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Orthopedics in ER

Orthopedics in ER. Parham Daneshvar PGY3. Overview. Upper extremity injuries Pelvic injuries Lower extremity injuries Spine injuries Compartment Syndrome Necrotizing Fascitis. Distal Radius Fractures. Majority are Colles’ Smith’s fracture are rare, but unstable 2 major groups:

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Orthopedics in ER

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  1. Orthopedics in ER Parham Daneshvar PGY3

  2. Overview • Upper extremity injuries • Pelvic injuries • Lower extremity injuries • Spine injuries • Compartment Syndrome • Necrotizing Fascitis

  3. Distal Radius Fractures • Majority are Colles’ • Smith’s fracture are rare, but unstable • 2 major groups: • Young patients  high E fractures • Older osteoporotic patients  low E fractures • Know radiological rules for reduction

  4. Radiological parameters

  5. Radial inclination: 22°(15-25) Radial inclination

  6. Radial Height: 11mm

  7. Ulnar +ve is never Normal Usually means there is radial shortening If unsure of significance, compare to N side Ulnar variance: Neutral or –ve + 3

  8. Anything less than neutral is unacceptable Keep in mind age and activity level of patient Volar Tilt: 11° (5-15)

  9. Reduction • Hematoma block (consider conscious sedation) • Plan landmarks prior to giving the block • Be aware of ulnar sided injury (may need some freezing as well) • Do in sterile fashion • Have assistance for traction and holding

  10. Reduction Tips • Relax the muscle groups involved • For wrists  bend elbow • Position patient properly for comfort • Plan position of your hands, and where you’ll be applying P. prior to reduction • Apply 3 point moulding • Don’t do the “Orthopedic sandwich”

  11. Reduction and Moulding Tips • Apply pressure over bone ends and not over joints  avoid excessive flexion/extension • Gently keep palms moving to distribute pressure over larger area

  12. 3 point cast • To figure out your 3 points you need understand the nature of the fracture Colles  Smith’s

  13. Casting • Good cast Bad Cast

  14. Complications • Loss of reduction  can be inevitable Risk Factors: • Dorsal comminution • Radial shortening of >= 1cm • Associated ulnar fracture • Osteoporotic bone • Dorsal tilt of >20° 2) Tight cast  may require splitting or redoing - Compartment syndrome is very rare, but be careful with young patients with high E mechanism 3) Be aware of open #’s: much more common if there is an associated ulna fracture

  15. 4) Associated injuries - Check joints above and below - Scaphoid fractures  do not miss these  detrimental outcome if missed - Scapho-lunate ligament disruption - SL space should not exceed 2mm - Carpal Tunnel syndrome - DRUJ injury: more common w radial shaft fractures(Galleazzi)

  16. Junction of middle & distal 1/3 radial shaft # + disruption of DRUJ Easy to concentrate on the fracture DRUJ is most stable with wrist in supination Radial shaft fractures almost always require ORIF Galleazzi fracture

  17. Scaphoid fractures • Can be difficult to dx • 3 common tests: • Watson’s test (most sensitive) • Axial loading of 1st MC • Snuff box (not sensitive) • If unsure, place in thumb spica and F/U weekly w x-rays  fracture will present with/in 1-2wks, or may require further w/up to assess ligamentous injuries

  18. Injuries around the Elbow • Montaggia #’s • Radial head #’s • Coronoid fractures • Elbow Dislocations • Distal humerus fractures • Biceps tendon Ruptures

  19. Montaggia # • Prox. Ulnar shaft # w an associated radial head dislocation • Don’t mistake this w a nightstick fracture • If radial head dislocation is not addressed  loss of forearm rotation

  20. Radial head/neck #’s • Often txed conservatively • Imp. to have close f/u • Require early ROM to avoid stiffness • R/O elbow instability/possible dislocation

  21. Coronoid fractures • Often associated with elbow dislocation • Key buttress for elbow stability • If less than 50% involved it elbow is usually stable Type I Type II Type III

  22. Elbow dislocations • 2nd most common joint dislocation • Most commonly (up to 90%) posterior • Simple dislocation involves no #’s • ER Care: • NV status pre and post reduction • Reduce (use thumb on olecranon technique) • Once reduced assess stability(usually left for Ortho)  can assess varus/valgus • Splint at 90° w pronation • R/O other injuries (Assess wrist(DRUJ), Shoulder)

  23. Distal humerus Fractures • Do full NV exam • Number one nerve injury is AIN(radial N. is most common in mid shaft #’s)

  24. Distal biceps tendon rupture • Very common in Males in their 40’s • Clinical diagnosis: • Hx  lifting • Px  swelling  Palpate defect, compare to other side  Don’t mistake biceps aponeurosis  w/out surgical repair, pts will lose about 50% of supination and 30% flexion strength

  25. Humeral shaft fractures • Open vs. closed • NV assessment • Asses radial nerve status (injured in 5-10%) • Most can be treated non-operatively • Sugar tong splint

  26. Prox. Humerus #s • R/O dislocation(ant. Vs. Post) • Relocate if dislocated • Young pts w dislocation have high recurrence • <20yo up to 80% redislocation rate • >40yo goes down to about 40% • Uncommon in elderly • True AP, Y-lateral, & Axillary Views(Axillary most imp.) do trauma axillary view

  27. Classification • Neer classification divides Prox. Humerus #’s into parts: • 2 , 3, or 4 part • 1cm displacement or 45° rotation • Tx: age, # pattern • Non-op • Plate fixation • Hemiarthroplasty

  28. AC separation • Common sport inj. • Most can be txed conservatively • If >100- 200% displace consider OR especially in active pts(ie. overhead atheletes)

  29. Clavicle fractures • Most common involve middle 3rd (85%) • Most can be txed non-opertively(Cuff & collar) • Recent studies: • Better shoulder power by ~ 10% w ORIF w sign. displaced and shortened #’s • ORIF possible better union rates in displaced #’s

  30. Sternoclavicular dislocation • Most are anterior • Usually relocate easily • Post. Dislocations concerning • Require intra-op relocation w presence of Thoracic Surgeon • Possible vascular inj.

  31. Scapular Fractures • High E fractures • Often txed conservatively unless intra articular involvement • Be aware of other injuries associated • Rib fractures • C-spine injuries • Lung inj.

  32. Pelvis and The Hip • X-rays • Pelvic injuries • Acetabular fractures • Hip Dislocations • Hip fractures

  33. Radiology: • Six fundamental radiographic landmarks of Letournel: • posterior wall of the acetabulum • anterior wall of the acetabulum • (3) roof (dome or tectum) • (4) teardrop • (5) ilioischial line (posterior column) • (6) iliopectineal line (anterior column)

  34. Pelvic Fractures • ATLS protocal • These are often multi-trauma pts. • Can involve sign. Blood loss • 3% of all fractures • 25% of “polytrauma” pts • 42% of MVC mortalities

  35. O/E • Open fractures: rectal, vaginal examination • Bladder injuries • Urethral injuries • Neurological injuries: • Sacral nerve root injuries S1-S4 • Peroneal nerve injuries • Pudendal nerve injuries • Associated #’s

  36. Understand the different injuries (A,B,C) • Open book (type A)(AP compression) can have ++ blood loss • Mostly venus (90%) from plexus on ant. Sacrum • Arterial blood loss most commonly from: - Internal pudendal artery - Obturator Artery - superior gluteal artery • Type B(Lateral compression) are often T-bone inj.  no need for towel reduction • Type C(Shear mechanism)  high E mechanism(Fall from height, MVC, etc)  unstable horizontally and vertically

  37. Young and Burgess classification

  38. Obtain inlet and outlet views to assess the ring

  39. Acetabular fractures • Be aware of associated injuries: • Lumber spine injuries • Femoral head fractures • Tibial plateau #’s • Pilon #’s • Calcaneus Fractures • Sciatic nerve injuries(especially w dislocations)

  40. Imaging

  41. Hip Dislocation • Majority are Posterior • Leg is in IR, Flexion, and shortened • Associated w: • Post. Acetabular wall # • Femoral head fracture • Knee inj. • Sciatic Nerve inj.

  42. Reduction tips: • Conscious sedation w muscle relaxant • Need pelvis stabilized by assistant for counter traction • Avoid torquing the femur  risk of fracture • Get on the table, put knee over shoulder • Combination of traction and upward pull +/- some IR

  43. Hip dislocations after THA • Can be anterior or posterior • W ant. Dislocation, often leg is more in ER • A lat. X-ray is useful

  44. Femoral Neck Fractures • Common in the elderly • An Emergency in younger patients • Intracapsular #’s damage blood supply to the head of the femur  high risk of AVN • Urgently send to ortho for ORIF • In the Elderly tx requires hemiarthroplasty

  45. Radiological sign • Shenton’s line

  46. Hip Fracture in elderly Three groups • Femoral neck: -Subcapital -Mid-cervical -Basi-cervical • Inter-trochanteric: -Usually txed w Dynamic hip screw • Sub-trochanteric -Usually txed w Cephalomedullary nail

  47. Hemiarthroplasy • Bipolar Moores • DHS Cephalomedullary Nail 

  48. Knee dislocations • Always be suspicious of popliteal artery injury (up to 50%) • ABI if <0.9 95% sensitive for injury • If unsure  arteriogram • Early vascular consult • High risk of Peroneal nerve inj. 20-30%  about ½ are permanent

  49. Knee dislocation • Up to ½ of the knees are re-located when present in ER • Need full hx of mechanism of injury • Complete Physical exam of the knee • R/O other injuries • Observe for Compartment syndrome • High risk of delayed thrombus, aneurysm  observe pts for 24-48hrs

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