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1
We’ve Got a Bone to Pick….�Pearls, Pitfalls & High-Yield Orthopedics
David J. Heath, DO, MS, ATC, FAAEMFacility Medical Director, Emergency Medicine
Saint Joseph-London HospitalAdjunct Clinical Professor, LMU-DCOM
Educational Objectives
Upon hearing & assimilating this program, clinician will be better able to:
1. Identify each section of long-bone anatomy;2. Identify & describe various types of fractures, including transverse,
oblique, spiral, comminuted & segmental;3. Correctly diagnose & describe pediatric fractures, including greenstick,
buckle, & growth plate fractures using Salter-Harris classification;4. Identify & describe from radiographs common hand/wrist fractures,
ankle/foot fractures, different types of hip fractures, common spine fractures & common shoulder fractures;
5. Institute appropriate treatments for each of demonstrated fractures.
Systematic Approach to PE• History
– It’s ALL about that history!• Observation
– Abnormalities & symmetry• Palpation
– Temperature, tenderness• Range of Motion
– PROM & AROM• Strength
– Full & equal• Special Tests
– “Provocative” testsHOPRSS
Long Bone Anatomy
4
5 6
2
Fracture Nomenclature
7
Description of Fractures
• Open v. closed– Open = bone exposed– Closed = overlying soft tissue intact
• Location (be precise)– Left v. right– Anatomic orientation
• Proximal/distal, medial/lateral, anterior/posterior
– Anatomic landmarks & name of bone
• Lines– See next slide 8
Lines of Fractures
• Transverse– Right angles to long axis
• Oblique– Diagonal to long axis
• Spiral– Rotational force to shaft
• Comminuted– Bone > 2 fragments
• Segmental– Free floating central component– At least 2 fx lines present 9
Position & Alignment
• Degree of fracture– Complete v. incomplete
• Rotation– Fragments rotated relative to each other– Interval v. external
• Angulation– Loss of ANATOMICAL alignment in angular fashion– Valgus v. varus
• Displacement/shortening– Loss of AXIAL alignment– Fragments shifted relative to each other 10
Describe rotation, angulation &
displacement by direction of DISTAL
segment!
Descriptive Modifiers
• Position overall• Intra/extraarticular
– Extends/involves articular surface• Impaction/distraction
– Shortening or widening– NO loss of alignment
• Pathologic– Suspected w/ trivial trauma
• Skeletal maturity– Growth plates present 11
Incomplete Pediatric Fractures
12
3
Greenstick Fracture
• Incomplete angulated w/ cortical breech to one side of bone
• Usually mid-diaphyseal• Treatment
– Splint w/ F/U to ortho
13
Buckle (Torus) Fractures
• Compression-type force applied to relatively soft, immature bone
• Incomplete fracture– Bulging of cortex– Trabecular compression 2* axial loading to long axis– Commonly involve distal radial metaphysis
• Treatment– Volar fx = Splint molded in EXTENSION– Dorsal fx = Removable Velcro splint
14
Solely relying on radiology report
15
Dorsal Torus
Fracture
Salter-Harris Fxs
Separated Above Lower Through Rammed
SALTR
6% 75% 10% 10% 1%MOST
COMMONInfants & toddlers
Growth complications
ñ I to V
Salter-Harris Fractures
• Demographics– Most common age = 10 to 16 (80%) – Mostly males (2* delayed skeletal maturity)
• Physis (growth plate)– Composed of cartilage cells (not seen on XR)– Weaker than supporting ligaments
• Blood supply to GP from epiphysis– ñ epiphyseal injury = ñ growth disturbances – Type I = least growth disturbance– Type V = most growth disturbance 17
Hand & Wrist
18
4
19
DORSALVOLAR
Scaphoid Fracture
• Rare in kiddos• Pain in snuffbox & ulnar deviation• Imaging
– 1st XR = 14% missed– 2nd XR in 7 days– Bone scan to confirm dx
• Complication– High risk of AVN
• Treatment– Nondisplaced = thumb spica splint
Most common carpal fx (62-87% of all wrist fxs)
Scaphoid Blood Supply`
Scaphos = peanut
DORSAL VOLAR
Lunate & Perilunate Dislocations
• Lunate– MC carpal bone to dislocate– Volar swelling w/ palpable mass– Treatment
• Immediate reduction w/ surgical repair
• Perilunate– Dorsal swelling w/ palpable mass– Treatment
• Immediate reduction w/ surgical repair
24
5
25
Lunate Dislocation
Piece of Pie Sign• Abnormal triangular
appearance of lunate on AP XR
Spilled Teacup Sign• Abnormal volar
displacement & tilt of dislocated lunate 26
Lunate Dislocation
27
Perilunate Dislocation
Lunate & Perilunate Dislocations
DorsalVolar
Boxers Fracture
• Fracture to neck of 5th metacarpal w/ volar angulation
• MOI– Punching injury
• Treatment– Closed reduction + ulnar gutter splint– Close F/U for loss of reduction
29
Always suspect “Fight Bite”
30
Boxers Fracture
Rotational displacement
UNACCEPTABLE!
6
Colles’ Fracture
• Most common fracture in adults >50 yo
• “Dinner fork” deformity – Distal radius at metaphysis– Dorsal displacement– Ulnar styloid fracture common
• Treatment– Closed reduction + cast x 6-8 wks– Intraarticular requires surgery
31
Complication = Median nerve injury
32
Colles’ Fracture
Smith Fracture
• “Reverse” Colles’ fracture– Volar displacement of distal radius
• Associated median nerve and flexor tendon injury
• Treatment– Closed reduction
33 34
Smith Fracture
Triquetrum Fracture
• Most common dorsal chip fracture of wrist • Pain on dorsum of wrist & ulnar styloid• Painful to flexion
35
2nd most common carpal fracture
Triquetral Fracture
DORSALVOLAR
7
Upper Forearm Fractures
• Galeazzi– DRUJ hurts, radial head does not
• Monteggia– DRUJ painless, RH painful
• Essex-Lopresti– BOTH DRUJ & RH painful
37
DRUJ confidently found via Lister’s tubercle
Galeazzi Fracture
• Distal 1/3 radial fx, usually dorsal angulation• Disrupted DRUJ• Complication
– Ulnar nerve injury • Treatment
– ORIF
38GaleazziRadial fxUlnar fxMonteggia
Monteggia Fracture
• Apex of ulna fx points in direction of radial head dislocation
• Treatment– ORIF
39
GaleazziRadial fxUlnar fxMonteggia
Essex-Lopresti Fracture
• Radial head fracture • Dislocation of DRUJ• Interosseous membrane disruption • Treatment
– ORIF generally needed
40
The Shoulder
41
Shoulder Anatomy
42
8
Shoulder Anatomy
43
SITS• Supraspinatus• Infraspinatous• Teres minor• Subscapularis
Shoulder Anatomy
44
Clavicle Fractures
• Most common bone fractured in children
• Middle 1/3– Most commonly fractured (75-80%)
• Distal 1/3– Associated w/ ruptured coracoclavicular jt + significant medial elevation
• Treatment– Nondisplaced = sling x 3-4 wks à 3-4 wks, AROM– Displaced > 100% (nonunion 4.5%) = ORIF 45
Clavicle Fractures
46
Clavicle Fractures
• Medial 1/3– Uncommon– Requires STRONG forces– Search for associated injuries
• Indications for surgery– Displaced distal third– Open– Bilateral– Neurovascular injury
47
Medial 1/3 =Consider intrathoracic trauma!
Humeral Shaft Fracture
• Most common associated injury = radial nerve– Injured in 20% cases– Most improve w/o intervention– Supination weak 2* radial innervation
• Complications– R/O brachial artery injury
• Treatment– Sling & swathe IF no nerve injury!– Nerve injury = surgery
48
9
49
Proximal Humeral Fracture
Humerus Fractures
• Proximal humerus fracture– Injury to axillary nerve à deltoid fxn– Common w/ falls in elderly
• Midshaft distal fracture– Injury to radial nerve à wrist extension + 1st web space– Consider PATHOLOGICAL fracture
• Treatment– Sling & swath x 4 wks, early ROM– Surgery = compound fx or head displacement
50
The �Hip
51
Hip Anatomy
52
Hip Anatomy
53 54
PosteriorAnterior
LateralMedial
10
Hip Fractures
55
• Intertrochanteric– Most common type
• Femoral neck– Common in elderly females– Complication = aseptic necrosis
• Subtrochanteric– High energy injury in young
Femoral Neck Position• Short + ER + ABDIntertrochanteric Position• Short + ER
Hip Fractures
56
Types of Hip Fxs
57
Subcapital Transcervical Base Neck
Intertrochanteric Peritrochanteric Subtrochanteric58
Left Intertrochanteric
Fracture
59
Left Subcapital
Femoral Neck Fracture
60
Right Subtrochanteric
Fracture
11
The Foot & Ankle
62
63
Weber A• Inferior to tibiotalar joint• No syndesmosis disruption• Usually stable• Reduction + cast• Occasional ORIF
Weber C• Above tibiotalar joint• Syndesmosis disruption• Unstable• Medial fx + deltoid• ORIF
Weber B• Level to tibiotalar joint• Partial syndesmosis
disruption• Variable stability• May require ORIF
Weber Classification Maisoneuvve Fracture
• External ankle rotation– Mortis often open or unstable– Rupture of medial deltoid ligament– Proximal fibular fx
• Treatment– ORIF
64
Beware litigation 2* peroneal nerve injury
Calcaneal Fractures
• Most common tarsal bone fx
• MOI = compression 2* fall– Lumbosacral fxs– Contralateral calcaneus
• Bohler’s angle– Normal = 20-40°– Decreased = fracture
65
Bohler’s Angle
66
12
5th Metatarsal Fracture
• Pseudo-Jones (styloid) fracture– Avulsion fx of base of 5th metatarsal (peroneus brevis)– Inversion injury– Treatment
• Walking boot + WB as tolerated
• Jones fracture– Transverse fx of proximal diaphysis– Common in athletes – Treatment
• ORIF or cast 67
Jones = HIGH risk of malunion w/ running/jumping sports
68
Consider even w/ NORMAL XR!
Jones Fracture• Distal to styloid process
of 5th metatarsal
Lisfranc Injury
• Disruption of 2nd metatarsal & Lisfranc ligament– Unstable ≥ 1mm between bases of 1st & 2nd metatarsal
• Planar ecchymosis sign– Bruising in plantar aspect of midfoot
• Treatment– Nondisplaced < 1mm = NWB + splint
• Reeval at 2 wks + progressive WB x 6 wks
– Displaced = unstable & surgery
69
Pain w/ torsion of midfoot
Lisfranc Injury
• ?
2nd Metatarsal
1st Metatarsal
Lisfranc joint
1st, 2nd & 3rd cuneiforms
Lisfranc joint
complex
Cuboid
Homolateral Isolated Divergent
The Cervical
Spine
71
Unstable Cervical Fxs
• Jefferson fx – Burst fx to ring of C1– Axial loading force (diving)
• Bilateral facet dislocation– Severe flexion injury– 50% subluxation of superior VB– Both ant/post ligament disruption– Typically in lower C-spine
• Odontoid fx (types 2 & 3)– Dens of axis (C2) 72
13
Unstable Cervical Fxs
• AA or AO dislocation– Typically fatal– Head detached from spine– More common in kiddos
• Hangman C2 pedicular fx– Hyperextension injury– Chin hits dashboard in MVC– Ant C2 VB dislocation + bilateral C2 pars interarticularis
73
Unstable Cervical Fxs
• Teardrop fx– Hyperextension injury– Sudden pull of ALL into ant/inf aspect of VB (usually C2)
74
Stable Cervical Fxs
• More common than unstable fxs– Wedge fx– Process fx (SP &TP)– Unilateral facet dislocation– Vertebral burst fx (excluding C1)
• All other fxs considered unstable or potentially unstable
75
Thank you!David J. Heath, DO, MS, ATC
Cell: 865-585-0621Email: [email protected]
Abbreviated References1. Babcock O’Connell C. A Comprehensive Review for the Certification and
Recertification Examinations for PAs. 5th Ed. 20142. Diamond MA. Davis’s PA Exam Review: Focused Review for the PANCE &
PANRE. 1st Ed. 2008.3. Dietrich A et al. Carol Rivers’ Preparing for the Written Board Exam in EM.
6th Ed. Ohio ACEP. 2014.4. Herbert M. Hippo PANCE/PANRE Board Review for the PA.5. Rhee JV. PA Board Review: Certification and Recertification. 2nd Ed.6. Paulk DP & Agnew D. JB Review: PA Review Guide. 2010.
http://www.aapa.org/twocolumn.aspx?id=1306#review_books