FRACTURES  BY  MECHANISM  Lucas  Friedman,  MD  

EPICC  March  21,  2014  

OBJECTIVES  

   Triaging     Physical  Exam  and  Can’t  Miss  Injuries  

   Immobilization  

   Pain  Management  

   Fracture  Principles     Upper  Extremity  Fractures  

   Lower  Extremity  Fractures  

DISCLOSURE  

  No  Financial  or  Commercial  Bias  

   Although,  if  REI  is  listening  I’m  ready  for  sponsorship  

TRIAGE  

PHYSICAL  EXAM  &  CAN’T  MISS  INJURIES  

PHYSICAL  EXAM  

   Neurovascular/Motor  (CMS)  distal  to  injury     ABI  (<0.9),    Compartment  pressure  (>30)  

   X-­‐ray       ≥  2  views       Joints  Above/Below     +/-­‐  Comparison  views  

   Ultrasound     CT     Severe  trauma     Complex  fractures  

   MRI     Non-­‐bone  (e.g.  SCIWORA,  Joints,  etc.)  

CAN’T  MISS  –  COMPARTMENT  SYNDROME  

   P:  PAIN  

   P:  PALLOR  (poor  perfusion)  

   P:  PULSE  (weak  to  pulselessness)  

   P:  PARALYSIS     P:  PARESTHESIA  

   Don’t  forget  about  the  K+  

CAN’T  MISS  –  CHILD  ABUSE  

   Skeletal  series       +  <  2  yo     +/-­‐  2-­‐5  yo     -­‐  >  5  yo  

CAN’T  MISS  –  CERVICAL  SPINE  INJURY  

   Red  Flags    NEXUS  

   PECARN  

   SCIWORA  

IMMOBILIZATION  

   Goals:     Immobilize  potentially  broken  bones     Reduce  chance  for  further  soft  tissue/neurovascular  injury  

   Decrease  pain  

SPINAL  PRECAUTIONS  

   Fulcrum  at  C2-­‐C3  or  Age  –  2  

   Î  C-­‐spine  injuries    =  Î  Mortality  

SPLINTING  

   CMS  Check  

   Reduce       Elderly  vs  Peds  skin     Resistance     Open  and  dirty    

   Padding  (1/2,  no  wrinkles,  extra)  

   Plaster  >  Fiberglass  (above/below  &  MOLD)     Room  Temp  Water     Width  >  ½  Circumference     10-­‐14  plaster  layers     Palms  (no  bumps—pressure  necrosis)     Smooth  edges  (lacerations)     Not  too  tight  (compartment  syndrome)  

   Position  of  function    =  Less  Contractures     CMS  Check  

   Crutches  >  6  years  old  

TRACTION  

   Indications     Closed/Open  Femur/Tibia  Shaft  Fractures     Pain  management     Minimize  hemorrhage  from  unstable  fractures  

   Contra-­‐indictations     Pelvic/Hip/Knee/Ankle/Foot  Injury  

   Complications     Peroneal  nerve  injury     Compartment  syndrome     DVT     Pressure  sore  

PAIN  MANAGEMENT  

  NPO     Intranasal     IM     IV  (LMX,  EMLA,  J-­‐tip-­‐>Sedation)     Hematoma  block     Nerve  /  Bier  Block  

   Ibuprofen  =  Oxycodone  

PEDIATRIC  BONES  PRINCIPLES  

Growth  plate  fractures    >    

Sprains  /  Dislocations  

Bend  >  Break  

TORUS  (BUCKLE)  VS  GREENSTICK  FRACTURE  

ORTHO  SPEAK  

   Location     Angulation     Shortening/Distraction     Displacement  

  Orientation  to  the  physis  

  Open/Closed  

   Comminuted  

   Intra-­‐articular  

SALTER-­‐HARRIS  FRACTURES  

  Slipped    Above    Lower    Through    Rammed  

OSSIFICATION  CENTERS  BY  AGE  

UPPER  EXTREMITY  INJURIES  

CLAVICLE  FRACTURE  

   Mechanism:  Fall  onto  shoulder  

   2-­‐12%  of  Fractures  (44-­‐66%  Shoulder  area  Fractures)     Middle  (80%)     Proximal  (5%)  

   Complications:     Pneumothorax     Brachial  Plexus  Injury     Vascular  Injury  

   Treatment:       Sling  =  figure  of  8       Surgery    

   Z,  >  2cm     Open     Proximal  Posterior  Displacement    

SUPRACONDYLAR  FRACTURE  

   60%  of  Elbow  Fractures  

   Mechanism:       FOOSH  with  hyperextension  

   Complications:     Bracheal  Artery     Median/Radial  Nerve     Volkmann  Ischemic  Contracture  (compartment  syndrome)  

   Treatment:     Immobilize  in  position  (<20-­‐30  degree  flexion)  

   Posterior  long  arm  splint  (<90  degree  flexion)  vs.  Reduction  and  Internal  Fixation  

NURSEMAID’S  ELBOW  

   Annular  Ligament  Displacement  (Radial  Head  Subluxation)  

C-­‐R-­‐I-­‐T-­‐O-­‐E  

Capitellum Radial Head Internal epicondyle Trochlea Olecranon Ext. Epicondyle 1 3 5 7 9 11 years

IF  FRACTURE  LOOK  FOR  DISLOCATION  

   Radial/Ulnar  Fractures  2nd  MC  Fx  

   Mechanism:    FOOSH     Shaft     GRUM  

   Galeazzi  (Radial  Fx)     Monteggia  (Ulnar  Fx)  

   Distal     Collies,  Smith,  etc.  

   Complications:       Compartment  syndrome     CMS  (pronation/supination,  PIN  

   Treatment     Reduction     Sugar-­‐tong,  Volar     ORIF,  Pining  

LOWER  EXTREMITY  INJURIES  

SLIPPED  CAPITAL  FEMORAL  EPIPHYSIS  (SCFE)  

   Mechanism:  Puberty,  Obesity,  &  minimal  trauma  

   Diagnosis:       Limp     Decreased  Internal  rotation,  Flexion,  Abduction  

   X-­‐ray  (frog  legs  for  Klein  lines)     MRI  

   Complications:     AVN  

   Treatment:     NWB     Pining  

PATELLAR  INJURIES  

   Avultion  of  the  inferior  pole  of  the  patella  

Osgoog-­‐schlatter  diease  &  Sinding-­‐Larsen-­‐Johansson  disease  

Patellar  Dislocation  and  Fracture  

KNEE  INJURY  

   Don’t  miss:     Proximal  Tibia  Fracture  (Salter)     Compartment  syndrome     Valgus  deformity  

TODDLER’S  FRACTURE  

  Mechanism:  Toddler  with  minor  trauma  (external  rotation)  

   Diagnosis:       Limp     X-­‐ray  (spiral,  oblique  distal  Tibia  Fx)  

   Complications:     Not  seen  on  initial  x-­‐ray     Other  source  for  limp  missed  

   Treatment:     Long  leg  splint  

REFERENCES:  

   Egol,  Kenneth  A.    Handbook  of  Fractures  4th  edition.    Lippincott  Williams  &  Wilkins,  a  Wolters  Kluwer  business,  2010.  

   Fleisher.    Textbook  of  Pediatric  Medicine.    Lippincott  Williams  &  Wilkins;  Sixth  edition,  May  20,  2010.  

   Google  Images  

   Journal  of  EMS  8/2004  www.jems.com  

   Lee,  C.  Prehospital  management  of  lower  limb  fractures.    Emerg  Med  J  2005;22:660-­‐663  doi:10.1136/emj.2005.024489  

   Uptodate.  Evaluation  and  management  of  supracondylar  fractures  in  children.  Feb  10,  2014  

   Website  to  learn  more:  

   http://ota.org/research/fracture-­‐and-­‐dislocation-­‐compendium/