We’ve Got a Bone to Pick…. Pearls, Pitfalls & High-Yield Orthopedics Educational Objectives

Upon hearing & assimilating this program, clinician will be better able to:

1. Identify each section of long-bone anatomy; 2. Identify & describe various types of fractures, including transverse, oblique, spiral, comminuted & segmental; 3. Correctly diagnose & describe pediatric fractures, including greenstick, buckle, & growth plate fractures using Salter-Harris classification; 4. Identify & describe from radiographs common hand/wrist fractures, David J. Heath, DO, MS, ATC, FAAEM ankle/foot fractures, different types of hip fractures, common spine Facility Medical Director, Emergency Medicine fractures & common shoulder fractures; Saint Joseph-London Hospital Adjunct Clinical Professor, LMU-DCOM 5. Institute appropriate treatments for each of demonstrated fractures. [email protected]

Systematic Approach to PE

• History – It’s ALL about that history! • Observation – Abnormalities & symmetry Long Bone • Palpation – Temperature, tenderness Anatomy • Range of Motion – PROM & AROM • Strength – Full & equal • Special Tests HOPRSS – “Provocative” tests 4

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1 Description of Fractures

• Open v. closed – Open = bone exposed – Closed = overlying soft tissue intact Fracture • Location (be precise) Nomenclature – Left v. right – Anatomic orientation • Proximal/distal, medial/lateral, anterior/posterior – Anatomic landmarks & name of bone

• Lines 7 – See next slide 8

Lines of Fractures Position & Alignment

• Transverse • Degree of fracture – Right angles to long axis – Complete v. incomplete • Oblique • Rotation – Diagonal to long axis – Fragments rotated relative to each other • Spiral – Interval v. external – Rotational force to shaft • Angulation • Comminuted – Loss of ANATOMICAL alignment in angular fashion – Bone > 2 fragments – Valgus v. varus • Segmental Describe rotation, • Displacement/shortening angulation & – Free floating central component displacement by – Loss of AXIAL alignment direction of DISTAL 9 10 – At least 2 fx lines present – Fragments shifted relative to each other segment!

Descriptive Modifiers

• Position overall • Intra/extraarticular Incomplete – Extends/involves articular surface • Impaction/distraction Pediatric – Shortening or widening Fractures – NO loss of alignment • Pathologic – Suspected w/ trivial trauma • Skeletal maturity

– Growth plates present 11 12

2 Greenstick Fracture Buckle (Torus) Fractures

• Incomplete angulated w/ cortical breech to one • Compression-type force applied to relatively soft, side of bone immature bone • Usually mid-diaphyseal • Incomplete fracture • Treatment – Bulging of cortex – Splint w/ F/U to ortho – Trabecular compression 2* axial loading to long axis – Commonly involve distal radial metaphysis

• Treatment – Volar fx = Splint molded in EXTENSION Solely relying on – Dorsal fx = Removable Velcro splint 13 radiology report14

Salter-Harris Fxs

6% 75% 10% 10% 1% Infants & MOST toddlers COMMON

Separated Above Lower Through Rammed

Dorsal Growth Torus complications Fracture 15 SALTR ñ I to V

Salter-Harris Fractures

• Demographics – Most common age = 10 to 16 (80%) – Mostly males (2* delayed skeletal maturity) • Physis (growth plate) Hand & Wrist – Composed of cartilage cells (not seen on XR) – Weaker than supporting ligaments

• Blood supply to GP from epiphysis – ñ epiphyseal injury = ñ growth disturbances – Type I = least growth disturbance – Type V = most growth disturbance 17 18

3 19

VOLAR DORSAL

Scaphoid Fracture

• Rare in kiddos • Pain in snuffbox & ulnar deviation • Imaging – 1st XR = 14% missed – 2nd XR in 7 days Most common carpal fx – Bone scan to confirm dx (62-87% of all wrist fxs) • Complication – High risk of AVN • Treatment – Nondisplaced = thumb spica splint

Scaphoid Blood Supply` Lunate & Perilunate Dislocations

Scaphos = peanut • Lunate – MC carpal bone to dislocate – Volar swelling w/ palpable mass – Treatment • Immediate reduction w/ surgical repair

• Perilunate – Dorsal swelling w/ palpable mass – Treatment DORSAL VOLAR • Immediate reduction w/ surgical repair

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4 Lunate Dislocation

Piece of Pie Sign Spilled Teacup Sign • Abnormal triangular • Abnormal volar appearance of lunate displacement & tilt of Lunate on AP XR dislocated lunate 25 Dislocation 26

Lunate & Perilunate Dislocations

Volar Dorsal

Perilunate Dislocation 27

Boxers Fracture Boxers Fracture • Fracture to neck of 5th metacarpal w/ volar angulation

• MOI – Punching injury

• Treatment Always suspect “Fight Bite” – Closed reduction + ulnar gutter splint – Close F/U for loss of reduction

Rotational displacement 29 UNACCEPTABLE! 30

5 Colles’ Fracture

• Most common fracture in adults >50 yo

• “Dinner fork” deformity – Distal radius at metaphysis – Dorsal displacement – Ulnar styloid fracture common

• Treatment – Closed reduction + cast x 6-8 wks – Intraarticular requires surgery Complication = Median nerve injury Colles’ 31 Fracture 32

Smith Fracture

• “Reverse” Colles’ fracture – Volar displacement of distal radius

• Associated median nerve and flexor tendon injury

• Treatment – Closed reduction

Smith 33 Fracture 34

Triquetrum Fracture Triquetral Fracture

• Most common dorsal chip fracture of wrist • Pain on dorsum of wrist & ulnar styloid • Painful to flexion

2nd most common carpal fracture

35 VOLAR DORSAL

6 Upper Forearm Fractures Galeazzi Fracture

• Galeazzi • Distal 1/3 radial fx, usually dorsal angulation – DRUJ hurts, radial head does not • Disrupted DRUJ • Complication • Monteggia – Ulnar nerve injury – DRUJ painless, RH painful • Treatment – ORIF • Essex-Lopresti Galeazzi – BOTH DRUJ & RH painful 38 Radial fx DRUJ confidently found Ulnar fx via Lister’s tubercle 37 Monteggia

Monteggia Fracture Essex-Lopresti Fracture • Apex of ulna fx points in direction of radial head • Radial head fracture dislocation • Dislocation of DRUJ • Treatment • Interosseous membrane disruption Galeazzi – ORIF Radial fx • Treatment Ulnar fx – ORIF generally needed Monteggia

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Shoulder Anatomy The Shoulder

41 42

7 Shoulder Anatomy Shoulder Anatomy

SITS • Supraspinatus • Infraspinatous • Teres minor • Subscapularis 43 44

Clavicle Fractures Clavicle Fractures

• Most common bone fractured in children

• Middle 1/3 – Most commonly fractured (75-80%)

• Distal 1/3 – Associated w/ ruptured coracoclavicular jt + significant medial elevation

• Treatment – Nondisplaced = sling x 3-4 wks à 3-4 wks, AROM – Displaced > 100% (nonunion 4.5%) = ORIF 45 46

Clavicle Fractures Humeral Shaft Fracture

• Medial 1/3 • Most common associated injury = radial nerve – Uncommon Medial 1/3 = – Injured in 20% cases Consider – Requires STRONG forces intrathoracic – Most improve w/o intervention – Search for associated injuries trauma! – Supination weak 2* radial innervation

• Indications for surgery • Complications – Displaced distal third – R/O brachial artery injury – Open – Bilateral • Treatment – Neurovascular injury – Sling & swathe IF no nerve injury! – Nerve injury = surgery 47 48

8 Humerus Fractures

• Proximal humerus fracture – Injury to axillary nerve à deltoid fxn – Common w/ falls in elderly

• Midshaft distal fracture – Injury to radial nerve à wrist extension + 1st web space – Consider PATHOLOGICAL fracture

• Treatment Proximal – Sling & swath x 4 wks, early ROM Humeral – Surgery = compound fx or head displacement Fracture 49 50

Hip Anatomy

The Hip

51 52

Hip Anatomy

Anterior Posterior

53 54 Medial Lateral

9 Hip Fractures Hip Fractures

• Intertrochanteric – Most common type

• Femoral neck – Common in elderly females – Complication = aseptic necrosis

• Subtrochanteric – High energy injury in young Femoral Neck Position • Short + ER + ABD Intertrochanteric Position • Short + ER 55 56

Types of Hip Fxs

Subcapital Transcervical Base Neck

Left Intertrochanteric 57 58 Intertrochanteric Peritrochanteric Subtrochanteric Fracture

Right Left Subtrochanteric Subcapital Fracture Femoral Neck Fracture

59 60

10 The Foot & Ankle

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Weber Classification Maisoneuvve Fracture

• External ankle rotation Beware – Mortis often open or unstable litigation 2* peroneal nerve – Rupture of medial deltoid ligament injury – Proximal fibular fx

• Treatment – ORIF

Weber A Weber B Weber C • Inferior to tibiotalar joint • Level to tibiotalar joint • Above tibiotalar joint • No syndesmosis disruption • Partial syndesmosis • Syndesmosis disruption • Usually stable disruption • Unstable • Reduction + cast • Variable stability • Medial fx + deltoid • Occasional ORIF • May require ORIF • ORIF 63 64

Bohler’s Angle Calcaneal Fractures

• Most common tarsal bone fx

• MOI = compression 2* fall – Lumbosacral fxs – Contralateral calcaneus

• Bohler’s angle – Normal = 20-40° – Decreased = fracture

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11 5th Metatarsal Fracture

• Pseudo-Jones (styloid) fracture – Avulsion fx of base of 5th metatarsal (peroneus brevis) – Inversion injury Jones Fracture • Distal to styloid process – Treatment of 5th metatarsal • Walking boot + WB as tolerated

• Jones fracture – Transverse fx of proximal diaphysis – Common in athletes Jones = HIGH risk of malunion w/ running/ – Treatment jumping sports Consider even w/ • ORIF or cast NORMAL XR! 67 68

Lisfranc Injury Lisfranc Injury

• Disruption of 2nd metatarsal & Lisfranc ligament • ? – Unstable ≥ 1mm between bases of 1st & 2nd metatarsal

nd • Planar ecchymosis sign 2 Metatarsal 1st Metatarsal – Bruising in plantar aspect of midfoot

Lisfranc joint Lisfranc • Treatment joint complex – Nondisplaced < 1mm = NWB + splint 1st, 2nd & 3rd cuneiforms Cuboid • Reeval at 2 wks + progressive WB x 6 wks – Displaced = unstable & surgery Pain w/ torsion of midfoot 69 Homolateral Isolated Divergent

Unstable Cervical Fxs

• Jefferson fx – Burst fx to ring of C1 The – Axial loading force (diving) Cervical • Bilateral facet dislocation – Severe flexion injury Spine – 50% subluxation of superior VB – Both ant/post ligament disruption – Typically in lower C-spine

• Odontoid fx (types 2 & 3) 71 – Dens of axis (C2) 72

12 Unstable Cervical Fxs Unstable Cervical Fxs

• AA or AO dislocation • Teardrop fx – Typically fatal – Hyperextension injury – Head detached from spine – Sudden pull of ALL into – More common in kiddos ant/inf aspect of VB (usually C2) • Hangman C2 pedicular fx – Hyperextension injury – Chin hits dashboard in MVC – Ant C2 VB dislocation + bilateral C2 pars interarticularis

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Thank you! Stable Cervical Fxs David J. Heath, DO, MS, ATC • More common than unstable fxs Cell: 865-585-0621 Email: [email protected] – Wedge fx – Process fx (SP &TP) – Unilateral facet dislocation – Vertebral burst fx (excluding C1)

• All other fxs considered unstable or potentially unstable

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Abbreviated References

1. Babcock O’Connell C. A Comprehensive Review for the Certification and Recertification Examinations for PAs. 5th Ed. 2014 2. Diamond MA. Davis’s PA Exam Review: Focused Review for the PANCE & PANRE. 1st Ed. 2008. 3. Dietrich A et al. Carol Rivers’ Preparing for the Written Board Exam in EM. 6th Ed. Ohio ACEP. 2014. 4. Herbert M. Hippo PANCE/PANRE Board Review for the PA. 5. Rhee JV. PA Board Review: Certification and Recertification. 2nd Ed. 6. Paulk DP & Agnew D. JB Review: PA Review Guide. 2010.

http://www.aapa.org/twocolumn.aspx?id=1306#review_books

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