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ORTHOPEDIC PRINCIPLES

ORTHOPEDIC PRINCIPLES. William Beaumont Hospital Department of Emergency Medicine. FRACTURES IN KIDS. Salter Harris Classification 1. Injuries to epiphyseal growth plate result from compressive or shearing forces 2. The weak cartilaginous growth zone

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ORTHOPEDIC PRINCIPLES

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  1. ORTHOPEDIC PRINCIPLES William Beaumont Hospital Department of Emergency Medicine

  2. FRACTURES IN KIDS • Salter Harris Classification 1. Injuries to epiphyseal growth plate result from compressive or shearing forces 2. The weak cartilaginous growth zone separates before tendons or bones 3. If unsure, get comparison views 4. Type I and V not always evident on x-ray, so immobilize if clinically suspect fracture

  3. NAME THAT SALTER HARRIS FRACTURE

  4. Salter Harris ClassificationMnemonic “ ME ”

  5. A B C

  6. EXAMINATION BASICS • Determine the point of maximum tenderness • Examine the joint above and below the site of injury • Check for joint stability - ie drawer sign (ankle, knee) • Check the neurovascular status of the extremity distal to the site of injury. • Neurovascular compromise requires emergent reduction of the fracture or dislocation • Is the fracture open – high risk of osteomyelitis - consult Ortho early • Signs of compartment syndrome – Five P’s

  7. COMPARTMENT SYNDROME • Ischemic injury to the muscles and nerves in a particular closed fascial compartment • Caused by edema in a closed compartment. This leads to: • Decreased venous return • Eventual decreased arterial flow • Commonly seen with tibia or forearm fractures • Most commonly seen in lower extremity compartments Anterior> lateral > deep posterior> posterior • Upper extremities: deep flexor compartment

  8. COMPARTMENT SYNDROME • Fractures not necessary • Can occur with excessive muscle contractions, crush injury, circumferential burns, prolonged compression (ie. drug 0D) • Earliest and most reliable sign is referred pain to the compartment with passive stretch of the ischemic muscle group (ie plantar foot flexion causing pain in the anterior leg compartment)

  9. COMPARTMENT SYNDROME • Signs 1. burning, poorly localized pain disproportionate to injury 2. pain on active or passive stretch of muscles 3. paresthesias in distribution of nerves 4. pallor – late and ominous sign 5. pulselessness – late and ominous sign 6. skin color, temperature, cap refill, and distal pulses are important to document but are unreliable monitors for compartment syndrome because the pressure needed to produce compartment syndrome are well below arterial • Diagnosis – hand held device for measuring compartment pressure • - pressures > 30mmHg are abnormal • Treatment – immediate fasciotomy

  10. NERVE INJURIES ACCOMPANYING ORTHO INJURIES ORTHO INJURY NERVE INJURY Elbow injury median or ulnar Shoulder dislocation axillary Sacral fracture cauda equina Acetabular fracture sciatica Hip dislocation femoral Femoral shaft fracture peroneal Knee dislocation tibial or peroneal

  11. XRAY EVALUATION • Rule of two's • Minimal of 2 views perpendicular to each other when possible • Include 2 joints - the joint above and the joint below • Include 2 limb comparison views Variant anatomy - ie. sesamoid bones Particularly important to assess growth plates in kids • 2 sets of x-rays a. Prereduction and postreduction films Obtain prereduction x-rays unless neurovascular compromise b. Possible repeat x-ray in 7-10 days for suspected occult fractures (ie scaphoid fractures) • Is the fracture intraarticular? – increased risk of subsequent arthritis • Are the fragments distracted? • Is there a joint dislocation?

  12. TREATMENT PRINCIPLES • The first priorities remain ABCs • Obvious fractures should NOT deter one from following the ABCs. • Hypovolemic shock possible secondary to fractures 1. Pelvic fracture 2. Secondary to multiple fractures 3. Worsened by third spacing loss of ECF as edema in injured soft tissue seen with crush injuries • Possible blood loss secondary to specific fractures 1. Pelvic fracture - 2 Liters 2. Femur fracture - 1.5 Liters 3. Tibia or humerus fracture - 0.5 Liters

  13. TREATMENT PRINCIPLES • Immobilize the joint proximal and distal to the fracture • For joint injuries, immobilize the affected joint only • Always reassess neurovascular status after immobilization or manipulation • Plaster Splinting • Circumferential casting rarely done in the ED for an acute fracture -> evolving edema may lead to compartment syndrome • Ice and elevate for 48 hours post injury • Healing occurs over 4-10 weeks if properly immobilized • Consider analgesia and/or sedatives prior to attempting reduction -> propofol, etomidate, etc.

  14. Cervical Spine Injuries • MVC account for 50%, falls 20%, sports 15% • C spine fractures are classified as stable or unstable and by the mechanism of injury (flexion, extension, rotation, compression) • Anterior column – vertebra, discs, and anterior and posterior longitudinal ligaments • Posterior column – spinal cord, pedicles, facets, spinous processes, held together by the nuchal and capsular ligaments, and ligamentum flavum

  15. Let’s move on to the specifics…

  16. Anatomy of the Cervical Spine

  17. Navigating the C Spine Xray • Always count vertebrae – if you don’t see all of C7 and the C7-T1 interface the film is inadequate • The Key – integrity of the anterior cervical line, posterior cervical line and spinolaminar line • Anterior cervical line maintained by anterior longitudinal ligament • Posterior cervical line maintained by the posterior longitudinal ligament • Spinolaminar line maintained by ligamentum flavum

  18. Cervical Spine Xray

  19. Cervical Spine Injury • An unstable C spine injury occurs when there is disruption of the ligaments of the anterior and posterior column elements • Chance of spinal cord injury great • Unstable fractures: C1 (Jefferson burst), odontoid, C2 (Hangman), flexion tear drop, bilateral facet dislocation • Stable fractures: wedge fracture, Clayshoveler’s fracture, transverse process fracture, vertebral body burst fracture, unilateral facet dislocation

  20. Jefferson Burst Fracture • Burst fracture of C1 ring • Axial loading force on the occiput such as diving into shallow water, falling from a height. • Lateral displacement of the lateral masses • Unstable fx, but often no neuro deficit because the ring widens when it fractures limiting cord compression

  21. Hangman Fracture

  22. Hangman’s Fracture • The result of a head on MVC where the skull is thrown into extreme hyperextension as a result of abrupt deceleration. • Bilateral fractures of the pedicles of C2 create an unstable fracture • Spinal cord damage is minimal because the bilateral fractures allow the spinal cord to decompress.

  23. Odontoid fracture • 15% of all C spine fractures • Result of MVC or fall • Type 1 – tip fracture • Type 2 – base fracture, unstable, most common 60% of odontoid fx • Type 3 – thru body of C3 very unstable

  24. Odontoid Fracture

  25. Flexion Teardrop Fracture

  26. Flexion Tear Drop Fracture • Flexion and axial loading forces cause avulsion of anteroinferior portion of vertebral body. • Unstable fracture • Involves injury to anterior and posterior longitudinal ligaments creating spinal instability • Often associated with spinal cord damage

  27. Extension Tear Drop • As with flexion teardrop fracture, extension teardrop fracture also manifests with a displaced anteroinferior bony fragment. • The anterior longitudinal ligament pulls fragment away from the inferior aspect of the vertebra because of sudden hyperextension. • A true avulsion, in contrast to the flexion teardrop fracture in which the fragment is produced by compression of the anterior vertebral aspect due to hyperflexion • Common after diving accidents and tends to occur at lower cervical levels • Associated with the central cord syndrome due to buckling of the ligamentum flavum into spinal canal during the hyperextension

  28. Extension Tear Drop Fracture

  29. Wedge Fracture

  30. Wedge Fracture • With a pure flexion injury, a longitudinal pull is exerted on the nuchal ligament complex that, because of its strength, usually remains intact. • The anterior vertebral body bears most of the force, sustaining simple wedge compression anteriorly without any posterior disruption. • On xray, the anterior border of the vertebral body has diminished height and increased concavity along with increased density due to bony impaction. • The prevertebral soft tissues are swollen. • Stable fracture

  31. Burst Fracture

  32. Burst Fracture • Downward compressive force is transmitted to lower levels in the cervical spine -> The body of the cervical vertebra can shatter outward, causing a burst fracture. • This fracture involves disruption of the anterior and posterior longitudinal ligaments • Xray - a vertical fracture line in the frontal projection and protrusion of the vertebral body anteriorly and posteriorly. • Posterior protrusion of the fracture may extend into the spinal canal and be assoc with anterior cord syndrome. • Burst fractures always require a CT or MRI to document amount of retropulsion.

  33. Clayshoveler’s Fracture

  34. Clayshoveler’s Fracture • Abrupt flexion of neck combined with muscular contraction of upper body/neck muscles causes avulsion of C6 or C7 spinous process. • Also a result of a direct blow to neck • Seen best on lateral c spine xray • Stable fracture

  35. Any questions about the cervical spine? Let’s Move On

  36. UPPER EXTREMITY INJURIES SHOULDER DISLOCATION • 98% are anterior • Mechanism: abduction and external rotation with a posterior force (line backer injury) • SSx: squared shoulder, held in abduction/external rotation, anterior shoulder appears full • Check axillary nerve function motor - abduction of arm - Deltoid muscle (unable to do from pain) sensory - sergeant stripe distribution • Treatment – closed reduction by hanging weight, scapular manipulation, traction/countertraction • 2% are posterior -> common cause = seizure X Ray – light bulb sign

  37. ANTERIOR SHOULDER DISLOCATION

  38. FOREARM FRACTURES • Monteggia's fracture - fracture of the proximal 1/3 ulna with an associated radial head dislocation • Galeazzi fracture - fracture distal 1/3 radius with dislocation of the distal radioulnar joint • Treatment – urgent Ortho consult for operative repair

  39. MONTEGGIA FRACTURE

  40. GALLEAZZI FRACTURE

  41. Fat Pad Sign normal anterior fat pad abnormal fat pad

  42. Significance of the Fat Pad Sign • Anterior fat pad may be seen in normal elbow but usually is a thin strip • Posterior fat pad sign indicates occult fracture – in children indicates supracondylar fracture and in adults indicates radial head fracture • Pathophysiology – intraarticular hemorrhage or effusion causes distention of synovium making posterior fat pad visible on xray

  43. WRIST FRACTURES COLLES fracture • Distal radius fracture with dorsal displacement of the distal fragment • Mechanism: fall on an outstretched hand • Swan neck or dinner fork deformity • Treatment non-displaced -> volar splint displaced or angulated -> urgent orthopedic referral SMITH’S fracture or “reverse Colles” • distal radius fracture with volar displacement of the distal fragment • Mechanism – fall backwards on outstretched hand, direct blow • Treatment - same as Colles

  44. COLLES’ FRACTURE

  45. SMITH’S FRACTURE

  46. EXAM OF THE INJURED HAND Tendon examination of the hand • Flexor Digitorum Profundis • Flex DIP joint against resistance, while blocking MCP and PIP action • Flexor Digitorum Superficialis • Flex MCP joint - block other digits • With partial tendon laceration - may be able to flex or extend, but will be weak or painful • For most injuries, immobilize fingers with MCP flexed and PIP partially extended – position of function (holding a can)

  47. EXAM OF THE INJURED HAND Hand - sensory exam • Ulnar: tip of little finger • Median: tip of middle finger or volar pad of index finger • Radial: 1st dorsal web space Hand- motor exam • Ulnar: abduct (spread) fingers against resistance, injury causes a claw hand • Median: oppose thumb (recurrent branch) injury causes thenar eminence muscles to atrophy giving the hand an “apelike” appearance • Radial: extend wrist, injury causes wrist drop

  48. Boxer’s fracture • 5th metacarpal fracture, less common 4th metacarpal • Mechanism: punching • Be suspicious of any laceration over the knuckles – often the result of fist hitting mouth, have a high incidence of infection, and need to be treated with antibiotics • Treatment: Ulnar gutter splint to the PIP joint • If laceration over MCP joint consider human bite injury

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