture

fracture line with angle other than right angle

spiral fracture

fracture line encircles bone

comminuted fracture

fracture in more than 2 pieces

non-displaced fracture

bone cracks partly or all the way through, does not move, maintains its alignment

linear fracture

fracture runs parallel to long axis of bone

impacted fracture

collapse of one fragment of bone into another

avulsion fracture

occurs when a ligament or tendon pulls fragment of bone away

dislocation

complete disruption in normal relationship of articular surfaces of bones comprising a joint

subluxation

incomplete dislocation

segmental fracture

fracture in 2 parts of the same bone

torus/buckle fracture

fracture ends are driven into each other

often seen in kids

*differs from impacted fx: m/c in kids, not a complete break in the bone

greenstick fracture

incomplete fracture; bone bent

stress fractures occur most commonly occur in

in lower extremity

stress fractures are typically due to? and they are?

repetitive trauma; subtle

stress fracture diagnosis

bone scan or MRI

epiphysis

distal end of bone

physis

growth plate

metaphysis

bone shaft

salter-harris fractures are

growth plate injuries in children

type I salter harris fracture

epiphysis separated from metaphysis

type II salter harris fracture

fracture through physis, oblique fracture of metaphysis

type III salter harris fracture

vertical fracture of epiphysis perpendicular to physis, extending into growth plate

type IV salter harris fracture

vertical splitting of epiphysis, extending through physis and metaphysis

type V salter harris fracture

crush to epiphysis at physis

s/sx clavicle fracture

clavicle:

- deformity

- swelling

- tenderness

- crepitus

Tx of clavicle fracture

if open: abx

if closed: sling

orthopedic referral

what is the most commonly dislocated joint?

shoulder (anterior dislocation 90% of the time)

PE and diagnosis of shoulder dislocation

PE:

- AC step-off

- ROM

- neurovascular status

Imaging:

- Y-view XR

shoulder dislocation treatment

reduction and immobilization

with ortho f/u

s/sx of radial head fracture

- limited ROM

- pain with pronation and supination

- posterior fat pad (occult fx)

radial head fracture treatment

splint, sling

what occurs during nursemaid elbow?

subluxation of the radial head

nursemaids elbow typically effects what ages?

s/sx?

1-3

child will not move arm

nursemaid elbow treatment

reduction

mechanism of colles' fracture

FOOSH

colles' fracture

transverse fracture of distal radius with dorsal angulation

colles' fracture treatment

sugar tong splint

sling

scaphoid fractures are often?

scaphoid fractures carry a high risk for?

missed

avascular necrosis due to poor blood supply

s/sx of scaphoid fracture

snuffbox tenderness

if tender, ask for specific XR of this area

treatment for scaphoid fracture

thumb spica splint, sling

boxer's fracture definition

fracture of the neck of the 5th metacarpal

boxer's fracture s/sx and mechanism

hand swelling, tenderness, open wounds

typically after punching

boxer's fracture treatment

- ulnar gutter splint, sling

- antibiotics

s/sx of hip fracture

- groin pain

- shortening and external rotation

hip fracture treatment

- immobilization

- orthopedic consult

knee sprain: causes and s/sx

- ligament injuries or meniscal tears

- tenderness, joint effusion

diagnosis and treatment for knee sprain

diagnosis: XR to r/o fracture

treatment: immobilization, crutches

malleolar fractures s/sx

- point tenderness at malleolus

- swelling

- pain with walking

Maisonneuve fracture

proximal fibular fx (near head) as a result of torsional stress

diagnosis and treatment of malleolar fracture

diagnosis

- XR: also EXCLUDE MAISONNEUVE fracture!

- Ottawa ankle rules

treatment:

- posterior splint with stirrup

- crutches

- ortho referral

what is the most commonly affected ligament in ankle sprains

anterior talofibular ligament

mechanism and s/sx of ankle sprains

falling & twisting

s/sx:

- swelling

- ecchymosis

- point tenderness

diagnosis and treatment of ankle sprains

diagnosis: anterior drawer test

treatment: RICE, crutches

jones fracture

fractured base of 5th metatarsal

mechanism and s/sx of jones fracture

mechanism: crush or twist

tenderness and swelling

treatment for jones fracture

posterior splint, crutches

history to obtain in evaluating extremity trauma

- MOI

- associated events

- hx of previous fractures

- PMHx, PSHx, social history, occupation, medications, allergies

outline the PE pertinent to the eval of the upper and lower extremity trauma

- Trauma: primary and secondary surveys

- ROM of all joints

- Assess joints above and below injury

- Neurovascular status

- Associated injuries

grade I sprain and treatment

- Incomplete tear

- Swelling, ecchymosis

treatment: immobilization

grade II sprain and treatment

- Significant incomplete tear

- Swelling, ecchymosis, LAXITY IN JOINT

treatment: immobilization, orthopedic follow-up

grade III sprain and treatment

- Complete disruption

- Joint unstable

treatment: orthopedic consult for surgical repair

MOI of compartment syndrome

- fractures

- crush injury

compartment syndrome is m/c where? causes?

lower extremity, 4 compartments. causing:

- swelling

- vascular compression

- neurologic compromise

what are the 6 Ps of compartment syndrome

Pallor: pale, shiny skin

Paralysis: inability to move

Pulselessness: late finding

Pain: out of proportion to exam

Paresthesias: pins and needles

Poikilothermia: different limb temperatures

all distal to the area of injury

diagnosis of compartment syndrome

measure intracompartmental pressure

Level >30 mmHg ABNORMAL

complications of compartment syndrome

loss of function of limb

loss of limb

treatment of compression syndrome

- Immobilize

- Elevate

- Cool

- Remove bandages

- Fasciotomy

ED treatment for sprains and fractures (procedural sedation)

- For reduction, need muscle relaxation and pain control

- IM or IV sedation: meds with rapid onset and short-acting medicines

ED treatment for sprains and fractures (splinting and disposition)

splinting while patient is still sedated

disposition:

- hospital admission for surgery

- discharge with outpatient orthopedic referral