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 #long bone image
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

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

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

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

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

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

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

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.


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


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)

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)

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


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

 

References:
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Posted in 40 Fractures, 99 Priority Topics, FM 99 priority topics, Rheum

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