Orthopedic Principles William Beaumont Hospital Department of Emergency Medicine.

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


Type 3


Type 4


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 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

Orthopedic Principles William Beaumont Hospital Department of Emergency Medicine.

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Transcript of Orthopedic Principles William Beaumont Hospital Department of Emergency Medicine.