Fractures – TN2014

Fractures Description

1) Integrity of skin / soft tissue

• Closed: skin / soft tissue over and near fracture is intact
• Open: skin / soft tissue over & near # is lacerated or abraded, # exposed to outside environment
  • Signs: continuous bleeding from puncture site or fat droplets in blood are suggestive of an open #

2) Location

• Epiphyseal: end of bone
• Metaphyseal: the flared portion of the bone at the end of the shaft
• Diaphyseal: the shaft of a long bone – proximal, middle, distal
• Physis: growth plate

3) Orientation / Fracture Pattern

• Transverse, Oblique, butterfly, segmental, spiral, comminuted (>2 # fragements)
• Intra-articular
• Avulsion: tendon or ligament tears / pulls fragment off bone – often in children
• Torus: a buckle # of one cortex – often in children
• Green-stick: an incomplete # of one cortex, often in children
• Pathologic: # through bone weakened by dz/tumor

4) Displacement

• Non-displaced vs displaced (refers to position of the distal fragment relative to the proximal fragment)
• Distracted: # fragments are separated by a gap
• Angulated: direction of # apex, eg. varus (apex away from midline) /valgus (apex toward midline)
• Translated: % of overlapping bone at # site
• Rotated: # fragment rotated about long axis of bone

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Evaluation of Healing

• Clinical: No longer tender to palpation or stressing on PEx
• X-ray: trabeculate cross # site, visible callus bridging site on at least 3/4 cortices

# Healing

• 0-3 wk: hematoma, macrophages
• 3-6 wk: Callus forms, osteoclasts remove sharp edges
• 6-12 wk: bone forms within callus
• 6-12 mo: cortical gap is bridged
• 1-2 yr: remodelling, normal architecture

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1. In a patient with multiple injuries, stabilize the patient (e.g., airway, breathing, and circulation, and life-threatening injuries) before dealing with any fractures.

Management of #

1. ABCs, primary survey & secondary survey (ATLS)
   • r/o other # / injuries
   • r/o open fracture
2. AMPLE Hx: Allergies, Medications, PMH, Last meal, Events surrounding injury
   • Consider pathologic # with Hx of only minor trauma
3. Analgesia + splint extremity: splinting provides
   • pain control,
   • reduces further damage to vessels, nerves, and skin
   • Decreases risk of inadvertently converting closed to open #
   • Facilitates pt transport
4. Imaging – x-ray rule of 2s
   • 2 sides = bilateral
   • 2 views = AP + lateral
   • 2 joints = joint above + below
   • 2 times = before + after reduction

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2  When examining patients with a fracture, assess neurovascular status and examine the joint above and below the injury.

Quick Nerve Exam – hand

• Thumbs Up = PIN (radial nerve)
• Ok Sign = AIN (Median nerve)
• Spread fingers = ulnar nerve

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3  In patients with suspected fractures that are prone to have normal X-ray findings (e.g., scaphoid fractures in wrist injuries, elbow fracture, growth plate fracture in children, stress fractures), manage according to your clinical suspicion, even if X-rays are normal.

A # may not be radiologically evident up to 2 wk after acute injury, so if a pt complains of pain and + PEx, treat as if positive for # and repeat x-ray 2 wk later to r/o a fracture. If x-ray still negative, order CT or MRI

Scaphoid #

• Common in young men from FOOSH injury

Clinical Features

• Pain with wrist movement
• Tenderness in the anatomical snuff box (100% sen, 29% specific), over scaphoid tubercle, and with long axis compression into scaphoid
• Usually undisplaced

Ix:

• X-ray: PA, lateral, scaphoid views with wrist extension and ulnar deviation
• If negative, but clinical suspicion, Tx as positive for fracture and repeat X-ray in 2 weeks
• CT or MRI if repeat x-ray at 2 wk is still negative but clinical suspicion
• Bone scan rarely used

Tx:

• Non-displaced: Long-arm thumb spica cast x 4 wk, then short arm cast until radiographic evidence of healing is seen (2-3mo)
• Displaced: ORIF

C/I:

• Non-union / mal-union
• AVN of the proximal fragment
• Delayed union – recommend surgical fixation

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Growth Plate # – SALTER classification

• I – Same – Transverse through growth place
  • Closed reduction & cast immobilization except SCFE (Slipped Capital Femoral Epiphysis)- ORIF
  • Don’t affect growth
• II – Above -Throughmetaphysis & along growth place
  • Closed reduction & cast if anatomic; otherwise ORIF
• III. Low – Through epiphysis to plate & along growth plate
  • Anatomic reduction by ORIF to prevent growth arrest, avoid fixation across growth plate
• IV. Through – Through epiphysis and metaphysis
  • Closed reduction and cast if anatomic; otherwise ORIF
• V Ram – Crushinjuryofgrowth plate
  • High incidence of growth arrest

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Ossification Centres of the Elbow (Come Rub My Tree Of Love)

• Capitellum: 1yr
• Radial head: 4 yr
• Medial epicondyle: 6 yr
• Trochlea: 8 yr
• Olecranon: 10 yr
• Lateral epicondyle: 12 yr

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4  In assessing elderly patients with an acute change in mobility (i.e., those who can no longer walk) and equivocal X-ray findings (e.g., no obvious fracture), investigate appropriately (e.g., with bone scans, computed tomography) before excluding a fracture.

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5  Identify and manage limb injuries that require urgent immobilization and/or reduction in a timely manner.

Closed Reduction

• Apply traction in the long axis of the limb
• Reverse the mechanism that produced the #
• Reduce with IV sedation and muscle relaxation (fluoroscopy prn)

Open Reduction

• Indications: NO CAST
  • Non-union
  • Open #
  • NV compromise
  • Intra-Articular #
  • Salter-Harris 3-5
  • PolyTrauma
  • Failed closed reduction
  • Not able to cast or apply traction due to site (eg Hip #)
  • Pathologic #
  • Potential for improved function with ORIF
• Re-check NV status after reduction and obtain post-reduction x-ray

Maintain the reduction

• External stabilization: splints, casts, traction, external fixator
• Internal stabilization: percutaneous pinning, extramedullary fixation (screws, plates, wires), intramedullary fixation (rods)
• f/u: evaluate bone healing

Rehabilitate to regain function and avoid joint stiffness

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6  In assessing patients with suspected fractures, provide analgesia that is timely (i.e., before X- rays) and adequate (e.g., narcotic) analgesia.

Hydromorphone 0.5 – 1mg IV Q15min prn

• Keep giving to pt till pain is managed (no upper limit)

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7  In patients presenting with a fracture, look for and diagnose high-risk complications (e.g., an open fracture, unstable cervical spine, compartment syndrome).

Orthopedic Emergencies – VON CHOP

• Vascular compromise
• Open #
• Neurological compromise / cauda equina syndrome
• Compartment syndrome
• Hip Dislocation
• Osteomyelitis / septic arthritis
• Unstable Pelvic #

Etiology:

• High energy trauma. MVA, fall from height
• May be associated with spinal injuries or life-threatening visceral injuries

Clinical Presentation

• Local swelling, tenderness, deformity of the limbs, and instability of the pelvis or spine
• ↓LOC, HoTN, Hypovolemia
• Consider involvement of EtOH or other substances

Ix

• Trauma Survey
• X-rays: lateral cervical spine, AP chest / pelvis, AP and lateral of all bones suspected to be injured
• Other views of pelvis: AP, inlet and outlet, Judet views for acetabular #

Tx:

• ABCDEs and initiate resuscitation
• Assess GU injury (rectal exam / vaginal exam mandatory)
• External or internal fixation of all #
• DVT prophylaxis
• Open #: 33% pt have multiple injuries
  • Remove FB, Irrigate with NS, cover with sterile dressing,
  • immediate IV abx (Ancef / Vanco / penicillin (clostridium), Tetanus,
  • reduce & splint #
  • NPO & prepare for OR (B/W, consent, ECG, CXR)

General # Complications

Early:

• Local:
  • Compartment Syndrome: ↑ interstitial P in an anatomical compartment (forearm, calf) where mm / tissue are bounded by fascia & bone
    • Interstitial P > capillary perfusion P: mm necrosis in 4-6 h & eventually nn necrosis
    • Clinical Features:
      • Swollen / tense compartment, Pain w/ active CTX, passive stretch, suspicious Hx
      • Late sign: 5 P’s
        • Pain out of proportion & not relieved by analgesics (↑ w/ passive stretch – most specific)
        • Paresthesia
        • Pallor, Paralysis, Pulselessness (late findings)
    • Clinical Dx – monitor with compartment Pressure catheter
      • Req serial examinations
    • Tx:
      • Remove constrictive dressing (casts, splints), elevate limb
      • Urgent fasciotomy – 48-72 hr post-op wound closure ± necrotic tissue debridement
    • C/I:
      • Rhabdomyolysis, renal failure due to myoglobinuria
      • Volkmann’s ischemic contracture – ischemic necrosis of muscle, followed by secondary fibrosis & calcifications
  • Neurological injury
  • Vascular injuiry
  • Infection
  • Implant failure
  • # blisters
  • Bladder / bowel injury
• Systemic:
  • Sepsis – if missed open #
  • DVT / PE
  • ARDS secondary to fat embolism syndrome (SOB, hypoxemia, petechial rash, thrombocytopenia, neurological symptoms)
  • Hemorrhagic shock – hemorrhage and can be life threatening

Late:

• Mal/non-union
• AVN
• Osteomyelitis
• Post-traumatic OA -esp with intra-articular #
• Heterotrophic ossification
• Jt stiffness / adhesive capsulitis
• CRPS type 1 / RSD (chronic pain)

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8  Use clinical decision rules (e.g., Ottawa ankle rules, C-spine rules, and knee rules) to guide the use of X-ray examinations.

Clinical Judgement should prevail over the rules if the pt:

• intoxicated or uncooperative
• Other distracting painful injuries
• diminished sensation in the legs
• Gross swelling which prevents palpation of malleolar bone tenderness

Give written instructions and encourage f/u in 5-7 days if pain and ability to walk are not better

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Ottawa knee rules

Canadian C-Spine rules (see neck pain post)

• Stable, Age >16, non-pregnant, GCS15, non-penetrating injury <48hr, no vertebral dz
• X-ray if
  • Age >65
  • Dangerous mechanism: Fall >3ft / 5 stairs, axial load, MCV >100km/h, motorized recreation vehicle / bicycle struck
  • Paresthesia in extremities
• Low risk factors for assessment of ROM
  • sitting position in ER
  • ambulatory at any time
  • Simple rearend MVA: except pushed into traffic, hit by bus, rollover, hit by high speed vehicle
  • Delayed onset of pain
  • No Midline C-spine tenderness
  • Rotate Neck 45 degree L and R 
    • X-ray if Can’t rotate neck 45 degree

Ottawa Knee rules – X-ray if

• Age >55
• Isolated patellar tenderness
• Tenderness of head of fibula
• Inability to flex 90 degree
• Inability to wt bear (4 steps) immediately AND in ER

Ottawa Ankle Rules – Not for pt <18yo

• Ankle X-ray if Pain in malleolar zone &
  • Bone tenderness on posterior 6cm of lateral or medial malleolus
  • Inability to wt bear (4 steps) both immediately and in ER
• Foot X-ray if Pain in midfoot zone &
  • Bone tenderness at base of 5th metatarsal
  • Bone tenderness at navicular bone
  • Inability to wt bear both immediately and in ER

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References:

• TN 2014
• http://www.emottawa.ca/assets/documents/research/cdr_cspine_poster.pdf
• http://www.ohri.ca/emerg/cdr/docs/cdr_ankle_poster.pdf
• http://www.emottawa.ca/assets/documents/research/cdr_knee_card.pdf