We’ve Got a Bone to Pick….! Pearls, Pitfalls & High-Yield Orthopedics Educational Objectives Upon hearing & assimilating this program, clinician will be better able to: 1. Identify each section of long-bone anatomy; 2. Identify & describe various types of fractures, including transverse, oblique, spiral, comminuted & segmental; 3. Correctly diagnose & describe pediatric fractures, including greenstick, buckle, & growth plate fractures using Salter-Harris classification; 4. Identify & describe from radiographs common hand/wrist fractures, David J. Heath, DO, MS, ATC, FAAEM ankle/foot fractures, different types of hip fractures, common spine Facility Medical Director, Emergency Medicine fractures & common shoulder fractures; Saint Joseph-London Hospital Adjunct Clinical Professor, LMU-DCOM 5. Institute appropriate treatments for each of demonstrated fractures. [email protected] Systematic Approach to PE • History – It’s ALL about that history! • Observation – Abnormalities & symmetry Long Bone • Palpation – Temperature, tenderness Anatomy • Range of Motion – PROM & AROM • Strength – Full & equal • Special Tests HOPRSS – “Provocative” tests 4 5 6 1 Description of Fractures • Open v. closed – Open = bone exposed – Closed = overlying soft tissue intact Fracture • Location (be precise) Nomenclature – Left v. right – Anatomic orientation • Proximal/distal, medial/lateral, anterior/posterior – Anatomic landmarks & name of bone • Lines 7 – See next slide 8 Lines of Fractures Position & Alignment • Transverse • Degree of fracture – Right angles to long axis – Complete v. incomplete • Oblique • Rotation – Diagonal to long axis – Fragments rotated relative to each other • Spiral – Interval v. external – Rotational force to shaft • Angulation • Comminuted – Loss of ANATOMICAL alignment in angular fashion – Bone > 2 fragments – Valgus v. varus • Segmental Describe rotation, • Displacement/shortening angulation & – Free floating central component displacement by – Loss of AXIAL alignment direction of DISTAL 9 10 – At least 2 fx lines present – Fragments shifted relative to each other segment! Descriptive Modifiers • Position overall • Intra/extraarticular Incomplete – Extends/involves articular surface • Impaction/distraction Pediatric – Shortening or widening Fractures – NO loss of alignment • Pathologic – Suspected w/ trivial trauma • Skeletal maturity – Growth plates present 11 12 2 Greenstick Fracture Buckle (Torus) Fractures • Incomplete angulated w/ cortical breech to one • Compression-type force applied to relatively soft, side of bone immature bone • Usually mid-diaphyseal • Incomplete fracture • Treatment – Bulging of cortex – Splint w/ F/U to ortho – Trabecular compression 2* axial loading to long axis – Commonly involve distal radial metaphysis • Treatment – Volar fx = Splint molded in EXTENSION Solely relying on – Dorsal fx = Removable Velcro splint 13 radiology report14 Salter-Harris Fxs 6% 75% 10% 10% 1% Infants & MOST toddlers COMMON Separated Above Lower Through Rammed Dorsal Growth Torus complications Fracture 15 SALTR ñ I to V Salter-Harris Fractures • Demographics – Most common age = 10 to 16 (80%) – Mostly males (2* delayed skeletal maturity) • Physis (growth plate) Hand & Wrist – Composed of cartilage cells (not seen on XR) – Weaker than supporting ligaments • Blood supply to GP from epiphysis – ñ epiphyseal injury = ñ growth disturbances – Type I = least growth disturbance – Type V = most growth disturbance 17 18 3 19 VOLAR DORSAL Scaphoid Fracture • Rare in kiddos • Pain in snuffbox & ulnar deviation • Imaging – 1st XR = 14% missed – 2nd XR in 7 days Most common carpal fx – Bone scan to confirm dx (62-87% of all wrist fxs) • Complication – High risk of AVN • Treatment – Nondisplaced = thumb spica splint Scaphoid Blood Supply` Lunate & Perilunate Dislocations Scaphos = peanut • Lunate – MC carpal bone to dislocate – Volar swelling w/ palpable mass – Treatment • Immediate reduction w/ surgical repair • Perilunate – Dorsal swelling w/ palpable mass – Treatment DORSAL VOLAR • Immediate reduction w/ surgical repair 24 4 Lunate Dislocation Piece of Pie Sign Spilled Teacup Sign • Abnormal triangular • Abnormal volar appearance of lunate displacement & tilt of Lunate on AP XR dislocated lunate 25 Dislocation 26 Lunate & Perilunate Dislocations Volar Dorsal Perilunate Dislocation 27 Boxers Fracture Boxers Fracture • Fracture to neck of 5th metacarpal w/ volar angulation • MOI – Punching injury • Treatment Always suspect “Fight Bite” – Closed reduction + ulnar gutter splint – Close F/U for loss of reduction Rotational displacement 29 UNACCEPTABLE! 30 5 Colles’ Fracture • Most common fracture in adults >50 yo • “Dinner fork” deformity – Distal radius at metaphysis – Dorsal displacement – Ulnar styloid fracture common • Treatment – Closed reduction + cast x 6-8 wks – Intraarticular requires surgery Complication = Median nerve injury Colles’ 31 Fracture 32 Smith Fracture • “Reverse” Colles’ fracture – Volar displacement of distal radius • Associated median nerve and flexor tendon injury • Treatment – Closed reduction Smith 33 Fracture 34 Triquetrum Fracture Triquetral Fracture • Most common dorsal chip fracture of wrist • Pain on dorsum of wrist & ulnar styloid • Painful to flexion 2nd most common carpal fracture 35 VOLAR DORSAL 6 Upper Forearm Fractures Galeazzi Fracture • Galeazzi • Distal 1/3 radial fx, usually dorsal angulation – DRUJ hurts, radial head does not • Disrupted DRUJ • Complication • Monteggia – Ulnar nerve injury – DRUJ painless, RH painful • Treatment – ORIF • Essex-Lopresti Galeazzi – BOTH DRUJ & RH painful 38 Radial fx DRUJ confidently found Ulnar fx via Lister’s tubercle 37 Monteggia Monteggia Fracture Essex-Lopresti Fracture • Apex of ulna fx points in direction of radial head • Radial head fracture dislocation • Dislocation of DRUJ • Treatment • Interosseous membrane disruption Galeazzi – ORIF Radial fx • Treatment Ulnar fx – ORIF generally needed Monteggia 39 40 Shoulder Anatomy The Shoulder 41 42 7 Shoulder Anatomy Shoulder Anatomy SITS • Supraspinatus • Infraspinatous • Teres minor • Subscapularis 43 44 Clavicle Fractures Clavicle Fractures • Most common bone fractured in children • Middle 1/3 – Most commonly fractured (75-80%) • Distal 1/3 – Associated w/ ruptured coracoclavicular jt + significant medial elevation • Treatment – Nondisplaced = sling x 3-4 wks à 3-4 wks, AROM – Displaced > 100% (nonunion 4.5%) = ORIF 45 46 Clavicle Fractures Humeral Shaft Fracture • Medial 1/3 • Most common associated injury = radial nerve – Uncommon Medial 1/3 = – Injured in 20% cases Consider – Requires STRONG forces intrathoracic – Most improve w/o intervention – Search for associated injuries trauma! – Supination weak 2* radial innervation • Indications for surgery • Complications – Displaced distal third – R/O brachial artery injury – Open – Bilateral • Treatment – Neurovascular injury – Sling & swathe IF no nerve injury! – Nerve injury = surgery 47 48 8 Humerus Fractures • Proximal humerus fracture – Injury to axillary nerve à deltoid fxn – Common w/ falls in elderly • Midshaft distal fracture – Injury to radial nerve à wrist extension + 1st web space – Consider PATHOLOGICAL fracture • Treatment Proximal – Sling & swath x 4 wks, early ROM Humeral – Surgery = compound fx or head displacement Fracture 49 50 Hip Anatomy The ! Hip 51 52 Hip Anatomy Anterior Posterior 53 54 Medial Lateral 9 Hip Fractures Hip Fractures • Intertrochanteric – Most common type • Femoral neck – Common in elderly females – Complication = aseptic necrosis • Subtrochanteric – High energy injury in young Femoral Neck Position • Short + ER + ABD Intertrochanteric Position • Short + ER 55 56 Types of Hip Fxs Subcapital Transcervical Base Neck Left Intertrochanteric 57 58 Intertrochanteric Peritrochanteric Subtrochanteric Fracture Right Left Subtrochanteric Subcapital Fracture Femoral Neck Fracture 59 60 10 The Foot & Ankle 62 Weber Classification Maisoneuvve Fracture • External ankle rotation Beware – Mortis often open or unstable litigation 2* peroneal nerve – Rupture of medial deltoid ligament injury – Proximal fibular fx • Treatment – ORIF Weber A Weber B Weber C • Inferior to tibiotalar joint • Level to tibiotalar joint • Above tibiotalar joint • No syndesmosis disruption • Partial syndesmosis • Syndesmosis disruption • Usually stable disruption • Unstable • Reduction + cast • Variable stability • Medial fx + deltoid • Occasional ORIF • May require ORIF • ORIF 63 64 Bohler’s Angle Calcaneal Fractures • Most common tarsal bone fx • MOI = compression 2* fall – Lumbosacral fxs – Contralateral calcaneus • Bohler’s angle – Normal = 20-40° – Decreased = fracture 65 66 11 5th Metatarsal Fracture • Pseudo-Jones (styloid) fracture – Avulsion fx of base of 5th metatarsal (peroneus brevis) – Inversion injury Jones Fracture • Distal to styloid process – Treatment of 5th metatarsal • Walking boot + WB as tolerated • Jones fracture – Transverse fx of proximal diaphysis – Common in athletes Jones = HIGH risk of malunion w/ running/ – Treatment jumping sports Consider even w/ • ORIF or cast NORMAL XR! 67 68 Lisfranc Injury Lisfranc Injury • Disruption of 2nd metatarsal & Lisfranc ligament • ? – Unstable " 1mm between bases of 1st & 2nd metatarsal nd • Planar ecchymosis sign 2 Metatarsal 1st Metatarsal – Bruising in plantar aspect of midfoot Lisfranc joint Lisfranc • Treatment joint complex – Nondisplaced < 1mm = NWB + splint 1st, 2nd & 3rd cuneiforms Cuboid • Reeval at 2 wks + progressive WB x 6 wks – Displaced = unstable & surgery Pain w/ torsion of midfoot