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Orthopedic Principles

Orthopedic Principles. William Beaumont Hospital Department of Emergency Medicine. Fractures in Kids – Salter Harris Classification. Injuries to epiphyseal growth plate result from compressive or shearing force

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Orthopedic Principles

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  1. Orthopedic Principles William Beaumont Hospital Department of Emergency Medicine

  2. Fractures in Kids – Salter Harris Classification • Injuries to epiphyseal growth plate result from compressive or shearing force • The weak cartilaginous growth zone separates before tendons or bones • If unsure, get comparison views • Type I and V not always evident on x-ray, so immobilize if clinically suspect fracture

  3. Salter Harris ClassificationMnemonic “ ME ”

  4. What Salter-Harris type is this? Type 2

  5. What Salter-Harris type is this? Type 3

  6. What Salter-Harris type is this? Type 3

  7. What Salter-Harris type is this? Type 4

  8. What Salter-Harris type is this? Type 1

  9. Examination Basics • Determine the point of maximum tenderness • Examine the joint above and below the site of injury • Check for joint stability • Check the neurovascular status • Neurovascular compromise requires emergent reduction of the fracture or dislocation • Is the fracture open? • Early Ortho consult • Signs of compartment syndrome – Five P’s

  10. Compartment Syndrome • Ischemic injury to muscles and nerves in a closed fascial compartment • Caused by edema in a closed compartment • Decreased venous return • Eventual decreased arterial flow • Commonly seen with tibia or forearm fractures • Most common lower extremity compartments: anterior > lateral > deep posterior > posterior • Most common upper extremity compartment: deep flexor compartment

  11. Compartment Syndrome • Fracture not necessary • Can occur with excessive muscle contractions, crush injury, circumferential burns, prolonged compression (i.e. drug OD) • Earliest and most reliable sign is referred pain to the compartment with passive stretch of the ischemic muscle group (i.e. plantar foot flexion causes pain in the anterior leg compartment)

  12. Compartment Syndrome - Signs • Pain • burning, poorly localized, disproportionate to injury • pain on active or passive stretch of muscles • Paresthesias in distribution of nerves • Pallor – late and ominous sign • Paralysis • Pulselessness – late and ominous sign

  13. Compartment Syndrome • Diagnosis – hand held device for measuring compartment pressure • Pressures > 30mmHg are abnormal • Treatment – immediate fasciotomy

  14. Associated Nerve Injuries ORTHO INJURY NERVE INJURY Elbow injury median or ulnar Shoulder dislocation axillary Sacral fracture cauda equina Acetabular fracture sciatica Hip dislocation femoral Femoral shaft fracture peroneal Knee dislocation tibial or peroneal

  15. Radiographic Evaluation • Rule of two's • Minimal of 2 views perpendicular to each other when possible • Include 2 joints • Include 2 limb comparison views • 2 sets of X-rays • Pre-reduction and post-reduction films; obtain pre-reduction x-rays unless neurovascular compromise • Possible repeat x-ray in 7-10 days for suspected occult fractures (i.e. scaphoid fractures)

  16. Radiographic Evaluation Is the fracture intraarticular? – increased risk of subsequent arthritis Are the fragments distracted? Is there a joint dislocation?

  17. Treatment Principles • The first priority = ABCs • Obvious fractures should NOT deter from ABCs. • Hypovolemic shock possible secondary to fractures • Pelvic fracture – 2 Liters • Femur fracture – 1.5 Liters • Multiple fractures • Worsened by third spacing

  18. Treatment Principles • For fractures: immobilize the joint proximal and distal • For joint injuries: immobilize the affected joint only • Reassess neurovascular status after immobilization or manipulation • Consider analgesia and/or sedatives prior to attempting reduction

  19. Treatment Principles Plaster splinting Circumferential casting rarely done in the ED for an acute fracture  evolving edema may lead to compartment syndrome Ice and elevate for 48 hours post injury Healing occurs over 4-10 weeks if properly immobilized

  20. Cervical Spine Injuries • Etiology: • MVC 50% • Falls 20% • Sports 15% • Classified as stable or unstable and by injury mechanism (flexion, extension, rotation, compression) • Anterior column – vertebra, discs, and anterior and posterior longitudinal ligaments • Posterior column – spinal cord, pedicles, facets, spinous processes, held together by the nuchal and capsular ligaments, and ligamentum flavum

  21. Let’s move on to the specifics…

  22. Anatomy of the Cervical Spine

  23. Navigating the C Spine X-ray • Count vertebrae – if you don’t see C7 and the C7-T1 interface the film is inadequate • The Key – integrity of the anterior cervical line, posterior cervical line and spinolaminar line • Anterior cervical line maintained by anterior longitudinal ligament • Posterior cervical line maintained by the posterior longitudinal ligament • Spinolaminar line maintained by ligamentum flavum

  24. Cervical Spine Xray

  25. Unstable Cervical Spine Injuries • An unstable C spine injury occurs when there is disruption of the ligaments of the anterior and posterior column elements • Chance of spinal cord injury great

  26. Unstable Cervical Spine Injuries C1 (Jefferson burst fracture) C2 (Hangman fracture) Odontoid fracture Flexion tear drop fracture Bilateral facet dislocation

  27. Jefferson Burst Fracture • Burst fracture of C1 ring • Mechanism: axial loading force on the occiput • Diving into shallow water • Falling from a height • Lateral displacement of the lateral masses • Disruption of the transverse ligament • Unstable, but often no neuro deficit because the ring widens when it fractures limiting cord compression

  28. Jefferson Burst Fracture

  29. Hangman Fracture • Mechanism: skull is thrown into extreme hyperextension as a result of abrupt deceleration (i.e. MVC). • Bilateral fractures of the pedicles of C2 • Spinal cord damage is minimal because the bilateral fractures allow the spinal cord to decompress • Unstable fracture

  30. Hangman Fracture

  31. Odontoid Fracture • 15% of all C spine fractures • Mechanism: MVC or fall • Type 1 – tip fracture • Type 2 – base fracture, unstable, most common 60% of odontoid fx • Type 3 – thru body of C3 very unstable

  32. Odontoid Fracture

  33. Flexion Tear Drop Fracture • Mechanism: flexion and axial loading forces cause avulsion of anteroinferior portion of vertebral body • Involves injury to anterior and posterior longitudinal ligaments creating spinal instability • Often associated with spinal cord damage • Unstable fracture

  34. Flexion Tear Drop Fracture

  35. Stable Cervical Spine Injuries Wedge fracture Vertebral body burst fracture Clay Shoveler’s fracture Transverse process fracture Unilateral facet dislocation

  36. Wedge Fracture • Mechanism: Flexion injury causes a longitudinal pull on the nuchal ligament complex that, because of its strength, usually remains intact. • The anterior vertebral body bears most of the force, sustaining simple wedge compression anteriorly without any posterior disruption. • The prevertebral soft tissues are swollen. • Stable fracture

  37. Wedge Fracture

  38. Vertebral Burst Fracture • Mechanism: Downward compressive force is transmitted to lower levels in the C spine  vertebra can shatter outward, causing a burst fracture • Disruption of anterior and posterior longitudinal ligaments • Posterior protrusion of the fracture may extend into the spinal canal and be associated with anterior cord syndrome • Burst fractures require a CT or MRI to document degree of retropulsion

  39. Vertebral Burst Fracture

  40. Clay Shoveler’s Fracture • Avulsion of C6 or C7 spinous process • Mechanism: Abrupt flexion of neck combined with muscular contraction of upper body/neck muscles; can also result from a direct blow to neck • Seen best on lateral C spine X-ray • Stable fracture

  41. Clay Shoveler’s Fracture

  42. Any questions about the cervical spine? Let’s Move On

  43. Anterior Shoulder Dislocations • Mechanism: abduction and external rotation with a posterior force (line backer injury) • 98% are anterior • Signs & Symptoms: squared shoulder, held in abduction/external rotation, anterior shoulder appears full • Check axillary nerve function: abduction of arm and sensory sergeant stripe distribution • Treatment: closed reduction by hanging weight, scapular manipulation, traction/countertraction

  44. Posterior Shoulder Dislocations 2% are posterior Most common cause is from a seizure X-ray – light bulb sign

  45. Anterior Shoulder Dislocations

  46. Forearm Fractures • Monteggia fracture– fracture of the proximal 1/3 ulna with an associated radial head dislocation • Galeazzi fracture – fracture distal 1/3 radius with dislocation of the distal radioulnar joint • Treatment– urgent Ortho consult for operative repair

  47. Monteggia Fracture

  48. Galleazzi Fracture

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