1. Orthopedic Trauma Landon C. Bartlett, MHS,PA-C, EMCAQ ER Physician Assistant St. Joseph Mercy Livingston Emergency Dept Brighton Emergency Department St. Joseph Mercy Ann Arbor ED EMPG, PC August 2012

3. Initial Management • ABCDEs of Trauma Evaluation • Primary Survey • Airway, Breathing, Circulation, Disability, Exposure • Secondary Survey • Head to toe examination, maintain C-spine immobilization • Reduce orthopedic emergencies: Vascular Compromise • Manage Limb Threatening Injures • Traumatic Amputation • Compartment Syndrome

4. Manage Limb Threatening Injures • Traumatic Amputation • Guillotine best for reimplantation • Crush injuries less successful • X-ray: • help establish precise location of injury • Treatment: • Moist saline dressing of stump and amputated part • Place amputated part in plastic bag on ice • Do not allow to freeze • Viability 6-8 hours, 12-24 with cooling • Antibiotics and Tetanus • Disposition • Admit limb amputation to appropriate service • Digit amputation: Specialty eval. In ER or close follow up

5. Compartment Syndrome • Lower extremities, but can occur anywhere (hand, forearm, abdomen) • Crush Injury, fractures, surgery, etc. • Neurovascular compromise due to swelling in compartment • 5 P’s • Pallor, Pulselessness (late), Pain, Paresthesias and Poikilothermia • Early findings • Pain out of proportion with passive ROM • Sensory hypoesthesia • Measure intracompartmental pressure • Stryker or Arterial Line Pressure Monitor • Above 30 mmHg ABnormal • Decompression Fasciotomy within 4-8 hours

6. General Considerations • Fractures and Dislocations • Terminology: open/closed, proximal/distal, transverse/oblique, displaced anterior/posterior/medial/lateral, angulated • Describe relative to distal structures relation to proximal portion • Type of Injury (Special Names) • Salter Harris • Lisfranc

7. Describe This Fracture

8. Salter Harris Fractures • Type I • Through physis • Excellent prognosis • Type II • Most common • Through physis with oblique Metaphyseal fracture • Excellent prognosis • Type III • Epiphysial fracture through physis • Common in distal tibia • Requires appropriate reduction to prevent growth plate arrest • Good prognosis • Type IV • Through Metaphysis, Epiphysis and physis • Surgical Repair to prevent growth plate arrest • High risk for growth plate arrest • Type V • Rare, usually distal tibia and knee • Crushing forces • No fracture visible = frequently missed • Shortening and angular deformity due to growth plate arrest

9. Sprains & Strains • Can be associated with fracture • Grades I-III • I: incomplete tear, conservative care • II: Significant incomplete tear, joint laxity, splint with follow-up • III: Complete disruption, unstable joint, splint with follow-up • RICE, NSAIDS, APAP • When in doubt splint and follow-up

10. Splinting • Stabilize injury, pain relief, prevent further injury • Splint one joint above and one joint below the injury • Check neurovascular prior to discharge, after splint • Fiberglass, plaster, premolded

11. Procedural Sedation • Goal: Analgesia, amnesia and relaxation without general anesthesia • Policy • Requirements: • Functioning IV, Supplemental Oxygen, Pulse Oximeter, Suction, Intubation Equipment, BVM • Etomidate, Versed/Opiate, Ketamine, Propofol • Discharge when ambulatory and tolerating PO fluid • Hematoma Block • Local anesthetic injection into fracture site

13. Shoulder Girdle Injuries • Sternoclavicular Joint Dislocation • Clavicle Fracture • Acromioclavicular Joint Injury • Scapula Fractures • Rotator Cuff Injury • Shoulder Dislocation

14. Shoulder Girdle Injuries • Sternoclavicular Joint Dislocation • Anterior most common • Immobilize (sling/swath) after reduction, analgesia, ortho follow-up • Posterior result of crushing forces to chest • 25% superior mediastinal injuries • CT all posterior dislocation • Specialty consultation, many require surgical repair • Usually require admission • Graded I-III • I: Mild sprain, analgesia and sling • II: Subluxation, rupture of ligament, analgesia, sling/swath • III: Complete Dislocation • Tender SCJ • X-rays: Chest, Clavicle and Sternal

15. Shoulder Girdle Injuries • Clavicle Fracture • Fall onto shoulder, direct blow • Tender clavicle, possible deformity • X-ray: Clavicular • Closed fractures • Analgesia, sling or sling/swath, f/u ortho • Open Fractures • Antibiotics, Td, ortho consultation

16. Shoulder Girdle Injuries • Acromioclavicular Joint Injury • 25% of shoulder girdle dislocations • Fall onto shoulder with point tender AC Joint • Grade I-III • I: Sprain, minimal tear, Ice, sling, analgesia • II: Small tear, no change with weight, Ice, sling, analgesia • III: Complete AC ligament disruption, coracoclavicular ligament and muscular attachments. Ortho referral with conservative or surgical treatment.

17. Shoulder Girdle Injuries • Scapula Fractures • Uncommon, 1% of all fractures, well protected • Direct blow (high force) – other injuries i.e.. Rib fracture, lung contusion, pneumothorax, humerus fracture • Type I-IV • I: Coracoid process, acromion process or scapular spine • II: Scapular neck • III: Glenoid fossa, intra-articular • IV: Body, most common, risk of pulmonary contusion • Sling and swath, analgesia for isolated fractures

18. Shoulder Girdle Injuries • Rotator Cuff Injury • Falls • SITS muscles (subscapularis, infraspinatus, teres minor and supraspinatus. • Positive “Drop Arm Test” • X-ray to rule out fracture • MRI, as outpatient • Sling, analgesia, ortho follow-up

19. Shoulder Girdle Injuries • Shoulder Dislocation • Most common major joint dislocation • 95% Anterior Dislocations • Posterior dislocation -- seizures or electrocution • Neurovascular exam -- axillary nerve at lateral aspect of shoulder • Neurologic deficit - - contact ortho • X-rays: Y-view reveals anterior or posterior dislocation • Hill-Sachs deformity – Impacted post/lat. humeral head • Bankart Fracture – ant/inferior glenoid rim fracture, assoc. with anterior dislocation, may only be seen on CT • Reduction • Adequate sedation • Method: Scapular Manipulation, Traction-Counter traction • Sling/Swath, analgesia, Ortho follow-up 2-3 days

21. Upper Extremity Injuries • Humerus Fracture • Supracondylar Fracture • Elbow Injures • Olecranon Fracture • Radial Head Fracture • Elbow Dislocation • Radial Head Subluxation (Nursemaid’s Elbow) • Forearm Fracture • Wrist & Hand Injuries • Lunate/Perilunate dislocation • Scapholunate Dislocation • Carpal Bone Fractures • Metacarpal Fractures • Phalanx Fracture/Dislocation • Ulnar collateral ligament rupture

22. Upper Extremity Injuries • Humerus Fracture • Frequent in elderly, FOOSH • Neurovascular • Brachial artery • Radial nerve -- Wrist drop • Easily seen on x-ray • Conservative management • Sling & Swath or coaptation splint, analgesia, Orthopedic follow-up, contact while in ED. • Nearly 100% rate of union

23. Upper Extremity Injuries • Supracondylar Fracture • Children predominantly • Risk for serious morbidity • Volkmann Contracture: Ischemic muscle damage • Neurovascular exam • Ulnar nerve most commonly injured (ABduction of fingers) • X-ray • Fracture, displacement • Anterior and Posterior Fat Pads • Orthopedic Referral for all! • Don’t reduce yourself. • Posterior long arm splint • Nondisplaced fractures can be discharged home with prompt ortho evaluation

24. Upper Extremity Injuries • Olecranon Fracture • Direct trauma or avulsion • X-ray: AP, lateral • Acute orthopedic consult • Ulnar nerve injury • Displaced >2 mm • Posterior long arm and sling • Analgesia

25. Upper Extremity Injuries • Radial Head Fracture • FOOSH or Direct Trauma • Pain with supination/pronation • X-rays • Occult fracture common • Posterior Fat: Never normal • Anterior Sail Sign • Simple nondisplaced • Splint, sling, analgesia, follow-up • Comminuted • Call orthopedist

26. Upper Extremity Injuries(Radial Head Fracture)

27. Upper Extremity Injuries • Elbow Dislocation • 2nd most common dislocated major joint • Posterior most common • Ulna posterior to humerus • Fractures common • Deformity visible at olecranon • Neurovascular (brachial artery and median nerve • Reduce immediately if neurovascular compromise • Reduction • Sedation • Traction (1-3 person) • Posterior long arm splint, sling, analgesia, Ortho follow-up

28. Upper Extremity Injuries • Radial Head Subluxation (Nursemaid’s Elbow) • Children < 5 yo, 25% of elbow injuries in children • Traction injury, with slipping of annular ligament proximally • Child will not use arm, held in slight flexion and pronation forearm • Radial head tender, child resists supination • X-rays • Not needed if excellent story. Obtain if not. • Normal x-rays • Reduction (all with thumb on radial head) • Supination • Supination with flexion • Pronation with flexion • Successful if child resume usage in several minutes • “Positive sucker sign”

29. Upper Extremity Injuries • Forearm Fractures • FOOSH injuries • Assess nerve injury • 6 Common Fractures • Colles’- transverse distal radius with dorsal angulation • Smith - transverse distal radius with volar angulation • Barton– oblique, intra-articular of distal radius with dorsal displacement of distal fragment along with dorsal carpus subluxation • Chauffeur’s – intra-articular distal radial styloid • Monteggia – Ulnar fracture with radial head dislocation • Galeazzi – Distal 1/3 radius fracture with dislocation of distal radioulnar joint • GRUM/MUGR • Galeazzi=radial fracture • Ulna=Monteggia

30. Upper Extremity Injuries • Forearm Fractures • Nondisplaced • Volar or sugar-tong splint to metacarpals • Ortho follow-up • Displaced • Reduction • Hematoma block, traction, analgesia • Sugar-tong splint • Orthopedic referral

31. Colles’ Fracture • Transverse distal radius with dorsal angulation • SMITH Fracture • “Reverse Colles” • Transverse distal radius with volar angulation

32. Smith Fracture • “Reverse Colles” • Transverse distal radius with volar angulation

33. Barton Fracture • oblique, intra-articular of distal radius with dorsal displacement of distal fragment along with dorsal carpus subluxation

34. Chauffeur’s Fracture • Intra-articular distal radial styloid

35. Monteggia Fracture • Ulnar fracture with radial head dislocation • Need good lateral x-ray • Proximal Radial Line bisects Anterior Humeral line • Open Reduction if prolonged dislocation • Loss of range of motion

36. Monteggia Fracture

37. Galeazzi Fracture • Distal 1/3 radius fracture with dislocation of distal radioulnar joint

38. Upper Extremity Injuries • Hand and Wrist Injuries • Anatomy • Carpal bones • “Sally Left The Party To Take Connie Home” • Tenuous blood supply • Avascular Necrosis • When in doubt: Splint and refer to Ortho

39. Upper Extremity Injuries • Perilunate/Lunate Dislocation • FOOSH • Severe pain, swelling, decreased ROM • Median nerve injury possible • Lateral Wrist X-ray (most important) • Spilled tea cup • Line through center of radius and capitate with lunate either dorsal or volar displaced • Urgent reduction in the ER • Surgery likely due to extensive ligamentous injury even if reduction successful

40. Perilunate/Lunate Dislocation

41. Upper Extremity Injuries • Scapholunate Dislocation • Frequently missed as sprain • FOOSH • AP Wrist x-ray • “Terry Thomas Sign” • Space between scaphoid and lunate more than 3mm • Splint, analgesia • Refer to orthopedist for repair

42. Upper Extremity Injuries • Carpal Bone Fracture • FOOSH • Kienbock Disease • AVN of Scaphoid and/or Lunate • Scaphoid Fracture • Snuff Box tenderness • splint with ortho follow-up • Risk of AVN • Treatment • Thumb Spica: Scaphoid • Ulnar Gutter: Triquetral • Repeat x-rays in 1-2 weeks for occult fractures • Orthopedic follow up

43. Upper Extremity Injuries • Metacarpal Fractures • Boxer’s Fracture (5th Metacarpal) • Most common • Punching • Angulation Indicates Reduction: 10/20/30/40 • Laceration of 4th/5th MCPJ = “Fight Bite” (human bite) • Infection and tendon injury – HIGH RISK • Antibiotic - Augmentin • No wound closure • Splint in position of function • Hand Surgeon

44. Upper Extremity Injuries • Metacarpal Fractures • Bennet Fracture • Intra-articular base of 1st metacarpal • Require operative repair as outpatient • X-rays • Displacement and Angulation • 10,20,30,40 rule • Reduction • Hematoma Block, traction and manipulation • Splint • Volar Splint for 2nd-4th Metacarpal Fractures • Ulnar Gutter for Boxer’s Fracture • Thumb Spica Splint for Bennet Fracture

45. Upper Extremity Injuries • Phalanx Fractures and dislocations • Neurovascular • Rotational injury • X-ray • Reduction • Digital Block with Bupivacaine • Finger splint with Hand Surgeon Follow-up

46. Distal Extensor Tendon Injuries • Mallet Finger • Extensor tendon laceration/avulsion at distal phalanx insertion • Unable to straighten finger tip (DIPJ) • Possible avulsion fracture • Splint at DIPJ for 6 weeks • Open wounds • Antibiotics • Hand surgeon follow up

47. Distal Extensor Tendon Injuries • Boutonniere Deformity (Button Hole) • Rupture of central portion of extensor tendon at insertion of middle phalanx • Trauma i.e.. Jammed finger • Pain, swelling dorsal PIPJ • Insidious onset 7-21 days • X-rays usually normal • Splint in extension for 6 weeks, leave DIP alone • Open injury– Hand surgeon

49. Pelvic Girdle Injuries • Pelvic Fractures • Hip Injures • Hip Fractures • Hip Dislocations

50. Pelvic Girdle Injuries • Pelvic Fractures • Stable • Ground level fall • Unilateral super/inf. Rami fracture • Analgesia, weight bare as tolerated, DVT prophylaxis • Unstable • High impact injury • Multisystem trauma • 50% mortality if Shock • Bilateral ring disruption • Rami + Sacrum or Ilium • Symphysis pubis + sacral fracture/sacroiliac ligament disruption • Assoc. with genitourinary injury • High riding prostate/meatal blood • Retrograde cystogram • Blood loss of 1-5 liters • ABCs, Resuscitation • Operative Treatment