Clinical Excellence Series Volume V an Evidence-Based Approach to Traumatic Emergencies

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Clinical Excellence Series n Volume V

An Evidence-Based Approach To Traumatic Emergencies

Inside Neck Trauma: Don’t Put Your Neck On The Line Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking Wrist Injuries: Emergency Imaging And Management

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The Emergency Medicine Practice Clinical Excellence Series, Volume V: An Evidence-Based Approach To Traumatic Emergencies is published by EB Practice, LLC, 5550 Triangle Pkwy Ste 150, Norcross, GA 30092. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Emergency Medicine Practice, The Emergency Medicine Practice Clinical Excel- lence Series, and An Evidence-Based Approach to Traumatic Emergencies are trademarks of EB Practice, LLC. Copyright © 2009 EB Practice, LLC. All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC. Price: $199. Call 1-800-249-5770 to ask about multiple-copy discounts. Brought to you exclusively by the publisher of:

Editor-in-Chief Nicholas Genes, MD, PhD Emergency Medicine, Massachusetts Corey M. Slovis, MD, FACP, FACEP International Editors Andy Jagoda, MD, FACEP Instructor, Department of General Hospital, Harvard Medical Professor and Chair, Department Peter Cameron, MD Professor and Chair, Department Emergency Medicine, Mount Sinai School, Boston, MA of Emergency Medicine, Vanderbilt Chair, Emergency Medicine, of Emergency Medicine, Mount School of Medicine, New York, NY University Medical Center, Charles V. Pollack, Jr., MA, MD, Monash University; Alfred Hospital, Sinai School of Medicine; Medical Nashville, TN Michael A. Gibbs, MD, FACEP FACEP Melbourne, Australia Director, Mount Sinai Hospital, New Chief, Department of Emergency Chairman, Department of Jenny Walker, MD, MPH, MSW York, NY Medicine, Maine Medical Center, Emergency Medicine, Pennsylvania Assistant Professor; Division Chief, Giorgio Carbone, MD Editorial Board Portland, ME Hospital, University of Pennsylvania Family Medicine, Department Chief, Department of Emergency Health System, Philadelphia, PA of Community and Preventive Medicine, Ospedale Gradenigo, William J. Brady, MD Steven A. Godwin, MD, FACEP Medicine, Mount Sinai Medical Torino, Italy. Professor of Emergency Medicine Associate Professor, Associate Michael S. Radeos, MD, MPH Center, New York, NY and Internal Medicine; Vice Chair Chair and Chief of Service, Assistant Professor of Emergency Amin Antoine Kazzi, MD, FAAEM of Emergency Medicine, University Department of Emergency Medicine, Medicine, Weill Medical College of Ron M. Walls, MD Associate Professor and Vice of Virginia School of Medicine, Assistant Dean, Simulation Cornell University, New York, NY Professor and Chair, Department Chair, Department of Emergency Charlottesville, VA Education, University of Florida of Emergency Medicine, Brigham Medicine, University of California, Robert L. Rogers, MD, FACEP, COM-Jacksonville, Jacksonville, FL and Women’s Hospital, Harvard Irvine; American University, Beirut, Peter DeBlieux, MD FAAEM, FACP Medical School, Boston, MA Lebanon Professor of Clinical Medicine, Gregory L. Henry, MD, FACEP Assistant Professor of Emergency LSU Health Science Center; CEO, Medical Practice Risk Medicine, The University of Scott Weingart, MD Hugo Peralta, MD Director of Emergency Medicine Assessment, Inc.; Clinical Professor Maryland School of Medicine, Assistant Professor of Emergency Chair of Emergency Services, Services, University Hospital, New of Emergency Medicine, University Baltimore, MD Medicine, Elmhurst Hospital Hospital Italiano, Buenos Aires, Orleans, LA of Michigan, Ann Arbor, MI Center, Mount Sinai School of Argentina Alfred Sacchetti, MD, FACEP Medicine, New York, NY Wyatt W. Decker, MD John M. Howell, MD, FACEP Assistant Clinical Professor, Maarten Simons, MD, PhD Associate Professor of Emergency Clinical Professor of Emergency Department of Emergency Medicine, Emergency Medicine Residency Medicine, Mayo Clinic College of Medicine, George Washington Thomas Jefferson University, Research Editor Director, OLVG Hospital, Medicine, Rochester, MN University, Washington, DC; Director Philadelphia, PA Lisa Jacobson, MD Amsterdam, The Netherlands of Academic Affairs, Best Practices, Francis M. Fesmire, MD, FACEP Scott Silvers, MD, FACEP Chief Resident, Mount Sinai School Inc, Inova Fairfax Hospital, Falls Director, Heart-Stroke Center, Medical Director, Department of of Medicine, Emergency Medicine Church, VA Erlanger Medical Center; Assistant Emergency Medicine, Mayo Clinic, Residency, New York, NY Professor, UT College of Medicine, Keith A. Marill, MD Jacksonville, FL Chattanooga, TN Assistant Professor, Department of CME Accreditation Information

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Table Of Contents

Introduction...... 3 by Matt S. Friedman, MD

Neck Trauma: Don’t Put Your Neck On The Line...... 5 by Jeffrey Schaider, MD and John Bailitz, MD

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department...... 37 by Lisa Freeman, MD, FACEP and Adam Corley, MD

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking...... 67 by John A. Marx, MD

Wrist Injuries: Emergency Imaging And Management...... 99 by Scot Hill, MD and Eric Wasserman, MD

CME Answer Form...... 129

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Class I Class II Class III Indeterminate tatives from the resuscitation • Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research councils of ILCOR: How to De- • Definitely useful • Probably useful • Possibly useful • No recommendations until velop Evidence-Based Guidelines • Proven in both efficacy and • Considered optional or alterna- further research for Emergency Cardiac Care: effectiveness Level of Evidence: tive treatments Quality of Evidence and Classes • Generally higher levels of Level of Evidence: of Recommendations; also: Level of Evidence: evidence Level of Evidence: • Evidence not available Anonymous. Guidelines for car- • One or more large prospective • Non-randomized or retrospec- • Generally lower or intermediate • Higher studies in progress diopulmonary resuscitation and studies are present (with rare tive studies: historic, cohort, or levels of evidence • Results inconsistent, contradic- emergency cardiac care. Emer- exceptions) case control studies • Case series, animal studies, tory gency Cardiac Care Committee • High-quality meta-analyses • Less robust RCTs consensus panels • Results not compelling and Subcommittees, American • Study results consistently posi- • Results consistently positive • Occasionally positive results Heart Association. Part IX. Ensur- tive and compelling Significantly modified from: The Emergency Cardiovascular Care ing effectiveness of community- Committees of the American wide emergency cardiac care. Heart Association and represen- JAMA. 1992;268(16):2289-2295.

The Emergency Medicine Practice Clinical Excellence Series Volume V An Evidence-Based Approach To Traumatic Emergencies

Introduction

Welcome to Volume V in The Emergency Medicine while increasing the efficiency of their treatment in the Practice Clinical Excellence Series. Our primary goal is to emergency room. update previous editions with recent publications to Emergency Medicine Practice strives to provide its inform our readers of the latest evidence applicable to readers with evidence-based perspectives on clini- emergency medicine. Our secondary goals are to inte- cal care. This volume contains over 500 references, grate evidence-based concepts into the daily practice including 63 new references, with distinct, underlined of emergency medicine, to incite discussion, to further paragraphs authored by the editors that offer the most research, and to initiate modifications to the standard recent updates, most of which relate to literature pub- of care. lished in the last several years. The articles selected for this book detail 4 distinct We hope that this volume of The Emergency Medicine trauma topics, which are applicable to the trauma team Practice Clinical Excellence Series will fine tune your man- in a level 1 trauma center, the solo emergency medicine agement of trauma and provoke inquiries into current practitioner in a 100-bed community hospital, and the practice. We also hope that you find our future volumes ER doc moonlighting in an urgent care clinic. The lit- as insightful and helpful to your clinical practice. erature on the management of trauma is vast and never stagnant. This book provides a focused discussion of Matt Samuel Friedman, MD, Editor neck trauma, orthopedic sports injuries, blunt abdomi- Department of Emergency Medicine nal trauma, and wrist injuries. These discussions allow Mount Sinai School of Medicine emergency practitioners to remain knowledgeable and New York, NY apprised of hot topics in our field in order to provide the best possible care for the patient. Benjamin W. Friedman, MD, MS, FAAEM, Editor Management of abdominal and neck trauma is Assistant Professor of Emergency Medicine variable in different shops across the country. Recent Albert Einstein College of Medicine literature has addressed lingering questions and chal- Montefiore Medical Center lenged old dogma. While less controversial, the man- Bronx, NY agement of orthopedic and wrist trauma is constantly manipulated to lessen the inconvenience to patients

3 4 An Evidence-Based Approach To Traumatic Emergencies Neck Trauma: Don’t Put Your Neck On The Line

Authors Errington C. Thompson, MD, FACS Assistant Director of Trauma/Surgical Critical Care, Trinity Mother Frances Jeffrey Schaider, MD Hospital, Tyler, TX. Vice Chairman, Department of Emergency Medicine, Cook County Hospital; Associate Professor, Department of Emergency Medicine, Rush Medical College, Chicago, IL. CME Objectives Upon completing this article, you should be able to: John Bailitz, MD 1. Describe the importance of early and appropriate airway management. Chief Resident, Department of Emergency Medicine, Cook County Hospital, 2. Describe the diagnostic approach to vascular injuries by zone of injury Chicago, IL. in neck trauma. 3. Identify and provide initial management for laryngeal injury. 4. Discuss the importance of early recognition of esophageal trauma and Peer Reviewers the accuracy of available diagnostic modalities. Michael Lucchesi, MD Associate Professor and Chairman, Department of Emergency Medicine, Date of original release: July 1, 2003. SUNY Downstate/Kings County Hospital, University Hospital of Brooklyn, Date of most recent review: August 1, 2009. Brooklyn, NY.

At 3:00 a.m. on a humid August morning, the telemetry The majority of studies are retrospective reviews nurse informs you that an ambulance is bringing in a of various diagnostic modalities. In comparison 27-year-old male shot in the neck. Paramedics reported to cervical spine injury, relatively few prospective minimal blood at the scene. In the field, the paramedics studies address the ED management of blunt and applied a bandage and initiated 0.9 normal saline. Just penetrating neck trauma. Specific practice guide- as you step into the resuscitation room, a second call lines for these injuries are not adequately covered comes over the radio. Another ambulance is bringing in a in the Advanced Trauma Life Support course, 19-year-old unrestrained front seat passenger complain- American College of Emergency Physicans clini- ing of hoarseness and trouble breathing after striking her cal policies, or practice guideline Web sites. The neck on the dash. institutional capabilities and current opinions of the radiologist and trauma surgeon on call dictate hether at a busy level I trauma center or a small imaging studies and treatment. Wrural hospital, emergency clinicians must be familiar with the complex anatomy, pathophysiology, Epidemiology evaluation, and treatment of patients with penetrating and blunt neck trauma. Injuries range from obvi- Incidents of penetrating neck trauma tend to clus- ous to subtle and can result in both immediate and ter in specific urban areas and are often managed delayed complications. Presentation can be dramatic at level I trauma centers. At other hospitals, lack of in patients with penetrating airway and vascular familiarity and the complexity of the problem make injury or insidious as with blunt vascular dissection this a “high-risk” situation for both the patient and or missed esophageal disruption. the emergency clinician. Penetrating neck injuries This chapter provides a comprehensive review account for 5% to 10% of all traumatic injuries and of penetrating and blunt neck trauma with a focus have an overall mortality of up to 10%.1 Most inju- on the evaluation and management of injuries ries to the neck are in zone II (between the cricoid to the airway, vascular, and digestive systems. and angle of the jaw).2 (Please also see the October 2001 issue of Emer- Blunt neck trauma is less frequent and dramatic, gency Medicine Practice, “Cervical Spine Injury: A yet it is equally life threatening. Although vascular State-Of-The-Art Approach To Assessment And injuries predominate in penetrating trauma, airway Management,” which is available online for sub- injuries prevail in blunt trauma. Blunt neck injuries scribers at www.ebmedicine.net.) are often initially overlooked in the setting of multisystem trauma.3 The neck’s complex framework of Critical Appraisal Of The Literature supporting fascial planes, musculature, and cartilage result in minimal physical findings and delayed The emergency medicine, trauma, anesthesia, complications.4 A high index of suspicion is essential radiology, and otolaryngology literature on to avoid significant morbidity and mortality from penetrating and blunt neck trauma is enormous, delayed infection, airway obstruction, or cerebrovas- is often contradictory, and concentrates more on cular events. specific diagnostic modalities and surgical treat- The prevalence of blunt carotid injury varies ment than on initial management. (See Table 1.) widely among studies. In 1 series, there were only

Neck Trauma: Don’t Put Your Neck On The Line 5 49 patients with blunt carotid injury identified at 11 secondary to involvement of intrathoracic structures; trauma centers for 6 years.5 Other reviews place the hemothorax, pneumothorax, and great vessel injury prevalence between 0.1% and 0.33%.6,7 are common. Fortunately, the incidence of neck trauma has studiesBecause address of theits exposureED management during of physicalblunt and ex- between studies. In one series, there were only 49 not increased during the past 5 years. But consid- amination,penetrating zoneneck trauma. II injuries Specific are thepractice most guidelines clinically for patients with blunt carotid injury identified at 11 trauma 11 erable research has been published recently, with obviousthese injuries and tendare not not adequately to lead tocovered occult in injuries. the ATLS centers over a six-year period.5 Other reviews place the many long-term studies reaching their desired pow- However,course, ACEP most clinical carotid policies, injuries or practice are associated guideline withWeb incidence between 0.1% and 0.33%.6,7 11 er, enabling further insight into the best manage- zonesites. IIThe injuries. institutional This capabilities is because and zone current I is opinionspartially ment of critical neck trauma. One sonographic study protectedof the radiologist by the andbony trauma thorax surgeon and clavicle on call dictate and the Anatomy published in 2008 noted that carotid artery injuries mandibularimaging studies ramus and treatment.provides protection to critical result from penetrating trauma 80% of the time, zone III structures such as the internal carotid, inter- Complexity and proximity define the challenging whereas vertebral artery injuries are much more nalEpidemiology jugular, and cranial nerves.12 However, zone II is anatomy of the neck. The respiratory, vascular, nervous, gastrointestinal, skeletal, endocrine, and common in blunt trauma.8 It is difficult to expound relatively vulnerable to an anterior insult, explaining Penetrating neck trauma tends to cluster in specific urban lymphatic systems all traverse the narrow confines on previous data when the incidence is so low, even the association with carotid injuries. areas and is often cared for at Level I trauma centers. At of this space. The structures of the anterior neck are at trauma centers. Tracheobronchial injuries occur The neck is also divided into triangles. The other hospitals, this lack of familiarity and the complexity especially vulnerable. even less commonly than vascular trauma. In 12,789 anteriorof the problem triangle make is borderedthis a “high-risk laterally” situation by the for anterior both To simplify the approach to injuries, current trauma trauma patients presenting to an ED, only 16 (0.13%) borderthe patient of the and sternocleidomastoid, the physician. Penetrating superiorly neck injuries by literature divides the neck anatomically into zones. (See 9 had tracheobronchial injuries. theaccount inferior for 5%-10%mandible, of all and traumatic medially injuries by theand anteriorhave an Figure 1.) Zone I, between the sternal notch and the midlineoverall mortality of the neck. of up Injuries to 10%.1 toMost the injuries anterior to thetriangle neck cricoid cartilage, contains the proximal subclavian, Anatomy permitare in Zone easy II access (between for the initial cricoid evaluation and angle andof the surgi jaw).-2 vertebral, and carotid arteries, apices of the lung and cal management.Blunt neck trauma The isposterior less frequent triangle and dramatic, is bordered yet trachea, esophagus, thoracic duct, and thyroid and Complexity and proximity define the challeng- posteriorlyit is equally life-threatening.by the anterior While surface vascular of the injuries trapezius, parathyroid glands. Zone II, between the cricoid cartilage ing anatomy of the neck. The respiratory, vascular, anteriorlypredominate by in the penetrating posterior trauma, surface airway of the injuries sterno- and angle of the mandible, contains the carotid and nervous, gastrointestinal, skeletal, endocrine, and cleidomastoid,prevail in blunt trauma.and inferiorly Blunt neck by injuries the middle are often third of vertebral arteries, trachea, larynx, esophagus, spinal cord, 3 lymphatic systems all traverse the narrow confines theinitially clavicle. overlooked Injuries in tothe the setting posterior of multisystem triangle trauma.defy and vagus and recurrent laryngeal nerves. Zone III, of this space. The structures of the anterior neck are simpleThe neck evaluation’s complex orframework control. of supporting fascial above the angle of the mandible, contains the pharynx, planes,The musculature, neck is further and cartilagedivided resultinto fascialin minimal planes. salivary glands, distal carotid and vertebral arteries, and especially vulnerable. 4 To simplify the approach to injuries, current Thephysical platysma, findings a broadand delayed thin sheetcomplications. of muscle A highextend- several cranial nerves. index of suspicion is essential in order to avoid signifi- Zone II injuries are the most common and have the trauma literature divides the neck anatomically ing from the facial muscles to the thorax, is a tra- cant morbidity and mortality from delayed infection, best prognosis. The anatomy allows for relatively simple into zones. (See Figure 1.) Zone I, between the ditional surgical landmark for penetrating trauma. Woundsairway obstruction, that penetrate or cerebrovascular the platysma require events. surgical surgical exposure, application of direct pressure, and sternal notch and the cricoid cartilage, contains the The incidence of blunt carotid injury varies widely control of vessels.8 Exposure and control of injury is proximal subclavian, vertebral, and carotid arteries, consultation. The platysma is covered by superficial fascia anteriorly and the deep fascia posteriorly. The much more difficult with Zone I and III injuries. Zone I apices of the lung and trachea, esophagus, thoracic injuries have the highest mortality secondary to involve- deepTable fascial 1. Recent layers controversiesof the neck include in penetrating the investing, duct, and thyroid and parathyroid glands. Zone and blunt neck trauma. ment of intrathoracic structures; hemothorax, pneu- pretracheal, and prevertebral fascia. These 3 fascial II, between the cricoid cartilage and angle of the mothorax, and great vessel injury are common. layers help support the neck and may contain hem- mandible, contains the carotid and vertebral arteries, The neck is also divided into triangles. The anterior • Method of airway management and role of paralytics trachea, larynx, esophagus, spinal cord, and vagus orrhage within a single compartment. The pretra- triangle is bordered laterally by the anterior border of the • Mandatory vs. selective exploration of penetrating neck and recurrent laryngeal nerves. Zone III, above the cheal fascia is continuous with the anterior pericar- sternocleidomastoid, superiorly by the inferior mandible, injuries angle of the mandible, contains the pharynx, sali- dium, providing a route for infection to spread to and medially by the anterior midline of the neck. Injuries the• mediastinumDiagnostic testing in inpatients the asymptomatic with aerodigestive patient with tract vary glands, distal carotid and vertebral arteries, penetrating neck trauma to the anterior triangle permit easy access for initial and several cranial nerves. injury.• Flexible (See vs. Figure rigid fiberoptic 2.) endoscopy in penetrating evaluation and surgical management. The posterior Zone II injuries are the most common and have neck trauma triangle is bordered posteriorly by the anterior surface of the best prognosis. The anatomy allows relatively • Indications for vascular imaging in blunt neck trauma the trapezius, anteriorly by the posterior surface of the simple surgical exposure, application of direct pres- sternocleidomastoid, and inferiorly by the middle third sure, and control of vessels.10 Exposure and control FigureFigure 1.1. Injury Areaszones. of the clavicle. Injuries to the posterior triangle defy of injury is much more difficult with zone I and III simple evaluation or control. injuries. Zone I injuries have the highest mortality The neck is further divided into fascial planes. The platysma, a broad thin sheet of muscle extending from the facial muscles to the thorax, is a traditional surgical landmark for penetrating trauma. Wounds that penetrate Table 1. Recent Controversies In Penetrating the platysma require surgical consultation. The platysma is And Blunt Neck Trauma covered by superficial fascia anteriorly and the deep fascia posteriorly. The deep fascial layers of the neck • Method of airway management and role of paralytics include the investing, pretracheal, and prevertebral • Mandatory vs. selective exploration of penetrating neck injuries fascia. These three fascial layers help support the neck • Diagnostic testing in the asymptomatic patient with penetrating and may contain hemorrhage within a single compart- neck trauma ment. The pretracheal fascia is continuous with the • Flexible vs. rigid fiberoptic endoscopy in penetrating neck trauma anterior pericardium, providing a route for infection to • Indications for vascular imaging in blunt neck trauma spread to the mediastinum in cases of aerodigestive tract injury. (See Figure 2 on page 3.)

6 An Evidence-Based Approach To Traumatic EmergenciesEmergency Medicine Practice 2 www.empractice.net • July 2003 Pathophysiology tion is difficult to predict. Descriptions regarding blade Pathophysiology ofsize, least depth resistance of penetration, and may and result body inposition pellet atemboli impact to For the purpose of this article, neck trauma is divided themay heart be misleading. or other organs.14 Stab wounds may leave a into penetrating, blunt, and strangulation injury. For the purpose of this chapter, neck trauma is seeminglyPenetrating innocent vascular wound, injuries but can the be depth rapidly and fatal path The pathophysiology of penetrating injury varies divided into penetrating, blunt, and strangulation offrom penetration a variety of is mechanisms. difficult to Whilepredict. any Descriptionslarge vessel with mechanism. Gunshot wounds may be divided into injury. The pathophysiology of penetrating injury regardinginjury can leadblade to size,hemorrhagic depth of shock, penetration, carotid injuries and body can low- and high-energy wounds. A high-velocity military varies with mechanism. Gunshot wounds may be positionalso produce at impact a rapidly may expanding be misleading. hematoma that may assault rifle fired into the neck at 50 feet will produce divided into low- and high-energy wounds. A high- distortGunshot or occlude wounds the airway. generally Large cause lacerations greater of injurythe more extensive tissue damage than a low-velocity velocity military assault rifle fired into the neck at 50 thanjugular stab venous wounds system because can generate of a bullet’s an air increasedembolism, handgun fired from the same distance. In addition to feet (15 meters) will produce more extensive tissue force,causing which hypotension penetrates and respiratorydeeper and distress. causes11 cavita- energy, multiple other factors determine the extent of damage than a low-velocity handgun fired from tion,Blunt damaging neck trauma structures may initiallyoutside gothe unrecognized bullet tract. injury, including mass, shape, fragmentation of the the same distance. In addition to energy, multiple Higherdue to more velocity noticeable bullets damage generate to the a straight chest, abdomen, and or missile, and the tissue penetrated.9 Low-energy shotgun other factors determine the extent of injury, includ- predictablehead. Common path mechanisms as opposed include to the a erratic motor vehicleroute pellets follow erratic trajectories along the tissue pathway ing mass, shape, fragmentation of the missile, and fromcollision a handgun. involving Thesean unrestrained lower velocity passenger (energy) decelerat- mis- of least resistance and may result in pellet emboli to the the tissue penetrated.13 Low-energy shotgun pellets silesing against cause the50% dash fewer (“the clinically padded significantdash syndrome injuries”), a heart or other organs.10 Stab wounds may leave a seem- follow erratic trajectories along the tissue pathway becauseshoulder ofharness decreased creating bone shearing and bullet injury fragmentation to the neck, ingly innocent wound, but the depth and path of penetra- and lesserand blunt blast neck effects. trauma In accordancesecondary with to airbagthis, 75% of Figure 2. Neck Anatomyanatomy. gunshotdeployment, wounds clothesline, to the neck necessitateand bicycle surgical handlebar exploration,injuries. whereas12-15 only Laryngeal 50% of necktrauma stab wounds may result require from aa surgicalsharp procedure. blow to the11 anterior Penetratingneck that compresses vascular the injuriesthyroid can andbe rapidly cricoid fatal fromcartilages a variety against of mecha the- nisms.cervical Although spine. any large vessel injuryMultiple can mechanismslead to hemorrhagicof vascular shock, injury carotid occur in injuriesblunt can neck also trauma. produce Direct a rapidlyblows expanding to the anterior hema neck- tomacan that compress may distort the carotid, or occludewhile the blows airway. to the Large head lacerationsthat cause of therotation jugular and venoushyperextension system can stretchgenerate the an aircarotid embolism, artery causingacross the hypotensioncervical spine. and respiratory Abrupt full distress.flexion15 of the neck may Bluntcrush theneck internal trauma carotid may initiallyartery go between unrecognized the angle becauseof the of mandible more noticeable and damageupper to cervicalthe chest, vertebrae, abdomen,allowing or head. for Common delayed mechanismsdissection. include12,16 Carotid a motor vehicleartery injury collision also involv occurs- ing anin unrestrainedthe setting of blunt pas- oral sengertrauma decelerating and basilar against skull the dashfracture. (“the Blunt padded carotid dash syndrome”),injury may a shoulderoccur in 0.7% harness ofcreating patients; shearing patterns injury of to theinjury neck, include and blunt dissection, neck traumapseudoaneurysm secondary to forma-airbag deployment,tion, and thrombosis.clothesline,17 and bicycleBecause handlebar the sympa- inju- ries.16-19thetic Laryngeal fibers from trauma the may thoracicresult from chain a windsharp blowaround to the theanterior carotid neck artery, that injurycompresses to the arterythe thy that- Used with permission from Icon Learning Systems. Used with permission from Icon Learning Systems. roid disruptsand cricoid these cartilages fibers will against the cervical spine. July 2003 • www.empractice.net 3 Emergency Medicine Practice Neck Trauma: Don’t Put Your Neck On The Line 7 Multiple mechanisms of vascular injury occur in Traumatic arterial lesions, such as dissections, blunt neck trauma. Direct blows to the anterior neck false aneurysms, or arteriovenous fistulas largely can compress the carotid, whereas blows to the head monopolize the literature, whereas venous le- that cause rotation and hyperextension stretch the sions are often overlooked. One article attributes carotid artery across the cervical spine. Abrupt full the effects of thrombosis of venous vasculature flexion of the neck may crush the internal carotid following penetrating trauma to the disruption artery between the angle of the mandible and upper to the venous epithelial lining. An intramural cervical vertebrae, allowing delayed dissection.16,20 thrombus results generally within 48 hours, which Carotid artery injury also occurs in the setting of can extend, leading to venous hypertension and blunt oral trauma and basilar skull fracture. Blunt increased intracranial pressure. A venous angiog- carotid injury may occur in 0.7% of patients; pat- raphy might reveal delayed arterial transit time or terns of injury include dissection, pseudoaneurysm filling of collateral veins; however, venous injury formation, and thrombosis.21 is most often suggested because of nonvisualiza- Blunt trauma causes 3% to 10% of cervical vas- tion of the affected vasculature.23 cular injuries, and hyperextension of the neck is the most common cause.22 Diagnosing cervical vascular Having the critics praise you is like having injuries quickly is crucial, as morbidity and mortal- the hangman say you’ve got a pretty neck. ity increase drastically if delays occur. Emergency —Eli Wallach clinicians frequently face situations in which severe injury has occurred with little obvious external Differential Diagnosis trauma. Often, the only symptom of carotid injury is minor carotodynia: neck pain along the course of the Isolated injuries to the neck are the exception—mul- 23 artery. It is at these times when practitioners must tiple system injury and unexpected injury are the be the most skeptical and order extensive radiologi- rule. The true path of a bullet may or may not follow cal studies in seemingly stable blunt trauma patients a straight line between the entrance and exit wound to avoid potential dire consequences. (or from entrance wound to the final location of the Because the sympathetic fibers from the tho- bullet within the neck). Likewise, the depth and path racic chain wind around the carotid artery, injury of stab wounds are difficult to evaluate from exter- to the artery that disrupts these fibers will produce nal inspection. Strangulation survivors (especially Horner’s syndrome (small pupil, droopy lid, and those who have attempted to hang themselves) may inability to sweat on the side of the face ipsilateral appear stable on arrival only to decompensate dra- to the carotid injury). Because carotid disruption can matically hours after presentation. produce ischemia to the ipsilateral cerebral cortex, During the secondary survey, the emergency cli- patients may present with paralysis contralateral to nician must methodically search for signs and symp- the injured carotid. Blunt carotid injuries can also toms of injury, system by system, as described in the cause a rapidly expanding hematoma that can dis- following physical examination section. Even in the tort or occlude the airway. absence of hard findings, clinical suspicion combined Patients with vertebral artery trauma may with an organized diagnostic approach will provide present with a puzzling clinical picture. Some have the best and most cost-effective patient care. vague complaints of visual changes, nausea, and Esophageal injuries are the least common but are vertigo. Notably, neurologic deficits do not relate the most frequently missed injuries in penetrating to the particular vertebral artery involved. Because neck trauma.28 A low incidence and a lack of sensi- a clot in a vertebral artery will pass through the tive and specific clinical signs make the diagnosis basilar artery and then into the posterior circulation, of esophageal injury difficult. Furthermore, esopha- emboli from the right vertebral artery can travel to geal injuries may be masked by other injuries. One either the right or left posterior brain, resulting in a study of penetrating laryngotracheal injuries found hodgepodge of cranial nerve deficits or alterations esophageal injuries in 11 of 57 patients.29 In another 24-26 in mental status. Esophageal injury due to blunt study of esophageal injury, 35 of 48 patients had at trauma is extremely rare and should only be investi- least 1 other injury, with 9 patients having at least 3 gated when there are clinical findings suggestive of other injuries.30 Delayed operative repair of esopha- injury, such as significant pain on swallowing or the geal injuries results in high morbidity and mortality 27 presence of unexplained subcutaneous air. due to early contamination of the paraesophageal Different sources state that cerebral vascular space.31 Rapid diagnosis of occult esophageal injury trauma occurs in from 0.18% to 1.55% of all trauma must be a high priority in penetrating neck trauma. patients. However, 2:1 internal carotid/vertebral Even stable, apparently uninjured patients with 23 artery involvement is generally agreed on. The neck trauma need to be treated in a methodical, sys- variation may exist because the vertebral bodies of- tematic manner. Esophageal injuries often have an fer significant protection to a posterior insult. insidious presentation, but a 24-hour delay in diag-

8 An Evidence-Based Approach To Traumatic Emergencies nosis increases mortality markedly. Esophageal and be necessary even before a patient is completely tracheal injuries are so rare that additional aerodi- undressed and log rolled. Nurses should provide gestive studies often seem like extraneous work. In supplemental oxygen and establish vascular access an 8-year study including 12,780 consecutive trauma shortly after patient arrival. Throughout the ED patients, only 12 (0.09%) had aerodigestive injuries.9 evaluation and management of trauma, any deterio- Other surveys found the injury rate closer to 5%, but ration should trigger reassessment and stabilization the point should be taken that although rare, severe of the ABCs. morbidity and mortality will be avoided by diagnosing these injuries early. Airway Management If consciousness is impaired, open the airway with a Prehospital Care jaw thrust in the setting of suspected cervical trauma or with a head tilt and chin lift in the absence of 35,36 Information obtained by the paramedics may help such injury. The timing of more definitive airway determine the type of weapon used, range, position management is controversial. The fundamental of the patient at the time of penetration, and trajec- principle, however, is that earlier intubation leads to tory. Within many urban settings, field triage criteria easier intubation. Earlier intubation allows less time mandate transport of all penetrating neck trauma for anatomical distortion and patient deteriora- to the closest regional trauma center. On the other tion. “Playing it safe” by intubating early decreases hand, patients with isolated blunt neck trauma may the need for later crash intubation away from the 37 be taken to non–level I trauma centers, especially “friendly confines” of the ED. when there is no evidence of multisystem injury. In a large retrospective study, Eggen et al de- Airway management in the field by emergency fined the following criteria for emergent intubation: medical technicians is fraught with unforeseen haz- severe respiratory distress, airway compromise from ards. Hematomas and laryngotracheal injuries both blood or secretions, extensive subcutaneous emphy- 38 necessitate and complicate initial airway manage- sema, tracheal shift, or alteration in mental status. ment. Even common bag-valve-mask techniques They recommend elective prophylactic intubation may worsen injuries and distort anatomy by dissec- for minimally symptomatic patients in case of sus- tion of air into the surrounding tissues. pected progressive airway compromise or if such a Indications for airway management in the field patient is likely to be out of the ED for a prolonged 38 include long transport times with an unstable or time for diagnostic studies. Walls et al suggest in- potentially unstable patient, stridor or severe respira- tubation for all gunshot wounds to the neck regard- 37 tory distress, apnea, and impending cardiopulmonary less of evidence of vascular or direct airway injury. arrest. Orotracheal intubation allows direct assess- Radiographic clearance of the cervical spine is ment of the airway and placement of the airway with not necessary before airway manipulation when an the fewest complications. Prehospital cricothyrotomy experienced member of the team provides cervical is indicated only with failed orotracheal intubation, spine immobilization. Rapid sequence intubation entrapment at the scene with the need for a secure (RSI) may be performed with in-line cervical spine airway, or significant maxillofacial trauma in patients immobilization before formal radiographic clearance 39-42 requiring airway management.32 If the cervical spine of the cervical spine. Unstable cervical injuries is at risk from either blunt or penetrating trauma, are rare with penetrating neck trauma in the pres- medics should immobilize the neck before transport. ence of a neurologic examination without any posi- Prehospital providers must perform a rapid as- tive findings. sessment for tension pneumothorax and other imme- Multiple retrospective studies demonstrate the diate life threats. Intravenous lines should be inserted potential difficulty of securing an airway in penetrat- 29,37,38,43 en route. In the presence of air sucking or bubbling ing neck trauma. In a recent large retrospec- neck wounds, apply an occlusive dressing to the tive review, Mandavia et al reported on 748 consecu- wound. Some authorities suggest placing the patient tive patients with penetrating neck trauma. Eighty- in the Trendelenburg position to decrease the chance two (11%) required intubation; 6 out of the 39 patients of fatal air embolism,28,33,34 although this recommen- who underwent RSI required multiple attempts, and dation has not been studied in a prospective fashion. 3 of 12 patients who initially underwent fiber-optic 43 Apply direct pressure to control active bleeding. intubation required rescue RSI. In a retrospective analysis of 114 patients with penetrating neck trauma, ED Management Eggen et al reported that 26 of 69 intubation attempts were initially unsuccessful, with 6 requiring an alternative to endotracheal intubation.38 Initial Management The ideal method of airway management is also As with any trauma patient, simultaneous evalu- controversial. Management options for the patient ation and treatment begins with the ABCs of the with neck trauma in the ED include RSI, oral in- primary trauma survey. Airway intervention may tubation with sedation or local airway anesthesia,

Neck Trauma: Don’t Put Your Neck On The Line 9 endotracheal tube through an open wound or into a segments, which makes it impossible to ventilate or visible distal segment of the trachea.33 intubate—leaving the only therapeutic alternative blind nasotracheal intubation, direct fiber-optic immediatean ED median surgical sternotomy airway to andlook neckfor the exploration missing in nasotrachealOrotracheal or Intubation orotracheal intubation, retrograde theproximal operating trachea. room. Awake intubation with local guideSeveral wire retrospective orotracheal reviews intubation, support cricothyrotomy, orotracheal anesthesia and endotracheal intubation over a fiber- tracheostomy,intubation as the and initial placement modality of of the choice. endotracheal23,31,32,37 opticAlter nativbronchoscopee Approaches are otherTo The alternatives Airway to consider tubeOrotracheal through intubation an open woundprovides or direct into visualizationa visible distal of inUse the alternative difficult airway(and fortunately approaches rare)when caseorotracheal of blunt segmentthe vocal of cords, the trachea. the fewest39 complications, and the highest neckintubation trauma is unsuccessfulwith significant or contraindicated. laryngeal injury. Blind4,44 successThere rate. is still The notfamiliarity a clear ofconsensus ED physicians on if with or when RSI nasotrachealWith penetrating intubation trauma, is not generally open injuries recommended to the in a makesseemingly this a stable preferred patient technique with inneck the traumamajority should of cases larynxpatients may with facilitate neck trauma; direct it canintubation be especially of distal dangerous seg- beof intubated. penetrating Clinical neck trauma. judgment Mandavia should et al still reported pre- that ments.when there44 Grasp is a possibilitythe distal ofsegment dislodging with a clot.a towel In clip vailtwo-thirds about whether of all critical to monitor airways thewere airway, managed carefully with RSI, toaddition, stabilize the the distorted trachea anatomy and directly leads tointubate a higher through failure watchingwith a 100% for successimpending rate, includingcompromise two rescueor to intubate cases of therate neck for blind wound. nasotracheal (See Figure intubation. 3.) Intubation over a 37 earlyfailed to fiberoptic avoid distorted intubations. anatomies, Likewise, complicated in the anesthesia fiberopticBeware bronchoscope the clothesline is time-consuming, injury; this particularly and a bloody intubations,literature, Shearer or surgical and Giesecke airways. had Obviously, a 98% success any rate lethalairway mechanism makes it a challenging occurs when procedure the rider even of ina motorexperi-- 33 33 unstableusing RSI patient in patients or any with worsening penetrating airway neck trauma. warrants cycle,enced snowmobile,hands. Retrograde or bicycle intubation runs intousing an a guideunseen wire immediateTo prevent intubation. the “can With’t intubate/can the development’t ventilate and” wireinserted or tree in the limb. cricothyroid In such amembrane patient, the and trachea brought out widespreadnightmare, avoiduse of paralyzing fiber-optic patients intubation, who cannot difficult easily maythrough be transsected, the mouth is makingoften slow RSI and a dangerousrequires experience pro- airwaysbe bagged. are Aless morbidly intimidating obese male and with intubations a thick beard with cedure.and skill. Pharmacologic paralysis may result in loss spinalcovering precautions a small mouth are less should challenging. raise this concern. In of supporting muscle tone and misalignment of the Cricothyrotomy addition, significant distortion of the airway due to discontinuous tracheal segments, which makes it expanding hematomas or direct airway trauma may Surgical airways are often the rescue method of choice. Orotracheal Intubation impossible to ventilate or intubate—leaving the only render the bag-valve-mask impossible. Cricothyrotomy is a quick and easy procedure in the Several retrospective reviews support orotracheal therapeutic alternative an ED median sternotomy to Oral intubation with sedation alone (awake intuba- absence of anatomic distortion. Some believe that a intubation as the initial modality of choice.29,37,38,43 look for the missing proximal trachea. tion) is indicated when bag-mask ventilation may be horizontal incision directly through the skin into the Orotracheal intubation provides direct visualization difficult. Sedation is best performed with ketamine (1-2 cricothyroid membrane is preferred when landmarks are of the vocal cords, the fewest complications, and the Alternative Approaches To The Airway mg/kg slow IV push) or rapid-acting reversible agents easily palpable, while an initial vertical incision may highest success rate. The familiarity of emergency Use alternative airway approaches when orotracheal (such as midazolam 0.05 mg/kg or fentanyl 1-2 mcg/kg). allow for better identification of the cricothyroid mem- clinicians with RSI makes this a preferred technique intubation is unsuccessful or contraindicated. Blind Preservation of respiratory drive is the biggest advantage brane when there is swelling or anatomic distortion. in the majority of patients with penetrating neck nasotracheal intubation is not generally recommend- of ketamine. If time permits, have the patient breathe Cricothyrotomy is contraindicated (or relatively contrain- trauma. Mandavia et al reported that two-thirds of ed in patients with neck trauma; it can be especially nebulized 4% lidocaine to anesthetize the airway and dicated) in the presence of an expanding hematoma over all critical airways were managed with RSI, with a dangerous when there is a possibility of dislodging facilitate cooperation. Direct local airway anesthesia is the cricothyroid membrane. In patients with laryngeal 100% success rate, including 2 rescue cases of failed a clot. In addition, the distorted anatomy leads to a another option; however, it may be difficult to perform trauma, tracheostomy is preferred over cricothyrotomy if fiber-optic intubations.43 Likewise, in the anesthesia higher failure rate for blind nasotracheal intubation. on a moving target unless combined with adequate time permits. However, if the patient with laryngeal literature, Shearer et al had a 98% success rate using Intubation over a fiber-optic bronchoscope is time patient sedation. 39 trauma is dying from asphyxiation, perform an emergent RSI in patients with penetrating neck trauma. consuming, and a bloody airway makes it33 a challeng- Special caution is indicated in the patient with cricothyrotomy (or needle cricothyrotomy). 39 significantTo prevent blunt the or “can’tpenetrating intubate/can’t laryngeal injury. ventilate” ing procedure even in experienced hands. Retro- nightmare,With blunt avoidtrauma, paralyzing closed laryngeal patients injury who may cannot gradePercutaneous intubationTranstr usingacheal a guideVen tilawiretion inserted in the easilymake be orotracheal bagged. intubationA morbidly impossible. obese male With with massive a cricothyroidPercutaneous membrane transtracheal and jet broughtventilation out (needle through the thickblunt beard laryngeal covering trauma a smallin the patientmouth maintaining should raise an this mouth is often slow and requires experience and skill. concern.airway, avoidIn addition, paralysis significant and prepare distortion for an immediate of the air- FigureAlthough 3. Direct blind intubation nasotracheal of intubation trachea. has waysurgical due airwayto expanding and neck hematomas exploration orin thedirect operating airway previously been discouraged because of the pos- traumaroom. Awake may render intubation the bag-valve-maskwith local anesthesia impossible. and In cases of open tracheal wounds, the best (and sometimes only) airway strategy may be direct endotrachealOral intubation intubation with over sedation a fiberoptic alone bronchoscope (awake Figureintubation 3. Directthrough Intubation the defect. Of Trachea intubation)are other alternatives is indicated to considerwhen bag-mask in the difficult ventilation (and mayfortunately be difficult. rare) case Sedation of blunt is neckbest traumaperformed with signifi-with ketaminecant laryngeal (1-2 mg/kg injury.4,38 slow IV push) or rapid-acting reversibleWith agentspenetrating (such trauma, as midazolam open injuries 0.05 to mg/kg the larynx ormay fentanyl facilitate 1-2 direct mcg/kg). intubation Preservation of distal segments. of respira38- toryGrasp drive the isdistal the segmentbiggest advantagewith a towel of clip ketamine. to stabilize If the timetrachea permits, and directly have the intubate patient through breathe the nebulized neck wound. 4% lidocaine(See Figure to 3anesthetize.) the airway and facilitate cooperation.Beware Direct the clothesline local airway injury; anesthesia this particularly is another option;lethal mechanism however, itoccurs may whenbe difficult the rider to of perform a motorcycle, on a snowmobile,moving target or bicycleunless runscombined into an withunseen adequate wire or patienttree limb. sedation. In such a case, the trachea may be transsected, makingSpecial RSI caution a dangerous is indicated procedure. in Pharmacologicthe patient with significantparalysis may blunt result or inpenetrating loss of supporting laryngeal muscle injury. Withtone bluntand misalignment trauma, closed of the laryngeal discontinuous injury tracheal may make orotracheal intubation impossible. With mas- siveEmergency blunt laryngeal Medicine Practice trauma in the patient maintain- 6 In cases of open tracheal wounds,www.empractice.net the best (and sometimes • July only) 2003 ing an airway, avoid paralysis and prepare for an airway strategy may be direct intubation through the defect.

10 An Evidence-Based Approach To Traumatic Emergencies sibility of distorted anatomy or dislodging a clot, a Tracheostomy: Although more difficult to study published in 2004 demonstrated a 90% success perform, tracheostomy may be required when rate with prehospital patients using this technique. other techniques have failed and cricothyrotomy The mean number of attempts was 1.16 (range 1-4), is contraindicated.43 Formal tracheostomy and the mortality rate was 5%, similar to that in is usually left to the surgical consultant but orotracheally intubated patients. Furthermore, none may be accomplished by emergency clinicians of the patients experienced the complications that experienced in the procedure. Airway approach previous literature has suggested. Although the recommendations by clinical presentation are study enrolled only 40 patients, it does advocate this reviewed in the “Clinical Pathways.” procedure as an alternative approach, especially by emergency medical services (EMS) when orotracheal Breathing intubation cannot be achieved.45 Patients with zone I injuries are especially prone to pneumothorax and hemothorax. The combination Cricothyrotomy: Surgical airways are often the of hypotension, respiratory distress, and unilateral rescue method of choice. Cricothyrotomy is a quick decreased breath sounds should prompt immediate and easy procedure in the absence of anatomic needle thoracentesis followed by tube thoracostomy. distortion. Some believe that a horizontal incision Many emergency clinicians argue that needle directly through the skin into the cricothyroid thoracentesis is an unnecessary step and that once membrane is preferred when landmarks are easily a pneumothorax is suspected, tube thoracostomy palpable, whereas an initial vertical incision may should be initiated. Once the skin is incised, subcuta- allow better identification of the cricothyroid neous tissue dissected, and the pleural cavity pene- membrane when there is swelling or anatomic trated, the pneumothorax will be decompressed. This distortion. Cricothyrotomy is contraindicated should take as much time as needle thoracentesis. (or relatively contraindicated) in the presence of Only after decompressing the pneumothorax should an expanding hematoma over the cricothyroid the chest tube be inserted and properly positioned. membrane. In patients with laryngeal trauma, A chest tube is necessary after needle thoracen- tracheostomy is preferred over cricothyrotomy tesis, so placing the chest tube first eliminates an if time permits. However, if the patient with unnecessary procedure. Additionally, there is a risk laryngeal trauma is dying of asphyxiation, of penetrating important vasculature in the second perform an emergent cricothyrotomy (or needle intercostal space with thoracentesis, especially when cricothyrotomy).39 the positioning is too medial. Thus for safety, speed, and a lower complication rate, many ED intensiv- Percutaneous Transtracheal Ventilation: Percutaneous ists urge practitioners to proceed directly with tube transtracheal jet ventilation (needle cricothyrotomy) thoracostomy. is a valuable airway rescue technique for patients Ultrasonography is now readily used to check for with distorted anatomy who cannot be intubated pneumothoraces. The mechanics of how to do so are orally.46 It is an alternative airway of choice beyond the scope of this chapter; however, the sensi- for children younger than 8 years in whom tivity and specificity are well known to be above 95%. cricothyrotomy is contraindicated. A large-bore Although the average practitioner probably does not catheter placed through the cricothyroid membrane have the same expertise as those ultrasonographers provides up to an hour of ventilation until a formal in various studies, ultrasonography will undoubtedly tracheotomy can be performed by a surgeon.47 aid the emergency clinician’s assessment of a patient Insert a 10- or 12-gauge needle through the with a potential pneumothorax. cricothyroid membrane (directed toward the feet) while aspirating with a syringe. Once air is aspi- Circulation rated, advance the catheter, withdraw the needle, Control Bleeding and secure the catheter. Attach the catheter to Use direct pressure to control bleeding. Clamping of high-pressured ventilation tubing connected to vessels—blind or otherwise—should never be done in the the standard wall oxygen outlet at 55 pounds per ED. Only the trauma surgeon should clamp vessels, square inch. A finger control valve can be used to and then only in the operating room with appropri- achieve an inspiratory/expiratory ratio of at least ate exposure, as inappropriate use of a clamp can 1:3 to avoid barotrauma. Percutaneous transtracheal lead to ischemic cerebrovascular accident or iatro- ventilation devices are available commercially or can genic nerve injury. be constructed from parts available to any respira- If the hemorrhage cannot be staunched with tory therapist.48,49 The emergency clinician should pressure because the wound is particularly large assemble this kit before it is needed, as the arrival of and deep, consider the placement of a Foley cath- a patient with a compromised airway is no time to eter. Insert the Foley as far as possible, and inflate start searching for parts. the balloon with water until the bleeding stops or resistance is felt.50 This technique is especially valu-

Neck Trauma: Don’t Put Your Neck On The Line 11 cricothyrotomy) is a valuable airway rescue technique hemodynamic instability.44 for patients with distorted anatomy who cannot be ableintubated in penetrating orally.39 It is wounds an alternative to zone airway I. Because of choice of VascularTo repeat Acc whatess others have said, requires education; involvementin children under of the 8 years subclavian in whom vessels, cricothyrotomy such bleeding is Establish vascularto challenge access. Someit, requires authorities brains. suggest iscontraindicated. notoriously difficult A large-bore to cathetermanage in placed the ED.through Uncon- placing—Mary the Pettibone IV in the Poole, extremity “A Glass opposite Eye at the a Keyhole,” injury under 1938 trolledthe cricothyroid intrathoracic membrane hemorrhage provides from up to a an zone hour I injuryof the assumption that fluid or blood administered on the mayventilation require until an aemergent formal tracheotomy thoracotomy. can 2be Ligation performed of Historyside of the injury is more likely to leak out any venous simpleby a surgeon. venous40 injuries is acceptable in the setting of Askingwound in the the patient neck.45 hisHowever, or her thisname assertion provides is not im- hemodynamicInsert a 10- orinstability. 12-gauge51 needle through the cricothy- well-studied.mediate useful information regarding mental status roid membrane (directed toward the feet) while aspirat- and Atairway. least two No large-boreanswer or IVs a harsh of crystalloid or muffled solution voice Vascularing with a Access syringe. Once air is aspirated, advance the givenshould“wide-open prompt immediate” is a traditional intervention. standard in the Establishcatheter, withdraw vascular the access. needle, Some and authoritiessecure the catheter. suggest hypotensive Determine patient. the mechanismHowever, the of amount injury, of weapons fluid that placingAttach the the catheter IV in the to high-pressured extremity opposite ventilation the injury, tubing shouldinvolved, be givennumber remains of shots controversial. fired (if itDespite is a gunshot the underconnected the toassumption the standard that wall fluid oxygen or outletblood atadminis 55 - “wound),common andwisdom other” of details providing from large-volume the scene. When crystal- teredpounds on per the square side ofinch. the A injury finger is control more valvelikely can to leakbe loidevaluating resuscitation neck fortrauma, traumatic it may shock, be helpful no controlled to divide outused any to achieve venous an wound inspiratory-to-expiratory in the neck.52 However, ratio of thisat clinicalthe questions trials demonstrate into organ-specific a benefit to clusters. early aggressive “Airway assertionleast 1:3, to is avoid not well barotrauma. studied. Percutaneous transtra- resuscitationquestions” would (especially include prior any to control shortness of bleeding). of breath, chealAt ventilation least 2 large-bore devices are IVs available of crystalloid commercially solution or Animaldifficulty data speaking, suggest that pain aggressive with inspiration, fluid resuscitation and he- givencan be “wideconstructed open” from is a parts traditional available standard to any respiratory in the maymoptysis. actually Inquire increase whether bleeding the in patientuncontrolled has pain hemor- with hypotensivetherapist.41,42 Assemble patient. However,this kit before the you amount need ofit, asfluid the rhage.swallowing46 One prehospital(an important study clue examined to esophageal this issue disrup in a - thatarrival should of a patient be given with remains a compromised controversial. airway isDespite no time tion).series of“Neurologic nearly 600 hypotensive questions” patientswould addresswith penetrating numb- theto start “common searching wisdom” for parts. of providing large-volume nesstorso orinjuries. weakness47 In this with trial, special strictly attention limiting toprehospital whether crystalloid resuscitation for traumatic shock, no con- fluidsthe deficit improved is on outcomes, the right andversus patients left sidein this (associated group trolledTracheost clinicalomy trials demonstrate a benefit to early demonstratedwith carotid injury both lower or stroke) mortality as opposed and fewer to complica- arms aggressiveAlthough more resuscitation difficult to (especiallyperform, tracheostomy before control may of be tions.versus However, legs (more the oftenrole of linked hypotensive with spinal resuscitation injury). bleeding).required when Animal other data techniques suggest have that failed aggressive and fluid requiresAsk whether further the study. patient had associated head trauma resuscitationcricothyrotomy may is contraindicated. actually increase37 Formal bleeding tracheostomy in un- or loss of consciousness. “Vascular questions” focus iscontrolled usually left hemorrhage. to the surgical53 One consultant prehospital but may study be ex- onCardiac blood Arrest loss, swelling of the neck, or the sound of accomplishedamined this issue by emergency in a series physicians of nearly experienced 600 hypoten in- “whooshing”It comes as no surprisein the ears that (pulsatile cardiac arrest tinnitus), in the settingwhich ofis thesive procedure. patients with Airway penetrating approach recommendationstorso injuries.54 In by this associatedpenetrating withneck traumacarotid isdissection. a poor prognostic sign. Heroic clinicaltrial, strictly presentation limiting are prehospital reviewed the fluids Clinical improved Pathways interventionsIn assessing may the include past EDmedical thoracotomy history, to determine cross- onoutcomes, pages 12-17. and patients in this group demonstrated whetherclamp the the aorta patient and perform has had open any cardiac prior neck massage, or chest both lower mortality and fewer complications. How- surgeriesobtain control and of assess bleeding whether vessels, the and patient possibly is on to warfa- ever,Breathing the role of hypotensive resuscitation requires rinaspirate or other the right medications ventricle thatto treat can air affect embolism. hemostasis. furtherPatients study.with Zone I injuries are especially prone to pneumothorax and hemothorax. The combination of PhysicalStandard Trauma Examination Interventions Cardiachypotension, Arrest respiratory distress, and unilateral de- AttentionIf an impaled to theobject ABCs, is in vitalplace signs, (knife, and stick, mental etc.), leavestatus it Itcreased comes breath as no sounds surprise should that promptcardiac immediatearrest in the needle set- aloneprovides. (See important Figure 4.) Impaled clues regarding objects may clinical tamponade stability. tingthoracentesis of penetrating followed neck by tubetrauma thoracostomy. is a poor prognostic Inspectlacerated the vessels; airway ED for removal signs ofcould injury, precipitate bleeding, life- and sign. Heroic interventions may include ED thora- thethreatening patient’s hemorrhage. ability to protect Such objects his or shouldher airway. be removed As- cotomyCirculation to crossclamp the aorta and perform open sess breathing by looking for symmetrical chest rise cardiacControl massage,Bleeding obtain control of bleeding vessels, Figure 4. Knife in neck. andUse directpossibly pressure aspirate to control the right bleeding. ventricle Clamping to treat of air vessels—blind or otherwise—should never be done in the ED. In cases of impalement, leave the implement alone! This embolism. Figure 4. Knife In Neck Only the trauma surgeon should clamp vessels, and then knife should be removed in the operating room. Standardonly in the Trauma operating Interventions room with appropriate exposure, as Ifinappropriate an impaled use object of a isclamp in place could (eg, lead a knifeto ischemic or a stick),cerebrovascular leave it alone accident (see orFigure iatrogenic 4). Impaled nerve injury. objects mayIf tamponade the hemorrhage lacerated cannot vessels; be staunched ED removal with pressure may precipitatebecause the woundlife-threatening is particularly hemorrhage. large and Suchdeep, objects shouldconsider be the removed placement in of the a Foleyoperating catheter. room. Insert the FoleyMost as far of as the possible standard and traumainflate the interventions, balloon with watersuch asuntil monitoring the bleeding vital stops signs or resistance and electrocardiogram, is felt.43 This andtechnique Foley is catheterization, especially valuable remain in penetrating unchanged wounds in the to patientZone I. Because with neck of involvement trauma, with of 1the exception. subclavian The vessels, placementsuch bleeding of isa nasogastricnotoriously difficult tube is tocontroversial, manage in the as someED. Uncontrolled theorize that intrathoracic the tube may hemorrhage dislodge from a clot a Zone and I worseninjury may the require hemorrhage. an emergent28,55 Consult thoracotomy. the treating2 Ligation of surgeonsimple venous in regard injuries to thisis acceptable decision. in the setting of In cases of impalement, leave the implement alone! This knife should July 2003 • www.empractice.net 7 be removed in the operating room.Emergency Medicine Practice

12 An Evidence-Based Approach To Traumatic Emergencies and fall, auscultating the neck and chest for stridor or may provide an important clue to carotid dissection other abnormal sounds, and palpating the neck and or injury.7 Inspect the wounds by gently separat- chest for obvious injury, subcutaneous emphysema, ing wound edges to determine if the wound has and hematomas. Circulation can be evaluated by penetrated the platysma; if so, a surgical consult is palpating the arterial pulses in the neck, face, and ex- needed. Avoid probing past the platysma to prevent tremities and assessing mental status, blood pressure, clot disruption and false passages and to prevent and heart rate. Check disability via the AVPU scale otherwise aggravating the injury. (Alert, responds to Verbal stimuli, responds to Painful stimuli, or is Unresponsive) or the Glasgow Coma Scale. Exposure is essential in all trauma patients, given the likelihood of multiple injuries, often incom- Table 2. Clinical Findings By System plete histories, and delayed development of injury.

The secondary survey begins with a head-to- Airway injury toe physical examination of the patient. Location of • Voice changes wounds and number of missiles may help direct the • Respiratory compromise / stridor necessary workup. The secondary survey in neck • Airway compromise trauma must focus on airway, digestive tract, vascu- • Subcutaneous emphysema lar, and nervous system injury. • Hemoptysis • Bubbling wound Neck Examination Signs of laryngeal injury include pain or tenderness, Penetrating vascular injury hoarseness or voice alteration, stridor, subcutane- • Shock with or without active bleeding • Expanding or pulsatile hematoma ous emphysema, dysphagia, hemoptysis, bubbling • Brisk bleeding from wound site wounds, and deformity of external landmarks. Pay • Airway compromise particular attention to the character of the patient’s • Decreased pulse (radial, ulnar, carotid, temporal, facial arteries) voice. Any intrinsic laryngeal injuries can lead to • Carotid bruit / thrill hoarseness. Extrinsic laryngeal injuries resulting • Hemothorax in voice changes include recurrent laryngeal nerve • Air embolism injury and extralaryngeal hematoma. Minimal initial • Cerebrovascular accident voice changes and physical examination findings • Neurologic findings incongruent with head CT may progress into life-threatening injuries. Increas- • Asymptomatic interval between trauma and symptoms with nega- ing intralaryngeal hematoma and edema may not tive head CT reach the maximum until several hours postinjury, • Ipsilateral headache • Ipsilateral Horner’s syndrome necessitating repeated examinations and close atten- • Facial or neck pain tion to respiratory status.3 The literature continues to differ on whether Blunt vascular injury airway compromise will commonly be clinically evi- • Carotid artery injury dent on initial presentation. Eighty of 106 consecu- n Hematoma lateral neck tive neck trauma patients who had tracheal injuries n Bruit over carotid all presented to the ED with signs of airway compro- n Horner’s syndrome mise, such as tachypnea, dsypnea, cyanosis, subcu- n Transient ischemic attack teanous emphysema, and abnormal respiration.56 n Aphasia n Contrasting that study, other researchers argue that Contralateral hemiparesis breathing difficulty may not manifest until hours af- • Vertebral artery injury ter initial presentation, and necessary studies should n Ataxia be ordered, even without obvious signs of tracheal n Vertigo 57 injury. Additionally, practitioners should also be n Nystagmus aware of coughing, drooling, crepitation, and asym- n Hemiparesis metry as potential signs of tracheal injury. n Dysarthria The clinical findings associated with penetrating n Diplopia vascular injury to the neck may be obvious (eg, brisk bleeding accompanied by shock) or subtle and detect- Digestive tract injury able only through careful physical examination. Signs • Pain on swallowing of vascular injury (see Table 2) include expanding • Neck pain or tenderness hematomas, carotid bruits/thrills, hemothorax, and • Resistance of neck to passive motion • Subcutaneous emphysema cerebrovascular injury from air embolism. • Dyspnea Listen over the carotids for bruits (put the dia- • Bleeding from mouth or nasogastric tube phragm inside a glove to avoid getting blood on the • Clinical signs often non-diagnostic stethoscope in case of penetrating trauma). A bruit

Neck Trauma: Don’t Put Your Neck On The Line 13 The clinical signs of esophageal injuries include a lucid interval between trauma and symptoms, neck pain and tenderness, resistance to passive mo- ipsilateral headache, and facial or neck pain.59 tion of the neck, subcutaneous emphysema, dysp- A 2005 study attempted to determine the frequen- nea, dysphagia, and bleeding from mouth or naso- cy of stable versus unstable cervical spine fractures gastric tube. and the need for a cervical collar and spinal precau- A palpable thrill and a bruit on auscultation tions in patients sustaining gunshot wounds to the can be appreciated when an arteriovenous fistula is face and neck. The cervical collar poses significant present, indicating the high-volume vascular chan- hindrance—especially in neck trauma—to lifesaving nel from the high-pressure artery to a lesser flow airway or vascular procedures. Emergency practitio- adjacent vein. A pulsatile mass with a palpable thrill ners often struggle to maintain in-line cervical stabi- and an audible to and fro murmur signifies that a lization while grappling with intubations or surgical pseudoaneurysm lies underneath. The pseudoan- airways. Of 65 patients who were awake and alert eurysm forms by trauma to all 3 layers of the artery, without a neurological deficit, none of them had an un- forming a hematoma that is contained by the sur- stable fracture and only 5% had a stable one.60 Thus, rounding tissues and contiguous with the artery.8 c-collar and spinal precautions should not obstruct Clinical signs that present after neck trauma emergent airway or vascular procedures in awake can be categorized into the likelihood of vascular and neurologically intact patients. However, a c-collar injury. “Hard signs” such as bruits, thrills, pulsa- should be replaced once emergency procedures are tile or expanding hematomas, pulsatile or severe finished, and more definitive imaging looking for -oc hemorrhage, and pulse deficits are highly indicative cult fractures should be obtained. of vascular injury. “Soft signs” such as hypotension and shock; stable, nonpulsatile hematomas; parath- Skin Examination esias; central or peripheral nervous system ischemia; For patients with strangulation injury, the skin or proximity to a major vascular structure are less examination is revealing. Patients may present with predictive of vascular injury.58 These signs can be petechiae in the face and neck and often demon- used to guide practitioners about the severity of an strate subconjunctival hemorrhage. injury and the need to expedite surgical exploration. Diagnostic Maneuvers Chest Examination There are several important diagnostic maneuvers Palpation of the anterior chest may reveal subcuta- that can greatly augment the physical examination. neous air associated with pneumothorax. Listen for First, have the patient cough to determine if he or asymmetry of breath sounds, another important clue she has hemoptysis; then, have the patient swal- to air in the pleural space. Cardiac auscultation can low to check for dysphagia; and finally, listen to the demonstrate a crunching sound with each beat of patient speak to assess laryngeal function. A positive the heart, a finding known as “Hamman’s crunch.” finding resulting from these challenges will prompt This sound can occur with any condition that leads further evaluation of the airway, esophagus, and pneumomediastinum; esophageal perforation is a larynx, respectively. rare but important cause. Diagnostic Studies Vascular Examination An important early decision involves the decision In addition to evaluation of the carotids (eg, assess “to test or to treat.” In a practical sense, this amounts pulses, bleeding, hematomas, and bruits) carefully to mandatory operation versus a strategy of selec- examine the peripheral pulses—most importantly tive operation combined with a targeted diagnostic the radial or brachial pulses. A deficit in an upper evaluation. An even more controversial issue is extremity pulse may signal a subclavian injury. selective testing, where testing is based on clinical findings and not the mere fact of neck injury. Neurologic Examination Motor deficits may be secondary to stroke related to Mandatory Versus Selective Operative Intervention carotid artery injury, spinal cord damage, or injury Mandatory neck exploration has mostly been sup- to the peripheral nerves (in particular, the brachial planted by selective neck exploration of wounds plexus). In zone II injuries, carefully examine the that penetrate the platysma. During World War II, cranial nerves; damage to the facial nerve produces all wounds penetrating the platysma were surgically a traumatic Bell’s palsy, whereas hypoglossal nerve explored.1 There are several advantages of emergent injury will deviate the tongue. operating room exploration. A negative neck explo- Clinical findings in blunt vascular injury de- ration involves only a short, simple procedure, fewer pend on whether the carotid or vertebral artery is additional diagnostic tests, and a shorter length of involved. Classic features include neurologic ab- stay in the hospital compared with other manage- normalities incongruent with head computerized ment strategies.61 Patients with negative neck explo- tomography (CT) (including stroke-like symptoms),

14 An Evidence-Based Approach To Traumatic Emergencies showed that selective neck exploration with selective Laboratory Investigation ancillary diagnostic testing safely excludes injury while Laboratory investigation of significant blunt and pen- rations require only a short period of observation decreasingand screen, the depending negative exploration on the clinical rate. circumstances. etrating neck trauma includes some initial (and often and can avoid the disastrous complications of an InjuryIndications patients forwith immediate known or operative suspected intervention liver disease, serial) measurements of hemoglobin or hematocrit. occult vascular injury. However, mandatory explora- withoutpatients further on warfarin, diagnostic or those evaluation with persistentare presented bleed in - Patients who are hemodynamically unstable, signifi- tion results in a high negative exploration rate with Tableing are 3. Ifcandidates immediate for surgical coagulation exploration studies. is not indi- cantly anemic, or show evidence of ongoing blood loss the resultant morbidity of needless explorations (al- cated, Early then measurementfurther evaluation of systemic is required acidosis to exclude (base should receive a type and crossmatch or type and screen, though the morbidity of an exploration with nega- occultdeficit, injuries. lactate, or pH) can provide important clues depending on the clinical circumstances. Injury victims 66 tive findings is usually low). to occultTranscervical shock. gunshot It may woundsalso be helpfulremain anto areafollow of the with known or suspected liver disease, patients on During the 1990s, selective neck exploration of controversy.trend of acidosis In a retrospective over time to review determine by Hirshberg the success et al, warfarin, or those with persistent bleeding are candidates 67 stable patients with penetrating injuries became the of 41the patients resuscitation. with a transcervical gunshot wound, 83% for coagulation studies. standard of care. Many surgeons questioned the need had positive neck explorations.54 However, in a more Early measurement of systemic acidosis (base to apply lessons from high-velocity military weapons recentRadiology prospective study utilizing a selective approach, deficit, lactate, or pH) can provide important clues to civilian injuries.10,28,61-63 Asensio et al reviewed and onlyChest 21% and of necktranscervical radiographs gunshot are wounds an important had a thera- part to occult shock.55 It may also be helpful to follow the combined data from 26 studies of mandatory and peuticof the operation.initial workup52 The differenceof blunt and between penetrating these numbers neck trend of acidosis over time to determine the success selective exploration that included more than 4000 maytrauma. relate (See to a Figurebaseline 5. difference) The initial in acuity.x-rays In should the study of the resuscitation.56 patients.1 The percentage of surgeries with negative byalways Hirshberg be done et al, in nearly the resuscitation 40% of the patients room ofhad the ED findings decreased from 46% in the mandatory group evidenceand not inof thelife-threatening radiology suite. injuries Positive on ED presentation.findings Radiology to 30% using a selective approach, with no change in on soft tissue neck radiographs (see Table 4, page Chest and neck radiographs are an important part of the mortality rate. Many of these studies showed that 16.) include subcutaneous emphysema, preverte- the initial work-up of blunt and penetrating neck trauma. selective neck exploration with selective ancillary di- Table 3. Indications for immediate operative (See Figure 5.) The initial x-rays should always be done agnostic testing safely excludes injury while decreas- repair by system. in the resuscitation room of the ED and not in the ing the negative exploration rate. Table 3. Indications For Immediate Operative radiology suite. Positive findings on soft-tissue neck Indications for immediate operative intervention SystemRepair By System Finding radiographs (see Table 4) include subcutaneous emphy- without further diagnostic evaluation are presented sema, prevertebral emphysema, and the location of Vascular Shock in Table 3. If immediate surgical exploration is not System Finding any missile or fragment. Chest x-ray may reveal pneu- indicated, then further evaluation is required to Pulse deficit (absent radial pulse)* mothorax, hemothorax, mediastinal air, widened medias- Vascular UncontrolledShock bleeding exclude occult injuries. tinal structures, and the location of missile fragments. Rapidly expanding hematoma Transcervical gunshot wounds remain an area Pulse deficit (absent radial pulse)* In a retrospective study of 110 bullet wounds to the of controversy. In a retrospective review by Hirsh- Respiratory Stridor*Uncontrolled bleeding neck, 48 patients had positive chest x-ray findings, berg et al, of 41 patients with a transcervical gunshot Hemoptysis* including six hemothoraces, nine pneumothoraces, Rapidly expanding hematoma wound, 83% had neck explorations with positive Dysphonia* and four hemopneumothoraces.57 64 Respiratory Stridor* findings. However, in a more recent prospec- Digestive Hematemesis* tive study using a selective approach, only 21% of Dysphagia*Hemoptysis* Targeted Diagnostic Strategies patients with transcervical gunshot wounds had a Neurologic NeurologicDysphonia* deficits* therapeutic operation.62 The difference among these All of the following diagnostic algorithms depend on a Digestive Hematemesis* central premise—that the patient is clinically stable. Most numbers may relate to a baseline difference in acuity. * In conjunction with other clinical findings In the study by Hirshberg et al, nearly 40% of the Dysphagia* unstable patients, as well as patients who become unstable, need to go to the operating room without patients had evidence of life-threatening injuries on Neurologic Neurologic deficits* ED presentation. Figure 5. X-ray of Zone I injury. diagnostic delay. An exception would include those in In patients with penetrating neck trauma, selec- whom interventional angiography may be life-saving. *In conjunction with other clinical findings tive management is considered safe and practical Zone I injuries are often associated with severe trauma and is now routinely used. In a 2001 study, unstable to intrathoracic structures. Always obtain a chest x-ray inFigure patients 5. withX-ray these Of injuries.Zone I Injury Table 4. Important neck and chest hemodynamics, airway obstruction, active bleeding radiograph findings in neck trauma. from the wound, or evidence of aerodigestive tract injuries were indications for an immediate surgical procedure, and 40 of 57 patients underwent neck ex- Neck ploration for one of these reasons. But the 17 patients • Subcutaneous emphysema who appeared stable on initial presentation had • Prevertebral emphysema • Missile fragments uneventful conservative treatment with a complete • Fractured calcified larynx radiological workup with negative results and no 65 need for a surgical procedure. Chest • Pneumothorax Laboratory Investigation • Hemothorax Laboratory investigation of significant blunt and pen- • Mediastinal air etrating neck trauma includes some initial (and often • Pleural effusion serial) measurements of hemoglobin or hematocrit. • Widened mediastinum Patients who are hemodynamically unstable, signifi- • Missile fragments cantly anemic, or show evidence of ongoing blood loss should receive a type and crossmatch or type Zone I injuries are often associated with severe trauma to intrathoracic Emergencystructures. Always Medicine obtain Practice a chest x-ray in patients with these injuries. 10 www.empractice.net • July 2003

Neck Trauma: Don’t Put Your Neck On The Line 15 bral emphysema, and the location of any missile or an important adjunctive role. Findings on soft tissue fragment. Chest x-ray may reveal pneumothorax, cervical radiographs include subcutaneous or pre- hemothorax, mediastinal air, widened mediastinal vertebral air or a fractured calcified larynx. structures, and the location of missile fragments. CT scanning plays a central role in the evalu- In a retrospective study of 110 patients with bullet ation of suspected airway injury, especially in the wounds to the neck, 48 patients had positive chest case of suspected laryngeal involvement. It accu- x-ray findings, including 6 with hemothoraces, 9 rately identifies the location and extent of laryngeal with pneumothoraces, and 4 with hemopneumotho- fractures.74-77 Perform CT when the diagnosis of races.68 laryngeal fracture is suspected, even in the presence Aerodigestive injury most commonly creates of an endolarynx examination without any positive subcutaneous emphysema as the initial presenting findings or when the endolarynx cannot be visual- sign. Fortunately, predictable air patterns on x-rays ized (intubated patients). CT findings determine the indicate the most likely injury. Laryngeal trauma need for operative intervention and guide preopera- leads to significant deep and superficial cervicofacial tive planning in displaced fractures.28,78 Laryngeal emphysema, whereas patients with tracheal injury injuries are classified into 4 groups depending on the often have vast mediastinal and deep cervical em- degree of injury. (See Table 5.) physema without pneumothorax.69 Selective management is now the norm for patients post–neck trauma because of the wide array of Targeted Diagnostic Strategies tools we have to evaluate airway injuries. A combination of physical examination, plain radiographs, CT All of the following diagnostic algorithms depend scans, and bronchoscopy should be used to assess on a central premise—that the patient is clinically patients. CT scanners, with their improved speed, stable. Most unstable patients, as well as patients enhanced resolution of images, and reconstructive who become unstable, need to go to the operating abilities, have obviated the need for routine bronchos- room without diagnostic delay. An exception would copy to determine laryngeal or tracheal injury. include those in whom interventional angiography may be lifesaving. Vascular Injuries Angiography Airway Injuries Angiography has been the traditional criterion stan- Airway evaluation is essential for patients with a dard in the diagnosis of vascular injuries. However, change in voice, subcutaneous air, hemoptysis, or the best method of vascular imaging in penetrat- respiratory difficulties. Conversely, the absence of ing injuries continues to evolve as newer and less clinical findings reliably excludes laryngeal trauma invasive imaging techniques become more widely in both blunt and penetrating laryngeal injuries.28,70 available. In zone III injuries, angiography may play The diagnostic evaluation of penetrating and both a therapeutic and a diagnostic role. blunt airway injury begins with visualization of the endolarynx via a fiber-optic scope or indirect or Carotid Duplex Scanning direct laryngoscopy.3,15,71-73 Laryngoscopy is indi- Proponents of carotid duplex scanning point to the cated with positive clinical findings or a significant invasive nature and high cost of routine angiogra- mechanism to evaluate the extent of intraluminal phy. Multiple studies comparing angiography with injury.4 Conventional radiographic evaluation serves

Table 5. Laryngeal Injury Classification By Table 4. Important Neck And Chest Schaefer Radiograph Findings In Neck Trauma Group Findings

Neck 1 Minor endolaryngeal hematoma or lacerations, absence • Subcutaneous emphysema of detectable laryngeal fractures, and minimal airway • Prevertebral emphysema compromise • Missile fragments 2 Edema, hematoma or minor mucosal disruption without • Fractured calcified larynx exposed cartilage, varying degrees of airway compromise 3 Massive edema, large mucosal lacerations, exposed Chest cartilage, displaced fractures, vocalcord immobility, varying • Pneumothorax degrees of airway compromise • Hemothorax 4 As in group 3, with disruption of the anterior larynx or • Mediastinal air unstable laryngeal cartilaginous skeleton • Pleural effusion • Widened mediastinum Source: Schaefer SD. Primary management of laryngeal trauma. Ann • Missile fragments Otol Rhinol Laryngol 1982 Jul-Aug;91(4 Pt 1):399-402.

16 An Evidence-Based Approach To Traumatic Emergencies Clinical Pathway: Initial Approach To The Airway In Patients With Neck Trauma

Immediate indications for airway management • Stridor • Respiratory distress Yes Intubate • Profound shock (Class I) • Rapidly expanding hematoma Options: • RSI—if not difficult to bag and no anatomical disrup- NO tion (airway of choice) (Class I) • Awake intubation—if anticipated to be difficult to bag or suspected tracheal disruption (Class II) • Fiberoptic intubation—if skilled operator and no sig- Urgent or prophylactic indications for airway nificant blood in airway (Class II-III) management • Cricothyrotomy—can’t RSI and no hematoma over • Progressive neck swelling cricothyroid membrane or laryngeal fracture (Class • Need to transfer symptomatic patient I-II) • Voice changes • Needle cricothyrotomy—if child or other relative con- • Progressive symptoms Yes traindication to cricothyrotomy (Class II) • Extensive subcutaneous emphysema, edema, or • Tracheostomy—can’t RSI and contraindications to tracheal shift cricothyrotomy (Class I-II) • Alteration in mental status • Direct tracheal intubation—open trachea (Class II) • Prolonged time away from the ED for diagnostic study is anticipated and patient symptomatic

Continue to re-evaluate airway status

For Class of Evidence Definitions, see page 1.

Neck Trauma: Don’t Put Your Neck On The Line 17 Clinical Pathway: Management Of Penetrating Neck Trauma

Platysma intact? Yes Local wound repair and discharge

Patient unstable? Yes • Consult surgeon • Resuscitate NO • Manage airway • Type and cross-match • Direct pressure on bleeding sites • Consult surgeon (Class I) • Facilitate transfer to operating room or trauma center • Chest x-ray (Class I) • Neck films (Class II-III) • Hemoglobin/hematocrit (Class I-II) • Lactate or base deficit (Class II-III)

Zone III Yes • Color-flow Doppler or CT angiography (Class II-III) (Above the angle of the jaw) • Angiography (Class I-II) • CT of head if suspected intracranial penetration or neurologic findings (Class I) • Evaluate for esophageal injury if pain on swallowing NO or subcutaneous air (Class I) • Esophagoscopy (Class I-II) • Esophagography (Class I-II) • Laryngoscopy or CT of neck (if clinical findings of airway injury) (Class II) • Bronchoscopy (if clinical findings) (Class II-III)

Zone I • Angiography (Class I-II) Yes (Below the cricoid cartilage) • Color-flow Doppler or CT angiography (Class II-III) • Evaluate for esophageal injury if pain on swallowing or subcutaneous air (Class I) NO • Esophagoscopy (Class I-II) • Esophagography (Class I-II) • Laryngoscopy or CT of neck (if clinical findings of airway injury) (Class II) • Bronchoscopy (if clinical findings) (Class II-III)

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For Class of Evidence Definitions, see page 1.

18 An Evidence-Based Approach To Traumatic Emergencies Clinical Pathway: Management Of Penetrating Neck Trauma (continued from page 18)

Zone II (Between the cricoid cartilage and angle of the jaw)

Indications for immediate operation? • Facilitate transfer to operating room or to trauma • Shock Yes center • Uncontrolled bleeding • Resuscitate as possible • Rapidly expanding hematoma • Pulse deficit (absent radial pulse)* • Stridor* • Hemoptysis* • Dysphonia* • Hematemesis* • Dysphagia* • Neurologic deficits* * In conjunction with other clinical findings

• Abnormal voice • Laryngoscopy (fiberoptic or direct) (Class I-II) • Subcutaneous air Yes • CT scan of larynx (Class I-II) • Respiratory signs or symptoms • Bronchoscopy (Class II-III) • Blood in airway

• Pain on swallowing Contrast study of esophagus with radiocontrast oral • Abnormal air on neck or chest x-ray Yes agent. If negative, then contrast study with barium; if • Altered mental status negative, then esophagoscopy.

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For Class of Evidence Definitions, see page 1.

Neck Trauma: Don’t Put Your Neck On The Line 19 Clinical Pathway: Management Of Penetrating Neck Trauma (continued from page 19)

• Slowly expanding hematoma • Angiography (Class I) • Carotid bruit or thrill Yes • Color-flow Doppler (Class II-III) • Neurologic deficit unexplained by head CT or periph- • Helical CT angiogram (Class II-III) eral nerve injury • Horner’s syndrome

Stable, asymptomatic patient with Zone II injury*

Option 1: Selective diagnostic testing Option 2: Mandatory diagnostic testing

Admit for observation and serial examinations Vascular evaluation (Class I-II) • Angiography (Class II) OR • Helical CT angiography (Class II-III) OR • Color-flow Doppler (Class II-III) Esophageal evaluation

Esophageal evaluation • Contrast studies and endoscopy (Class II) Airway evaluation Airway evaluation • Laryngoscopy and CT (Class II)

* Management of stable asymptomatic zone II injuries is very institution- and surgeon-dependent

For Class of Evidence Definitions, see page 1.

20 An Evidence-Based Approach To Traumatic Emergencies Clinical Pathway: Management Of Blunt Neck Trauma

Patient unstable? Yes • Consult surgeon • Resuscitate • Manage airway • Direct pressure on bleeding sites • Facilitate transfer to operating room or trauma center

Chest x-ray (Class II-III)

• Altered mental status or intoxication Yes Cervical spine films • Distracting injury • Tenderness over cervical spine • Neurologic deficit

• Abnormal voice • Laryngoscopy (fiberoptic or direct) (Class I-II) • Stridor Yes • CT scan of larynx (Class I-II) • Subcutaneous air • Bronchoscopy (Class II-III) • Respiratory signs or symptoms • Blood in airway

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For Class of Evidence Definitions, see page 1.

Neck Trauma: Don’t Put Your Neck On The Line 21 Clinical Pathway: Management Of Blunt Neck Trauma (continued from page 21)

• Carotid bruit or thrill • Angiography (Class I) • Unexplained neurologic deficit Yes • Color-flow Doppler (Class II-III) • Horner’s syndrome • Helical CT angiogram (Class II-III) • Basilar skull fracture through carotid canal • Fracture through the foramen transversarium • Severe flexion or extension cervical spine fracture • Massive facial fractures • Significant neck hematoma

Contrast study of esophagus with Gastrografin. If nega- Yes • Pain on swallowing tive, then contrast study with barium; if negative, then esophagoscopy.

Note: Blunt esophageal trauma is extremely rare

• Admit for observation and serial examinations (Class I-II) • Discharge with close follow-up (Class I-II)

For Class of Evidence Definitions, see page 1.

22 An Evidence-Based Approach To Traumatic Emergencies carotid duplex scanning have found the sensitivity spine trauma. A study of 36 patients reveals that the of carotid duplex scanning in excluding vascular sensitivity and specificity of MRI for assessing verte- injury ranges from 90% to 100%.79-81 These stud- bral artery injury were 100% and 84.6%, respectively. ies recommend carotid duplex scanning to exclude Although the criterion standard for diagnosing injury in asymptomatic zone II and III penetrating vertebral artery injury was cervical 4-vessel arteriog- injuries. Because of occasional false-positive studies, raphy with a sensitivity of 97%, MRIs provide a non- carotid duplex scanning with positive results should invasive, less time-consuming, and accurate alterna- be followed by angiography to confirm the injury. tive. At an age when increasing numbers of magnetic A 2008 article in the Journal of Ultrasound in resonance (MR) machines are becoming more accessi- Medicine supports color Doppler duplex scanning ble in theory and moving closer physically to the ED, (CDDS) as the current first-line radiographic study another new modality exists in the armory to assess for evaluation of vascular injuries, with reported and aid in the best management for the patient.87 sensitivity of 95% to 97% and accuracy of 95% to 98%. It is widely available, noninvasive, and accu- Special Considerations In Penetrating Trauma rate. However, some limitations, such as large he- Indications for immediate exploration of vascular inju- matomas, subcuteanous air, and large skin wounds ries include shock, pulse deficit, and a rapidly expand- or burns, can disrupt CDDS performance. Operator ing hematoma. In stable patients with penetrating neck dependence and length of the examination may also injuries, diagnostic evaluation varies by the neck zone be limiting factors.8 injured. For zone I injuries, perform angiography in all patients to exclude injury to intrathoracic vessels. In Helical CT Angiography stable patients with indications for operative repair, an- Helical CT angiography (HCTA) is an alternative to giography determines the need for thoracotomy before both carotid duplex scanning and angiography in neck exploration to repair thoracic outlet vessels.61,88-91 the evaluation of penetrating vascular injury. Several For stable patients without indications for operative prospective studies have examined the role of CT in therapy, a small recent retrospective study has chal- penetrating neck trauma. In a recent small study of lenged the need for routine angiography. Of 138 zone I 14 patients, Mazolewski et al demonstrated that dy- injuries from 5 level I trauma centers during 10 years, namic CT was 100% sensitive in excluding vascular none of the 36 patients with normal physical examina- injury.82 In another study, Munera et al found that tion and chest x-ray results had an arterial injury. The HCTA was 90% sensitive and 100% specific com- authors concluded that patients with normal physical pared with angiography.83 Using direct and indirect examination and chest x-ray results may not require signs of injury on HCTA, LeBlang et al reported a routine angiography. sensitivity of 100% and a specificity of 97%.84 Other Zone II injuries in patients with indications for a centers have not had such compelling results; the surgical procedure do not require diagnostic inves- Memphis center found HCTA to be less than 50% tigations before a surgical procedure because the sensitive in detecting blunt carotid injuries.85 anatomy allows the easy exploration and repair of Direct signs of vascular injury include wall ir- injuries. The diagnostic approach to patients without regularity, contrast extravasation, lack of vascular indications for a surgical procedure is controversial enhancement, and caliber changes. Indirect signs because of the debate of the reliability of physical included bone or bullet fragments less than 5 mm examinations to exclude serious vascular injuries in from a major vessel, path of injury through a major penetrating zone II neck injuries. Some centers rely vessel, and a hematoma in the carotid sheath.84 Ar- on the physical examination to determine that patients tifact and scatter associated with metallic fragments require vascular imaging; other centers perform these can complicate interpretation. However, with more studies routinely. It becomes a matter of local practice and larger studies, HCTA may become an appropri- because the literature is so conflicted. ate screening tool for vascular injury in neck trauma. Some studies show that physical examination is a reliable determinant of who needs vascular Magnetic Resonance Imaging imaging (angiography or color-flow Doppler). The Case reports demonstrate that magnetic resonance authors reviewed 8 studies with a total of 1216 imaging (MRI) can reveal a variety of vascular le- patients. Of the 837 patients observed without hard sions. However, MRI has not been used specifically signs of injury, 5 (0.6%) patients had injuries that in patients with neck trauma and is limited by cost required intervention. Three prospective studies and logistical constraints.86 involving 688 patients with zone II injuries report Strides have been made recently to increase a missed injury rate of less than 1% using physical the use of MRIs after blunt neck trauma to evalu- examination alone in select patients.92-94 Because ate vascular injuries. Studies have always shown transcervical and gunshot wounds are considered the proficiency of MRI at diagnosing cervical cord “high risk,” many centers perform routine angiogra- injury, but MRIs have also proven advantageous for phy on such patients despite a physical examination assessing vertebral artery injury after blunt cervical with normal findings.

Neck Trauma: Don’t Put Your Neck On The Line 23 Other studies have found a higher number of new onset neurologic deficits, and 23% by physical missed injuries when physical examination alone examination (neck injury, Horner’s syndrome).7 is used to detect vascular trauma. In a retrospective Patients with altered mental status who have review, Meyer et al studied 113 asymptomatic zone either significant external cervical trauma or basilar II–injured patients who underwent arteriography, skull fracture should also be studied. In patients laryngotracheoscopy, esophageal contrast studies, with a high-risk mechanism of injury (cervical hy- and esophagoscopy followed by neck exploration. perextension or hyperflexion, direct cervical blow, In these 113 patients, clinical assessment alone had near hanging) and injury pattern (carotid canal, only a 68% accuracy in detecting injuries (although midface, and cervical spine fracture), 27% suffered most missed injuries were nonoperative in nature).95 vascular injuries.103 In a study from South Africa of 393 consecutive Using screening criteria, the detection rate for stab wounds to the neck, clinical signs were absent injury is much higher. Rozycki et al performed in 30% of neck explorations with positive findings HCTA or conventional angiography on 131 patients (defined as an injury to the pharynx, esophagus, with a cervicothoracic seat belt sign. They found a trachea, or vascular structure).96 These studies and 3% prevalence of occult vascular injury, a number others support the authors’ recommendation that significantly higher than that found in other studies both physical examination and ancillary diagnostic (0.24%-0.86%).104 The presence of these vascular in- testing are required to rule out vascular injury. juries was strongly associated with a Glasgow Coma For zone III penetrating injuries, physical exami- Scale score of less than 14, severe associated injuries nation is not reliable in excluding vascular injuries. (an Injury Severity Score > 16), and a clavicle and/or Angiography is recommended because high internal first rib fracture. carotid injuries may be difficult to visualize at opera- However, 1 patient with blunt carotid injury tion and embolization may provide the most effec- presented with a Glasgow Coma Scale score of 15, tive care.89,97,98 normal neurologic examination results, and an ecchymosis (but no hematoma) over her right clavicle. Blunt Trauma During an 18-month period, Kerwin et al used the The prevalence of vascular injury in the setting of following criteria to screen 1935 patients for pos- closed head injury is 0.08 to 1.00%.99,100 A recent sible blunt vascular injury: anisocoria, unexplained 2-year prospective study of the trauma registry at hemiparesis or other neurologic deficit, basilar skull the University of Tennessee reported a prevalence fracture through or near the carotid canal, fracture of blunt cerebrovascular injury in 1% of all blunt through the foramen transversarium, cerebrovascu- trauma patients.101 Ninety-three percent of lesions lar injury/transient ischemic attack, massive epistax- occur at the bifurcation of carotids or higher. Mul- is, severe flexion or extension cervical spine fracture, tiple vessel injuries are found in 40% to 80%.7,99 In 1 massive facial fractures, and neck hematoma. Forty- study of 66 patients with blunt carotid injury, angio- eight patients had a positive finding and underwent graphic findings included 54 intimal dissections, 11 angiography. Injuries were identified in 21 (44%) pseudoaneurysms, 17 thromboses, 4 carotid cavern- patients. The overall prevalence of blunt carotid/ ous fistulas, and 1 transsected internal carotid artery. vertebral injury was 2.5% of patients admitted.105 No The diagnosis of vascular injury in blunt trauma patient screened for a neck hematoma alone had a is difficult. Coexisting injuries mask the clinical carotid injury. signs of carotid or vertebral injury, and 25% to 50% Almost 25% of blunt neck trauma patients first of patients have no external signs of neck trauma.102 develop signs and symptoms of vascular injury 24 Delayed neurologic deficits are the rule rather than hours after presenting.104 Unfortunately, the frequent the exception. More than 90% of patients are asymp- initial manifestation is a severe ischemic stroke tomatic from hours to weeks after the injury; how- secondary to a thromboembolic event. If the vas- ever, 10% of patients experience a transient ischemic cular injury is treated early, permanent neurologic attack or cerebrovascular injury within 1 hour, and sequelae are less likely. Rozycki’s study pointed out 17% develop symptoms days to weeks postinjury. that a cervicothoracic seat belt sign raises the risk of Indications for diagnostic investigation of sus- vascular injury threefold. Patients with any external pected blunt vascular injury include positive screen- signs of trauma following blunt neck trauma should ing criteria (as described later in this section), neuro- be given highest priority until they are reliably ex- logic findings incongruent with head CT, and mono- cluded with appropriate imaging. paresis or hemiparesis with normal mental status. Diagnostic imaging for blunt trauma with In patients with neurologic deficits unexplained by suspected vascular injury is institution specific and CT findings, spinal cord injury, or peripheral nerve depends on equipment availability and the skill of the injury, the prevalence of vascular injury is 21%. In a radiology investigators. Angiography is recommend- series of 66 patients with blunt carotid artery injury, ed in the severely injured and symptomatic patient.7 the conditions of 34% of patients were diagnosed by Color-flow Doppler ultrasonography may be incompatible neurologic and CT findings, 43% by used to screen lower risk patients.7 Color-flow Dop-

24 An Evidence-Based Approach To Traumatic Emergencies pler provides rapid identification and quantification in 1992, recommends digitized or MR angiography of arterial dissection but is operator-dependent and diagnostic evaluations, somewhat antiquating itself, unable to assess the upper extracranial and intracra- as newer radiological techniques exist to determine nial internal carotid arteries. management. HCTA has been used as a screening modality for Cervical fractures encompass higher risks than patients at risk for blunt carotid injury.86 However, dislocations. A cervical fracture has an odds ratio of the diagnostic accuracy has not been well estab- 2.6 for carotid injury and 30.6 for vertebral artery inju- lished in blunt trauma. The use of HCTA did signifi- ry, indicating the potential severity of injury involved cantly decrease the time to diagnosis from 156 hours in a fracture and the higher association between to 5.9 hours and demonstrated an increased detec- blunt trauma and vertebral artery injuries.111 Even tion rate of cervical arterial injuries.100 transverse process fractures alone have an odds ratio MR angiography accurately detects carotid and of 19.5 for vertebral artery injuries. Thus, cervical de- vertebral artery injuries.106-108 Reported sensitiv- formities in blunt trauma patients should prompt CT ity and specificity are greater than 95% for carotid angiography looking for vasculature injury. Identify- artery dissection. MR angiography is currently ing a thrombus and preventing it from embolizing recommended as a follow-up test for stable patients could result from the astute practitioner’s recognition because it is difficult to perform in severely injured of the risks associated with cervical injury. or unstable patients.7,107,108 Perform MR angiography as a screening tool in stable patients to assess for Digestive Tract Injuries occult carotid injury in patients who have sustained Penetrating Trauma blunt trauma with severe closed head injury. The indications for diagnostic testing for esopha- Digital subtraction angiography (DSA) was the geal injury in penetrating neck injury include any accepted criterion standard for imaging neck vessels; positive clinical findings (especially pain on swal- but as mentioned previously, newer, noninvasive lowing), a projectile in proximity to or trajectory techniques such as MR angiography, duplex sonog- crossing the midline, a projectile beyond the limits of raphy, and CT angiography have emerged. The surgical exploration, and the presence of subcutane- trend away from DSA arose because of the increased ous air on cervical or chest radiographs.30,63,112 In 1 risk with an invasive procedure, the length of the prospective study, Demetriades et al found pain on procedure, and the additional resources needed. MR swallowing water or saliva to be a sensitive sign.63 angiography is not first line because it is less avail- Their data indicated that normal physical examina- able than CT angiography and possibly prohibitive- tion results (no dysphagia, no hemoptysis on cough- ly long, even for hemodynamically stable patients. ing, and no subcutaneous air) had a 100% negative However, faster MR machines that are positioned predictive value for esophageal injury in awake closer to EDs are challenging these concepts, conjur- patients. However, in a review, Weigelt et al found ing an image that one day they may be as readily that physical examination was only 80% sensitive for available as a CT scanner. esophageal injury.113 Color Doppler sonography’s pitfall is its reliance The exclusion of penetrating esophageal injury on operator ability and difficulty in imaging patients must include some combination of physical exami- with difficult anatomy or neck hematomas. As the nation, plain radiographs, contrast radiographs, trend continues toward newer modalities, DSA’s endoscopy, and surgical exploration. A patient with only role may be for therapeutic interventions or fur- suspected esophageal injury may undergo several ther diagnostic investigations, given initial equivocal sequential tests (assuming that each study has nega- 109 or nondiagnostic results. tive results), usually starting with a radiocontrast Although vascular neck injuries are well known oral agent, followed by barium swallow, and finally to occur following penetrating trauma, they are endoscopy. The importance of early detection and much less commonly associated with blunt cervical treatment of these injuries, with operative repair and trauma. The differences do not stop there. Penetrat- antibiotics for the prevention of serious complica- ing injuries to the vertebral artery are easily recog- tions and death, cannot be overemphasized. nized owing to clinical signs of hemorrhage or the Plain radiographs, esophageal contrast studies, trajectory of the object that penetrated. However, the and esophagoscopy are frequently used together first obvious signs of blunt arterial injury are gener- to assess for esophageal injuries; however, none of ally those associated with vertebrobasilar ischemia the tests in isolation has the sensitivity to reliably or infarction when it is far too late to act. Thus, a exclude these injuries. Plain radiographs of the high degree of suspicion should dictate management neck may reveal subcutaneous emphysema or an based on the mechanism. increased prevertebral shadow. Chest x-ray findings One retrospective study looking at lateral cervi- suggestive of esophageal injury include pleural effu- cal dislocations revealed a high risk of vertebral sions, pneumothorax, mediastinal air, and widening artery occlusion and distal infarction, necessitating of the superior mediastinum. Normal radiograph conservative management.110 The study, published

Neck Trauma: Don’t Put Your Neck On The Line 25 results do not reliably exclude injury. In 1 study, 6 of toms, which are 80% sensitive, include dysphagia, 17 patients with penetrating esophageal trauma had odynophagia, drooling, and hematemesis.118 At times, cervical and chest radiographs read as normal.112 crepitus or subcuteanous emphysema may be the Multiple studies show that esophageal contrast only indication that an esophageal injury is present. studies have a sensitivity of only 50% to 90%.30,112 Large-scale studies still have not been per- Many centers begin with a radiocontrast oral agent formed to assess CT sensitivity in diagnosing (because it causes less pleural irritation than barium digestive tract injuries although there is hope that should the contrast material leak from a perforation) CT will prove to have 100% negative predictive followed by the more sensitive barium study if the a value. But until then, according to a 2007 review, a radiocontrast oral agent swallow is negative. If the barium swallow and an endoscopy must follow a CT results from both swallowing studies are negative, with normal findings if there is a high suspicion of perform esophagoscopy. Three small studies suggest esophageal perforation.58 flexible endoscopy alone may be adequate, each reporting a sensitivity of 100% and specificities of 83% Blunt Injury to 93%.113-116 In another trial, rigid esophagoscopy Esophageal injury is exceedingly rare in patients demonstrated a higher diagnostic yield than flexible with blunt neck trauma. In the world’s literature, esophagoscopy.117 However, flexible endoscopy is there are only 10 reported cases of esophageal injury easier to perform, is less likely to cause injury, allows due to blunt trauma.27 Diagnostic investigation for evaluation of the stomach and duodenum, and does these injuries is unnecessary unless clinical find- not require general anesthesia when compared with ings are present. The classic clinical findings include rigid endoscopy.115,116 In a study by Horwitz et al (il- subcutaneous air and pain on swallowing; however, lustrated in Table 6), the combination of physical ex- these presentations are not unique to blunt esopha- amination, barium swallow, and endoscopy missed geal injury and are found more commonly with no injuries.116 laryngotracheal injuries. Two groups report surgical exploration of all patients with abnormal soft tissue air without em- Strangulation Injury ploying contrast studies or esophagoscopy, claiming Up to 10% of all violent deaths each year are due low sensitivity of these tests.88,89 They recommend to strangulation. In many cases, physical findings esophageal contrast studies and endoscopy only in are absent in nonfatal strangulation.119 Strangula- zone I penetrating injuries if the wound approaches tion injury may be defined as any mechanism that the mediastinum but not in zone II and zone III inju- produces compression of the neck. Proposed mecha- ries, owing to overlying bony shadows and contrac- nisms include hanging, postural strangulation, tions of the pharyngeal muscles, which often make ligature strangulation, and manual strangulation.120 the studies technically inadequate. Others disagree With hanging, the patient’s body is either totally or with this aggressive operative strategy, pointing partially suspended by a ligature. Transverse intimal out that only 36% of patients with penetrating neck tears at the bifurcation of the common carotid artery trauma and subcutaneous emphysema require an are common in judicial hangings. operation.94 Postural strangulation occurs when the pa- Early detection of penetrating esophageal inju- tient’s neck is stretched over an object and then ries remains paramount but difficult. Ninety percent compressed by the pressure of her or his own body. of patients survive an esophageal injury if detected Ligature strangulation results when a ligature is within 24 hours; but the rate decreases drasti- pulled around the neck. Half of all survivors of cally afterward, usually from mediastinitis or other ligature strangulation have hyoid and laryngeal infectious complications. Clinical signs and symp- injuries. Manual strangulation is often associated with fracture of the larynx, hyoid bone, and thyroid cartilage. Autoerotic self-strangulation occurs when Table 6. Accuracy Of Independent the patient (almost always a male) ties a ligature Diagnostic Tests in Esophageal Injuries around his neck, masturbates, and then tightens the ligature to induce hypoxia near the moment of Sensitivity* Specificity Accuracy orgasm (presumably to increase sexual pleasure).121 Physical examination 80% 64% 72% This technique is sometimes employed in conjunc- Contrast study 89% 100% 94% tion with inhaled nitrates. Endoscopy 89% 95% 94% The supposed mechanism of death in strangulation patients is progressive cerebral ischemia and *Combination of all modalities missed no injuries hypoxia caused by compression of blood vessels in the neck. Pressure on the neck obstructs venous circu- Source: Horwitz B, Krevsky B, Buckman RF Jr, et al. Endoscopic evaluation of penetrating esophageal injuries. Am J Gastroenterol lation, causing stagnant hypoxia. The resulting loss of 1993 Aug;88(8):1249-1253. consciousness and decreased muscle tone in the neck

26 An Evidence-Based Approach To Traumatic Emergencies allow occlusion of the arterial circulation. Total block- patient may be intoxicated or appear hysterical. age of the airway occurs later, when the full weight Abused women may minimize events and symp- of the body creates enough pressure to occlude the toms to avoid police involvement that they fear trachea. Cervical spine injury is rare in patients who could worsen the cycle of domestic violence. History sustain near-strangulation or nonjudicial hangings; provided by witnesses may be purposely inaccurate. in-hospital death or complications are usually due to Clinical findings such as hoarseness and conjunc- noncardiogenic pulmonary edema.122,123 tival hemorrhage may be misinterpreted as benign As in the case of blunt neck trauma, strangu- illness.119 Because hyperventilation may result from lation patients are often “underevaluated.” The

Risk Management Pitfalls For Neck Trauma

1. “He was still breathing on his own! Airway 6. “There was no evidence of a fractured larynx management wasn’t indicated.” on the x-ray!” In the setting of neck trauma, early intubation Clearly visualizing a fractured larynx may leads to easier intubation. Waiting to see if that not be possible unless the patient’s cartilage is pulsatile mass will continue to expand is never calcified. Physical examination findings include recommended. Elective or prophylactic intubation voice changes, respiratory compromise, tender- should be considered even for the mildly symp- ness, deformity, subcutaneous emphysema, and tomatic—especially if swelling is progressive. abrasions. Carefully palpate the neck for subcutaneous air. CT scan and a thorough endolaryn- 2. “But the cric is the rescue procedure of choice!” geal examination are the diagnostic modalities Cricothyrotomy is relatively contraindicated of choice. when an expanding hematoma is present over the cricothyroid membrane or the patient has 7. “I had to assess for laryngeal injury before a suspected laryngeal fracture. In such circum- intubating!” stances, tracheostomy is indicated if RSI should Save the patient—then get the study. CT scan fail. In certain situations, fiber optics may be the can be used to assess the larynx while providing modality of choice. Awake oral intubation with information on the vascular and gastrointestinal local airway anesthesia is also useful. tract in the intubated patient.

3. “I had to explore to the full depths of the 8. “I ran his workup by the book. I managed the wound!” airway, ordered vascular studies, and evaluated With adequate lighting and good retraction, the the larynx and esophagus.” superficial tissues can be spread to see if the Why didn’t you call the surgeon the instant you platysma has been violated. Further exploration that saw the knife went through the platysma? in the ED is not warranted. Aggressive deep Early surgical consultation is one of the corner- probing to explore the depths of the wound is stones in the management of penetrating neck best left to the surgeon in the operating room. trauma.

4. “It was a tiny neck wound! How was I sup- 9. “The results of his examination was negative, posed to know the path of the ice pick?” but I still did an x-ray and an upper GI with You can’t, and so you must suspect the worst. barium!” Any wound that penetrates the platysma (or The lack of sensitive and specific clinical signs cannot be proven not to penetrate the platysma) makes the diagnosis of esophageal injury dif- should be aggressively treated as a penetrating ficult. Physical examination, neck and chest neck injury. radiographs, contrast studies, and endoscopy should be used to exclude esophageal injury. 5. “The patient had no evidence of vascular injury on examination and his head CT results were 10. “There was a fountain of blood. I had to start normal! I thought he was being dramatic.” clamping and tying.” About 25% to 50% of patients with vascular Direct pressure is the best method to control injury after blunt neck trauma have no external bleeding. Clamping and blindly “tying off all the evidence of injury. Neurologic deficits not ex- big bleeders” is best avoided in the ED. plained by head CT imaging are the hallmark of vascular injury in blunt neck trauma. Image the great vessels of the neck in such patients.

Neck Trauma: Don’t Put Your Neck On The Line 27 airway edema and aspiration pneumonia, anxiety 40%.125-127 Gunshot wounds and glass and other must always be a diagnosis of exclusion in the ED. types of stab wounds are responsible for the major- Few formal algorithms exist for the evaluation ity of penetrating injuries. of strangulation injury. A high index of suspicion The evaluation and management of pediatric is essential to avoid delayed morbidity and mortal- penetrating neck trauma parallels that of adults, ity. Clinical evaluation may include pulse oximetry, with many of the same controversies. Indications chest and neck radiographs, angiography, HCTA, for immediate operative intervention are identical to MR, carotid Doppler ultrasonography, pharyn- adults.125 The debate over diagnostic testing in the goscopy, and fiber-optic laryngobronchoscopy, as asymptomatic patient takes on added importance. described for blunt neck injuries.119 Admission or Some authors argue that the workup itself may observation is prudent in survivors of hangings to be dangerous in children because of the need for monitor the development of noncardiogenic pul- general anesthesia for endoscopy and the higher risk monary edema. of iatrogenic injury with angiography.125 They argue that in stable, asymptomatic pediatric patients, Pediatric Neck Trauma observation without invasive diagnostic testing is Several anatomical differences between children a reasonable course of action. After stabilization, and adults affect ED management. In children, the transport pediatric patients with penetrating neck larynx is higher and better protected,124 rendering trauma to a level I trauma center, preferably one it less susceptible to injury. Several studies suggest with pediatric surgeons on call. that the prevalence of pediatric penetrating neck Although less common, significant blunt pediat- trauma is increasing, with mortality rates of up to ric injuries are reported to be more devastating, have

Cost- And Time-Effective Strategies For Neck Trauma

1. Quickly check to see if the wound penetrates des et al for penetrating neck trauma reduced the platysma. If it does, call a surgeon—right emergent operative procedures and significantly then. Wounds that violate the platysma require decreased costs without missing significant surgical consultation. injury.62 Similar protocols have been published Caveat: Carefully lift the wound edges enough in multiple other studies. to determine platysmal violation; anything be- Caveat: Selective operation and selective testing yond that is unnecessary and risky. Avoid blind require strict adherence to established protocols probing, which could dislodge a clot. and may be very labor intensive. Whether this strategy can be extended to all institutions (espe- 2. Employ simple, quick, and low-cost diagnostic cially those without in-hospital surgical support) maneuvers. remains unclear. Surgical consultation is essen- Have stable patients speak, cough, and swallow tial in determining diagnostic evaluation. to determine whether they have an abnormal voice, hemoptysis, or dysphagia. Auscultate their 4. Consider alternatives to angiography. carotid arteries for bruits. Use the physical exami- HCTA may soon replace screening angiography nation and clinical maneuvers to determine the in the evaluation of neck injury. The use of color- need for further testing (selective testing). flow carotid Doppler is already well established. Caveat: Any patient who cannot cooperate with In a study by Fry et al, color-flow Doppler cost a clinical examination, such as those who are $1200 less than angiography and resulted in intoxicated or comatose, needs either a surgical no false-negative or false-positive injuries.79 procedure or an objective test. Local practice Demetriades et al showed that the combination will often determine whether testing strategies of physical examination and color-flow Dop- are selective (based on the clinical picture) or pler resulted in no significant missed injuries in mandatory (all patients undergo a battery of patients with penetrating wounds to the neck.138 diagnostic tests). Caveat: Although color-flow Doppler is well studied in penetrating trauma of the neck, it is 3. Employ selective versus mandatory exploration less well studied in blunt injuries. HCTA has and testing. great potential, and early prospective studies are Limited data exist on the analysis of cost-effec- encouraging; however, larger studies are needed tive strategies for blunt and strangulation neck before it becomes the standard of care. injury. An algorithm validated by Demetria-

28 An Evidence-Based Approach To Traumatic Emergencies a longer hospital course, and more often require a and breathing spontaneously (such a procedure is surgical procedure than do penetrating neck in- traditionally left to an experienced surgeon).73 With juries.19 Typical mechanisms in children include tracheal transsection and other severe injuries, RSI minibike clothesline injuries and bicycle handlebar may convert a partial airway obstruction to a com- injuries. Blunt neck injuries more commonly present plete airway obstruction if supporting muscle tone is with respiratory distress. If endotracheal intubation lost with paralysis. appears difficult or impossible, intubation over a Nondisplaced fractures are generally treated fiber-optic bronchoscope or formal tracheostomy are nonoperatively, whereas displaced fractures require the preferred methods of airway management.19 Cri- early surgical intervention. Administer antibiotics in cothyrotomy is contraindicated in patients younger the ED in case of suspected aerodigestive injuries.133 than 5 to 10 years because of the potential for devel- Initial broad-spectrum antibiotics with anaerobic oping subglottic stenosis, although needle cricothy- coverage include clindamycin 900 mg IV or ampicil- rotomy may be lifesaving. Adverse outcomes are lin/sulbactam 3 g IV.56 often related to delays in diagnosis.19 Pediatric strangulation injuries are likewise Vascular Injuries ruinous. Injuries involving car windows, window Penetrating Trauma covering cords, cribs, high chairs, furniture, and Not all carotid injuries require surgical intervention. clothing are common mechanisms in children Nonoperative management of carotid injuries is younger than 5 years.128,129 Accidental strangula- indicated for clinically occult injuries, low-velocity tion with rope and cords predominate in younger injuries (such as stab wounds), intimal defects of children, whereas teens may be at risk for autoerot- less than 5 mm, and pseudoaneurysms of less than 5 ic asphyxia or suicide, with an increasing male/ mm. Patients with these conditions must have intact female predominance with age.130,131 The initial distal circulation and adhere to regular follow-up to airway, pulmonary, and nervous system injuries detect progression of the injury. are often obvious, but delayed rises in intracranial pressure with “late herniations” have also been Blunt Trauma described.132 The extent of initial injury and the The management of vascular injuries in blunt effectiveness of ED resuscitation were the main fac- trauma depends on the size of the lesions and the tors of successful outcomes.129 overall clinical picture. Options include observation, anticoagulation, antiplatelet agents, arterial We rationalize, we dissimilate, we pretend: we pretend reconstruction, endovascular stenting, and liga- that modern medicine is a rational science, all facts, no tion.134,135 Although some data suggest that hepa- nonsense, and just what it seems. But we have only to tap rin improves outcome,7 none of the treatments its glossy veneer for it to split wide open, and reveal to us are very successful; there is still a high stroke and its roots and foundations, its old dark heart of metaphys- mortality rate with all of the therapeutic options. ics, mysticism, magic, and myth. A proposed grading and management scale is —Oliver Sacks, in Awakenings, 1987 presented in Table 7.136 Treatment of blunt vascular injury should aim Treatment at preventing thromboembolic complications (via anticoagulation) and maintaining the patency of the The definitive treatment of serious neck injuries is stenotic vessel. Endovascular stenting or surgical generally beyond the scope of this chapter and rests intervention (bypass graft, thrombectomy, or resec- in the hands of surgical consultants. However, a tion of aneurysm or stenoses) should be reserved brief discussion of management principles may be for those patients who are symptomatic but cannot helpful to the emergency clinician. be treated by anticoagulation, as it may be contraindicated in a trauma patient. Treatment of venous Airway Injuries injury should aim at avoiding progression of throm- Treatment begins with early aggressive airway bus by avoiding dehydration and jugular venous management. Perform oral endotracheal intubation lines, although intravenous anticoagulation should for patients with suspected group 1 and 2 injuries as be contemplated and likely initiated. described in Table 5.16 Cricothyrotomy is relatively contraindicated with significant laryngeal disrup- Digestive Tract Injuries tion. The utility of endotracheal intubation over a Penetrating Trauma fiber-optic bronchoscope depends on availability, Surgical repair and drainage of deep neck spaces are secretions and bleeding, and emergency clinician indicated for cervical esophageal and lower hypopha- experience.4 In severe injuries, perform tracheos- ryngeal injuries, and early repair can decrease compli- tomy under local anesthesia with the patient awake cations.31 Nonsurgical management is recommended for injuries to the upper portion of the hypopharynx.

Neck Trauma: Don’t Put Your Neck On The Line 29 Blunt Trauma without continuous monitoring and immediate Management of blunt esophageal injury is based surgical support should be transferred to a level on the size of the perforation. Antibiotics with I trauma center. Focus on the airway of patients anaerobic activity are indicated for all patients with who require transfer, as they may lose it during suspected aerodigestive injury. Surgical therapy is transport. If in doubt, intubate. recommended for esophageal or large (> 2 cm) pha- If the platysma is intact, patients may be safely ryngeal perforations and medical therapy for small discharged in the absence of significant associated (< 2 cm) pharyngeal perforations.137 injury. Superficial neck injuries can be managed according to standard principles: Repair clean wounds Strangulation Injuries less than 12 hours old, but high-risk wounds (old Treatment of patients with strangulation injuries and/or very dirty wounds) should be left open to begins with aggressive respiratory management for heal by secondary intention. Administer tetanus symptomatic patients. These patients are at high toxoid as indicated. risk for progressive edema of the uvula, epiglottis, Patients reporting strangulation should be larynx, and vocal cords; pulmonary edema; pneu- admitted for observation, further evaluation, and monia; and adult respiratory distress syndrome. coordination of police and social services to se- Strangulation survivors are also at risk for posttrau- cure a safe environment. Patients with historical matic stress disorder and other behavioral and psy- features or clinical findings of prolonged stran- chiatric problems. Measures to decrease intracranial gulation (eg, attempted hangings) should either pressure are indicated for patients with significant be admitted or observed for 6 to 8 hours because neurologic deterioration with impending herniation. minimally symptomatic patients may develop Seizure prophylaxis and control may be helpful. delayed noncardiogenic pulmonary edema and Blunt vascular, laryngeal, and esophageal injuries other sequelae.118 are managed as described. Summary Disposition Penetrating and blunt neck injuries continue to Admission is indicated for all patients with pen- challenge emergency clinicians caring for trauma etrating neck trauma that violates the platysma patients. Understanding the fundamental principles and for patients with significant blunt trauma. of neck trauma is vital during the critical first hour. Close observation of initially benign appearing Airway management is crucial; when in doubt, early patients is required to detect delayed presentation intubation usually means easier intubation. The of airway, vascular, digestive tract, and nervous specific approach is dictated by clinical presentation, system injury. Patients with significant mecha- and management often requires skill in multiple nism, physical examination findings, or positive airway techniques. findings during imaging must be followed in an Isolated injury to a single organ system is the intensive care unit with ready access to the operat- exception. Concurrent injuries to the airway, vascu- ing room. Patients initially stabilized in hospitals lar, and gastrointestinal tract demand an organized

Table 7. Blunt Carotid Arterial Injury Grading Scale With Suggested Treatment

Injury grade Description Treatment

I Luminal irregularity or dissection with < 25% Anti-platelet therapy vs. anticoagulation luminal narrowing (non clinically significant narrowing)

II Dissection or intramural hematoma with Surgical repair if accessible > 25% luminal narrowing, intraluminal Anticoagulation if surgically inaccessible thrombus, or raised intimal flap (potentially clinically significant)

III Pseudoaneurysm Surgical repair if accessible Stenting if surgically inaccessible

IV Occlusion Surgical repair if accessible Anticoagulation if surgically inaccessible

V Transsection with free extravasation (usually Surgical repair if accessible lethal injuries) Balloon occlusion or embolization

Source: Biffl WL, Moore EE, Offner PJ et al: Blunt carotid arterial injuries: implications of a new grading scale. J Trauma 1999;47:845-853.

30 An Evidence-Based Approach To Traumatic Emergencies approach to initial evaluation and management. 7. Fabian TC, Patton JH Jr, Croce MA, et al. Blunt carotid The evaluation of injuries to zones I and III injury: importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996;223(5):513-522; discussion 522- is fairly straightforward and generally requires 525. (Retrospective; 67 patients with 87 blunt carotid vascular imaging studies. Management of zone II injuries) injuries varies widely depending on the institu- 8. Gaitini D, Razi NB, Ghersin E, Ofer A, Soudack M. Sono- tion: Some centers perform mandatory explora- graphic evaluation of vascular injuries. J Ultrasound Med. tion, some mandatory testing, and others rely on 2008;27(1):95-107. selective testing driven by the history, physical, 9. Huh J, Milliken JC, Chen JC. Management of tracheobron- and plain radiographs. chial injuries following blunt and penetrating trauma. 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Neck Trauma: Don’t Put Your Neck On The Line 31 502. (Retrospective; 57 patients) balloon tamponade. Injury. 1992;23(8):557-559. (Prospective; 30. Symbas PN, Hatcher CR Jr, Vlasis SE. Esophageal gunshot 10 patients) injuries. Ann Surg. 1980;191(6):703-707. (Retrospective; 48 51. Nair R, Robbs JV, Muckart DJ. Management of penetrating patients) cervicomediastinal venous trauma. Eur J Vasc Endovasc Surg. 31.* Asensio JA, Chahwan S, Forno W, et al. Penetrating esopha- 2000;19(1):65-69. (Retrospective; 49 patients) geal injuries: multicenter study of the American Association 52. Sweeney M. Vascular access in trauma—options, risks, for the Surgery of Trauma. J Trauma. 2001;50(2):289-296. benefits, and complications.Anesthesiol Clin North Am. (Retrospective, multicenter; 405 patients) 1999;17(1):97-106. (Review) 32. Gerich TG, Schmidt U, Hubrich V, et al. Prehospital airway 53. Stern SA. 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Ann Emerg Med. tive; 41 patients) 2000;35(3):221-225. (Retrospective; 748 patients) 65. Sriussadaporn S, Pak-Art R, Tharavej C, Sirichindakul B, 44.* Walls RM. Management of the difficult airway in the trauma Chiamananthapong S. Selective management of penetrat- patient. Emerg Med Clin North Am. 1998;16(1):45-61. (Review) ing neck injuries based on clinical presentations is safe and 45. Weitzel N, Kendall J, Pons P. Blind nasotracheal intuba- practical. Int Surg. 2001;86(2):90-93. tion for patients with penetrating neck trauma. J Trau- 66. Tremblay LN, Feliciano DV, Rozycki GS. Assessment of ma. 2004;56(5):1097-1101. initial base deficit as a predictor of outcome: mechanism of 46. Patel RG. Percutaneous transtracheal jet ventilation: a safe, injury does make a difference. Am Surg. 2002;68(8):689-693; quick, and temporary way to provide oxygenation and ven- discussion 693-694. (Retrospective; 3275 patients) tilation when conventional methods are unsuccessful. Chest. 67. 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32 An Evidence-Based Approach To Traumatic Emergencies 71. Thompson JN, Strausbaugh PL, Koufman JA, et al. Pen- 91. Eddy VA. Is routine arteriography mandatory for penetrat- etrating injuries of the larynx. South Med J. 1984;77(1):41-45. ing injury to zone 1 of the neck? Zone 1 Penetrating Neck (Retrospective; 19 patients) Injury Study Group. J Trauma. 2000;48(2):208-213; discussion 72. Schaefer SD. Primary management of laryngeal trauma. Ann 213-214. (Retrospective; 138 patients) Otol Rhinol Laryngol. 1982;91(4, pt 1):399-402. (Review) 92.* Sekharan J, Dennis JW, Veldenz HC, et al. Continued experi- 73. Reece GP, Shatney CH. Blunt injuries of the cervical trachea: ence with physical examination alone for evaluation and review of 51 patients. South Med J. 1988;81(12):1542-1548. management of penetrating zone 2 neck injuries: results of (Retrospective; 51 patients) 145 cases. J Vasc Surg. 2000;32(3):483-489. (Prospective; 145 patients) 74. Gussack GS, Jurkovich GJ. 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Computed tomograph- tomographic scan can be used for surgical decision making ic angiography as a screening modality for blunt cervical in zone II penetrating neck injuries. J Trauma. 2001;51(2):315- arterial injuries: preliminary results. J Trauma. 1999;46(3):380- 319. (Prospective; 14 patients) 385. (Retrospective; 17 patients) 83.* Munera F, Soto JA, Palacio D, et al. Diagnosis of arterial in- 101.* Miller PR, Fabian TC, Croce MA, et al. Prospective screen- juries caused by penetrating trauma to the neck: comparison ing for blunt cerebrovascular injuries: analysis of diagnostic of helical CT angiography and conventional angiography. modalities and outcomes. Ann Surg. 2002;236(3):386-393; Radiology. 2000;216(2):356-362. (Prospective; 60 patients) discussion 393-395. (Prospective; 216 patients) 84. LeBlang SD, Nunez DB, Rivas LA, et al. Helical computed 102. Opeskin K, Burke MP. Vertebral artery trauma. Am J Forensic tomographic angiography in penetrating neck trauma. 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Neck Trauma: Don’t Put Your Neck On The Line 33 109. Stuhlfaut JW, Barest G, Sakai O, Lucey B, Soto JA. Impact 129. Sabo RA, Hanigan WC, Flessner K, et al. Strangulation of MDCT angiography on the use of catheter angiography injuries in children, Part 1: clinical analysis. J Trauma. for the assessment of cervical arterial injury after blunt or 1996;40(1):68-72. (Retrospective; 13 children) penetrating trauma. Am J Roentgenol. 2005;185:1063-1068. 130. Rauchschwalbe R, Mann NC. Pediatric window-cord 110. Parent AD, Harkey HL. Lateral cervical spine dislocation strangulations in the United States, 1981-1995. JAMA. and vertebral artery injury. Neurosurgery. 1992;31(3):501-509. 1997;277(21):1696-1698. (Retrospective; 183 strangulations) 111. Winslow J, Neiberg R. Cervical spine fracture increases risk 131. Hanigan WC, Aldag J, Sabo RA, et al. Strangulation injuries of blunt carotid and vertebral artery injuries in victims of in children, Part 2: cerebrovascular hemodynamics. J Trauma. blunt trauma. Acad Emerg Med. 2006;13:38-39. 1996;40(1):73-77. (Case report; 2 patients) 112.* Glatterer MS Jr, Toon RS, Ellestad C, et al. Management of 132. Armstrong WB, Detar TR, Stanley RB. Diagnosis and man- blunt and penetrating external esophageal trauma. J Trauma. agement of external penetrating cervical esophageal injuries. 1985;25(8):784-792. (Retrospective; 26 patients) Ann Otol Rhinol Laryngol. 1994;103(11):863-871. (Retrospec- 113. Weigelt JA, Thal ER, Snyder WH 3rd, et al. Diagnosis tive; 23 patients) of penetrating cervical esophageal injuries. Am J Surg. 133. Okada Y, Shima T, Nishida M, et al. Traumatic dissection 1987;154(6):619-622. (118 patients) of the common carotid artery after blunt injury to the neck. 114. Srinivasan R, Haywood T, Horwitz B, et al. Role of flexible Surg Neurol. 1999;51(5):513-519; discussion 519-520. (Case endoscopy in the evaluation of possible esophageal trauma report; 5 patients) after penetrating injuries. Am J Gastroenterol. 2000;95(7):1725- 134. Eachempati SR, Vaslef SN, Sebastian MW, et al. Blunt 1729. (Retrospective; 55 patients) vascular injuries of the head and neck: is heparinization 115. Flowers JL, Graham SM, Ugarte MA, et al. Flexible endos- necessary? J Trauma. 1998;45(6):997-1004. (Retrospective; 23 copy for the diagnosis of esophageal trauma. J Trauma. patients) 1996;40(2):261-265; discussion 265-266. (Prospective; 31 135. Coldwell DM, Novak Z, Ryu RK, et al. Treatment of post- patients) traumatic internal carotid arterial pseudoaneurysms with 116. Horwitz B, Krevsky B, Buckman RF Jr, et al. Endoscopic endovascular stents. J Trauma. 2000;48(3):470-472. (Prospec- evaluation of penetrating esophageal injuries. Am J Gastroen- tive; 14 patients) terol. 1993;88(8):1249-1253. (Retrospective; 13 patients) 136. Biffl WL, Moore EE, Offner PJ, et al. Blunt carotid arte- 117. Stanley RB Jr, Armstrong WB, Fetterman BL, et al. Manage- rial injuries: implications of a new grading scale. J Trauma. ment of external penetrating injuries into the hypopharyn- 1999;47(5):845-853. (Retrospective; 109 injuries) geal-cervical esophageal funnel. J Trauma. 1997;42(4):675-679. 137. Niezgoda JA, McMenamin P, Graeber GM. Pharyngoesopha- (Retrospective; 77 patients) geal perforation after blunt neck trauma. Ann Thorac Surg. 118. Greene R, Stark P. Trauma of the larynx and trachea. Radiol 1990;50(4):615-617. (Review) Clin North Am. 1978;16(2):309. 138. Demetriades D, Theodorou D, Cornwell E 3rd, et al. Pen- 119.* McClane GE, Strack GB, Hawley D. A review of 300 at- etrating injuries of the neck in patients in stable condition. tempted strangulation cases, Part II: clinical evaluation of the Physical examination, angiography, or color flow Doppler surviving victim. J Emerg Med. 2001;21(3):311-315. (Retro- imaging. Arch Surg. 1995;130(9):971-975. (Prospective; 82 spective; 300 patients) patients) 120. Iserson KV. Strangulation: a review of ligature, manual, and postural neck compression injuries. Ann Emerg Med. 1984;13(3):179-185. (Review) CME Questions 121. Tournel G, Hubert N, Rouge C, et al. Complete autoerotic asphyxiation: suicide or accident? Am J Forensic Med Pathol. 1. Most injuries to the neck: 2001;22(2):180-183. (Case report) a. Are in Zone I 122. Kaki A, Crosby ET, Lui AC. Airway and respiratory b. Are in Zone II management following non-lethal hanging. Can J Anaesth. c. Are in Zone III 1997;44(4):445-450. (Review) d. Are blunt carotid injuries 123. Shumaker D, Kottamasu S, Preston G, et al. Acute pulmonary edema after near strangulation. Pediatr Radiol. 1988;19(1):59-60. (Case report) 2. Wounds that penetrate the platysma: 124. Balkany TJ, et al. The management of neck injuries. In: a. Always require surgical consultation Zuidema GD, Rutherford RB, Ballinger WF, eds. The Manage- b. Only require surgical consultation in cases ment of Trauma. 4th ed. Philadelphia, PA: W.B. Saunders, Co; of high-velocity injuries 1985. (Textbook chapter) c. Only require surgical consultation if the 125. Hall JR, Reyes HM, Meller JL. Penetrating zone-II neck inju- emergency physician has trouble probing ries in children. J Trauma. 1991;31(12):1614-1617. (Retrospec- past the platysma tive; 24 patients) d. Only require surgical consultation if the 126. Mutabagani KH, Beaver BL, Cooney DR, et al. Penetrat- ing neck trauma in children: a reappraisal. J Pediatr Surg. emergency physician is unable to clamp off 1995;30(2):341-344. (Retrospective; 46 children) the bleeding vessels 127. Kim MK, Buckman R, Szeremeta W. Penetrating neck trauma in children: an urban hospital’s experience. Otolaryngol Head 3. Horner’s syndrome is defined as small pupil, Neck Surg. 2000;123(4):439-443. (Retrospective; 35 children) droopy lid, and lack of ability to sweat on the 128. Strauss RH, Thompson JE, Macasaet A. Accidental stran- side of the face ipsilateral to the carotid injury. gulation by a motor vehicle window. Pediatr Emerg Care. a. True 1997;13(5):345-346. (Review, case report) b. False

34 An Evidence-Based Approach To Traumatic Emergencies 4. Esophageal injuries: 10. In stable patients with penetrating neck inju- a. Are the least common but are the most ries in Zone I, the best study to exclude injury frequently missed injuries in penetrating to intrathoracic vessels is: neck trauma a. Angiography b. Are difficult to diagnose because of their b. MRI low incidence and lack of sensitive and c. CT scanning specific clinical signs d. Carotid duplex scanning c. May often be masked by other injuries d. Must be diagnosed early, because delayed 11. Which of the following most reliably excludes operative repair results in high morbidity carotid or vertebral artery injury in blunt and mortality due to early contamination of trauma? the paraesophageal space a. No external signs of neck trauma e. All of the above b. Absence of neurologic deficits c. Absence of neck hematoma 5. In which of the following circumstances is ear- d. Angiography ly intubation of the patient with neck trauma suggested? 12. Which of the following is least likely to be as- a. Patients with acute respiratory distress or sociated with esophageal injury? airway compromise from blood or secretions a. Pain on swallowing b. Patients with gunshot wounds b. Diplopia c. Symptomatic patients who are likely to be c. Subcutaneous emphysema out of the ED for a prolonged time for d. Hemoptysis on coughing diagnostic studies d. None of the above 13. Patients with penetrating neck trauma in e. All of the above whom the platysma is intact: a. Should be admitted to the intensive care 6. Neck pain and tenderness, resistance to pas- unit sive motion of the neck, subcutaneous emphy- b. Should be admitted for observation sema, dysphagia, and bleeding from mouth or c. Should be transferred to a Level I trauma nasogastric tube most likely suggest: center a. Pneumothorax d. May be safely discharged in the absence of b. Blunt vascular injury significant associated injury c. Air embolism d. Esophageal injuries 14. Which of the following is/are indication(s) for immediate exploration of vascular injuries? 7. To control bleeding in patients with neck a. Shock trauma, emergency physicians should use di- b. Pulse deficit rect pressure. Clamping of vessels should only c. A rapidly expanding hematoma be performed by a trauma surgeon. d. All of the above a. True b. False 15. Objects that are causing penetrating neck wounds should be removed by the emergency 8. Which of the following is not a possible sign physician in the ED once the airway has been of airway injury in patients with neck trauma? established. a. Voice changes a. True b. Subcutaneous emphysema b. False c. Diplopia d. Hemoptysis 16. Which of the following can cost-effectively e. Bubbling wound help determine the need for further testing in a patient with neck trauma? 9. The location and extent of laryngeal fractures a. Having the patient cough to determine if he is most accurately identified by: or she has hemoptysis a. clinical examination. b. Having the patient swallow to check for b. laryngoscopy. dysphagia c. CT scanning. c. Listening to the patient speak to assess d. neck radiographs. laryngeal function d. Auscultating the patient’s carotid arteries for bruits e. All of the above

Neck Trauma: Don’t Put Your Neck On The Line 35 36 An Evidence-Based Approach To Traumatic Emergencies Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department

Authors Center—University of Washington Emergency Medicine Residency; Clinical Assistant Professor of Medicine, University of Washington; Adjunct Assistant Lisa Freeman, MD, FACEP Professor of Military; and Emergency Medicine, Uniformed Services Assistant Residency Director, Department of Emergency Medicine, University, Tacoma, WA University of Texas Medical School at Houston, Houston, TX

Adam Corley, MD CME Objectives Department of Emergency Medicine, University of Texas Upon completing this article, you should be able to: Medical School at Houston, Houston, TX 1. List conditions or circumstances that require orthopedic or surgical consultation or referral in patients with sports injuries. Peer Reviewers 2. Describe the appropriate treatment and disposition for common orthopedic sports injuries. Mohamud Daya, MD, MS, FACEP, FACMT, DTM&H 3. Describe clinical decision rules such as the Ottawa knee rules that are Associate Professor of Emergency Medicine, Oregon Health & Science used to determine the need for radiography. University, Portland, OR 4. Discuss different techniques for shoulder reduction.

David Della-Giustina, MD, FACEP Date of original release: April 1, 2003. LTC, U.S. Army; Emergency Medicine Consultant to the Surgeon General Date of most recent review: August 1, 2009. of the Army; Chairman and Program Director, Madigan Army Medical

Friday night, 8:50 p.m.: Paramedics radio ahead—they body parts most frequently involved are the ankles are bringing in a local high school football player who was (12.1%), fingers (9.5%), face (9.2%), head (8.2%), and tackled during a game. He can’t feel or move anything be- knees (8.1%). Overall, 2.3% of people with sports- low his waist. The news media are already at the hospital and recreation-related injuries were hospitalized asking questions. The paramedics want to know whether (see Table 1, page 38).1 they should start steroids. The on-call neurosurgeon is not This chapter describes management strategies answering his pages. for common orthopedic sports injuries. Prior issues of Emergency Medicine Practice, such as the January ports injuries present unique challenges to the 2000 issue on mild head trauma, the February 2000 Semergency clinician. From the little leaguer issue on back pain, the October 2001 issue on cervi- to the cardiac rehabilitation patient, millions of cal spine injuries, the November 2001 issue on wrist Americans participate in sports or fitness activities. injuries, and the May 2002 issue on ankle injuries, Although an athletic injury rarely requires a life- or also provide pertinent information. limb-saving intervention in the emergency department (ED), the personal impact on the player can be When I played pro football, I never set out to hurt any- monumental. Emergency clinicians must be expert body deliberately, unless it was, you know, important, like in the diagnosis and initial treatment of sports-relat- a league game or something. ed injuries. —Dick Butkus Each year in the United States, an estimated 150 million adults participate in some type of non– Critical Appraisal Of The Literature work-related physical activity, and approximately 30 million children and adolescents participate in orga- Sports medicine, which has long been more of an 1 nized sports. From July 2000 through June 2001, an art, is slowly becoming more of a science. However, estimated 4.3 million sports- and recreation-related few large, randomized, controlled trials provide injuries were treated in U.S. EDs, comprising 16% evidence for many of the treatments used for sports 1 of all unintentional injury-related ED visits. The injuries. A recent study attempted to examine the percentage was highest for those 10 to 14 years old evidence base of sports medicine research. In evalu- and lowest for those older than 45. Among all ages, ating 4 major journals that present core research 1 rates were higher for males than for females. Males in sport and exercise medicine, it was noted that are most often injured during playground activities, randomized, controlled trials comprised 10% or less cycling, football, and basketball. In girls, most inju- of all original research articles. Observational/de- ries are caused by playground activities, basketball, scriptive studies were the most commonly published 1 cycling, and general exercise. study design. When good-quality research methods The most frequent diagnoses include strains/ (randomized, controlled trials as well as case-control sprains (29.1%), fractures (20.5%), contusions/ and cohort studies) were categorized together, the abrasions (20.1%), and lacerations (13.8%). The difference between sports journals and other medical

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 37 journals was not significant (P = 0.09). This seems to Unlike the AC joint, the GH joint is designed indicate that the quality of sports medicine research for function and mobility rather than stability. The is comparable to that in other specialties.2 humeral head articulates with the shallow glenoid Well-designed clinical decision rules such as the fossa of the scapula. The 3:1 humeral-head/glenoid- Ottawa knee and ankle rules are excellent examples of surface ratio allows this joint to enjoy the greatest evidence-based medicine. Such rules begin with a deri- mobility of any joint in the body. It is especially vation set (in these cases, indications for radiography) susceptible to dislocation. later confirmed in a prospective validation study. Like the AC joint, the GH joint is stabilized by several ligaments and muscles. The subacromial Prehospital Care space is defined superiorly by the coracoacromial arch and inferiorly by the greater tuberosity of Prehospital care personnel should first ensure the humerus. This space includes the rotator cuff adequate airway, breathing, and circulation. Medics tendon, the long head of the biceps, and the subac- should splint suspected fractures before moving the romial bursa. The rotator cuff includes the supraspi- patient and straighten severely angulated fractures. natus muscle, which helps abduct the arm; the teres Emergency practitioners should confirm neurovas- minor and the infraspinatus (external rotators); and cular status in injured extremities before and after the subscapularis (internal rotator). The rotator cuff splinting. Helmets should be stabilized rather than muscle complex serves as a humeral head depressor removed in the field unless the helmet prevents con- (it lowers the head in the glenoid). trol of a bleeding site or airway management. The biceps muscle has a long head and a short head. The long head of the biceps tendon originates ED Evaluation: Shoulder Injuries at the supraglenoid tubercle, exits the GH joint, and runs distally through the bicipital groove. The short head arises from the coracoid process. The long head The shoulder is composed of 3 joints—the gle- and short head form 1 tendon distally that inserts nohumeral (GH), the acromioclavicular (AC), and the into the bicipital tubercle of the radius. The biceps sternoclavicular—and 1 articulation (the scapulotho- tendon provides flexion and supination of the elbow racic). The GH and AC joints are the most relevant joint, and the long head of the biceps acts as an ad- in the practice of sports medicine. The AC joint has a ditional depressor of the humeral head. limited range of motion and is stabilized by several ligaments and muscle attachments. (See Figure 1.)

Table 1. Sports-Related Injury Sites

Sport Injury site (most likely > less likely) Figure 1. Shoulder Anatomy Baseball and softball shoulder >> elbow/forearm, wrist, fingers > ankle, hip, back Basketball and volleyball ankle, knee >> hip/thigh > Achilles tendon, Coracoclavicular Ligament heel, thigh, foot Acromioclavicular Football knee > ankle > head, shoulder, neck > Ligament Trapezoid Ligament Conoid Ligament back, face, wrist/fingers Clavicle Hockey head/neck > ankle, knee, shoulder/arm > Acromion eye, wrist/hand Gymnastics shoulders > torso/back/hip, wrist > elbow > Humerus ankle, head/neck Roller-blading distal forearm/wrist > lower leg > elbow > Scapula knee > head Snowboarding wrist > head >> upper extremity > lower extremity Snow skiing lower extremity, leg/knee >> head >> Coracoid Process thumb, shoulder, ankle Soccer knee/ankle >> shin/foot, hip/thigh >> shoul- Coracoacromial Ligament ders, cervical spine, head Swimming shoulder > knee > elbow, head/spine (div- Schematic representation of the normal ligamentous attachments ing) between the acromion and the coracoid process of the scapula and Wrestling shoulder >> knee >> back/neck, foot/ankle, the clavicle. wrist/hand

Source: Luckstead EF Sr, Satran AL, Patel DR. Sports injury profiles, Reproduced with permission from: Harris JH Jr, Harris WH. The training and rehabilitation issues in American sports. Pediatr Clin North Radiology of Emergency Medicine. 4th ed. Philadelphia: Lippincott, Am 2002. Aug;49(4):753-767. Williams & Wilkins; 2000:304. Figure 9.

38 An Evidence-Based Approach To Traumatic Emergencies History Low-risk patients were then defined as5 As with most musculoskeletal injuries, the patient • those with no fall and no swelling history is crucial. Many shoulder injuries occur in • those with a fall but no swelling or pain at rest overhead athletic activities, such as baseball or bas- • those with a fall and pain at rest but no swelling ketball, and are chronic in nature. However, in the and normal range of motion ED, patients often present with new traumatic injuries or with extreme exacerbations of chronic conditions. Another area of contention is whether pre- and Historical factors relating to the sport—such as repeti- postreduction radiographs are required in patients tive motion, conditioning, and requirements for that with clinically obvious and likely uncomplicated an- sport—are important considerations. Knowledge terior shoulder dislocations. In 1 prospective study about the position of the arm at the time of injury, the of 97 patients with possible shoulder dislocations, degree of muscle contraction or relaxation, and the prereduction radiographs did not affect the manage- direction of momentum of the athlete help determine ment in any patients and added about 30 minutes the type and severity of the injury.3 Also note any to the treatment time.6 In a different retrospective history of previous orthopedic procedures on the study of 175 patients with shoulder dislocations, shoulder as well as any previous injury or dislocation. only 1 patient had a change in management dictated by the postreduction radiograph (a persistent 7 Physical Examination dislocation). However, the studies to date have been Examination of the shoulder should be performed small, and many believe that more data are needed with both of the shoulders completely exposed. Com- before routine x-raying in such patients is discontin- pare both sides, looking for asymmetry, bony defor- ued. One argument for a prereduction radiograph mities, and chronic muscular changes. It may help involves identification of 2-part proximal humeral to palpate the opposite shoulder to determine the fracture-dislocations. These fracture-dislocations distinctive anatomy. Palpate the bones of the affected should never be reduced in the ED, because it is pos- shoulder for tenderness, crepitus, and deformity. sible to dislocate the articular head from the humeral The rotator cuff muscles should be palpated along shaft, leading to permanent avascular necrosis. the muscle belly, tendon, and at the insertion at the It has been the standard of care to ionize patients greater tuberosity. Evaluate the AC joint for tender- with a presumed shoulder dislocation twice—to ness and asymmetry. The entire clavicle should also confirm the dislocation and rule out a fracture, as be examined. Note the active and passive ranges of well as to obtain a postreduction radiograph to motion of both the normal and affected shoulder. confirm relocation and ensure no fracture resulted A detailed neurovascular examination is very im- from the reduction. As alluded to in the previous portant with all shoulder injuries but especially with paragraph, the debate continues about the necessity a proximal humerus fracture because of the proxim- of pre- and postreduction radiographs. Although the ity of the brachial plexus, axillary nerve, and vascu- data accumulated to date seems to obviate the need lature. The axillary nerve supplies motor branches for 2 radiographs, studies continue to be small and to the deltoid and teres minor and sensory fibers to lack the desired power to change practice. the skin that overlies the lateral aspect of the upper A 2007 article in the Journal of Emergency Medi- arm. (Note: The “regiment’s band,” or upper lateral cine discussed examining postreduction radiographs cutaneous nerve of the arm, is the more precise term to determine what information is added. In 40 for this sensory portion of the axillary nerve.) The tip patients with 16 total fractures, 37.5% of the frac- of the shoulder is actually innervated by the supra- tures were seen only on postreduction radiographs, clavicular nerve. Test and document both, especially with the vast majority of the missed fractures being 8 with a suspected shoulder dislocation. Hill-Sachs or Bankhard fractures. Postreduction radiographs confirmed all the reductions. Thus, Diagnostic Testing sparing the patient from a postreduction radiograph An optimal shoulder series includes 3 views: a true will miss slightly more than one-third of the frac- anterior-posterior (AP) (which unlike the standard tures associated with anterior shoulder dislocations; AP projects the GH joint without bony overlap), however, none of these are significant fractures that transscapular lateral, and axillary lateral.4 Scapu- would change ED management. lar views can be obtained if there is suspicion of a We can conclude that all significant shoulder scapular fracture. fractures will be seen on prereduction radiographs, Which patients with a shoulder injury require clinicians do not need postreduction x-rays to con- radiographs? One prospective study of 206 patients firm relocation, and reduction-caused fractures are with shoulder pain obtained radiographs on all rare and clinically insignificant if they do occur. We patients, and 88% of the radiographs were deemed hope this will encourage emergency physicians to therapeutically uninformative. avoid postreduction radiographs and shorten the ED visit for the patient.

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 39 Clavicle Fracture to the humerus, such as a fall onto an outstretched, Clavicle fractures account for 5% of all fractures and abducted arm. Symptoms of a proximal humerus result from a direct blow to the clavicle or a fall on fracture include pain, inability to move the arm, pain an outstretched arm.4 The proximal fragment may with passive range of motion, deformity, swelling, be displaced upward by the action of the sterno- and discoloration. Once identified radiographically, cleidomastoid, and deformity and crepitus may be further studies are generally not indicated. palpable over the fracture site. Some experts main- The majority of simple, nondisplaced proximal tain that all patients with pain, deformity, or crepitus humerus fractures can be treated conservatively require a chest radiograph, as some reports note with ED immobilization and referral. (Some simple, that routine clavicle radiographs may miss fractures nondisplaced fractures can be managed by a pri- owing to the overlap of surrounding structures. The mary care physician.) More than 80% of all proximal literature, however, provides no strong studies that humerus fractures are nondisplaced and can be 4 prove the best approach to radiography. Although immobilized in a sling and swathe. Comminuted or pneumothorax is a rare complication of clavicle frac- multipart fractures usually require open reduction ture, a lung examination and a careful assessment of and internal fixation. Complications from a proximal the x-ray for pneumothoraces are necessary.9 humerus fracture include avascular necrosis of the Fractures of the middle third of the clavicle humeral head, brachial plexus injury, frozen shoul- 13 account for approximately 80% of all clavicular der syndrome (adhesive capsulitis), and nonunion. fractures and should be treated with shoulder sling It seems that ultrasonography is plunging into immobilization and pain control.10 Until the late every field of medicine, with orthopedics being no 1980s, the figure-of-eight clavicle strap was used exception. Investigators have proven ultrasonogra- to immobilize all middle-third clavicle fractures. phy’s efficiency at evaluating patients with orthope- The more comfortable simple sling has generally dic fractures. The U.S. military published a study in replaced this figure-of-eight strap, as randomized, 2008 that assessed the accuracy of ultrasonography controlled clinical trials show equivalent outcomes.11 versus x-ray to determine the success of fracture The patient should be referred to an orthopedist or reduction. Ultrasonography accurately visualized 5 14 family physician experienced with these fractures. out of 5 successful reductions of hand fractures. Distal clavicle fractures often produce minimal Although small, this study offers the possibility deformity and may be confused with AC joint injury that soon malalignment will be seen before the cast Some types of distal clavicle fractures may require has even set or patients will be discharged quicker operative repair, so early referral to an orthopedist is with 1 less x-ray taken. If either becomes routine, this useful. Proximal clavicle fractures are the least com- new imaging capability will have obvious applicabil- mon and are difficult to diagnose because of bony ity and beneficial effects on emergency medicine. overlap. Treatment is usually conservative.12 Emergency clinicians were the major players in Open clavicle fractures, posterior sternoclavicu- another, larger study published in 2009, where they lar dislocations, and fractures associated with a sonographed patients, assessing for the presence of pneumothorax require urgent orthopedic and surgi- orthopedic fractures. Ultrasonography yielded an cal consultation. overall sensitivity of 100% and a specificity of 94% for diagnosing fractures.15 Glenoid Fractures Although these studies were conducted to facili- The classic mechanism of injury for a glenoid frac- tate ultrasonography use in combat zones or remote ture involves falling onto the point of the shoulder regions, it seems a very natural progression into EDs, with the arm adducted. An anterior shoulder dislo- even though the x-ray machine is down the hallway. cation may also fracture the glenoid (the so-called Bankart’s fracture). Symptoms of a glenoid frac- AC Separation ture include pain, decreased range of motion, and, The AC joint is often injured by a fall onto the occasionally, deformity. Glenoid fractures may be outstretched hand or onto the point of the shoulder, associated with other injuries, such as rib fractures, one of the most common injuries among bicyclists. pneumothorax, GH or AC shoulder dislocation, and Symptoms include point tenderness on or around nerve or tendon injury. the joint, pain with movement (especially adduc- All glenoid fractures require urgent orthopedic tion), swelling, deformity, and discoloration. consultation. In most cases, a CT scan of the shoul- Although there is a 6-stage classification system der is also necessary for treatment decisions (the of AC joint separation, most emergency clinicians timing of which may be deferred to the consultant). are familiar with the 3-grade system. (See Figure 2.) Severity of injury may range from strains of the liga- Proximal Humerus Fractures mentous complex with tenderness over the AC joint and normal radiograph findings to joint dislocation Athletes may suffer a proximal humerus fracture 4 when a significant amount of force is transmitted and clavicle displacement.

40 An Evidence-Based Approach To Traumatic Emergencies approximately 80% of all clavicular fractures and should be Symptoms of a proximal humerus fracture include treated withAll shoulder suspected sling immobilizationinjuries to the andAC painjoint should be pain, inabilityrotation to andmove abduction. the arm, pain There with is passive often rangea prominent of 9 control.x-rayed Until the to late exclude 1980s, athe distal figure-of-eight clavicle fracture. clavicle Special motion,acromion deformity, and swelling, depression and discoloration. of the area Once normally occu- strap wasAC used views to immobilizeare best, as all standard middle-third AP clavicleand axillary later- identifiedpied radiographically, by the humeral further head, studies leading are generallyto a “squared off” fractures.al viewsThe more of thecomfortable shoulder simple rotate sling the has AC generally joint. Studies not indicated.deformity to the arm. replacedindicate this figure-of-eight that stress strapradiography as randomized, views controlled are low-yield The majorityThe axillary of simple, nerve non-displaced supplies sensation proximal to the skin 11 clinicaland trials therefore show equivalent are generally outcomes. unnecessary. The patient16 humerusthat fractures overlies can the be lateraltreated aspectconservatively of the shoulder with ED and should be referredED management to an orthopedist is conservative or family physician regardless of immobilizationmotor innervation and referral. to (Some the deltoid simple, non-displacedand teres minor experiencedgrade with of injury. these fractures. Minor injuries can be treated with fracturesmuscle. can be Assessmanaged and by documenta primary care the physician.) status of the Distalsling clavicle immobilization, fractures often nonsteroidal produce minimal anti-inflam- More thanaxillary 80% ofnerve all proximal before andhumerus after fractures reduction, are asnon- axil- 4 deformitymatory and may drugs be confused(NSAIDs), with ice, AC and joint relatively pathology. early displacedlary and nerve can beinjury immobilized is seen in in 5%a sling to 54% and swathe.of patients.19 Some typesmobilization. of distal clavicle Grade fractures III injuries may require operative outpatient ComminutedFortunately, or multi-part nerve fracturesfunction usually usually require returns open with time. repair, orthopedicso early referral referral to an orthopedistand may benefit is useful. from operative reductionAthletes and internal who sustain fixation. injury to the axillary nerve Proximalintervention clavicle in fractures selected are patients. the least common and Complicationshave variable from prognosis a proximal for humerus recovery, fracture although return are difficult to diagnose because of bony overlap. Treatment includeof avascular function necrosis is typically of the good humeral to excellent.head, brachial20 Other 10 is usuallyGH conservative. Dislocations plexus neurovascularinjury, frozen shoulder injuries syndrome include (adhesivedamage to the brachial Open clavicle fractures, posterior sternoclavicular capsulitis), and non-union.12 More than half of all dislocations treated by the plexus, radial nerve, and axillary artery. The most dislocations, and fractures associated with a pneumothorax emergency clinician involve the GH joint. The GH common bony deformity is a Hill-Sach’s lesion; this require urgent orthopedic and surgical consultation. Acromioclavicular Separation joint may dislocate anteriorly, posteriorly, inferiorly, involves indentation of the humeral head by the in- The AC joint is often injured by a fall onto the outstretched or superiorly. Anterior dislocations account for more ferior glenoid or the coracoid process. Fracture of the Glenoid Fractures hand or onto the point of the shoulder and is one of than 95% of all shoulder dislocations.17 They are greater tuberosity is also possible, and disruption of The classic mechanism of injury for a glenoid fracture the most common injuries in bicyclists. Symptoms exceedingly common in contact sports, such as foot- the rotator cuff can occur with inferior GH shoulder involves falling onto the point of the shoulder with the arm include point tenderness on or around the joint, pain ball, rugby, lacrosse, and wrestling. Posterior dislo- dislocations, especially in those older than age 40. adducted. An anterior shoulder dislocation may also with movement (especially adduction), swelling, cations are rare and usually result from a seizure or The incidence of nerve damage following shoul- fracture the glenoid (the so-called Bankart’s fracture). deformity, and discoloration. electrical injury.18 der dislocation or humeral neck fracture remains un- Symptoms of a glenoid fracture include pain, decreased While there is a six-stage classification system of AC When the humeral head dissociates anteriorly certain. In a study enlisting 101 patients with these range of motion, and occasionally deformity. Glenoid joint separation, most physicians are familiar with the three- from the glenoid fossa, it can rest under the inferior injuries, 45% demonstrated electrophysiological fractures may be associated with other injuries such as rib grade system. (See Figure21 2.) Severity of injury may range rim of the glenoid, beneath the coracoid process, nerve damage. The prevalence was much higher fractures, pneumothorax, GH or AC shoulder dislocation, from strains of the ligamentous complex with tenderness and, less commonly, in an intrathoracic or subclavic- when the patients were older or when they also and nerve or tendon injury. over the AC joint and normal radiographs, to joint disloca- ular fashion. (See Figure 3, page 42.) The mecha- sustained a hematoma. Most had partial or complete All glenoid fractures require urgent orthopedic tion and clavicle displacement.4 nism of injury for anterior dislocation is commonly recovery of nerve function within 4 months, and consultation. In most cases, a CT scan of the shoulder is also All suspected injuries to the AC joint should be x-rayed abduction, extension, and external rotation. (Think only 8 had residual motor loss. Nerve function dete- necessary for treatment decisions (the timing of which may to exclude a distal clavicle fracture. Special AC views are of a football quarterback about to pass downfield riorates unless early detection is made that facilitates be deferred to the consultant). best, as standard AP and axillary lateral views of the who gets struck in the arm before starting the power appropriate treatment. The study notes that the shoulder rotate the AC joint. Studies indicate that stress portion of the throw.) highest injury loss was seen in axillary nerves (37%) Proximal Humerus Fractures radiography views are low yield and therefore are Patients complain of exquisite pain around the followed by suprascapular nerves (29%) and radial Athletes may suffer a proximal humerus fracture when a generally unnecessary.13 shoulder, and the shoulder is often held in external nerves (22%). significant amount of force is transmitted to the humerus, ED management is conservative regardless of grade of such as a fall onto an outstretched, abducted arm. injury. Minor injuries can be treated with sling immobiliza-

Figure 2. Acromioclavicular Separation Types Figure 2. Acromioclavicular separation types.

Type I Type I Type I (a) (b) (c) • Type I (a): Ligamentous strain—no deformity, but tenderness of AC joint • Type• IIType (b): IRupture (a): Ligamentous of acromioclavicular strain—no deformity, ligament but tenderness—can of have AC joint slight deformity on physical examination • Type• IIIType (c): IIRupture (b): Rupture of ofboth acromioclavicular acromioclavicular ligament—can and coricoclavicularhave slight deformity ligament on physical— examinationsignificant deformity on physical examination,• Type III (c): bottom Rupture of of clavicleboth acromioclavicular at or above and top coricoclavicular of acromion ligament—significant on x-ray deformity on physical examination, bottom of clavicle at or above top of acromion on x-ray Reproduced with permission from: Harries M, Williams C, Stanish WD, et al, eds. Oxford Textbook of Sports Medicine. New York: Oxford University Press; 1996:454.Reproduced Figure 1. with permission from: Harries M, Williams C, Stanish WD, et al, eds. Oxford Textbook of Sports Medicine. New York: Oxford University Press; 1996:454. Figure 1. Emergency Medicine Practice 4 www.empractice.net • April 2003 Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 41 The electromyogram studies revealed that all bulb” appearance to the humeral head because the of the lesions were due to axonal loss. The finding shoulder is internally rotated.4 that hematomas increase the odds of nerve damage Inferior GH dislocation, also known as luxatio indicates the higher level of trauma to the neuro- erecta, is rare but striking in its presentation. The vascular bundle in these patients. The study also classic presentation is an arm that is hyperabducted reported that sensation loss did not have diagnostic and locked above the head. The mechanism of significance, as motor lesions were not necessar- injury is hyperabduction of the humerus, which ily associated with sensory loss. Thus, patients for then impinges on the acromion, causing a tear in the whom clinical assessment is difficult because of pain inferior GH capsule with disruption of the rotator should be referred for electrophysiological evalua- cuff. Rarely, a violent force directly applied to the tion to dictate early treatment. Practitioners should shoulder from above can produce this injury.22 be highly suspicious of a nerve injury, because such Obviously, all dislocations of the GH joint a large percentage of patients develop this and early require reduction. There are several common and recognition is necessary to prevent residual neuro- accepted methods of reducing GH shoulder dislo- logical deficits. cations. The vast majority of anterior dislocations tion, non-steroidal anti-inflammatory drugs (NSAIDs), ice, PosteriorPosterior shoulder shoulder dislocations dislocations comprise comprise only 2% of all can be reduced by the emergency clinician without 18 and relatively early mobilization. Grade III injuries require GHonly dislocations 2% of all andGH are dislocations frequently missed.and are Thefrequently injury may orthopedic consultation. Although previous doctrine outpatient orthopedic referral and may benefit from occurmissed. after22 a The fall ontoinjury an mayoutstretched occur after hand awith fall theonto arm an in held that patients generally required conscious seda- operative intervention in selected cases. flexion,outstretched adduction, hand and with internal the rotationarm in orflexion, from a directadduc- tion before reduction attempts, new research indi- 4 blowtion, to and the internalanterior shoulder. rotation Onor fromexamination, a direct abduction blow to is cates that this may not be necessary. Glenohumeral Dislocations severelythe anterior limited shoulder. and external4 On rotation examination, is blocked. abduction The Several studies show that intraarticular lido- More than half of all dislocations treated by the emergency shoulderis severely has alimited flattened, and squared-off external appearancerotation is withblocked. a caine is an acceptable alternative to conscious seda- physician involve the GH joint. The GH joint may dislocate prominentThe shoulder coracoid has process. a flattened, The humeral squared-off head may appear be - tion. Reduction success rates are statistically similar 4 anteriorly, posteriorly, inferiorly, or superiorly. Anterior palpatedance with posteriorly. a prominent Standard coracoid radiographs process. may appear The hu- in the conscious sedation and intraarticular lidocaine dislocations account for more than 95% of all shoulder deceptivelymeral head normal. may However, be palpated there posteriorly.are some signs4 Standard that can be groups.23 Intraarticular lidocaine is similarly effec- 14 dislocations. They are exceedingly common in contact helpfulradiograph when present.results Themay “ rimappear sign ”deceptively refers to the increasednormal. tive in facilitating reduction and reducing pain but sports like football, rugby, lacrosse, and wrestling. Posterior distanceHowever, between there the are anterior some signsglenoid that rim can and bethe helpful articular significantly shortens ED stays and reduces costs dislocations are rare and usually result from a seizure or surfacewhen ofpresent. the humeral The “rimhead onsign” a true refers AP view. to the There increased may significantly.24,25 The procedure of intraarticular 15 electrical injury. bedistance a loss of betweenthe elliptical the overlap anterior of theglenoid humeral rim head and and the analgesia begins with prepping the shoulder with When the humeral head dissociates anteriorly from the thearticular glenoid surface fossa or ofa “ light-bulbthe humeral” appearance head on to a thetrue AP povidone-iodine. Inject 20 mL of 1% lidocaine via a 4 glenoid fossa, it can rest under the inferior rim of the humeralview. There head becausemay be the a loss shoulder of the is ellipticalinternally overlaprotated. of long 20-gauge needle from just off the lateral edge of glenoid, beneath the coracoid process, and, less commonly, the Inferiorhumeral GH head dislocation, and the also glenoid known fossa as luxatio or a erecta,“light is the acromion.25 Certain methods of reduction (such in an intrathoracic or subclavicular fashion. (See Figure 3.) rare but striking in its presentation. The classic presentation as scapular manipulation) require neither conscious The mechanism of injury for anterior dislocation is com- is an arm that is hyperabducted and locked above the head. sedation nor local anesthetics. monly abduction, extension, and external rotation. (Think Mechanism of injury is hyperabduction of the humerus, An Emergency Medicine 2007 study attempts to of a football quarterback about to pass downfield who Figure 3. Types of Anterior Glenohumeral put the intraarticular lidocaine versus conscious seda- gets struck in the arm before he starts the power portion tion debate to rest by conducting a nonblind, ran- FigureDislocations 3. Types of anterior glenohumeral dislocations. of his throw.) domized clinical trial. Moharari initiated the project Patients complain of exquisite pain around the because of the conflicting literature on whether lido- shoulder, and the shoulder is often held in external rotation caine offers the same pain relief as the intravenously and abduction. There is often a prominent acromion and injected narcotics and benzodiazepines. Prior studies depression of the area normally occupied by the humeral championing intraarticular injection highlight that the head, leading to a “squared off” deformity to the arm. A B reduction was comparatively easier. Moharari’s study, The axillary nerve supplies sensation to the skin that which enrolled 48 patients, revealed that lidocaine of- overlies the lateral aspect of the shoulder, and motor fered the same pain relief as intravenous meperidine innervation to the deltoid and teres minor muscle. Assess and diazepam and resulted in fewer complications.26 and document the status of the axillary nerve before and The drawback is lidocaine needs 15 minutes to after reduction, as axillary nerve injury is seen in 5%-54% of take full effect, lengthening the duration of the pro- 16 patients. Fortunately, nerve function usually returns with cedure. Intraarticular infection is another rare event time. Athletes who sustain injury to the axillary nerve have reported following lidocaine injections, but this variable prognosis for recovery, though return of function is C D study reported no such event. Although the reduc- 17 typically good to excellent. Other neurovascular injuries tion process took slightly longer with the lidocaine, include damage to the brachial plexus, radial nerve, and the recovery period and time spent in the ED were axillary artery. The most common bony deformity is a Hill- considerably less. Fifty-eight percent of the intrave- Sach’s lesion. This involves indentation of the humeral head A: subarachnoid; B: subglenoid; C: subclavicular; D: intrathoracic.A: subcoracoid; B: subglenoid; C: subclavicular; D: intrathoracic. nous group experienced complications as opposed by the inferior glenoid or the coracoid process. Fracture of to 13% in the intraarticular group. The complications the greater tuberosity is also possible, and disruption of the ReproducedReproduced with with permissionpermission from: Marx JA, Hockberger Hockberger RS,RS, Walls Walls RH, in descending order of frequency were drowsiness, rotator cuff can occur with inferior GH shoulder disloca- etRH, al. eds.et al. Rosen eds. ’sRosen’s Emergency Emergency Medicine Medicine.. 5th ed. St. 5th Louis: ed. St.Mosby; Louis: Mos- respiratory depression, hypotension, headache, nau- tions, especially in those over the age of 40. 2002:593.by; 2002:593. Figure Figure 46-26. 46-26. With permissionWith permission from fromElsevier Elsevier Science. Science. sea, and localized parathesias. Importantly, 5 people

42 General Treatment Principles For MusculoskeletalAn Evidence-Based Injuries Approach To Traumatic Emergencies

The RICE regimen (rest, ice, compression, and elevation) is outcome.93 The target temperature reduction is 10ºC-15ºC. generally recommended for patients with orthopedic sports Using repeated rather than continuous ice applications helps injuries. Analgesia—usually NSAIDs—may also be sustain reduced muscle temperatures without compromising appropriate depending on the circumstances. the skin. There are no large, randomized studies to help the A systematic literature review suggests that melted ice physician decide how often and how long to use ice.94 water applied through a wet towel for 10-minute intervals is Heat is generally not recommended for acute injury, but most effective in lowering the temperature of the underlying it has theoretical benefit. No large, controlled trials of heat structures, but there is no proof that this affects clinical therapy for acute injury were found in one MEDLINE search.93

April 2003 • www.empractice.net 5 Emergency Medicine Practice inwhich the conscious then impinges sedation on the group acromion required causing bag-valve- a tear in the andpound senior weight staff. is attachedAdditionally, to the extremitythey found and that allowed 73% to which then impinges on the acromion causing a tear in the pound weight is attached to the extremity and allowed to maskinferior ventilation GH capsule because with disruption of respiratory of the rotator depression. cuff. ofhang. patients As the who muscles underwent relax, the shoulder shoulder reductionwill auto-reduce with in inferior GH capsule with disruption of the rotator cuff. hang. As the muscles relax, the shoulder will auto-reduce in Rarely,The atraction-countertraction violent force directly applied method to the of shouldershoulder from thisabout technique 20 minutes. did22 not(See requireFigure 5 .)any sedation.28 Rarely, a violent force directly applied to the shoulder from about 20 minutes.22 (See Figure 5.) reductionabove can involves produce this an assistantinjury.18 who holds a sheet ScapularThe external manipulation rotation method involves involves having gently the and patient slowly above can produce this injury.18 The external rotation method involves gently and slowly placedObviously, around the all dislocations torso in the of axilla the GH and joint the require emer- lieexternally prone with rotating the theaffected shoulder arm and hanging flexing theoff shoulderthe bed to Obviously, all dislocations of the GH joint require externally rotating the shoulder and flexing the shoulder to gencyreduction. clinician There placing are several traction common on andthe acceptedaffected methodslimb. or90 havingº. This will the reposition patient sit the up humeral while headan assistant about the ap glenoid- reduction. There are several common and accepted methods 90º. This will reposition the humeral head about the glenoid Thisof reducing can dislodge GH shoulder the humeral dislocations. head The from vast its majority resting of pliesor coracoid forward and traction generally to effectthe arm. reduction. The emergency An alternative cli- of reducing GH shoulder dislocations. The vast majority of or coracoid and generally effect reduction. An alternative positionanterior underdislocations the glenoid can be reduced or coracoid. by the emergencyQuite a lot niciantechnique uses involves one hand adducting to rotate the the shoulder inferior so thetip patientof the ’s anterior dislocations can be reduced by the emergency technique involves adducting the shoulder so the patient’s ofphysician traction withoutis generally orthopedic required consultation. to overpower Though the scapulaelbow is medially against his while or her stabilizing chest wall, thenthe superior slowly externally and physician without orthopedic consultation. Though elbow is against his or her chest wall, then slowly externally musclesprevious and doctrine tendons held thatthat patientsare maintaining generally requiredthe dislo- medialrotating edges the arm with completely. the other The hand. Milch ( Seetechnique Figure is similar 6, p. to previous doctrine held that patients generally required rotating the arm completely. The Milch technique is similar to catedconscious position. sedation (See prior Figure to reduction 4.) attempts, new 44.external)4 Unlike rotation, the other but it techniques,involves hyperabduction scapular manipu first, then- conscious sedation prior to reduction attempts, new external rotation, but it involves hyperabduction first, then researchThe Stimson indicates method that this involves may not placingbe necessary. the patientSeveral lationexternal attempts rotation to when reposition the arm theis fully glenoid hyper-abducted, fossa rather as if research indicates that this may not be necessary. Several external rotation when the arm is fully hyper-abducted, as if pronestudies with show the that dislocated intraarticular limb lidocaine hanging is anoff acceptable a stretch- than“picking the humeral an apple fromhead. a Studiestree.” One show study that indicated the proce that the- studies show that intraarticular lidocaine is an acceptable “picking an apple from a tree.” One study indicated that the er.alternative A 10-pound to conscious (4.5 kg) sedation. weight isReduction attached success to the rates dureMilch is techniquesimple, and was the easy reduction to employ isand accomplished had equal success in alternative to conscious sedation. Reduction success rates Milch technique was easy to employ and had equal success extremityare statistically and allowed similar in to the hang. conscious As the sedation muscles and relax, lessrates than when a minute used by inboth most junior cases. and Thissenior technique staff. Addition- may are statistically similar in the conscious sedation and rates when used by both junior and senior staff. Addition- theintraarticular shoulder willlidocaine autoreduce groups.19 in Intraarticular about 20 minutes. lidocaine is alsoally, reduce they found the needthat 73% for of premedication. patients who underwent McNamara intraarticular lidocaine groups.19 Intraarticular lidocaine is ally, they found that 73% of patients who underwent (Seesimilarly Figure effective 5.)27 in facilitating reduction and reducing demonstratedshoulder reduction that withno premedication this technique did was not needed require in similarly effective in facilitating reduction and reducing shoulder reduction with this technique did not require painThe but external significantly rotation shortens method ED involvesstays and gentlyreduces and costs 64%any of sedation. patients23 whose shoulders were reduced with pain but significantly shortens ED stays and reduces costs any sedation.23 slowlysignificantly. externally20,21 The rotating procedure the of shoulder intraarticular and analgesia flexing this technique.Scapular manipulation29 involves having the patient lie significantly.20,21 The procedure of intraarticular analgesia Scapular manipulation involves having the patient lie thebegins shoulder with prepping to 90°. This the shoulder will reposition with povidone-iodine. the humeral proneA recently with affected introduced arm hanging technique off the forbed theor having reduc thebegins with prepping the shoulder with povidone-iodine. prone with affected arm hanging off the bed or having the headInject about 20 mL the of 1%glenoid lidocaine or coracoidvia a long and20-gauge generally needle, tionpatient of anterior sit up while shoulder an assistant dislocations applies forward is the Spaso traction to Inject 20 mL of 1% lidocaine via a long 20-gauge needle, patient sit up while an assistant applies forward traction to causefrom reduction.just off the lateral An alternative edge of the techniqueacromion.21 involvesCertain technique.the arm. The30 To physician perform uses this one reduction, hand to rotate place the the inferior pa- from just off the lateral edge of the acromion.21 Certain the arm. The physician uses one hand to rotate the inferior adductingmethods of the reduction shoulder (such so as the scapular patient’s manipulation) elbow is tienttip of in the the scapula prone medially position while and stabilizinggently grasp the superiorthe wrist methods of reduction (such as scapular manipulation) tip of the scapula medially while stabilizing the superior againstrequire his neither or her conscious chest wall sedation then nor slowly local anesthetics. externally onand the medial affected edges side. with The the limbother shouldhand.4 (See gently Figure and 6 on require neither conscious sedation nor local anesthetics. and medial edges with the other hand.4 (See Figure 6 on rotatingThe the traction-counter-traction arm completely. method of shoulder reduc- slowlypage 7.) be Unlike elevated the other until techniques, it is vertical, scapular then manipulationtraction The traction-counter-traction method of shoulder reduc- page 7.) Unlike the other techniques, scapular manipulation tionThe involves Milch an technique assistant iswho similar holds toa sheet external placed rota around- shouldattempts be to applied. reposition While the glenoid maintaining fossa rather traction, than the the tion involves an assistant who holds a sheet placed around attempts to reposition the glenoid fossa rather than the tion,the torsobut it in involves the axilla hyperabductionand the physician placingfirst, then traction exter on- shoulderhumeral shouldhead. Studies be gently show externallythat the procedure rotated. is simpleIt may the torso in the axilla and the physician placing traction on humeral head. Studies show that the procedure is simple nalthe rotation affected whenlimb. This the can arm dislodge is fully the hyperabducted, humeral head from as beand necessary the reduction to palpate is accomplished the humeral in less head than anda minute gently in the affected limb. This can dislodge the humeral head from and the reduction is accomplished in less than a minute in if its“picking resting position an apple under from the a glenoidtree.” One or coracoid. study indicat Quite a- lot nudgemost cases. it into This the technique glenoid mayfossa. also A reducerecent thearticle need for its resting position under the glenoid or coracoid. Quite a lot most cases. This technique may also reduce the need for edof that traction the isMilch generally technique required was to overpower easy to employ the muscles and indicatedpremedication. that this McNamara technique demonstrated is highly effectivethat no pre- in of traction is generally required to overpower the muscles premedication. McNamara demonstrated that no pre- hadand equal tendons success that are rates maintaining when used the dislocated by both juniorposition. reducingmedication anterior was needed shoulder in 64% dislocations of patients who and were (in their and tendons that are maintaining the dislocated position. medication was needed in 64% of patients who were (See Figure 4.) study)reduced induced with this no technique. complications.24 30 (See Figure 4.) reduced with this technique.24 The Stimson method involves placing the patient prone A recently introduced technique for the reduction of The Stimson method involves placing the patient prone A recently introduced technique for the reduction of 25 with the dislocated limb hanging off of a stretcher. A 10- anterior shoulder dislocations is the Spaso technique25. To Figurewith the dislocated4. The Traction-Countertraction limb hanging off of a stretcher. A 10- anterior shoulder dislocations is the Spaso technique. To Reduction Figure 5. The Stimson Maneuver FigureFigure 4 .4 The. The traction-counter-traction traction-counter-traction reduction. reduction. FigureFigure 5 .5 The. The Stimson Stimson maneuver. maneuver.

ThisThis is is the the safest safest and and most most effective effective method method of of The patient lies prone with a weight attached to the wrist. The tech- Thisreducingreducing is the safest an an anterior andanterior most dislocation.effective dislocation. method If If anof an reducing assistant assistant an anterioris is TheThe patient patient lies lies prone prone with with a aweight weight attached attached to to the the nique is easy to perform and comfortable for the patient. However, it is dislocation.unavailableunavailable If an to assistantto apply apply iscounter-traction, counter-traction,unavailable to apply the counter-traction, the sheet sheet around around the wrist.wrist. The The technique technique is is easy easy to to perform perform and and comfortable comfortable time-consuming. sheetthethe patient around patient the’s ’sbody patient’s body can can body be be can attached attached be attached to to theto the the stretcher. stretcher.stretcher. forfor the the patient. patient. However, However, it itis is time-consuming. time-consuming. Reproduced with permission from: Harries M, Williams C, Stanish WD, ReproducedReproduced with with permission permission from: from: Harries Harries M, M,Williams Williams C, C,Stanish Stanish WD, ReproducedReproduced with with permission permission from: from: Harries Harries M, M, Williams Williams C, C, Stanish WD, Reproduced with permission from: Harries M, Williams C, Stanish WD, et al, eds. Oxford Textbook of Sports Medicine. New York: Oxford WD,et al,et eds.al, eds. Oxford Oxford Textbook Textbook of Sports of Sports Medicine. Medicine. New York:New OxfordYork: Oxford WD,et al, et eds. al, Oxfordeds. Oxford Textbook Textbook of Sports of Sports Medicine. Medicine. New York: New Oxford York: Oxford et al, eds. Oxford Textbook of Sports Medicine. New York: Oxford University Press; 1996:429. Figure 12. UniversityUniversity Press; Press; 1996:429. 1996:429. Figure Figure 11. 11. UniversityUniversity Press; Press; 1996:429. FigureFigure 12.12. University Press; 1996:429. Figure 11.

EmergencyEmergencyOrthopedic Medicine Medicine Practice Practice Sports Injuries: Off The Sidelines66 And Into The Emergencywww.empractice.netwww.empractice.net Department • April• April 2003 200343 perform Reduction this reduction, of posterior place the patient dislocations in the prone involves athlete.cant Participants in competitive in tennis, sports basketball, but also volleyball, applicable and to the positionaxial andtraction gently with grasp pressure the wrist on on thethe affectedhumeral side. head The and baseballweekend frequently warrior. experience rotator cuff injuries. limbslow should external gently rotation. and slowly Reduction be elevated of until luxatio it is vertical; erecta is AcuteThe injury current of the literature rotator cuff is stillis marked in conflict by a sudden about then,accomplished traction should via be traction applied. Whileapplied maintaining in an upward traction, and tearingwhether sensation certain in the maneuvers shoulder followed decrease by thesevere rate pain of theoutward shoulder shoulddirection be gently on the externally extended rotated. arm and It may counter be - radiatingrecurrence. to the arm.Cadaveric The pain and is often clinical poorly studies localized have but necessarytraction to appliedpalpate the across humeral the headtop of and the gently shoulder nudge and it mayproven be present that at there the insertion are lower of the recurrence rotator cuff rates tendon, when intochest the glenoid wall in fossa. the oppositeA recent article direction. indicated22 Orthopedic that this alongthe the shoulder mid-substances is immobilized of the rotator in external cuff muscles, rotation. or may32 techniqueconsultation is highly may effective be helpful. in reducing anterior shoulder radiateBut upthose to the results, neck or like down other to the nonsurgical arm. Subjective methods, dislocations It is andvery (in important their study) to induced reassess no thecomplications. shoulder 25 weaknesswere not of the reproducible shoulder muscles in other as well studies. as history There of also examinationReduction of posteriorfollowing dislocations successful involves reduction, axial as it is recurrentcontinues dislocations to be no may consensus be present. regarding An acute tearthe ofduration the tractionpossible with topressure injure on the the axillary humeral nerve head and or fractureslow the rotatorof sling cuff isimmobilization uncommon. Neer that proposed is necessary that 95% to of prevent externalhumerus, rotation. glenoid, Reduction or otherof luxatio bony erecta structure. is accom- Teens rotatoror reduce cuff tears repeated are related shoulder to chronic dislocations. impingement of the plishedand viayoung traction adults applied who in dislocatean upward their and outward shoulder rotator cuffA 2007 between study the analyzing humeral head the managementand the of directionhave aon recurrence the extended rate arm of and 79% countertraction to 100% and applied must coracoacromialshoulder dislocations arch.97 It can found result fromthat thefalling duration on an of acrossreceive the top orthopedic of the shoulder follow-up. and chest27 wallPatients in the should opposite outstretchedimmobilization arm. Typically, had no tears impact are chronicon the rateand resultof recur- direction.also receive18 Orthopedic appropriate consultation analgesia may be and helpful. sling immo- fromrence. progressive33 It also degeneration. revealed that27 the younger the patient bilizationIt is very important for 2 or 3 to weeks. reassess31 the The shoulder duration examina- of sling onLitaker a first-time et al identified dislocation, three componentsthe higher theof the likelihood physical tionimmobilization following successful varies, reduction, but concerns as it is possible over frozento injure examinationof a recurrence. that can Patients identify rotatorwho were cuff tears.between These 14 and theshoulder axillary nerve have or reducedfracture the the humerus, length glenoid,in recent or years. other include20 years supra- of andage infraspinatuswhen they first atrophy, suffered weakness a dislocation with bonyFor structure. most patients, 2 weeks followed by a rehabilita- elevationhad an or 89% external chance rotation of recurrence, of the shoulder, whereas and the patients tionTeens program and young is suggested. adults who dislocate their shoulder impingementwhose first-time sign.28 Impingement dislocation refersoccurred to inflammatory when they were have a recurrenceThe debate rate continues of 79%-100% about and mustwhether receive the changesbetween due to21 repetitive and 30 years compression of age had of the a recurrencerotator cuff rate orthopedicmanagement follow-up. of shoulder22 Patients shoulddislocation also receive should be andof associated 70%. When structures a first-time between dislocation the humeral occurred head and in a appropriatechanged. analgesia Historically, and sling patients immobilization with shoulder for two or coracoacromialpatient older arch. than27 The 30, Neerthe rate’s impingement dropped dramatically, test threedislocations weeks.26 The were duration immobilized of sling immobilization with a sling varies and involvesto 30% moving to 40%. the Interestingly, patient’s straightened men had arm a 57% to full rate of butunderwent concerns over physical frozen shoulder therapy. have However, reduced thethis length treat- abduction.recurrence The comparedHawkins’ impingement with women, test at involves 42%. in recentment years.has led In mostto an cases, extremely two weeks high followed recurrence by a rate, positioning Emergency the patient clinicians’s arm in 90usedº of abductionHippocrates’ and 90 methodº of rehabilitationwith patients program younger is suggested. than 30 suffering the most. elbowfor flexion,reduction then for rotating 70% ofthe the arm patients inwardly and across Milch’s the Surgical treatment offers both a lower recurrence patientprocedure’s body. Painfor 30%; reproduced the success by either rates one were of these 90% and Rotatorrate and Cuff a Injurieshigher level of function, which is signifi- maneuvers67%, respectively. is considered Hippocrates’ an impingement method sign.27 was found The rotator cuff muscles play an important role in virtually toRadiographs be more effective may exclude in relocation bony problems of the such humeral as every sport but are absolutely crucial to the overhead thickhead acromion, but unfortunately bone spur, glenoid was erosions,more painful Hill-Sach and’s re- lesions, and others. While the radiographs may show Figure 6. Scapular Manipulation quired 2 people to properly perform the maneuver. Figure 6. Scapular manipulation. evidence There of degeneration, has been a the trend hallmark over ofthe a completepast decade tear of theor sorotator to surgically cuff complex correct is superior shoulder displacement dislocations of the humeralin younger head that patients is best seento prevent in the externally repeated rotated episodes AP view.and4 Other to enhance imaging function. techniques A such prospective as magnetic study reso- of 46 nanceyoung imaging athletes (MRI) revealed or arthrogram that thereshould was be reserved only a 4% for outpatientrecurrence evaluation. rate in a surgical group versus a 95% recurrenceAcute tears rate should in thebe immobilized nonsurgical in group. a sling 34and This referredfinding for prompt should orthopedic encourage evaluation. all emergency Unless otherwiseclinicians indicated,to recommend most patients a definitive should be surgicalstarted on procedureNSAID to all therapy.younger Many patients require narcoticpresenting analgesia. with shoulderRest, avoidance disloca of - painfultions; activities this would and positions, benefit andthe orthopedicpatient as referralwell as are reduce important.the workload It is usually for othernot possible practitioners. or necessary to differentiate between an acute tear, a chronic tear, or a flare of rotatorRotator cuff tendinitis Cuff Injuries in the ED. These patients should be treatedThe inrotator the same cuff manner muscles and play given an timely important referral. role in virtually every sport, but are absolutely crucial to Bicepsthe overhead Tendinitis athlete. Participants in tennis, basket- In pitchers,ball, volleyball, weight-lifters, and baseballand other frequentlyathletes, the experiencelong biceps tendonrotator may cuff become injuries. inflamed. Symptoms of biceps tendinitis include pain with shoulder extension or elbow Proper hand positioning and direction of rotation Acute injury of the rotator cuff is marked by a duringProper shoulder hand positioning relocation and direction using ofthe rotation scapular during shoulder flexion,sudden pain tearing when trying sensation to reach in into the theshoulder back pocket, followed and manipulationrelocation using technique. the scapular manipulation technique. painby around severe the pain anterior radiating shoulder. to the On arm.physical The examination, pain is often palpationpoorly of localized the tendon but within may the be bicipital present groove at the repro- insertion Reproduced with permission from: Marx JA, Hockberger RS, Walls Reproduced with permission from: Marx JA, Hockberger RS, Walls RH, ducesof thethe pain,rotator as doescuff forearmtendon supination.along the midsubstances et al.RH, eds. et Rosen al. eds.’s Emergency Rosen’s Emergency Medicine. 5th Medicine. ed. St. Louis: 5th ed. Mosby; St. Louis: Mos- Treatment of biceps tendinitis is similar to other 2002:595. Figure 46-31. With permission from Elsevier Science. of the rotator cuff muscles or may radiate up to the by; 2002:595. Figure 46-31. With permission from Elsevier Science. overuse syndromes. Most patients should be begun on

April44 2003 •An www.empractice.net Evidence-Based Approach To Traumatic7 Emergencies Emergency Medicine Practice neck or down to the arm. Subjective weakness of scribed oral NSAID therapy. Athletes should be en- the shoulder muscles as well as history of recurrent couraged to rest, ice, and avoid painful movements dislocations may be present. A severe tear of the ro- and positions. Orthopedic referral is appropriate in tator cuff is uncommon. Neer proposed that 95% of most patients if symptoms persist.38,39 rotator cuff tears are related to chronic impingement of the rotator cuff between the humeral head and the ED Evaluation: Hand Injuries coracoacromial arch.35 It can result from falling on an outstretched arm. Typically, tears are chronic and 36 History And Physical Examination result from progressive degeneration. The patient history should include the position of Litaker et al identified 3 components of the the hand at the time of injury, mechanism of injury, physical examination that can identify rotator previous hand injuries, occupation, and hand cuff tears. These include supra- and infraspinatus dominance. Physical examination should assess for atrophy, weakness with elevation or external rota- 37 tenderness, tendon integrity, joint stability, range of tion of the shoulder, and the impingement sign. motion, 2-point sensation, capillary refill, and mo- Impingement refers to inflammatory changes due tor function.40 to repetitive compression of the rotator cuff and associated structures between the humeral head Mallet Finger and coracoacromial arch.36 Neer’s impingement test Mallet finger (also known as baseball finger) is a involves moving the patient’s straightened arm to rupture of the extensor tendon that attaches to the full abduction. Hawkins’ impingement test involves dorsal side of the distal phalanx of the finger. This positioning the patient’s arm in 90° of abduction and tendinous injury occurs when there is a forced flex- 90° of elbow flexion then rotating the arm inwardly ion of a fully extended finger, commonly involving across the patient’s body. Pain reproduced by either a baseball or volleyball striking the tip. This forced one of these maneuvers is considered an impinge- flexion can cause a rupture of the extensor tendon ment sign.36 or an avulsion of the bone at the tendon insertion. Radiographs may exclude bony problems such With the extensor mechanism disrupted, the patient as thick acromion, bone spur, glenoid erosions, and will be unable to fully extend the distal phalanx, Hill-Sach’s lesions. Although the radiographs may although passive extension will be possible. show evidence of degeneration, the hallmark of a Although the physical examination will be diag- complete tear of the rotator cuff complex is superior nostic, a radiograph should be obtained to rule out displacement of the humeral head that is best seen in an associated avulsion fracture of the distal phalanx. the externally rotated AP view.4 Other imaging tech- Treatment is conservative and involves immobiliz- niques, such as magnetic resonance imaging (MRI) ing the joint in an extension splint in a neutral posi- or arthrogram, should be reserved for outpatient tion (some recommend slight hyperextension) for 6 evaluation. to 8 weeks. The patient should be referred to a hand Severe tears should be immobilized in a sling, specialist for follow-up. and patients should be referred for prompt orthopedic evaluation. Unless otherwise indicated, most patients should be started on NSAID therapy. Many Jersey Finger require narcotic analgesia. Rest, avoidance of painful Jersey finger, or a tear of the flexor digitorum pro- activities and positions, and orthopedic referral are fundus, is essentially the opposite of mallet finger, as important. It is usually not possible or necessary to there is a forced extension of the finger during an ef- differentiate among a severe tear, a chronic tear, or fort to actively flex the digit. The classic description a flare of rotator cuff tendinitis in the ED. Patients is that of a football player trying to grab an oppo- with these should be treated in the same manner nent’s jersey as the opponent is running downfield. and given timely referral. The physical examination, again, is diagnostic, as the patient is unable to flex the distal phalanx at the distal interphalangeal joint. Radiographs should be Biceps Tendinitis obtained to rule out an associated avulsion fracture In pitchers, weight lifters, and other athletes, the of the distal phalanx. long biceps tendon may become inflamed. Symp- Jersey finger is usually managed operatively toms of biceps tendinitis include pain with shoulder within 14 days of the injury. The finger should be extension or elbow flexion, pain when trying to splinted with the finger and wrist flexed, and the -pa reach into the back pocket, and pain around the an- tient should be urgently referred to a hand specialist. terior shoulder. On physical examination, palpation of the tendon within the bicipital groove reproduces the pain, as does forearm supination. Gamekeeper’s Thumb Treatment of biceps tendinitis is similar to other Gamekeeper’s thumb, also known as skier’s thumb overuse syndromes. Most patients should be pre- (because skiing is now more common than twisting off the heads of rabbits), refers to injury of the ulnar

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 45 collateral ligament (UCL) of the thumb’s metacarpal nonaffected side. Additionally, examine the cervical phalangeal joint. On examination, there is tender- spine and image when indicated. (See the October ness over the ulnar side of the joint and weakness 2001 issue of Emergency Medicine Practice.) MRI is of pinch. Valgus stress testing of the thumb UCL reserved for patients in whom a cervical spinal cord should be done both in full extension and in 30° of injury cannot be excluded or an as outpatient test for flexion. Greater than 35° of joint laxity or 15° more those with persistent symptoms.43 laxity than the contralateral side UCL indicates a Rest and NSAID therapy may be helpful. Pa- complete UCL rupture.4,41 tients should have a thorough and normal neurolog- Radiographs should be obtained before stressing ical examination before resuming athletic activities. the joint to exclude associated avulsion or condy- Some may benefit from a short course of physical lar fractures. Treatment of a partial UCL rupture therapy.43,44 involves immobilization in a thumb spica cast for 4 weeks. Complete tears require a surgical procedure. Transient Quadriplegia All patients with this injury suspected should be im- Transient quadriplegia most frequently occurs with mobilized and referred to an orthopedist, as under- an axial load injury to the cervical spine or after diagnosis can lead to chronic disability.4 hyperextension or hyperflexion.45 Typically, the patient experiences transient upper and lower extrem- ED Evaluation: Selected Neurologic Injuries ity paralysis and numbness that resolves over a period of minutes. The results of plain radiographs Although a full discussion of neurologic sports and computed tomography of the spine, as well as injuries is beyond the scope of this chapter, the MRI of the spine, are usually normal (but still may August 2005 issue of Emergency Medicine Practice be indicated depending on the clinical circumstanc- “Mild Traumatic Brain Injury: What To Do When es, such as cervical spine tenderness). Before the There is Nothing (Obviously) Wrong,” provides an athlete is allowed to return to play, spinal steno- excellent overview. For a complete discussion of sis must be ruled out, because this is an absolute cervical spine injuries, see the October 2001 issue of contraindication for return to training.45 Cervical Emergency Medicine Practice, “Cervical Spine Injury: spinal stenosis can increase the risk of permanent A State-Of-The-Art Approach to Assessment and neurologic injury.46,47 Management,” and the April 2009 issue of Emergency Medicine Practice, “An Evidence-Based Evaluation Of ED Evaluation: Elbow Injuries The Patient With Blunt Cervical Trauma.” Elbow Dislocation Brachial Plexus Injuries The elbow is second only to the shoulder as the ma- Brachial plexus injuries are common in contact jor joint most frequently dislocated. Football players sports, especially football and rugby. A “stinger” or and other contact sports participants are particularly “burner” is classically defined as unilateral burning vulnerable. Most dislocations are posterior, although dysesthesias from the shoulder to the hand, with the elbow may also dislocate medially, laterally, or occasional weakness or numbness in the C5 and C6 anteriorly. (See Figure 7.)4,48 distribution.42 The mechanism of injury is usually The classic mechanism of injury is a fall onto the sudden forced flexion forward or laterally of the cer- outstretched hand with the elbow extended. Patients vical spine, resulting in a stretch injury, presumably will have a marked deformity on the injured side to the sixth cervical spinal nerve root. and a prominent olecranon. They often maintain the For the vast majority of brachial plexus inju- elbow in about 45° of flexion. ries, the consequences of cervical root strains are Frequent neurovascular examinations are minimal. Patients experience pain, numbness, and crucial. The median nerve and brachial artery are tingling of the extremity opposite to the direction at particular risk. Brachial artery injury is noted in of lateral bending (ie, if the head is forced to the 5% to 13% of patients.49 Nerve and vascular injury left side, the right arm will be affected). Rarely, after reduction have been reported.49,50 Treatment is there can be more severe damage to the nerves. The prompt reduction. If the neurovascular status of the symptoms typically last minutes but can persist for extremity is compromised, immediately reduce the days to weeks. The unilaterality, brevity, and pain-free elbow. Reduction of a posterior dislocation is accom- range of motion in the athlete can assist in discriminat- plished by stabilization of the humerus and gentle ing between a “stinger” and a cervical cord injury.42 traction of the wrist with flexion of the elbow if the Neck pain is usually not a prominent feature in joint does not easily reduce. In most cases, elbow traction injuries.43 reduction is uneventful. ED examination of brachial plexus injuries Most patients will require conscious sedation or should include a thorough neurological examina- intraarticular anesthesia. Obtain postreduction ration. Compare the strength and sensation with the diographs and range the elbow through flexion and

46 An Evidence-Based Approach To Traumatic Emergencies or hyperflexion.36 Typically, the patient experiences transient articular anesthesia. Obtain post-reduction films and range extension to ensure stability. Immobilize the elbow History And Physical Examination upper- and lower-extremity paralysis and numbness, which the elbow through flexion and extension to ensure stability. in 90° of flexion. Phone consultation with an ortho- As with any injury, the surrounding events should be resolves over a period of minutes. Plain radiographs and Immobilize the elbow in 90º of flexion. Phone consultation pedist may be helpful, because the stability of reduc- noted. Determine the position the leg was in when computed tomography of the spine, as well as MRI of the with an orthopedist may be helpful, since the stability of tion and neurovascular status of the elbow must be the injury occurred, whether there was a pop heard spine, are usually normal (but still may be indicated reduction and neurovascular status of the elbow must be closely monitored, especially for development of a or felt, and whether the patient could ambulate or depending on the clinical circumstances, such as cervical closely monitored, especially for development of a forearm forearm compartment syndrome. Most patients who resume play immediately after the injury. True hip spine tenderness, etc.). Before the athlete is allowed to compartment syndrome. Most patients who dislocate their dislocate their elbow without comorbid fractures joint pain often localizes to the groin. Examine the return to play, spinal stenosis must be ruled out, since this elbow without comorbid fractures have an excellent long- have an excellent long-term prognosis. involved leg for deformity, shortening, rotation, and is an absolute contraindication for return to training.36 term prognosis. ecchymoses. Active and passive range of motion Cervical spinal stenosis can increase the risk of permanent ED Evaluation: Hip Injuries should be evaluated as long as the emergency clini- neurologic injury.37,38 Emergency Department Evaluation: Hip Injuries cian is reasonably sure there is no fracture or dislocation present. Look for tenderness of the iliac crest, AnatomyEmergency Department Evaluation: Anatomy pubic rami, or ischial rami. Hip pain with weight TheElbow hip Injuries is a ball-and-socket joint that consists of the The hip is a ball-and-socket joint that consists of the acetabulum and the proximal femur 2 to 3 inches bearingacetabulum despite and the no proximal positive femurfindings 2-3 inches on radiographs below the belowElbow theDislocation lesser trochanter. There is a strong fibrous maylesser indicate trochanter. an There occult is fracturea strong fibrousof the joint.capsule surround- capsuleThe elbow surrounding is second only the to thejoint. shoulder as the major joint ing theMusculotendinous joint. injuries around the hip are most frequently dislocated. Football players and other usually the result of an actively contracting muscle Overviewcontact sports participants are particularly vulnerable. Most thatOverview encounters abrupt resistance. This is most com- Severedislocations hip painare posterior, in athletes although is almost the elbow always may the also monlyAcute hip seen pain in in track athletes and is fieldalmost but always can theoccur result in ofany a resultdislocate of medially,a strain orlaterally, musculotendinous or anteriorly.4,39 (Seeinjury. Figure In chil7.) - sportstrain orthat musculotendinous involves rapid injury.acceleration In children and and decelera adoles-- drenThe and classic adolescents, mechanism these of injury injuries is a fallare ontooften the avul- tion,cents, such these asinjuries soccer are or often missing avulsion a kick fractures in football. involving sionoutstretched fractures hand involving with the theelbow iliac extended. crest, anterior Patients willsupe- the iliacSymptoms crest, anterior include superior a pop and or inferior snap andiliac spines,sudden, and riorhave and a marked inferior deformity iliac spines, on the andinjured lesser side trochanterand a promi- or severelesser trochanter localized or pain ischial and tuberosity. immediate Hip fractures disability. and ischialnent olecranon. tuberosity. They Hip often fractures maintain and the elbowdislocations in about are 45º Walkingdislocations is aredifficult uncommon or impossible. in sports activities The site and ofusually the in- uncommonof flexion. in sports activities and usually occur as juryoccur is as tender, a result andof a high-speed swelling iscollision. variable.32 The muscle a resultFrequent of a high-speedneurovascular collision. examinations41 are crucial. The is usuallyAvulsion tense. fractures, Suspect such an as avulsionavulsion of fracture the anterior if medianAvulsion nerve and fractures, brachial such artery as are avulsion at particular of the risk. an- theresuperior is tendernessiliac spine, are on the palpation result of sudden, at any forceful of the ten- teriorBrachial superior artery injury iliac isspine, noted arein 5%-13% the result cases. of40 sudden, Nerve and doncontraction insertions. of the sartoruis muscle. This fracture is usually forcefulvascular injurycontraction after reduction of the sartorius have been muscle. reported. This40,41 seenMuscular in children injuryand adolescents is frequently before encountered the physis closes. in the fractureTreatment is usually is prompt seen reduction. in children If the and neurovascular adolescents 3The major same muscle mechanism groups in adults of the results leg: thein a hamstrings,strain instead of beforestatus of the the physis extremity closes. is compromised, The same mechanismimmediately reducein quadriceps,a fracture. and the iliopsoas. Strain of the ham- adultsthe elbow. results Reduction in a strain of a posterior instead dislocation of a fracture. is accom- strings is common with running and sudden ac- plished by stabilization of the humerus and gentle traction celeration.History And The Physical patient Examination develops sudden and severe of the wrist with flexion of the elbow if the joint does not painAs with in theany posteriorinjury, the surroundingthigh. Range events of motion should ofbe thenoted. easily reduce. In most cases, elbow reduction is uneventful. hipDetermine is painful, the position and no the bony leg wastenderness in when theis present. injury Most patients will require conscious sedation or intra- Treatmentoccurred, whether involves there crutches was a pop with heard toe-touch or felt, and weight Figure 7. Complete Posterior Dislocation Of bearingwhether the(only patient the toescould bear ambulate weight) or resume as tolerated. play The Elbow immediatelyThe quadriceps after the injury. are the True most hip commonjoint pain oftenmuscular Figure 7. Complete posterior dislocation of the elbow. groupslocalizes to to sufferthe groin. complete Examine tears. the involved When theleg formuscles defor- aremity, contracted shortening, suddenly rotation, and against ecchymoses. the body’s Active weight, and suchpassive as range stumbling of motion to preventshould be a evaluatedfall, the quadriceps as long as the canphysician suffer is various reasonably degrees sure there of tearing. is no fracture On examina or disloca-- tion,tion present. there is Look pain for with tenderness passive of and the iliac active crest, knee pubic extension;rami, or ischial with arami. complete Hip pain tear, with active weight-bearing knee extension despite againstnegative gravityradiographs is impossible. may indicate Treatment an occult fracture consists of of weight-bearingthe joint. with crutches. InjuryMusculotendinous of the iliopsoas injuries aroundis commonly the hip areseen usually in gymnaststhe result of and an actively dancers contracting and is the muscle result that of encounterssudden, forcefulabrupt resistance. hip flexion This isagainst most commonly resistance. seen There in track is sudden,and field severe but paincan occur in the in anygroin, sport thigh, that involvesor low back.rapid Thereacceleration may andalso deceleration, be abdominal such pain as soccer at the or origin missing of a thekick iliopsoas. in football. On examination, the groin is tender to palpationSymptoms and includethere is a painpop or with snap active and sudden, hip range severe of motion.localized Radiographspain and immediate of the disability. femur should Walking be is obdifficult- AP and lateral views of posterior elbow dislocation. AP and lateral views of posterior elbow dislocation. tainedor impossible. to exclude The site a fracture of the injury of the is tender, lesser andtrochanter. swelling is Treatment is bed rest for 7 to 10 days with partial Reproduced with permission from: Harris JH Jr, Harris WH, Novelline variable. The muscle is usually tense. Suspect an avulsion Reproduced with permission from: Harris JH Jr, Harris WH, Novelline 4 RA. The Radiology of Emergency Medicine. 3rd ed. Baltimore: Williams flexionfracture ifat there the isknee tenderness and hip. on palpation at any of the RA. The Radiology of Emergency Medicine. 3rd ed. Baltimore: Wil- & Wilkins; 1993:344. Figure 5.13. tendonWith insertions. most muscular injuries, complete the eval- liams & Wilkins; 1993:344. Figure 5.13.

April 2003 • www.empractice.net 9 Emergency Medicine Practice Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 47 uation with a pelvic or hip radiograph to exclude as- 1 study of 208 males who underwent knee arthros- sociated avulsion fractures. The standard treatment copy after trauma, a significantly greater number of of compression and ice is difficult to accomplish in anterior cruciate ligament (ACL) tears were associ- the hip. Ambulation with crutches and bed rest are ated with sports activity (P = 0.032). Sports injuries recommended.51 As with other musculotendinous also resulted in a significantly greater number of injuries, active and isometric stretching should be meniscal injuries (P = 0.028), whereas sedentary started in 48 hours. patients had a greater number of osteochondral frac- A contusion of the iliac crest is also known as tures (10%) than the sports group (5%).57 a hip pointer. The iliac crest is very vulnerable to direct blows due to its poor protection. This injury Anatomy may result in severe disability because the iliac crest The knee (see Figure 8) is a complex diarthro- serves as an anchor for abdominal and hip muscu- dial hinged joint that is frequently injured during lature. The history is significant for a direct blow to sports activities. The knee is positioned between the hip, such as from a football helmet or fall onto a the 2 longest bones in the body—the femur and the hard surface (which is common in soccer, football, tibia—but has minimal bony stability. There are 3 and ice hockey). This painful blow is instantly dis- primary articulations within the joint complex. The abling. On examination, the iliac crest is tender and patellofemoral articulation involves the patella and there is a variable amount of swelling. The abdomen the distal femur, whereas the other 2 articulations is often rigid because of abdominal wall spasm. involve the distal femur and the proximal tibia. The Radiographic evaluation of the pelvis may re- nonbony elements include 2 menisci, 4 ligaments veal a compression fracture. Consider intraabdomi- (medial and lateral collateral ligaments and the nal injury in the presence of significant abdominal anterior and posterior cruciate ligaments), and the tenderness. In addition to ice and analgesics, a 6- to surrounding capsule. The fibrocartilaginous menisci 8-day steroid burst may reduce the duration of dis- distribute weight and stabilize the knee. The medial ability.51 meniscus is injured more frequently than the lateral meniscus.49 ED Evaluation: Thigh Injuries The medial and lateral collateral ligaments resist valgus and varus stress, respectively. The anterior Quadriceps Tendon Rupture and posterior cruciate ligaments resist anterior and Quadriceps (or extensor tendon) rupture results from posterior stress and are the major stabilizing liga- powerful muscle contractions secondary to a fall or ments of the knee. The ACL is ruptured more often. in conjunction with severe ligamentous disruption at the knee. This is typically an injury seen in older patients, but it may occur in younger patients involved in jumping activities.52 In athletes, the rupture most often occurs in high-power sports events, such as the Figure 8. Knee Anatomy high jump, basketball, and weightlifting.53 Patients report hearing a loud pop and are immediately unable Femur to extend the leg or bear weight. Posterior They may complain of buckling of the knees or cruciate ligament 54 inability to walk up stairs or up an incline. Often Medial there is a palpable soft tissue defect proximal to the collateral ligament superior pole of the patella, but this may be obscured Anterior 52 by edema. All patients have marked weakness of cruciate ligament the knee extensors, and most have an inability to perform a straight leg raise test when supine. Ra- Lateral meniscus diographs of the knee may reveal a poorly defined suprapatellar mass, an obliterated quadriceps tendon, 54 Medial and a joint effusion. Early diagnosis is important, as Lateral collateral meniscus surgical repair within 48 to 72 hours is necessary to ligament preserve the extensor mechanism of the knee.52

ED Evaluation: Knee Injuries Patellar tendon

There are 1.3 million visits to U.S. EDs because of Tibia Fibula knee trauma each year.55,56 Knee injuries produced by recreational sports tend to follow a different Reproduced with permission from: Anderson MK, Hall SJ. Sports Injury pattern than other mechanisms of casual injuries. In Management. Baltimore: Williams & Wilkins; 1995:271. Figure 81C.

48 An Evidence-Based Approach To Traumatic Emergencies History patellar tendon). Specific tests are then performed to A careful history is often needed to ascertain the evaluate the mechanical integrity of the components severity of the injury, as chronic overuse injuries of the knee joint. Obtain radiographs before stress- can present with severe exacerbations (see Tables 2 ing the knee if a fracture is likely. and 3). An audible pop at the time of the injury and Ligamentous injuries of the knee usually occur immediate swelling suggest a significant internal as a result of hyperextension or abnormal rotation. derangement. Sudden onset of a large effusion suggests Identifying an internal derangement is more impor- an ACL injury. Note the patient’s ability to ambulate tant than identifying the specific injury. immediately following the injury and the position of A recent literature review compared physical the leg at the time of injury. For example, a football examination with either MRI or arthroscopy for me- player tackled from the side while his foot is planted niscal or ligamentous injuries of the knee. Although is at risk for a medial collateral ligament injury. It is there were limitations in the data, the authors found especially important to consider the hip as a source the Lachman test excellent for both ruling in and rul- of referred knee pain. Determine any previous knee ing out a tear of the ACL. The anterior drawer test injuries, any knee surgical procedure, and the func- was not particularly useful under any conditions, tional status before injury. and there is no reliable examination for meniscal injuries. Potentially useful physical findings include Physical Examination alignment during standing or walking, active and passive range of motion, the presence of effusion, The examination begins with an inspection of the en- 58 tire limb for deformity, bruising, and swelling. (See joint line tenderness, and the Lachman test. Table 4.) Comparison to the opposite leg is help- In a 2006 evidence-based emergency medicine ful. Palpate for localized tenderness, beginning in review of the Journal of the American Medical Associa- the nonpainful areas. The knee’s active and passive tion (JAMA) rational clinical examination article, range of motion, within the limits of pain, should Strayer finds that level 1 evidence indicates that be tested next. It is important to specifically test the the anterior drawer test has a sensitivity of 18%, contrasting the 70% sensitivity mentioned below in knee extension against gravity to ensure integrity of 59 the extensor mechanism (quadriceps, patella, and the “Physical Examination Maneuvers” section. The general examination of the PCL had the highest sensitivity (91%) and specificity (98%) for injury followed by a respectable sensitivity (82%) and speci- Table 2. Differential Diagnosis Of Acute ficity (94%) of the complete physical examination of Traumatic Knee Pain the ACL. However, the general examination of the menis- Most serious cus was not very informative, with a sensitivity of • Knee dislocation 77% and specificity of 91%. The Lachman test had • Fracture of distal femur, patella, proximal tibia, or fibula a sensitivity of 84%, a specificity of 100%, a positive • Patellar or quadriceps tendon rupture likelihood ratio of 42, and a negative likelihood ratio • Meniscal injuries of 0.1 compared with joint line tenderness with a • Ligamentous injuries sensitivity of 79%, specificity of 15%, a positive like- Most common lihood ratio of 0.9, and a negative likelihood ratio of • Sprains/strains • Contusions • Patellar dislocation or subluxation Table 4. Significant Physical Examination Findings In Knee Injuries Table 3. Significant Historical Points In Knee Injuries • Effusion or acute swelling • Positive Lachman test • Acute onset of pain within 72 hours of injury • Patellar tenderness or abnormal position • Audible pop and immediate swelling with twisting or forced • Tenderness of the lateral or medial aspect of the knee or head hyperextension of fibula • Direct blow to anterior tibia, forced hyperextension, or axial load • Joint line tenderness or positive McMurray’s test • Direct blow to the medial or lateral aspect of the knee • Inability to straighten or flex the knee greater than 90º • Varus or valgus stress to knee • Inability to perform straight-leg raise • Twisting injury—painful popping and catching, delayed swelling • Positive posterior drawer test • Direct blow to patella or hyperflexion • Valgus or varus joint instability • Prior knee surgery • Inability to bear weight for four steps without assistance

Source: Beatty JH, ed. Orthopaedic Knowledge Update 6: Home Adapted from: Beatty JH, ed. Orthopaedic Knowledge Update 6: Study Syllabus. Rosemont, IL: American Academy of Orthopaedic Home Study Syllabus. Rosemont, IL: American Academy of Orthopae- Surgeons; 1999. dic Surgeons; 1999.

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 49 49 1.1. Strayer offers the critique that the participants the thigh, and pushes the tibia backward. The loca- in the JAMA article were examined by orthopedists tion of the anterior proximal tibia in relation to the who conduct many more knee examinations than patella and femoral condyles is used to estimate do emergency clinicians and the participants com- the posterior movement of the tibia on the femur. plained of chronic knee pain that is easier to manip- Positive test results when the tibia moves posterior ulate than the acute injuries seen in the ED. to the femoral condyles.49 A blinded, randomized, Both of these factors limit the applicability of controlled study of 39 patients showed it to be 96% this study to ED management. The review article accurate, 90% sensitive, and 99% specific. (The concludes that no single physical examination ma- examiners in this study, however, were orthopedic neuver can reliably guide treatment of potentially surgeons trained in sports medicine.64) injured ligaments or menisci, but a comprehensive The McMurray test evaluates the menisci. The ex- physical examination performed by an experienced aminer grasps the lower leg and flexes and extends emergencymedial and lateral clinician collateral should ligaments. be able Injuries to affect to theman- sensation,the knee whilewhich constitutesinternally aand positive externally test. It is rotating also the agementmedial collateral in those ligament patients are whobased can on thewithstand amount of an laxity consideredtibia on the significant femur. The if the other patient hand experiences is used painto palpate during adequatepresent. The physical knee should examination. be tested by The applying emergency a valgus internalthe knee and for external a clicking rotation. sensation,55 This test which is not constitutes specific for medicinestress in full review extension recommends and 30º of knee a low flexion. threshold A grade for I ameniscal positive problems finding. as itIt alsois also detects considered soft-tissue significant injuries.4 if orthopedicinjury has 0-5 referral mm of laxity, because a grade of the II injury aforementioned has 5-10 mm of the patientThe apprehension experiences sign is pain used during to diagnose internal a partial and ex- limitations.laxity, and a grade III injury, which means complete ternaldislocation rotation. (subluxation)65 This testof the is patellanot specific or recent for patellar meniscal ligamentous disruption, has greater than 10 mm of laxity. problems,dislocation thatas it has also spontaneously detects soft reduced. tissue injuries. This sign4 PhysicalWhen the Examinationknee is tested in Maneuvers full extension, any laxity with describesThe apprehensionthe anxiety exhibited sign is byused the topatient diagnose as the a par- Thevalgus value stress of implies any of complete these maneuvers medial collateral is best ligament de- tialexaminer dislocation attempts (subluxation) to slide the patella of the laterally, patella which or recent termineddisruption. 50by Injury comparison to the lateral to the collateral uninjured ligament, knee, which as patellarresults in dislocationpain and forceful that contractionhas spontaneously of the quadriceps reduced. abnormalitiesis uncommon, is may tested be by subtle. applying a varus force to the knee Thisfemoris sign muscle. describes the anxiety exhibited by the in extensionThe collateral and 30 ºligament of flexion. stress Lateral test laxity tests of the more integ than- 10 patient as the examiner attempts to slide the patella ritymm withoutof the medial a firm endpoint and lateral reflects collateral complete ligaments. lateral laterally,Knee Radiography which results in pain and forceful contrac- Injuriescollateral toligament the medial rupture, collateral while less ligament than 10 mm are ofbased laxity tionMore of than the $1 quadriceps billion is spent femoris on emergency muscle. radiography of onsuggests the amount a partial of tear. laxity51 Whenever present. testing The kneelaxity, shouldcompare to the knee each year in the United States, with 90%-92% of bethe testeduninjured by knee,applying as some a valgus patients stress have considerablein full exten- Kneethese studies Radiography showing no fracture.46,47 A standard knee series sionnormal and laxity. 30° of knee flexion. A grade I injury has 0 Moreincludes than the $1AP, billion lateral, isand, spent in most on emergencyhospitals, oblique radiogra- to 5 ThemmLachman of laxity, test a gradeevaluates II theinjury ACL has and is5 tothe 10single mm best of phyviews. of These the knee films each should year be examinedin the United for loose States, bodies, with clinicallaxity, testand for a determininggrade III injury, the integrity which of the means ACL. completeIt is also 90%osteochondral to 92% of injuries, these studiesand avulsion showing fractures. no fracture. Additional55,56 oneligamentous of the only disruption, reliable tests hasin a patientgreater with than an 10 acute mm of Aviews, standard such as knee a “sunrise series” includesview or “tunnel the AP,” view, lateral, are and, hemarthrosis.laxity. When4,52 the Have knee the is patient tested lie in supine full extension, and flex the any insometimes most hospitals, needed. A oblique sunrise viewviews. is a These tangential radiographs view that laxityknee to with 20º-30 valgusº. The examiner stress implies stabilizes complete the femur medial with one provides good visualization of the patella and handcollateral and pulls ligament the tibia disruption. forward with60 Injury the other to thehand, lateral while Continued on page 14 estimatingcollateral theligament, amount which of anterior is uncommon, movement. A is distinct tested endpointby applying at which a varus forward force displacement to the knee stops in extension suggests that Figure 9. The Lachman Test theand ACL 30° isof intact. flexion. The anteriorLateral drawerlaxity testof moreis much than less 10 mm Figure 9. The performance of the Lachman test. reliablewithout than a firm the Lachman endpoint test reflects for evaluating complete the ACL lateral (70% vs.collateral 99% accuracy ligament in one rupture, study) and whereas should less not bethan used. 1040,53 mm of(See laxity Figure suggests 9.) a partial tear.61 Whenever testing laxity,The compare posterior drawerwith the test uninjuredis the gold standard knee, as used some to patientsevaluate the have posterior considerable cruciate ligament.normal laxity. The examiner flexesThe the Lachman patient’s kneetest evaluates to 90º, anchors the ACL the thigh,and is and the single bestpushes clinical the tibia test backward. for determining The location the integrity of the anterior of the ACL. Itproximal is also tibiaone inof relation the only to reliablethe patella tests and in femoral a patient condyles withis used a tosevere estimate hemarthrosis. the posterior4,62 movement Have the of thepatient tibia onlie supinethe femur. and A positiveflex the test knee results to when20° to the30°. tibia The moves examiner stabilizesposterior to the the femurfemoral with condyles. one 40hand A blinded, and pulls randomized, the controlledtibia forward study with of 39 the patients other showed hand whileit to be estimating 96% accurate, 90%the amountsensitive, of and anterior 99% specific. movement. (The examiners A distinct in this end- study,point however,at which were forward orthopedic displacement surgeons trainedstops suggests in sportsthat the medicine. ACL is54 intact.) The anterior drawer test is muchThe less McMurray reliable test than evaluates the Lachman the menisci. test The for examinerevaluat- graspsing the the ACL lower (70% leg andvs. 99%flexes accuracy and extends in 1the study) knee whileand Reproduced with permission from: Simon R, Koenigsknecht S. internallyshould not and be externally used. (See rotating Figure the 9.tibia)49,63 on the femur. The EmergencyReproduced Orthopedics: with permission The Extremities. from: Simon New R, York:Koenigsknecht McGraw-Hill; S. other The hand posterior is used todrawer palpate test the is knee the forcriterion a clicking standard 1995:371.Emergency Figure Orthopedics: 27-9. The Extremities. New York: McGraw-Hill; used to evaluate the posterior cruciate ligament. The 1995:371. Figure 27-9. examiner flexes the patient’s knee to 90°, anchors Cost-Effective Strategies For Orthopedic Sports Injuries 50 An Evidence-Based Approach To Traumatic Emergencies

1.Don’t x-ray every knee, ankle, or foot. The Ottawa knee, 3. Avoid the use of ketorolac for acute musculoskeletal ankle, and foot criteria are sensitive and specific. injuries. Ibuprofen has been shown to be just as effective Adherence to these criteria whenever possible will for acute pain and is significantly less expensive. If decrease the number of knee radiographs ordered.51 ibuprofen is ineffective in relieving the patient’s pain, opioid narcotic analgesics should be prescribed. 2. Do not order an MRI from the ED for knee injuries. MRI is 4. Learn to use intra-articular lidocaine to reduce shoulder an outpatient study that should be ordered by the dislocations. It is cheaper and faster than intravenous orthopedic consultant who will be managing the patient. sedation and is just as efficacious.19,20▲

Emergency Medicine Practice 12 www.empractice.net • April 2003 Clinical Pathway: Evaluation Of Knee Injuries

Knee pain after an injury

Evaluate for Ottawa criteria Possible knee dislocation Radiographs recommended if any of the following are met: • the patient is 55 years or older • there is tenderness at the head of the fibula • there is isolated tenderness of the patella Neurovascular deficits? • the patient is unable to flex the knee to 90º • the patient is unable to take four steps both at the time of the injury and at the time of the evaluation Yes NO (Class II)

Obtain radiograph; Reduce immediately then reduce if dislocated (Class I) None present One or more present (Class I)

No radiograph Obtain radiograph Hard signs of vascular injury? (Class II) (Class II) • active hemorrhage • expanding hematoma • absent pulse • distal ischemia Negative finding Positive finding • bruit/thrill over the popliteal artery

Yes NO

Findings of ligamentous Treat and refer instability? • Treat as indicated Consult orthopedics Immediate orthopedic • Orthopedics referral and admit to hospital; con- and vascular surgery (Class I) sider ankle/brachial pres- consult; consider sure ratio—if < 0.8, consider angiography angiography (Class II) Treat (Class III) • Arthrocentesis (Class III) • RICE (Class II) • Knee immobilizer/crutches (Class II) • NSAIDs (Class II) • Orthopedics referral (Class I)

For Class of Evidence Definitions, see page 1.

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 51 should be examined for loose bodies, osteochondral applied in 750 patients and demonstrated a sensitiv- injuries, and avulsion fractures. Additional views, ity of 97% with a specificity of only 27%.70 such as a “sunrise” view or “tunnel” view, are sometimes needed. A sunrise view is a tangential Magnetic Resonance Imaging view that provides good visualization of the patella MRI is the imaging modality of choice to diagnose and patellofemoral joint. A tunnel view images the significant acute and chronic soft tissue injuries of intercondylar notch and detects tibial spine fractures the knee. However, at the present time MRI is costly and loose bodies within the notch.4 and has limited availability. Because the definitive Clinical decision rules such as the Ottawa or evaluation of these injuries is rarely necessary on an Pittsburgh knee rules are a cost-effective way to emergent basis, the use of MRI is best deferred to the improve radiograph use. The Ottawa rules were consultant. developed from a prospective evaluation of 23 clinical indicators in 1047 adult patients with knee injuries.66 ACL Injuries The Ottawa knee rules, which have been validated by The ACL is the most frequently injured major liga- numerous other investigators,67,68 recommend radio- ment in the knee and is frequently torn in skiing and graphs if any of the following conditions are met:69 contact sports, most commonly football.4 The ACL • the patient is 55 years or older is injured during recovery from falling backward (in • there is tenderness at the head of the fibula expert skiers) or hyperflexion and internal rotation • there is isolated tenderness of the patella of the knee (in lower level skiers).72 This injury can • the patient is unable to flex the knee to 90° also occur in basketball players when the hyperex- • the patient is unable to take 4 steps both at tended knee is twisted or when the patient collides the time of the injury and at the time of the with another player. An audible pop, immediate evaluation swelling, and inability to continue the activity mark this injury. The Lachman test is diagnostic.49 A study of 1522 adults designed to validate the Ottawa knee rules found the sensitivity for detect- Collateral Ligament Injuries 67 ing clinically important fractures to be 100%. The medial collateral ligament is a medial stabilizer of Like all decision rules, the Ottawa knee rule has its the knee and is most commonly injured by a blow limitations. The rule was not designed to apply to to the lateral aspect of the knee or by the patient patients younger than 18 years, pregnant patients, planting the foot and then colliding with another patients with isolated skin injuries, patients with athlete.49 Patients usually report hearing a pop at the injuries more than 7 days old, patients with altered time of the injury, although this finding is not specif- level of consciousness, or patients who have multi- ic. There is often an associated ACL injury as well. A 70 ple injuries. The Ottawa definition for ambulation first- or second-degree sprain will have tenderness, is also quite liberal, with any minimal foot transfer, usually at the medial femoral epicondyle. Swelling including severe limping, considered as “able to will occur quickly, but bruising is often delayed 24 70 bear weight.” to 36 hours. A third-degree sprain may not cause Although the Ottawa knee rules were not origi- severe pain, but the patient cannot continue the ac- nally intended for the pediatric population, a recent tivity after the injury, limps, and cannot fully extend study evaluated its applicability in children. In a the leg.49 The degree of injury can be estimated by prospective study of 234 patients 2 to 18 years old, the amount of joint line opening. An isolated tear the rule reduced the need for radiography but only usually heals without surgical intervention. 71 had a sensitivity of 92% for detecting fractures. Injury of the lateral collateral ligament is less Another clinical decision rule, developed at the common but more disabling. It occurs via hyperex- University of Pittsburgh, uses different criteria. The tension with varus stress or from a direct blow or Pittsburgh rules were designed using a retrospective rotation. review of 11 clinical indicators in 201 patients with knee injuries. The Pittsburgh knee rules recommend 70 Posterior Cruciate Ligament Injuries radiography in the following circumstances: Injury to this ligament is less common than to the • a fall or blunt trauma in patients older than 50 or ACL because of the strength of the ligament. It is younger than 12 usually caused by a direct blow to the anterior tibia • a fall or blunt trauma with the inability to walk 4 or a fall. The posterior drawer test is diagnostic, and steps in the ED treatment is conservative. A prospective study of 934 patients found that Meniscal Injuries the Pittsburgh knee rules outperformed the Ottawa The menisci are often co-injured with other struc- knee rules. In the 745 patients in whom the Pitts- tures, usually as a result of a twisting motion to burgh rules were applied, the sensitivity was 99% a flexed knee. Unlike collateral ligament injuries, and the specificity was 60%. The Ottawa rules were

52 An Evidence-Based Approach To Traumatic Emergencies pain with meniscal injury is usually worse with is usually grossly swollen, painful, and unstable. weight bearing.61 The classic clinical triad is joint Sometimes with complete disruption of the joint line pain, swelling, and locking. On examination, capsule, the hematoma leaks into the thigh or calf there is tenderness and effusion along the me- and the knee is almost normal in size. Results of the dial or lateral joint lines and pain in the posterior vascular examination may be normal or show signs aspect of the knee on passive extension and flex- of popliteal artery or peroneal nerve injury. Peroneal ion. There may be locking immediately after the nerve injury is the most common major neurological injury because of a displaced meniscal fragment.4 A problem associated with knee dislocation. The per- McMurray test exhibiting a positive finding is help- oneal nerve is evaluated by testing sensation in the ful in the diagnosis, but a negative result does not first dorsal web space and having the patient extend exclude injury. Evaluate for a locked knee, where the big toe or dorsiflex the ankle.4 the knee becomes fixed in flexion due to a mechani- The association between knee dislocations and cal block from the displaced cartilage.73 popliteal artery injury has been known for almost In 2008, British investigators conducted a a century.79 Despite this knowledge, controversy prospective study using ultrasonography to assess remains concerning the necessity of angiography of menisci compared with MRI. MRIs are costly, much the popliteal artery to determine the presence of a less accessible, and significantly longer examinations vascular injury. compared with ultrasonography. Ultrasonography Historically, all patients with knee dislocations revealed a sensitivity of 86% and a specificity of 69% have undergone angiography, even those whose at assessing meniscal tears compared with MRI’s vascular examination results are normal.80-83 It is 86% and 100% respectively.74 Although ultrasonog- currently felt that patients with low-energy knee raphy matched the sensitivity of MRI, the number dislocations whose vascular examination results are of false-positives was remarkably higher. Thus, the normal do not require arteriography but do require technique will need to be improved to become clini- serial examination.36,61 A study by Miranda et al cally useful, especially in the ED. describe their experience using selective arteriography in 35 patients with knee dislocations during Disposition Of Ligamentous And Meniscal Injuries 10 years. In this study, patients with hard signs of The definitive treatment of ligamentous and menis- vascular injury at the time of evaluation had angiog- cal injuries is not emergent. Patients are to be im- raphy. “Hard signs” included active hemorrhage, ex- mobilized, instructed to elevate the leg, and referred panding hematoma, absent pulse, distal ischemia, or to an orthopedist in 2 to 4 days. The exception is the bruit/thrill over the popliteal artery. None of the 27 severely locked knee, in which case the orthopedist patients with negative findings during their physi- should be consulted while the patient is in the ED. cal examinations during their hospitalization ever developed limb ischemia, needed a surgical proce- Knee Dislocation dure for a vascular injury, or experienced limb loss. Despite its dense protective shell of 11 cruciate and This limited series demonstrates that serial physical collateral ligaments and tendons, significant blunt examinations have a 94.3% positive predictive value forces can cause subluxation of the tibia over the and 100% negative predictive value in diagnosing femur, causing dislocation of the knee.75 This often popliteal artery injury.79 occurs as a result of a high-speed motor vehicle ac- Dennis et al reported a study of 38 knee disloca- cident, but it can also occur during a sports activity, tions. Two of these patients had hard vascular signs such as football, waterskiing, or skateboarding. Knee and popliteal artery occlusion on angiography. The dislocations are classified according to the direction remaining dislocations had no hard signs of vascular that the tibia is displaced in relation to the femur. injury. Fifty percent of these were treated conserva- Of knee dislocations, 50% to 60% are anterior, but tively with no angiography and no adverse seque- popliteal artery injury is most commonly associ- lae. The remaining patients had selective angiogra- ated with posterior dislocations.76,77 The prevalence phy, revealing intimal defects or narrowing of the of popliteal artery injury in association with knee popliteal artery, all of which were treated conserva- dislocations varies from 21% to 80%.78 The risk of tively with no reported complications.84 vascular injury appears to be less when the disloca- Some authorities believe that serial physical tion is relatively low energy, such as those associated examinations can obviate the need for arteriography with athletic events.4 in patients with a knee dislocation that has been There is a high incidence of spontaneous reduc- reduced and who have normal physical examination tion of a dislocated knee before ED evaluation, and results. Doppler pressure measurements may serve the evaluating emergency clinician must maintain as rapid methods for assessing the vascular status. a high index of suspicion for this injury. The patient When the ankle/brachial pressure ratio (obtained by may give a history of the knee popping out and then dividing the ankle Doppler arterial pressure by the popping back into place. On examination, the knee brachial Doppler arterial pressure) is less than 0.8, arteriography should be considered.77

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 53 Risk Management Pitfalls For Orthopedic Sports Injuries

1. “He said that he just turned his ankle. He and the patient needs to be referred to an ortho- didn’t mention hearing a pop. I didn’t think he pedist in a timely manner. would have an Achilles injury.” All patients with an ankle or foot injury should 6. “He said he had knee pain. His knee exami- have their Achilles tendon examined for injury, nation results were normal, so I diagnosed a as this can present in a similar manner as an strain and discharged him.” ankle sprain. This is often a surgically correct- Hip disorders can cause referred knee pain and able injury that must not be missed. should be considered in any patient with knee pain and normal knee examination results. 2. “I know she was in too much pain to let me Even if there is no complaint of hip pain, the hip stress her knee, but it seemed like a simple should be examined, and this should be docu- knee strain. I didn’t think she needed referral mented. to an orthopedist.” Internal derangements of the knee may be dif- 7. “The results of her shoulder series of radio- ficult to diagnose in the acute setting because graphs were normal. The technician forgot to of pain and edema. A conservative approach of do an axillary view, but I didn’t think it was referral is usually warranted for any patient for important.” whom an internal derangement is suspected. Sometimes the only way to diagnose a posterior shoulder dislocation is via an axillary (or 3. “I’m pretty sure that he broke his humeral scapular-Y) view. This is an important injury head as a result of the fall that caused his that cannot be missed. It is the responsibility of shoulder dislocation. I really don’t think I did the ordering emergency clinician to be sure that it as a result of the reduction.” an appropriate series of radiographs is obtained. Yes, but you can’t prove it. Whenever possible, obtain a radiograph of a patient with a suspect- 8. “He was too sleepy after the conscious seda- ed shoulder dislocation before attempting reduction I gave him to reduce his elbow dislocation. The emergency clinician should attempt tion. He didn’t complain of any numbness or a “blind” reduction only if there is evidence of weakness in his hand.” serious neurovascular compromise and if there Ulnar nerve entrapment should be considered will be a significant delay in obtaining a radio- after reduction of an elbow dislocation. The pa- graph. tient may not volunteer that he or she has ulnar nerve distribution numbness and weakness. 4. “I didn’t think he had a knee dislocation. His This needs to be tested and documented before knee joint appeared normal on x-ray.” and after the reduction. Many knee dislocations reduce spontaneously before evaluation by a emergency clinician, and 9. “His x-ray results were normal. I didn’t think all that remains is edema and ligamentous insta- he broke his ankle. Sure, he couldn’t bear bility. Consider the mechanism of injury (es- weight on it, but he’s just a kid. They heal pecially high-energy injuries) and the patient’s quickly, right?” history with regard to the appearance of the In children, fractures are more common than knee just after the injury. Document a thorough sprains. Some Salter-Harris injuries are difficult neurovascular examination (including ankle/ to detect on initial radiograph. Use caution and brachial index in the case of significant trauma) assume a fracture to be present; then treat it ac- and always consider a popliteal artery injury. cordingly. Assume a dislocation if the knee is grossly unstable on examination. 10. “How could he have ruptured his quadriceps muscle? He was able to walk, and I could move 5. “You manage a Jones fracture the same as any his knee without any problem.” other metatarsal fracture—with a cast shoe. Patients with rupture of the extensor mechanism Right?” of the knee can still can walk and have normal Wrong. These injuries have a higher number of passive range of motion—they just cannot ex- complications, such as nonunion, and need to tend their knee against gravity. be immobilized properly with a posterior splint,

54 An Evidence-Based Approach To Traumatic Emergencies The dislocation should be reduced immediately It is important to evaluate the knee for ligamentous with longitudinal traction after appropriate analge- or meniscal injuries, because 12% of patella disloca- sia and sedation. The reduction is usually accom- tions will have a concomitant major injury.72 Severe plished with very little difficulty. The leg should be hemarthrosis is most commonly seen with an osteo- placed in a long leg posterior splint with 15° to 20° chondral fracture or ACL injury. Standard radio- of flexion. graphs should be evaluated for avulsion fracture, Current recommendations continue to mandate intraarticular fragments, osteochondral fracture, and that absent pedal pulses or signs of distal isch- patella dislocation.4,88,89 emia require immediate angiography and vascular To reduce a patella, extend the patient’s leg surgery consultation. Those patients with a delay in while applying gentle pressure on the patella in diagnosis often fail to revascularize within the 6 to 8 the medial direction. Conscious sedation may be recommended hours, resulting in unnecessarily high required. Once reduced, place the knee in an immo- amputation rates. Greater than 8 hours of ischemic bilizer in full extension with ice application for 20 time leads to an 85% amputation rate compared with minutes per hour during the first 24 hours. The knee 85% successful revascularization when ischemia immobilizer should be worn for 3 to 7 weeks, with lasts less than 8 hours.85 progressive weight bearing as tolerated. Refer the Perron’s study points out that dislocations that patient to an orthopedist. spontaneously reduce have the same risk of arterial injury as those knees still dislocated. Thus, patients Patella Tendon Rupture with blunt knee trauma without “hard signs” of Ruptures of the patella tendon usually result vascular injury, with an ankle-brachial index greater from pivoting, twisting, or a deceleration, such as than 0.9, and with normal pulses require frequent rebounding in basketball. They are usually associ- neurovascular checks. Patients who do not meet ated with other significant ligamentous injuries. those criteria need emergent angiograms. On examination, place the knee in 90° of flexion A 2009 case report in the Journal of Emergency and palpate for a gap in the tendon or a high- Medicine cautions against confusing compartment riding patella (patella alta). It is important to note syndrome with popliteal injury in patients without that patients with quadriceps or patellar tendon lower extremity pulses.86 In a patient (thought to ruptures can still walk. (They have a peculiar be assaulted) complaining only of lower extrem- forward-leaning gait that allows gravity to ex- ity pain, compartment pressures were found to be tend the knee.) The best way to test the extensor elevated, radiographs revealed no fractures, the mechanism is to have the patient extend his or her white blood cell count was elevated at 21,000, he- knee against gravity—passive range of motion moglobin was 8.8 g/dl, and an anion gap acidosis may be normal. Radiographs may reveal a patella of 25 mEq/L was found. riding high on the femur rather than in its usual Only after an emergent fasciotomy and persis- location over the knee joint. tent absence of lower extremity pulses did a com- Early diagnosis of patellar tendon rupture is im- puted tomography angiogram reveal the popliteal portant, as undetected injuries can lead to proximal injury. The patient had a posterior dislocation that retraction of the patella with resultant quadriceps spontaneously reduced, leading practitioners down contraction and adhesions.52 Emergent orthopedics the wrong path. Both conditions can cause severe consultation is indicated. (See Figure 10.) pain, swelling, exquisite tenderness limiting a physical examination, paresthesias, and pallor. However, General Treatment Strategies For Knee the total loss of pulses is a late finding in compart- Injuries ment syndrome, unlike the immediate loss following After any significant knee injury, protect the knee blunt knee trauma. with a knee immobilizer, placing the knee in 20° to 30° of flexion. The RICE mnemonic (rest, ice, com- Patella Dislocation pression, and elevation) is generally recommended. The common mechanism of injury for a patella Orthopedic referral is indicated for all patients with dislocation involves a twisting injury when the foot suspected ligamentous instability or a fracture.51 is planted. The patella can also dislocate following a direct blow.36,87 The patella usually dislocates later- Arthrocentesis ally and in many cases will spontaneously relocate. Arthrocentesis in the setting of a severe injury has Patients often give a history of the knee “going out limited diagnostic value. Any immediate posttrau- of place” and then returning to normal. (Also con- matic effusion is assumed to be a hemarthrosis. sider knee dislocation in this scenario.) Although fat globules in the aspirate are charac- If the physical examination reveals only a teristic of intraarticular fractures, they can also tender swollen knee and the patella appears to be represent significant soft tissue injury.90 To visual- in place, then the apprehension test may be useful. ize the globules, place the aspirate in an emesis

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 55 basin for a few minutes, allowing the globules to Achilles tendon rupture is missed in up to twisting, or a deceleration,51 such as rebounding in basketball. tends to recur within the first 24 hours due to the loss of the riseThey to are the usually surface. associated with other significant ligamen- 25%tamponade of patients effect. byThe the usual initial treatment examiner, of rest, perhapsice, compres- Arthrocentesis may permit better examination of because patients can still plantar flex (using the tous injuries. On examination, place the knee in 90º of sion, and elevation—especially compression97 —is important theflexion injured and palpate knee. Decompression for a gap in the tendon of a large or a high-riding effusion toepost-arthrocentesis. flexors and other42 muscles). Although the andpatella instillation (patella alta). of a It local is important anesthetic to note affords that patients signifi- defectIntraarticular in the tendon injection may of bemorphine palpated, and bupivacaineedema and cantwith painquadriceps relief. or This patellar relief tendon is only ruptures temporary, can still how walk.- hemorrhagehas been used canfor its quickly analgesic obscure effect after the traumatic gap. This knee ever,(They and have the a peculiar hemarthrosis forward-leaning tends to gait recur that within allows the injuryinjuries is and best elective assessed knee arthroscopy.using the Thompson’s Recent studies testhave firstgravity 24 to hours extend because the knee.) of Thethe bestloss wayof the to testtamponade the extensor (alsoshown known that both as drugs the Thompson’s reduce the need squeeze for systemic test). effect.mechanism The usualis to have treatment the patient of rest,extend ice, his compression, or her knee Theanalgesia; patient morphine is placed is more prone effective on the and bed can withprovide his relief and elevation—especially compression—is impor- or her knees flexed78,95-97 to 90° (feet in the air). The calf against gravity—passive range51 of motion may be normal. for up to 24 hours. However, these few studies have all tantRadiographs postarthrocentesis. may reveal a patella riding high on the femur musclesbeen done are in post-operativesqueezed just patients distal without to their acute widest injury. ratherIntraarticular than in its usual injection location of over morphine the knee andjoint. bupi- girth,The typical and dosethe movement is 1-5 mg of morphineof the foot (1 mg/mL is observed. diluted in vacaineEarly has diagnosis been used of patellar for its tendon analgesic rupture effect is important, after Thenormal absence saline toof a plantar total volume flexion of 30 mL),of the although foot defines a more traumaticas undetected knee injuries injuries can andlead toelective proximal knee retraction arthros of- the aconcentrated positive test. dose This with was less volumeshown is to a reasonablebe accurate option. in copy. Recent studies have shown that both drugs 19 of 19 cases in an autopsy series reported by patella with resultant quadriceps contraction and adhe- 98 reducesions.43 Emergentthe need orthopedicsfor systemic consultation analgesia; is morphine indicated. (See ThompsonAchilles Tendon and Doherty. Rupture Although this test can is more effective and can provide relief for up to 24 have negative results with partial tears, incom- Figure 91-9410.) Of all spontaneous tendon ruptures, complete Achilles hours. However, these few studies have all been pletetendon injuries tears are are most thought closely associatedto be uncommon. with sports doneGeneral in postoperative Treatment Strategies patients Forwithout Knee severe Injuries injury. activities.MRI 44is This diagnostic injury usually but is occursusually with left sudden to the accelera-con- TheAfter typical any significant dosage kneeis 1 toinjury, 5 mg protect of morphine the knee with(1 mg/ sultant.tion or jumping, Some emergency such as in soccer, clinicians track obtain and field, plain basket- mL diluted in normal saline to a total volume of 30 radiographs to exclude a fracture, as associated ankle a knee immobilizer, placing the knee in 20º-30º of flexion. ball, or racquet sports, but it can even occur just99-101 by stepping mL),The RICE although mnemonic a more (rest, concentrated ice, compression, dosage and elevation)with less oroff foot a curb. fractures44 Conditions are sporadically that predispose reported. to Achilles tendon Treat- volumeis generally is a recommended. reasonable option. Orthopedic referral is indicated mentrupture involves include castingrheumatoid and/or arthritis, a surgical gout, systemic procedure. lupus for all patients with suspected ligamentous instability or Iterythematosus, is important hyperparathyroidism,to make this diagnosis chronic at the renal time failure, of Achillesa fracture.42 Tendon Rupture initialand corticosteroid evaluation, or because fluoroquinolone this can use.be a79,80 debilitating The patient Of all spontaneous tendon ruptures, complete Achil- injuryusually if experiences left untreated. a sudden If the pop patient or snap is indischarged, the foot or lesArthrocentesis tendon tears are most closely associated with splintankle withthe foot associated in plantar pain. flexionThe pain andmay havebe minimal the patient and 53 73 sportsArthrocentesis activities. in the This setting injury of an usually acute injury occurs has with limited seeresolve the orthopedistspontaneously. within several days. suddendiagnostic acceleration value. Any orimmediate jumping, post-traumatic such as in soccer, effusion is Achilles tendon rupture is missed in up to 25% of trackassumed and to field, be a hemarthrosis. basketball, orWhile racquet fat globules sports, inbut the it can Gastrocnemiuspatients by the initial Strain examiner,81 perhaps because patients 53 evenaspirate occur are justcharacteristic by stepping of intraarticular off a curb. fractures, Conditions they Gastrocnemiuscan still plantar flex strain, (using also the knowntoe flexors as and“tennis other leg,” is thatcan alsopredispose represent to significant Achilles soft-tissuetendon rupture injury.77 include In order amuscles). strain involving While the defectthe musculotendinous in the tendon may be junction palpated, of rheumatoidto visualize the arthritis, globules, gout, place systemic the aspirate lupus in an erythema emesis - theedema medial and hemorrhagehead of the can gastrocnemius quickly obscure and the the gap. Achil This - tosus,basin forhyperparathyroidism, a few minutes, allowing chronic the globules renal tofailure, rise to and lesinjury tendon. is best The assessed injury using occurs the Thompson following’s atest vigorous (also 95, 96 corticosteroidthe surface.42 or fluoroquinolone use. The patient propulsiveknown as the movement Thompson ’suchs squeeze as a test). jump The or patient sudden is usuallyArthrocentesis experiences may a sudden permit better pop orexamination snap in the of footthe start.placed The prone patient on the reports bed with a hispop or in her the knees medial flexed upper to 90º orinjured ankle knee. with Decompression associated pain. of a The large pain effusion may and be mini- calf.(feet Therein the air). is instant The calf pain, muscles and are spasm squeezed of the just calf distal mus to - malinstillation and resolve of a local spontaneously. anesthetic affords significant pain relief. clestheir results widest ingirth, plantar and the flexion. movement On ofexamination, the foot is ob- there This relief is only temporary, however, and the hemarthrosis isserved. exquisite The absencepoint tenderness of plantar flexion at the of medial the foot junction defines a ofpositive the middle test. This and was proximal shown to thirds be accurate of the in calf. 19 of Swell 19 cases- Figure 10. Knee Injuries ingin an and autopsy ecchymosis series reported usually by occur Thompson distally. and AssessDoherty. the82 Figure 10. Knee injuries. AchillesWhile this tendon test can function be negative using with the partial Thompson’s tears, incomplete test. Treatmentinjuries are involvesthought to a be posterior uncommon. splint with the foot at 90°.MRI Dorsiflexion is diagnostic butmust is usuallybe started left towithin the consultant. 24 hours 51 postinjurySome physicians to regain obtain ankle plain motion.radiographs to exclude a fracture, as associated ankle or foot fractures are sporadi- callyED Evaluation:reported.83-85 Treatment Ankle Injuriesinvolves casting and/or surgery. It is important to make this diagnosis at the time of Theinitial May evaluation, 2002 issue because of Emergency this can be Medicinea debilitating Practice, injury if “Ankleleft untreated. Injuries If the In patientThe ED: is discharged,How To Provide splint the Rapid foot in Andplantar Cost-Effective flexion and have Assessment the patient Andsee the Treatment,” orthopedist fea- A B C D tureswithin a severalfull discussion days.63 of ankle injuries. Key points A: Rupture of a quadriceps tendon; B: Fracture of the concerning sports-related ankle injuries follow. A: Rupture of a quadriceps tendon; B: Fracture of the patella; C: Rup- patella; C: Rupture of the patella tendon; D Avulsion of ture of the patella tendon; D: Avulsion of the tibial tuberosity. GastrocnemiusAnkle sprains Strain are the most common of all the tibial tuberosity. ankleGastrocnemius injuries (85%strain, of also all known severe as ankle “tennis injuries leg,” is area strain 102 Reproduced with permission from: Simon R, Koenigsknecht S. sprainsinvolving the) and musculotendinous are especially likelyjunction to of be the sustained medial Reproduced with permission from: Simon R, Koenigsknecht S. 52 EmergencyEmergency Orthopedics: TheThe Extremities. Extremities. New New York: York: McGraw-Hill; McGraw-Hill; inhead sports of the and gastrocnemius recreational and activities. the Achilles At tendon. present, The 1995:362.1995:362. Figure 27-4. functionalinjury occurs treatment following isa vigorousthe rule, propulsive and less impormovement-

56EmergencyAn Medicine Evidence-Based Practice Approach To Traumatic16 Emergencies www.empractice.net • April 2003 such as a jump or sudden start. The patient reports a pop in and the base of the fifth metatarsal should be targeted for special tancethe medial is attributed upper calf. to There differentiating is instant pain, between and spasm single of aattention, neurovascular as these bones examination, are statistically and the mostrange-of-motion likely injured.88 andthe calf multiple muscles ligament results in plantarinjuries. flexion.52 The On ankle examination, is often examination.A standard Tendernessradiographic over series the of navicular the foot includes and the AP, injuredthere is exquisite during pointfootball tenderness when a at player the medial attempts junction to of baselateral, of andthe fifth45º internal metatarsal oblique should views. be Overlapping targeted for bones,special changethe middle direction and proximal quickly thirds on ofan the outside calf. Swelling leg that and is attention,accessory centers as these of bonesossification, are statistically and sesamoids the most can likely plantedecchymosis during usually pivoting. occurs distally. A player’s Assess ankle the Achilles may also tocomplicate be injured. interpretation.105 4 betendon injured function by being using thestepped Thompson on. ’s test. Treatment A standard radiographic series of the foot involves Some a posterior controversy splint exists with the regarding foot at 90 ºthe. Dorsiflexion optimal includesTypes Of AP,Injuries lateral, and 45° internal oblique views. musttreatment be started of ankle within sprains. 24 hours A post-injury recent systematic to regain OverlappingA variety of athletic bones, activities accessory can result centers in foot of ossification,injuries. An anklereview motion. of 1242 studies of high methodological quality andinjury sesamoids identified with can increasingcomplicate frequency interpretation. in snowboarders4 evaluated functional treatment versus immobiliza- (but difficult to detect on plain radiographs) is fracture of tion.Emergency The data Department favor the functional Evaluation: approach (early Typesthe lateral Of process Injuries of the talus.89 The midfoot is also fre- mobilizationAnkle Injuries as tolerated) for the following out- quentlyA variety injured, of athletic especially activities the tarsometatarsal can result in joint, foot also comes: return to work and sports, short-term resolu- knowninjuries. as AnLisfranc injury’s joint. identified A Lisfranc with injury increasing is any injury fre- to The May 2002 issue of Emergency Medicine Practice, “Ankle tion of swelling, and intermediate subjective stabil- thisquency joint inor bonessnowboarders contiguous (but with difficult the joint. 43to These detect injuries on Injuries In The ED: How To Provide Rapid And Cost- ity. Immobilized patients were more likely to have plaincan occur radiographs) in a sport that is fractureinvolves fixationof the lateralof the forefoot, process of Effective Assessment And Treatment,” features a full impaired range of motion. Patients in the functional thesuch talus. as equestrian106 The midfootactivity and is alsowindsurfing. frequently This injured, injury also discussion of ankle injuries. Key points concerning sports- management group were more likely to be satisfied especiallyoccurs in football the tarsometatarsal when the player joint,sustains also a blow known to the as related ankle injuries follow. with their care in the short and intermediate term Lisfranc’sback of the heel,joint. or A in Lisfranc baseball injurywhile sliding is any into injury a base. to 43 Ankle sprains are the most common of all ankle injuries and tended to report less pain. No differences were this Onjoint examination, or bones contiguous there is tenderness with the along joint. the52 dorsal These (85% of all acute ankle injuries are sprains86) and are noted between subjective stability and rates of recur- injuriesaspect of canthe midfoot occur in and a sportvariable that amounts involves of swelling. fixation of especially likely to be sustained in sports and recreational rent ankle pain.103 theJoint forefoot, laxity may such be present. as equestrian Spontaneous activity reduction and wind of this- activities.43 At present, functional treatment is the rule, and Current treatment advocates early mobilization surfing.fracture often This occurs, injury resulting also occurs in subtle in footballradiographic when the less importance is attributed to differentiating between for lateral ankle sprains. Unfortunately, pain may playerchanges. sustains On the lateral a blow view, to thelook back for anatomic of the heel, alignment or in of single and multiple ligament injuries.43 The ankle is often be a limiting factor in enabling patients to meet this baseballthe dorsal while margin sliding of the first into metatarsal a base.52 with the lateral injured during football when a player attempts to change therapeutic goal. A 2006 double blind, randomized cuneiform.On examination, AP views should there reveal is tenderness exact alignment along of the the direction quickly on an outside leg that is planted during study in the Annals of Emergency Medicine compared dorsalmedial edgeaspect of theof thesecond midfoot metatarsal and variableand intermediate amounts pivoting. A player’s ankle may also be injured by being extended release acetaminophen with ibuprofen for ofcuneiform. swelling. Fractures Joint laxity of the maybases be of present.the metatarsals Spontane or - stepped on. grade I or II lateral ankle sprains. Although acet- ouscuboid reduction fracture suggestof this severefracture ligamentous often occurs, injury resulting as well. Some controversy exists regarding the optimal treat- aminophen is an efficacious analgesic, studies have inInitial subtle management radiographic involves changes. splinting On and the outpatient lateral view, ment of ankle sprains. A recent systematic review of 12 never been conducted to prove efficacy in ankle lookorthopedic for anatomic referral to alignment assess the need of the for dorsal surgical margin repair.43 of studiessprains. of The high study’s methodological noninferior quality design evaluated revealed functional that treatmentacetaminophen vs. immobilization. was no worse The datathan favor ibuprofen the functional and approachspared some (early of mobilization the gastrointestinal as tolerated) symptoms, for the following such Figure 11. Foot Anatomy outcomes:as nausea return and dyspepsia, to work and commonly sports, short-term experienced resolution Figure 11. Foot anatomy. ofafter swelling, ibuprofen and intermediate ingestion.104 subjective stability. Immobi- lized It patients was thought were more that likely ibuprofen to have wasimpaired needed range to of motion.treat these Patients injuries, in the because functional it managementhas anti-inflammatory group were more likely to be satisfied with their care in the short and effects that acetaminophen does not possess. How- Phalanges intermediateever, we can term conclude and tended from to this report study less thatpain. the No swell- Fore- differencesing resulting were from noted mild between to moderate subjective injuries stability suchor rates as of recurrent ankle pain.87 foot grades I and II lateral ankle sprains will spontane- Metatarsals ously resolve, and treatment to decrease the inflam- Emergency Department Evaluation: mation is not necessary. 1 Foot Injuries 2 3 Mid- C C foot C Anatomy,ED Evaluation: History, FootAnd Physical Injuries Examination Cuboid The foot is divided into three anatomic regions: the Navicular

Anatomy,hindfoot, which History, includes And the talus Physical and calcaneus; Examination the Hind- Talus Themidfoot, foot whichis divided includes into the 3 anatomic navicular, regions:cuboid, and the foot hindfoot,cuneiforms; which and the includes forefoot, the which talus includes and calcaneus; the metatar- the Calcaneus midfoot,sals, phalanges, which and includes sesamoids. the navicular, (See Figure cuboid, 11.) and cuneiforms;Determine and thewhether forefoot, the injury which was includes a result the of direct metatar- b traumasals, phalanges, or a torsional and force. sesamoids. Ask the ( patientSee Figure about 11. the) location Determine of the pain, whether ability to the ambulate, injury wasas well a resultas previous of a: Anteroposterior radiograph of a normal adult foot; a: Anteroposterior radiograph of a normal adult foot; b: Schematic injuries and operations. A directed physical examination b: Schematic representation of the bones of the foot. direct trauma or a torsional force. Ask the patient representation of the bones of the foot. shouldabout theinclude location inspection of the for pain, edema ability and ecchymosis, to ambulate, palpation to localize pain, a neurovascular examination, and Reproduced with permission from: Harris JH Jr, Harris WH. The and previous injuries and operations. A directed RadiologyReproduced of Emergencywith permission Medicine. from: 4th Harris ed. Philadelphia:JH Jr, Harris WH.Lippincott, The range-of-motionphysical examination examination. should Tenderness include over inspection the navicular for WilliamsRadiology & ofWilkins; Emergency 2000:868. Medicine. Figure 4th 1. ed. Philadelphia: Lippincott, edema and ecchymosis, palpation to localize pain, Williams & Wilkins; 2000:868. Figure 1. April 2003 • www.empractice.net 17 Emergency Medicine Practice Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 57 (See Figure 12.) ion also helps to relieve pain and control swelling.43 43 (Seethe firstFigureThe Jones 12metatarsal.) fracture is witha transverse the lateral fracture cuneiform. at the proximal AP ionbetweenCortisone also helps theor anesthetic toseverity relieve injectionspainof the and mechanism control are not swelling.indicated and the and viewsmetaphyseal-diaphysealThe should Jones fracture reveal is exacta junctiontransverse alignment of thefracture fifth of atmetatarsal.the the medial proximal (See Cortisonedegreecan prolong of or injury recovery.anesthetic to 90the injections Lisfranc are joint, not indicated meaning and that 90 metaphyseal-diaphysealedgeFigure of 13 the.) This second is commonly metatarsal junction confused of and the withintermediatefifth ametatarsal. fracture of (See the cana simple prolong fall recovery. has caused complete dislocation of the Figurecuneiform.tuberosity 13.) Thisof Fracturesthe is fifth commonly metatarsal of the confused bases base. ofThesewith the a are metatarsalsfracture different of the joint.Special The Considerations best indicator for For severity Injuries of injury was the tuberosityorinjuries cuboid and of fracture requirethe fifth diverse suggestmetatarsal management. severe base. Theseligamentous The are Jones different fractureinjury SpecialtotalIn Young number Considerations Athletes of fractured Formetatarsals Injuries and whether injuriesashas well. a significant and Initial require managementrisk diverse of delayed management. involvesunion or non-union. Thesplinting Jones fracture Theand Inthe Young midtarsal Athletes region was involved. hasoutpatientmechanism a significant oforthopedic injury risk of is delayeda loadreferral applied union to assess orto thenon-union. lateralthe need forefoot The for SchmidtAn articleand Hollwarth in Annals compared of Emergency the frequency Medicine of sports Schmidt and Hollwarth compared the frequency91 of sports mechanismsurgicalwithout inversion, repair. of injury52 such is a asload in sportsapplied involving to the lateral running forefoot and concernedinjuries in children about with the theircommon physical misdiagnosis location. They of Lis- injuries in children with their physical location.91 They without jumping.Although inversion,4 Most metatarsalLisfranc such as ininjuriesfractures sports involving arecan rarebe treated (occurringrunning with and a francfound fractures/dislocationsthat almost 44% of all injuries points involve out the that upper gross 4 found that almost 44% of all injuries involve the upper jumping.incast 1 shoe,per 55,000 Mostbut the metatarsal personsJones fracture fracturesper year),requires can misdiagnosis be splinting treated andwith oca - subluxationextremities, 16% or involve lateral the deviation head, and of 34.5% the involveforefoot the is extremities, 16% involve the head, and 34.5% involve the castcurspossible shoe, in approximatelysurgical but the management.Jones fracture 20% Anrequiresof allacute cases. splinting fracture107 Prolonged canand be oftenlower extremities.not present. The109 peak The incidence usual symptoms for injuries isare age mid 12.- lower extremities. The peak incidence for injuries is age 12. possibledisabilitytreated by surgical immobilization and chronicmanagement. pain in a posteriorAn can acute result splintfracture from with can misdiag non- be - footIn general, pain, sprains, swelling, contusions, and difficulty and lacerations bearing account weight. for In general, sprains, contusions, and lacerations account for treatednosisweight-bearing or by delay immobilization and of appropriateorthopedic in a posterior referral. treatment. 4splint with An articlenon- Whilemost injuries. holding In the the lower hindfoot, extremities, the practitioner the knee joint is the 4 most injuries. In the lower extremities,51,74 the knee joint is the weight-bearingin theTurf Journal toe refers andof Traumato orthopedic a sprain reports of referral. the firstthat metatarsopha- the injury is shouldmost commonly gently injuredsupinate area. and pronate the forefoot. most commonly injured area.51,74 frequentlylangealTurf joint. toe refers missed This toterm a in sprain was the coined EDof the although infirst 1976, metatarsopha- when no data the are This maneuver will invoke pain in patients with langealpresented joint. to This support term was that. coined108 Vuori in 1976, does when comment, the aEpiphyseal Lisfranc injury. Injuries Edema persisting after 10 days injury was attributed to hard, artificial turf playing sur- Epiphyseal Injuries injurythough,faces.43 was In thatmost attributed Lisfranc cases, tothe hard, jointinjury artificial injuries occurs turf as can a playing result be caused of sur- by shouldThe ligaments initiate and a articular workup capsule for Lisfranc are firmer injuries. than bone The 43 The ligaments and articular capsule are92 firmer than bone faces.low-energyhyperextension In most trauma, cases, (dorsiflexion) the such injury asof occurs thea stumble joint. as a Examination result or fall, of 33% distaland the skin, epiphyseal dorsalis plate pedis in children. pulse, Asand a result, capillary trauma to and the epiphyseal plate in children.92 As a result, trauma to hyperextensionofreveals the time.pain and (dorsiflexion) swelling of the of thegreat joint. toe Examinationwith painful refillthis region should of the be maturing gauged skeleton because usually cases injures of dorsalis the this region of the maturing skeleton4 usually injures the reveals rangeHigh-energy of pain motion. and swellingRadiographs forces of cause the may great the show toe same witha capsular percentage painful of pediscartilaginous compression epiphyseal or plate. laceration These injurieshave been result report from - cartilaginous epiphyseal plate.4 These injuries result from rangeinjuries,avulsion of motion. fractureand the Radiographs involving article advocates the may first show metatarsal keeping a capsular head this or injury edshearing following and avulsion Lisfranc forces trauma. as well110 as compression. The shearing and avulsion forces as well as compression. The avulsioninthe mind base offracture for the a proximalsimple involving twisting phalanx. the first injuryThe metatarsal mainstay to the head offorefoot treatment or cartilaginousThe Jones cells fracture of the is epiphysis a transverse may fracturebe damaged, at the cartilaginous cells of the epiphysis may be damaged, thewithfor basethis persistent injury of the isproximal rest, pain. which Nophalanx. isassociation difficult The mainstay to enforcewas discovered of in treatment some proximalresulting inmetaphyseal-diaphyseal premature closure of the epiphyseal junction ofplate the and resulting in premature closure of the epiphyseal plate and forathletes. this injury Compression is rest, which dressing, is difficult elevation, to enforce and ice in are some also fifthdisturbance metatarsal. in bone See( growth. Figure (See 13. Figure) This 14 ison commonly page 19.) disturbance in bone growth. (See Figure 14 on page 19.) athletes.useful, as Compression well as NSAIDs. dressing, Taping elevation, the toe toand resist ice aredorsiflex- also confused with a fracture of the tuberosity of the fifth useful, as well as NSAIDs. Taping the toe to resist dorsiflex- metatarsalUpper-Extremity base. These Injuries are different injuries and Figure 12. Lisfranc Fracture-Dislocation With Upper-Extremity Injuries Figure 12. Lisfranc fracture-dislocation with an requireThe clavicle diverse is the management.most commonly The fractured Jones bone fracture in has An Avulsion Fracture (Arrow) Of The Lateral The clavicle81 is the most commonly fractured bone in Figure 12. Lisfranc fracture-dislocation with an achildren. significant Most risk of these of delayed fractures unionare greenstick or nonunion. injuries ofThe Aspectavulsion fractureOf the (arrow)First Cuneiform of the lateral aspect of children.81 Most of these fractures are greenstick injuries of avulsion fracture (arrow) of the lateral aspect of mechanismthe midshaft clavicle.of injury Associated is a load neurovascular applied to the injury lateral is the first cuneiform. the midshaft clavicle. Associated neurovascular injury is the first cuneiform. forefootrare. However, without as in inversion, adults, posterior such asdisplacement in sports involv of the - rare. However, as in adults, posterior displacement of the ingclavicle running from theand sternoclavicular jumping.4 Most joint metatarsal can cause compres- fractures clavicle from the sternoclavicular joint can cause compres- cansion beof thetreated trachea with or mediastinal a cast shoe, vessels. but the Treatment Jones fracture is sling sionof the of shoulder the trachea and or analgesia. mediastinal vessels. Treatment is sling of the shoulder and analgesia.

FigureFigure 13 13.. Jones Jones fracture. Fracture Figure 13. Jones fracture.

This patient complained of injuring her ankle, and the This patient complained of injuring her ankle, and the Thisankle patient was complained examined of radiographically.injuring her ankle, and The the frontalankle was (a) exam- ankleand internally was examined rotated radiographically. oblique (b) projections The frontal (a) andined radiographically.internally rotated The frontal oblique (a) and (b) internally projections rotated oblique (b) projectionsdemonstrate demonstrate the Jones the Jones fracture fracture (arrow) (arrow) of of the base base of ofthe demonstratethe fifth metatarsal. the Jones fracture (arrow) of the base of thefifth fifthmetatarsal. metatarsal. Reproduced with permission from: Harris JH Jr, Harris WH. The Reproduced with permission from: Harris JH Jr, Harris WH. The ReproducedRadiology of withEmergency permissionpermission Medicine. from: from: 4th Harris Harris ed. Philadelphia:JH JH Jr, HarrisHarris WH. WH.Lippincott, The The ReproducedRadiology of withEmergency permission permission Medicine. from: from: 4thHarris Harris ed. JHPhiladelphia: JH Jr,Jr, Harris WH.WH. Lippincott, The The RadiologyWilliams & ofof Wilkins; EmergencyEmergency 2000:885. Medicine. Medicine. Figure 4th 4th 46. ed. ed. Philadelphia: Philadelphia: Lippincott, Lippincott, RadiologyWilliams & of Wilkins; EmergencyEmergency 2000:883. Medicine. Medicine. Figure 4th 4th 40. ed. ed. Philadelphia: Philadelphia: Lippincott, Lippincott, Williams & Wilkins;Wilkins; 2000:885.2000:885. Figure Figure 46. 46. Williams & Wilkins; 2000:883.2000:883. Figure Figure 40. 40. Emergency Medicine Practice 18 www.empractice.net • April 2003 Emergency Medicine Practice 18 www.empractice.net • April 2003 58 An Evidence-Based Approach To Traumatic Emergencies requires splinting and possible surgical manage- a result of hyperextension (dorsiflexion) of the joint. ment. A severe fracture can be treated by immobili- Examination reveals pain and swelling of the great zation in a posterior splint with nonweight bearing toe with painful range of motion. Radiographs may and orthopedic referral.4 show a capsular avulsion fracture involving the first Turf toe refers to a sprain of the first metatar- metatarsal head or the base of the proximal phalanx. sophalangeal joint. This term was coined in 1976, The mainstay of treatment for this injury is rest, when the injury was attributed to hard, artificial turf which is difficult to enforce in some athletes. Com- playing surfaces.52 In most cases, the injury occurs as pression dressing, elevation, and ice are also useful, as well as NSAIDs. Taping the toe to resist dorsi- flexionalso helps to relieve pain and control swelling.52 Cortisone or anesthetic injections are not indicated Figure 14. Salter-Harris Classification Of 111 Epiphyseal-Metaphyseal Fractures and can prolong recovery. Special Considerations For Injuries I. Widened In Young Athletes

Schmidt et al compared the frequency of sports inju- 112 Non-displaced Displaced ries in children with their physical location. They found that almost 44% of all injuries involve the II. upper extremities, 16% involve the head, and 34.5% involve the lower extremities. The peak prevalence for injuries is age 12. In general, sprains, contusions, and lacerations account for most injuries. In the Non-displaced Displaced lower extremities, the knee joint is the most commonly injured area.61,87 III. Epiphyseal Injuries The ligaments and articular capsule are firmer than bone and the epiphyseal plate in children.113 As a Non-displaced Displaced result, trauma to this region of the maturing skeleton usually injures the cartilaginous epiphyseal plate.4 IV. These injuries result from shearing and avulsion forces as well as compression. The cartilaginous cells of the epiphysis may be damaged, resulting in premature closure of the epiphyseal plate and distur- Non-displaced Displaced bance in bone growth. (See Figure 14.) Impaction V. Compression Upper Extremity Injuries The clavicle is the most commonly fractured bone in children.97 Most of these fractures are greenstick injuries of the midshaft clavicle. Associated neurovas- • Type I: The epiphyseal line (physis) is widened secondary to some cular injury is rare. However, as in adults, posterior degree of epiphyseal separation. The epiphysis may or may not be displacement of the clavicle from the sternoclavicu- displaced. lar joint can cause compression of the trachea or • Type II: There is some large or small metaphyseal fracture fragment mediastinal vessels. Treatment is sling of the shoul- in association with widening of the epiphyseal line. The epiphysis and der and analgesia. fracture fragment may or may not be visibly displaced. GH dislocations are unusual before physeal closure. • Type III: In this type, the fracture occurs through the epiphysis and As in adults, most dislocations are anterior. Diagno- the fracture may or may not be displaced. When displacement occurs, sis and treatment are the same. Orthopedic referral often only part of the fractured epiphysis is displaced. is essential, as many of these patients can develop • Type IV: A fracture exists through the epiphysis and the metaphysis; chronic instability. displacement of the fragments may or may not be present. More than 50% of elbow fractures are supracon- • Type V: An impaction fracture with injury of the epiphyseal plate only is present. No roentgenographic findings other than swelling around dylar and occur as a result of a fall on an outstretched the involved epiphyseal-metaphyseal junction usually are present. arm with hyperextension at the elbow. Direct vascular injury is uncommon, but the pulse may be dimin- Reproduced with permission from: Swischuk LE. Emergency Imaging ished secondary to arterial spasm. Neurologic deficits of the Acutely Ill or Injured Child. 4th ed. Philadelphia: Lippincott Wil- are usually transient but can be due to direct nerve liams & Wilkins; 2000. Figure 4.8. injury. Emergent orthopedic consultation is usually

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 59 General Treatment Principles For Musculoskeletal Injuries

The RICE regimen (rest, ice, compression, and 10°C (50° F) to 15°C (59° F). Using repeated rather elevation) is generally recommended for patients than continuous ice applications helps sustain re- with orthopedic sports injuries. Analgesia—usually duced muscle temperatures without compromising NSAIDs—may also be appropriate, depending on the skin. There are no large, randomized studies to the circumstances. help the emergency clinician decide how often and A systematic literature review suggests that how long to use ice.115 melted ice water applied through a wet towel for Heat is generally not recommended for severe 10-minute intervals is the most effective technique injury, but it has theoretical benefit. No large, con- for lowering the temperature of the underlying trolled trials of heat therapy for severe injury were structures, but there is no proof that this affects clini- found in 1 MEDLINE search.114 cal outcome.114 The target temperature reduction is

required for these injuries. Forearm compartment proximal tibia is avulsed secondary to flexion, twist- syndrome is a feared complication. ing, or hyperextension. The elbow is dislocated more often than any In pediatric knee injuries, radiograph results other major joint in children and adolescents, but may be normal but be suggestive of a significant it is still an unusual injury. Associated fractures are injury if the knee is unstable. An unwary emergency common. Neurovascular examination is important to clinician may mistake a tibial tubercle for an avul- evaluate for ulnar nerve and brachial artery injury.97 sion fracture. Meniscal problems in this age group are uncommon.65 Hip/Pelvis Injuries Physeal fractures in the region of the knee may be 4 The presence of unfused epiphyses predisposes the associated with ligamentous injuries. Immobilization pediatric hip and pelvis to traction injuries. Large and prompt orthopedic referral are mandatory. fragments of bone can be avulsed with sudden and unexpected loads. The anterior superior iliac spine Ankle Injuries can be avulsed during football when the kicking foot The twisting injuries that cause a fracture in adults is suddenly blocked or tackled. The psoas muscle produce a different pattern of injury in the im- can also avulse off the lesser trochanter. The whole mature skeleton. Inversion trauma to the ankle of apophyseal plate of the ischium can separate via a a skeletally immature patient frequently causes pull of the hamstrings. This can be caused by over- separation of the distal fibularphysis and spares the stretching the leading leg while running. Treatment lateral ligaments. Physeal fractures are commonly for any of these injuries is conservative, and a surgi- misdiagnosed as ankle sprains, because spontane- cal procedure is rarely needed.65 ous reduction usually occurs and radiographs reveal no bony abnormality.52 In general, ankle fractures in Knee Injuries children are minimally displaced. However, when An avulsion injury may mimic a tear of the ACL. they involve the articular surface, they may require a The ACL remains intact, but a large piece of the surgical procedure.

Cost-Effective Strategies For Orthopedic Sports Injuries

1. Do not x-ray every knee, ankle, or foot. The Ot- 3. Avoid the use of ketorolac for severe musculo- tawa knee, ankle, and foot criteria are sensitive skeletal injuries. Ibuprofen has been shown to and specific. Adherence to these criteria whenbe just as effective for severe pain and is signifi- ever possible will decrease the number of knee cantly less expensive. If ibuprofen is ineffective radiographs ordered.61 in relieving the patient’s pain, opioid narcotic 2. Do not order an MRI from the ED for knee inju- analgesics should be prescribed. ries. MRI is an outpatient study that should be 4. Learn to use intraarticular lidocaine to reduce ordered by the orthopedic consultant who will shoulder dislocations. It is less expensive and be treating the patient. faster than intravenous sedation and is just as efficacious.23,24

60 An Evidence-Based Approach To Traumatic Emergencies Conclusion 7. Hendey GW, Kinlaw K. Clinically significant abnormalities in post-reduction radiographs after anterior shoulder dislocation. Ann Emerg Med. 1996;28(4):399-402. (Retrospective; Although sports injuries are common, they do pres- 175 patients) ent several distinct challenges to the emergency 8. Kahn JH, Mehta SD. The role of post-reduction radiographs clinician. Above all, the emergency clinician must after shoulder dislocation. J Emerg Med. 2007;33(2):169-173. accurately determine whether the injury is stable 9. Williams RJ. Significant pneumothorax complicating a or unstable. This key determination drives further fractured clavicle. J Accid Emerg Med. 1995;2(3):218-219. (Case management, including the type of follow-up and report) referral that are necessary. Knowing which types of 10. Post M. Current concepts in the treatment of fractures of the Clin Orthop. Review serious injuries can masquerade as seemingly trivial clavicle. 1989;245:89-101. ( ) injuries will serve the patient and emergency clini- 11. Anderson K, Jenson PO. Treatment of clavicle fracture: figure of 8 bandage vs. simple sling.Acta Orthop Scand. cian alike. 1987;58(1):71-74. (Prospective; 79 patients) Radiography associated with orthopedic sports 12.* Blake R, Hoffman J. Emergency department evaluation and injuries is costly, and the radiographs are often nega- treatment of the shoulder and humerus. Emerg Med Clin tive. Important aspects of the history and physical North Am. 1999;17(4):859-876. (Review) examination, including some physical examination 13. McLaughlin JA, Light R, Lustrin I. Axillary artery injury as a maneuvers, can help obviate the need for radiog- complication of proximal humerus fractures. J Shoulder Elbow raphy under some circumstances and increase the Surg. 1998;7(3):292-294. (Case report) index of suspicion for serious injury in others. Clini- 14. McManus JG, Morton MJ. Use of ultrasound to assess acute fracture reduction in emergency care settings. Am J Disaster cal decision rules such as the Ottawa ankle rules, Med. 2008;3(4):241-247. Ottawa knee rules, and Pittsburgh knee rules are 15. McNeil CR, McManus J. The accuracy of portable ultra- medically appropriate and cost-effective. sonography to diagnose fractures in an austere environment. Prehosp Emerg Care. 2009;13(1):50-52. References 16. Bossart PJ, Joyce SM, Manaster BJ, et al. Lack of efficacy of ‘weighted’ radiographs in diagnosing acute acromioclavicular separation. Ann Emerg Med. 1988;17(1):20-24. (Compara- Evidence-based medicine requires a critical ap- tive, randomized, controlled trial; 83 patients) praisal of the literature based on study methodology 17. Tzannes A, Murrell GA. Clinical examination of the unstable and number of participants. Not all references are shoulder. Sports Med. 2002;32(7):447-457. (Review) equally robust. The findings of a large, prospective, 18. Ghafil D, Putz P. Subnormal functional activity in a ne- randomized, and blinded trial should carry more glected posterior dislocation of the shoulder. Acta Orthop weight than a case report. Belg. 1998;64(3):339-342. (Case report) To help the reader judge the strength of each 19. Perlmutter GS. Axillary nerve injury. Clin Orthop. reference, pertinent information about the study, 1999;368:28-36. (Review) such as the type of study and the number of patients 20. Perlmutter GS, Apruzzese W. Axillary nerve injuries in contact sports: recommendations for treatment and rehabilita- in the study, is included in bold type following the tion. Sports Med. 1998;26(5):351-361. (Review) reference, where available. In addition, the most 21. De Laat E, Visser C. Nerve lesions in primary shoulder dis- informative references cited in the chapter, as deter- locations and hymeral neck fractures: a prospective clinical mined by the authors, are noted by an asterisk (*) and EMG study. J Bone Joint Surg Br. 1994;76-B:381-383. next to the number of the reference. 22. Grate I. Luxatio erecta: a rarely seen but often missed shoulder dislocation. Am J Emerg Med. 2000;18(3):317-321. (Case 1. Centers for Disease Control and Prevention (CDC). Nonfatal series) sports- and recreation-related injuries treated in emergency 23. Kosnik KJ, Shamsa F, Raphael E, et al. Anesthetic methods departments—United States, July 2000-June 2001. MMWR for reduction of acute shoulder dislocations: a prospec- Morb Mortal Wkly Rep. 2002;51(33):736-740. (Epidemiological tive randomized study comparing intraarticular lidocaine data) with intravenous analgesia and sedation. Am J Emerg Med. 2. Bleakely C, MacAuley D. The quality of research in sports 1999;17(6):566-570. (Prospective, randomized, controlled journals. Br J Sports Med. 2002;36(2):124-125. (Review) trial; 49 patients) 3. Owen S, Itamura JM. Differential diagnosis of shoulder 24. Matthews PE, Roberts J. Intraarticular lidocaine versus ininjuries in sports. Orthop Clin North Am. 2001;32(3):393-398. travenous analgesia for reduction of acute anterior shoulder (Review) dislocation. Am J Sports Med. 1995;23(1):54-58. (Prospective; 30 patients) 4. Marx JA, Hockberger RS, Walls RH, et al, eds. Rosen’s Emer- gency Medicine. 5th ed. St. Louis, MO: Mosby; 2002. (Text- 25. Miller SL, Cleeman E, Auerbach J, et al. Comparison of in- book) traarticular lidocaine and intravenous sedation for reduction of shoulder dislocations. J Bone Joint Surg. 2002;84:2135-2139. 5. Fraenkel L, Shearer P, Mitchell P, et al. Improving the selec- (Prospective; 30 patients) tive use of plain radiographs in clinically evident anterior shoulder dislocation. Am J Emerg Med. 1999;17(7):653-658. 26. Moharari RS, Khademhosseini P. Intra-articular lidocaine (Prospective; 206 patients) versus intravenous meperidine/diazepam in anterior shoulder dislocation: a randomised clinical trial. Emerg Med 6. Shuster M, Abu-Laban RB, Boyd J. Prereduction radiographs J. 2008;25:262-264. in clinically evident anterior shoulder dislocation. Am J Emerg Med. 1999;17(7):653-658. (Prospective; 97 patients) 27. Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Orthop Clin North Am. 1980;2:253-270. (Review)

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Posterior elbow dis- parison of two clinical decision rules for the use of radi- location with associated vascular injury after blunt trauma. J Trauma. 1999;46(5):948-950. (Retrospective; 4 patients)

62 An Evidence-Based Approach To Traumatic Emergencies ography in acute, high-risk knee injuries. Ann Emerg Med. 91. VanNess SA, Gittins ME. Comparison of intra-articular mor- 1998;32(1):8-13. (Prospective, blinded, multicenter; 934 phine and bupivacaine following knee arthroscopy. Orthop patients) Rev. 1994;23(9):743-747. (Prospective; 81 patients) 71. Khine H, Dorfman DH, Avner JR. Applicability of Ottawa 92. Guler G, Karaoglu S, Velibasoglu H, et al. Comparison of knee rule for knee injury in children. Pediatr Emerg Care. analgesic effects of intra-articular tenoxicam and morphine 2001;17(6):401-404. (Prospective; 234 patients) in anterior cruciate ligament reconstruction. Knee Surg Sports 72. Laskowski ER. Snow skiing. Phys Med Rehabil Clin N Am. Traumatol Arthrosc. 2002;10(4):229-232. (Randomized, con- 1999;10(1):189-211. (Review) trolled trial; 42 patients) 73.* Roberts JR. Roberts’ Practical Guide to Common Medical Emer- 93. Ho ST, Wang TJ, Tang JS, et al. Pain relief after arthroscopic gencies. Philadelphia, PA: Lippincott-Raven; 1996:211-219. knee surgery: intravenous morphine, epidural morphine, (Textbook) and intraarticular morphine. Clin J Pain. 2000;16(2):105-109. (Randomized, controlled trial; 75 patients) 74. Shetty AA, Tindall AJ. Accuracy of hand-held ultrasound scanning in detecting meniscal tears. Bone Joint Surg Br. 94. Lundin O, Rydgren B, Swärd L, Karlsson J. Analgesic 2008;90(8):1045-1048. effects of intra-articular morphine during and after knee arthroscopy: a comparison of two methods. Arthroscopy. 75. Roman PD, Hopson CN, Zenni EJ Jr. Traumatic dislocation 1998;14(2):192-196. (Randomized, controlled trial; 50 pa- of the knee: a report of 30 cases and literature review. Orthop Rev. 1987;16(12):917-924. (Clinical trial, review) tients) 76. Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: 95. Kao NL, Moy JN, Richmond GW. Achilles tendon rupture: initial assessment and implications for treatment. J Orthop an underrated complication of corticosteroid treatment. Trauma. 1997;11(7):525-529. (Retrospective; 50 patients) Thorax. 1992;47(6):484. (Letter) 77. Potter HG. Imaging of the multiple-ligament-injured knee. 96. Huston KA. Achilles tendinitis and tendon rupture due to Clin Sports Med. 2000;19(3):425-441. (Review) fluoroquinolone antibiotics.N Engl J Med. 1994;331(11):748. (Letter) 78. Kendall RW, Taylor DC, Salvian AJ, et al. The role of arteriography in assessing vascular injuries associated with 97. Landvater SJ, Renstrom PA. Complete Achilles tendon rup- dislocations of the knee. J Trauma. 1993;35(6):875-878. (Retro- tures. Clin Sports Med. 1992;11(4):741-758. (Review) spective; 35 patients) 98. Thompson TC, Doherty JH. Spontaneous rupture of 79.* Miranda FE, Dennis JW, Veldenz HC, Dovgan PS, Frykberg tendon of Achilles: a new clinical diagnostic test. J Trauma. ER. Confirmation of the safety and accuracy of physical exam- 1962;2:126-129. (Case series) ination in the evaluation of knee dislocation for injury of the 99. Lubin JW, Miller RA, Robinson BJ, et al. Achilles ten- popliteal artery: a prospective study. J Trauma. 2002;52(2):247- don rupture associated with ankle fracture. Am J Orthop. 251; discussion 251-252. (Prospective; 35 patients) 2000;29(9):707-708. (Case report) 80. Melton SM, Croce MA, Patton JH Jr, et al. Popliteal artery 100. Assal M, Stern R, Peter R. Fracture of the ankle associated trauma. Systemic anticoagulation and intraoperative throm- with rupture of the Achilles tendon: case report and review bolysis improves limb salvage. Ann Surg. 1997;225(5):518- of the literature. J Orthop Trauma. 2002;16(5):358-361. (Re- 527; discussion 527-529. (Follow-up study; 102 patients) view, case report) 81. Rose SC, Moore EE. Trauma angiography: the use of clinical 101. Martin JW, Thompson GH. Achilles tendon rupture: findings to improve patient selection and case preparation.J occurrence with a closed ankle fracture. Clin Orthop. Trauma. 1988;28(2):240-245. (Retrospective; 280 patients) 1986;(210):216-218. (Case report) 82. Bryan T, Merritt P, Hack B. Popliteal arterial injuries associ- 102. Garrick JG. The frequency of injury, mechanism of in- ated with fractures or dislocations about the knee as a result jury, and epidemiology of ankle sprains. Am J Sports Med. of blunt trauma. Orthop Rev. 1991;20(6):525-530. (Retrospec- 1977;5(6):241-242. (Retrospective; 2840 patients) tive; 73 patients) 103. Kerkhoffs GM, Rowe BH, Assendelft WJ, et al. Immobilisation 83. Gable DR, Allen JW, Richardson JD. Blunt popliteal artery for acute ankle sprain; a systematic review. Arch Orthop Trauma injury: is physical examination alone enough for evaluation? Surg. 2001;121(8):462-471. (Literature review; 22 studies) J Trauma 1997;43(3):541-544. (Review) 104. Dalton JD Jr, Schweinle JE. Randomized controlled noninfe- 84. Dennis JW, Jagger C, Butcher JL, et al. Reassessing the role of riority trial to compare extended release acetaminophen and arteriograms in the management of posterior knee dislo- ibuprofen for the treatment of ankle sprains. Ann Emerg Med. cations. J Trauma. 1993;35(5):692-695; discussion 695-697. 2006;48(5):615-623. (Retrospective; 37 patients) 105. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules 85. Perron AD, Brady WJ, and Sing RF. Orthopedic pitfalls in the for the use of radiography in acute ankle injuries: refinement ED: vascular injury associated with knee dislocation, Am J and prospective validation. JAMA. 1993;269(9):1127-1132. Emerg Med. 2001;19:583-588. (Prospective survey: validation and refinement of the origi- 86. Steele HL, Singh A. Vascular injury after occult knee disloca- nal rules (first stage) and validation of the refined rules tion presenting as compartment syndrome. J Emerg Med. (second stage); 1032 patients in the first stage, 453 patients 2009; (Epub ahead of print) in the second stage) 87. Bruns W, Maffulli N. Lower limb injuries in children in 106. Janes PC, Paul C. The snowboarder’s talus fracture. Paper sports. Clin Sports Med. 2000;19(4):637-662. (Review) presented at: 10th International Symposium on Skiing Trauma and Safety; May 1993; Zellam See, Austria. (Review) 88. Krodel A, Refior HJ. Patellar dislocation as a cause of osteochondral fracture of the femoro-patellar joint. Unfallchirurgie. 107. Kaplan JD, Karlin JM, Scurran BL, et al. Lisfranc’s fracture- 1990;16(1):12-17. German. (Retrospective; 78 patients) dislocation: a review of the literature and case reports. J Am Podiatr Med Assoc. 1991;81:531-539. 89. Nietosvaara Y, Aalto K, Kallio PE. Acute patellar dislocation in children: incidence and associated osteochondral fractures. J 108. Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms Pediatr Orthop. 1994;14(4):513-515. (Prospective; 72 patients) and associated injuries. J Trauma. 1993;35:40-45. 90. Gregg JR, Nixon JE, DiStefano V. Neutral fat globules in trau- 109. Englanoff G, Anglin D. Lisfranc fracture-dislocation: a fre- matized knees. Clin Orthop. 1978;(132):219-224. (Prospective; quently missed diagnosis in the emergency department. Ann 146 patients) Emerg Med. 1995;26(2):229-233.

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 63 110. Arntz CT, Hansen ST. Dislocations and fracture disloca- 21. Reduction of glenohumeral dislocations: tions of the tarsometatarsal joints. Orthop Clin North Am. a. Requires orthopedic consultation in the vast 1987;18:105-114. majority of cases 111. Wedmore IS, Charette J. Emergency department evaluation b. Generally requires conscious sedation and treatment of ankle and foot injuries. Emerg Med Clin North Am. 2000;18(1):85-113, vi. (Review) c. Can often be performed with intraarticular 112. Schmidt B, Hollwarth ME. Sports accidents in children and lidocaine, which shortens ED stays and adolescents. Z Kinderchir. 1989;44(6):357-362. (Retrospective; reduces costs significantly, instead of 2617 patients) conscious sedation 113. Spongeller P, Beatty JH. Fractures and dislocations about the d. Does not require orthopedic follow-up in knee. In: Fractures in Children. 4th ed. Philadelphia, PA: children Lippincott-Raven; 1996. (Textbook) 114.* MacAuley D. Ice therapy: how good is the evidence? Int J 22. All of the following are true about “jersey fin- Sports Med. 2001;22(5):379-384. (Review) ger” except: 115.* MacAuley D. Do textbooks agree on their advice on ice? Clin J Sport Med. 2001;11(2):67-72. (Review) a. It is a rupture of the extensor tendon that attaches to the dorsal side of the distal phalanx of the finger. CME Questions b. It is a tear of the flexor digitorum profundus. c. The physical examination is diagnostic of 17. Patients with low-risk shoulder injuries in- this injury. clude: d. The finger should be splinted with the finger a. Those with no fall and no swelling and wrist flexed and urgently referred to a b. Those with a fall but no swelling or pain hand specialist for operative management. at rest c. Those with a fall and pain at rest but no 23. Rotator cuff tears: swelling and normal range of motion a. Are usually acute d. Any of the above b. Can be identified by supra- and e. None of the above infraspinatus atrophy, weakness with elevation or external rotation of the 18. Two-part proximal humeral fracture-disloca- shoulder, or the impingement sign tions should be reduced in the ED. c. Require MRI for ED diagnosis a. True d. Usually don’t require analgesia b. False 24. The unilaterality, brevity, and pain-free range 19. All of the following are true about clavicle of motion in the athlete can assist in discrimi- fractures except: nating between a “stinger” and a cervical cord a. They usually result from a direct blow to the injury. clavicle or a fall on an outstretched arm. a. True b. Pneumothorax is a common complication of b. False clavicle fracture. c. Most clavicle fractures occur in the middle 25. The sport most likely to result in an elbow third of the clavicle. dislocation is: d. Randomized, controlled clinical trials show a. Gymnastics equivalent outcomes with figure-of-eight b. Tennis clavicle straps and simple slings for c. Football middle-third clavicle fractures. d. Weight-lifting

20. The appropriate disposition of patients with 26. A “hip pointer”: glenoid fractures is: a. Is a contusion of the iliac crest a. Immobilization and orthopedic referral b. May result in severe disability because the within three days iliac crest serves as an anchor for abdominal b. Urgent orthopedic consultation and hip musculature c. Urgent surgical consultation c. Usually results from a direct blow to the hip d. Discharge home with the RICE regimen and d. Is treated with ice, analgesics, and possibly a NSAIDs six-to-eight-day steroid burst to reduce the duration of disability e. All of the above

64 An Evidence-Based Approach To Traumatic Emergencies 27. ACL tears and meniscal injuries are more likely to result from sports injuries than other mechanisms. a. True b. False

28. The Lachman test evaluates the ACL and is the single best clinical test for determining the integrity of the ACL. a. True b. False

29. All of the following are part of the Ottawa knee rules except: a. The patient is 55 years or older b. There is tenderness at the head of the fibula or isolated tenderness of the patella c. The patient is unable to flex the knee to 90º d. The patient is unable to take four steps both at the time of injury and at time of evaluation e. The injury is more than seven days old

30. Meniscal injuries: a. Classically involve joint line pain, swelling, and locking b. Can be ruled out by a negative McMurray test c. Require urgent orthopedic consultation d. Can be ruled out if the knee has been fractured or displaced

31. In orthopedic foot injuries, the navicular and the base of the fifth metatarsal are statistically the least likely to be injured. a. True b. False

32. All of the following are true about sports injuries in children except: a. The ligaments and articular capsule are firmer than bone and the epiphyseal plate. b. 44% of all the injuries involve the upper extremities, 16% involve the head, and 34.5% involve the lower extremities. c. In contrast to adults, trauma in children is more likely to injure the cartilaginous epiphyseal plate than ligaments. d. Epiphyseal injuries are unlikely to disturb future bone growth.

Orthopedic Sports Injuries: Off The Sidelines And Into The Emergency Department 65 66 An Evidence-Based Approach To Traumatic Emergencies Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking

Authors CME Objectives John A. Marx, MD Upon completing this article, you should be able to: Chair and Chief, Department of Emergency Medicine, Carolinas Medical 1. Name typical mechanisms of injury for solid and hollow visceral Center, Charlotte, NC; Clinical Professor, Department of Emergency trauma. Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 2. Explain the appropriate diagnostic approach based upon the clinical scenario. 3. Describe which clinical and laboratory features are useful for patients Peer Reviewers with blunt abdominal trauma. 4. Adapt the management approach in the context of special patient and Carolyn J. Sachs, MD, MPH clinical circumstances. Assistant Professor, UCLA Emergency Medicine Center, Los Angeles, CA Date of original release: May 1, 2001. Alan E. Jones, MD Date of most recent review: August 1, 2009. Chief Resident, Carolinas Medical Center, Charlotte, NC

Four a.m. — things are just starting to calm down in the they develop indications for specific diagnostic ED. Suddenly, a worried mom arrives with her 14-year- studies.1 Decision trees vary widely among institu- old son. It seems he was doing tricks on his scooter, and tions according to the reliability and availability of during a flip he rammed the handlebar into his upper the various technologies as well as the experience abdomen. He wouldn’t eat dinner and started vomiting and preference of emergency clinicians, trauma around midnight. His belly is fairly benign except for a surgeons, and radiologists at the respective sites.2,3 bruise just below his xiphoid. Oh, well — it’s probably What is clear is that pragmatic thinking, attention to just another case of gastroenteritis. detail, and effective clinical algorithms will help the emergency clinician detect occult injury and treat the he belly is benign” takes its place among oth- traumatized patient. This chapter outlines just such “Ter cringe-causing statements in the emergen- an approach. cy medicine lexicon (such as “Remember that older gentleman you sent home last night?”). What should Epidemiology accompany such abominable proclamations is the trailing caveat “but he’s intoxicated...is head in- Blunt abdominal trauma is responsible for 10% of all jured...has a fractured femur...has a seat belt mark... trauma deaths. Motor vehicle crashes and automo- has a cervical cord injury...” and so forth. Worse, bile/pedestrian injuries are responsible for one-half though, is the failure even to suspect that abdominal to three-quarters of blunt abdominal injury, and as- trauma is a possibility in the well-appearing patient. saults and falls make up the majority of the remain- The diagnostic approach to blunt abdominal der.4 Importantly, the bulk of patients with abdomi- injury has shifted in the past 4 decades. Before the nal trauma present within the context of multisys- advent of diagnostic peritoneal lavage (DPL) in tem trauma. These are often patients involved in a 1964, clinical examination was the primary modal- high-speed crash who present with simultaneous ity. However, its limited accuracy led to a consider- closed head injury, hemopneumothorax, multiple able number of unneeded laparotomies and, more extremity fractures, and numerous lacerations. disturbingly, failure to operate in a timely manner Nonaccidental trauma in children can be an on those in need. DPL was the mainstay from its especially elusive diagnosis. A history of child abuse inception until the 1980s, when computed tomogra- is often difficult to secure based on the child’s fear phy (CT) became routinely available. Over the past coupled with the parents’ misdirection.5 These small decade, ultrasonography (US) has found its way into patients may also suffer less common injuries, such the mix, mostly as a noninvasive replacement for as duodenal hematoma or pancreatic injury. Like- DPL to search for intraperitoneal blood. Today, these wise, domestic violence may result in occult abdomi- 4 tools are used in various combinations for differing nal trauma, especially in females and, more par- clinical scenarios in emergency departments (EDs) ticularly, in pregnant women. Iatrogenic injury can across the country. be induced by bag-mask ventilations, inadvertent Current practice emphasizes cost-effective and esophageal intubation, external cardiac compres- efficient approaches. This may include a strategy of sions, and the Heimlich maneuver.6,7 simply observing patients with reliable examinations without any positive findings unless and until

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 67 Pathophysiology Prehospital Care

Three basic mechanisms cause intraabdominal Paramedics are the emergency clinicians’ eyes and injury.8 First, an external force applied to the ante- ears at the scene. They can transmit invaluable infor- rior wall and the posterior thoracic cage or vertebral mation on the mechanism of injury and can deter- column can crush those organs caught between. This mine seat belt use, starred windshields, bent steering is more likely to occur to solid organs (particularly wheels, and vehicular intrusion. They provide clues the liver and spleen) and in those with lax abdomi- to severity of injury by reporting prehospital vital nal walls (typical of the elderly as well as alcoholic signs and neurologic status. patients). Second, abrupt and powerful external From a management perspective, the “scoop and forces can suddenly increase intraabdominal pres- run” strategy prevails. Procedures such as intrave- sure and burst a hollow viscus. This is exemplified nous insertion and intubation can usually be carried by lap belt injuries.9 Third, extreme acceleration- out in the rig. Wherever possible, paramedics should deceleration can shear the solid viscera as well as notify receiving hospitals regarding high-acuity vascular pedicles. patients to allow preparation.12 The appropriate The spleen is the most frequently damaged receiving hospital is determined by a combination of intraperitoneal organ, followed by the liver. The triage-scoring systems and paramedic judgment.13 intestine is the most likely hollow viscus to sustain Nearly all studies show that the pneumatic an- injury. tishock garment (PASG), a device prematurely popu- larized in the 1970s, is ineffective in most patients Differential Diagnosis who suffer blunt trauma.14 However, in 1 retrospective, nonrandomized study, severely hypotensive Sure, it is possible that a patient presenting with trauma patients (blood pressure ≤ 50) seemed to 15 abdominal pain and tenderness following a major car benefit from the application of the PASG. How- crash is simply doubled over from preexistent pelvic ever, it or an alternative pelvic-stabilizing device is inflammatory disease, appendicitis, lead poisoning, indicated to mitigate the massive retroperitoneal or even acute intermittent porphyria. Guess again. hemorrhage that can occur in patients with pelvic 16 The traditional differential formula does not adapt fracture. Although it appears reasonable that the well to abdominal trauma. With that in mind, though, PASG would assist hemorrhage control in unstable there are 3 considerations that warrant mention: pelvic fractures, no large, randomized, controlled 1. Single- versus Multisystem Trauma: Major trials have evaluated this. forces inflicted by vehicles at high speeds tend to Finally, recent studies have elaborated potential produce multisystem trauma. It is ill-considered risks of aggressive crystalloid resuscitation, especially 17,18 to suppose that a patient thrown 50 feet from in patients with penetrating torso trauma. This the train that hit him has an isolated leg fracture. issue remains unresolved at this time, specifically for Suspect the abdomen in this scenario. the patient with blunt trauma. It is reasonable, then, to 2. Single- versus Multiple-Organ Injury: There place lines in the field but to avoid overzealous fluid has been considerable emphasis in the past administration, particularly in those patients injured 15 years on avoiding laparotomy when there shortly before transport who have brief transport is known or strongly suspected isolated solid times. Although the definition of “overzealous” re- organ (ie, spleen, liver) injury. This is especially mains a moving target, high-volume infusions are not true in children.10 Unfortunately, coincident hol- indicated in those with relatively stable vital signs. low viscus rupture is not rare in these circumstances and can be very difficult to identify by ED Evaluation clinical examination or certain diagnostic studies, such as CT.11 I had...come to an entirely erroneous conclusion which 3. Trauma versus Medical: Medical problems can shows, my dear Watson, how dangerous it always is to precipitate or coexist with trauma, especially in reason from insufficient data. the elderly. Metabolic, anaphylactic, cardiac, or —Arthur Conan Doyle, “The Adventures of the Speckled neurologic emergencies may cause the fall or Band,” 1892 motor vehicle crash. What appears to be closed head injury may simply be hypoglycemia. History Although not always available, the patient’s history Patients with enlarged or abnormal intraperi- can be extremely valuable. The patient interview may toneal organs (eg, the enlarged spleen of infectious be compromised or impossible due to severe head mononucleosis) or coagulation disorders can have injury, alcohol or drug intoxication, or the unavailabil- profound injuries subsequent to what seems to be ity of key and credible witnesses. Remote history of the most trivial trauma. trauma may be forgotten or considered trivial.

68 An Evidence-Based Approach To Traumatic Emergencies The prehospital events can provide key insight tis. Local pain can also occur; for instance, splenic and should include assessment of vital signs, physi- injury can produce pain in the left upper quadrant cal assessment, and response to therapy. Consider or referred pain in either shoulder tip or the neck. asking the paramedics, “What was the highest This referred pain is probably due to intraperitoneal pulse and lowest blood pressure?” Outside records, irritation of the diaphragm and can sometimes be including x-rays, must be reviewed carefully. elicited by placing the patient in the Trendelenburg Ask the scene personnel about the extent of position (Kehr’s sign).20 Shortness of breath may damage to the vehicle, amount of passenger com- occur with diaphragmatic irritation or the herniation partment intrusion, the condition of the steering of intraabdominal structures into the chest through wheel and windshield, whether seat belts were used, a diaphragmatic tear. Nausea and vomiting may whether front or side airbags were deployed, and accompany hypovolemia or peritoneal irritation. the speed and size of the striking vehicle. Persistent vomiting may be secondary to obstruction Certain mechanisms portend particular injury and is frequent with duodenal hematoma.21 patterns. Compressive forces, especially to the rib cage, are associated with liver and spleen fractures. Past Medical History Sudden high-energy forces over a small impact zone An understanding of the patient’s comorbid medical are known as “spearing” mechanisms (eg, nose of a conditions such as cardiovascular disease and coag- football, bike handlebars, and lap belt-only restraint). ulation disorders or coagulopathic medications (eg, These frequently result in hollow viscus injury. The warfarin) can be critical to the management schema, organ “speared” can be predicted somewhat based particularly fluid and blood component therapy. on whether the trauma was centered in the epigas- Patients on warfarin may develop life-threatening trium (duodenal hematoma or rupture, pancreatic hemorrhage after relatively minor trauma.22 contusion), mid-abdomen (jejunum, ileum), or lower abdomen (ilium, bladder). Finally, high-speed decel- Physical Findings eration (eg, a fall from 4 stories or 80 miles per hour Examine everything; then do it again...and again. into a tree) can shear solid viscera from their vascular The emergency clinician who fails to perform pedicles, most notably the kidney. complete primary, secondary, and tertiary surveys The condition of the patient at the scene may will miss clues to shock and serious injury. This suggest that a medical concern precipitated the crash admonition certainly applies to the peritoneal cavity. or fall. These underlying conditions may contribute Although the abdomen should never be ignored, it to or be wholly responsible for the patient’s status. cannot be the sole focus of the emergency clinician. Seizures, arrhythmias, and hypoglycemia are no- It may not be easy to perform a careful abdomi- table culprits. nal examination in the midst of a critical resuscita- Ask about loss of consciousness (LOC) in tion — both the patient and the emergency clinician patients who have experienced blunt trauma. In 1 may be distracted from the abdomen. However, study, transient LOC in the field was significantly abdominal tenderness, peritoneal irritation, gastroin- associated not only with head injuries but with testinal hemorrhage, and hypovolemia not attribut- extracranial injuries as well. In this series, nearly able to extraabdominal causes should always sug- 20% of patients suffering LOC required a surgical gest intraperitoneal injury. That is the good news. procedure for life-threatening injuries; many needed The bad news is that even in the alert and conscious laparotomies.19 patient, reliance on the abdominal examination can The patient with abdominal trauma may have lead to false-positive and false-negative errors.23,24 In a variety of complaints. There are 2 main presenta- some patients, the examination may be unremark- tions. First is volume loss, which, depending on the able despite intraperitoneal injury, whereas in others rate and severity of bleeding, can produce thirst, it suggests injury when none exists. This situation is orthostatic dizziness, light-headedness, confusion, made worse by compromising factors-altered sen- or obtundation. Second, irritation of the peritoneum sorium, distracting injury, and the like. Overall, the incites pain and will result directly from hematic accuracy of a single physical examination in blunt (eg, bleeding from the liver, spleen, or great vessels), abdominal trauma is 55% to 65%.2,25 infectious (eg, leaking bowel or colon), or enzymatic (eg, pancreas, bowel, gallbladder) irritation. Pain Vital Signs may be present at the outset or lag by hours to days, Blood pressure and pulse should be considered in particularly in the case of hollow viscus or pancre- context. Frank hypotension, tachycardia, or both atic injury. Remember that the sensation of pain may strongly suggest hemorrhage. However, these find- be diminished or rendered absent by the presence of ings are not specific for abdominal injury. In addi- competing pain at another body site, altered senso- tion, premorbid circumstances such as hypertension rium, possible intoxication, or spinal cord injury. and the presence of various drugs and medications Abdominal pain may be diffuse, as when it can alter or mask the response to blood loss. An follows gross hemoperitoneum and septic peritoni-

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 69 elderly patient with preexisting hypertension who However, no prospective studies have validated is taking a beta-blocker can be in profound shock this finding in the trauma patient. despite a “perfect” blood pressure of 120/80 mm Hg Forty percent of patients with hemoperitoneum and a pulse of 80. have a benign belly without any peritoneal signs.34 Even healthy adults may not develop tachycar- Although some of these patients have head trauma dia despite profound shock. In a study of more than or are intoxicated, the point remains that a physical 10,000 major trauma patients, relative bradycardia examination provides limited information. Prac- (defined as a systolic pressure < 90 mm Hg and a titioners need to be meticulous about looking for pulse rate < 90 beats per minute) occurred in nearly the caveats to the physical examination mentioned 30% of all hypotensive patients.26 above. Injury to the spleen and the resulting hemorrhage is the number one cause of hypotension after Abdominal Examination blunt abdominal trauma.35 Inspection of the abdomen may reveal distension or ecchymoses. In the case of distension, likely Extraabdominal Examination culprits include pneumoperitoneum, gastric dila- In addition to auscultation and inspection of the tation, or ileus. Distension produced by hemoperi- chest, palpate the lower chest for rib fractures. As toneum alone is extraordinarily ominous and is many as 20% of patients with left lower rib fractures an extremely late finding. Because 2 liters of free have plenic injury, whereas slightly fewer with right blood in the abdominal cavity will distend the lower rib fractures suffer liver damage.36 Assess the belly almost imperceptibly,27 never wait for this pelvis for tenderness and stability. sign to prompt laparotomy. Inspection of the bare The rectal examination is rarely of value in trunk may also reveal telltale ecchymosis. Bruis- severe blunt trauma. It may be valuable in the ing of the flanks (Grey Turner’s sign) or umbilicus male with pelvic fracture who is at risk for urethral (Cullen’s sign)28 represents hemorrhage in the injury but who has no blood at the meatus. In such retroperitoneal or peritoneal spaces, respectively. a patient, the discovery of a high-riding prostate However, these signs are typically delayed by 6 will prompt the need for urologic studies. In addi- hours to several days. tion, a sacral fracture resulting in sensory loss in the More valuable is the presence of a lap belt sign. posteromedial thigh and buttocks (S2-S4) demands This finding suggests worrisome intraabdominal assessment of rectal tone. Finally, certain intrahepat- injury-notably, perforation of the small bowel. As ic hematomas can “liquefy” and empty through the many as one-third of patients with a lap belt sign hepatobiliary tree into the duodenum and ultimately will have injury to the bowel or mesentary.29 In 1 the colon. However, this takes place 2 to 3 weeks or prospective study, 36% of patients with a seat belt more after the original trauma-a long time to wait sign required operative intervention.30 with a hemoccult card in hand. Auscultation of the injured abdomen provides Pay special attention to palpating the lumbar little information. Many experienced practitioners spine in the patient with abdominal wall ecchymo- believe that the presence of bowel sounds does not sis. Patients with a lap belt sign may have sustained rule out ileus or serious injury, and their absence a coincident burst fracture of the upper lumbar in no way proves that injury exists. However, this vertebrae (Chance fracture).37 The combination of a premise has not been subjected to in-depth study. lap belt sign and lumbar fracture places the patient Perhaps the most valuable physical finding in at very high risk for hollow viscus injury.38,39 abdominal trauma comes from palpation. Local or generalized tenderness is found in approxi- Serial Examinations mately 90% of alert patients with intraabdominal Repeated examinations by the same examiner are visceral injury.25,31 However, not all abdominal helpful in alert patients and are especially so in pa- tenderness represents intraabdominal injury. The tients with an altered sensorium. Appropriate docu- presence of thoracoabdominal wall trauma (eg, mentation should accompany these examinations. lower chest rib fractures) can make the patient wince in reaction to abdominal palpation that too Diagnostic Studies closely approaches the injured chest. Likewise, Patients in whom physical examination results are severe contusions of the abdominal wall can reliable and normal often require nothing but serial cause tenderness and guarding. Carnett’s sign examinations. In those with clinical evidence of is tenderness of the abdominal wall elicited by hemodynamic compromise or clear thoracoabdomi- palpating the abdomen during contraction of the nal injury, immediate testing is needed, including rectus muscles (as when the supine patient lifts baseline hematocrit, type and hold/cross, and 1 or 32,33 his or her head or legs off the gurney). If the more of the big 3: DPL, US, or CT. Likewise, pa- abdomen is more tender with the rectus muscle tients with blunt multisystem trauma who cannot tense and less tender with the muscles relaxed, be adequately observed in the ED should undergo this implies muscle as opposed to visceral injury.

70 An Evidence-Based Approach To Traumatic Emergencies sufficient diagnostic evaluation to preclude life- of volunteer patients with blood loss of at least 40% threatening intraabdominal injury before a nonab- of total blood volume (how much were these volun- dominal operation (eg, craniotomy, thoracotomy) teers paid?), this rate could be as high as 1500 mL in or diagnostic study (eg, aortogram). Occasionally, the first 90 minutes following injury.45 the patient with overwhelming clinical indications Although a low hemoglobin level observed for laparotomy may be taken to the operating room after injury usually indicates serious hemorrhage (OR) with no additional testing. Such patients may (and occasionally underlying anemia), most trauma include those with isolated abdominal trauma who patients have an initial hemoglobin in the normal have a rigid abdomen, refractory hypotension, and range, even despite significant blood loss.46 Serial no other possible sources of blood loss. levels are often more informative. Recall, however, that 1 liter of intravenous fluids alone (without Laboratory Studies blood loss) may decrease the hemoglobin level by I have become deeply impressed with the general reliance a point or more.47 Part of medical mythology holds on laboratory methods shown by practitioners recently that an elevated white count on the complete blood out of college, and at the same time with their inability count suggests splenic injury. However, leukocyto- accurately to observe or appreciate the significance and sis with a count of 12,000 to 20,000 and moderate value of symptoms as compared with the finding of the left shift is a common occurrence within several microscope or test tube. hours of any major injury. It is entirely nonspecific —Robert Hall Babcock, The Lancet Clinic, 191140 and has no diagnostic significance.

Overall, hematologic and chemical tests provide little Blood Type assistance to the patient with severe blunt trauma.41 Some suggest that the single most important laborato- Instead of routine testing, laboratory investigation is ry test in the seriously injured patient is the type and best tailored to the clinical circumstances. In 1 pro- crossmatch. A number of decision rules have been spective study, researchers divided trauma patients suggested to determine the need for blood typing into 2 categories: Trauma Blue-severe injury likely in the trauma patient, none of which has been pro- (Glasgow Coma Score [GCS] < 13; systolic blood pres- spectively validated. A type and screen is probably sure < 100 mm Hg at any time; significant head, chest, adequate for most patients who are hemodynami- abdominal, or proximal long bone injury; or clinical cally stable but who remain at risk for intraabdominal suspicion of need for operative or intensive care unit injury as determined by the initial evaluation. management) and Trauma Yellow-severe injury unlikely. The tests ordered for Trauma Blue included an Chemical Although often helpful, no chemical analysis needs arterial blood gas (including pH, PO2, PCO2, HCO3, base deficit, hemoglobin, sodium, potassium, and to be routine. An increased base deficit or elevated ionized calcium), blood alcohol, type and screen or serum lactate can be an early harbinger of hemor- crossmatch, and urine dipstick. rhagic shock. Substantive abnormalities such as Tests for the Trauma Yellow group were limited a base deficit of -6 or greater are strongly associ- to a venous blood gas and blood alcohol. In this ated with the need for early transfusion, increased study, no patient suffered delay in care because of intensive care unit and hospital stays, and shock- lack of laboratory testing-and cost savings were related complications.48,49 However, measures of $29.82 per patient (or $20,000 a year) at this institu- acidosis are superfluous in those in obvious shock. tion.42 However, this study did not examine the Conversely, the emergency clinician should never be equally appealing hypothesis that no tests may be reassured by a normal base deficit in the presence of required in the patient in whom the emergency clini- deteriorating vital signs. cian does not suspect serious injury. Other studies Although it would be helpful to have labora- have shown similar results.43 tory tests that could identify specific organ injury, this is simply wishful thinking. Although elevated Hematology serum transaminases may reflect hepatic injury, The hematocrit is most useful as a baseline study they can be falsely positive in patients with alcohol- or when significantly low when the patient arrives induced liver damage. Additionally, because liver (< 30%). Remember that the hematocrit reflects function test results are frequently negative despite some combination of a pretrauma value, the lag hepatic trauma, they are as likely to mislead as from hemorrhage, and dilutional effects of exog- assist in management.50 The situation is no better enous fluid administration and endogenous plasma when it comes to pancreatic trauma. Serum amy- refill.44 In patients with a 10% to 20% blood loss, the lase, lipase, and amylase isoenzymes all lack sen- endogenous plasma refill proceeds at a modest rate sitivity and specificity.51 Elevated or rising levels of 40 mL/h for the first 10 hours, continuing for 30 may indicate damage, but in and of themselves are to 40 hours. However, in a very remarkable study not conclusive.52

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 71 Urinalysis other than in the genitourinary tract. The clinical A visual examination of the urine can be extremely rules consisted of hypotension, a GCS score less than helpful for patients with significant blunt trauma. 14, costal margin or abdominal tenderness, femur The most consistent sign of serious renal injury is fracture, hematuria greater than 25 red blood cell gross hematuria. All patients with gross hematuria (RBC)/hpf, hematocrit level less than 30%, and ab- require investigation of the genitourinary system, normal chest radiograph results (rib fracture, pneu- either before laparotomy in the stable patient or after mothorax). Patients without any of these risk factors or during laparotomy for the patient with intractable will have greater risks associated with abdominal shock. For the stable patient, if the urine is clear CT scanning than benefit. Interestingly, flank tender- yellow on visual inspection, significant renal injury ness, abdominal distention, and peritoneal irritation is exceedingly unlikely. Although a visual appraisal were considered for inclusion but were left off the alone is adequate for the hemodynamically stable list because of insufficient interobserver reliability. patient, a dipstick or microscopic evaluation is 53,54 indicated in adults with shock. At least 1 study Plain Radiographs showed that a dipstick examination is adequate to The most common radiographs ordered for the 55 exclude traumatic hematuria. Children who suffer multitrauma patient consist of the chest x-ray, the significant trauma should undergo dipstick or mi- anteroposterior pelvis radiograph, and the 3-view croscopic analysis of the urine, as visual examination cervical spine series. The chest radiograph can help 56,57 alone is inadequate. distinguish pneumothorax, hemothorax, diaphrag- A dipstick urinalysis or microscopic urinalysis matic rupture, and rib fractures as well as an abnor- may tip the diagnostic scales in the patient with ab- mal mediastinal contour and other signs of potential dominal tenderness, especially when the emergency aortic disruption. clinician is not sure that the patient requires an ab- A pelvic fracture can be a significant source of dominal CT. In 1 prospective study in adult patients blood loss. Although this study is often routine in who have undergone blunt trauma, the combination the multitrauma patient, certain clinical criteria can of a tender abdomen and microscopic hematuria was safely determine its need. These clinical criteria are43 58 very specific for intraabdominal injury on CT (94%). • Unstable vital signs This combination, however, was only 64% sensitive. • Significantly altered mental status • Ecchymosis, swelling, laceration to the pelvis Radiology and surrounding structures • Blood at urethral meatus, gross hematuria Studies should be obtained only if they are likely to • Tender pelvis, sacrum, or lower lumbar spine assist management and their benefits outweigh the • Neurologic deficit in lower extremities risks. Chief among those risks is leaving the resus- • Abnormal rectal examination results (lax tone, citation area to languish in the dark and unfriendly bloody stools, abnormal prostate) confines of radiology. These dangers have earned the • Pain on hip movement CT scanner the grim nickname “the circle of death.” A recent article in the Annals of Emergency Medi- Abdominal plain radiographs have essentially cine attempted to identify patients who sustained no role in severe blunt trauma. Suggestion of sig- blunt torso trauma but who were so low risk for nificant hemoperitoneum can be seen on a supine intraabdominal injury that no radiological workup anterior-posterior AP of the abdomen, but the was warranted. The authors devised clinical predic- sensitivity pales in comparison with DPL, US, or CT. tion rules that exhibited high sensitivity and nega- Small quantities of readily detectable free intraperi- tive predictive value, as well as high levels of inter- toneal air are present in most patients with gastric, observer agreement among emergency clinicians. duodenal bulb, and colonic perforations but in a Obviously, reducing the number of CT scans would minority of patients with jejunal and ileal perfora- decrease radiation exposure and potential malignant tion. These are more readily seen on CT than plain neoplasm, the length of time in the ED, health care radiographs.59 costs, and associated risks, such as contrast material- induced nephropathy and reactions and aspiration Computed Tomography of oral contrast material. CT is supremely capable of defining injured organs. During the derivation phase, 3381 abdominal CT It is most accurate for solid visceral injury. It is often scans were performed, and it was later determined able to distinguish the presence, source, and approx- that one-third of these were not necessary per their imate quantity of intraperitoneal hemorrhage.60 clinical rules.35 The prediction rule given the most weight in their study with the highest relative risk Findings On CT for intraabdominal injury was significant hematuria, The major findings on CT relate to detection of organ which is incorrectly rarely used to screen for injuries injury and free intraperitoneal fluid. Free fluid alone

72 An Evidence-Based Approach To Traumatic Emergencies (absent signs of organ injury) in the adult patient and mesentery.72,73 The latter 2 are of particular con- can be suggestive of serious disease. One retrospec- cern, as hollow viscus injury may occur in approxi- tive study showed that exploratory laparotomy was mately 5% of patients with significant blunt abdomi- therapeutic in 94% of patients with isolated intrap- nal trauma.74 Complications, albeit uncommon, can eritoneal fluid on CT scan.61 Other studies support stem from reactions to intravenous or oral contrast this conclusion.62 material.75 In addition, oral contrast material is asso- The presence of intraabdominal free air on CT ciated with an increased likelihood of emesis, early is not an indication for laparotomy. This is because aspiration, and pneumonia.70 of the fact that free intraperitoneal air can be gener- The cost of CT scanning can be substantial, par- ated by mediastinal or pulmonary injury as well as ticularly when employed in an overly liberal fash- barotrauma and thus is not pathognomonic of hol- ion. In 1 prospective study, intraabdominal injuries low viscus perforation.59 were identified in only 11% of patients undergoing In contradistinction to DPL and US, CT scan- CT scans of the abdomen.58 ning coincidentally evaluates the retroperitoneum and therefore can be helpful in the evaluation of Ultrasonography 63 hematuria. If a hemodynamically stable patient has In the past decade, US has come to the forefront as a hemoperitoneum demonstrated by DPL or US, a a cornerstone study in the initial evaluation of the subsequent CT can evaluate organ injury and assist blunt trauma patient. Its primary role is in the detec- in the decision of whether nonoperative, expectant tion of free intraperitoneal blood via scan of Mori- 3 management is appropriate. If CT is performed son’s pouch (RUQ), the splenorenal recess (LUQ), after DPL, inform the radiologist of this fact to avoid and the pouch of Douglas (pelvis), all dependent confusing residual lavage fluid with hemoperito- portions of the intraperitoneal cavity where blood neum or succus. is likely to accumulate. (See the April 2001 issue of Emergency Medicine Practice, “Emergency Imaging Issues In Using CT For The 21st Century: Where Does Ultrasound Fit The value of the CT in trauma management depends In?”) The focused assessment with sonography in on a number of variables. Patient factors include trauma (FAST) includes these 3 views plus a subxi- hemodynamic stability and cooperation (either phoid cardiac view for the purpose of determining voluntary or pharmacologic). Scanner issues relate hemopericardium.76 to the distance the scanner is located from the ED Novel positioning may increase the sensitivity of and the generation of the machine. Helical (spiral) the FAST examination. One prospective observation- scanners provide faster examinations, with im- al study used increasing aliquots of lavage fluid in proved visualization of solid organs and reduced CT hemodynamically stable patients undergoing DPL. 64 artifacts. Spiral CT may even demonstrate areas of Trendelenburg positioning allowed recognition of active hemorrhage and can help predict the success only 400 cc of intraperitoneal fluid, compared with 65,66 (or failure) of nonoperative management. An 700 cc in the supine position.77 important caveat is that the accuracy of abdominal US has become a necessary diagnostic tool for the 67 CTs in trauma is very reader-dependent. trauma patient. The ability to assess hemodynami- The use of intravenous contrast media allows cally unstable patients without moving them from better visualization of solid organs and sharpens the the resuscitation bay has lifesaving potential. In an distinction between normal and injured tissue. How- attempt to diagnose hollow viscus injury, 289 patients ever, an oral contrast medium does not provide any sustaining severe torso blunt trauma and 195 patients significant benefit. Several studies prove that oral with severe abdominal pain were assessed for intra- contrast media rarely add to diagnostic accuracy and peritoneal free air. The sensitivity of gastrointestinal cause considerable lengthening of the time required perforation by US was 85.7% (free air visualized in 46 68,69 for study completion. One retrospective study of 54 patients) and the specificity was 99.6%.78 Three showed that 60% of patients given oral contrast me- of the 8 patients missed by US did not have free air on 70 dia had inadequate opacification of the gut. their CT. The major caveat to this study was that the practitioners performing the examinations had been Disadvantages using US for more than 5 years and were comfortable The greatest hazard of CT follows from ill-advised with abdominal examinations. or poorly supervised studies wherein the dynamics Free air was diagnosed if a high-echoic spot of illness cause stable patients to crash and unstable or area with hyperechoic tail was detected in the patients to die. In 1 large review of blunt trauma, the ventral space of the liver, which was easily mov- authors described 2 preventable deaths, both sec- able and changed its image with compression. This ondary to operative delay associated with obtaining study supports the need for emergency clinicians to 71 an abdominal CT. become skilled at identifying free air with US. It is a Other disadvantages of CT include its modest useful adjunct to CT, especially when free air is visu- sensitivity for injury of the pancreas, small bowel,

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 73 alized on the CT adjacent to the diaphragm, which was reduced significantly in the US group (60 min could be a false-positive result. Two patients in the from 157 min).84 This fact alone should motivate all study had a false-positive CT finding; however, free emergency clinicians to become sufficiently skilled air was not seen with US. Having this modality can at FAST, a feat that takes approximately 2 hours.85 reduce the number of unnecessary laparotomies An important aspect of FAST is that it is a good because of false-positives on the CT scan. “rule in” test with a likelihood ratio of 86 for tests with positive findings. The negative predictive value Advantages of 0.98 makes it a useful screening tool to rule out US has many advantages. First of all, it is accurate. patients as well.85 A recent study examined 2576 patients who under- However, a potentially problematic issue with went US for blunt abdominal trauma. Fewer than FAST scans is that its goal is confusing. FAST is 2% had a false-negative examination. Overall, US not used to detect intraabdominal organ injury had a sensitivity of 86%, a specificity of 98%, and but rather the bleeding that is often secondary to an accuracy of 97% for detection of intraabdominal an injured abdominal organ. Thus, although there injuries.79 One study showed that in the hypotensive may be an injury, FAST will only be diagnostic if patient with blunt abdominal trauma, US is 100% there is resulting bleeding. When there is not a sensitive and specific.80 significant amount of bleeding or fluid, which often The instrument is portable and routinely housed occurs in bowel, mesenteric, and diaphragmatic in the trauma resuscitation room and can accomplish injuries, the FAST examination will have negative the FAST examination in fewer than 5 minutes. Sen- results. Most studies suggest that 250 to 620 ml of sitivity for detection of as little as 100 mL, but more fluid must accumulate before FAST can be diagnos- typically 500 mL, of intraperitoneal fluid ranges tic.85 Although less fluid is needed if the patient is from 60% to 95%, with excellent specificity.80 placed in the Trendelenburg position. Second, it can US can replace DPL in rapidly answering the take some time for a significant amount of blood key question of whether hemoperitoneum is pres- to accumulate after an injury. Thus, to ensure that ent. In contrast to DPL, US can also evaluate the there is no intraperitoneal fluid in a patient based mediastinum, is not invasive, and can be performed solely on sonography, FAST should be repeated 4 to repeatedly by multiple individuals. In contrast to 6 hours after the initial scan.85 CT, it poses no radiation or contrast material hazard, Although performing the FAST before enough and usage is not restricted to radiologists. Accuracy fluid has accumulated can lead to a false-negative of performance is correlated with length of train- test, waiting too long can lead to the same result. If ing and experience, but competence can readily be too much time has elapsed, blood can clot and ap- acquired. In 1 study, emergency clinicians were able pear hyperechoic or isoechoic, making recognition to detect hemoperitoneum more than 90% of the difficult. Additionally, an empty bladder can lead to time after only 2 hours of training (1 hour, theory; 1 missing free fluid in the pelvis, resulting in a false- hour, practical).81 All in all, US provides a relatively negative scan. If a foley is inserted before the FAST accurate, rapid, safe, and less expensive diagnostic examination or if it is necessary to repeat the FAST, screening tool.82 the emergency clinician can irrigate saline through the foley to refill the bladder provided that there are Limitations no contraindications.85 It is important to understand that, in the United As is often true for CT, US often fails to recog- States at least, US is not used to image solid nize bowel injury, but relies on the visualization parenchymal damage, the retroperitoneum, or of small amounts of intraperitoneal fluid. Studies the diaphragm. Technical difficulties can occur in show that the majority of patients with isolated obese patients, as well as those with a great deal bowel and mesenteric injury have a negative US of of bowel gas or subcutaneous emphysema. In gen- the abdomen.86 eral, US is less sensitive than DPL for the presence of hemoperitoneum. Like DPL, US is insensitive Miscellaneous when there is organ injury but no free intraperi- Angiography is an invasive and time-consuming toneal blood, as in subcapsular hematoma of the procedure. Its use is generally restricted to 2 instanc- spleen. In 1 retrospective review, surgical or anes. Most often, it is employed as a diagnostic and giographic intervention (or both) was required in therapeutic agent for bleeding pelvic vessels. Oc- 26 patients (17%) without hemoperitoneum; such casionally, in selected centers, it is used to detect and patients would be expected to have a FAST exam embolize actively bleeding intraparenchymal vessels with negative results.83 (usually in the spleen).87 In patients for whom pan- FAST has dramatically improved ED through- creatic injury is suspected, endoscopic retrograde put time for patients with blunt abdominal trauma. cholangiopancreaticoduodenography (ERCP) is The first sonography outcomes assessment program used to evaluate the ductal system.88 trial (SOAP-1) revealed the median time till the OR

74 An Evidence-Based Approach To Traumatic Emergencies Special Procedures 2 hours is required before this dissection can occur, but the accuracy of this in humans is unknown. In Diagnostic Peritoneal Lavage the hemodynamically stable patient with a pelvic After nearly 40 years, DPL remains a valued tool fracture, a DPL with positive results by red cell criteria should ordinarily prompt CT to better define the in abdominal trauma. It entails 2 steps. First is the 90 attempted aspiration of free intraperitoneal blood need for laparotomy. (known as peritoneal aspiration or peritoneal tap). Second is the lavage portion, in which fluid is used Techniques DPL can be conducted by closed (Seldinger tech- to wash the peritoneal cavity then is recovered by 91 gravity drainage and subsequently analyzed. nique), semiopen, or open technique. Relative contraindications to DPL include a prior midline Advantages surgical procedure, history of significant intraperi- The signal virtue of DPL is in the multiple trauma toneal infection, coagulopathy, obesity, or second or patient with hemodynamic instability. DPL, like third trimester of pregnancy. However, any of these US, can promptly discover or refute the presence of can be overcome when necessary. intraperitoneal hemorrhage. It is sensitive to bowel The open method is the most arduous and perforations, where other diagnostic tests (CT, US) is reserved for circumstances in which the other often fail. It is especially valuable in patients who techniques have failed or are deemed unsafe, as in are poor candidates for ongoing clinical evalua- the presence of pelvic fracture, pregnancy, obesity, tion because of severe head injury, for example (see or a prior abdominal surgical procedure. (See Table Table 1). 2.) However, the reputed advantages of the open technique for some of these conditions may be over- DPL And Pelvic Fractures stated. In a retrospective review, the authors found The prevalence of false-positive peritoneal lavage in that “the complication rate and accuracy of closed pelvic fracture is as high as 29%.89 Therefore, author- DPL in patients with previous abdominal surgery were similar to those for DPL performed in patients ities recommend an open supraumbilical approach 92 to avoid transgressing a preperitoneal hematoma without previous abdominal surgery.” that has dissected out of the pelvis to the anterior In a prospective study comparing the closed abdominal wall. It is estimated that a lag of at least with the open technique, the authors found that

Table 1. Clinical Purpose Of Diagnostic Peritoneal Lavage Following Blunt Mechanism

Purpose Circumstance Alternate or Complementary Study

Rapidly determine presence of Multiple blunt trauma, Ultrasound intraperitoneal hemorrhage hemodynamically unstable

Determine presence of intraperitoneal Suspected or known blunt trauma with CT organ injury unreliable examination

Determine presence of intraperitoneal Multiple trauma patients who require CT, ultrasound hemorrhage or injury general anesthesia or lengthy diagnostic studies for other injuries

Adapted from: Marx JA. Peritoneal procedures. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia: W.B. Saunders; 1997.

Table 2. Preferred Site Of Diagnostic Peritoneal Lavage

Clinical Circumstance Site Method

Standard adult Infraumbilical midline Closed or semi-open

Standard pediatric Infraumbilical midline Closed or semi-open

Second- and third-trimester pregnancy Supra-uterine Fully open

Midline scarring Left lower quadrant* Fully open*

Pelvic fracture Supra-umbilical* Fully open*

*Empirical data to support these recommendations are limited.

Adapted from: Marx JA. Peritoneal procedures. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia: W.B. Saunders; 1997.

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 75 the closed peritoneal lavage was superior to open viscus injury and obviating the need for laparotomy lavage in abdominal trauma; it was faster, easier to in hemodynamically stable patients with free fluid use, less expensive, and as safe as open lavage.93 A found on CT scan but without evidence of solid recent meta-analysis examined all of the prospective, organ injury.34 These latter patients can be treated randomized, controlled trials comparing the closed nonoperatively, and once practitioners learn to use with the open technique of DPL. In this analysis, the each of these diagnostic resources together, nonther- closed DPL technique was as accurate and safe as apeutic laparotomies should become very rare. the standard open DPL technique.94 Laparoscopy Interpretation Laparoscopy has been most useful in assessing pen- The aspiration of at least 10 cc of blood has a posi- etrating trauma;100 however, very little experience tive predictive value of greater than 90% for intrap- has been acquired in the setting of blunt trauma. eritoneal injury, typically solid visceral or vascular. This finding is responsible for approximately 80% of Nasogastric Tube 95 true positive DPLs in blunt trauma. The RBC count Penetrating trauma to the epigastrium, left upper threshold for lavage effluent is set at 100,000/cc. quadrant, or low chest may result in gastroduode- Other laboratory parameters of DPL are less nal hemorrhage and result in positive aspiration by useful. A white blood cell (WBC) count exceeding nasogastric tube placement. In severe blunt trauma, 500/cc can herald hollow viscus injury but tends to gastric perforation from sudden and severe forces 96 lag this by 3 to 6 hours and is often nonspecific. can occur but is very uncommon. This will result Elevated lavage amylase and alkaline phosphatase, in free intraperitoneal air and possibly intragastric particularly the former, have been demonstrated in bleeding.101 Otherwise, nasogastric tube placement the immediate postinjury period following small may be useful for the evacuation of gastric air and 97 intestinal injury. Bile staining and Gram’s staining contents in the supine patient, particularly one of lavage fluid lack accuracy such that their routine about to be intubated (although Sellick’s maneuver use is proscribed. should suffice). The volume of returned lavage fluid may be important. One study showed that in patients suffering Management blunt abdominal trauma, the RBC count of DPL fluid regularly increases as more fluid is recovered. The authors suggest collecting at least 600 cc of effluent General to avoid a false-negative lavage.98 The real crux of abdominal trauma management lies first in the suspicion of injury and then in the use Limitations of the best diagnostic tools. Appropriate and timely On the one hand, thanks to the exquisite sensitivity consultation of a surgeon, when necessary, is a vi- of DPL for blood, the threshold of 100,000 RBC/cc tally important ED intervention. can produce unnecessary laparotomy for trivial inju- Unlike penetrating trauma, laparotomy for blunt ry, typically to the spleen or liver. On the other hand, mechanism is rarely mandated solely by clinical pa- injury to certain structures — notably the bowel and rameters. Relative clinical indications for laparotomy the diaphragm — produces limited hemorrhage, are found in Table 3. Blunt trauma patients typically such that RBC counts of 20,000 to 100,000 RBC/cc have numerous potential sources of blood loss, both should be considered carefully in clinical context intra- and extra-abdominal. This can complicate the and for an observation period of 12 to 24 hours.99 decision to operate on the abdomen. Furthermore, DPL has very limited utility in today’s era of reliance on physical examination alone can be pre- diagnostic tools as long as US and CT are easily carious for many reasons, including altered mental accessible. Its value remains in diagnosing hollow status, paralysis, and altered sensation.

Table 3. Clinical Indications For Laparotomy Following Blunt Trauma

Manifestation Pitfall

Unstable vital signs with strongly suspected abdominal injury Alternate sources shock

Unequivocal peritoneal irritation Unreliable

Pneumoperitoneum Insensitive and non-specific; may be due to cardiopulmonary source or invasive procedures (DPL, laparoscopy)

Evidence of diaphragmatic injury Nonspecific

Significant gastrointestinal bleeding Uncommon, unknown accuracy

76 An Evidence-Based Approach To Traumatic Emergencies This conundrum is profound. Rushing a patient 2 of these were stable grade I liver injuries, and 1 to what proves to be a nontherapeutic laparotomy was a missed diaphragmatic injury diagnosed the leads to delay in more vital diagnostic and therapeu- day after admission.103 tic undertakings. Alternatively, failure to determine Another retrospective investigation examined the the need for exigent laparotomy has even more utility of physical examination in detecting intraab- grave consequences. Thus, in multisystem blunt dominal injury in intoxicated blunt trauma patients. abdominal trauma, diagnostic studies (DPL, US, CT) All study patients had a blood alcohol level of 80 mg/ are frequently indicated. (See Table 4.) dL or greater, a GCS score of 15, and an unremarkable Traditional indications for diagnostic tests in- abdominal examination. In only 2 (0.6%) patients did clude102 physical examination miss an injury requiring ab- • Suspected intraabdominal injury dominal exploration. The authors found a significant • Equivocal abdominal examination association between major chest injury and abdomi- • Altered sensorium due to drugs, alcohol, or nal injury and concluded that physical examination head trauma and attention to clinical risk factors allow accurate • Distracting injury abdominal evaluation without CT.104 • Spinal cord injury with abdominal anesthesia As both of the above-mentioned studies were • Unexplained hypotension retrospective, further evaluation of who needs ab- • Multiple trauma patients who must undergo dominal evaluation is required. general anesthesia for orthopedic, neurosurgical, or other injuries Management Schemata A small minority of patients undergo laparotomy These criteria have not been subjected to rigor- based on clinical indicators alone. For the remainder, ous prospective examination. Several retrospective abdominal trauma can be categorized at the primary studies suggest that repeated physical examination level by whether the patient is hemodynamically in the intoxicated patient with a relatively normal stable or unstable. (See Table 4.) Within these 2 pos- mental status is generally reliable. For instance, 1 sibilities is a second level of staging based on other study retrospectively examined a cohort of intoxi- urgent concerns or “special circumstances” that cated but hemodynamically stable and alert pa- coexist with the possibility of intraperitoneal inju- tients to determine the need for abdominal testing ries. (See “Clinical Pathway: Management Of Blunt (CT, US, or DPL) before an emergent extraabdomi- Abdominal Trauma.”) nal surgical procedure. All patients had a GCS of 14 or greater and an abdominal physical examination Hemodynamically Unstable with negative findings. Only 3 (1.4%) intraperitone- In the multiple blunt trauma patient in shock, 3 cavi- al injuries were diagnosed in the study population; ties — the thoracic, abdominal, and retroperitoneal

Table 4. Diagnostic Studies In Blunt Abdominal Trauma

Scenario Study Purpose Primary Study Alternate/Compensatory Hemodynamically unstable General Intraperitoneal hemorrhage DPL, US — Pelvic fracture Intraperitoneal hemorrhage DPL,* US —

Hemodynamically stable General Organ injury† CT DPL, US‡ Nonoperative management§ Organ injury CT# DPL,** US‡ Closed-head injury Organ injury, hollow viscus injury DPL,** CT# US‡ Blunt aortic disruption Intraperitoneal hemorrhage DPL, US CT‡‡

* Positive peritoneal aspirate mandates laparotomy; positive RBC count only warrants attention to pelvic fracture. † Specific organ damage or fluid/blood suggesting injury. ‡ US for organ injury much less reliable than for intraperitoneal hemorrhage. § Institutional capability should be carefully considered. # CT less reliable for hollow viscus than for solid visceral injury. ** Complementary to CT if hollow viscus suspected. ‡‡ May be more appropriate if can be rapidly acquired or if CT primary study for blunt aortic disruption.

DPL: Diagnostic peritoneal lavage US: Ultrasound CT: Computed tomography

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 77 — warrant immediate attention. Clinical exami- The role of US in the hemodynamically stable nation and chest x-ray will identify blood in the patient is less clear. If the patient has a relatively thoracic space or suggest the presence of blunt aortic benign abdominal examination, normal initial US re- disruption (BAD). The pelvis radiograph, if positive sults are likewise reassuring. Such a patient may be for significant disruption, can predict a retroperito- followed with serial physical examinations and pos- neal hemorrhage. sibly serial US without the use of CT. This strategy The third space, the peritoneal cavity, should be is best suited to those who have suffered a mild to targeted by peritoneal aspiration or US to reveal or moderate mechanism of injury, have a normal sen- exclude the presence of blood. A positive study in a sorium, and have no significant distracting injuries. clinically unstable patient mandates laparotomy. The The question then becomes “Which stable patient unstable patient is not a candidate for CT scanning. deserves ED US?” (as opposed to simply undergoing The unstable patient with a hemoperitoneum serial physical examinations). needs to be moving to the OR or to another hospital Although treatment of hemodynamically for laparotomy (if local facilities are unavailable). unstable patients with positive FAST examinations While the patient is being “packaged for transport” is quite clear, the same cannot be said for stable to either of these locations, the emergency clinician patients with positive FAST. A study in the Journal of may treat the patient with fluids and blood. Predic- Emergency Medicine performed a retrospective cohort tors of need for transfusion include48, 105, 106 looking at normotensive blunt trauma patients with • Shock positive FAST examinations. Thirty-seven percent • Hematocrit less than 30% of these patients required a therapeutic laparotomy • Observed blood loss of at least 500 cc or grossly compared with 0.5% with a FAST examination with visible gastrointestinal bleeding negative results.107 Thus the study recommends • Emergency operation with anticipated blood performing FAST examinations on all normotensive loss blunt trauma patients to risk-stratify them. Practi- • Prehospital systolic blood pressure less than 100 tioners need to be aware of the strong association mm Hg between therapeutic laparotomy and positive FAST • A base deficit more negative than -6 results in normotensive blunt trauma patients and aware of the exceedingly unlikely need for a laparo- Hemodynamically Stable tomy in these patients with a negative FAST results. In this circumstance, CT scanning is widely pre- There has been considerable research on man- ferred as it can specify organ damage, assess he- agement to avoid unnecessary laparotomies and moperitoneum, and evaluate nonabdominal body their associated cost. One multicenter study exam- regions. In a stable patient, positive findings on CT ined different management and evaluation strate- do not necessarily mandate laparotomy. Rather, gies of asymptomatic patients with abdominal stab expectant treatment can be accomplished in select wounds. Although this is not blunt abdominal patients with low to moderate grades of liver or trauma, the study has applicability to the current spleen trauma. In such cases the patient should be topic. Of 278 patients, only 61 (22%) who did not otherwise normal (eg, absent coagulopathy), and the have an immediate reason for surgical exploration center should be able to provide adequate monitor- (shock, evisceration, and peritonitis) received a ing and support. The ideal candidate for CT would therapeutic laparotomy.108 Obviously patients exhib- have normal sensorium and minor to intermediate iting shock or intestinal evisceration need immediate severity of mechanism. laparotomies: 88% of patients in shock and 100% of Treating pain is an important part of caring for patients with intestinal evisceration had therapeutic the trauma patient. Caution should be exercised laparotomies. in the administration of analgesics and sedative- In patients with peritonitis as their only finding, hypnotics to patients being observed for intraperito- 29% had laparotomies with negative results. This neal injury. As there are no prospective data on the high rate is explained by peritonitis being a fairly matter, usage of these medications must be judicious subjective criterion for laparotomy. Interestingly, to optimize recognition of symptoms by the patient 81% of patients with diffuse peritonitis had thera- and signs by the care provider. peutic laparotomies compared with 50% of patients There are pitfalls in expectant management. with local peritonitis. Thus, practitioners need to First, coincident hollow visceral injury that is not become better at differentiating true peritoneal signs detected by CT can lead to disastrous consequences from physical signs related to an abdominal wound (see subsequent section).11 Second, expectant man- or point of impact. agement tends to lead to increased use of blood FAST has less benefit in patients with pen- products. Finally, should this approach fail, the lag etrating abdominal wounds than those with blunt from injury to operation lengthens, with a resultant trauma. FAST guided decision-making in only 4% of increase in morbidity, fatality, and the likelihood of the participants in this study. Hemoperitoneum does organ resection. not necessarily correlate well with injuries requir-

78 An Evidence-Based Approach To Traumatic Emergencies ing operative interventions. Ten of 36 patients with state that when expert interpretation is available, CT abnormal FAST examination results had negative is accurate in detecting hollow viscus injury as long laparotomies, and 23% of patients with normal FAST as unexplained free fluid, bowel wall thickening or results ultimately had a therapeutic laparotomy. The enhancement, mesenteric fat streaking, and bowel study concluded that normal FAST results should dilatation are assumed to represent injury. If the not be the primary factor in safely discharging scan quality is suboptimal or expert interpretation is patients from the ED. CT’s downside is that results unavailable, the authors recommend DPL.111 can be misleading: 46 asymptomatic patients found Solid organ injury is much more common than to have abnormal findings were taken to the OR and hollow viscous injury (HVI), constituting 95% of 24% of them had nontherapeutic laparotomies. significant injuries in blunt abdominal trauma.112 Of the remaining 35 patients with surgical thera- The prevalence of HVI in blunt trauma is only ap- py, 18 only had solid organ injuries or fascial defects proximately 1%.113 Interestingly, it occurs much that could have been managed nonoperatively. Thus, more frequently when multiple solid organs are like FAST, although CT scan does reveal evidence of injured than when just 1 organ is injured severely. intraperitoneal fluid, the significance of the findings Patients with multiple intraabdominal injuries had a is at times unclear. Consequently, CT scan should 6.7 higher risk of additionally having HVI than did not be the lone factor in determining the need for patients with a single solid organ injury.114 surgical exploration. McStay wrote a recent review about appropriate The study concludes that without hard signs management of HVI, citing that although seat belt of significant intraabdominal injury such as shock, marks, abdominal wall ecchymosis, distention, and evisceration, and generalized peritonitis, diagnostic vomiting are all associated with viscus injury, the ac- tests in the remaining patients are associated with a curacy and positive predictive value of these signs are substantial number of nontherapeutic laparotomies low.112 Gross blood on rectal examinations increases and extensive, unnecessary costs. None of these di- the probability of viscus injury, but in general, the agnostic examinations fared better than the others in physical examination is notoriously inaccurate. determining the need for therapeutic laparotomies. Although free air on a chest x-ray would indicate The only test to limit hospital admissions was local to practitioners the need for a therapeutic laparotomy wound exploration for peritoneal cavity penetration. in patients sustaining bowel injury, free air is rarely If there was peritoneal penetration, then the patient visualized in supine trauma patients. Thus there is should be monitored with serial examinations for need to rely on definitive diagnostic testing to rule decompensation. out bowel injury in all patients with blunt abdominal trauma. Although FAST has a high sensitivity and Suspected Bowel Injury specificity for intraabdominal injuries, the examina- The patient with suspected bowel injury provides a tion relies on the presence of 250 to 620 cc of free fluid, significant diagnostic challenge. Delayed or missed as mentioned previously.85 Unfortunately, the sensitiv- diagnosis can result in considerable morbidity or fa- ity for viscus injury is much lower, as that much free tality. In 1 series of patients with hollow viscus injury, fluid is rarely found following viscus injury. delays in the diagnosis were directly responsible for The newest data on CT scanning reveals sensi- almost half of the deaths. Even delays of as little as 8 tivities for bowel injuries of 83% to 94% and accura- hours result in significant morbidity and fatality.109 cies of 84% to 99%.112 A study in 2004 retrospectively There is also great debate as to the study of choice assessed 1082 patients with blunt abdominal trauma in patients likely to have hollow viscus injury, es- with noncontrast abdominal CT, revealing a sensitiv- pecially those with a seat belt sign. In 1 prospective ity of 82% and specificity of 99% for HVI.115 Unfor- study, 36% of patients with a seat belt sign required tunately, concurrent solid organ injury can mask CT operative intervention, most of whom had small findings of HVI that delays diagnosis and increases bowel perforation. In this series, DPL was 100% sensi- morbidity and fatality.116 Controversy exists about tive for the diagnosis of intestinal perforation (5 of 5 the need for oral contrast material and potential patients), whereas the initial CT scan was only 33% adverse effects of aspiration and delays in scanning, sensitive.30 In another study examining the prospec- and there is still no general consensus. tive CT diagnosis of bowel injury, CT had a sensitiv- Extraluminal gas or oral contrast material or in- ity of 64%, an accuracy of 82%, and a specificity of testinal content, intramural air, or discontinuity of the 97%.110 These and other articles have led some to sug- bowel wall can appear following full thickness bowel gest that patients with a seat belt sign need a study injury and signify the need for emergent surgical other than CT to rule out intestinal injury. exploration; but these findings are not always pres- However, a recent review regarding the use of ent. Mesenteric hematomas and hemoperitoneum are CT in this situation is more sanguine. In this review, nonspecific and highlight the trouble with CT in that the authors searched MEDLINE between 1980 and the significance of findings is at times unclear. 1998 to evaluate the performance of DPL and CT in One retrospective study of patients with free detecting blunt gastrointestinal tract injuries. They fluid and no solid organ injury seen by FAST and CT

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 79 found that 76% of these patients had viscus injury Distracting injury is so called as the patient, the when taken to the OR.112 However, that is a high emergency clinician, or both are...well...distracted. rate of nontherapeutic laparotomies. Additionally, Distracting injury is one of those concepts all of us Livingston found only a 7% association between free understand but none of us can quantify. However, fluid without evidence of organ injury and bowel it must be appreciated, as it is well known to cause injury.112 His work recommended the more cost-effi- missed abdominal as well as cervical spine injuries. cient method of management: observation and serial In a recent prospective study, 7% of patients with no examinations. abdominal pain or tenderness but with distracting Multidetector CT has made scanning more extraabdominal injury were found to have intraab- rapid, lowering the risk in moving unstable patients dominal injury.126 to the CT suite, as there is less time for patients Patients with altered mental status are also at to decompensate. Increased sensitivity is another high risk for undetected/unsuspected abdominal feature resulting from thinner sections and reduced injury. Nearly 10% of patients with suspected “iso- motion artifacts, leading to higher resolution and lated” head injury may have intraabdominal find- 3-dimensional images. ings.127 In a different retrospective study of comatose One retrospective review reported that CT diag- but normotensive trauma patients, the use of clinical nosed 85 out of 87 hollow viscus injuries. The review signs alone resulted in more missed injuries than concluded that the CT was adequately sensitive to did using an objective test (in this study, DPL).27 The rule out HVI.112 However, a much larger study that authors suggested that all unconscious blunt trauma enrolled 2632 patients reported a false-negative rate patients undergo objective testing of the abdomen to of 13% and expressed caution about solely relying avoid missing life-threatening injuries. on CT scans to rule out viscus injury.112 As mentioned, a delay of as little as 6 to 8 hours can result Multisystem Injury in bile or intestinal contamination and sepsis and In patients with more than 1 critically injured bodily severely high fatality rates. The American College of system, a rigid management algorithm does not Emergency Physicians Clinical Policy statement in and should not exist. In these situations, the deci- 2004 reports that CT alone cannot reliably exclude sion making needs to be fluid and responsive to the hollow viscus, diaphragmatic, or pancreatic injury.117 minute-to-minute changes of the patient. The incidence of traumatic viscus injury is so It is correct that active and substantive intraperi- low that it is difficult for practitioners to get accus- toneal hemorrhage in an unstable patient demands tomed to diagnosing and managing it. To date, no immediate attention — specifically, lifesaving lapa- diagnostic model with high sensitivity and speci- rotomy. However, a patient can have a minor splenic ficity exists to guide practitioners in discharging injury with evidence of hemorrhage on US, DPL, patients after blunt abdominal trauma with imaging CT, or some combination of tests, yet other demands with negative results. McStay’s article recommends (such as an unstable pelvic fracture) will be greater dividing patients into high risk (severe mechanism, at that point in time. Likewise, certain intraperito- significant abdominal tenderness, seat belt sign neal injuries, such as a perforated jejunum, require or ecchymoses, gross hematuria, free air on chest operation, but a delay of at least 8 hours is accept- x-ray) and low risk (no significant injuries, low-risk able while more pressing concerns are addressed. mechanism, no tenderness in a reliable patient). In In summary, the key point is that an unstable high-risk patients with no radiographic findings, patient with a significant hemoperitoneum must un- admission for observation is encouraged, whereas dergo laparotomy or face imminent exsanguination. discharge is safe in low-risk patients.112 Pelvic Fracture Special Circumstances An unstable patient with a significant pelvic fracture and bloody peritoneal aspirate or positive US find- Missed Injuries ing must proceed to emergency laparotomy. (See Missed injury is common in trauma management. “Clinical Pathway: Management Of Combined Pel- As many as 25% of seriously injured trauma patients vic Fracture And Abdominal Trauma.”) This is behave at least 1 injury that is overlooked during the cause approximately 85% of such patients will have initial evaluation.118, 119 Missed injuries are most active intraperitoneal hemorrhage at laparotomy. common in patients who have altered mental status, Some unstable patients with severe pelvic fracture those who are intubated, and those who need an im- will demonstrate an US and/or a negative peritoneal mediate operation.120, 121 aspirate with normal findings. Barring other nonab- Although the most frequently missed injuries are dominal sources, the presumed origin of shock is the orthopedic,122-124 missed abdominal injury is far more retroperitoneum. Therefore, the patient would then lethal. In fact, missed intraabdominal injury is the proceed to angiography for possible embolization to most common preventable cause of trauma deaths.125 staunch hemorrhage.

80 An Evidence-Based Approach To Traumatic Emergencies Clinical Pathway: Management Of Blunt Abdominal Trauma

Blunt abdominal trauma mechanism

Clinical mandate for laparotomy?

Yes NO

Laparotomy (Class II) Hemodynamically unstable?

Yes NO

Intraperitoneal hemorrhage? Unreliable examination?*

NO Yes

DPL, US† (Class II) Abdominal tenderness?

Yes NO

Intraperitoneal injury?‡ Laparotomy (Class II) • CT (Class II) • DPL (Class II) NO • Serial physical examinations; with or without ED US (Class II)

Yes NO

Injury requires laparotomy?§

Yes NO

Laparotomy (Class II) Observe (Class II)

Discharge (Class II)

* Can be unreliable because of closed-head injury, intoxicants, distracting injury, or spinal cord injury. † Determined by unequivocal free intraperitoneal fluid on ultrasound or positive peritoneal aspiration on DPL. ‡ One or more studies may be indicated. § Need for laparotomy is based on clinical scenario, diagnostic studies, and institutional resources.

For Class of Evidence Definitions, see page 1.

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Copyright © 2009 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC.

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 81 Clinical Pathway: Management Of Combined Pelvic Fracture And Abdominal Trauma

Pelvic fracture

Hemodynamically unstable?

Yes NO

Intraperitoneal hemorrhage?* • Ultrasound (Class II) • Diagnostic peritoneal aspiration (Class II)

Yes NO

• Angiography (Class II) Laparotomy (Class II) • Pelvic fracture stabilization (Class II)

Intraperitoneal injury?† • Computed tomography (Class II) • Diagnostic peritoneal lavage (Class II)

Yes NO

Injury requires laparotomy?‡

Yes NO

Laparotomy (Class II) Observe (Class II)

Laparotomy (Class II) Discharge (Class II)

* Determined by unequivocal free intraperitoneal fluid on ultrasound or positive peritoneal aspiration on DPL. † One or more studies may be indicated. ‡ Need for laparotomy is based on clinical scenario, diagnostic studies, and institutional resources.

For Class of Evidence Definitions, see page 1.

82 An Evidence-Based Approach To Traumatic Emergencies Clinical Pathway: Management Of Combined Head And Abdominal Trauma

Head injury

Management of airway and intracranial pressure (Class II)

Hemodynamically unstable? Yes NO

Hemoperitoneum?*

Positive Negative

Lateralizing signs? Lateralizing signs?

Yes NO Yes NO

Laparotomy¶ (Class II) • Head and abdominal Head CT or craniotomy‡ Consider head CT† Laparotomy (Class II) CT (Class II) (Class II) (Class II) • Continue resuscitation (Class II) • Manage intracranial pressure (Class II)

Abdominal CT, DPL§ Head CT (Class II) (Class II)

* Based on ultrasound, diagnostic peritoneal aspiration, or both. † Consider pre-laparotomy head CT based on clinical picture and availability of CT. ‡ Burr holes or craniotomy based on clinical picture and availability of CT. § DPL can be complementary to CT in determining hollow viscus injury. ¶ Consider burr holes or craniotomy simultaneous with laparotomy.

For Class of Evidence Definitions, see page 1.

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 83 Clinical Pathway: Management Of Combined Wide Mediastinum And Abdominal Trauma

Wide mediastinum*

Initial resuscitation (Class II)

Hemodynamically unstable?

Yes NO

Helical CT of chest and abdomen Hemoperitoneum?† (Class II)

Positive Negative

Laparotomy (Class II) Helical CT of chest and • Left lateral thoracotomy abdomen (Class II) if rupture suspected‡ (Class II) • Consider intraoperative transesophageal echocardiogram or aortogram (Class II)

* Preferably based on upright PA film and mechanism of injury. † Based on ultrasound, diagnostic peritoneal aspirate or both. ‡ Allows surgical access to majority of disruption sites.

For Class of Evidence Definitions, see page 1.

84 An Evidence-Based Approach To Traumatic Emergencies Before proceeding to angiography, a pelvic- lish whether significant intraperitoneal injury exists, stabilizing device is indicated to reduce pelvic as the RBC count alone in this circumstance can be volume, stabilize displaced fracture segments, falsely positive. and tamponade venous bleed. The PASG, vacuum splint, or even a tightly wrapped sheet about the Closed Head Injury pelvis when necessary can serve in this capacity.16 Patients with surgically correctable injuries of both The placement of an external fixator, typically by the head and the abdomen are rare, although the an orthopedist, is advised by some.128 However, literature is divided regarding which injury is more this requires a much more laborious application, common in the comatose hypotensive patient.129,130 and there are no prospective, randomized trials to The presence or absence of lateralizing findings support its use. (such as a unilateral blown pupil or asymmetric In a patient with pelvic fracture and apparent posturing) is key. Generally speaking, patients with hemodynamic stability, a CT of the abdomen is usu- severe closed head injury but without lateralizing ally warranted. If an US was performed and demon- findings do not require craniotomy.130 Should later- strated some measure of fluid, CT can help decipher alizing features and blunt abdominal injury coexist, the need for laparotomy. If DPL effluent returns with the clinician is faced with the choice of rapid prelap- a positive RBC count result only (but a negatively re- arotomy CT scan of the head versus preemptive burr sulting aspirate), CT should again be used to estab-

Risk Management Pitfalls For Blunt Abdominal Trauma (Continued on page 86)

1. “We thought the hypotension was caused by 4. “The patient had a horrible pelvic fracture, and head injury, not abdominal trauma.” we knew external fixation and angiography Not so — with few exceptions. First, the infant were the only steps that could save him.” with cephalohematoma, intracranial hemor- In some cases, that may well be true. However, rhage, or both, can house sufficient blood in when pelvic fracture is present, intraperitoneal those spaces to cause hemorrhagic shock. hemorrhage is frequently present as well. The Second, patients in the agonal phase of severe abdomen should be assessed in all cases of pel- closed-head injury may demonstrate hypoten- vic fracture. In the unstable patient, ultrasound sion. This is simply a pre-terminal event. or DPL is indicated to rapidly determine whether there is intraperitoneal hemorrhage. If there is 2. “Hey, the abdomen was definitely soft and significant hemoperitoneum on ultrasound or a nontender on my exam, and even the bowel positive aspirate on DPL (not simply a positive sounds were normal.” lavage), urgent laparotomy is indicated prior to Many factors can confound the patient’s ability angiography. to sense pain and the physician’s skill in determining tenderness. These include distracting 5. “We screened our patient with our standard injury, altered sensorium, and spinal cord injury. measures: hematocrit, urinalysis, and chest and Even in the alert patient without confounders, abdominal films. They were all normal.” false-positive and false-negative examinations Unfortunately, you did the wrong tests. The he- can still occur. When the mechanism is worri- matocrit is not used as a marker for the presence some and the patient cannot be reliably exam- of intraperitoneal trauma. Serum amylase and ined and re-examined, abdominal diagnostic lipase, and amylase isoenzymes, have very low studies are in order. As far as the bowel sounds positive predictive value for pancreaticoduode- are concerned, that’s a definite “so what?” nal injury. Plain films of the abdomen are practically of historical interest only. The discovery of 3. “You can’t perform DPL in pregnant women.” free intraperitoneal injury by these can be useful, Yes, you can, but the technique may have to be but sensitivity and specificity are so incredibly modified. In the first trimester, no alteration is low in comparison with US, DPL, and CT that necessary. In the second and third trimesters, as this film is not routinely obtained. the uterus has risen out of the protective confines of the pelvis, an open and supra-uterine 6. “Sure, the radiology department is one floor technique should be utilized. The interpretation above our ED. But CT is a much better test of peritoneal aspiration and DPL fluid is un- than US.” changed. Ultrasound, of course, is an acceptable The statement that CT is superior to US for defi- alternative. nition of intraperitoneal organ injury is absolute-

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 85 holes in the ED or during laparotomy. (See “Clinical Blunt Aortic Disruption Pathway: Management Of Combined Head And Potential BAD presents even more controversies. Abdominal Trauma.”) (See “Clinical Pathway: Management Of Combined Neurosurgeons prefer the former approach Wide Mediastinum And Abdominal Trauma.”) The whenever possible, but hemodynamic instability injury itself is frequently lethal, and its time course is may compel the latter. The emergency clinician sort- highly unpredictable. The delay to rupture may entail ing this out must measure the timeliness of CT avail- hours to days (and, rarely, weeks). The time bomb ability, when the neurosurgeon is expected to arrive, metaphor is supremely apropos. and, most importantly, the severity and direction of The usual indication for diagnostic evaluation is hemodynamic changes. abnormal chest x-ray results. The chest radiograph One study suggests that patients with hemo- shows characteristic or suggestive findings in at peritoneum and lateralizing signs are candidates least 93% of all patients with aortic injury.132 Un- for emergent head CT only if their blood pressure fortunately, many chest x-rays in severe trauma are 131 stabilizes with fluids or blood. However, immedi- necessarily acquired in supine anteroposterior fash- ate laparotomy is indicated in patients who remain ion, and a significant number of patients without 129 hemodynamically unstable. aortic injury may have a wide mediastinum on the supine view.133 An upright or reverse Trendelenburg

Risk Management Pitfalls For Blunt Abdominal Trauma (Continued from page 85)

ly correct. Unfortunately, the patient in this case 9. “It was just an isolated head injury. His pulse was hemodynamically unstable, a direct result and blood pressure were fine, and his abdomen of a grade IV splenic injury. When patients pres- was not distended.” ent to the ED in shock, a test that can quickly Physical examination (including vital signs) can- visualize peritoneal blood allows timely triage to not rule out abdominal injury in the comatose the operating room. DPL or US serves this func- patient. If you wait for the abdomen to distend tion well; CT does not. Unstable patients should from blood loss, it’s time to call the coroner, not rarely be removed from the safety of the ED. the surgeon.

7. “The patient had a bad head injury, and we 10. “The orthopedist had a full schedule in the needed a head CT right away.” morning, and it was getting close to 2 a.m.” Sure, there is a natural compulsion to get head- Consequently, the orthopedist absconded injured patients to CT. But first, the abdominal with this multisystem injured and profoundly cavity must be considered. If the patient is he- intoxicated patient to the OR for a washout of modynamically unstable, DPL or US should be a matching pair of open tib-fib fractures. No undertaken immediately in order to determine abdominal studies were undertaken, and the the likelihood of intraperitoneal bleeding. The small pneumothorax was unknown to the ortho patient in this case had no localized findings on operating team. In the OR, the combination of neurologic examination; therefore, the chance of tension pneumothorax induced by intubation an operative lesion was extremely low. Besides, and positive-pressure ventilation plus the grade you can’t save a patient from a head injury if she III liver injury led to a patient who was hard to dies from intraperitoneal hemorrhage first. bag and a pulse that was impossible to palpate. Practically any consultant, including the ortho- 8. “Okay, there was a seat-belt mark, but the pedist in this scenario, will have blinders on. examination was otherwise just fine.” They typically see a general trauma patient from A low-lying transverse abdominal ecchymosis the perspective of their single discipline — in has a strong association with hollow viscus in- this case, a large bone. The emergency physician, jury. In turn, hollow viscus injury often does not together with the trauma or general surgeon, produce any pain or tenderness until 6-8 hours should orchestrate the resuscitation and deter- following the traumatic event. At a bare mini- mine the disposition. mum, patients with lap-belt contusions should undergo serial abdominal examinations over this time course. Findings of abdominal tenderness should prompt diagnostic study (e.g., abdominal CT) or laparotomy.

86 An Evidence-Based Approach To Traumatic Emergencies inspiratory radiograph is helpful if the patient can Special Populations tolerate this position. Even the pristine, upright, inspiratory posterior- Pediatrics anterior radiograph is imperfect in predicting the As with adults, motor vehicle crashes cause most presence or absence of this lesion. More accurate of the morbidity and fatality in cases of pediatric means of determination include helical chest CT, trauma; automobile/pedestrian injuries and falls out transesophageal echocardiography, and angiogra- of cars represent a large subset of these. Handlebar phy. However, these tests take precious time. injuries and lap belt-only restraints are much more In the relatively stable patient, there is good likely to be seen in children and can lead to pancrea- evidence to show that normal helical (not standard) ticoduodenal and small bowel injury.21 Child abuse contrast-enhanced CT of the chest results reliably 124,134 is both common and terribly harmful. Abdominal excludes aortic injury. The unstable patient with injuries are second only to head injuries as a cause of hemoperitoneum must proceed immediately to lapa- death in abused children. rotomy. The patient can undergo mediastinal evalua- A child’s abdomen has poorly developed tion with transesophageal echocardiography during 135 musculature and a relatively small anteroposterior the operation. Angiography, once the sovereign di- diameter. These facts amplify the vulnerability of agnostic modality in aortic injuries, is now relegated intraperitoneal organs to compressive forces. The to a subordinate role in many trauma centers.136, 137

Cost-Effective Strategies For Managing Patients With Blunt Abdominal Trauma

1. Use your physical examination. spective center’s resources, can curb some of the While this article has pointed out the weak- unnecessary enthusiasm. nesses of physical examination, it is certainly not Caveat: CT is a powerful tool in the right cir- without value. Patients with low-to-moderate cumstances. It can grade organ injury and is an trauma mechanism can often be managed with important modality in those with altered senso- clinical examination alone. rium and suspicious abdominal examinations. Caveat: Patients with distracting injuries, altered sensorium, and spinal cord injuries are likely to 4. Employ ED ultrasound. have unreliable examinations. This wonderful tool can serve as an excep- tional screening measure. From a strict cost (vs. 2. Avoid unnecessary laboratory studies. charges) standpoint, abdominal ultrasounds are Mandatory testing of any kind for blunt abdomi- extremely cost-effective. nal trauma is an obsolete notion, and deservedly Caveat: Recognize the limitations of ED ultra- so. Beyond that, certain tests have very limited sound. While it can detect 400 cc or more of value (eg, serum amylase). Others add nothing intraperitoneal blood, it is insensitive to bowel to the equation. For example, in a patient with a and retroperitoneal injury and cannot reliably blood pressure of 60 and a positive abdominal grade organ injury or routinely detect isolated ultrasound, serum lactate and hepatic enzymes subcapsular hematomas. couldn’t be more irrelevant. Caveat: Certain tests in the severely injured 5. Document, document, document! patient are very important. These may include a As with every aspect of medicine, adequate type and screen or crossmatch, as well as serial documentation keeps the plaintiff’s lawyer hemoglobin levels. A visual examination of the away. Make it clear that you considered the pos- urine is important in adults, as is a dipstick or sibility of abdominal trauma, and then clarify microscopic examination in children. your thought processes, diagnostic pursuit, and disposition. A thorough initial evaluation, serial 3. Avoid unnecessary abdominal imaging. examinations, and a final comparison prior to CT is overutilized in many institutions, and a disposition are essential. thoughtful clinical pathway, based on the re-

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 87 rib cage is very compliant in children, and although initial and serial physical examinations are more reli- less prone to fractures, it provides limited protec- able than diagnostic testing in children with small tion against upper quadrant solid visceral injury. bowel injuries.146 Solid organ injuries predominate in children and are Thirty years ago, pediatric patients with sig- responsible for 66% - 90% of intraperitoneal injuries. nificant abdominal trauma underwent exploratory As in adults, most hematologic and serum laparotomies for diagnostic evaluations. Abdomi- chemical studies do not have adequate positive or nal imaging with CT has replaced that modality of negative predictive value to warrant their routine diagnosis. The most common indication in children use.138 Perhaps the most valuable laboratory test for abdominal CT after blunt trauma is hematuria. for intraabdominal injury in children is urinalysis. Hematuria does not necessarily imply urinary tract In 1 retrospective study of 285 injured children, the injury, as most children with hematuria have non- physical examination combined with urinalysis urinary tract injuries.142 Currently, however, a surgical showing more than 5 RBC/hpf had a sensitivity of procedure is usually performed only when there is a 100% and a specificity of 64% in detecting intraab- clinical indication, not based on imaging findings. dominal injury.138 Microscopic hematuria portends A study of 1500 consecutive children who had a reasonable likelihood of injury to the liver, spleen, abdominal CT imaging following trauma revealed or kidneys. It may also be a reflection of a previously that only 7% underwent a surgical procedure and unknown coagulopathy or intraabdominal anomaly 75% of those decisions were based on clinical crite- (eg, Wilms’ tumor). The threshold at which consider- ria.142 Many practitioners question the value of CT if ation should be given to further diagnostics, notably positive findings do not necessarily lead to a surgical CT, varies from 20 to 50 RBC/hpf.139 procedure in stable patients, especially in pediatric The important diagnostic tests used in adults patients where the radiation risk is much higher. with abdominal trauma (CT, US, and DPL) have However, 1 study reveals that CT scans lead somewhat different roles in children. US has been to a change in diagnosis in 84% of patients and a found to have comparable ability to screen for intra- 44% rate in change of treatment with 38% of those peritoneal hemorrhage in adults.140, 141 patients, constituting a decrease in monitoring and There has been a fair amount of controversy intensity of care and 6% requiring increasing care.147 over the sensitivity and specificity of FAST in chil- Thus, abnormal CT scan results may not influence dren, with many critics arguing that it is not reliable. the decision for a surgical procedure; however, However, a meta-analysis revealed a sensitivity of normal CT results aid in diagnostic certainty and 80% (95% confidence interval [CI], 76%-84%) and discharge decisions. Although costly initially, it specificity of 96% (95% CI, 95%-97%) in pediatric decreases the length and cost of hospital stay. These trauma patients.142 This is comparable to reported factors need to be weighed against radiation expo- sensitivities and specificities in adult patients. sure in pediatric patients. However, DPL is used differently in the injured A recent article in Academic Emergency Medi- child. It has an important role in the hypotensive cine attempts to clarify the significance of a nega- child with multisystem blunt trauma in whom US tive abdominal CT in pediatric patients following is unavailable or equivocal. However, children with blunt trauma. Currently, many trauma centers stable hemodynamics and hemoglobin who have admit pediatric patients for serial examinations blood discovered in their abdomen are much more even with normal abdominal CT scan results. The likely to be treated without laparotomy than are prospective observational cohort study enrolled adults. Therefore, DPL is generally not indicated if 1295 pediatric patients, and 84% of them had the child can be stabilized with blood and fluids. normal abdominal CT scan results.148 Of the 1085 CT, with its ability to discern specific organ inju- with normal scan results, 2 were later identified ry both in the peritoneal and retroperitoneal spaces, with intraabdominal injury: mesenteric hematoma remains a mainstay diagnostic test. The important and perinephric hematoma; however, neither un- caveat that applies to CT in adults applies to chil- derwent specific therapy. dren as well; false-negative rates for hollow visceral The negative predictive value of normal abdom- and pancreatic injury are substantial: 26% and 15%, inal CT scan results for intraabdominal injury was respectively.143, 144 99.8% (95% CI, 99.3%-100%). The article concluded Some authors believe that serial physical exami- that children who sustain blunt abdominal trauma nations are more important than CT in the diagnosis with normal abdominal CT results are at very low of pediatric bowel injury. In 1 retrospective study, all risk of having intraabdominal injury and are very children with major intestinal injury had suggestive unlikely to require further intervention. Thus, hos- signs on presentation or shortly thereafter.145 These pitalization for these children is generally unneces- signs included seat belt ecchymoses or diffuse ab- sary and concurs with the previous paragraph that dominal tenderness. The abdominal CT was insensi- normal CT results significantly decreases cost and tive in making the diagnosis and detected only 1 in length of stay in the hospital. 13 bowel injuries. Another study confirmed that the

88 An Evidence-Based Approach To Traumatic Emergencies Geriatrics out. The clinical diagnosis of shock is impaired The diagnostic approach to the elderly patient is un- during pregnancy because of the significant changed. However, it is critical to bear 2 facts in mind. cardiovascular changes. A pregnant woman may These patients are far more likely to have significant lose 30% to 35% of her blood volume — 1.5 liters comorbid disease and to be on medications that alter — before demonstrating any physiologic signs of 152 their presentation, including vital signs, as well as shock. In addition, stretching of the peritoneum their ability to tolerate these injuries. In addition, decreases the ability of the emergency clinician to this group has increased morbidity and fatality for detect hemoperitoneum. In an early series, 50% of virtually any injury sustained when compared with pregnant women with massive hemoperitoneum 153 younger cohorts.149 As such, management and dispo- had no peritoneal signs. sition decisions should lean well toward the conser- The management of shock also changes in preg- vative end of the spectrum. At least 1 study suggests nancy. The “supine hypotensive syndrome” may that an elevated base deficit (more negative than -6) occur after 20 weeks’ gestation. This syndrome is during the first hour of care can help predict severe caused by uterine pressure on the inferior vena cava, injury or death in the elderly trauma patient.150 resulting in a drop in cardiac output of up to 28% and systolic blood pressure of 30 mm Hg.154 One of Pregnancy the first interventions by prehospital care providers Trauma is frequent during pregnancy. Women are and ED personnel alike is to “unload” the vena cava more subject to falls after 20 weeks of gestation com- by pushing the uterus to the left. Alternatively, tow- pared with nonpregnant patients, and the prevalence els placed under the right side of a backboard will of physical abuse is 4% to 17% during pregnancy.151 cause the uterus to fall to the side, accomplishing the Certain physiologic changes affect the ap- same purpose. proach to abdominal trauma. The systolic and The 3 primary diagnostic agents can be used diastolic blood pressures decline 2 to 4 mm Hg throughout pregnancy, with certain precautions. US and 5 to 15 mm Hg, respectively, in the first and is presumed safe and accurate in this setting, but a second trimester and then normalize in the third large, prospective trial has not yet been conducted. trimester; in addition, an increase in pulse of 10 to With regard to CT, the fetus is most vulnerable to ra- 15 beats per minute can be anticipated through- diation while it is from 2 to 7 weeks’ gestational age.

Key Concepts In Blunt Abdominal Trauma

1. Physical Examination sound is noninvasive and slightly less sensitive, The accuracy of the physical examination is not but it can simultaneously evaluate for blood in perfect and is rendered less so by distracting in- the pericardial space. jury, head trauma, alcohol or drug intoxication, and spinal cord injury. 5. Pelvic Fracture In the unstable, blunt, multi-system trauma pa- 2. Diagnostic Tests tient with pelvic fracture, immediate ultrasound The selection of major diagnostic studies for or peritoneal aspiration can determine the need abdominal trauma should be based upon the for urgent laparotomy. If these studies are un- clinical setting, the timely availability of the equivocally negative, attention can be turned to study, and the trustworthiness of that study in other sources of hemorrhage, notably the pelvic the respective center. vessels.

3. Clinical Indications for Laparotomy 6. Special Circumstances These are quite helpful in penetrating trauma. The preferred human qualities in managing However, in blunt multi-system trauma, these critical blunt trauma patients are common sense are less dependable and are very uncommonly and quick reflexes. An algorithm can’t cover the sole reason a patient proceeds to laparotomy. all of the permutations in the patient with some complex combination of head, chest, mediasti- 4. The Unstable Patient nal, intraperitoneal, and pelvic trauma. The The critical determinant in this patient is the organ system that takes precedence is the one rapid determination of the presence or absence that is most immediately life-threatening. Then, of hemoperitoneum. DPL is a very sensitive but simply do your best contending with the others invasive method of accomplishing this. Ultra- until the most imminent disaster is managed.

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 89 A modified abdominal CT limited to the areas above administration of butyrophenones should place the the uterus (basically the liver and spleen) incurs a patient (and thus the treating emergency clinician) in safe dosage of less than 3 rads to the fetus. Including a much better mood. the pelvis in the scan generates an undesirable 3 to 9 Severely intoxicated patients with suspected rads. However, spiral CT reduces fetal radiation ex- minimal trauma can be observed or committed to posure 14% to 30%.155 DPL is known to be accurate one or more of the diagnostic tests. This is a clini- in pregnancy153, 156 but should be performed by the cal decision that rests with the understanding of the open supraumbilical technique after the first trimes- mechanism, the clinical circumstances of the patient, ter.91 Cut-off values for DPL effluent are identical to and the institutional resources. For example, a very those of nonpregnant patients. busy ED with limited personnel should move more Maternal resuscitation is the prevailing tenet, quickly toward definitive diagnostics rather than and indications for abdominal laparotomy are serial observations. Finally, in patients with known unchanged. One disposition matter is key: Patients intraperitoneal injury as determined particularly by beyond 20 weeks’ gestation (ie, in whom the fetus is CT, expectant management (ie, the deliberate ob- viable) who sustain torso trauma of any magnitude servation of a patient in whom laparotomy may be and who appear otherwise well should undergo at unnecessary) is more hazardous than in the nonalco- least 4 hours of fetal monitoring. This allows early holic patient.161 detection of placental abruption, a complication of even trivial trauma.157 Disposition

Alcoholic Patients Three central issues face the emergency clinician: Bacchus has drowned more men than Neptune. consultation, transfer, and discharge home. —Thomas Fuller40 Consultation Both acute and chronic alcohol usage increase Consultation should be made as soon as the need is the risk of abdominal trauma. From a physiologic apparent. This can be based on the paramedic report perspective, alcoholics tend to have a lax abdomi- from the scene or one glance at the patient being nal wall and therefore incur greater morbidity from wheeled by stretcher through the doors of the ED. 158 anteroposterior compressive and burst forces. The purpose of consultation is, in turn, twofold. Alcoholic hepatitis and cirrhotic liver disease lead to an enlarged liver and congested spleen, respectively. Need For Operation As such, these are afforded less protection by the This is the easy one. Consultation is made as soon as rib cage, and their increased intracapsular pressure there is strong suspicion or knowledge that laparo- decreases their resistance to blunt forces. Pancreatic tomy is necessary. The tricky part is knowing whom pseudocysts are also subject to rupture from blunt 159 to call. In a trauma center, there is rarely debate, as trauma. Finally, chronic alcoholism may result in a trauma surgeon is on call and usually in-house. coagulopathy with resultant exacerbated hemor- At the other end of the spectrum is the community rhage and complicated management. hospital that has no trauma designation and limited The clinical examination and major diagnostic commitment to trauma. Here, the call should go to procedures can all be affected by acute and chronic the general surgeon, who should respond in a timely intoxication. In a recent series, intoxicated patients manner. Unfortunately, the willingness and expertise were nearly 5 times more likely to have an unsus- (or lack thereof) of this consultant can vary. Obvi- pected injury than were patients who had a negative 160 ously, hospital and interrelated departments need blood alcohol level. If the patient’s mental status to acknowledge these scenarios and be proactive is impaired by severe intoxication or hepatic enceph- instead of simply reactive. alopathy, the ability of the patient and the examiner to appreciate intraperitoneal and retroperitoneal Need For Evaluation manifestation is impaired. For the obviously and seriously injured trauma Ascites can create difficulties in the interpreta- patient, an immediate consult with the trauma or tion of DPL, CT, and US. If coagulopathy is present general surgeon allows the team to evaluate, then or suspected, some authorities suggest that DPL expedite, care. It is right for the emergency clinician, should be performed by the semiopen or fully open the surgeon, and the patient. technique, with careful attention to hemostasis. Por- The approach to the relatively stable patient var- tal hypertension in the chronic alcoholic can lead to ies among and within hospitals. Optimally, the emer- engorgement of umbilical veins that pose additional gency medicine, surgical, subsurgical, and radiology hazard to the performance of DPL, particularly if groups will have convened and agreed on diagnostic percutaneous. Combativeness obviously is prob- and management algorithms. Otherwise, the number lematic for any of the procedures, but appropriate of permutations in management is enormous.

90 An Evidence-Based Approach To Traumatic Emergencies Admission practices vary widely among hos- following serial observation, it is far wiser to consult pitals. Many authorities favor admitting multiple the trauma surgeon and proceed with further obser- trauma patients with, for example, orthopedic con- vation or studies. cerns to the trauma or general surgeon with consul- For patients with a CT with negative results , tation by the orthopedist and not vice versa-at least conservative pundits argue that 12 to 24 hours of infor the first 24 to 48 hours of care. This basic prin- hospital observation is mandatory. This is to enable ciple applies to the pregnant, pediatric, and geriatric discovery of late presenting injury, particularly bowel patients as well. However, no prospective studies disruption missed by CT, as well as allow the oppor- have evaluated this approach. tunity for CT to be read by the institution’s expert the following morning. However, 1 recent observational Transfer study of 2299 blunt trauma patients demonstrated The patient must be transferred if the base hospital that normal abdominal CT scan results ruled out is incapable of providing adequate care. The miss- significant injury in 99.63% of patients. In this series, ing ingredient(s) may include a diagnostic test OR there were only 6 therapeutic laparotomies in patients surgical staff, surgeon, monitored bed, or specialist. with initially normal CT scan results (intestine in 3, Once it becomes clear that transfer is needed, delay bladder in 1, kidney in 1, and diaphragm in 1). The in transfer should be strictly avoided. In general, authors concluded that most patients with a CT scan diagnostic studies — particularly those that are time with negative results after suspected blunt abdominal consuming — should be undertaken at the receiving trauma do not require either hospital admission or hospital, unless that test is integral to determining prolonged observation.24 the need for transfer in the first place. The approach to discharging a patient with nor- The transfer itself should abide by EMTALA mal abdominal CT results and no other significant regulations. The mode of transfer and the type of injuries is best individualized according to the center personnel involved rest with the patient’s clinical and the patient. Consider the resources available to status, available resources, weather conditions, traf- the patient and his or her ability to recognize clinical fic patterns, and the like. worsening and then return should it occur. One thorny issue that may arise in smaller hospitals relates to the hypotensive patient with prob- Summary able intraabdominal bleeding. Such patients may not survive the transfer to a higher level of care. For The recipe for successful abdominal trauma such patients, it is useful to consult the local surgeon management calls for just a few main ingredients. regarding the possibility of “damage control” lapa- First, the prospect of the existence of abdominal rotomy. In such a case, the local surgeon would per- injury must be considered. When that suspicion form an emergent laparotomy with the sole purpose has arisen, appropriate diagnostic studies, clinical of staunching life-threatening hemorrhage. When observation, or both should identify those with the bleeding is controlled, the patient may then be abdominal injury in reasonably short order. For in- transferred (even with an open abdomen with packs juries that may be missed because of insensitivity in place) to the trauma center.162, 163 of the physical examination and inaccuracy of the If a damage control surgical procedure is an diagnostic study, further observation or testing is option, then the emergency clinician may elect to warranted. Patients whose medical needs cannot perform a DPL or US on such unstable blunt trauma be met should be delivered to regional centers for patients early in the course of evaluation. care as quickly as possible. Finally, close cooperation with trauma-related services and adminis- Discharge Home trators encourages good outcomes and efficient Certain patients — notably, those with single-system resource use. trauma and stable vital signs — can be discharged home after a period of observation with or without References US, DPL, CT, or some combination thereof. These patients can be sent home only if their mental status, Evidence-based medicine requires a critical ap- vital signs, and host status (immune, coagulation) praisal of the literature based on study methodology are at or close to baseline and their social support and number of participants. Not all references are systems competent. The emergency clinician must equally robust. The findings of a large, prospective, be very cautious for those at increased risk for de- randomized, and blinded trial should carry more layed presentation or worsening, such as the patient weight than a case report. with mechanism (eg, spearing, as with a handlebar To help the reader judge the strength of each injury) or clinical features (eg, seat belt mark) con- reference, pertinent information about the study, sistent with hollow viscus injury. In these situations such as the type of study and the number of patients or for patients with persistent abdominal tenderness in the study, is included in bold type following the

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 91 reference, where available. In addition, the most 17. *Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus informative references cited in the chapter, as deter- delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105-1109. mined by the authors, are noted by an asterisk (*) (Prospective, randomized; 598 patients) next to the number of the reference. 18. Sampalis JS, Tamim H, Denis R, et al. Ineffectiveness of on-site intravenous lines: is prehospital time the culprit? J 1. Jacobs DG, Sarafin JL, Marx JA. Abdominal CT scanning Trauma. 1997;43:608-615. (Observational, nonrandomized; for trauma: how low can we go? Injury. 2000;31(5):337-343. 217 patients) (Retrospective CT use review; 1147 patients) 19. Owings JT, Wisner DH, Battistella FD, et al. Isolated transient 2. Brown CK, Dunn K, Wilson K. 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Principles and Practice of Emergency Medicine. 4th ed. Phila- 84. Melniker L, Liebner E, McKenney MG, Lopez, P. Random delphia, PA: Williams & Wilkins; 1999. (Textbook chapter) ized controlled trial of point-of-care, limited ultrasonog 103. Gonzalez RP, Dziurzynski K, Maunu M. Emergent extra-ab- raphy (PLUS) for trauma in the emergency department: the dominal trauma surgery: is abdominal screening necessary? first sonography outcomes assessment program trial.Ann J Trauma. 2000;49(2):195-198; discussion 198-199. (Retrospec- Emerg Med. 2006;48(3):227-235. tive; 210 patients) 85. Tsui C, Fung H, Chung K, Kam C. Focused abdominal 104. Mavridis SP, Firilas AM. Blunt trauma in intoxicated sonography for trauma in the emergency department for patients: is computed tomography of the abdomen always blunt abdominal trauma. Int J Emerg Med. 2008;1(3):183-187. necessary? South Med J. 2000;93(4):403-405. (Retrospective; 86. Richards JR, McGahan JP, Simpson JL, et al. 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(Collective series; and therapeutic laparotomy in normotensive blunt trauma 12 patients) patients. J Emerg Med. 2007;33(3):265-271. 89. Hubbard SG, Bivins BA, Sachatello CR, et al. Diagnostic er- 108. Biffl WL, Kaups K. Management of patients with anterior rors with peritoneal lavage in patients with pelvic fractures. abdominal stab wounds: a western trauma association mul Arch Surg. 1979;114(7):844-846. (Retrospective; 222 patients) ticenter trial. J Trauma. 2009;66:1294-1301. 90. Mendez C, Gubler KD, Maier RV. Diagnostic accuracy of 109. Fakhry SM, Brownstein M, Watts DD, et al. Relatively peritoneal lavage in patients with pelvic fractures. Arch Surg. short diagnostic delays (< 8 hours) produce morbidity and 1994;129:477-482. (Retrospective cohort; 497 patients) mortality in blunt small bowel injury: an analysis of time 91. Marx JA. Peritoneal procedures. In: Hedges JR, Roberts JR, to operative intervention in 198 patients from a multicenter eds. 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94 An Evidence-Based Approach To Traumatic Emergencies 111. Hughes TM. The diagnosis of gastrointestinal tract in- 130. *Thomason M, Messick J, Rutledge R, et al. Head CT scan- juries resulting from blunt trauma. Aust N Z J Surg. ning versus urgent exploration in the hypotensive blunt 1999;69(11):770-777. (Review; 16 references) trauma patient. J Trauma. 1993;34:40-45. (Retrospective; 734 112. McStay C, Ringwelski A, Levy P, Legome E. Hollow viscus patients) injury. J Emerg Med. 2009. [Epub ahead of print] 131. Winchell RJ, Hoyt DB, Simons RK. Use of computed 113. Watts D, Fakhry S; EAST Multi-Institutional Hollow Viscus tomography of the head in the hypotensive blunt-trauma Injury Research Group. Incidence of hollow viscus injury patient. Ann Emerg Med. 1995;25:737-742. (Retrospective; 212 in blunt trauma: an analysis from 275,557 trauma admis- patients) sions from the EAST Multi-Institutional Trial. J Trauma. 132. Fabian TC, Richardson JD, Croce MA, et al. Prospec- 2003;54:289-294. tive study of blunt aortic injury: Multicenter Trial of the 114. Nance ML, Peden G, and Shapiro MB, et al. Solid viscus in- American Association for the Surgery of Trauma. J Trauma. jury predicts major hollow viscus injury in blunt abdominal 1997;42(3):374-380. (Prospective; 274 patients) trauma. J Trauma. 1997;43:618-623. 133. Schwab CW, Lawson RB, Lind JF, et al. Aortic injury: com- 115. Stuhlfaut JW, Soto JA, and Lucey BC, et al. Blunt abdominal parison of supine and upright portable chest films to evalu- trauma: performance of CT without oral contrast material. ate the widened mediastinum. Ann Emerg Med. 1984;13:896- Radiology. 2004;233:689-694. 899. (Comparative; 55 patients) 116. Hackam DJ, Ali J, and Jastaniah SS. Effects of other intra- 134. Dyer DS, Moore EE, Ilke DN, et al. Thoracic aortic injury: abdominal injuries on the diagnosis, management, and how predictive is mechanism and is chest computed to- outcome of small bowel trauma. J Trauma. 2006;49:606-610. mography a reliable screening tool? A prospective study of 1,561 patients. J Trauma. 2000;48:673-682. (Prospective; 1561 117. ACEP Clinical Policies Committee. Clinical Policies Subcom- patients) mittee on Acute Blunt Abdominal Trauma, Clinical Policy: critical issues in the evaluation of adult patients presenting 135. Brathwaite CE, Cilley JM, O’Connor WH, et al. The pivotal to the emergency department with acute blunt abdominal role of transesophageal echocardiography in the manage- trauma. Ann Emerg Med. 2004;43:278-290. ment of traumatic thoracic aortic rupture with associated intra-abdominal hemorrhage. Chest. 1994;105(6):1899-1901. 118. Chan RN, Ainscow D, Sikorski JM. Diagnostic failures in the (Case report) multiple injured. J Trauma. 1980;20:684-687. (Retrospective; 327 patients) 136. Fabian TC, Davis KA, Gavant ML, et al. Prospective study of blunt aortic injury: helical CT is diagnostic and antihyper- 119. Dove DB, Stahl WM, DelGuercio LR. A five-year review of tensive therapy reduces rupture. Ann Surg. 1998;213:666-667. deaths following urban trauma. J Trauma. 1980;20:760-766. (Prospective; 494 patients) (Retrospective; 108 patients) 137. Mirvis SE, Shanmuganathan K, Buell J, et al. Use of spiral CT 120. Aaland MO, Smith K. Delayed diagnosis in a rural trauma for the assessment of blunt trauma patients with potential center. Surgery. 1996;120(4):774-778. (Prospective; 68 delayed aortic injury. J Trauma. 1998;45:922-930. (Prospective; 1104 diagnoses in 1876 patients evaluated) patients) 121. Rizoli SB, Boulanger BR, McLellan BA, et al. Injuries missed 138. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine during initial assessment of blunt trauma patients. Accid laboratory testing for detecting intra-abdominal injury in the Anal Prev. 1994;26(5):681-686. (Retrospective; 432 patients) pediatric trauma patient. Pediatrics. 1993;92(5):691- 694. (Bi- 122. Enderson BL, Maull KI. Missed injuries: the trauma phasic [retrospective and model application]; 285 patients) surgeon’s nemesis. Surg Clin North Am. 1991;71:399-418. 139. Abou-Jaoude WA, Sugarman JM, Fallat ME, et al. Indicators (Review) of genitourinary tract injury or anomaly in cases of pediatric 123. Hirshberg A, Wall MJ Jr, Allen MK, et al. Causes and patterns blunt trauma. J Pediatr Surg. 1996;31:86-89. (Retrospective; of missed injuries in trauma. Am J Surg. 1994;168:299-303. 100 patients) (Follow-up; 123 missed injuries in 117 patients) 140. Katz S, Lazar L, Rathaus V, et al. Can ultrasonography 124. Laasonen EM, Kivioja A. Delayed diagnosis of extrem- replace computed tomography in the initial assessment ity injuries in patients with multiple injuries. J Trauma. of children with blunt abdominal trauma? J Pediatr Surg. 1991;31:257-260. (340 patients) 1996;31:649-651. (Retrospective; 124 patients) 125. Davis JW, Hoyt DB, McArdle MS, et al. An analysis of er- 141. Akgur FM, Aktug T, Olguner M, et al. Prospective study rors causing morbidity and mortality in a trauma system: a investigating routine usage of ultrasonography as the initial guide for quality improvement. J Trauma. 1992;32(5):660-665; diagnostic modality for the evaluation of children sustaining discussion 665-666. (Retrospective) blunt abdominal trauma. J Trauma. 1997;42:626-628. (Pro- 126. *Ferrera PC, Verdile VP, Bartfield JM, et al. Injuries distract- spective, observational, nonrandomized; 217 patients) ing from intra-abdominal injuries after blunt trauma. Am J 142. Sivit CJ. Abdominal trauma imaging: imaging choices and Emerg Med. 1998;16:145-148. (Prospective, nonrandomized; appropriateness. Pediatr Radiol. 2009;39(suppl 2):S158-S160. 350 patients) 143. Arkovitz MS, Johnson N, Garcia VF. Pancreatic trauma in 127. Schurink GW, Bode PJ, van Luijt PA, et al. The value of children: mechanisms of injury. J Trauma. 1997;42:49-53. physical examination in the diagnosis of patients with (Case series) blunt abdominal trauma: a retrospective study. Injury. 144. Taylor GA. Imaging of pediatric blunt abdominal trauma: 1997;28(4):261-265. (Retrospective) what have we learned in the past decade? Radiology. 128. Riemer BL, Butterfield SL, Diamond DL, et al. Acute mortal- 1995;195:600-601. (Editorial) ity associated with injuries of the pelvic ring: the role of 145. Jerby BL, Attorri RJ, Morton D. Blunt intestinal injury in early patient mobilization and external fixation.J Trauma. children: the role of the physical examination. J Pediatr Surg. 1993;35:671-675; discussion 676-677. (Retrospective with 1997;32(4):580-584. (Retrospective; 32 patients) historical cohort) 146. Moss RL, Musemeche CA. Clinical judgment is superior to 129. Wisner DH, Victor NS, Holcroft JW. Priorities in the manage- diagnostic tests in the management of pediatric small bowel ment of multiple trauma: intracranial versus intra-abdom- injury. J Pediatr Surg. 1996;31(8):1178-1181; discussion 1181- inal injury. J Trauma. 1993;35:271-276. (Retrospective; 800 1182. (Retrospective; 48 patients) 133. patients)

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 95 147. Donnelly LF. Imaging issues in CT of blunt trauma to the 34. A multiple blunt trauma patient has blood chest and abdomen. Pediatr Radiol. 2009;39(suppl 3):S406- pressure of 70, severe closed head injury (GCS S413. 6, nonlocalizing neurologic examination), an 148. Awasthi S, Mao A, Wooton-Gorges SL, Wisner DH, Kupper- AP pelvis radiograph with negative results, mann N, Holmes JF. Is hospital admission and observation required after a normal abdominal computed tomography and greater than 10 cc gross blood byDPL. He scan in children with blunt abdominal trauma? Acad Emerg is most likely to have: Med. 2008t;15(10):895-899. a. An epidural hematoma 149. Tornetta P 3rd, Mostafavi H, Riina J, et al. Morbidity and b. An intraventricular bleed mortality in elderly trauma patients. J Trauma. 1999;46:702- c. A grade III liver laceration 706. (Retrospective; 326 patients). d. Significant retroperitoneal hemorrhage 150. Davis JW, Kaups KL. Base deficit in the elderly: a marker of severe injury and death. J Trauma. 1998;45:873-877. (Com- parative; 274 patients) 35. The “spearing” mechanism to the mid-abdo- 151. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med men is likely to result in: Assoc J. 1993;149:1257. (Survey) a. Splenic fracture 152. Neufeld JD, Moore EE, Marx JA, et al. Trauma in pregnancy. b. Retroperitoneal hematoma Emerg Med Clin North Am. 1987;5: 623-640. (Review) c. Perforated ileum 153. Rothenberger DA, Quattlebaum FW, Zabel J, et al. Diagnos- d. Myocardial contusion tic peritoneal lavage for blunt trauma in pregnant women. Am J Obstet Gynecol. 1977;129:479-481. (Case report; 12 36. The PASG has been proven to: patients) a. Diminish fatality in penetrating trauma 154. Walters WA, MacGregor WG, Hills M. Cardiac output at rest during pregnancy and the puerperium. Clin Sci. 1966;30:1-11. patients (Nonrandomized, observational) b. Diminish fatality in blunt trauma patients 155. Hidajat N, Maurer J, Schroder RJ, et al. Radiation exposure c. Decrease systemic vascular resistance in spiral computed tomography: dose distribution and dose d. Decrease retroperitoneal hemorrhage in reduction. Invest Radiol. 1999;34:51-57. (Straight physics) certain pelvic fractures 156. Esposito TJ, Gens DR, Smith LG, et al. Evaluation of blunt abdominal trauma occurring during pregnancy. J Trauma. 37. A motor vehicle crash survivor presents to the 1989;29:1628-1632. (Retrospective; 40 patients) ED with a blood pressure of 118/70, pulse of 157. Dahmus MA, Sibai BM. Blunt abdominal trauma: are there any predictive factors for abruptio placentae or maternal- 92, upper chest abrasions, and bilateral open fetal distress? Am J Obstet Gynecol. 1993;169:1054-1059. tibia-fibula fractures. He smells of alcohol but (Retrospective; 233 patients) is clinically sober. Under what circumstances 158. Mosher JF, Jernigan DH. Public action and awareness to should the patient undergo US before going to reduce alcohol-related problems: a plan of action. J Public the OR for washout of the fractures? Health Policy. 1988;9(1):17-41. (Policy description) a. No matter what 159. Marx JA. Alcohol and trauma. Emerg Med Clin North Am. b. If the abdomen is tender to examination 1990;8:929-938. (Review) c. Only if the hemoglobin is less than 12 gm/ 160. Fabbri A, Marchesini G, Morselli-Labate AM, et al. Blood dL alcohol concentration and management of road trauma patients in the emergency department. J Trauma. 2001;50(3):521- d. Only if the serum ETOH is greater than 100 528. (Prospective cohort) mg/dL 161. Pories SE, Gamelli RL, Vacek P, et al. Intoxication and injury. J Trauma. 1992;32:60-64. (Retrospective; 427 patients) 38. CT has less sensitivity for the detection of 162. Moore EE, Burch JM, Franciose RJ, et al. Staged physi- which pair of the following? ologic restoration and damage control surgery. World J Surg. a. Large bowel, liver 1998;22(12):1184-1190. (Review) b. Small bowel, pancreas 163. Bowley DM, Barker P, Boffard KD. Damage control surgery- c. Kidney, pancreas concepts and practice. J R Army Med Corps. 2000;146(3):176- 182. (Review) d. Kidney, liver

39. A pedestrian struck by a car presents with a CME Questions blood pressure of 60, pulse of 124, 400 cc in a right chest tube, and a right femur fracture. Be- 33. In patients with known pelvic fracture, DPL cause of hypotension, he should next undergo should be performed by which one of the fol- which one of the following? lowing? a. Abdominal laparotomy a. Seldinger technique infraumbilically b. Abdominal CT b. Seldinger technique supraumbilically c. DPL c. Fully open technique infraumbilically d. Serial abdominal examinations d. Fully open technique supraumbilically

96 An Evidence-Based Approach To Traumatic Emergencies 40. A patient falls out of a 2-story window, lands 44. A 26-week pregnant 21-year-old presents after on his buttocks, and sustains a pelvic fracture. falling down 3 steps. Her examination results His blood pressure at the scene is 100 mm Hg, are entirely normal, including US results, and in the ED after 500 cc normal saline, it is which demonstrate a fetal heart rate of 130 and 120 with a pulse of 100. The aspiration por- no intraperitoneal fluid. The correct disposition of DPL is negative, but the RBC count of tion for her is the recovered effluent is 100,000 RBC/hpf. He a. Helical abdominal CT should now undergo: b. Fetal monitoring for 4 hours a. Abdominal laparotomy c. Fetal monitoring every 24 hours b. Abdominal US d. Discharge home c. Abdominal CT d. Pelvic angiography 45. Which of the following is true regarding isolated small bowel injury? 41. A pedestrian struck by a car presents with a. Clinical signs are often delayed by more blood pressure of 80, pulse of 110, a moderately than 6 hours. wide mediastinum without hemothorax on an b. DPL red cell threshold of 100,000 is usually anteroposterior radiograph, and a positively exceeded. resulting FAST for intraperitoneal fluid. The c. US has grossly positive results. next step for this patient should be: d. Plain radiograph always demonstrates free a. Posterior-anterior upright chest radiograph air. b. Abdominal CT c. Thoracotomy 46. A 10-year-old child presents with abdominal d. Laparotomy pain after being tackled in a football game. His examination, including vital signs, is 42. Regarding diagnostic studies in pediatric blunt unremarkable. His hemoglobin is 13.4 and UA abdominal trauma patients, which one of the reveals 50 RBC/hpf. He should now receive: following is false? a. Intravenous pyelogram a. US has the excellent ability to determine the b. Abdominal CT presence of hemoperitoneum. c. Abdominal US b. CT is the procedure of choice for d. Follow-up with his pediatrician nonoperative management. c. DPL is useful in hemodynamically unstable 47. What measure of pulse change (beats per min- patients. ute) can be expected throughout pregnancy? d. Serum amylase and liver function tests are a. Increase of 10 to 15 effective screens for intraabdominal injury. b. Increase of 20 to 30 c. Decrease of 10 to 15 43. Which of the following should be absolutely d. Decrease of 20 to 30 avoided in the blunt trauma patient who is in the third trimester of pregnancy? 48. When compared with the healthy patient, a. Abdominal US which of the following regarding the chronic b. Infraumbilical Seldinger technique DPL alcoholic blunt abdominal patient is true? c. Upper abdominal CT a. Intraperitoneal solid organ injury is less d. Abdominal helical CT likely following compressive forces. b. Intraperitoneal hollow viscus injury is less likely following “spearing” mechanism. c. Expectant management of known intraperitoneal injury is more successful. d. Fatality is greater for comparable levels of intraperitoneal injury.

Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking 97 98 An Evidence-Based Approach To Traumatic Emergencies Wrist Injuries: Emergency Imaging And Management

Authors E. Parker Hays Jr., MD, FACEP Scot Hill, MD Assistant Director, Emergency Medicine Residency Assistant Clinical Professor, Department of Emergency Medicine, Mount Program, Carolinas Medical Center, Charlotte Sinai School of Medicine, New York, NY CME Objectives Eric Wasserman, MD Clinical Instructor, Department of Emergency Medicine, Mount Sinai School Upon completing this article, you should be able to: of Medicine, New York, NY; Attending Physician, Department of Emergency 1. List both common and rare types of bone, muscle, and ligamentous Medicine, Jersey City Medical Center, Jersey City, NJ wrist injuries. 2. Explain the indications for radiography and other diagnostic studies in the scenario of wrist injury. Peer Reviewers 3. Describe how the mechanism of injury as well as patient age and occupation affect wrist injuries and their management. Charles Stewart, MD, FACEP 4. Discuss appropriate emergency management of wrist injuries, Colorado Springs, CO including pain management as well as indications for splinting, referral, and follow-up. Kurt R. Denninghoff, MD, FACEP Associate Professor and Research Director, Department of Emergency Date of original release: November 1, 2001. Medicine, University of Alabama at Birmingham, Birmingham, AL Date of most recent review: August 1, 2009.

March 15, 2000: A 20-year-old woman presents to the ED clinician is often left without a comprehensive guide after falling while she was rollerblading. She has a swollen for the evaluation and management of wrist injuries. wrist, but no tenderness in the snuffbox. Her films are This chapter aims to fill this void by describing the normal. She is discharged with instructions to return if state of the art emergency department (ED) manage- she has any problems. ment of wrist injuries. August 12, 2001: You receive an operative report from a local orthopedist. He has copied you on a procedure State Of The Literature note regarding a 21-year-old woman with a condition you’ve never heard of—“Kienbock’s disease.” You wonder, Much of the management of wrist injuries is based “What does this have to do with me?” on anecdote, tradition, and local practice. There are few prospective, randomized trials to support the lthough wrist injuries are common, they can different emergency treatment strategies. Moreover, Ahardly be described as routine. True, most of given the nature of wrist injuries, this is unlikely to us can identify a radius fracture when we see one, change. Imagine trying to convince the hospital’s and we can usually recognize a carpal fracture. We institutional review board to randomize ulnar dislo- also know that navicular tenderness suggests an cations to either next-day reduction or treatment in occult fracture, which requires follow-up with an the ED. It would be no easier to persuade multiple orthopedist. centers to standardize treatments and enroll pa- However, wrist injuries are often quite complex. tients for once-a-year occurrences such as perilunate They comprise a continuum of bony, muscle, and dislocations. Therefore, we as emergency clinicians ligamentous damage. Physical examination and are largely left with small retrospective series and radiographic findings are rarely conclusive. More- “common sense.” Common sense, however, does over, both recognized and occult injuries can lead to not lend itself to the rigorous methodology that is significant long-term sequelae. Because patients rely the foundation of evidence-based medicine. As one on their hands for careers and day-to-day activities writer mused, “Common sense is part of the home- of all kinds, complete recoveries are usually a must. made ideology of those who have been deprived of It is little wonder that wrist injuries (especially with fundamental learning, of those who have been kept missed or delayed diagnoses as well as inadequate ignorant.”2 treatment) are common causes of malpractice suits against emergency clinicians.1 The literature on wrist injuries can be confusing. Epidemiology The emergency literature is sparse, and studies in the orthopedic, hand, and radiologic journals focus Injuries to the wrist account for about 2.5% of orthopedic injuries seen in the average community on retrospective, operative, and often theoretic con- 3 cerns. Short of splinting everything, the emergency ED. In 1 study, the incidence of wrist injuries that prompted radiography was 26 per 10,000 per year.4

Wrist Injuries: Emergency Imaging And Management 99 In more practical terms, the average emergency cli- Articulations nician sees wrist injuries at least several times each The proximal row of carpals sits in the concavity month, if not every day or week. formed by the triangular fibrocartilaginous complex Most wrist injuries (90%) are the result of a fall (TFC) and the radial styloid. The articulation between on an outstretched hand. Although the characteris- the 2 rows of carpals is called the midcarpal joint, and tics of wrist injuries vary with age, no age group is the scaphoid bridges and stabilizes the 2 rows. spared. Children fall at play; the elderly fall in their The radius articulates with the lunate, scaphoid, homes. A recent study also suggests that wrist frac- and ulna. The ulna has no direct connection with the tures in the elderly may be strongly associated with carpals, but it is joined to the triquetrum by the TFC. falls due to vestibular dysfunction.5 Articulation between the radius and ulna is through Although falls are the predominant cause of the TFC and the sigmoid notch on the ulnar surface wrist injuries among patients of all ages, the type of the distal radius, which allows rotation of the and outcomes of the injuries sustained do vary forearm. Because the TFC forms the ulnar border of by age. Young children almost never have carpal the wrist, it is important to the wrist’s stability. fractures but may sustain distal radial fractures (especially torus [bulging of the cortex] and green- Muscles stick fractures). A fall on an outstretched hand in a Most of the muscles that move the wrist attach to the toddler or young child may also result in a radial metacarpals, allowing the carpals to move passively. head or supercondylar humerus fracture. Adoles- The flexor carpi ulnaris is the only muscle that cents and young adults are more likely to injure the connects to the carpal bones (the pisiform). About carpal bones, especially the scaphoid. When they do 60% of flexion and radioulnar deviation occurs at sustain a distal radius fracture, it is often complex the midcarpal joint, 60% of extension occurs at the and associated with other injuries. With increasing radiocarpal joint, and rotation occurs mostly at the patient age, scaphoid fractures become less common, radioulnar joint.6 whereas distal radius fractures become more so. In addition, adults are more involved in the Ligaments kinds of sports and recreation activities that put Although the bones are easily discernible on x-ray, it them at higher risk for wrist injuries. This accounts is the ligamentous elements that stabilize the wrist. for a rise in high-velocity injuries associated with They dictate much of the injury pattern and account bicycling, skating, and other outdoor sports seen in for many missed wrist injuries. The ligamentous suburban EDs. Emergency clinicians in urban areas support of the wrist consists of the extrinsic liga- may also see crush injuries due to industrial injuries. ments (which bind carpal to forearm) and intrinsic (which bind carpal to carpal). There are many Pathophysiology: Anatomy And Biomechanics named ligaments making up these groupings, but to the nonoperative emergency clinician, the overall The wrist joint allows a range of motion from about function is best conceptualized in groups. The indi- 75° volar flexion to 70° dorsal extension, with about vidual extrinsic ligaments essentially form a single 45° of ulnar and radial deviation and 180° of rota- dorsal and 2 volar arcades. tion. This mobility, in combination with the extrinsic The volar arcades approximate 2 “V”-shaped flexors and extensors, permits remarkable dexterity. arches starting at the radial styloid, reaching the car- The wrist includes all of the bones and articula- pals distally, and returning toward the ulnar styloid, tions from the distal radius and ulna to the carpo- attaching at the TFC. The proximal ligamentous arch metacarpal joint. This includes the bases of the 5 reaches the lunate in the proximal row of carpals; metacarpals, 8 carpal bones arranged in 2 rows, and the distal ligamentous arch reaches to the capitate. the distal 4 to 5 cm of the radius and ulna. As you Between these 2 arches is an unreinforced area of read this section, palpate your own anatomy and the joint capsule called the space of Poirier, at the identify the important landmarks. approximate level of the lunocapitate junction. With forceful extension, this space can widen and tear; Bones failure of ligamentous integrity can lead to instabil- The carpals are arranged in 2 semiparallel arches. ity or dislocation between the carpal rows.7 Because From radius to ulna the proximal arch includes the the extrinsic ligaments attach at the styloids, their scaphoid, lunate, triquetrum, and pisiform. The integrity is crucial to the stability of the wrist. distal row (radius to ulna) includes the trapezium, trapezoid, capitate, and hamate. The trapezium and Believe those who are seeking the truth. trapezoid are also known as the greater and lesser Doubt those who find it. multangulars. Because the distal carpals are inti- —André Gide mately connected to the metacarpals, they are more stable and less frequently injured.

100 An Evidence-Based Approach To Traumatic Emergencies ED Evaluation surgical procedure is anticipated, determine the time of the patient’s last meal. Standard questions regard- Serious or life-threatening injuries take precedence ing allergies and current medications may be helpful during any patient encounter in the ED. With the if analgesics, antibiotics, or other medications are exception of an uncontrolled arterial bleed, acute anticipated. wrist injuries by themselves are never a life threat. However, do not be lulled by a primary complaint of Physical Examination wrist pain before evaluating the patient. That wrist Once the ABCs have been addressed, evaluation of complaint may simply be the most painful of the any orthopedic injury starts with confirmation of injuries caused by a high fall; likewise, it could be a neurovascular integrity. Both the ulna and radial marker of cardiac syncope in an elderly patient. arteries are readily available to examination. In addition to the usual volar location, the radial pulse History can often be palpated in the snuffbox as well. In Important historical considerations include when most people, patency of either one of these vessels is and how the injury occurred. Remember that cuts sufficient to perfuse the hand. Capillary refill at the and even superficial abrasions (“hesitation cuts”) to fingertips will confirm the distal circulation. the volar wrist may be evidence of a suicide attempt; The Allen test may be helpful in patients with 10,11 at least 7% of suicidal adolescents present with wrist suspected arterial injury. To perform this test, the lacerations.8 Understanding how the various mecha- patient should be supine with his or her hand in the nisms influence wrist injury will help direct both the air. Then have the patient repeatedly pump his or physical examination and evaluation of radiographs. her fist. Instruct the patient to clench his or her fist As mentioned, 90% of traumatic wrist injuries tightly for several minutes while applying firm pres- result from a fall on the outstretched hand, giving us sure to both the ulnar and radial arteries. Initially the onomatopoeic acronym “FOOSH.”9 FOOSH inju- release the radial artery and determine how long it ries comprise the most frequent and well-recognized takes for the blanched hand to return to its normal trauma to the wrist—fractures of the distal radius color. Repeat this test, this time releasing the ulnar and scaphoid. This same mechanism can also break artery while maintaining pressure on the radial ar- bones located on the palmar surface of the hand by tery. Use the opposite hand as a control. A significant direct impact (ie, the hamate and pisiform) and can delay in refill time requires emergent consultation lead to significant ligamentous injuries. A fall on an with a surgical specialist. Remember that patients outstretched hand may cause more proximal injury with arterial injuries will likely have nerve damage as well, often to the elbow or even shoulder. as well because of the proximity of these structures. Direct trauma to the wrist usually breaks the Neurologic integrity of the hand is best con- more exposed bones, such as the styloids and firmed with 2-point discrimination. Most people can triquetrum or metacarpals. The carpals, especially detect 2 points at 0.5 cm apart on the finger pads. the hamate, may be injured if someone wielding a Splitting a tongue blade with a twisting motion stick (eg, golf club, baseball bat, or nightstick) hits provides 2 sharp points that can be placed in the an unyielding object (eg, ground, fastball, or skull). longitudinal axis of the fingertip border (so as not Extension or rotational injuries can lead to disloca- to cross between nerve fields). Motor testing be- tions, such as ulnar dislocation. Injuries outside the comes difficult with pain, but gross function should FOOSH mechanism typically do not cause scaphoid be confirmed. Test all 3 major nerves. To test ulnar fracture or Colles’-type radius fractures. nerve motor function, ask the patient to abduct his Punctures, foreign bodies, amputations, punch or her fingers (spread them apart against resistance). injuries, and crush (roller) injuries probably cause This will challenge the first dorsal interossei, which more disabilities than fractures. If the injury is open, are supplied by the ulnar nerve. The sensory branch determine what contaminants are possible, such as supplies the volar aspects of the fifth finger and the water, soil, or foreign bodies. In such patients, teta- radial and the ulnar half of the fourth finger. nus status is an important concern. To test the median nerve, have the patient lay In patients with severe injuries, pain in the wrist his or her hand flat with the palm up and then lift is the predominant symptom. When patients present the thumb straight up from the palm. Press against days to weeks after injury, they may have other com- the thumb to determine appropriate resistance plaints. Patients with ligamentous injury may note (the median nerve innervates the abductor pollicis a “clunk” or snapping sensation with movement of brevis). The sensory function of the median nerve the wrist and frequently report loss of hand strength. is best tested at the distal pulp of the index finger. Ask about preexisting medical conditions such The radial nerve supplies the motor function to as rheumatoid arthritis as well as previous injuries, wrist and finger extension via the extensor muscles because these may alter the baseline function and of the forearm but does not innervate the intrinsic radiographic appearance of the wrist. If an emergent muscles of the hand; therefore, a motor deficit of the

Wrist Injuries: Emergency Imaging And Management 101 radial nerve is unlikely in an isolated wrist injury. To force on the fingers (and thus the associated meta- test the motor branch of the radial nerve, have the carpals), the carpal bones are stressed. For example, patient extend the thumb or wrist against gravity. axial loading of the third digit will elicit pain in The sensory innervation of the radial nerve is best capitate or lunate fractures. Pain increased by axial examined in the first dorsal web space (between the loading of fourth and fifth metacarpals is frequent thumb and index finger).12 with hamate injury. Flexion of these fingers will also Suspicion of a particular injury should prompt cause pain in the hypothenar eminence in those with targeted assessment of the jeopardized nerve. For a fracture of the hook of the hamate. instance, when a hamate injury is suspected (classic A meticulous wrist examination is, of course, mechanism or tenderness over the base of the hy- crucial. Occasionally, tenderness and swelling will pothenar eminence), closely examine the motor and limit the examination, but time devoted to careful sensory function of the ulnar nerve. This nerve passes examination is likely to be fruitful. Physical exami- close to the hook of the hamate and can be crushed nation is the best guide to which (if any) radiographs during trauma to the hamate. When a Colles’ fracture are necessary. Order additional radiographs based is likely, perform a detailed assessment of the median on your examination to focus on the suspected in- nerve. This nerve may be damaged by either direct jury. Snuffbox tenderness mandates different radio- injury from a fracture fragment or by stretching. graphic views than tenderness of the ulnar styloid or Stated a different way and perhaps more obvi- the hamate. ous to the practitioner, neurologic symptoms such The skin and connective tissue around the wrist as paresthesias or weakness should offer clues that is generally mobile and devoid of fatty deposit. The something is amiss after a traumatic incident. No bones of the wrist are small but close to the surface. one should be discharged from the ED complain- Most of the carpal bones are palpable—try to feel ing of numbness or neurological deficits without each one to determine the point of maximal tender- appropriate imaging or consultation. Paresthesias ness. Remember key aspects of the surface anatomy within the median nerve distribution suggest lunate of the wrist. Important landmarks include the ana- dislocation into the carpal tunnel. Carpal tunnel syn- tomical snuffbox on the radial border of the wrist, drome differs from a lunate dislocation in that the the scaphoid tubercle (palpable below the thenar onset of symptoms would be gradual and have noc- eminence), the pisiform (felt below the ulnar border turnal exacerbations. Ulnar paresthesias or inability of the hypothenar eminence), and the radial and to abduct one’s fingers suggest a fractured pisiform ulnar styloids. or hamate compromising Guyon’s canal.13 The proximal extent of the wrist is marked by Look for any break in the skin in association the radial and ulnar styloids. The anatomic snuffbox is with an orthopedic injury, as this may represent an defined proximally by the radial styloid, dorsally by open fracture. In addition, depending on the mecha- the extensor pollicis longus tendon, and volarly by nism, a search for foreign bodies may be warranted. the extensor pollicis brevis and the abductor pol- In addition to examining for injury to the hand, licis longus tendons (the ideal location for snorting manipulation of the fingers and metacarpals can snuff). The scaphoid (navicular in the older litera- provide clues to carpal injury. Look at the stance of ture) is palpated in the floor of the snuffbox. the resting hand. Are all of the fingers in a normal Lister’s tubercle is the prominence on the dorsal cascade (index and thumb the least flexed position, aspect of the distal edge of the radius, just radial to progressing to greater flexion in the third, fourth, the middle of the wrist. Rolling distally, just over the and fifth digits)? An extended finger usually signi- tubercle, and slightly ulnar, with the wrist in neutral fies a flexor tendon injury, whereas abnormal flexion position, there is a small depression. This depression identifies an extensor tendon defect. marks the space between the radius and the capitate Next, examine the range of motion of each finger and the scapholunate joint. As the wrist is flexed, the and test the tendon strength against resistance. Test lunate is palpable as it rises out of this depression. the flexor digitorum profundus (FDP) and flexor This is one of the easiest places to palpate a wrist ef- digitorum superficialis (FDS) separately. Test the fusion, traumatic or otherwise. (This is also the best FDP by having the patient flex the distal interpha- place to tap a wrist.) Moving toward the ulna just langeal joint of each finger. To test the FDS of an distal to the ulnar styloid is the TFC; distal to that is individual digit, hold all of the other fingers in full the triquetrum. extension at the distal joint while asking the patient On the volar side of the wrist, the scaphoid tu- to flex the proximal interphalangial (PIP) joint of bercle is palpable just distal to the palmar margin of the finger in question. It is important to test both the the radial styloid, at the base of the thenar eminence. FDP and the FDS, because patients with a complete Across the wrist crease, at the base of the hypoth- laceration of the superficial tendon may still be able enar eminence, is the pisiform. Just distal and radial to flex the finger by using the FDP.14 to this, the hook of the hamate is palpable in the In the patient with blunt wrist trauma, push meat of the hypothenar eminence. The volar wrist each finger directly into the hand. By applying axial crease marks the base of the proximal row of carpals.

102 An Evidence-Based Approach To Traumatic Emergencies Because of its ubiquity and high complication emergency clinicians face a difficult management rate when missed, a diligent search for signs of dilemma when they are forced to decide whether to scaphoid injury is useful. Snuffbox tenderness is the immobilize a patient with scaphoid tenderness and most familiar sign, but tenderness of the scaphoid a negative plain radiograph, risking unnecessary tubercle is also an important finding.15 Supination immobilization and costs or the chance of the rare of the forearm against resistance exerts shear forces possibility of avascular necrosis. This debate is the across the scaphoid, and pain with this maneuver most controversial issue currently affecting patients suggests fracture. To perform this test, ask the pa- with wrist injuries. Although this will be more thor- tient to “shake hands” with you and tell the patient oughly discussed later, the best management is to not to let you twist her or his wrist. In the presence splint these patients in a removable, less-inhibiting of a scaphoid injury, the patient will complain of splint with early orthopedic follow-up for patients pain in the snuffbox when you try to twist her or his with persistent pain or to CT these patients to ob- rigid hand. An alternative test involves axial loading tain diagnostic certainty. of the thumb. By pushing directly down the axis of Although most injuries occur on the radial side an extended thumb, pressure is applied directly to of the wrist, do not neglect the ulnar aspect during the scaphoid. the examination. The ulna can displace dorsally or Waeckerle examined these 3 signs in 85 patients volarly. Pain and deformity in the area of the ulnar (with 40 fractures identified acutely or on follow-up) styloid are the hallmarks of a radial ulnar disloca- and found snuffbox tenderness had a sensitivity of tion, but this finding is difficult to interpret when 100% and a specificity of 98% for ultimate detection associated with other wrist injuries. With disruption of fracture (either on immediate radiography or at of the radioulnar joint, rotation of the forearm will 2-week follow-up). Supination against resistance be exquisitely painful. had a sensitivity of 100% and a specificity of 98%. A final caveat: When examining the wrists, Longitudinal compression of the thumb had a sensi- always take advantage of the fact that the wrist is a tivity of 98% and a specificity of 98%.16 paired structure. To detect subtle findings, have the In a separate prospective study, other authors patient hold both arms out together and compare evaluated 4 clinical signs believed to be useful in both sides. the diagnosis of scaphoid fracture.17 They examined 215 consecutive patients with suspected scaphoid You can observe a lot by just watching. fracture on 2 separate occasions for the follow- —Yogi Berra ing clinical variables: tenderness in the anatomical snuffbox; tenderness over the scaphoid tubercle; Radiology pain on longitudinal compression of the thumb; and the range of thumb movement. At the initial exami- The Ottawa rules provide an excellent guide to nation, tenderness in the snuffbox, tenderness over determine when to order ankle radiographs. How- the scaphoid tubercle, and longitudinal compression ever, the anatomy of the wrist is more complex, with of the thumb were all 100% sensitive for detecting a wider range of injuries, and radiographs harbor scaphoid fracture. However, their specificities were more subtle findings. There have been attempts dramatically lower than those in Waeckerle’s study, to develop an algorithm that defines criteria for with specificities of only 9% for snuffbox tenderness, radiography in the injured wrist or extremity among 30% for tubercle tenderness, and 48% for pain with children,19-21 but none has been validated or is pow- axial compression of the thumb. erful enough to influence clinical practice. In fact, the Abnormalities in the range of thumb movement authors of one orthopedic text summarize current had 69% sensitivity and 66% specificity. However, practice by stating, “With rare exceptions…imaging the authors found that the combination of snuffbox is an absolute requirement in the diagnosis of injury and tubercle tenderness along with pain on com- or disease involving the wrist.”22 pression of the thumb was 100% sensitive and 74% Algorithms and recommendations for imag- specific within the first 24 hours following injury. ing in wrist trauma come from the orthopedic and Unfortunately, this algorithm has never been re- hand literature, and many are impractical for the validated. Note also that in this study, 6 of the 56 emergency clinician. They start with x-rays, move to scaphoid fractures were reported as nontender in the special views, and get progressively more expensive 17 snuffbox at the 24-hour follow-up. (magnetic resonance imaging [MRI], bone scan, or Importantly, the article just referenced reports computerized tomography [CT]) or invasive (ar- that the 9% specificity of snuffbox tenderness for throgram and arthroscopy).23,24 Several studies in scaphoid fractures leads to overtreatment of 85% the emergency literature examine x-ray strategies 18 of patients with acute wrist injuries. Overtreat- for specific wrist injuries, but they are predicated ment involves unnecessary immobilization of the on determining the specific wrist injury in question joint, missed financial and recreational opportu- before obtaining the imaging studies. It should be nities, and needless health care expenses. Many

Wrist Injuries: Emergency Imaging And Management 103 stressed that the literature about missed injuries is PA View far more abundant than guidelines attempting to The hand should be in neutral position with the axis curtail x-ray use.25-30 In general, any patient with of the middle metacarpal lining up with the axis wrist trauma who has point tenderness of the wrist of the radius. Although the distal radius and ulna or a test suggesting a scaphoid injury should have should not touch at the radioulnar joint, the gap an x-ray. Beyond this, the literature on who needs a should be less than 2 mm. The ulnar styloid should radiograph is silent. project laterally from the end of the ulna in a true Wrist radiographs can be intimidating. The 14 PA. Superimposition of the styloid on the ulna sug- bones have subtle relationships that change with gests rotation or improper positioning.33,34 wrist positioning. Therefore, it is essential to have a system or mental checklist to evaluate wrist radio- Lateral View graphs. (See Table 1.)31 First, assess the adequacy On the lateral view, the axis of the middle metacarpal of the radiograph, then look at the alignment and should continue through the capitate, lunate, and ra- angles of the bones, and, finally, note the bone shape. dius. The dorsal surface of the ulna should be overlying, or less than 3 mm posterior to the dorsal surface Adequacy Of Radiographs of the radius. The 4 ulnar metacarpals should overlap The standard wrist series includes both a posterior- one another (see Figures 1 and 2), and the pisiform anterior (PA) and lateral view. Although controver- should overlie the head of the scaphoid. sial, some hospitals routinely include an oblique view. In 1 prospective study that examined the Alignment And Angles utility of oblique views in extremity trauma in 1461 On the PA view of a normal wrist, the radius and patients, the addition of the oblique view changed ulna are the same length at the radioulnar joint. the interpretation in 70 (4.8%) examinations as The radial styloid projects 11 to 12 mm farther—a well as increasing diagnostic confidence.32 Radio- distance known as “radial length.” There is a “radial graphs should include the carpometacarpal joint to inclination” (the slope of the radius from the styloid the distal 5 to 6 cm of the radius. When taking the down to the radioulnar joint) of 16° to 28°.35 The radiograph, the patient’s elbow should rest on the carpal bones line up as 2 arches, with up to 2 mm x-ray table in 90° flexion, with the shoulder in 90° between the individual carpals and between the 2 abduction. The beam is centered on the carpals. For rows. Three smooth radiographic arcs should be rec- this reason, hand radiographs, although they include the ognizable. (See Figure 3, page 106.) The first follows carpals, are inadequate for wrist assessment. Deviation the proximal cortexes of the scaphoid, lunate, and or rotation of the hand will alter the appearance and triquetrum; the second outlines the distal surfaces of alignment of the carpal bones and their relation to this proximal carpal row; and the third outlines the the ulna and radius. Therefore, the emergency clini- proximal surfaces of the capitate and hamate.36 cian should first assess the positioning of the hand On the lateral view of the normal wrist, the on radiographs using the following guidelines. radius has a “volar tilt” of 9° to 13° and the scaphoid

Table 1. Systematic Assessment Of The Wrist Radiograph

Adequacy: Bony shape: • Carpal-metacarpal junction to distal 5 cm of radius is included. • The scaphoid shows a cortical ring when dislocated on the PA view. • Hand is neutral in both the PA and lateral views. The axis of the • The lunate should be quadrangular on PA view; triangular shape middle metacarpal lines up with the middle of the radius. implies rotation or displacement. • Rotation (PA view): There is a gap between the two bones at the • The pisiform is the last carpal to ossify up to age 12 years. radioulnar joint. The ulnar styloid projects laterally. • Rotation (lateral view): The radius and ulna are superimposed or Special views: within 3 mm dorsally. The pisiform should overlie the head to the • Scaphoid: Views the long axis of the scaphoid. scaphoid. • Carpal tunnel: Views the pisiform and hamate. • Semi-pronated: Views the radial elements (trapezium and scaphoid Alignment and angles: tuberosity). • The three smooth articulating cortical lines of the carpals are vis- • Semi-supinated: Views the ulnar elements (pisiform and hamate). ible. • There is no more than 2-3 mm between individual carpal bones. • The radius articulates with at least half the lunate. • Radial inclination is 16-28° on PA view. • Radial volar (or palmar) tilt is 0-22° on lateral view. • Scapholunate angle is < 65° on lateral view. • The radial length is 11-12 mm.

104 An Evidence-Based Approach To Traumatic Emergencies Posterior-anterior View two rows. Three smooth radiographic arcs should be The hand should be in neutral position with the axis of the recognizable. (See Figure 3 on page 7.) The first follows the shouldmiddle metacarpalbe palmar (MC) flexed, lining withup with a normal the axis scapholuof the - proximaldeviation. cortexes It projects of the scaphoid, the length lunate, of andthe triquetrum; scaphoid bet- nateradius. angle While of the 30° distal to 60° radius from and the ulna axis should of the not carpals. touch at theter second than outlines the routine the distal views. surfaces (See of Figure this proximal 6, page 107.) the radioulnar joint, the gap should be less than 2 mm. The carpalThe row;supination and the obliquethird outlines view theis anproximal anterior-posterior surfaces of 34 ulnar styloid should project laterally from the end of the the(AP) capitate rather and thanhamate. PA view. It is shot with the radial Bonyulna in Shapea true PA. Superimposition of the styloid on the ulna On the lateral view of the normal wrist, the radius has a side lifted 45° and the ulnar side of the dorsum of Insuggests addition rotation to fracture or improper lines positioning. and displacement,31,32 the “volar tilt” of 9-13˚ and the scaphoid should be palmar Posterior-anterior View thetwo handrows. Threeon the smooth cassette. radiographic This gives arcs better should exposurebe shape of the carpal bones provides valuable clues to flexed, with a normal scapholunate angle of 30-60˚ from the injury.The handOn the should PA beprojection, in neutral positionthe scaphoid with the length axis of isthe torecognizable. the pisiform (See andFigure hamate. 3 on page (See 7.) The Figures first follows 7 and the 8, Lateralmiddle View metacarpal (MC) lining up with the axis of the axisproximal of the carpals. cortexes of the scaphoid, lunate, and triquetrum; seen, and it will gently cup the capitate. If it rotates, page 107.) The carpal tunnel view is shot through the Onradius. the lateral While view, the thedistal axis radius of the and middle ulna metacarpalshould not touch at the second outlines the distal surfaces of this proximal as in some dislocations, it will be foreshortened, carpal tunnel with the wrist maximally extended. shouldthe radioulnar continue throughjoint, the the gap capitate, should lunate,be less thanand radius. 2 mm. The Bonycarpal Shape row; and the third outlines the proximal surfaces of and the cortex of the distal pole will superimpose It provides a look at the bones forming the tunnel, Theulnar dorsal styloid surface should of the project ulna shouldlaterally be from overlying, the end or of less the In theaddition capitate to fractureand hamate. lines34 and displacement, the shape of over the body, projecting the illusion of a “signet mainly the hamate and pisiform.37 thanulna 3 mm in a posteriortrue PA. Superimposition to the dorsal surface of the of styloidthe radius. on the The ulna the carpalOn bonesthe lateral provides view valuableof the normal clues wrist,to pathology. the radius On has a The literature is rife with reports trumpeting the ring.”foursuggests ulnar The metacarpals rotationproperly or improper alignedshould overlap lunatepositioning. one will another31,32 be generally (see the“ volarPA projection, tilt” of 9-13 the˚ andscaphoid the scaphoid length is should seen, and be palmar it will limitations of plain radiography in wrist injury. But trapezoidalFigure 1 and Figureon the 2), PA and view. the pisiform As it rotates should overlievolarly, the as gentlyflexed, cup with the acapitate. normal Ifscapholunate it rotates, as anglein some of dislocations,30-60˚ from the do we have an imaging alternative? One interesting inhead dislocations,Lateral of the View scaphoid. it will look more like a triangle. (See it willaxis beof foreshortened,the carpals. and the cortex of the distal pole will FiguresOn the 4 lateral and 5,view, page the 106. axis )of the middle metacarpal superimposestudy compared over the plainbody, projectingradiographs the illusion and MRI of a in 67 Alignmentshould continue And Angles through the capitate, lunate, and radius. “signetpatientsBony ring. Shape with” The properlysevere wrist aligned trauma. lunate willThree be generallyradiologists SpecialOnThe the dorsal PA Viewsview surface of a normal of the ulna wrist, should the radius be overlying, and ulna or are less trapezoidalevaluatedIn addition on toboth the fracture PA the view. standardlines As and it rotates displacement, x-rays volarly, and asmagnetic the in shape of Specialthethan same 3 views mmlength posterior areat the generally radioulnar to the dorsal ordered joint. surface The when radialof the a styloidradius. specific The dislocations,resonancethe carpal bonesit (MR) will provideslook images more valuable inlike a ablinded triangle. clues to fashion(See pathology. Figure in 4 allOn pa- injuryprojectsfour isulnar 11-12 suspected. metacarpals mm farther In —shouldthea distance pronated overlap known oblique one anotheras “view,radial (see the andtients.the Figure PA projection,One-third 5 on page the 7.)of scaphoidthe 37 fractures length is seen,(n = and13) observedit will radiallength.Figure palm” There1 and is isFigure lifted a “radial 2 ),45°, and inclination leaving the pisiform” the (the shouldulnar slope of palmoverlie the on the ongently MR cup images the capitate. were missedIf it rotates, on asthe in radiographs.some dislocations, The theradiushead cassette. from of the the Thisscaphoid. styloid view down offers to the a betterradioulnar view joint) of theof tra- Specialauthorsit will beViews foreshortened,recommended and that the MRIcortex be of consideredthe distal pole in will se- 33 pezium16-28˚. Theand carpal scaphoid bones tuberosityline up as two as arches, well as with the up bases Specialveresuperimpose viewswrist aretrauma over generally the when body, ordered projecting“1) There when the isa specific aillusion clear injury discrepanof a is - to 2 mm between the individual carpals and between the suspected. In the pronated oblique view, the radial palm is of theAlignment first 2 Andmetacarpals. Angles Thescaphoid view, or ulnar- cy“signet between ring.” the The clinical properly status aligned and lunate a negative will be generally radiog- lifted 45˚, leaving the ulnar palm on the cassette. This view deviatedOn the PA PA, viewis shot of awith normal the wrist, palm the flat radius and and in ulnaulnar are raphytrapezoidal and onwhen the PA splint view. treatment As it rotates would volarly, increase as in cost Figurethe same 1. PA length view atof the the radioulnar wrist. It should joint. The be obviousradial styloid that offersbydislocations, causinga better view occupationalit will of lookthe trapezium more restrictions; like aand triangle. scaphoid and (See 2) tuberos- Figure Healing 4 theprojects bones 11-12 are all mm there; farther however,—a distance they ’knownre difficult as “ radialto ityofand as trauma well Figure as the5 diagnosed on bases page of 7.) the as first contusion two metacarpals. or distension The does Figuredelineatelength. 1.” individually,There PA Viewis a “radial whichOf Theinclination is why Wrist a” system(the slope of of the not occur within the expected time.”38 However, the assessment is so necessary when looking at the wrist. radius from the styloid down to the radioulnar joint) of Figurecost,Special 2implications,. Lateral Views view ofand the utility wrist. of this recommendation 16-28˚.33 The carpal bones line up as two arches, with up haveSpecial not views been are prospectively generally ordered examined. when a specific injury is to 2 mm between the individual carpals and between the suspected.Because In the the pronated wrist obliquein the view,most the commonly radial palm in is- juredlifted 45 joint˚, leaving and fracturesthe ulnar palm are onoften the cassette.subtle on This plain view Figure 1. PA view of the wrist. It should be obvious that offers a better view of the trapezium and scaphoid tuberos- the bones are all there; however, they’re difficult to ity as well as the bases of the first two metacarpals. The delineate individually, which is why a system of assessment is so necessary when looking at the wrist. FigureFigure 2 .2. Lateral Lateral view Viewof the wrist.Of The Wrist

Reproduced with permission from: Harris JH, Harris WH, eds. ItThe should Radiology be obvious of Emergency that the bones Medicine. are all 3rd there; ed. however, Baltimore: they’re dif- ficultLippincott to delineate Williams individually, & Wilkins which Publishers; is why a 1993:377.system of Fig.assessment 6.2B. is so necessary when looking at the wrist. Emergency Medicine Practice 6 November 2001 Reproduced with permission from: Harris JH, Harris WH, eds. The Ra- diology of Emergency Medicine. 3rd ed. Baltimore: Lippincott Williams & Wilkins Publishers; 1993:377. Fig. 6.2B. Reproduced with permission from: Harris JH, Harris WH, eds. The Radiology of Emergency Medicine. 3rd ed. Baltimore: Lippincott Williams & Wilkins Publishers; 1993:377.Wrist Fig. 6.2B. Injuries: Emergency Imaging And Management 105

Emergency Medicine Practice 6 November 2001 radiographs, leading to missed diagnoses in the Figure 3. Diagram Of The Alignment And ED,scaphoid further view radiological, or ulnar deviated aid shouldPA, is shot be with used the to palm avoid flat scaphoidscaphoid view view, or, or ulnar ulnar deviated deviated PA PA, is, isshot shot with with the the palm palm flat flat SpacingFigure 3. Diagram Of The of Carpal the alignment Arches and spacing of the missingand in injuriesulnar deviation. and the It projectsresulting the chronic length of pain the scaphoid and FigureFigure 3 . 3Diagram. Diagram of of the the alignment alignment and and spacing spacing of of the the andand in in ulnar ulnar deviation. deviation. It Itprojects projects the the length length of of the the scaphoid scaphoid carpal arches. disability.better than Having the routine a 9.3% views. misinterpretation (See Figure 6 on page rate 8.) on The carpalcarpal arches. arches. FigureFigure 6 6 plainbetterbettersupination radiograph than than the oblique the routine routine radiography,view views. views.is an (Seeanterior-posterior (See wrists onareon page 1page (AP) of 8.) the 8.)rather The The 4 mostsupinationsupinationthan common PA obliqueview. oblique radiologicalIt view is view shot is is anwith an anterior-posterior anterior-posterior theerrors radial and side 1 lifted of(AP) (AP) the 45rather rather˚3 and most the commonthanthanulnar PA PA sideview. errors view. of It the Itis of is shotdorsum shotclinical with with of the importance. thethe radial handradial side on side the lifted39 lifted cassette. 45 45˚ and˚ and This the the ulnarulnargivesA siderecent sidebetter of of the studyexposure the dorsum dorsum out to of of theof the Souththe pisiform hand hand Koreaon onand the the hamate. cassette.examined cassette. (SeeThis This the addedgivesgivesFigure better benefit better 7 and exposure exposure Figure that 8toa onto theCT thepage pisiformof pisiform the 8.) Thecarpal and andcarpal hamate. hamate.bones tunnel (See (Seeviewwould is FigureFigure 7 7 FigureFigure 8 8 addshot to plainthroughandand radiography the carpal on on page tunnelpage in8.) 8.) diagnosing Thewith The carpal the carpal wrist tunnel tunnel wrist maximally view view inju is is- shotshot through through the the carpal carpal tunnel tunnel with with the the wrist wrist maximally maximally ries.extended. Patients It withprovides wrist a look injuries at the bonesunderwent forming routine the tunnel, extended.extended. It Itprovides provides a looka look at at the the bones bones forming forming the the tunnel, tunnel, plainmainly radiography the hamate includingand pisiform. wrist35 AP, lateral and mainlymainly the the hamate hamate and and pisiform. pisiform.35 35 wrist andThe hand literature oblique is rife withradiographs, reports trumpeting and hand the PA limitationsTheThe literature literature of plain is isrife radiography rife with with reports reports in wristtrumpeting trumpeting injury. theBut the do we andlimitationslimitations oblique of of views.plain plain radiography radiographyIf certain infractures in wrist wrist injury. injury. were But But suspect do do we we- ed,have additional an imaging views alternative? were obtained One interesting such asstudy ulnar- com- havehavepared an an imagingplain imaging films alternative? alternative? and MR imaging One One interesting interesting in 67 patients study study withcom- com- acute deviatedparedpared plain plain PA films viewfilms and and for MR MRa imagingpotential imaging in inscaphoid67 67 patients patients withfracture with acute acute or a supinationwrist trauma. oblique Three radiologists view for aevaluated possible both pisiform the or wristwriststandard trauma. trauma. x-rays Three Three and radiologists radiologistsMR images evaluated evaluatedin a blinded both both fashion the the in all hookstandardstandard of the x-rays x-rays hamate and and MR fracture.MR images images in in a blindeda blinded fashion fashion in in all all patients.When aOne-third fracture of was the 37 not fractures seen on (n= the 13) plainobserved on patients.patients.MR images One-third One-third were ofmissed of the the 37 on37 fractures thefractures radiographs. (n= (n= 13) 13) observed observedThe authors on on radiographs but was suspected clinically or when MRMRrecommended images images were were thatmissed missed MR on imaging on the the radiographs. radiographs. be considered The The inauthors authorsacute additional fractures were suspected, a wrist or car- recommendedrecommendedwrist trauma that when: that MR MR “ 1)imaging imagingThere isbe bea considered clear considered discrepancy in in acute acute between pal CT was performed. The sensitivity and specific- wristwristthe traumaclinical trauma statuswhen: when: and“1) “1) Therea Therenegative is isa cleara radiography clear discrepancy discrepancy and between when between itythe thesplintof clinical plainclinical treatment status radiographs status and would and a negativea negativeincrease were, radiography costrespectively,radiography by causing and and 69.7%occupa-when when andsplintsplinttional 83.3% treatment treatmentrestrictions; compared would would and increasewith 2)increase Healing the cost cost100% of by bytrauma causing causingsensitivity diagnosed occupa- occupa- and as tionaltional restrictions; restrictions; and and 2) 2) Healing Healing40 of of trauma trauma diagnosed diagnosed as as specificitycontusion orof thedistension CT scan. does notThere occur were within cases the expectedof both Reproduced with permission from: Schwartz DT, Reisdorff EJ, false-negativecontusioncontusion36 or or distension distension and false-positive does does not not occur occur results within within inthe the x-rays expected expected of ReproducedReproduced with with permission permission from: from: Schwartz Schwartz DT, DT, Reisdorff Reisdorff EJ, EJ, time.” However, the cost, implications, and utility of this Reproducededs. Emergency with permissionRadiology. from:New SchwartzYork: McGraw-Hill DT, Reisdorff Professional EJ, eds. time.time.”36” 36However, However, the the cost, cost, implications, implications, and and utility utility of of this this eds.eds. Emergency Emergency Radiology. Radiology. New New York: York: McGraw-Hill McGraw-Hill Professional Professional therecommendation wrist: CT scan have revealed not been 10 prospectivelyfractures not examined. seen on EmergencyPublishing; Radiology. 2000:56. NewFig. 4-7. York: McGraw-Hill Professional recommendationrecommendation have have not not been been prospectively prospectively examined. examined. Publishing;Publishing; 2000:56. 2000:56. Fig. Fig. 4-7. 4-7. x-ray and 2 fractures were noted to be falsely posi- Publishing; 2000:56. Fig. 4-7. tive by the scans. The study also noted that the sca- Figure 4 andFigure 5. In the PA view (Figure 4; left), the lunate has taken on a more triangular shape, and the carpal arcs FigureFigureare completely 4 4and andFigureFigure disrupted. 5 . 5In. In the the The PA PA viewlateral view (Figure (Figureview (Figure 4; 4;left), left), 5;the theright) lunate lunate shows has has takenthe taken capitate on on a morea outsidemore triangular triangular of the cupshape, shape, of theand and lunate, the the carpal carpal but arcsthe arcs arearelunate completely completely is essentially disrupted. disrupted. in normal The The lateral lateralposition. view view (Figure (Figure 5; 5;right) right) shows shows the the capitate capitate outside outside of of the the cup cup of of the the lunate, lunate, but but the the Figurelunatelunate is 4.isessentially essentially The PA in Viewin normal normal position. position. Figure 5. The Lateral View

In the PA view, the lunate has taken on a more triangular shape, and The lateral view shows the capitate outside of the cup of the lunate, the carpal arcs are completely disrupted. but the lunate is essentially in normal position. November 2001 7 Emergency Medicine Practice NovemberNovember 2001 2001 7 7 EmergencyEmergency Medicine Medicine Practice Practice 106 An Evidence-Based Approach To Traumatic Emergencies ED Management Of Wrist Injuries tissues may provide clues to scaphoid injury. The scaphoid fat stripe lies parallel and just radial to the scaphoid on the Scaphoid Fractures PA view. It should be slightly bowed inward toward the EDScaphoid Management fractures comprise Of Wrist 60%-80% Injuries of all carpal fractures. bone;tissues obliteration may provide or cluesoutward to scaphoid deviation injury. of the The stripe scaphoid may Because the scaphoid forms a bridge between the carpal suggestfat stripe occult lies parallel fracture. and However, just radial false-negative to the scaphoid rates on of the rows,Scaphoid it must Fractures withstand dramatic forces across its waist PA view. It should be slightly bowed inward toward the duringScaphoid forced fractures extension comprise of the 60%-80% wrist. Although of all carpal common, fractures. bone; obliteration or outward deviation of the stripe may scaphoidBecause the fractures scaphoid can forms be difficult a bridge to visualizebetween theon film.carpal In suggestFigure 7occult and Figurefracture. 8 .However, The pronated false-negative view (Figure rates 7;of top) phoidEDmanyrows, Management and itseries, must the 10%-20% withstandtriquetrum Of Wristof dramatic scaphoid were Injuries forces thefractures most across are commonly its not waist visible tissuespresents may providean alternative clues to view scaphoid of the injury. radial The side scaphoid bony fracturedonduring the initial forced carpal x-rays. extension bones.37,38 However, of the wrist. a significant Although percentage common, of fatFigure elements,stripe lies 7. parallelwhereas The andPronated as justthe radialsupinated View to the viewscaphoid (Figure on the8; Scaphoid Fractures Figure 7 andFigure 8. The pronated view (Figure 7; top) thesescaphoidThis missed study fractures fractures presents can maybe supportingdifficult be obvious to visualize onevidence films on taken film. that two In PAbottom) view. It should presents be slightly the ulnar bowed elements. inward toward the Scaphoid fractures comprise 60%-80% of all carpal fractures. presents an alternative view of the radial side bony emergencyweeksmany series, post clinicians injury. 10%-20%39 (See shouldof Figure scaphoid not9 and fractures hesitate Figure 10are to on not obtain page visible 9.) bone; obliteration or outward deviation of the stripe may Because the scaphoid forms37,38 a bridge between the carpal on theSome initial studies x-rays. suggest However, that multiple a significant views percentage may of suggestelements, occult whereas fracture. asHowever, the supinated false-negative view (Figure rates of 8; CTsrows, for it must patients withstand with dramatic physical forces examinations across its waist that enhancethese missed radiographic fractures may visualization. be obvious In on one films study taken of two 90 bottom) presents the ulnar elements. differduring from forced what extension plain39 of radiographythe wrist. Although reports. common, This ad- EDweeks patients, post injury. 44 individuals (See Figure had 9 and evidence Figure of 10 scaphoid on page 9.) ditionalscaphoid stepfractures would can bereduce difficult the to numbervisualize onof film.incorrect In Figure 7 andFigure 8. The pronated view (Figure 7; top) fractureSome on studies a four-view suggest series that (PA, multiple lateral, views PA with may ulnar sprainedmany series, wrist 10%-20% diagnoses of scaphoid made fractures in the areED, not ensuring visible presents an alternative view of the radial side bony andenhance radial radiographic deviation).37 visualization. When the authors In one added study 25 of˚ 90 appropriateon the initial x-rays. follow-up37,38 However, and avoiding a significant permanent percentage of elements, whereas as the supinated view (Figure 8; EDsupination patients, and 44 individualspronation views, had evidence they detected of scaphoid an disability.these missed Obviously fractures may this be will obvious slow on the films throughput taken two bottom) presents the ulnar elements. fractureadditional on 11 a four-viewscaphoid fractures,series (PA, making lateral, the PA six-viewwith ulnar ofweeks these post patients injury.39 through(See Figure37 the 9 and ED, Figure result 10 inon manypage 9.) CT andradiography radial deviation). series 100% When sensitive the authors for scaphoid added fracture. 25˚ 37 scansSome with studies negative suggest results that atmultiple a high views financial may cost, However,supination these and pronationresults have views, not been they reproduceddetected an by andenhance increase radiographic the time visualization. to the scanner In one for study other of wait 90 - otheradditional researchers. 11 scaphoid fractures, making the six-view ED patients, 44 individuals had evidence of scaphoid 37 ingradiography patients.In addition series to special 100% views,sensitive inspection for scaphoid of the fracture. soft fractureHowever, on a thesefour-view results series have (PA, not lateral,been reproduced PA with ulnar by 37 andEDFigureother radialManagement researchers. 6 deviation).. The scaphoid Of When Wrist view the allows Injuriesauthors a better added view 25˚ of the supinationlengthIn additionof and the pronation scaphoid; to special views, compare views, they inspection with detected the of PA anthe or soft the additional 11 scaphoid fractures, making the six-view Scaphoidoblique views. Fractures radiographyFigure 6. The series scaphoid 100% sensitive view allows for scaphoid a better fracture.view of the37 Scaphoid fractures comprise 60% to 80% of all carpal However,length ofthese the results scaphoid; have compare not been with reproduced the PA or by the fractures. Because the scaphoid forms a bridge be- otheroblique researchers. views. tweenIn theaddition carpal to specialrows, itviews, must inspection withstand of dramaticthe soft forces across its waist during forced extension of the Figure 6. The scaphoid view allows a better view of the length of the scaphoid; compare with the PA or the oblique views. Figure 6. The Scaphoid View Figure 8. The Supinated View

Reproduced with permission from: Harris JH, Harris WH, eds. Reproduced with permission from: Harris JH, Harris WH, eds. The Radiology of Emergency Medicine. 3rd ed. Baltimore: The Radiology of Emergency Medicine. 3rd ed. Baltimore: Lippincott Williams & Wilkins Publishers; 1993:377. Fig. 6.2c Lippincott Williams & Wilkins Publishers; 1993:379. Fig. 6.4. Reproducedand Fig 6.2d. with permission from: Harris JH, Harris WH, eds. Reproduced with permission from: Harris JH, Harris WH, eds. TheThe pronated Radiology view of Emergency(Figure 7; top) Medicine. presents 3rd an ed. alternative Baltimore: view of the EmergencyThe Radiology Medicine of Emergency Practice Medicine. 3rd ed. Baltimore: 8 radialLippincott side bony Williams elements, & Wilkins whereas Publishers; as the supinated 1993:377.November view Fig. (Figure 6.2c 2001 8; Lippincott Williams & Wilkins Publishers; 1993:379. Fig. 6.4. bottom)and Fig presents 6.2d. the ulnar elements.

TheEmergency scaphoid view Medicine (Figure Practice6) allows a better view of the length of the 8ReproducedReproduced with with permissionpermission from: from: Harris Harris JH, JH, Harris HarrisNovember WH, WH, eds. eds. The2001 Ra- scaphoid;Reproduced compare with withpermission the PA or from: the oblique Harris views.JH, Harris WH, eds. Thediology Radiology of Emergency of Emergency Medicine. Medicine. 3rd ed. 3rd Baltimore: ed. Baltimore: Lippincott Williams The Radiology of Emergency Medicine. 3rd ed. Baltimore: Lippincott& Wilkins WilliamsPublishers; & Wilkins1993:377. Publishers; Fig. 6.2c and1993:377. Fig 6.2d. Fig. 6.2c ReproducedLippincott Williamswith permission & Wilkins from: Publishers; Harris JH, 1993:379.Harris WH, Fig. eds. 6.4. The Ra- and Fig 6.2d. diology of Emergency Medicine. 3rd ed. Baltimore: Lippincott Williams &Emergency Wilkins Publishers; Medicine 1993:379. Practice Fig. 6.4. 8 November 2001

Wrist Injuries: Emergency Imaging And Management 107 wrist. Although common, scaphoid fractures can be interrupt this tenuous blood supply. Inappropriate difficult15%-30%15%-30% to and andvisualize false-positive false-positive on a ratesradiograph. rates of of 12%-32% 12%-32% In limitmany limit the theseries, utility utility twotreatmenttwo weeks weeks post-injury. post-injury. because44 44Suchof Such a recommendationsmissed recommendations scaphoid were were fracture 10%ofof this tothis sign.20% sign.40-43 of40-43 scaphoid fractures are not visible on the commonlycancommonly result made made in anprior prior avascular to to the the widespread widespread necrosis availability availability of the proximal of of 41,42 initial x-rays. However, a significant percentage of magneticfragment.magnetic resonance resonance Unfortunately, imaging imaging (MRI) (MRI) even or or even ineven recognized bone bone scans. scans. This fracThis- theseMissedMissed missed Scaphoid Scaphoid fractures Fractures Fractures may be obvious on radiographs begsturesbegs the the thatquestion, question, are “treatedCan “Can early early appropriately, use use of of these these technologies technologies the chance of 43 takenA Asingle single 2 weeks artery artery postthat that enters injury. enters the the distal(See distal Figuresend end supplies supplies 9 and the the 10.) supplantnonunionsupplant prolonged prolonged or necrosis immobilization? immobilization? resulting” ” in persistent pain 48-50 scaphoidscaphoidSome bone; studies bone; thus, thus, suggest a fracturea fracture that can can multipleeasily easily interrupt interrupt views this thismay and loss of mobility is 5% to 12%. The com- enhancetenuoustenuous bloodradiographic blood supply. supply. Inappropriate Inappropriatevisualization. treatment treatment In 1 studydue due to to a a BoneplicationBone Scans Scans rate increases to 40% to 88% when the ofmissed 90missed ED scaphoid patients,scaphoid fracture fracture 44 individuals can can result result in in hadan an avascular avascularevidence necrosis necrosis of BonefractureBone scanning scanning is notbecame became recognized a populara popular tooland tool soon immobilized.soon after after it itwas was48-50 scaphoidofof the the proximal proximal fracture fragment. fragment. on a 4-viewUnfortunately, Unfortunately, series even(PA, even in lateral, in recognized recognized PA introduced.Theseintroduced. grim The The oddstiming timing have of of the the promptedscan scan in in cases cases someof of potential potential authors to withfracturesfractures ulnar that thatand are are radialtreated treated deviation).appropriately, appropriately,41 theWhen the chance chance the of authorsof non- non- scaphoidsuggestscaphoid fracture fractureprolonged is isan an important importantimmobilization consideration. consideration. for Scans all Scans patients addedunionunion or25° or necrosis necrosissupination resulting resulting and in in persistentpronation persistent pain painviews, and and loss they loss of of obtainedwithobtained scaphoid too too soon soon (1-3 tenderness,(1-3 days) days) after after injury regardless injury yield yield false-positives false-positivesof radio- detectedmobilitymobility isan is5%-12%. additional5%-12%.109-111109-111 The 11The complicationscaphoid complication fractures, rate rate increases increases mak to- to duegraphicdue to to periosteal periosteal findings. reaction, reaction,51 edema, edema, bone bone bruising, bruising, and and other other ing40%-88%40%-88% the 6-view when when theradiography the fracture fracture is isnot seriesnot recognized recognized 100% and sensitive and immobi- immobi- for conditions. conditions.On the Scans Scans other obtained obtained hand, 14 14 aggressivedays days after after injury injuryimmobiliza are are more more- scaphoidlized.lized.109-111109-111 fracture.These These grim grim41 oddsHowever, odds have have prompted promptedthese results some some authors have authors not to to sensitivetionsensitive is thannot than withoutconventional conventional consequences. radiography, radiography, butOnly but this this 6% mandates mandates to 20% 45,4645,46 beensuggestsuggest reproduced prolonged prolonged immobilizationby immobilization other researchers. for for all all patients patients with with a oftwo-weeka two-week patients period period placed of of immobilization inimmobilization plaster for prior aprior presumed to to the the scan. scan. occult In In 73 73 scaphoidscaphoidIn addition tenderness, tenderness, to special regardless regardless views, of of radiographic radiographic inspection findings. findings.of the onescaphoidone series series of of 100fracture 100 patients, patients, actually scans scans obtained prove obtained to on onhave day day 4 awere4 fracturewere soft tissuesOnOn the the othermay other hand,provide hand, aggressive aggressive clues toimmobilization immobilization scaphoid injury. is isnot not 100%at100% follow-up. sensitive sensitive and 52and Furthermore,92% 92% specific specific (and (and 6 hadweeks had a positivea positive of immobiliza- 45 45 Thewithoutwithout scaphoid consequences. consequences. fat stripe Only Only lies 6%-20% 6%-20%parallel of of patients and patients just placed placed radial in in predictivetionpredictive can value represent value of of 65%). 65%). a significant Despite Despite the the value inconvenience value of of early early bone bone for the plasterplaster for for a presumeda presumed occult occult scaphoid scaphoid fracture fracture actually actually scansscans in in this this study, study, many many hand hand surgeons surgeons use use nuclear nuclear studies studies to the scaphoid on the PA view. It should be slightly patient. proveprove to to have have a fracturea fracture at at follow-up. follow-up.44 44Furthermore, Furthermore, six six atat 2-4 2-4 weeks weeks and and limit limit them them to to cases cases in in which which the the x-ray x-ray and and bowed inward toward the bone; obliteration or weeksweeks of of immobilization immobilization can can represent represent a significanta significant clinicalclinical picture picture remain remain ambiguous. ambiguous. outward deviation of the stripe may suggest occult Imaging Strategies inconvenienceinconvenience for for the the patient. patient. fracture. However, false-negative rates of 15% to MagneticScaphoidMagnetic Resonance Resonancefractures Imaging are Imaging often undetectable on initial 30%Imaging and false-positive Strategies rates of 12% to 32% limit the radiographs.MRI has become The standard prevalence in the evaluation of occult of scaphoid suspected Imaging Strategies44-47 MRI has become standard in the evaluation of suspected utilityScaphoidScaphoid of thisfractures fractures sign. are are often often undetectable undetectable on on initial initial radio- radio- scaphoidfracturescaphoid fractures. fractures.at initial It It isexamination isnearly nearly 100% 100% sensitive, has sensitive, been provides providesestimated to 17 graphs.graphs. The The incidence incidence of of occult occult scaphoid scaphoid fracture fracture at at initial initial goodbegood 4% anatomic anatomic to 26%. detail, detail, Because and and is isaccurate accurateof this, in researchersin the the acute acute setting. setting. formerly Missedexamexam has Scaphoidhas been been estimated estimated Fractures to to be be 4%-26%. 4%-26%.16 16Because Because of of this, this, suggestedStudiesStudies of immobilizingof MRI MRI within within seven seven all days patients days of of injury injury with have have scaphoid Aresearchers singleresearchers artery formerly formerly that suggested suggestedenters theimmobilizing immobilizing distal end all all patientssupplies patients yieldedtendernessyielded sensitivity sensitivity and rates obtainingrates of of 100% 100% acompared repeatedcompared with withx-ray six-week six-week at 2 52 thewithwith scaphoid scaphoid scaphoid tendernessbone; tenderness thus, and and a obtaining fracture obtaining a canrepeata repeat easily x-ray x-ray at at radiologicweeksradiologic postinjury. follow-up follow-up using using Such plain plain recommendations films. films.47,4847,48 In In one one prospec- prospec- were

FigureFigure 9 9and andFigureFigure 10 10. The. The PA PA view view (Figure (Figure 9; 9;left) left) appears appears normal. normal. On On the the pronated pronated view view (Figure (Figure 10; 10; right), right), the the fracture fracture Figurelineline is isclearly 9.clearly The visible, visible, PA thoughView though subtle. subtle. It Itis isalso also visible visible on on the the scaphoid scaphoidFigure view view (not (not10. shown). shown).The Pronated View

➞➞

The PA view appears normal. On the pronated view, the fracture line is clearly visible, though subtle. It is also visible on the scaphoid view (not shown). NovemberNovember 2001 2001 9 9 EmergencyEmergency Medicine Medicine Practice Practice 108 An Evidence-Based Approach To Traumatic Emergencies commonly made before the widespread availability predictive value of the initial plan radiographs was of MRI or even bone scans. This begs the question, 84%. For each patient with a fracture, 5.25 patients “Can early use of these technologies supplant pro- were overtreated. The study also assessed different longed immobilization?” radiological options to assess these wrist injuries to reduce the amount of overtreatment. MR and CT Bone Scans both exhibited comparable rates of fracture detec- Bone scanning became a popular tool soon after it tion, and MR has the added benefit of detecting soft was introduced. The timing of the scan for patients tissue injuries and avoiding radiation. Ultrasonogra- with potential scaphoid fracture is an important con- phy, although rapid, accessible, and inexpensive had sideration. Scans obtained too soon (1-3 days) after the greatest number of false-positives and false-neg- injury yield false-positives due to periosteal reaction, atives for fracture detection. edema, bone bruising, and other conditions. Scans The article concluded that traditional manage- obtained 14 days after injury are more sensitive ment offers low diagnostic accuracy and routinely than conventional radiography, but this mandates a overtreats the majority of patients while offering 2-week period of immobilization before the scan.53,54 few negative outcomes, such as nonunion. Although In 1 series of 100 patients, scans obtained on day 4 CT and MR offer good detection rates and would were 100% sensitive and 92% specific (and had a greatly reduce the cost of unnecessary immobiliza- positive predictive value of 65%).53 Despite the value tion to the economy and health care system, the ar- of early bone scans in this study, many hand sur- ticle advocates more medicoeconomic research to be geons use nuclear studies at 2 to 4 weeks and limit conducted to assess the opportunity cost of routinely them to patients for whom the x-ray and clinical imaging these potential fractures. picture remain ambiguous. Determining Which Study To Choose Magnetic Resonance Imaging One study compared MRI with bone scans per- MRI has become standard in the evaluation of sus- formed an average of 19 days after suspected pected scaphoid fractures. It is nearly 100% sensi- scaphoid fracture. Both were extremely accurate. tive, provides good anatomic detail, and is accurate The nuclear studies had 1 false-positive versus none in the acute setting. in the MRI group; on the other hand, 2 people were Studies of MRI within 7 days of injury have unable to complete the MRI because of claustropho- yielded sensitivity rates of 100% compared with bia.61 Other studies also confirm that either bone 6-week radiologic follow-up using plain radio- scan or MRI delivers accurate information in the set- graphs.55,56 In 1 prospective, randomized study, the ting of suspected scaphoid fracture. Although MRI combination of repeated clinical examination and seems to have the advantage of earlier reliability and plain radiography was as sensitive as MRI in the de- better anatomic detail, bone scans are probably more tection of occult scaphoid fracture—only the injury widely available and less expensive. was diagnosed by day 3 in the MRI group versus One 1995 study published in the Journal of day 38 in the group treated using clinical examina- Nuclear Medicine, examined the cost of various diag- tion and plain radiograph.57 On the downside, MRI nostic strategies in suspected scaphoid fractures.62 is expensive, and no one has analyzed the cost/ben- The authors suggest that the most efficient approach efit ratio of routine MRI in the setting of suspected to the evaluation of patients with suspected sca- scaphoid injury. However, some argue that early phoid fractures consists of x-rays on day 1 followed MRI will prevent unnecessary immobilization.58,59 by delayed bone scintigraphy in patients with initial A 2008 study offers insight into the current scaphoid x-rays not revealing a fracture. management of suspected scaphoid fractures and the economical decisions encountered with potential Treatment wrist fractures. We know that anatomical snuffbox What remains alarming about these studies is the tenderness offers a high sensitivity in detecting frac- number of scaphoid and other carpal fractures tures but a low specificity. Additionally, initial plain missed on plain radiographs but identified using radiographs have a low sensitivity and miss up to advanced imaging techniques—a prevalence rang- 25% of fractures.60 Previous management called ing from 20% to 30% and even higher.42,47,55,61-64 for patients with snuffbox tenderness and negative Moreover, all of these data are probably moot vis-à- plain radiographs to be immobilized until radio- vis emergency practice. When patients have clinical graphs were repeated 2 weeks later, leading to a signs of scaphoid fracture (snuffbox tenderness, pain high rate of unnecessary immobilization. The study with axial compression of the thumb, pain on palpa- assessed 200 patients clinically suspected of having tion of the tubercle, and so on), treat them as if they a scaphoid fracture and found that only 16% were have a fracture—even in the presence of a x-ray with actually proven to have one.60 a negative finding. This means immobilization and The positive predictive value of initial clinical orthopedic follow-up in 7 to 10 days. The consul- examination was found to be 16% and the negative tant may then determine the appropriate study—

Wrist Injuries: Emergency Imaging And Management 109 whether it be MRI, bone scan, clinical examination, rate of fracture complications. We can conclude or simple radiography. Failure to immobilize these that if an emergency practitioner is unsure about a injuries in the emergency setting contributes to the diagnosis following a wrist injury, timely orthopedic already high amount of malunion and avascular follow-up will suffice to dictate proper management necrosis. as well as uncover the proper diagnosis, as fractures There is persistent controversy about the ideal will be persistently painful. immobilization for scaphoid fractures. Virtually all of the studies addressing this issue have significant Orthodox medicine has not found an answer to your com- weaknesses, the most common being failure to plaint. However, luckily for you, I happen to be a quack. define inclusion criteria other than snuffbox tender- —Richter cartoon caption ness. Most studies are small, so that 1 or 2 misreads considerably alter the statistical outcome. Other Carpal Fractures The basis of the controversy is that rotation of Triquetral Fractures the forearm applies shear to the scaphoid.65 Long Triquetral fractures, the second most common type arm casts prevent rotation of the forearm, but they of carpal fracture, occur with both direct trauma and are significantly more limiting and uncomfortable with FOOSH injuries. Dorsal chip fractures are due than short arm casts. Clinical studies are scarce and to hyperextension when the ulnar styloid is jammed contradictory. At least 1 clinical study (randomized, into the dorsum of the triquetrum. This produces 100 nondisplaced scaphoid fractures, long vs. short tenderness just distal to the ulnar styloid. These casts) showed significantly shorter times to union fractures require splinting and generally do well. when a long arm spica (which includes immobi- Transverse fractures are less frequent and more omi- lization of the thumb) was used.66 Another study nous. Fracture through the body of the triquetrum is showed no difference in outcome; however, this associated with perilunate, scaphoid, and ligamen- study included displaced fractures, which tend to do tous injury. Patients with triquetral fractures require poorly anyway.67 A review of the literature suggests a long arm splint and early referral. using a long arm spica for displaced fractures (> 1 mm displacement) and a short arm spica for nondis- Hamate Fractures placed fractures.68 A thumb spica splint as opposed Hamate fractures, which account for 2% to 4% of to a cast is probably adequate in the acute setting. carpal fractures, are becoming more common be- A study assessing injuries that are misdiag- cause of the popularity of racket sports and golf.72 nosed as sprained wrists in the ED determined that The hook of the hamate projects from the body into sprained wrist is the second most common initial di- the palm and defines the ulnar wall of the carpal agnosis in patients with diagnostic error made in the tunnel as well as serving as a pulley for the extrinsic ED.69 Two percent of patients whose injuries were flexors of the ring and small fingers. The hook can diagnosed as a sprained wrist had a more severe break with direct impact, as in a fall on the palm injury; this is particularly alarming because wrist or crush injury, or mechanisms where the extrinsic injury is one of the most common chief concerns flexor tendons are forced through the hook, such that we see in the ED. Greenstick or torus fractures as in racket, bat, or club sports. (The hamate is at of the distal radius represented 42% of these diag- particular risk when a golfer firmly strikes the sod in nostic errors, whereas scaphoid fractures and other a futile attempt to gain an additional 30 yards.) fractures of the distal radius make up the majority of Hamate fractures can be difficult to visualize on the remainder. Fortunately in this study, none of the standard views. If you suspect this injury, order a diagnostic errors resulted in additional harm to pa- carpal tunnel view (although this is often difficult to tients because torus fractures of the distal radius and perform in the painful acute setting) or a supinated scaphoid fractures do not need immediate treatment oblique view.26,72 One recent study of 16 patients with to achieve acceptable outcomes. a fracture of the hook of the hamate examined the A prospective, randomized trial of 201 consecu- value of various radiographic views.73 Of 13 patients, tive patients randomized torus fractures of the distal the routine PA view raised the suspicion of fracture in radius to a traditional forearm plaster cast or a wrist 4 (31%); of 14 patients, the carpal tunnel view demon- splint. The results revealed that there was no differ- strated the fractures in 6 (43%); but the supine oblique ence in outcome between the 2 types of immobiliza- radiographic view was the most valuable of the plain tion.70 Thus, patients misdiagnosed with sprains radiographs. Of 10 patients, it showed fractures in 8 who actually have torus fractures will have similar (80%). However, in this small series, CT proved to be outcomes in splints used to treat wrist sprains. the most accurate study of all. Another study examining 285 scaphoid fractures Missed injuries may lead to nonunion, stress, or found that there was no increase in the prevalence of rupture of flexor tendons as well as ulnar neuropa- nonunion or delay in bony union as long as sca- thy. Immobilization and early referral are adequate phoid fractures were immobilized within 4 weeks.71 treatment in the ED. Although no one has compared However, a delay more than 4 weeks led to a high

110 An Evidence-Based Approach To Traumatic Emergencies Clinical Pathway: Evaluation Of Wrist Injuries (Continued on page 112)

Life threats? • Manage ABCs (Class I) • Multiple trauma? • Evaluate and manage other injuries (Class I) Yes • Fall secondary to syncope, seizure, or vertigo? • Determine underlying cause of fall (Class I-II) • Lacerations compatible with suicide attempt? • Assess whether patient is suicidal (Class I-II)

Neurovascular compromise? • Loss of pulses or Doppler flow? • Emergent surgical consult for vascular injury (Class I) Yes • Abnormal Allen test? • Urgent surgical consult for neurologic deficit (Class II) • Cool hand? • Loss of distal motor function?

Manage pain (Class I-II) Is the patient in pain? Yes • NSAIDs and/or acetaminophen for mild pain • Opioids for moderate or severe pain (PO, IM, or IV NO depending upon severity)

Suspicion of navicular injury? Option I: • Tenderness over snuffbox • Three-view series (PA, lateral and scaphoid view of • Pain on axial compression of thumb wrist) (Class II) Yes • Tenderness of scaphoid tubercle (below thenar emi- Option II: nence) • Six-view series (PA, lateral, PA with ulnar andradial de- • Pain on resisted supination viation, 25° supination and pronation views) (Class II-III)

Go to “Suspicion of hamate hook injury” Is there a fracture? portion of pathway at top of next page

NO Yes

Immobilize in thumb spica splint or cast (Class II) Go to “Clinical Pathway: Management Of Wrist • Option I (standard): Refer for 7- to 10-day orthopedic Fractures And Dislocations,” page 113 follow-up (Class II) • Option II: Bone scan in four days (Class II-III) • Option III: MRI acutely or in 2-3 days (Class II-III)

For Class of Evidence Definitions, see page 1.

Wrist Injuries: Emergency Imaging And Management 111 Clinical Pathway: Evaluation Of Wrist Injuries (Continued from page 111)

Suspicion of hamate hook injury? Consider special views: • Racket or golf club swing mechanism Yes • Carpal tunnel (Class II-III) • Tenderness over hypothenar eminence • Supine oblique (Class II) • Pain in hypothenar eminence with flexion of fourth and fifth fingers

Is there a fracture?

Yes NO NO

Go to “Clinical Pathway: Management Of Wrist Fractures And Dislocations,” page 113

Tenderness of wrist after trauma? Yes • Standard wrist films (PA and lateral) (Class I-II) • Oblique views (Class II-III) NO

Exit pathway Negative x-rays X-ray positive for fracture or dislocation

Go to “Clinical Pathway: Management Of Wrist Fractures And Dis- locations,” page 113

High risk? • Splint or cast (Class II) • High mechanism of injury • Thumb spica if signs of scaphoid injury (Class II-III) • Tenderness of over scaphoid, lunate, or hamate Yes • Early referral (Class II) • Positive Watson’s test (scapholunate instability) • Emphasize the importance of follow-up (Class indeter- • “Clunking” with ROM wrist minate)

• Splint (Class III) • Refer to primary care physician or orthopedist (Class III)

For Class of Evidence Definitions, see page 1.

112 An Evidence-Based Approach To Traumatic Emergencies Clinical Pathway: Management Of Wrist Fractures And Dislocations

Lunate or perilunate dislocation Emergent/urgent surgical consult (Class II)

Radius fracture Urgent surgical consultation (within High risk High risk? hours) (Class II-III) • Angulation of > 20° • Ulnar separation • Dorsal comminution • Shortening of the radius > 5-10 mm • > 2 mm of articular step-off Not high risk Splint and refer (Class II-III) • Median nerve dysfunction

Scaphoid fracture • Displaced fractures (> 1 mm): Long arm spica splint or cast (Class II-III) • Non-displaced fractures: Short-arm spica splint or cast (Class II-III) • Refer all

Other carpal fractures • Immobilize: n Volar splint for most carpal fractures (Class indeterminate) n Ulnar gutter splint for hamate fractures (Class indeterminate) • Early referral (Class II-III)

Carpal instability or • Immobilize: scapholunate disruption (widened n Volar splint (Class indeterminate) scapholunate gap and cortical ring [or • Early referral (Class II-III) signet ring] sign on x-ray)

For Class of Evidence Definitions, see page 1.

Wrist Injuries: Emergency Imaging And Management 113 the various splints with their effect on outcome, an of Poirier (located between the proximal and distal ulnar gutter splint should reduce pain if it immobi- volar extrinsic ligaments) is open.74 As the distal row lizes the wrist as well as the fourth and fifth fingers slides dorsally over the proximal row, the scaphoid (whose tendons course beneath the hamate hook). sustains greater stress. Ultimately, the dorsal rim of the radius crashes into the scaphoid waist. Forced Lunate Fractures extension beyond this breaking point will damage Lunate fractures are uncommon. The mechanism is ligaments, bones, or both. The amount of radial or usually a fall, and patients may complain of diffuse ulnar deviation, rotation, and the location of impact or central wrist pain. Palpation of the bone distal to and duration of load will determine the nature of the Lister’s tubercle should elicit pain. Lunate fractures structural failure. can be difficult to visualize on radiographs. As with Although the most familiar manifestation of the scaphoid, suspicion of lunate fracture mandates this sequence is the scaphoid fracture, a wide range immobilization until it is ruled out at follow-up. of ligamentous injuries, dislocations, and fracture- Problems due to a tenuous blood supply threaten dislocations can be overlooked. Delay in diagnosis the lunate. Long-term complications include avascu- may allow the ligaments to fibrose and will limit lar necrosis (Kienbock’s disease). This leads to long- repair options. Physical examination is useful for term disability, collapse of the carpal space, migra- diagnosing ligamentous wrist injuries (as described tion of the capitate and scaphoid, and disruption of later in the text). Plain radiographs may be inad- the normal wrist mechanics. Acutely, these fractures equate, yet a number of other imaging techniques (or suspected fractures) need to be splinted, and the may fill this diagnostic void. These include CT and patient should be referred to an orthopedist. trispiral tomography, arthrography, videofluoros- copy, and MRI.75,76 Capitate Fractures Capitate fractures are rare because of the bone’s pro- Scapholunate Injury tected location in the center of the wrist. They occur The mechanics of ligamentous wrist injury have in dorsiflexion injuries, especially when radial devia- been described and staged by several authors,74,77-80 tion forces the radius into the capitate, which can including Mayfield, who vividly describes the pro- lead to fracture or dislocation. Displaced fractures cess: “In essence, the scaphoid and distal carpal row need referral and reduction, whereas nondisplaced are progressively peeled away from the lunate.”77 fractures require simple immobilization and referral. The first ligamentous complex to rupture is the scapholunate, causing what is variably described as Trapezium Fractures scapholunate instability, scapholunate dislocation, Trapezium fractures are rare and occur most often and rotary subluxation. These descriptive names through direct trauma. Movement of the thumb will invoke various degrees of damage to the scapholu- be limited. A thumb spica splint is adequate until the nate and radioscaphoid ligaments, but the principle orthopedic consultant sees the patient at follow-up. is essentially the same. The degree of instability will dictate the findings. Ligamentous Injuries Physical findings may include tenderness at the sca- Ligamentous wrist injuries can lead to significant pholunate joint just ulnar to the snuffbox or instabil- long-term sequelae; unfortunately, they are frequent- ity of the scaphoid elicited by the scaphoid shift or ly overlooked. This may be due to lack of familiarity Watson’s test. To perform this test, apply upward in how to detect these injuries on physical exami- pressure to the scaphoid tubercle (push from palmar nation and because x-ray findings may be subtle. toward dorsal) while moving the hand from ulnar to Disruption of these wrist stabilizers can lead to mi- radial deviation. With scapholunate instability, the gration of the carpal bones, disruption of the normal scaphoid may sublux dorsally, reproducing pain and mechanics, arthritis, and chronic pain. Once chronic movement of the bone. However, there are several sequelae develop, the outcome is usually poor de- drawbacks to Watson’s test. Not only is it painful in spite surgical treatment.25 Orthopedists often discuss the acute setting, but also it seems to have low speci- ligamentous injuries in terms of the injury location— ficity. In 1 study, 36% of unaffected individuals had that is, dorsal intercalated segment instability (DISI) positive findings on the scaphoid shift test.81 and volar intercalated segment instability (VISI). The wrist has no inherent architectural stabil- Radiology ity; no ball and socket, mortise, or hinge is involved. The expected radiographic findings of scapholunate Without the ligaments, the carpi are nothing more injury on the PA view include a widened scapholu- than a clattering bag of bones. In extension, the nate gap, and a cortical ring (or signet ring) sign as the volar ligaments progressively tighten between the lunate foreshortens and the tubercle is viewed on end. radius and the carpal rows. At maximal extension, (See Figures 11 and 12.) The lateral view may show the volar extrinsic ligaments are taut and the space an increase in the scapholunate angle. (See Figure 13,

114 An Evidence-Based Approach To Traumatic Emergencies pagelunate, 116 midshaft) Routine radius, radiographs and metacarpals; may itmiss will signsbe outside of this radiusquadrangular) fractures in young lunate adults and “ Collesa disruption’ fractures, of” becausethe arcs of injury.the cup Aof clenchedthe lunate. fist On view the PA may view, show look wideningfor a triangular of the theythe differ carpal in terms bones. of associated (See Figure damage, 4 and prognosis, Figure and 5, page 75 scapholunate(as opposed to quadrangular) space as the lunatecapitate and is a forceddisruption proximal of the - treatment.106) Also Young look adults for associated are more likely carpal to have fractures. greater83 lyarcs betweenlunate, of the carpalmidshaft the bones.scaphoid radius, (See and andFigure metacarpals; lunate. 4 and 79,82Figure it will 5 on be page outside soft-tissueradius fracturesinjury, as in well young as a adultshigher “incidenceColles’ fractures, of intra-” because 71 7.) Alsothe cup look of for the associated lunate. On carpal the PA fractures. view, look for a triangular articularLunatethey differ and Dislocations complex in terms fracture of associated patterns, damage, than childrenprognosis, or andthe 76 75 (as opposed to quadrangular) lunate and a disruption of the elderly.Furthertreatment. They disruption also Young have adults aof higher the are ligamentousmore expectation likely to of havesupport good greater leads Lunate Dislocations And Perilunate Dislocations functional outcome over a long remaining life span.77-80 If thearcs scaphoid of the carpal suffers bones. fracture (See Figure or 4ligament and Figure damage, 5 on page tosoft-tissue lunate dislocationinjury, as well in as which a higher the incidence lunate ofis intra-torn from Further7.) Also disruption look for of associated the ligamentous carpal fractures. support 71leads to articularOther wrist and injuriescomplex are fracture often seenpatterns, in association than children or the it can no longer stabilize the wrist. At this point, its normal position on the radius. This is most notable lunate dislocation, when the lunate is torn from its normal withelderly. distal76 radius They alsofractures. have Ina higher one study, expectation 68% of patientsof good further damage to the radiocapitate ligament, part on the lateral view, where the lunate is “spilling over” positionLunate on Dislocationsthe radius. This is most notable on the lateral requiringfunctional operative outcome repair over of a a long radius remaining fracture lifehad span. injuries77-80 of the volar extrinsic group, allows the capitate to toward the palm, rather than cupping the capitates. view,Further where disruption the lunate of is the“spilling ligamentous over” toward support the leads palm, to to the softOther tissues, wrist including injuries arethe oftenTFC, seenthe scapholunate, in association or (See Figures 14 and 15; also78 see Figure 16, pages slipratherlunate out than of dislocation, cupping its position the when capitate. in the the lunate (Seelunate Figure is torn cup, 14 from andleading itsFigure normal to the withlunate-triquetral distal radius ligaments. fractures. In Pay one special study, attention68% of patients to 116 and 117) Like any dislocation, lunate and peri- perilunate15 onposition page 17; ondislocation. alsothe radius.see Figure This Progressive 16 is on most page notable 18.)shearing on the forces lateral medianrequiring nerve operative function repairin patients of a radiuswith Colles fracture’ fractures. had injuries leadLike to rupture any dislocation, of the scapholunate,lunate and perilunate capitate-lunate, dislocations In onelunate study, dislocations acute median need neuropathy to be reduced was present sooner in 13% rather view, where the lunate is “spilling over” toward the palm, to the soft tissues, including the TFC,84 the scapholunate, or andneedrather lunate-triquetralto be than reduced cupping sooner the connections. rather capitate. than (See later ThisFigure (that destabiliza 14 is, and within Figure- of 536thanthe fractures, lunate-triquetral later (that and is,chronic withinligaments. median hours).78 Pay neuropathy special Once attention developedreduced, to the tionhours).15 may on72 Oncepage also reduced,17; encompass also see the Figure patient fracture 16 may on page stillof the require18.) involved surgery in 23%.patientmedian81 maynerve stillfunction require in patients a surgical with Collesprocedure’ fractures. at a later bones,at a later Likeusually time. any Specialty dislocation,the scaphoid consultation lunate or andtriquetrum, is mandatory. perilunate leadingdislocations time.InOver one Specialty study,the past acute decade, consultation median surgery neuropathy hasis mandatory. become was morepresent in 13% to aneed fracture-dislocation. to be reduced sooner rather than later (that is, within frequentof 536 in fractures, the treatment and chronic of these median fractures, neuropathy in an attempt developed to Radiushours).In spite Fractures72 Once of the reduced, forces the involved patient may and still seemingly require surgery attainRadiusin 23%.full anatomic81 Fractures correction. Surgery is generally indi- obviousDistalat a radius later radiographic time. fractures Specialty are findings,the consultation most common perilunate is mandatory. upper- and lunate catedDistal in Overthose radius the with past fractures so-called decade, “ arehigh-risksurgery the hasmost fractures. become common” “moreHigh- upper dislocationsextremity fracture are andcommonly represent missed.a large portion27,28 In of 1 the series of riskextremityfrequent” criteria in include fracturethe treatment fractures and of representwith these an fractures, angulation a large in an ofportion moreattempt of to 166overallRadius perilunate fractures Fractures seeninjuries, in the 25%ED. The were older missed literature initially, in- thantheattain 20 overall˚, ulnarfull anatomic separation, fractures correction. dorsalseen incomminution, Surgery the ED. is generallyThe shortening older indi- litera- cludingdepictedDistal thesebothradius asdislocations fractures simple injuries are the and thatmost fracture-dislocations. enjoyed common good upper- out- 83 turecated depicted in those with these so-called as simple “high-risk injuries fractures. that ”enjoyed “High- Outcomescomes.extremity This iswere fracture true inworse theand set represent when of patients diagnosis a large originally portion and defined oftreat the- Figuregoodrisk” 12 criteriaoutcomes.. The onlyinclude obvious This fractures is abnormalitiestrue with in anthe angulation set on of this patients of more mentby Collesoverall were in fractures 1814, delayed which seen by consistedin more the ED. than of The older 7older days. people literature who had PAoriginally viewthan 20is ˚the, ulnar definedprojection separation, by of thedorsalColles scaphoid comminution,in 1814, ring which (or shortening consisted reduceddepicted functional these as expectation simple injuries and whosethat enjoyed reduced good life out- signetof older ring) peopleand that who the scaphoidhad reduced is somewhat functional expecta- Perilunateexpectancycomes. This gave Dislocations is them true inless the time set ofto patientsdevelop originallylong-term defined foreshortened,tionFigure and 12 whose. The suggesting only reduced obvious that life abnormalitiesit mayexpectancy be rotated on gave this them Unlesscomplications.by Colles there in It has1814, may been which also spontaneousbe consisted a relatively of older minor reduction, people injury who infrac the had- outPA of viewits normal is the alignment.projection of the scaphoid ring (or pediatric age group. In both the young and the old, the ture-dislocationsreduced functional should expectation be evident and whose on radiograph.reduced life signet ring) and that the scaphoid is somewhat carpal bones are spared as the osteopenic or immature Onexpectancy the lateral gave view, them the less capitate time to developwill no long-termlonger sit in foreshortened, suggesting that it may be rotated radius gives way under impact.74 Figure 12. PA View, Scaphoid Ring thecomplications. same line with It may the also lunate, be a relatively midshaft minor radius, injury and in the out of its normal alignment. Since the radius in young adults is neither immature metacarpals;pediatric age it group. will be In outsideboth the youngthe cup and of the the old, lunate. the norcarpal osteopenic, bones these are spared are almost as the by osteopenic definition or high-energy immature On the PA view, look for a triangular (as opposed to injuries.radius It givesis probably way under inappropriate impact.74 even to call distal Since the radius in young adults is neither immature Figurenor osteopenic,11. In the PA these view, are scapholunate almost by definition injury high-energymay be Figuredetectedinjuries. 11. when It isPA probably the View, gap inappropriatebetween Scapholunate the evenbones to Injurywidens.call distal The finding may be subtle. Figure 11. In the PA view, scapholunate injury may be detected when the gap between the bones widens. The finding may be subtle.

The only obvious abnormalities on this PA view are the projection of In the PA view (Figure 11), scapholunate injury may be detected when the scaphoid ring (or signet ring) and that the scaphoid is somewhat theEmergency gap between Medicine the bones Practice widens. The finding may be subtle. 16 foreshortened, suggesting that it may be rotatedNovember out of its normal. 2001

Emergency Medicine Practice Wrist Injuries:16 Emergency Imaging And ManagementNovember 2001115 of the radius more than 5-10 mm, and more than 2 mm of radial fractures remains unclear. A Cochrane review articular step-off.20,79,80 There is significant controversy about examined randomized and quasi-randomized clinical trials how closely the anatomic configuration needs to be restored in adults with fracture of the distal radius in order to and whether this will prevent long-term complications78,79 of determine the most appropriate conservative treatment. carpal instability and hand weakness,82 delayed rupture of The authors included 31 trials totaling 3372 (mainly female finger flexors,83 chronic pain,84 neuropathy,85 cosmetic and older) patients. The authors stated, “There remains deformity, or arthritis.86 insufficient evidence from randomized trials to determine Despite years of study, the best approach to distal which methods of conservative treatment are the most appropriate for the more common types of distal radial Figure 13. The scapholunate angle. Acute injury to 87 of the radius more thanof the 5-10 radius mm, moreand more than than5-10 2mm, mm and of more than 2radial mm offractures remainsfracturesradial unclear. fractures in adults. A Cochrane remains” unclear.review A Cochrane review 20,79,80the ligaments that hold the scaphoid in relation articular step-off. articular There is step-off. significant20,79,80 controversy There is significant about controversyexamined about randomizedexaminedless and time quasi-randomized randomized to develop and long-term clinical quasi-randomized trials complications. clinical trials It may to the other carpals may allow the scaphoid to rotate Other Fractures Of The Distal Radius how closely the anatomicFigurehow closelyconfiguration 13. Thethe anatomic Scapholunate needs configurationto be restored Angle needs to bein restoredadults with fractureinalso ofadults thebe distal awith relatively fractureradius in minorof order the distal toinjury radius in thein order pediatric to age out of position. 78,79 78,79 There are other named fractures of the distal radius, each and whether this willand prevent whether long-term this will complications prevent long-term of complicationsdetermine of the most appropriatedeterminegroup. In the bothconservative most the appropriate young treatment. and conservative the old, thetreatment. carpal 82 82 associated with a specific mechanism. Rather than naming carpal instability andcarpal hand instabilityweakness, and delayed hand weakness,rupture of delayed ruptureThe authors of includedThebones 31 authorstrials are totaling sparedincluded 3372 as 31 (mainlythe trials osteopenic totaling female 3372 or (mainly immature female 83 84 83 85 84 85 the fracture, it is more important to identify and describe finger flexors, chronicfinger pain, flexors, neuropathy, chronic pain,cosmetic neuropathy, cosmeticand older) patients. Theandradius authorsolder) gives patients. stated, way “ The Thereunder authors remains impact. stated,85 “There remains deformity, or arthritis.86 86 insufficient evidencethe from lesion randomized in terms of trialslocation, to determine displacement, angulation, deformity, or arthritis. insufficient Because evidence the radius from randomized in young adultstrials to isdetermine neither Despite years of study, the best approach to distal which methods of andconservative comminution, treatment as these are theparameters most determine treatment Despite years of study, the best approach to distal whichimmature methods nor of osteopenic, conservative these treatment are arealmost the most by defini- appropriate for theand moreappropriate prognosis. common for types the more of distal common radial types of distal radial tion high-energy injuries. It is probably inappro- Figure 13. The scapholunateFigure 13 .angle. The scapholunate Acute injury angle.to Acute injuryfractures to in adults.”87fractures in adults.”87 the ligaments that thehold ligaments the scaphoid that inhold relation the scaphoid in relation Volarpriate Angulation even to call distal radius fractures in young to the other carpalsto may the allowother thecarpals scaphoid may allow to rotate the scaphoid toOther rotate Fractures TheOfOtheradults The Smith Distal Fractures “Colles’’s fracture Radius fractures,”(orOf Thereverse Distal Colles because Radius’ fracture) they occurs differ with in out of position. out of position. There are other nameddirectterms fractures blow of or associated offall the on distal the dorsumdamage, radius, ofeach theprognosis, wrist. It is and often treat the - There are86 other named fractures of the distal radius, each associated with a specificresultassociatedment. of mechanism. a bicyclist Young with a or specificadultsRather motorcyclist thanmechanism.are morenaming being likely Ratherthrown to than over have naming the greater the fracture, it is morehandlebars.thesoft important fracture, tissue By itinjury,to maintaining is identify more as important andwell a fiercedescribe as ato grip higher identify on the occurrenceand handlebars, describe of the lesion in termsthe oftheintraarticular location,patient lesion sustains displacement,in terms and a of distal location,complex angulation, radius displacement, fracture with patterns, angulation, volar, rather than 87 and comminution,than asandare these dorsal, childrencomminution, parameters angulation. or the determineas theseTreatmentelderly. parameters treatment criteria They determine alsoare similar have treatment to a higher and prognosis. dorsallyandexpectation prognosis. angulated of fractures.good functional outcome over a long remaining life span.88-91 Volar AngulationRadialVolar Other Styloid Angulation wrist Fracture injuries are often seen in association Reproduced with permission from: Schwartz DT, Reisdorff EJ, The Smith’s fractureThe Thewith(or chauffeur reverse Smith distal’s Colles fracture radius’ fracture) (orfractures. reverseHutchinson occurs Colles In with 1 fracture) study,’ fracture) 68%is a occurs break of pa within- Acuteeds. Emergency injury to the Radiology. ligaments thatNew hold York: the McGraw-Hill scaphoid in relationProfessional to the direct blow or fall onthedirecttients the radial dorsum blow requiring styloid. or of fall theIt isonoperative wrist. generally the dorsumIt is oftenduerepair of to the the direct of wrist. a radiusimpact It is oftenonfracture the the otherPublishing; carpals 2000:57.may allow Fig. the 4-8. scaphoid to rotate out of position. result of a bicyclistradial orresulthad motorcyclist side injuries of aof bicyclist the beingto wrist. the or thrown (Thesoftmotorcyclist archaictissues, over the referencebeing including thrown to the the over TFC, the the handlebars. By maintaining a fierce grip on the handlebars, 89 Reproduced with permission from: Schwartz DT, Reisdorff EJ, eds. handlebars.scapholunate, By maintaining or the lunate-triquetral a fierce grip on theligaments. handlebars, Pay the patient sustains athespecial distal patient radius attention sustains fracture toa distal withmedian radiusvolar, nerve rather fracture function with volar, in patients rather EmergencyFigure 14 Radiology. and New York: McGraw-Hill Professional Publish- than dorsal, angulation.thanwith Treatment dorsal, Colles’ angulation. criteriafractures. are Treatment similarIn 1 study, to criteria severe are similar median to ing;Figure 2000:57. 15. TheFig. 4-8. dorsally angulated fractures.dorsallyneuropathy angulated was fractures.present in 13% of 536 fractures, and lunate is now chronic median neuropathy developed in 23%.92 disoriented in Radial Styloid FractureRadial Styloid Fracture Reproduced with permissionrelationReproduced to from: the with Schwartz permission DT, Reisdorff from: Schwartz EJ, DT, ReisdorffThe chauffeur EJ, fractureThe (or chauffeur Hutchinson fracture fracture) (or Hutchinson is a break in fracture) is a break in eds. Emergency Radiology. New York: McGraw-Hill Professional radiuseds. Emergency on the Radiology. New York: McGraw-Hill Professionalthe radial styloid. It isthe generally radial styloid. due to It direct is generally impact dueon the to direct impact on the Publishing; 2000:57. Fig.Publishing; 4-8. 2000:57. Fig. 4-8. Figurelateral view 14. Lateral View, Disoriented Lunateradial side of the wrist.Figureradial (The side archaic 15. of the PA reference wrist. View, (The to Triangularthe archaic reference Lunate to the (Figure 14; left), and the Figure 14 and capitateFigure is14 no and Figure 15. The longerFigure 15. The lunate is now coaxial.lunate On is now disoriented in thedisoriented PA view in relation to the (Figurerelation 15; to the radius on the right),radius the on the lateral view lunatelateral is view (Figure 14; triangular(Figure 14; left), and the ratherleft), thanand the its capitate is no normalcapitate is no longer quadrangularlonger coaxial. On appearance.coaxial. On the PA view the PA view (Figure 15; (Figure 15; right), the right), the lunate is lunate is triangular triangular rather than its Novemberrather than 2001 its 17 Emergency Medicine Practice normal normal quadrangular quadrangular appearance. appearance.

November 2001TheNovember lunate is now 2001 disoriented in relation to the radius17 on the lateral 17 On the PAEmergency view (Figure 15),Medicine the lunateEmergency Practice is triangular Medicine rather than Practice its view (Figure 14), and the capitate is no longer coaxial. normal quadrangular appearance.

116 An Evidence-Based Approach To Traumatic Emergencies chauffeur involves a blow from the crankshaft handle of an or more relative to the ulna.92 In cases in which the antique car.) In this injury, the styloid is avulsed, including diagnosis is suspected but radiographs are equivocal, the attachmentOver the ofpast the decade,extrinsic ligaments surgical of procedures the wrist. CT of theMakhni wrist may assessed be helpful. the90,93 radiographic This test, however, success is of haveTherefore, become displaced more fractures frequent usually in the mandate treatment open of usuallynonsurgically left to the consultant. treated distal radial fractures in differ- 88 thesereduction fractures, and repair. in an attempt to attain full ana- ent age groups. Nonsurgical management included Treatment tomic“History correction. teaches usA thatsurgical men and procedure nations behave is wiselygener- casting alone or closed reduction with immobiliza- Delayed diagnosis makes closed reduction difficult. The key allyonce indicated they have exhausted in those all with other alternatives.so-called”— high-riskAbba Eban tion. When fractures were evaluated 8 weeks later, fractures. “High risk” criteria include fractures is tothere identify was the a significantdislocation both correlation in isolation between and in displace- Radioulnar Joint Injuries association with non-displaced fractures. Reduction of with an angulation of more than 20°, ulnar separa- ment rate and patients’ age in the closed reduction The distal radioulnar joint includes the TFC and the associated fractures will often bring the ulna back into tion, dorsal comminution, shortening of the radius group. Patients 65 years and older had the highest radioulnar articulation. Injuries to this joint are commonly position. Once reduction is achieved, immobilize the arm more than 5 to 10 mm, and more than 2 mm of displacement rate at 89%, patients between 45 and missed in the acute setting.89-91 Dislocation of the ulna with a long arm splint to prevent rotation at the injured articular step-off.21,90,91 There is significant contro- 64 years old had an 81% rate, and patients between commonly occurs with distal radius fractures and can be an joint. Damage to the TFC, which is the main 99stabilizer of the versyimportant about component how closely of some the fracture-dislocations anatomic configura of the - joint,18 andor inability 44 years to reduce old had the jointa 58% usually rate. mandates tionforearm. needs Occasionally, to be restored ulnar dislocation and whether at the radioulnar this will operative There repair. was94-96 no age correlation in secondary 89,90 preventjoint occurs long-term without bony complications injury. The injury can of resultcarpal from displacement in patients whose fractures were 93 instabilityfalls or axial anddistraction, hand asweakness, in sudden distraction delayed or rupture rotation Specialonly casted Circumstances without closed reduction. Emergency 94 95 96 of(such finger as sudden flexors, lifting chronic or grasping pain, a fixed neuropathy, object, like a practitioners must remain advocates for their pa- 97 cosmetichandrail or deformity, banister, against or arthritis. a fall). Radioulnar joint injuries Pediatrictients and Issues ensure they are appropriately referred to can alsoDespite result years from crush- of study, or wringer-type the best approach mechanisms. to Carpalorthopedists fractures are who extremely will operate rare in the if verya better young. outcome A distalIn radial order to fractures detect radioulnar remains dislocations unclear. radiographi-A Cochrane recentis more review likely, of pediatric especially carpal ininjuries patients describes older carpal than 65. 97 reviewcally, it is examined important torandomized get true PA and and lateral quasirandom views - injuriesWe should in terms also of case remain reports aware or small of series. the high The secondpaucity - ized(although clinical this trialsmay be in difficult adults in with the suffering fracture patient). of the of arycarpal displacement injuries is due rateto the within fact that 8 these weeks “bones in patients” are distalRemember radius that to the determine ulna has a fixed the mostrelationship appropriate to the morepost–closed cartilaginous reduction than calcified when and they are thus present relatively to the ED conservativeradius in true PA treatment. and lateral Thefilms. authors On the lateral included view, the31 resistantwith persistentto injury. Because pain theor neurologicalradius growth plate deficit is weaker imply- than the joint capsule, energy transmitted from a fall leads trialsdislocated totaling ulna will3372 project (mainly either female dorsally and or volarly older) to pa- ing malalignment. to epiphyseal rather than carpal injury. This produces torus tients.the radius. The On authors the AP, itstated, will overlap “There the remainsradius, and insuffi close - and greenstick fractures of the radius. Torus (doughnut- cientthe radioulnar evidence gap. from Other randomized suggestive signs trials of injuryto determine shaped)Other fractures Fractures are best Of appreciated The Distal as a tiny Radius bump on the whichinclude methods fracture of ofthe conservative ulnar styloid base treatment (which is areassoci- the There are other named fractures of the distal radius, ated with TFC injury) as well as radial shortening of 5 mm cortex of the distal radius on either the PA or lateral views. most appropriate for the more common types of eachAs theassociated child ages with and growtha specific plates mechanism. close, injury Rather 98 distal radial fractures in adults.” patternsthan naming approach the those fracture, of adults. it Inis oldermore children, important carpal to Figure 16. The lunate is now disoriented in relation to injuryidentify will occur, and describeand in young the adults,lesion scaphoidin terms fracture of location, is the radius on the lateral view, and the capitate is no thedisplacement, most common. angulation, and comminution, as these longer coaxial. On the PA view, the lunate is triangular Figure 16. Lunate parametersThe most common determine pitfall treatment in dealing andwith prognosis.wrist injuries rather than its normal quadrangular appearance. among children involves injury to the growth plates, especiallyVolar Angulation in the radius. One study revealed that 87% of 38 childrenThe Smith’s diagnosed fracture with wrist (or “reversesprain” inColles’ fact had fracture) Salter typeoccurs I injuries with (see direct Table blow2) of the or distal fall on radius. the 28dorsum of the wrist.In children, It is often fracture the lines result may of be a obscure,bicyclist especially or motorcy if - theclist fracture being occurs thrown through over the the growth handlebars. plate. Evaluating By maintain the - fating stripes a fierce of the wristgrip canon thebe helpful handlebars, in detecting the otherwisepatient sus- occulttains injury. a distal The pronatorradius fracture quadratus with muscle volar, attaches rather at the than dorsal, angulation. Treatment criteria are similar to Tabledorsally 2. Salter-Harris angulated Classification. fractures.

•Radial Type I Styloidinvolves theFracture growth plate. Radiographs may be Thenormal chauffeur or show fracturea displaced (or epiphysis. Hutchinson Often misdiag- fracture) is nosed as a “sprain.” •a Typebreak II involvesin the radial the growth styloid. plate Itand is agenerally triangular piecedue to directof the impactmetaphysis. on Itthe is theradial most side common of the type wrist. of growth (The archaicplate fracture reference and generally to the chauffeur has a good involvesoutcome. a blow •fromType the III passes crankshaft though handlethe growth of platean antique and the car.)epiphy- In thissis. Surgeryinjury, oftenthe styloid indicated is ifavulsed, fragments including are displaced. the •attachmentType IV involves of the the extrinsic epiphysis, metaphysis,ligaments andof the growth wrist. Therefore,plate. Surgery displaced usually indicated fractures and usually growth arrest mandate can open occur if alignment not restored. Reproduced with permission from: Harris JH, Harris WH, reduction and repair.100 Theeds. lunate The Radiology is now disoriented of Emergency in relation Medicine. to the 3rdradius ed. on the lateral • Type V represents a crush injury of the growth plate. Baltimore: Lippincott Williams & Wilkins Publishers; Radiographic findings may be subtle. Growth arrest view, and the capitate is no longer coaxial. On the PA view, the lunate History teaches us that men and nations behave wisely is1993:417. triangular Fig.rather 6.6A, than 6.6B. its normal quadrangular appearance. is common. once they have exhausted all other alternatives. ReproducedEmergency with Medicine permission Practice from: Harris JH, Harris WH, eds. The Ra- 18 —Abba Eban November 2001 diology of Emergency Medicine. 3rd ed. Baltimore: Lippincott Williams & Wilkins Publishers; 1993:417. Fig. 6.6A, 6.6B.

Wrist Injuries: Emergency Imaging And Management 117 Radioulnar Joint Injuries the ulnar styloid base (which is associated with TFC The distal radioulnar joint includes the TFC and injury) as well as radial shortening of 5 mm or more 104 the radioulnar articulation. Injuries to this joint are relative to the ulna. In cases in which the diagno- commonly missed in the acute setting.101-103 Disloca- sis is suspected but radiographs are equivocal, CT of 102,105 tion of the ulna commonly occurs with distal radius the wrist may be helpful. This test, however, is fractures and can be an important component of usually left to the consultant. some fracture-dislocations of the forearm. Occasion- ally, ulnar dislocation at the radioulnar joint occurs Treatment without bony injury. The injury can result from Delayed diagnosis makes closed reduction difficult. falls or axial distraction, as in sudden distraction or The key is to identify the dislocation both in isola- rotation (such as suddenly lifting or grasping a fixed tion and in association with nondisplaced fractures. object, such as a handrail or banister, against a fall). Reduction of associated fractures will often bring the Radioulnar joint injuries can also result from crush- ulna back into position. Once reduction is achieved, or wringer-type mechanisms. immobilize the arm with a long arm splint to prevent To detect radioulnar dislocations radiographi- rotation at the injured joint. Damage to the TFC, which cally, it is important to get true PA and lateral views is the main stabilizer of the joint, or inability to reduce 106-108 (although this may be difficult in the suffering pa- the joint usually mandates operative repair. tient). Remember that the ulna has a fixed relationship to the radius in true PA and lateral radiographs. Special Circumstances On the lateral view, the dislocated ulna will project either dorsally or volarly to the radius. On the AP, it Pediatric Issues will overlap the radius and close the radioulnar gap. Carpal fractures are extremely rare in the very young. Other suggestive signs of injury include fracture of A recent review of pediatric carpal injuries describes

Risk Management Pitfalls For Wrist Injuries (continued on page 119)

1. “The splint/cast was put on by the [choose might have disability insurance, but that’s no one: ortho resident, PA, nurse, med student]. substitute for your job. Treat wrist injuries with The patient was discharged by the [choose respect—immobilize and refer. one: nurse, PA, resident]. I thought he told the patient about signs of vascular compromise.” 4. “I didn’t document two-point discrimination. That’s right—he should have. But it was under She wasn’t complaining of numbness.” your authority and supervision; therefore, you The pain from the fracture was more significant should check the final product. Make sure the to her than the numbness. Maybe her two-point patient understands the warning signs of vascu- was intact at presentation—maybe not. But lar compromise (change of color, sensation, pain, you didn’t check, and the neurovascular exam significant swelling) and has access to medical wasn’t documented. care should it occur. Document these instructions, and make sure the patient has access to 5. “There was a lot of swelling. How was I sup- follow-up. Untreated or undertreated wrist posed to feel the pulse?” injuries can lead to lifelong complications. This is not an uncommon problem. If swelling obscures the pulse at the wrist, sometimes you 2. “It was just a nick in the skin. I didn’t think it can feel it in the snuffbox. Consider using a Dop- was an open fracture.” pler to detect the pulse. If these are absent, you Not every open fracture needs to be washed out still have access to capillary refill or the Allen in the OR. But that’s a decision best made by test. a surgeon. Osteomyelitis is low on everyone’s wish list. 6. “It was late. I didn’t want to wake my hand guy up for a wrist sprain, because I couldn’t be 3. “At the most, the guy will have some chronic sure that the lunate was dislocated.” pain in his wrist. I didn’t think to ask if he was By the time the hand specialist found out about a [choose one: cabinetmaker, aspiring concert the injury, it was the next afternoon. Wrist dis- violinist, wicked left-handed pitcher being locations do better if reduced early. Not every scouted by the Cubs, emergency physician].” wrist injury needs to be seen emergently, but it is Think about it. How much chronic pain would critical to recognize the ones that do. you be willing to tolerate in your job? You

118 An Evidence-Based Approach To Traumatic Emergencies carpal injuries in terms of case reports or small Another RCT aimed to change the current series.109 There are few carpal injuries because these management of wrist buckle fractures. A buckle “bones” are more cartilaginous than calcified and are fracture occurs when the bony cortex is compressed thus relatively resistant to injury. Because the radius inward on one side while the other cortex remains growth plate is weaker than the joint capsule, energy intact. Old management dictated 2 to 4 weeks in a transmitted from a fall leads to epiphyseal rather short arm cast, although currently casts and splints than carpal injury. This produces torus and greenstick are both commonly used. The aim of the RCT was to fractures of the radius. Torus (doughnut-shaped) compare the outcome in children with distal radius fractures are best appreciated as a tiny bump on the or ulna buckle fractures placed in removable splints cortex of the distal radius on either the PA or lateral with children placed in short arm casts. Casts result views. As the child ages and growth plates close, in more disability during immobilization, limiting injury patterns approach those of adults. In older chil- mobility and potentially unnecessarily burden- dren, carpal injury will occur, and in young adults, ing a family when a more manageable splint offers scaphoid fracture is the most common. equivalent pain relief. A recent randomized controlled trial (RCT) with Eighty-seven children 6 to 15 years old were 82 pediatric patients assessed the immobilization of randomly assigned to the 2 different immobilization torus fractures of the distal forearm. The results in- options. The results revealed that splints had less dicated that fiberglass volar slab immobilization was impact on a child’s daily functioning, such as bath- associated with increased duration of pain (6 days) ing and daily activities, and children in splints were compared with plaster casts (3 days) and a longer able to return to sports quicker without any undesir- disability time until resuming routine activities (at able effects such as increased pain or refractures.111 2 weeks, only 67% had resumed normal activities Children with wrist buckle fractures do not need compared with 95% in the casts group).110 3 weeks of constant immobilization, and although

Risk Management Pitfalls For Wrist Injuries (continued from page 118)

7. “There was no snuffbox tenderness, and the pulous examination of the wrist and the x-rays x-ray was negative. I was confident it wasn’t a to detect high-risk findings. scaphoid fracture.” You were right. It wasn’t a scaphoid fracture— 9. “I didn’t x-ray his wrist because he said that he the lunate was broken! You failed to do a com- didn’t feel any glass in the wound. Plus, when plete examination and take adequate precau- I explored the wound, there was too much tions (immobilization and referral). The patient blood for me to see anything.” went home with a “wrist sprain,” never had A patient who is cut by shattered glass can har- short-term follow-up, and developed perma- bor a foreign body. The patient’s testimony as to nent disability because of Kienbock’s disease whether or not there is a foreign body is notori- (osteonecrosis of the lunate). Examine the ously inaccurate. If you’re unable to visualize entire wrist. FOOSH mechanisms can result in the base of a wound, use a tourniquet or get an a variety of different injuries. Identify the likely x-ray if glass is involved.100 injuries by history and physical examination, and order any special views that will help you 10. “He could make a fist. That means the tendons make a diagnosis. were intact.” Not really. Patients with complete transection of 8. “It was a simple Colles’ fracture in a guy who a flexor superficialis tendon can still clench their fell off his bike in a race. I’ve treated dozens of fist using the deep finger flexors. The wrist -flex radius fractures in elderly people over the past ors can be cut and the patient can still flex his year just by splinting and getting a two-week wrist using the finger flexors. When performing follow-up.” the physical examination, isolate the deep from Elderly women fall down after tripping on the superficial tendons in order to be sure of proper sidewalk—low impact, brittle bones. They don’t function. When exploring the wound, look for generally hit the ground at 30 MPH, like this tendon injury even if the patient can move his or cyclist did. The distal radius fracture has a much her fingers. A patient with a 90% tendon rupture worse prognosis in high-energy injuries. They may still have finger movement. may be associated with carpal injuries, dislocations, or neurovascular damage. Perform a scru-

Wrist Injuries: Emergency Imaging And Management 119 adherence may prove problematic with removable ing bone (as in Figure 17).112 In 1 study, this sign was splints, it seems that splints should become the stan- positive in 74% of Salter type I radius fractures.30 dard of care for this injury. Comparison views of the opposite wrist may also be distaldistal third third of the of theradius radius and and ulna ulna and and is associated is associated with with an an WoundsWounds requiring requiring repair repair will will need need to be to anesthetized,be anesthetized, The most common pitfall in dealing with wrist helpful in evaluating epiphyseal injury.30 Treatment overlyingoverlying layer layer of fat. of fat.This This fat stripefat stripe is best is best seen seen on trueon true cleansed,cleansed, and and then then explored explored to identify to identify retained retained foreign foreign injurieslaterallateral projection among projection children(see (see Figure Figure involves 17 and17 and Figure injury Figure 18), to18 and ),the and normally growth normally bodiesoutcomesbodies or tendon or tendon are injuries. generally injuries. Because Becausegood. tendons tendons can can retract retract into into plates,bowsbows slightly especially slightly toward toward in thethe thebone radius. bone (as (asin One Figure in Figure study 18). 18). Outwardrevealed Outward the theforearm, forearm, examine examine the thewrist wrist in full in full extension extension and and look look at at thatbulgingbulging 87% or of obliteration or 38 obliteration children of the forof thefat whom stripefat stripe wristcan can signify “sprain” signify bleeding bleeding was theOpen thebase base of Injuries the of thewound wound Of during Theduring the Wrist thefull full range range of motion of motion for for diagnosedor edemaor edema in in the in fact theunderlying underlyinghad Salter bone bone type (as (asin I Figureinjuries in Figure 17). ( 17).see98 In98 Tableone In one theThe theappearance appearancemost significant of a of tendon a tendon stub.open stub. Theinjuries The most most superficialof thesuperficial wrist usually 30 2study,) ofstudy, the this distal this sign sign was radius. was positive positive In in children, 74% in 74% of Salter of fracture Salter type type I linesradius I radius may tendoninvolvetendon in the inthe thewrist volar wrist is the aspect.is thepalmaris palmaris Here longus. is longus. where This This tendonthe tendon tendons, is is befractures. obscure,fractures.28 Comparison 28especially Comparison views if theviews of fracture the of theopposite opposite occurs wrist wristthrough may may locatednerves,located in the andin themiddle vessels middle of the course.of thevolar volar wrist.A careful wrist. It becomes It distalbecomes very examina very - thealso alsogrowth be helpfulbe helpful plate. in evaluating in Evaluating evaluating epiphyseal epiphyseal the fat injury. stripes injury.28 Treatment of28 Treatmentthe prominenttionprominent of range when when theof motion thewrist wrist is partially andis partially neurovascular flexed flexed while while the supply the is wristoutcomesoutcomes can arebe arehelpfulgenerally generally in good. detecting good. otherwise occult patientessential.patient touches touches Although his hisor her or foreignher thumb thumb and bodies and fifth fifth fingermay finger be together. detectedtogether. injury. The pronator quadratus muscle attaches at the Interestingly,onInterestingly, wound 16% exploration, 16% of patients of patients mayconsider may be missingbe themissing use this thisof tendon diagnostic tendon in in distalOpenOpen third Injuries Injuries of the Of TheOfradius The Wrist Wristand ulna and is associated eitherimagingeither hand, hand, whenand and in anthe in additionalan risk additional of foreign 9%, 9%, the thebodiesabsence absence ismay high. may be bePlain withTheThe most an most overlying significant significant layeropen open injuriesof injuriesfat. Thisof the of fat thewrist stripewrist usually usually is best bilateral.radiographsbilateral.103 Division103 Division will of detect the of thepalmaris glasspalmaris longisand longis metals, tendon tendon iswhereas rarely is rarely seeninvolveinvolve on thetrue thevolar lateral volar aspect. aspect. projection Here Here is where is(see where theFigures thetendons, tendons, 17 nerves,and nerves, 18) clinicallyMRIclinically and significant significantultrasonography except except when when arethere thereuseful is injury is injuryfor to nonra the to the- andandand normallyvessels vessels course. course.bows A careful slightlyA careful distal towarddistal examination examination the bone of range of(as range in of of mediandiopaquemedian nerve, nerve, substances which which lies lies beneath. such beneath. as Lacerations wood Lacerations or plastic.of other of other113-116 Figuremotionmotion 18and). and neurovascularOutward neurovascular bulging supply supply or is obliterationessential. is essential. While While of foreign the foreign fat flexor flexor tendonsWounds tendons require requiringrequire surgical surgical repair consultation. consultation. will need to be anes- stripebodiesbodies can may may signify be detectedbe detected bleeding upon upon woundor woundedema exploration, exploration, in the underly consider consider- thetized,TheThe father father cleansed, of modern of modern and hand hand then surgery, surgery, explored Sterling Sterling toBunnell, identifyBunnell, the theuse use of diagnostic of diagnostic imaging imaging when when the therisk risk of foreign of foreign onceonce suggested suggested that that trying trying to repair to repair a hand a hand wound wound without without bodiesbodies is high. is high. Plain Plain films films will will detect detect glass glass and and metals, metals, a tourniqueta tourniquet was was like like “trying “trying to fix to afix Swiss a Swiss watch watch in a in a whereaswhereas MRI MRI and and ultrasound ultrasound are areuseful useful for fornon-radiopaque non-radiopaque bucketbucket of ink. of ink.”104 ”When104 When exploring exploring the thewrist, wrist, consider consider the theuse use substancessubstances such such as wood as wood or plastic. or plastic.99-10299-102 of aof tourniquet a tourniquet to provide to provide a bloodless a bloodless field. field. Since Since most most EDs EDs Figure 17 and Figure 18. The fracture shown in Figure 17 is subtle, as it can be in children. The comparison view (Figure 18) shows a normal pronator quadratus fat pad that is missing in the injuredFigureFigure 17 wrist. 17and andFigure AlongFigure 18 . 18Thewith. The fracture a fracture physical shown shown inexam Figure in Figure pinpointing 17 is17 subtle, is subtle, as ittheas can it tenderness,can be bein children. in children. Thethere The comparison comparisonis little viewdoubt view (Figure (Figure of the diagnosis.18)18) shows shows a normal a normal pronator pronator quadratus quadratus fat fatpad pad that that is missing is missing in the in the injured injured wrist. wrist. Along Along with with a physical a physical exam exam pinpointingpinpointing the the tenderness, tenderness, there there is little is little doubt doubt of theof the diagnosis. diagnosis.

120NovemberNovemberAn 2001 Evidence-Based 2001 Approach To Traumatic1919 Emergencies EmergencyEmergency Medicine Medicine Practice Practice retained foreign bodies or tendon injuries. Because Disposition tendons can retract into the forearm, examine the wrist in full extension and look at the base of the After an attentive examination and review of the x- wound during the full range of motion for the rays, the vast majority of wrist injuries can be safely appearance of a tendon stub. The most superficial discharged from the ED. Most fractures or suspected tendon in the wrist is the palmaris longus. This fractures can be splinted, and the patient can be sent tendon is located in the middle of the volar wrist. home. Provide clear instructions regarding splint It becomes very prominent when the wrist is par- care, and warn patients about any neurovascular tially flexed while the patient touches his or her changes that warrant a return to the ED. thumb and fifth finger together. Interestingly, 16% Some injuries necessitate emergent orthopedic of patients may be missing this tendon in either evaluation. These may include lunate and perilunate hand, and in an additional 9%, the absence may be dislocations, open fractures, any fracture with neuro- 117 bilateral. Division of the palmaris longis tendon vascular compromise, and grossly displaced frac- is rarely clinically significant except when there tures. These are injuries in which early reduction or is injury to the median nerve, which lies beneath. a surgical procedure may improve outcome.83,121,122 Lacerations of other flexor tendons require surgi- Notably, these are the same injuries that are most cal consultation. often missed on initial evaluation. The father of modern hand surgery, Sterling Most other wrist injuries, both fractures and Bunnell, once suggested that trying to repair a ligamentous trauma, can be immobilized, and the hand wound without a tourniquet was like “try- patient can then be discharged with follow-up. This 118 ing to fix a Swiss watch in a bucket of ink.” applies to simple fractures and even to scapholunate When exploring the wrist, consider the use of a separation that may ultimately need surgical repair. tourniquet to provide a bloodless field. Because Disposition may depend on factors other than the most EDs lack an automated pressure tourniquet, anatomic injury. Bilateral fractures, or a wrist frac- a blood pressure cuff will do. Have the patient ture in an elderly person who is walker dependent, lie on the gurney with the arm held directly may warrant hospital admission until appropriate overhead—that is, sticking straight up from the home help is ensured. stretcher. Place a blood pressure cuff around the arm and wrap tape completely around the cuff to Summary keep it from popping off. Have the patient force- fully pump, then clench his or her fist to exsan- Although wrist injuries rarely represent a threat to guinate the forearm (like Bruce Lee in Fists of life, they remain a unique challenge for emergency Fury). Then inflate the cuff above systolic pressure clinicians. The fact that they are more common but and begin the wound exploration. Limit tourni- less urgent than other conditions seen in the ED quet time to 10 minutes to avoid ischemic injury can lull the unwary emergency clinician into a false and patient discomfort. sense of security. However, the complex anatomy of the wrist, combined with the high level of manual Pain Management dexterity most people require, makes the management of wrist injuries a virtual minefield for emer- Pain management is an important and often over- gency clinicians. Vigilance is a must. looked aspect of wrist injuries. It may be of special Mechanism of injury and other data obtained significance in those with crush injuries, amputa- during the history and physical examination pro- tions, and fractures. Opioid analgesics are useful vide essential clues for the diagnosis and man- and may be given intravenously, intramuscularly, agement of wrist injuries. Radiography is almost or orally depending on the severity of the pain. The always required; emergency clinicians must insist hematoma block is another valuable technique. It on adequate radiographs and order the proper can provide rapid analgesia and is especially well views for the given scenario. Be systematic when suited to those with distal radius fractures that evaluating the radiographs. Furthermore, be 119,120 require manipulation. After identifying the aware that injuries to the ligaments, muscles, and fracture site by palpation and prepping the skin soft tissue can also lead to long-term sequelae if with iodine, insert a needle into the bony deficit not managed properly. and aspirate blood. Then infiltrate 5 to 10 cc of Although it is neither cost-effective nor neces- bupivacaine or lidocaine into the fracture site. Most sary to “splint and refer” all patients with wrist patients achieve significant relief within 15 min- injuries, it is generally better to err on the conser- utes. If the orthopedist is planning to come to the vative side. Be sure the patient understands the ED to reduce the fracture, coordinate the timing of discharge instructions—especially the importance the hematoma block appropriately. of follow-up with the appropriate consultant, if indicated. Provide written discharge instructions,

Wrist Injuries: Emergency Imaging And Management 121 and be sure to document each step of the patient 14. Verdile V, Ferrera P, Adams JG. Hand and wrist injuries. In: encounter thoroughly. Ferrera P, Colucciello SA, Verdile V, Marx JA, eds. Trauma Management: An Emergency Medicine Approach. St. Louis, MO: The management of wrist injuries is rarely clear- Mosby; 2001. (Textbook chapter) cut. Fortunately, though, a thorough and systematic 15. Grover R. Clinical assessment of scaphoid injuries and the approach to the evaluation and disposition can lead detection of fractures. J Hand Surg Br. 1996;21(3):341-343. to better outcomes for the patient and emergency (Prospective, comparative; 221 patients) clinician alike. 16.* Waeckerle JF. A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Ann Emerg Med. 1987;16(7):733- References 737. (Prospective; 85 patients) 17.* Parvizi J, Wayman J, Kelly P, et al. Combining the clinical Evidence-based medicine requires a critical ap- signs improves diagnosis of scaphoid fractures. A prospec- praisal of the literature based on study methodology tive study with follow-up. J Hand Surg Br. 1998;23(3):324-327. and number of participants. Not all references are (Prospective; 215 patients) equally robust. The findings of a large, prospective, 18. Parvizi J, Wayman J, Kelly P, et al. Combining the clinical randomized, and blinded trial should carry more signs improves diagnosis of scaphoid fractures: a prospective study with follow-up. J Hand Surg Br. 1998;23(3):324-327. weight than a case report. 19. Rivara FP, Parish RA, Mueller BA. Extremity injuries in To help the reader judge the strength of each children: predictive value of clinical findings.Pediatrics. reference, pertinent information about the study, 1986;78(5):803-807. (189 patients) such as the type of study and the number of patients 20. McConnochie KM, Roghmann KJ, Pasternack J, et al. Predic- in the study, is included in bold type following the tion rules for selective radiographic assessment of extremity reference, where available. In addition, the most injuries in children and adolescents. Pediatrics. 1990;86(1):45- informative references cited in the chapter, as deter- 57. (Prospective; 617 patients) mined by the authors, are noted by an asterisk (*) 21. Pershad J, Monroe K, King W, et al. Can clinical parameters Acad Emerg next to the number of the reference. predict fractures in acute pediatric wrist injuries? Med. 2000;7(10):1152-1155. (Prospective blinded case series) 22. Cooney WP, Linscheid RL, Dobyns JH. Fractures and 1.* Gwynne A, Barber P, Tavener F. A review of 105 negligence dislocations of the wrist. In: Heckman JD, Bucholz RW, eds. claims against accident and emergency departments. J Accid Rockwood and Green’s Fractures in Adults: Rockwood, Green, and Emerg Med. 1997;14(4):243-245. (Systematic review of socio- Wilkins’ Fractures. 4th ed. Philadelphia, PA: Lippincott Wil- demographic, clinical, and legal issues; 105 cases) liams & Wilkins; 1996:745-867. (Textbook chapter) 2. Berger J. A Fortunate Man. 1967:102. Cited by: The Columbia 23. Pin PG, Young VL, Gilula LA, et al. Wrist pain: a systematic World of Quotations. New York, NY: Columbia University approach to diagnosis. Plast Reconstr Surg. 1990;85(1):42-46. Press; 1996. (Algorithm, case report) 3. Schwartz DT, Reisdorff EJ, eds. Emergency Radiology. New 24. Larsen CF, Brondum V, Wienholtz G, et al. An algorithm for York, NY: McGraw-Hill Professional Publishing; 2000. (Text- acute wrist trauma. A systematic approach to diagnosis. J book) Hand Surg Br. 1993;18(2):207-212. (Clinical protocol, follow- 4. Larsen CF, Lauritsen J. Epidemiology of acute wrist trauma. up study; 641 patients) Int J Epidemiol. 1993;22(5):911-916. (Prospective) 25. Inoue G, Shionoya K. Late treatment of unreduced peri- 5. Kristinsdottir EK, Nordell E, Jarnlo GB, et al. Observation lunate dislocations. J Hand Surg Br. 1999;24(2):221-225. (28 of vestibular asymmetry in a majority of patients over 50 patients) years with fall-related wrist fractures. Acta Otolaryngol 26. Lacey JD, Hodge JC. Pisiform and hamulus fractures: easily 2001;121(4):481-485. (Observational; 66 patients) missed wrist fractures diagnosed on a reverse oblique radio- 6. Ruby LK, Cooney WP 3rd, An KN, et al. Relative motion of graph. J Emerg Med. 1998;16(3):445-452. (Review, case report) selected carpal bones: a kinematic analysis of the normal 27.* Perron AD, Brady WJ, Keats TE, et al. Orthopedic pitfalls wrist. J Hand Surg Am. 1988;13(1):1-10. (Cadaver study; 5 in the ED: lunate and perilunate injuries. Am J Emerg Med. specimens) 2001;19(2):157-162. (Review) 7. Chin HW, Visotsky J. Ligamentous wrist injuries. Emerg Med 28. Sochart DH, Birdsall PD, Paul AS. Perilunate fracture- Clin North Am. 1993;11(3):717-737. (Review) dislocation: a continually missed injury. J Accid Emerg Med. 8. Jay MS, Graham CJ, Flowers C. Adolescent suicide at- 1996;13(3):213-216. (Case report; 5 patients) tempters presenting to a pediatric facility. Adolescence. 1989; 29. Freed HA, Shields NN. Most frequently overlooked 24(94):467-472. (Retrospective; 4072 patients) radiographically apparent fractures in a teaching hospital 9.* Barnaby W. Fractures and dislocations of the wrist. Emerg emergency department. Ann Emerg Med. 1984;13(10):900-904. Med Clin North Am. 1992;10(1):133-149. (Review) (Retrospective review) 10. Altman RS, Harris GD, Knuth CJ. Initial management of 30. Musharafieh RS, Macari G. Salter-Harris I fractures of the hand injuries in the emergency patient. Am J Emerg Med. distal radius misdiagnosed as wrist sprain. J Emerg Med. 1987;5(5):400-403. (Review) 2000;19(3):265-270. (65 patients) 11.* Overton DT, Uehara DT. Evaluation of the injured hand. 31. Schernberg F. Roentgenographic examination of the wrist: Emerg Med Clin North Am. 1993;11(3):585-600. (Review) a systematic study of the normal, lax and injured wrist, 12. Trott AT. Wounds and Lacerations: Emergency Care and Closure. Part 1: The standard and positional views. J Hand Surg Br. 2nd ed. St. Louis, MO: Mosby-Year Book; 1997. (Textbook) 1990;15(2):210-219. (Comparative; 148 wrists) 13. Ritchie JV, Munter DW. Emergency department evaluation 32. De Smet AA, Doherty MP, Norris MA, et al. Are oblique and treatment of wrist injuries. Emerg Med Clin North Am. views needed for trauma radiography of the distal extremi- 1999;17(4):823-842. ties? AJR Am J Roentgenol. 1999;172(6):1561-1565. (Prospec-

122 An Evidence-Based Approach To Traumatic Emergencies tive; 1461 radiographs) 54. Bayer LR, Widding A, Diemer H. Fifteen minutes bone 33. Metz VM, Metz-Schimmerl SM, Yin Y. Ligamentous instabili- scintigraphy in patients with clinically suspected scaphoid ties of the wrist. Eur J Radiol. 1997;25(2):104-111. (Review) fracture and normal x-rays. Injury. 2000;31(4):243-248. (Ret- rospective; 40 patients) 34. Hardy DC, Totty WG, Reinus WR, et al. Posteroanterior wrist radiography: importance of arm positioning. J Hand 55. Breitenseher MJ, Metz VM, Gilula LA, et al. Radiographi- Surg Am. 1987;12(4):504-508. (9 patients) cally occult scaphoid fractures: value of MR imaging in detection. Radiology. 1997;203(1):245-250. (42 patients) 35. Mital RC, Beeson M. The wrist and forearm. In: Schwartz DT, Reisdorff EJ, eds. Emergency Radiology. New York, NY: McGraw- 56. Gaebler C, Kukla C, Breitenseher M, et al. Magnetic Hill Professional Publishing; 2000:47-75. (Textbook chapter) resonance imaging of occult scaphoid fractures. J Trauma. 1996;41(1):73-76. (Prospective; 32 patients) 36. Gilula LA. Carpal injuries: analytic approach and case exer- cises. AJR Am J Roentgenol. 1979;133(3):503-517. (Review) 57.* Gabler C, Kukla C, Breitenseher MJ, et al. Diagnosis of occult scaphoid fractures and other wrist injuries: are repeated 37. Abbitt PL, Riddervold HO. The carpal tunnel view: helpful clinical examinations and plain radiographs still state of the adjuvant for unrecognized fractures of the carpus. Skeletal art? Langenbecks Arch Surg. 2001;386(2):150-154. (Prospective, Radiol. 1987;16(1):45-47. (Case report; 4 patients) consecutive, randomized; 121 patients) 38. Lohman M, Kivisaari A, Vehmas T, et al. MR imaging 58. Imaeda T, Nakamura R, Miura T, et al. Magnetic resonance in suspected acute trauma of wrist bones. Acta Radiol. imaging in scaphoid fractures. J Hand Surg Br. 1992;17(1):20- 1999;40(6):615-618. (Comparative; 67 patients) 27. (28 patients with scaphoid fractures, 5 healthy volun- 39. Gleadhill DN, Thomson JY. Can more efficient use be made teers) of x ray examinations in the accident and emergency depart- 59. Lepisto J, Mattila K, Nieminen S, et al. Low field MRI and ment? Br Med J (Clin Res Ed). 1987;294;943-947. scaphoid fracture. J Hand Surg Br. 1995;20(4):539-542. (18 40. You JS, Pil S. The usefulness of CT for patients with carpal patients) bone fractures in the emergency department. Emerg Med J. 60. Jenkins PJ, Slade K. A comparative analysis of the accuracy, 2007;24:248-250. diagnostic uncertainty and cost of imaging modalities in 41. Mehta M, Brautigan MW. Fracture of the carpal navicular— suspected scaphoid fractures. Injury. 2008;39:768-774. efficacy of clinical findings and improved diagnosis with 61. Fowler C, Sullivan B, Williams LA, et al. A comparison of six-view radiography. Ann Emerg Med. 1990;19(3):255-257. bone scintigraphy and MRI in the early diagnosis of the oc- (Prospective; 90 patients) cult scaphoid waist fracture. Skeletal Radiol. 1998;27(12):683- 42.* Tiel-van Buul MM, van Beek EJ, Borm JJ, Gubler FM, 687. (Prospective; 43 patients) Broekhuizen AH, van Royen EA. The value of radiographs 62.* Tiel-van Buul MM, Broekhuizen TH, van Beek EJ, et al. and bone scintigraphy in suspected scaphoid fracture: a sta- Choosing a strategy for the diagnostic management of sus- tistical analysis. J Hand Surg Br. 1993;18(3):403- 406. (Prospec- pected scaphoid fracture: a cost-effectiveness analysis. J Nucl tive; 78 patients) Med. 1995;36(1):45-48. (Comparative) 43. Munk B, Frokjaer J, Larsen CF, et al. Diagnosis of scaphoid 63. Tiel-van Buul MM, van Beek EJ, Broekhuizen AH, et al. fractures: a prospective multicenter study of 1,052 patients Radiography and scintigraphy of suspected scaphoid frac- with 160 fractures. Acta Orthop Scand. 1995;66(4):359-360. ture: a long-term study in 160 patients. J Bone Joint Surg Br. (Prospective; 1052 patients) 1993;75(1):61-65. (Follow-up; 161 patients) 44. Dias JJ, Finlay DB, Brenkel IJ, et al. Radiographic assessment 64. van Beek EJ, van Buul MM, Broekhuizen AH. Diagnostic of soft tissue signs in clinically suspected scaphoid fractures: problems of scaphoid fractures: the value of radionuclide the incidence of false negative and false positive results. J bone scintigraphy. Neth J Surg. 1990;42(2):50-52. (Evaluation; Orthop Trauma. 1987;1(3):205-208. (127 patients) 33 patients) 45. Cetti R, Christensen SE. The diagnostic value of displace- 65. Kaneshiro SA, Failla JM, Tashman S. Scaphoid fracture dis- ment of the fat stripe in fracture of the scaphoid bone. Hand. placement with forearm rotation in a short-arm thumb spica 1982;14(1):75-79. (Retrospective; 125 patients) cast. J Hand Surg Am. 1999;24(5):984-991. 46. Terry DW Jr, Ramin JE. The navicular fat stripe: a useful 66. Gellman H, Caputo RJ, Carter V, et al. Comparison of short roentgen feature for evaluating wrist trauma. Am J Roent- and long thumb-spica casts for non-displaced fractures of genol Radium Ther Nucl Med. 1975;124(1):25-28. (400 wrists) the carpal scaphoid. J Bone Joint Surg Am. 1989;71(3):354-357. 47. Banerjee B, Nashi M. Abnormal scaphoid fat pad: is it a (Prospective; 51 patients) reliable sign of fracture scaphoid. Injury. 1999;30(3):191-194. 67. Alho A, Kankaanpaa. Management of fractured scaphoid (Retrospective; 80 patients) bone: a prospective study of 100 fractures. Acta Orthop Scand. 48. Perron AD, Brady WJ, Keats TE, et al. Orthopedic pitfalls in 1975;46(5):737-743. (Prospective; 100 patients) the ED: scaphoid fracture. Am J Emerg Med. 2001;19(4):310- 68. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the 316. (Review; 32 references) scaphoid: a rational approach to management. Clin Orthop. 49. Ring D, Jupiter JB, Herndon JH. Acute fractures of the sca- 1980;(149):90- 97. (Review) phoid. J Am Acad Orthop Surg. 2000;8(4):225-231. (Review; 33 69. Guly HR. Injuries initially misdiagnosed as sprained wrist references) (beware the sprained wrist). Emerg Med J. 2002;19:41-42. 50. Osterman AL, Mikulics M. Scaphoid nonunion. Hand Clin. 70. Davidson JS, Brown DJ. Simple treatment for torus fractures 1988;4(3):437-455. (Review; 84 references) of the distal radius. J Bone Joint Surg Br. 2001;83(8):1173-1175. 51. Stern JD, Reitman HS. Fractures of the scaphoid bone: 71. Langhoff O, Andersen JL. Consequences of late immobiliza- how to handle this common wrist injury. Postgrad Med. tion of scaphoid fractures. J Hand Surg Br. 1988;13(1):77-79. 1988;83(1):91-92, 95-97. 72. Walsh JJ 4th, Bishop AT. Diagnosis and management of 52. Staniforth P. Scaphoid fractures and wrist pain—time for hamate hook fractures. Hand Clin. 2000;16(3):397-403, viii. new thinking. Injury. 1991;22(6):435-436. (Editorial) (Review) 53. Murphy DG, Eisenhauer MA, Powe J, et al. Can a day 4 73. Kato H, Nakamura R, Horii E, et al. Diagnostic imaging for bone scan accurately determine the presence or absence of fracture of the hook of the hamate. Hand Surg. 2000;5(1):19- scaphoid fracture? Ann Emerg Med. 1995;26(4):434-438. (Pro- 24. (16 patients) spective; 99 patients)

Wrist Injuries: Emergency Imaging And Management 123 74. Mayfield JK. Wrist ligamentous anatomy and pathogenesis 96. Rubin M, Heise CW. Proximal neuropathy in Colles’ fracture. of carpal instability. Orthop Clin North Am. 1984;15(2):209- Can J Neurol Sci. 1997;24(1):77-78. (Case report; 2 patients) 216. (Review) 97. Field J, Warwick D, Bannister GC, et al. Long-term prognosis 75. Beltran J, Shankman S, Schoenberg NY. Ligamentous of displaced Colles’ fracture: a 10-year prospective review. injuries to the wrist: imaging techniques. Hand Clin. 1992 Injury. 1992;23(8):529-532. (Prospective) Nov;8(4):611-620. (Review) 98. Handoll HHG, Madhok R; Cochrane Musculoskeletal 76. Kursunoglu-Brahme S, Gundry CR, Resnick D. Advanced Injuries Group. Conservative interventions for treating imaging of the wrist. Radiol Clin North Am. 1990;28(2):307- distal radial fractures in adults. Cochrane Database Syst Rev. 320. (Review; 31 references) 2001;(2):CD000314. (Systematic review) 77. Mayfield JK. Patterns of injury to carpal ligaments: a spec- 99. Makhni EC, Ewald TJ. Effect of patient age on the radio- trum. Clin Orthop. 1984;(187):36-42. (Case report) graphic outcomes of distal radius fractures subject to nonop- 78. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: erative treatment. J Hand Surg Am. 2008;33(8):1301-1308. pathomechanics and progressive perilunar instability. J Hand 100. Bassett RL. Displaced intraarticular fractures of the distal Surg Am. 1980;5(3):226-241. (Cadaver study; 32 wrists) radius. Clin Orthop. 1987;(214):148-152. (Review) 79. Yeager BA, Dalinka MK. Radiology of trauma to the wrist: 101. Singletary EM. Volar dislocation of the distal radioulnar dislocations, fracture dislocations, and instability patterns. joint. Ann Emerg Med. 1994;23(4):881-883. (Case report) Skeletal Radiol. 1985;13(2):120-130. (Review) 102. Nicolaidis SC, Hildreth DH, Lichtman DM. Acute injuries 80. Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic inof the distal radioulnar joint. Hand Clin. 2000;16(3):449-459. stability of the wrist: diagnosis, classification, and pathome- (Review) chanics. J Bone Joint Surg Am. 1972;54(8):1612-1632. (Review) 103. Rainey RK, Pfautsch ML. Traumatic volar dislocation of the 81. Wolfe SW, Gupta A, Crisco JJ 3rd. Kinematics of the scaphoid distal radioulnar joint. Orthopedics. 1985;8(7):896-900. (Case shift test. J Hand Surg Am. 1997;22(5):801-806. (Comparative; report) 25 uninjured participants [50 wrists]) 104. Moore TM, Klein JP, Patzakis MJ, Harvey JP Jr. Results of 82.* Meldon SW, Hargarten SW. Ligamentous injuries of the compression-plating of closed Galeazzi fractures. J Bone wrist. J Emerg Med. 1995;13(2):217-225. (Review) Joint Surg Am. 1985;67(7):1015-1021. (Follow-up study; 1236 83. Herzberg G, Comtet JJ, Linscheid RL, et al. Perilunate dislo- fractures) cations and fracture-dislocations: a multicenter study. J Hand 105. Nakamura R, Horii E, Imaeda T, et al. Criteria for diagnosing Surg Am. 1993;18(5):768-779. (Retrospective; 166 perilunate distal radioulnar joint subluxation by computed tomogra- dislocations and fracture-dislocations from 7 centers) phy. Skeletal Radiol. 1996;25(7):649-653. (30 patients) 84. Sherman GM, Seitz WH Jr. Fractures and dislocations of the 106. Rodriguez Merchan EC, de la Corte H. Injuries of the distal wrist. Curr Opinion Orthop. 1999;10(4):237-251. radioulnar joint. Contemp Orthop. 1994;29(3):193-200. (Re- 85. Nguyen TV, Center JR, Sambrook PN, et al. Risk factors for view) proximal humerus, forearm, and wrist fractures in elderly 107. Dailey SW, Palmer AK. The role of arthroscopy in the evalu- men and women: the Dubbo Osteoporosis Epidemiology ation and treatment of triangular fibrocartilage complex Study. Am J Epidemiol. 2001;153(6):587-595. (Prospective; 1844 injuries in athletes. Hand Clin. 2000;16(3):461-476. (Review; patients) 74 references) 86. Rettig ME, Dassa GL, Raskin KB, et al. Wrist fractures in the 108. Corso SJ, Savoie FH, Geissler WB, et al. Arthroscopic repair athlete: distal radius and carpal fractures. Clin Sports Med. of peripheral avulsions of the triangular fibrocartilage 1998;17(3):469-489. (Review) complex of the wrist: a multicenter study. Arthroscopy. 87. Lindau TR, Aspenberg P, Arner M, et al. Fractures of the dis- 1997;13(1):78-84. (Multicenter, follow-up; 45 wrists) tal forearm in young adults: an epidemiologic description of 109. Light TR. Carpal injuries in children. Hand Clin. 341 patients. Acta Orthop Scand. 1999;70(2):124-128. (Descrip- 2000;16(4):513-522. (Review; 72 references) tive; 341 patients with 346 fractures) 110. Oakley EA, Ooi KS. A randomized controlled trial of 2 meth- 88. Gliatis JD, Plessas SJ, Davis TR. Outcome of distal radial ods of immobilizing torus fractures of the distal forearm. fractures in young adults. J Hand Surg Br. 2000;25(6):535-543. Pediatr Emerg Care. 2008;24(2):65-70. (Questionnaire; 169 fractures) 111. Plint AC, Perry JJ. A randomized, controlled trial of remov- 89. Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal able splinting versus casting for wrist buckle fractures in soft-tissue lesions associated with an intra-articular frac- children. Pediatrics. 2006;117(3):691-697. ture of the distal end of the radius. J Bone Joint Surg Am. 112. MacEwan DW. Changes due to trauma in the fat plane 1996;78(3):357-365. (Multicenter; 60 patients) overlying the pronator quadratus muscle: a radiologic sign. 90.* Rettig ME, Raskin KB. Acute fractures of the distal radius. Radiology. 1964;82:879-886. Hand Clin. 2000;16(3):405-415, ix. (Review) 113. Courter BJ. Radiographic screening for glass foreign 91. Dee W, Klein W, Rieger H. Reduction techniques in distal bodies—what does a “negative” foreign body series really radius fractures. Injury. 2000;31(suppl 1):48-55. (Review) mean? Ann Emerg Med. 1990;19(9):997-1000. (Animal model) 92. Cooney WP 3rd, Dobyns JH, Linscheid RL. Complication 114. Ginsburg MJ, Ellis GL, Flom LL. Detection of soft-tissue of Colles’ fractures. J Bone Joint Surg Am. 1980;62(4):613-619. foreign bodies by plain radiography, xerography, com- (565 fractures) puted tomography, and ultrasonography. Ann Emerg Med. 93. Stoffelen D, De Mulder K, Broos P. The clinical importance 1990;19(6):701-703. (Comparative, evaluation) of carpal instabilities following distal radial fractures. J Hand 115. Kaplan PA, Anderson JC, Norris MA, et al. Ultrasonography Surg Br. 1998;23(4):512-516. (Prospective) of post-traumatic soft-tissue lesions. Radiol Clin North Am. 94. Van Loon J, De Smet L, Fabry G. Rupture of all finger flexor 1989;27(5):973-982. (Review) tendons 17 years after a Colles’ fracture: a case report. J Hand 116. Lammers RL, Magill T. Detection and management of Surg Am. 1997;22(2):263-265. (Case report) foreign bodies in soft tissue. Emerg Med Clin North Am. 95. Field J, Atkins RM. Algodystrophy is an early complication 1992;10(4):767-781. (Review) of Colles’ fracture: what are the implications? J Hand Surg Br. 117. Thompson NW, Mockford BJ, Cran GW. Absence of the 1997;22(2):178-182. (Case-control; 100 patients) palmaris longus muscle: a population study. Ulster Med J.

124 An Evidence-Based Approach To Traumatic Emergencies 2001;70(1):22-24. (300 participants) 53. The cortical (or signet ring) sign signifies: 118. Boyes J, ed. Bunnell’s Surgery of the Hand. Philadelphia, PA: a. The sound that a healthy bone makes when J.B. Lippincott Co; 1970. (Textbook) tapped 119. Furia JP, Alioto RJ, Marquardt JD. The efficacy and safety of b. Abnormal scaphoid alignment the hematoma block for fracture reduction in closed, isolated c. Abnormal triquetral position fractures. Orthopedics. 1997;20(5):423-426. (Comparative; 61 patients) d. Artifact at midproximal fourth phalanx 120.* Singh GK, Manglik RK, Lakhtakia PK, et al. Analgesia for the reduction of Colles’ fracture: a comparison of hematoma 54. An injury sustained while swinging a bat or block and intravenous sedation. Online J Curr Clin Trials. club to hit a ball should raise suspicion for 1992;Doc No 23. (Randomized, controlled; 66 cases) which type of injury? 121. Adams BD, Divelbiss BJ. Reconstruction of the posttrau- a. Scaphoid fracture matic unstable distal radioulnar joint. Orthop Clin North Am. b. Triquetral injury 2001;32(2):353-363, x. (Review; 22 references) c. Dislocation around the lunate 122. Rettig ME, Kozin SH, Cooney WP. Open reduction and internal fixation of acute displaced scaphoid waist fractures. d. Hamate hook injury J Hand Surg Am. 2001;26(2):271-276. (14 patients) 55. Severe pain at the wrist sustained in a fall from a third-floor scaffolding should raise suspicion CME Questions for which type of injury? a. A high-energy wrist injury 49. Fractures at the radial or ulnar styloid are sig- b. A shoulder dislocation nificant because: c. A life-threatening blunt abdominal injury a. They will be the most cosmetically apparent d. All of the above after healing. b. The extrinsic ligaments that stabilize the 56. Which of the following is the most common carpals originate there. type of carpal fracture? c. They are most likely to become infected. a. Scaphoid d. There is a risk of avascular necrosis. b. Lunate c. Hamate 50. Supinated oblique views are useful for: d. Triquetrum a. Reviewing the scaphoid from a different angle 57. Most wrist injuries are caused by: b. Checking the alignment of the radius and a. Motor vehicle crashes ulna b. A fall on an outstretched hand c. Alternative views of the hamate and c. Typing for long stretches of time pisiform d. Sports and other pastimes d. Alternative views of the trapezium 58. The proximal arch includes all of the following 51. What is the advantage of a long arm spica over except: a short arm spica? a. The hamate a. It prevents rotation of the forearm in b. The scaphoid complex scaphoid injuries. c. The lunate b. It makes it more likely that the patient will d. The triquetrum seek medical attention for splint removal. e. The pisiform c. It bills better. d. It protects the elbow joint. 59. The distal row includes all of the following except: 52. Which of the following is a common pitfall in a. The trapezium the management of pediatric wrist injuries? b. The trapezoid a. Not examining the wrist carefully to know c. The capitate what injury to suspect d. The hamate b. Diagnosing a Salter injury at the distal e. The pisiform radius as a “sprain” c. Being intimidated by the absence of calcification in the carpi d. All of the above

Wrist Injuries: Emergency Imaging And Management 125 60. In patients with wrist injuries, which of the following should be determined as part of the patient history? a. Preexisting medical conditions such as rheumatoid arthritis b. The time of the patient’s last meal if an emergent surgical procedure is anticipated c. Any current medications/allergies d. All of the above

61. Finding a distal radius fracture in a young adult roller hockey player should prompt the emergency clinician to: a. Splint the wrist and send the patient home with a diagnosis of Colles’ fracture. b. Perform a conscientious search for associated wrist injuries. c. Suspect a pathological fracture. d. Call for an immediate orthopedic consultation.

62. Which of the following is the best strategy for patients with clinical signs of scaphoid fracture? a. Immobilization and orthopedic follow-up in 7 to 10 days, even in the absence of radiographic findings b. Immobilization and orthopedic follow-up in 7 to 10 days if a fracture is detected on x-ray c. Immediate surgical consult d. Discharge the patient with instructions to return to the ED if symptoms worsen

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The purchaser of this book can receive free CME credit. If you are the purchaser of this book, you do not need to enter your credit card information or send a check. Additional physicians can receive credit for a nominal charge of $30. Please complete this CME Answer Form and provide your credit card information below or submit a check (payable to EB Medicine). Visa/MC/AmEx Number: ______Exp Date: ______

Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] complete this form, you will need “An Evidence- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] education for physicians. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] should only claim credit commensurate with the extent of their participation in the activity. 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] Earning Credit: Practitioners who read “An Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] 21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. 25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] Please continue test and complete 33. [a] [b] [c] [d] [e] Evaluation Form on reverse side. 128 An Evidence-Based Approach To Traumatic Emergencies 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies CME Answer Form Please print the following information clearly: Name: ______Address: ______Phone number: ______E-mail address (required): ______Please write your email address clearly. Certificates will be sent by email. If you need your certificate mailed instead of emailed, check this box: 

Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] complete this form, you will need “An Evidence- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] education for physicians. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] should only claim credit commensurate with the extent of their participation in the activity. 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] Earning Credit: Practitioners who read “An Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] 21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. 25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] Please continue test and complete 33. [a] [b] [c] [d] [e] Evaluation Form on reverse side. 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 129 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies An Evidence-Based Approach To Traumatic Emergencies CME Evaluation Form CME Answer Form Please print the following information clearly: Please record actual time spent on this activity here, if less than designated time of 16 hours: _____ Name: ______Address: ______Please take a few moments to complete this form. Your opinions will ensure continuing program relevance and quality. ______Enter the extent to which you agree with the following statements. Response codes: 5=strongly agree; 4=agree; 3=neutral; 2=disagree; 1=strongly disagree Phone number: ______1. ____ The chapters were easy and enjoyable to read. E-mail address (required): ______2. ____ The information was presented in an impartial and unbiased manner, and the authors were not biased in their discussion of any Please write your email address clearly. Certificates will be sent by email. commercial product or service. If you need your certificate mailed instead of emailed, check this box:  3. ____ Adequate faculty disclosure was given. 4. ____ This activity improved my competence. The purchaser of this book can receive free CME credit. If you are the purchaser of this book, you 5. ____ This activity improved my performance. do not need to enter your credit card information or send a check. 6. ____ This activity improved outcomes for my patients. Additional physicians can receive credit for a nominal charge of $30. Please complete this CME Answer Form and provide your credit card information below or submit a check (payable to EB Medicine). Enter the extent to which the following objectives were met for each chapter. Visa/MC/AmEx Number: ______Exp Date: ______

Neck Trauma Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] 1. ____ Describe the importance of early and appropriate airway management; describe the diagnostic approach to vascular injuries by zone of complete this form, you will need “An Evidence- injury in neck trauma; identify and provide initial management for laryngeal injury; and discuss the importance of early recognition of esoph- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each ageal trauma and the accuracy of available diagnostic modalities. chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] Orthopedic Sports Injuries This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] 2. ____ List conditions or circumstances that require orthopedic or surgical consultation or referral in patients with sports injuries; describe the appropriate treatment and disposition for common orthopedic sports injuries; describe clinical decision rules such as the Ottawa knee rules that Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] are used to determine the need for radiography; and discuss different techniques for shoulder reduction. and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] Blunt Abdominal Trauma (ACCME) through the sponsorship of EB 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] 3. ____ Name typical mechanisms of injury for solid and hollow visceral trauma; explain the appropriate diagnostic approach based upon the Medicine. EB Medicine is accredited by the ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] clinical scenario; describe which clinical and laboratory features are useful for patients with blunt abdominal trauma; and adapt the management education for physicians. approach in the context of special patient and clinical circumstances. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] Wrist Injuries AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] 4. ____ List both common and rare types of bone, muscle, and ligamentous wrist injuries; explain the indications for radiography and other should only claim credit commensurate with the 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] diagnostic studies in the scenario of wrist injury; describe how mechanism of injury as well as patient age and occupation affect wrist injuries extent of their participation in the activity. 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] and their management; and discuss appropriate emergency management of wrist injuries, including pain management as well as Earning Credit: Practitioners who read “An indications for splinting, referral, and follow-up. Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] Please help us improve our study guide by answering the questions below. are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition 1. What clinical information did you learn that was of value to you and how did this information impact positively or change the way you care Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each for your patients?______participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] ______21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box ______with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. 2. Please provide any additional comments.______Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] ______Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. ______25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Please continue test and complete 33. [a] [b] [c] [d] [e] Email: [email protected] • Website: www.ebmedicine.net Evaluation Form on reverse side. 130 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies CME Answer Form Please print the following information clearly: Name: ______Address: ______Phone number: ______E-mail address (required): ______Please write your email address clearly. Certificates will be sent by email. If you need your certificate mailed instead of emailed, check this box: 

Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] complete this form, you will need “An Evidence- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] education for physicians. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] should only claim credit commensurate with the extent of their participation in the activity. 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] Earning Credit: Practitioners who read “An Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] 21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. 25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] Please continue test and complete 33. [a] [b] [c] [d] [e] Evaluation Form on reverse side. 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 131 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies An Evidence-Based Approach To Traumatic Emergencies CME Evaluation Form CME Answer Form Please print the following information clearly: Please record actual time spent on this activity here, if less than designated time of 16 hours: _____ Name: ______Address: ______Please take a few moments to complete this form. Your opinions will ensure continuing program relevance and quality. ______Enter the extent to which you agree with the following statements. Response codes: 5=strongly agree; 4=agree; 3=neutral; 2=disagree; 1=strongly disagree Phone number: ______1. ____ The chapters were easy and enjoyable to read. E-mail address (required): ______2. ____ The information was presented in an impartial and unbiased manner, and the authors were not biased in their discussion of any Please write your email address clearly. Certificates will be sent by email. commercial product or service. If you need your certificate mailed instead of emailed, check this box:  3. ____ Adequate faculty disclosure was given. 4. ____ This activity improved my competence. The purchaser of this book can receive free CME credit. If you are the purchaser of this book, you 5. ____ This activity improved my performance. do not need to enter your credit card information or send a check. 6. ____ This activity improved outcomes for my patients. Additional physicians can receive credit for a nominal charge of $30. Please complete this CME Answer Form and provide your credit card information below or submit a check (payable to EB Medicine). Enter the extent to which the following objectives were met for each chapter. Visa/MC/AmEx Number: ______Exp Date: ______

Neck Trauma Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] 1. ____ Describe the importance of early and appropriate airway management; describe the diagnostic approach to vascular injuries by zone of complete this form, you will need “An Evidence- injury in neck trauma; identify and provide initial management for laryngeal injury; and discuss the importance of early recognition of esoph- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each ageal trauma and the accuracy of available diagnostic modalities. chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] Orthopedic Sports Injuries This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] 2. ____ List conditions or circumstances that require orthopedic or surgical consultation or referral in patients with sports injuries; describe the appropriate treatment and disposition for common orthopedic sports injuries; describe clinical decision rules such as the Ottawa knee rules that Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] are used to determine the need for radiography; and discuss different techniques for shoulder reduction. and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] Blunt Abdominal Trauma (ACCME) through the sponsorship of EB 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] 3. ____ Name typical mechanisms of injury for solid and hollow visceral trauma; explain the appropriate diagnostic approach based upon the Medicine. EB Medicine is accredited by the ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] clinical scenario; describe which clinical and laboratory features are useful for patients with blunt abdominal trauma; and adapt the management education for physicians. approach in the context of special patient and clinical circumstances. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] Wrist Injuries AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] 4. ____ List both common and rare types of bone, muscle, and ligamentous wrist injuries; explain the indications for radiography and other should only claim credit commensurate with the 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] diagnostic studies in the scenario of wrist injury; describe how mechanism of injury as well as patient age and occupation affect wrist injuries extent of their participation in the activity. 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] and their management; and discuss appropriate emergency management of wrist injuries, including pain management as well as Earning Credit: Practitioners who read “An indications for splinting, referral, and follow-up. Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] Please help us improve our study guide by answering the questions below. are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition 1. What clinical information did you learn that was of value to you and how did this information impact positively or change the way you care Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each for your patients?______participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] ______21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box ______with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. 2. Please provide any additional comments.______Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] ______Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. ______25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Please continue test and complete 33. [a] [b] [c] [d] [e] Email: [email protected] • Website: www.ebmedicine.net Evaluation Form on reverse side. 132 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies CME Answer Form Please print the following information clearly: Name: ______Address: ______Phone number: ______E-mail address (required): ______Please write your email address clearly. Certificates will be sent by email. If you need your certificate mailed instead of emailed, check this box: 

Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] complete this form, you will need “An Evidence- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] education for physicians. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] should only claim credit commensurate with the extent of their participation in the activity. 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] Earning Credit: Practitioners who read “An Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] 21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. 25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] Please continue test and complete 33. [a] [b] [c] [d] [e] Evaluation Form on reverse side. 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 133 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies An Evidence-Based Approach To Traumatic Emergencies CME Evaluation Form CME Answer Form Please print the following information clearly: Please record actual time spent on this activity here, if less than designated time of 16 hours: _____ Name: ______Address: ______Please take a few moments to complete this form. Your opinions will ensure continuing program relevance and quality. ______Enter the extent to which you agree with the following statements. Response codes: 5=strongly agree; 4=agree; 3=neutral; 2=disagree; 1=strongly disagree Phone number: ______1. ____ The chapters were easy and enjoyable to read. E-mail address (required): ______2. ____ The information was presented in an impartial and unbiased manner, and the authors were not biased in their discussion of any Please write your email address clearly. Certificates will be sent by email. commercial product or service. If you need your certificate mailed instead of emailed, check this box:  3. ____ Adequate faculty disclosure was given. 4. ____ This activity improved my competence. The purchaser of this book can receive free CME credit. If you are the purchaser of this book, you 5. ____ This activity improved my performance. do not need to enter your credit card information or send a check. 6. ____ This activity improved outcomes for my patients. Additional physicians can receive credit for a nominal charge of $30. Please complete this CME Answer Form and provide your credit card information below or submit a check (payable to EB Medicine). Enter the extent to which the following objectives were met for each chapter. Visa/MC/AmEx Number: ______Exp Date: ______

Neck Trauma Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] 1. ____ Describe the importance of early and appropriate airway management; describe the diagnostic approach to vascular injuries by zone of complete this form, you will need “An Evidence- injury in neck trauma; identify and provide initial management for laryngeal injury; and discuss the importance of early recognition of esoph- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each ageal trauma and the accuracy of available diagnostic modalities. chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] Orthopedic Sports Injuries This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] 2. ____ List conditions or circumstances that require orthopedic or surgical consultation or referral in patients with sports injuries; describe the appropriate treatment and disposition for common orthopedic sports injuries; describe clinical decision rules such as the Ottawa knee rules that Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] are used to determine the need for radiography; and discuss different techniques for shoulder reduction. and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] Blunt Abdominal Trauma (ACCME) through the sponsorship of EB 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] 3. ____ Name typical mechanisms of injury for solid and hollow visceral trauma; explain the appropriate diagnostic approach based upon the Medicine. EB Medicine is accredited by the ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] clinical scenario; describe which clinical and laboratory features are useful for patients with blunt abdominal trauma; and adapt the management education for physicians. approach in the context of special patient and clinical circumstances. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] Wrist Injuries AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] 4. ____ List both common and rare types of bone, muscle, and ligamentous wrist injuries; explain the indications for radiography and other should only claim credit commensurate with the 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] diagnostic studies in the scenario of wrist injury; describe how mechanism of injury as well as patient age and occupation affect wrist injuries extent of their participation in the activity. 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] and their management; and discuss appropriate emergency management of wrist injuries, including pain management as well as Earning Credit: Practitioners who read “An indications for splinting, referral, and follow-up. Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] Please help us improve our study guide by answering the questions below. are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition 1. What clinical information did you learn that was of value to you and how did this information impact positively or change the way you care Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each for your patients?______participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] ______21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box ______with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. 2. Please provide any additional comments.______Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] ______Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. ______25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Please continue test and complete 33. [a] [b] [c] [d] [e] Email: [email protected] • Website: www.ebmedicine.net Evaluation Form on reverse side. 134 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies CME Answer Form Please print the following information clearly: Name: ______Address: ______Phone number: ______E-mail address (required): ______Please write your email address clearly. Certificates will be sent by email. If you need your certificate mailed instead of emailed, check this box: 

Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] complete this form, you will need “An Evidence- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] education for physicians. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] should only claim credit commensurate with the extent of their participation in the activity. 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] Earning Credit: Practitioners who read “An Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] 21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. 25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] Please continue test and complete 33. [a] [b] [c] [d] [e] Evaluation Form on reverse side. 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 135 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies An Evidence-Based Approach To Traumatic Emergencies CME Evaluation Form CME Answer Form Please print the following information clearly: Please record actual time spent on this activity here, if less than designated time of 16 hours: _____ Name: ______Address: ______Please take a few moments to complete this form. Your opinions will ensure continuing program relevance and quality. ______Enter the extent to which you agree with the following statements. Response codes: 5=strongly agree; 4=agree; 3=neutral; 2=disagree; 1=strongly disagree Phone number: ______1. ____ The chapters were easy and enjoyable to read. E-mail address (required): ______2. ____ The information was presented in an impartial and unbiased manner, and the authors were not biased in their discussion of any Please write your email address clearly. Certificates will be sent by email. commercial product or service. If you need your certificate mailed instead of emailed, check this box:  3. ____ Adequate faculty disclosure was given. 4. ____ This activity improved my competence. The purchaser of this book can receive free CME credit. If you are the purchaser of this book, you 5. ____ This activity improved my performance. do not need to enter your credit card information or send a check. 6. ____ This activity improved outcomes for my patients. Additional physicians can receive credit for a nominal charge of $30. Please complete this CME Answer Form and provide your credit card information below or submit a check (payable to EB Medicine). Enter the extent to which the following objectives were met for each chapter. Visa/MC/AmEx Number: ______Exp Date: ______

Neck Trauma Instructions for CME participants: To 1. [a] [b] [c] [d] [e] 34. [a] [b] [c] [d] [e] 1. ____ Describe the importance of early and appropriate airway management; describe the diagnostic approach to vascular injuries by zone of complete this form, you will need “An Evidence- injury in neck trauma; identify and provide initial management for laryngeal injury; and discuss the importance of early recognition of esoph- Based Approach To Traumatic Emergencies.” 2. [a] [b] [c] [d] [e] 35. [a] [b] [c] [d] [e] The test questions are included at the end of each ageal trauma and the accuracy of available diagnostic modalities. chapter. If you have any questions, please call 3. [a] [b] [c] [d] [e] 36. [a] [b] [c] [d] [e] 1-800-249-5770 or e-mail [email protected]. 4. [a] [b] [c] [d] [e] 37. [a] [b] [c] [d] [e] Orthopedic Sports Injuries This activity is eligible for CME credit through October 1, 2012. 5. [a] [b] [c] [d] [e] 38. [a] [b] [c] [d] [e] 2. ____ List conditions or circumstances that require orthopedic or surgical consultation or referral in patients with sports injuries; describe the appropriate treatment and disposition for common orthopedic sports injuries; describe clinical decision rules such as the Ottawa knee rules that Accreditation: This activity has been planned 6. [a] [b] [c] [d] [e] 39. [a] [b] [c] [d] [e] are used to determine the need for radiography; and discuss different techniques for shoulder reduction. and implemented in accordance with the 7. [a] [b] [c] [d] [e] 40. [a] [b] [c] [d] [e] Essentials and Standards of the Accreditation Council for Continuing Medical Education 8. [a] [b] [c] [d] [e] 41. [a] [b] [c] [d] [e] Blunt Abdominal Trauma (ACCME) through the sponsorship of EB 9. [a] [b] [c] [d] [e] 42. [a] [b] [c] [d] [e] 3. ____ Name typical mechanisms of injury for solid and hollow visceral trauma; explain the appropriate diagnostic approach based upon the Medicine. EB Medicine is accredited by the ACCME to provide continuing medical 10. [a] [b] [c] [d] [e] 43. [a] [b] [c] [d] [e] clinical scenario; describe which clinical and laboratory features are useful for patients with blunt abdominal trauma; and adapt the management education for physicians. approach in the context of special patient and clinical circumstances. 11. [a] [b] [c] [d] [e] 44. [a] [b] [c] [d] [e] Credit Designation: EB Medicine designates this educational activity for a maximum of 16 12. [a] [b] [c] [d] [e] 45. [a] [b] [c] [d] [e] Wrist Injuries AMA PRA Category 1 CreditsTM. Physicians 13. [a] [b] [c] [d] [e] 46. [a] [b] [c] [d] [e] 4. ____ List both common and rare types of bone, muscle, and ligamentous wrist injuries; explain the indications for radiography and other should only claim credit commensurate with the 14. [a] [b] [c] [d] [e] 47. [a] [b] [c] [d] [e] diagnostic studies in the scenario of wrist injury; describe how mechanism of injury as well as patient age and occupation affect wrist injuries extent of their participation in the activity. 15. [a] [b] [c] [d] [e] 48. [a] [b] [c] [d] [e] and their management; and discuss appropriate emergency management of wrist injuries, including pain management as well as Earning Credit: Practitioners who read “An indications for splinting, referral, and follow-up. Evidence-Based Approach To Traumatic 16. [a] [b] [c] [d] [e] 49. [a] [b] [c] [d] [e] Emergencies,” complete this CME Answer and Evaluation Form, and return it to EB Medicine 17. [a] [b] [c] [d] [e] 50. [a] [b] [c] [d] [e] Please help us improve our study guide by answering the questions below. are eligible for up to 16 hours of Category 1 18. [a] [b] [c] [d] [e] 51. [a] [b] [c] [d] [e] credit toward the AMA Physician’s Recognition 1. What clinical information did you learn that was of value to you and how did this information impact positively or change the way you care Award (PRA). Results will be kept confidential. 19. [a] [b] [c] [d] [e] 52. [a] [b] [c] [d] [e] CME certificates will be delivered to each for your patients?______participant scoring higher than 70%. 20. [a] [b] [c] [d] [e] 53. [a] [b] [c] [d] [e] ______21. [a] [b] [c] [d] [e] 54. [a] [b] [c] [d] [e] Instructions: Please fill in the appropriate box ______with the correct answer for each question. The 22. [a] [b] [c] [d] [e] 55. [a] [b] [c] [d] [e] test questions appear at the end of each chapter. 2. Please provide any additional comments.______Each question has only one correct answer. 23. [a] [b] [c] [d] [e] 56. [a] [b] [c] [d] [e] ______Upon completing the test, you may verify your 24. [a] [b] [c] [d] [e] 57. [a] [b] [c] [d] [e] answers in the back of the book. ______25. [a] [b] [c] [d] [e] 58. [a] [b] [c] [d] [e] Please make a copy of the completed answer form for your files and return this 26. [a] [b] [c] [d] [e] 59. [a] [b] [c] [d] [e] copy to the address or fax number below. 27. [a] [b] [c] [d] [e] 60. [a] [b] [c] [d] [e] 28. [a] [b] [c] [d] [e] 61. [a] [b] [c] [d] [e] 29. [a] [b] [c] [d] [e] 62. [a] [b] [c] [d] [e] 30. [a] [b] [c] [d] [e] 31. [a] [b] [c] [d] [e] 32. [a] [b] [c] [d] [e] 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Please continue test and complete 33. [a] [b] [c] [d] [e] Email: [email protected] • Website: www.ebmedicine.net Evaluation Form on reverse side. 136 5550 Triangle Parkway, Suite 150 • Norcross, GA 30092 • 1-800-249-5770 • Fax: 770-500-1316 Email: [email protected] • Website: www.ebmedicine.net An Evidence-Based Approach To Traumatic Emergencies CME Answer Form Please print the following information clearly: Name: ______Address: ______Phone number: ______E-mail address (required): ______Please write your email address clearly. Certificates will be sent by email. If you need your certificate mailed instead of emailed, check this box: 

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Please take a few moments to complete this form. Your opinions will ensure continuing program relevance and quality.

Enter the extent to which you agree with the following statements. Response codes: 5=strongly agree; 4=agree; 3=neutral; 2=disagree; 1=strongly disagree 1. ____ The chapters were easy and enjoyable to read. 2. ____ The information was presented in an impartial and unbiased manner, and the authors were not biased in their discussion of any commercial product or service. 3. ____ Adequate faculty disclosure was given. 4. ____ This activity improved my competence. 5. ____ This activity improved my performance. 6. ____ This activity improved outcomes for my patients.

Enter the extent to which the following objectives were met for each chapter.

Neck Trauma 1. ____ Describe the importance of early and appropriate airway management; describe the diagnostic approach to vascular injuries by zone of injury in neck trauma; identify and provide initial management for laryngeal injury; and discuss the importance of early recognition of esophageal trauma and the accuracy of available diagnostic modalities.

Orthopedic Sports Injuries 2. ____ List conditions or circumstances that require orthopedic or surgical consultation or referral in patients with sports injuries; describe the appropriate treatment and disposition for common orthopedic sports injuries; describe clinical decision rules such as the Ottawa knee rules that are used to determine the need for radiography; and discuss different techniques for shoulder reduction.

Blunt Abdominal Trauma 3. ____ Name typical mechanisms of injury for solid and hollow visceral trauma; explain the appropriate diagnostic approach based upon the clinical scenario; describe which clinical and laboratory features are useful for patients with blunt abdominal trauma; and adapt the management approach in the context of special patient and clinical circumstances.

Wrist Injuries 4. ____ List both common and rare types of bone, muscle, and ligamentous wrist injuries; explain the indications for radiography and other diagnostic studies in the scenario of wrist injury; describe how mechanism of injury as well as patient age and occupation affect wrist injuries and their management; and discuss appropriate emergency management of wrist injuries, including pain management as well as indications for splinting, referral, and follow-up.

Please help us improve our study guide by answering the questions below. 1. What clinical information did you learn that was of value to you and how did this information impact positively or change the way you care for your patients?______2. Please provide any additional comments.______

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