orthopedic principles william beaumont hospital department of emergency medicine
TRANSCRIPT
Orthopedic Orthopedic PrinciplesPrinciples
William Beaumont HospitalWilliam Beaumont Hospital
Department of Emergency Department of Emergency MedicineMedicine
Fractures in Kids – Fractures in Kids – Salter Harris Salter Harris
ClassificationClassification Injuries to epiphyseal growth plate Injuries to epiphyseal growth plate
result from compressive or shearing result from compressive or shearing forceforce
The weak cartilaginous growth zone The weak cartilaginous growth zone separates before tendons or bonesseparates before tendons or bones
If unsure, get comparison viewsIf unsure, get comparison views Type I and V not always evident on Type I and V not always evident on
x-ray, so x-ray, so immobilize if clinically immobilize if clinically suspect fracturesuspect fracture
Salter Harris ClassificationSalter Harris ClassificationMnemonic “ ME ”Mnemonic “ ME ”
What Salter-Harris type What Salter-Harris type is this?is this?
Type 2
What Salter-Harris type What Salter-Harris type is this?is this?
Type 3
What Salter-Harris type What Salter-Harris type is this?is this?
Type 3
What Salter-Harris type What Salter-Harris type is this?is this?
Type 4
What Salter-Harris type What Salter-Harris type is this?is this?
Type 1
Examination BasicsExamination Basics
Determine the point of maximum Determine the point of maximum tenderness tenderness
Examine the joint above and below the site Examine the joint above and below the site of injury of injury
Check for joint stabilityCheck for joint stability Check the neurovascular status Check the neurovascular status
Neurovascular compromise requires emergent Neurovascular compromise requires emergent reduction of the fracture or dislocation reduction of the fracture or dislocation
Is the fracture open?Is the fracture open? Early Ortho consultEarly Ortho consult
Signs of compartment syndrome – Five P’sSigns of compartment syndrome – Five P’s
Compartment SyndromeCompartment Syndrome Ischemic injury to muscles and nerves in a Ischemic injury to muscles and nerves in a
closed fascial compartment closed fascial compartment Caused by edema in a closed compartment Caused by edema in a closed compartment
Decreased venous returnDecreased venous return
Eventual decreased arterial flow Eventual decreased arterial flow Commonly seen with tibia or forearm Commonly seen with tibia or forearm
fracturesfractures Most common lower extremity compartments: Most common lower extremity compartments:
anterior > lateral > deep posterior > anterior > lateral > deep posterior > posteriorposterior
Most common upper extremity compartment: Most common upper extremity compartment: deep flexor compartment deep flexor compartment
Compartment SyndromeCompartment Syndrome Fracture not necessary Fracture not necessary Can occur with excessive muscle Can occur with excessive muscle
contractions, crush injury, contractions, crush injury, circumferential burns, prolonged circumferential burns, prolonged compression (i.e. drug OD) compression (i.e. drug OD)
Earliest and most reliable sign is Earliest and most reliable sign is referred pain to the compartment with referred pain to the compartment with passive stretch of the ischemic muscle passive stretch of the ischemic muscle group (i.e. plantar foot flexion causes group (i.e. plantar foot flexion causes pain in the anterior leg compartment)pain in the anterior leg compartment)
Compartment Syndrome Compartment Syndrome - Signs- Signs
PPainain burning, poorly localized, burning, poorly localized,
disproportionate to injurydisproportionate to injury pain on active or passive stretch of pain on active or passive stretch of
musclesmuscles
PParesthesias in distribution of nervesaresthesias in distribution of nerves
PPallor – late and ominous signallor – late and ominous sign
PParalysis aralysis
PPulselessness – late and ominous signulselessness – late and ominous sign
Compartment SyndromeCompartment Syndrome Diagnosis – hand held device for Diagnosis – hand held device for
measuring compartment pressure measuring compartment pressure
Pressures > 30mmHg are abnormalPressures > 30mmHg are abnormal
Treatment – immediate fasciotomyTreatment – immediate fasciotomy
Associated Nerve InjuriesAssociated Nerve Injuries
ORTHO INJURY ORTHO INJURY NERVE INJURYNERVE INJURY
Elbow injury Elbow injury median or ulnarmedian or ulnarShoulder dislocationShoulder dislocation axillary axillarySacral fractureSacral fracture cauda equinacauda equinaAcetabular fractureAcetabular fracture sciaticasciaticaHip dislocationHip dislocation femoralfemoralFemoral shaft fractureFemoral shaft fracture peroneal peroneal Knee dislocationKnee dislocation tibial or peronealtibial or peroneal
Radiographic EvaluationRadiographic Evaluation Rule of two's Rule of two's
Minimal of 2 views perpendicular to each Minimal of 2 views perpendicular to each other when possible other when possible
Include 2 jointsInclude 2 joints Include 2 limb comparison views Include 2 limb comparison views 2 sets of X-rays 2 sets of X-rays
Pre-reduction and post-reduction films; obtain Pre-reduction and post-reduction films; obtain pre-reduction x-rays unless neurovascular pre-reduction x-rays unless neurovascular compromisecompromise
Possible repeat x-ray in 7-10 days for Possible repeat x-ray in 7-10 days for suspected occult fractures (i.e. scaphoid suspected occult fractures (i.e. scaphoid fractures)fractures)
Radiographic EvaluationRadiographic Evaluation
Is the fracture intraarticular? – Is the fracture intraarticular? – increased risk of subsequent increased risk of subsequent arthritisarthritis
Are the fragments distracted?Are the fragments distracted? Is there a joint dislocation?Is there a joint dislocation?
Treatment PrinciplesTreatment Principles The first priority = ABCs The first priority = ABCs
Obvious fractures should NOT deter from ABCs. Obvious fractures should NOT deter from ABCs. Hypovolemic shock possible Hypovolemic shock possible
secondary to fracturessecondary to fractures Pelvic fracture – 2 LitersPelvic fracture – 2 Liters Femur fracture – 1.5 Liters Femur fracture – 1.5 Liters Multiple fractures Multiple fractures Worsened by third spacing Worsened by third spacing
Treatment PrinciplesTreatment Principles For fractures: immobilize the joint For fractures: immobilize the joint
proximal and distalproximal and distal For joint injuries: immobilize the For joint injuries: immobilize the
affected joint onlyaffected joint only Reassess neurovascular status after Reassess neurovascular status after
immobilization or manipulation immobilization or manipulation Consider analgesia and/or sedatives Consider analgesia and/or sedatives
prior to attempting reductionprior to attempting reduction
Treatment PrinciplesTreatment Principles Plaster splinting Plaster splinting Circumferential casting rarely done Circumferential casting rarely done
in the ED for an acute fracture in the ED for an acute fracture evolving edema may lead to evolving edema may lead to compartment syndrome compartment syndrome
Ice and elevate for 48 hours post Ice and elevate for 48 hours post injury injury
Healing occurs over 4-10 weeks if Healing occurs over 4-10 weeks if properly immobilized properly immobilized
Cervical Spine InjuriesCervical Spine Injuries Etiology:Etiology:
MVC 50% MVC 50% Falls 20%Falls 20% Sports 15%Sports 15%
Classified as stable or unstable and by injury Classified as stable or unstable and by injury mechanism (flexion, extension, rotation, mechanism (flexion, extension, rotation, compression)compression)
Anterior column – vertebra, discs, and anterior Anterior column – vertebra, discs, and anterior and posterior longitudinal ligamentsand posterior longitudinal ligaments
Posterior column – spinal cord, pedicles, facets, Posterior column – spinal cord, pedicles, facets, spinous processes, held together by the nuchal spinous processes, held together by the nuchal and capsular ligaments, and ligamentum and capsular ligaments, and ligamentum flavumflavum
Let’s move on to Let’s move on to the specifics…the specifics…
Anatomy of the Cervical Anatomy of the Cervical SpineSpine
Navigating the C Spine Navigating the C Spine X-rayX-ray
Count vertebrae – if you don’t see C7 and the Count vertebrae – if you don’t see C7 and the C7-T1 interface the film is inadequateC7-T1 interface the film is inadequate
The Key – integrity of the anterior cervical The Key – integrity of the anterior cervical line, posterior cervical line and spinolaminar line, posterior cervical line and spinolaminar line line
Anterior cervical line maintained by anterior Anterior cervical line maintained by anterior longitudinal ligament longitudinal ligament
Posterior cervical line maintained by the Posterior cervical line maintained by the posterior longitudinal ligamentposterior longitudinal ligament
Spinolaminar line maintained by ligamentum Spinolaminar line maintained by ligamentum flavumflavum
Cervical Spine XrayCervical Spine Xray
Unstable Cervical Spine Unstable Cervical Spine InjuriesInjuries
An An unstableunstable C spine injury occurs C spine injury occurs when there is disruption of the when there is disruption of the ligaments of the anterior and ligaments of the anterior and posterior column elementsposterior column elements
Chance of spinal cord injury greatChance of spinal cord injury great
Unstable Cervical Spine Unstable Cervical Spine InjuriesInjuries
C1 (Jefferson burst fracture) C1 (Jefferson burst fracture) C2 (Hangman fracture)C2 (Hangman fracture) Odontoid fractureOdontoid fracture Flexion tear drop fractureFlexion tear drop fracture Bilateral facet dislocationBilateral facet dislocation
Jefferson Burst FractureJefferson Burst Fracture Burst fracture of C1 ringBurst fracture of C1 ring Mechanism: axial loading force on the Mechanism: axial loading force on the
occiputocciput Diving into shallow waterDiving into shallow water Falling from a heightFalling from a height
Lateral displacement of the lateral Lateral displacement of the lateral massesmasses
Disruption of the transverse ligamentDisruption of the transverse ligament UnstableUnstable, but often no neuro deficit , but often no neuro deficit
because the ring widens when it because the ring widens when it fractures limiting cord compressionfractures limiting cord compression
Jefferson Burst FractureJefferson Burst Fracture
Hangman FractureHangman Fracture
Mechanism: skull is thrown into Mechanism: skull is thrown into extreme hyperextension as a result of extreme hyperextension as a result of abrupt deceleration (i.e. MVC).abrupt deceleration (i.e. MVC).
Bilateral fractures of the pedicles of Bilateral fractures of the pedicles of C2C2
Spinal cord damage is minimal Spinal cord damage is minimal because the bilateral fractures allow because the bilateral fractures allow the spinal cord to decompressthe spinal cord to decompress
Unstable fractureUnstable fracture
Hangman FractureHangman Fracture
Odontoid FractureOdontoid Fracture
15% of all C spine 15% of all C spine fracturesfractures
Mechanism: MVC or fallMechanism: MVC or fall Type 1 – tip fractureType 1 – tip fracture Type 2 – base fracture, Type 2 – base fracture,
unstable, most commonunstable, most common
60% of odontoid fx60% of odontoid fx Type 3 – thru body of C3Type 3 – thru body of C3
very unstablevery unstable
Odontoid FractureOdontoid Fracture
Flexion Tear Drop Flexion Tear Drop FractureFracture
Mechanism: flexion and axial loading Mechanism: flexion and axial loading forces cause avulsion of anteroinferior forces cause avulsion of anteroinferior portion of vertebral bodyportion of vertebral body
Involves injury to anterior and Involves injury to anterior and posterior longitudinal ligaments posterior longitudinal ligaments creating spinal instabilitycreating spinal instability
Often associated with spinal cord Often associated with spinal cord damagedamage
Unstable fractureUnstable fracture
Flexion Tear Drop Flexion Tear Drop FractureFracture
Stable Cervical Spine Stable Cervical Spine InjuriesInjuries
Wedge fractureWedge fracture Vertebral body burst fractureVertebral body burst fracture Clay Shoveler’s fractureClay Shoveler’s fracture Transverse process fractureTransverse process fracture Unilateral facet dislocationUnilateral facet dislocation
Wedge FractureWedge Fracture Mechanism:Mechanism: Flexion injury causes a Flexion injury causes a
longitudinal pull on the nuchal longitudinal pull on the nuchal ligament complex that, because of its ligament complex that, because of its strength, usually remains intact. strength, usually remains intact.
The anterior vertebral body bears most The anterior vertebral body bears most of the force, sustaining simple wedge of the force, sustaining simple wedge compression anteriorly without any compression anteriorly without any posterior disruption.posterior disruption.
The prevertebral soft tissues are The prevertebral soft tissues are swollen.swollen.
Stable fractureStable fracture
Wedge FractureWedge Fracture
Vertebral Burst FractureVertebral Burst Fracture Mechanism:Mechanism: Downward compressive Downward compressive
force is transmitted to lower levels in force is transmitted to lower levels in the C spine the C spine vertebra can shatter vertebra can shatter outward, causing a burst fractureoutward, causing a burst fracture
Disruption of anterior and posterior Disruption of anterior and posterior longitudinal ligamentslongitudinal ligaments
Posterior protrusion of the fracture Posterior protrusion of the fracture may extend into the spinal canal and may extend into the spinal canal and be associated with anterior cord be associated with anterior cord syndrome syndrome
Burst fractures require a CT or MRI to Burst fractures require a CT or MRI to document degree of retropulsiondocument degree of retropulsion
Vertebral Burst FractureVertebral Burst Fracture
Clay Shoveler’s FractureClay Shoveler’s Fracture
Avulsion of C6 or C7 spinous processAvulsion of C6 or C7 spinous process Mechanism: Mechanism: Abrupt flexion of neck Abrupt flexion of neck
combined with muscular contraction combined with muscular contraction of upper body/neck muscles; can of upper body/neck muscles; can also result from a direct blow to also result from a direct blow to neckneck
Seen best on lateral C spine X-raySeen best on lateral C spine X-ray Stable fracture Stable fracture
Clay Shoveler’s FractureClay Shoveler’s Fracture
Any questions about Any questions about the cervical spine?the cervical spine?
Let’s Move OnLet’s Move On
Anterior Shoulder Anterior Shoulder DislocationsDislocations
Mechanism: Mechanism: abduction and external abduction and external rotation with a posterior force (line rotation with a posterior force (line backer injury)backer injury) 98% are anterior98% are anterior
Signs & SymptomsSigns & Symptoms: squared shoulder, : squared shoulder, held in abduction/external rotation, held in abduction/external rotation, anterior shoulder appears fullanterior shoulder appears full
Check axillary nerve function: Check axillary nerve function: abduction of arm and sensory sergeant abduction of arm and sensory sergeant stripe distributionstripe distribution
Treatment: Treatment: closed reduction by hanging closed reduction by hanging weight, scapular manipulation, weight, scapular manipulation, traction/countertractiontraction/countertraction
Posterior Shoulder Posterior Shoulder DislocationsDislocations
2% are posterior2% are posterior Most common cause is from a Most common cause is from a
seizureseizure X-ray – light bulb signX-ray – light bulb sign
Anterior Shoulder Anterior Shoulder DislocationsDislocations
Forearm FracturesForearm Fractures
Monteggia fractureMonteggia fracture –– fracture of fracture of the proximal 1/3 ulna with an the proximal 1/3 ulna with an associated radial head dislocation associated radial head dislocation
Galeazzi fracture – Galeazzi fracture – fracture distal fracture distal 1/3 radius with dislocation of the 1/3 radius with dislocation of the distal radioulnar jointdistal radioulnar joint
TreatmentTreatment –– urgent Ortho consult urgent Ortho consult
for operative repairfor operative repair
Monteggia FractureMonteggia Fracture
Galleazzi FractureGalleazzi Fracture
Significance of the Fat Significance of the Fat Pad SignPad Sign
Anterior fat pad may be seen in normal Anterior fat pad may be seen in normal elbow but usually is a thin stripelbow but usually is a thin strip
Posterior fat pad sign indicates occult Posterior fat pad sign indicates occult fracture – in children indicates fracture – in children indicates supracondylar fracture andsupracondylar fracture and
in adults indicates radial head fracturein adults indicates radial head fracture Pathophysiology – intraarticular Pathophysiology – intraarticular
hemorrhage or effusion causes distention hemorrhage or effusion causes distention of synovium making posterior fat pad of synovium making posterior fat pad visible on X-rayvisible on X-ray
Fat Pad SignFat Pad Sign
normal anterior fat pad abnormal fat normal anterior fat pad abnormal fat padpad
Wrist Fractures – Colles Wrist Fractures – Colles FractureFracture
Distal radius fracture with dorsal Distal radius fracture with dorsal displacement of the distal fragment displacement of the distal fragment
Mechanism: fall on an outstretched Mechanism: fall on an outstretched handhand
Swan neck or dinner fork deformitySwan neck or dinner fork deformity
Treatment: non-displaced Treatment: non-displaced volar volar splint; displaced/angulated splint; displaced/angulated ortho ortho referral referral
Colles FractureColles Fracture
Wrist Fractures – Wrist Fractures – Smith’s Fracture Smith’s Fracture
Distal radius fracture with volar Distal radius fracture with volar displacement of the distal fragmentdisplacement of the distal fragment
Mechanism: fall backwards on Mechanism: fall backwards on outstretched hand, direct blowoutstretched hand, direct blow
Treatment: same as CollesTreatment: same as Colles
Smith’s FractureSmith’s Fracture
Exam of the Injured Hand – Exam of the Injured Hand – Tendon ExaminationTendon Examination
Flexor Digitorum ProfundisFlexor Digitorum Profundis Flex DIP joint against resistance, while Flex DIP joint against resistance, while
blocking MCP and PIP action blocking MCP and PIP action Flexor Digitorum SuperficialisFlexor Digitorum Superficialis
Flex MCP joint - block other digits Flex MCP joint - block other digits With partial tendon laceration - may With partial tendon laceration - may
be able to flex or extend, but will be be able to flex or extend, but will be weak or painfulweak or painful
Exam of the Injured HandExam of the Injured HandSensory examSensory exam UlnarUlnar: tip of little finger : tip of little finger MedianMedian: tip of middle finger or pad : tip of middle finger or pad
of index finger of index finger RadialRadial: 1st dorsal web space: 1st dorsal web spaceMotor examMotor exam UlnarUlnar: Spear fingers against : Spear fingers against
resistance, injury causes a claw handresistance, injury causes a claw hand MedianMedian: oppose thumb (recurrent : oppose thumb (recurrent
branch) injury causes thenar branch) injury causes thenar eminence muscles to atrophy giving eminence muscles to atrophy giving the hand an “apelike” appearancethe hand an “apelike” appearance
RadialRadial: extend wrist, injury causes : extend wrist, injury causes wrist dropwrist drop
Boxer’s FractureBoxer’s Fracture 5th metacarpal fracture5th metacarpal fracture Mechanism: punchingMechanism: punching
Be suspicious of any laceration over the Be suspicious of any laceration over the knucklesknuckles
Often the result of fist hitting mouthOften the result of fist hitting mouth High incidence of infection, may need High incidence of infection, may need
antibiotics antibiotics Treatment: ulnar gutter splint to the Treatment: ulnar gutter splint to the
PIP joint PIP joint
Boxer’s FractureBoxer’s Fracture
Mallet FingerMallet Finger
Mechanism: distal tip of finger is Mechanism: distal tip of finger is forcibly flexed, resulting in rupture forcibly flexed, resulting in rupture or avulsion of the lateral expansions or avulsion of the lateral expansions of the extensor hood of the extensor hood
Diagnosis: unable to extend DIP Diagnosis: unable to extend DIP joint; defect may not be seen for 5-7 joint; defect may not be seen for 5-7 days days
Treatment: splint DIP joint in slight Treatment: splint DIP joint in slight hyperextension for full 6 weeks hyperextension for full 6 weeks
Mallet FingerMallet Finger
Boutonniere DeformityBoutonniere Deformity
Mechanism: injured central band of the Mechanism: injured central band of the extensor hood extensor hood
Diagnosis: Diagnosis: painful, swollen PIP jointpainful, swollen PIP joint tenderness over PIP joint fixed flexion of PIPtenderness over PIP joint fixed flexion of PIP hyperextension of DIP, unable to extend PIP hyperextension of DIP, unable to extend PIP
Treatment: splint only the PIP joint in Treatment: splint only the PIP joint in extension extension
Boutonniere DeformityBoutonniere Deformity
Carpal Bone Injuries – Carpal Bone Injuries – Scaphoid FracturesScaphoid Fractures
Most common carpal bone fracture Most common carpal bone fracture Mechanism:Mechanism: fall on the outstretched palm fall on the outstretched palm Diagnosis:Diagnosis: snuff box tenderness or snuff box tenderness or
tenderness with axial loading of thumbtenderness with axial loading of thumb Treatment:Treatment: thumb spica with volar splint thumb spica with volar splint Complications:Complications:
Avascular necrosis if not correctly immobilized Avascular necrosis if not correctly immobilized Non-union, because scaphoid with unique distal Non-union, because scaphoid with unique distal
origin of blood supply origin of blood supply
Scaphoid FracturesScaphoid Fractures
OK, let’s move OK, let’s move downdown
Pelvic FracturesPelvic Fractures The pelvis is a ring structure, so if see The pelvis is a ring structure, so if see
1 fracture you need to check for 1 fracture you need to check for another another
Associated with bladder rupture or Associated with bladder rupture or membranous urethral injuriesmembranous urethral injuries Higher incidence with symphysis pubis Higher incidence with symphysis pubis
fracturefracture Retrograde cystourethrogram if: Retrograde cystourethrogram if:
High riding boggy prostateHigh riding boggy prostate Blood at urethral meatus Blood at urethral meatus
Common cause of mortality is Common cause of mortality is hemorrhagic shockhemorrhagic shock Open book fractureOpen book fracture Displacement of pelvic fracture > 0.5 cmDisplacement of pelvic fracture > 0.5 cm
Pelvic FracturesPelvic Fractures
Hip DislocationsHip Dislocations 80-90% are posterior high energy 80-90% are posterior high energy
injury injury Mechanism: Mechanism: strike knee on dash, strike knee on dash,
while leg flexed and adductedwhile leg flexed and adducted Presentation: Presentation: leg flexed, adducted, leg flexed, adducted,
shortened, and internally rotated with shortened, and internally rotated with knee resting on opposite thigh knee resting on opposite thigh
Associated injuries: Associated injuries: patellar patellar fracture, sciatic nerve (peroneal fracture, sciatic nerve (peroneal branch), femoral vesselsbranch), femoral vessels
Treatment: Treatment: immediate attempt at immediate attempt at closed reductionclosed reduction
Complications:Complications: Avascular necrosis Avascular necrosis
Hip DislocationsHip Dislocations
Hip DislocationsHip Dislocations
Hip FractureHip Fracture
Hip FractureHip Fracture
Hip Pain – Differential Hip Pain – Differential DiagnosisDiagnosis
Referred pain from back or kneeReferred pain from back or knee Herniated discHerniated disc DiscitisDiscitis Toxic synovitis, bursitis, tendonitis of hipToxic synovitis, bursitis, tendonitis of hip Septic jointSeptic joint Occult fracture of hipOccult fracture of hip Tumor (lymphoma)Tumor (lymphoma) DVT or arterial ischemiaDVT or arterial ischemia OsteomyelitisOsteomyelitis Slipped capital femoral epiphysisSlipped capital femoral epiphysis
Tibial Plateau FractureTibial Plateau Fracture High energy injury in younger age High energy injury in younger age
groupgroup Fall from heightFall from height MVCMVC
Low energy injury due to compressive Low energy injury due to compressive forces on osteoporotic bones forces on osteoporotic bones
Complications: Complications: Popliteal artery injuryPopliteal artery injury Lateral condyle fractureLateral condyle fracture Ligamentous injuriesLigamentous injuries Compartment syndromeCompartment syndrome
Tibial Plateau FracturesTibial Plateau Fractures
Knee DislocationKnee Dislocation Described by position of tibia in relation Described by position of tibia in relation
to femurto femur Considered high energy injury Considered high energy injury Anterior dislocation most common and Anterior dislocation most common and
caused by hyperextension of kneecaused by hyperextension of knee Posterior dislocation from direct trauma Posterior dislocation from direct trauma
to flexed kneeto flexed knee Initial evaluation may not reveal Initial evaluation may not reveal
obvious deformity because of obvious deformity because of spontaneous reduction spontaneous reduction so grossly so grossly unstable knee treated as if dislocation unstable knee treated as if dislocation occurredoccurred
Knee Dislocations - Knee Dislocations - ComplicationsComplications
Vascular injury to popliteal arteryVascular injury to popliteal artery Crucial to document DP & DT pulsesCrucial to document DP & DT pulses Highly predictive of arterial injury when Highly predictive of arterial injury when
diminished or absencediminished or absence Diagnose with arteriogramDiagnose with arteriogram Early revascularization within 6 hours Early revascularization within 6 hours
decreases risk of amputationdecreases risk of amputation Peroneal nerve injuryPeroneal nerve injury
Check sensation on dorsum of footCheck sensation on dorsum of foot Dorsiflex the ankle Dorsiflex the ankle
Knee DislocationsKnee Dislocations
The EndThe End