EM1Orthopedics Basic Fracture Care

1.         Define the following types of fractures and how they occur:

         a.            “Typical” fractures

         b.            Pathologic fractures

         c.            Stress fractures

         d.            Salter fractures

Zen Seeker Tinitinalli EM Fifth Edition

CLINICAL PHYSIOLOGY OF FRACTURES

The ability to properly assess and treat acutely injured patients in the emergency department depends largely on an understanding of the way fractures are created and how they heal. Practical knowledge of fracture physiology may provide the index of suspicion needed to diagnose an injury that might otherwise be missed. It may also help prevent or minimize complications and may form the basis for advising the patient regarding the outlook for ultimate recovery of function. 

How Fractures Occur

Although fractures are sometimes described in terms of the external mechanism by which they are created, they may also be thought of simply in terms of the physiologic processes involved.

“TYPICAL” FRACTURES

Most fractures are the result of significant trauma to healthy bone. The bony cortex may be disrupted by a variety of forces, including a direct blow, axial loading, angular (bending) forces, torque (twisting) stress, or a combination of these.

PATHOLOGIC FRACTURES

Fractures that occur from relatively minor trauma to diseased or otherwise abnormal bone are termed pathologic fractures. This implies that a preexisting pathologic process has weakened the bone and rendered it susceptible to fracture by forces that, under normal circumstances, would not disrupt the cortex. Common examples of such injuries are fractures through metastatic lytic lesions, fractures through benign bone cysts (as in the humerus of Little League pitchers), and—perhaps most common—vertebral compression fractures in patients with advanced osteoporosis. Numerous other disease processes may render patients susceptible to pathologic fracture.

Because these injuries are often not associated with a history of significant trauma, pathologic fractures may go undetected unless there is a preexisting index of suspicion based on the knowledge that such injuries can occur.

STRESS FRACTURES

In some cases, bone may undergo a “fatigue” fracture from repetitive forces applied before the bone and its supporting tissues have had adequate time to accommodate to such forces. An example is the insidious occurrence of a metatarsal shaft fracture in unconditioned foot soldiers (the so-called march fracture). The physiologic principle of stress fracture can be easily envisioned by anyone who has “cut” an aluminum finger splint to the desired length by bending it back and forth. The pliable metal—too hard to cut with an ordinary scissors—ultimately gives way in the face of repeated stresses requiring relatively little force.

The processes that render bone susceptible to stress fracture are not generally agreed upon. The important point is that diagnosis depends on a familiarity with the entity, because x- rays are typically negative early in the patient´s course. Early diagnosis may be purely clinical, based on the history and physical findings. Days or weeks may pass before the fracture line or new bone formation becomes visible on x-ray, ultimately confirming the suspicions of the physician who, having made the correct presumptive diagnosis, will have treated the patient appropriately from the outset.

SALTER (EPIPHYSEAL) FRACTURES

Fractures involving the physis—the cartilaginous epiphyseal plate near the ends of the long bones of growing children—are called Salter fractures after Salter and Harris, the physicians who devised the most popular method of classifying these injuries.1 The supply of new bone material needed for the elongation of bones during growth is provided by specialized cells within the physis. When growth is completed, the physis is transformed into bone, ultimately fusing with the surrounding bone and disappearing as a distinct entity. By definition, Salter fractures cannot occur in fully grown adults.

Any damage to the epiphyseal plate during a child´s growth may destroy part or all of its ability to produce new bone substance, resulting in aborted or deformed growth of the bone thereafter. The potential for growth disturbance from an epiphyseal injury is related to the number of years the child has yet to grow (the older the child, the less time remains for deformity to develop) and to the pattern of the fracture line through the epiphyseal area. Classification of Salter fractures and their clinical implications are discussed later in this chapter

Anonymous Tintinalli pg. 1739

a: “Typical” fractures    Most fractures are the result of significant trauma to healthy bone.  The bony cortex may be disrupted by a variety of forces, including a direct blow, axial loading, angular forces, torque stress or a combination of these.

b: Pathologic fractures   Fractures that occur from relatively minor trauma to diseased or otherwise abnormal bone.

c: Stress fractures    Occasionally bone may undergo a “fatigue” fracture from repetitive forces applied before the bone and its supporting tissues have had adequate time to accommodate to such forces. 

d:Salter fractures (epiphyseal)  fractures involving the physis.  These types of fractures occur only in children.  Any damage to the epiphyseal plate during a child’s growth may destroy part or all of its ability to produce new bone substance, resulting in aborted or deformed growth of the bone thereafter.

Kevin; Tintinalli 1739

1. “Typical” fractures:   A fracture that results from significan trauma that disrupts the bony cortex.  May result from direct blow, axial loading, angular bending forces, torque, stress, or a combo of all these.

2. Pathologic fractures:  Fractures that occur from relatively minor trauma to diseased or otherwise abnormal bone.   ( this implies that preexisting pathologic process has weakened the bone and rendered it susceptible to fracture by forces that, under normal circumstances, would not disrupt the cortex. 

EX:  vertebral compression fractures in patients with advanced osteoporosis. 

3. Stress fractures:  In some cases, bone may undergo a “fatigue” fracture from repetitive forces applied before tha bone and its supporting tissues have had adequated time to accommodate to such forces. 

EX:  bending a piece of metal back and forth so many times that it finally becomes weak and breaks.

4. Salter fractures:  Fractures involving the physis- the cartilaginous epiphyseal plate near the ends of the long bones of growing children. 

-         by definition, Salter fractures cannot occur in fully grown adults 

Anonymous Tintinalli 1739:

• “Typical” fractures – Most fractures are the result of significant trauma to the bone. The bony cortex may be disrupted by a variety of forces, including a direct blow, axial loading, angular forces, torque stress, or a combination of these.

• Pathologic fractures – Fractures that occur from relatively minor trauma to diseased or otherwise abnormal bone. A preexisting pathologic process has weakened the bone and rendered it susceptible to fractures. (Bone cancer…)

• Stress fractures – Bone may undergo a "fatigue" fracture from repetitive forces applied before the bone and its supporting tissue have had adequate time to accommodate such forces. An example is the metatarsal shaft fracture in unconditioned soldiers (the so-called march fracture)

• Salter fractures – Fractures involving the physis- the cartilaginous epiphyseal plate near the ends of the long bones of growing children.

Anonymous Tintinalli pg. 1740

a.)Typical Fracture- Most fractures are the result of significant trauma to healthy bone.  The bony cortex may be disrupted by a variety of forces, including, a direct blow, axial loading, bending forces, twisting stress, or a combination of both.

b.)Pathologic Fracture-Fractures that occur from relatively minimal trauma to diseased or otherwise abnormal bone.  This implies that a preexisting pathological process has weakened the bone and made it susceptible to fracture.  Examples: fractures through metastatic lytic lesions, fractures through benign bone cysts, and vertebral compression fractures in patients with osteoporosis.

c.)Stress Fractures-In this case bone undergoes fatigue from repetitive forces applied before the bone and its supporting tissues have had adequate time to accommodate to such forces.  An example is a metatarsal shaft fracture in unconditioned foot soldiers from repetitive trauma from marching or walking.

d.)Salter (epiphyseal) Fractures-Fractures involving the physis-the cartilagenous epiphyseal plate near the ends of the long bones of growing children.  The supply of new bone material needed for elongation of bones during growth is provided by specialized cells within the physis.  There are five classifications of Salter fractures:

Type 1- the entire epiphysis is broken off.

Type 2- the entire epiphysis with a portion of the metaphysis is broken off.

Type 3- A portion of the epiphysis is broken off.

Type 4- A portion of the epiphysis with a portion of the metaphysis is broken off.

Type 5- Nothing broken off.  Compression injury of the epiphyseal plate.

(Tintinalli pgs. 1739, 1734)

2.      Identify several factors that predict good bone remodeling.

Zen Seeker Tinitinalli EM Fifth Edition

Fracture Healing

The physiology of fracture healing constitutes the basis for many decisions in the emergency department. The judgment as to whether an angulated fracture requires reduction or can be left to heal as is, the choice of treatment modality in relation to the patient´s age, and the prognosis for regaining function or being left with residual deformity all require familiarity with the short- and long-term aspects of the healing process.

Fracture healing can be described in terms of three phases—the inflammatory, reparative, and remodeling— each of which gradually blends into the next.2  

When a fracture occurs, the microscopic vessels crossing the fracture line are severed, depriving the damaged bone ends of their blood supply. In the ensuing hours and days, the bone ends necrose, triggering a classic inflammatory response. This early phase is brief but creates the tissue environment for the most predominant aspect of fracture healing: the reparative phase.

Soon, granulation tissue begins to infiltrate the area. Within this tissue are specialized cells capable of forming collagen, cartilage, and bone, the ingredients of callus, which gradually surrounds the fractured ends and stabilizes them. With time, the callus becomes more densely mineralized. 

Meanwhile, the necrotic edges of the fragments are removed by osteoclasts, cells whose specific function is to resorb bone. That is why some “hairline” fractures do not appear on x-ray until days after injury. Initially invisible, the diagnostic fracture line appears only after necrotic bone has been resorbed from the area. 

The final phase of bone healing, the remodeling phase, is the longest, often lasting years. Remodeling is the tendency of bone to gradually regain its original shape and contour. During this phase, the superfluous portions of callus are resorbed, and new bone is laid down along natural lines of stress. These internal layers, easily visible in x-rays of normal bone, are the bony trabeculae. Formation of trabecular bone is a physiologically efficient process, providing maximum strength relative to the amount of bone material used.

The anticipated success of remodeling is related to a number of factors. Young children have a greater capacity for remodeling than adults do. Accordingly, their potential for residual deformity is less, other circumstances being equal. Remodeling is also related to the magnitude and direction of unreduced angulation and to the fracture´s location along the bone. Specific predictors of satisfactory remodeling include youth, proximity of the fracture to the end of the bone (but not involving the epiphyseal plate), and direction of angulation coinciding with the plane of natural joint motion.

Clinical decisions regarding the aggressiveness of fracture reduction are directly linked to a knowledge of this physiology. Angulation near the end of a long bone, for example, is more acceptable than angulation near the midshaft. Dorsal or volar angulation at the wrist has a better prognosis than ulnar or radial angulation because the natural plane of wrist motion is dorsal-volar. Mild angulation in a 2-year-old may be left to remodel on its own, whereas the same angulation in an adult may require correction.

Anonymous Tintinalli pg. 1740

Remodeling is the final phase in bone healing.  It is the tendency of bone to gradually regain its original shape and contour.  Young children have a greater capacity for remodeling that adults do.  It is also related to the magnitude (this does not include the epiphyseal plate) and direction of unreduced angulation and to the fracture’s location along the bone.    

Kevin; Tintinalli 1740

The anticipated success of remodeling is related to several facts:

-Youth

-Proximity of the fracture to the end of the bone (but not involving the epyphiseal plate.

-Direction of angulation coinciding with the plane of natural joint motion.

Anonymous Tintinalli 1740

The anticipated success of remodeling is related to a number of factors. Young have a greater capacity for remodeling than adults do. Their potential for residual deformity is less. Remodeling is also related to the magnitude and direction of undirected angulation and to the fracture's long bone. Specific predictors of satisfying bone remodel are youth, proximity of the fracture to the end of the bone, and direction of angulation coinciding with the plane of natural joint motion.

Anonymous Tintinalli pg.1740

Anticipated success of remodeling is related to several factors.  Young children have a greater capacity for remodeling than adults do, therefore, their potential for residual deformity is less.  It is also related to the magnitude and direction of unreduced angulation, and to the fractures location along the bone.  Specific predictors include: youth, proximity of the fracture to the end of the bone, and direction of angulation coinciding with the plane of natural joint motion.

3.      Define open fracture, identify an older term sometimes used, and identify the most serious complication.

Zen Seeker Tinitinalli EM Fifth Edition

ORTHOPEDIC EMERGENCIES

Some types of musculoskeletal trauma deserve special mention because a delay in their diagnosis or treatment can increase the chance of significant complications or a negative outcome.

Open Fracture

An open fracture (compound in older terminology) is a fracture associated with overlying soft tissue injury, creating communication between the fracture site and the external surface of the body. Although open fracture may initially convey the image of grossly exposed bone, the term is equally applicable to a simple puncture wound extending to the depth of an underlying fracture. Such puncture wounds may be created by external forces or by a sharp bone fragment transiently protruding through the skin before receding back beneath the surface.

The most dreaded complication of open fracture is osteomyelitis. Once established, osteomyelitis may result in months or years of pain, disability, medical therapy, surgical procedures, and ultimately amputation. Although osteomyelitis may be unavoidable in some cases, it becomes less likely when treatment is prompt and meticulous.

Open fractures are sometimes classified by severity, based on the length of the overlying laceration, extent of tissue damage, kinetic energy of the injuring force, and evidence or likelihood of significant contamination. Irrespective of these factors, any open fracture should be promptly and carefully treated. Elements in the care of open fractures are described later in this chapter.

Anonymous Tintinalli, p. 1740: 

An open fracture (“compound” in older terminology) is a fracture associated with overlying soft

tissue injury, creating communication between the fracture site and the external surface of the

body.  The most dreaded complication of open fracture is osteomyelitis. 

Kevin; Tintinalli 1740

Open Fracture:  is a fracture associated with overlying soft tissue injury, creating communication between the fracture site and the external surface of the body.  ***Although open fracture may initially convey the image of grossly exposed bone, the term is equally applicable to a simple puncture wound extending to the depth of an underlying fracture. 

Anonymous Tintinalli 1740

Open Fracture: An open fracture (compound in older terminology) is a fracture associated with overlying soft tissue injury, creating communication between the fracture site and the external surface of the body. A simple puncture wound extending to the depth of an underlying fracture is an open fracture.
The most dreadful complication of open fracture is osteomyelitis.

Anonymous Tintinalli pg.1740

An open fracture (compound in older terminology) is a fracture associated with overlying soft tissue injury.  The fracture creates an opening in the skin ranging from grossly exposed bone to a simple puncture.  The most serious complication is osteomyelitis.

4.      Define dislocation and subluxation.  Explain why these injuries need to be treated emergently.

Zen Seeker Tinitinalli EM Fifth Edition

Dislocation and Subluxation

A joint is dislocated when the articular surfaces of the bones that normally meet at the joint are completely out of contact with one another. This is distinct from subluxation, a condition in which the articular surfaces are only partially out of contact.

The urgency of treating dislocated joints is based on several factors. One is the potential for neurologic or circulatory compromise. The neurovascular bundle passing close to the affected joint is typically “kinked” around the deformity associated with the dislocation. Persistence of this condition can result in a neurologic or vascular deficit that may be temporary if the deformity is reduced promptly but irreversible if treatment is delayed.

Another consideration is that, the longer a joint has been dislocated, the more difficult it may be to reduce and the more likely it is to be unstable after reduction. This is probably due at least in part to edema, muscle spasm, and other tissue changes that increase over time.

Dislocation of the hip carries its own particular urgency in addition to those mentioned above: the danger of avascular necrosis of the femoral head. Avascular necrosis occurs because much of the blood supply to the femoral head is delivered through vessels that emerge from the acetabulum. When the joint is dislocated, circulation to the femoral head is disrupted. At some point, the vascular insult becomes irreversible, and bony necrosis is the ultimate result. Although aseptic necrosis may occur despite the physician´s best efforts, its likelihood increases with the time delay until reduction

Anonymous Tintinalli, p. 1740: 

A joint is dislocated when the articular surfaces of the bones that normally meet at the joint are completely out of contact with one another.  This is distinct from subluxation, a condition in which the articular surfaces are only partially out of contact.  The urgency of treating dislocated joints is based on several factors; one is the potential for neurologic or circulatory compromise.  Another consideration is that the longer a joint has been dislocated, the more difficult it may be to reduce and the more likely it is to be unstable after reduction. 

Kevin; Tintinalli 1740

A joint is dislocated when the articular surfaces of the bones that normally meet at the joint are completely out of contact with one another.  This is distinct from subluxation a condition in which the articular surfaces oare only partially out of contact

Anonymous

• Dislocation: A joint is dislocated when the articular surfaces of the bones that normally meet at the join are completely out of contact with one another.

• Subluxation: A subluxation is a condition in which the articular surfaces are only partially out of contact.

• The urgency of treating these types of injuries is based on several factors. The first is neurologic or circulatory compromise. The neurovascular bundle passing close to the affected joint is kinked around the deformity of the joint, which can lead to a neurolgic or circulatory deficit.

• The longer a joint has been dislocated, the more difficult it may be to reduce and the more likely it is to be unstable.

• Dislocation of the hip carries with it avascular necrosis of the femoral head.

Anonymous Tintinalli pg. 1740

Dislocation- Occurs when the articular surfaces of the bones that normally meet at the joint are completely out of contact with one another.  The potential for neurologic and circulatory compromise makes this condition emergent.  The neurovascular bundle can be “kinked.”

Subluxation- Occurs when the articular surfaces of the bones that normally meet at the joint are partially out of contact.  The potential for neurologic and circulatory compromise is again a concern.

5.      Explain why the joint above and below an injury should be x-rayed and why children often need comparison views. 

Zen Seeker Tinitinalli EM Fifth Edition

RADIOLOGIC EVALUATION

The area x-rayed and the particular views ordered should be based on the history and physical examination, rather than simply on where the patient reports subjective pain. The joint above and the joint below a fracture should be included on the films because injury at the proximal or distal joint may coexist with long-bone fractures.

Injuries that may require special views to be visualized include acromioclavicular separation, fracture of the scaphoid, posterior shoulder dislocation, and sternoclavicular dislocation. That is why formulation of a presumptive diagnosis prior to x-ray is crucial. The physician may never order the specialized views needed to demonstrate a particular injury unless he or she has already anticipated the injury by virtue of the history and physical examination.

Children who have sustained trauma at or near a joint may need comparison studies of the opposite extremity to differentiate fracture lines from normal epiphyseal plates or ossifying growth centers. This is particularly true for the pediatric elbow, which typically exhibits six separate ossification centers sequentially as the child grows.

Although the physician may be tempted to base diagnostic and treatment decisions on the radiologist´s written report, this is not advisable for at least two reasons. First, a report of negative findings does not rule out significant injury. Fractures of the radial head, scaphoid, or metatarsal shaft, for example, may initially be undetectable on x-ray, even when special views are taken. Second, the terminology used by radiologists to describe malposition of fracture fragments or disrupted joints is often different from the terminology used by orthopedists. Because the emergency physician will often be conferring with an orthopedist regarding the initial management of a patient, and because this interaction commonly involves describing the radiologic appearance of a patient´s injury, it is important that the two physicians “speak the same language.” This might not be achieved by simply relaying the radiologist´s written description.

Anonymous

The joint above and the joint below a fracture should be included on the films because injury at the proximal or distal joint may coexist with long-bone fracture.

Children may need comparison views of the opposite extremity to differentiate fracture lines from normal epiphyseal plates or ossifying growth centers. Tintinalli, p.1742

Kevin; Tintinalli 1742

Because injury at the proximal or distal joint may coexist with long-bone fractures. 

Children need comp views of the opposite extremity  to differentiate fracture lines from normal epiphyseal plates or ossifying growth centers.  This is especially true for the pediatric elbow which typically exhibits six separate ossification centers. 

Anonymous  Tintinalli 1742

• The joint above and below the fracture should be included on the films because of injury at the proximal or distal joint may coexist with long-bone fractures.

• Injuries may require special vies to be visualized including AC separation, scaphoid fracture, sternoclavicualr dislocation, and posterior shoulder dislocation.

• Children who have sustained trauma at or near a joint may need comparison studies of the opposite extremity to differentiate fracture lines from normal growth plate lines.

Anonymous Tintinalli pg.1742

The joint above and below the injury or fracture should be x-rayed because injury at the proximal or distal joint may coexist with long bone fractures.  Children need comparison views to differentiate fracture lines from normal epiphyseal plates or ossifying growth centers.

6.      Explain how x-rays are described according to location of the fracture.

Zen Seeker Tinitinalli EM Fifth Edition

Describing Radiographs

When orthopedic consultation is indicated, proper management of the patient may rest on the emergency physician´s accurate description of the x-ray. Often the narrative will influence the orthopedist´s decision regarding the need for hospital admission and whether surgical versus nonsurgical management is warranted. In essence, the emergency physician should be able to transmit a virtual copy of the x-ray by means of verbal description.

There are various ways of classifying or categorizing fractures. The method presented here is intended to be the most practical from the standpoint of effective communication with a consultant who is not physically present.3

LOCATION OF THE FRACTURE

Typical reference points used by orthopedists to describe the location of a fracture along the shaft of a long bone are the midshaft, the junction of the proximal and middle thirds, and the junction of the middle and distal thirds. Any fracture more proximal or distal than this may be localized in terms of its distance, in centimeters, from the bone end.

When a proximal or distal fracture extends into the adjacent joint, it is termed intraarticular. Intraarticular fractures have special significance because disruption of the joint surface may warrant surgery to restore the joint´s contour and prevent subsequent traumatic arthritis. This feature of a fracture line, if present, constitutes important information.

Anatomic bony reference points should be cited when applicable. A fracture just above the condyles of the distal humerus or femur, for example, is most precisely called a supracondylar fracture. A fracture running from the greater to the lesser trochanter of the proximal femur is an intertrochanteric hip fracture, whereas a fracture just below the trochanters is subtrochanteric, and a fracture just above is said to involve the femoral neck. The area at or proximal to the coronoid process of the ulna is the olecranon and should be referred to as such, rather than simply the proximal ulna. Other bony landmarks include the radial head (proximal), radial styloid (distal), and greater tuberosity of the humerus. Numerous additional examples exist

Zen Seeker Tintinalli 1743

Typical reference points used by orthopedists to describe the location of a fracture along the shaft of a long gone are the midshaft, the junction of the proximal and middle thirds, and the junction of the middle and distal thirds.  Any fracture more proximal or distal than this may be localized in terms of its distance, in centimeters, from the bone end.

            When a proximal or distal fracture extends into the adjacent joint, it is termed intraarticular.  Inraarticular fractures have special significance because disruption of the joint surface may warrant surgery to restore the joint’s contour and prevent subsequent traumatic arthritis.  This feature of a fracture line, if present, constitutes important information.

            Anatomic bony reference points should be cited when applicable.  A fracture just above the condyles of the distal humerus or femur, for example, is most precisely called a supracondylar fracture.  A fracture running from the greater to the lesser trochanter of the proximal femur is an introchanteric hip fracture, whereas a fracture just below the trochanters is subtrochanteric, and a fracture just above is said to involve the femoral neck.  The area at or proximal to the coronoid process of the ulna is the olecranon and should be referred to as such, rather than simply the proximal ulna.  Other bony landmarks include the radial head (proximal), radial styloid (distal), and greater tuberosity of the humerus.  Numerous additional examples exist.

Anonymous

Reference points describe location of a Fx along the shaft of a long bone: midshaft, junction of proximal and middle thirds, and junction of middle and distal thirds.  Any Fx more proximal or distal than this may be localized in terms of its distance in cm from bone end.  Fx extending into adjacent joint is termed intraarticular (no hyphen, one word), and disruption of joint surface may warrant surgery.  Anatomic bony reference points are cited:  Fx just above condyles of distal humerus or femur = supraconylar Fx.  If it runs from greater to lesser trochanter of proximal femur, it’s called intertrochanteric hip Fx.  Fx just below trochanters = subtrochanteric, fx just above is said to involve femoral neck.  Fx @ proximal ulna is called olecranon Fx.  Other examples exist, but the book indicates you just look them up as needed.  The point is to use specific rather than general location indicators for fractures.

VB. Tintinalli pg 1734

Described according to the location of the bone.  Midshaft, Junction of proximal and middle thirds, and the junction of the middle and distal thirds.  Any fracture more proximal or distal should be localized in terms of centimeters from the bone ends. If fracture extends to adjacent joint then it is intraarticular.  Whenever possible use bone landmarks (epicondyle, trochanter, neck, olecronon).

Anonymous Tintinalli 1743-1745.

• Open vs. Closed fractures: This aspect of an injury is among the most important.

• Location of the fracture:

  • Typical reference points used by the orthopedist to describe the location of the fracture along the shaft of the fracture are the midshaft, the junction of the proximal and middle thirds, and the junction of the middle and distal thirds. Any fracture more proximal or distal to this may be localized in terms of its distance, in centimeters, from the bone end.

  • Anatomic bony reference points should always be cited when applicable.  Orientation of the fracture line - Refer to fig 259-1 on page 1743

• Torus and greenstick fractures are most exclusively seen in children.

• Displacement refers to the position of the fracture fragments as non-concentric or offset from each other. It is expressed in terms of measurement (4-mm displacement) or in terms of the percent of the width of the bone (50% displacement or complete displacement).

• Shortening is the amount by which bone length has been reduced and is expressed in millimeters or centimeters

• Angulation is expressed as direction and amount.

• Rotational Deformity is the extent of which the distal fragment is twisted on its own axis relative to the proximal fragment-it is generally not measurable on x-ray.

• Fractures combined with dislocation or subluxation are described as fracture-dislocations, or fracture-subluxations.

• Salter fractures are described in reference to what is broken off (table 259-2 Pg 1745)

Salter Type – What is broken off

•        I - The entire epiphysis

•        II - The entire epiphysis with a portion of the metaphysis

•        III - A portion of the epiphysis

•        IV - A portion of the epiphysis with a portion of the metaphysis

•        V - Nothing: broken off" compression injury of the epiphyseal plate

Anonymous Tintinalli pg. 1743

Typical reference points used to describe the location of a fracture along the shaft of a long bone are the midshaft, the junction of the proximal and middle thirds, and the junction of the middle and distal thirds.  Any fracture more proximal or distal than this may be localized in terms of its distance, in centimeters, from the bone end.  

When a proximal or distal fracture extends into the adjacent joint, it is termed intraarticular.

Anatomic bony references should be used when applicable.  Examples: A fracture just above the condyles of the distal humerus or femur is called a supracondylar fracture.  A fracture just below the trochanters is termed subtochanteric.

7.      Be able to describe the orientation of the fracture line when shown the drawings in Tintinalli Fig. 259-1.

Zen Seeker Tinitinalli EM Fifth Edition

ORIENTATION OF THE FRACTURE LINE

The most common orientations of fracture lines are illustrated in Fig. 259-1. Torus and greenstick fractures are seen almost exclusively in young children, whose bones are more pliable than those of adults. Note the segmental fracture, which is commonly described incorrectly as a comminuted fracture. To an orthopedist, the term comminuted implies splintering or shattering. A single large free-floating segment of bone between two well-defined fracture lines is a segmental fracture.

Zen Seeker Tintinalli 1743

The most common orientations of fractures lines are illustrated in Fig 259-1.  Torus and greenstick fractures are seen almost exclusively in young children, whose bones are more pliable than those of adults.

Note the segmental fracture, which is commonly described incorrectly as a comminuted fracture.  To an orthopedist, the term comminuted implies splintering or shattering.  A single large free-floating segment of bone between two well-defined fracture lines is a segmental fracture.

Figure 259-1 fracture line orientation:

Anonymous Fig. 259-1.

Umm, it is probably best to take a look at figure 259-1 on page 1743 of Tintinalli.  We need to recognize the differences between:

A.     Transverse

B.     Oblique

C.     Spiral

D.     Comminuted

E.      Segmental

F.      Torus

G.   Greenstick

VB. Tintinalli pg 1743

Transverse/ oblique/ spiral/ comminuted/ segmental/ torous/ greenstick

Anonymous Tintinalli p. 1743

The most common orientation of fracture lines is illustrated in Fig. 259-1. Torus and greenstick fractures are seen almost exclusively in young children, whose bones are more pliable than adults. Note the segmental fracture, which is commonly described the incorrectly as a comminuted fracture. To an orthopedist, the term comminuted implies splintering or shattering. A single large free-floating segment of bone between two well-defined fracture lines is a segmental fracture.

Anonymous Tintinalli Fig. 259-1, pg.1743

a.       Transverse fracture- break in the shaft of a bone across its long axis.

b.      Oblique fracture-  oblique break in the shaft of a bone across its long axis.

c.       Spiral fracture- produced by twisting stress along the length of a bone.

d.      Comminuted fracture- splintering or shattering of the bone.

e.       Segmental fracture- a single large free-floating segment of bone b/w two well-defined fracture lines.

f.        Torus fracture- generally in children, from reaching out to cushion a fall.

g.       Greenstick fracture- generally in children.  Only one side of the shaft is broken.

8.      Describe how displacement and separation are measured, and be able to describe the fractures in Tintinalli Fig. 259.2.

Zen Seeker Tinitinalli EM Fifth Edition

Fracture displacement and separation. A. No displacement, slight separation. B. Fifty percent dorsal displacement. C. Complete dorsal displacement. D. Nondisplaced, no separation. E. A 4-mm separation.

DISPLACEMENT AND SEPARATION

Displacement refers to the position of the fracture fragments as nonconcentric or offset from each other. It is expressed in terms of direct measurement (4-mm displacement) or in terms of the percent of the width of the bone (e.g., 50 percent displacement or complete displacement). The direction of displacement is based on the position of the distal fragment in relation to the proximal.

Displacement should not be confused with separation, which is the distance two fragments have been pulled apart. Figure 259- 2 illustrates principles of displacement and separation.

Zen Seeker Tintinalli 1743

Displacement refers to the position of the fracture fragments as nonconcentric or offset from each other.  It is expressed in terms of direct measurement (4-mm displacement) or in terms of the percent of the widths of the bone (e.g., 50 percent displacement or complete displacement).  The direction of the displacement is based on the position of the distal fragment in relation to the proximal.

            Displacement should not be confused with separation, which is the distance two fragments have been pulled apart.  Figure 259-2 illustrates principles of displacement and separation.

Anonymous Fig. 259.2.

Displacement- refers to the position of the fracture fragments as nonconcentric or offset from each other. Expressed in terms of direct measurement (ie 4mm displacement) or in terms of the percent of the width of the bone (ie 50% displacement).

Separation- refers to the distance two fragments have been pulled apart. Expressed as direct measurement of distance from distal end of proximal fragment to proximal end of distal fragment. Tintinalli, pp 1743-1744

VB. Tintinalli pg 1744

Displacement- amount of offsetting of segments.  Measured in terms of direct distance.in (mm) or degree of offset  (%)

Seperation- distance two segments have been pulled apart.

Anonymous Tintinalli p. 1743

Displacement refers to the position of the fracture fragments as non-concentric or offset from each other. It is expressed in terms of the percent of the width of the bone (e.g., 50% displacement or complete displacement). The direction of the displacement is based on the position of the distal fragment in relation to the proximal. Displacement should not be confused with separation, which is the distance two fragments have been pulled apart. Fig 259-2 illustrates principles of displacement and separation.

Anonymous Tintinalli fig.259-2 pg.1744

Displacement- refers to the position of the fracture fragments as nonconcentric or offset from each other.  It is expressed in terms of direct measurement. Ex: 4mm displacement or in terms of the width of the bone. Ex: 50 % displacement or complete displacement.

Separation- the distance two fragments have been pulled apart.  Separation is measured the same way as displacement.

9.      Be able to measure shortening that can occur in a fracture.  Also describe what is meant by impaction and overriding. 

Zen Seeker Tinitinalli EM Fifth Edition

Shortening at fracture site. A. Complete displacement with overriding. B. Impaction. In both cases, the width of the shaded area represents the amount of shortening.

SHORTENING

Shortening is the amount by which the bone´s length has been reduced and is expressed in millimeters or centimeters. Shortening can occur by impaction (telescoping of the fragments into one another) or by the overlap of two completely displaced fragments (Fig. 259-3). The latter is referred to by some orthopedists as overriding. Because an x-ray affords no depth perception, a fracture that appears impacted on one view must also be visualized at an angle 90° from the first to differentiate it from a fracture whose ends are completely displaced and overriding.

Depending on the location of the fracture and the age of the patient, shortening may have long-range functional implications and may have to be corrected by closed manipulation or by surgery.

Zen Seeker Tintinalli 1744

Shortening is the amount by which the bone’s length bas been reduce and is expressed in millimeters or centimeters.  Shortening can occur by impaction (telescoping of the fragments into one another) or by the overlap of two completely displaced fragments (fig 259-3).  The latter is referred to by some orthopedists as overriding.  Because an x-ray affords no depth perception, a fracture that appears impacted on one view must also be visualized at an angle 90° from the first to differentiate it from a fracture whose ends are completely displaced and overriding.

            Depending on the location of the fracture and the age of the patient, shortening may have long-range functional implications and may have to be corrected by closed manipulation or by surgery.

Anonymous

Shortening- amount by which the bone’s length has been reduced. Expressed in millimeters or centimeters.

Impaction- telescoping of fragments onto one another.

Overriding- overlap of two completely displaced fragments. Tintinalli, p. 1744

VB. Tintinalli pg 1744

Shortning- amount by which bone length has been reduced in mm or cm

Impaction- telescoping of segments into eachother

Over riding- overlapping of completely displaced segments.

Anonymous  Tintinalli p. 1744

Shortening is the amount by which the bone’s length has been reduced and is expressed in mm or cm.  Shortening can occur by impaction (telescoping of the fragments into one another) or by the overlap of two completely displaced fragments (Fig 259-3). The latter is referred by to by some orthopedists as overriding. Because an x-ray affords no depth perception, a fracture that appears impacted on one view must be visualized at an angle of 90 degrees from the first to differentiate it from a fracture whose ends are completely displaced and overriding (also seen in Fig 259-3). Depending on the location of the fracture and the age of the patient, shortening may have long-range functional implications and may have to be corrected by closed manipulation or by surgery.

Anonymous Tintinall pg.1744

Shortening is the amount by which the bone’s length has been reduced and is expressed in millimeters or centimeters.  Shortening can occur by impaction, which is the telescoping of the fragments into one another, or by overriding, which is the overlap of two completely displaced fragments.

10.    Explain how to measure angulation, describing the deviation of the distal segment, and other anatomical terms that can be used depending on the location. 

Zen Seeker Tinitinalli EM Fifth Edition

Fracture angulation. All figures depict 30° dorsal angulation. A. and B. Direction is based on the apex of the angle drawn below the figures. C. Direction is based on the direction of the terminal fragment

ANGULATION

Angulation is expressed in terms of two parameters: direction and amount (Fig. 259-4). Quantifying the angulation is relatively simple. The physician need only estimate the amount of “unbending” (expressed in degrees) that would be required to make the fragments parallel.

Describing the direction of angulation is more difficult because the terminology is less consistent among clinicians. Generally, when a fracture is near the midshaft of a long bone, the direction of angulation is the direction of the apex of the angle formed by the two fragments. Figures 259-4A and B both represent 30° of dorsal angulation. When a fracture is located near the end of a bone, however, angulation is described in terms of the direction the terminal fragment is deviated. Figure 259-4C also represents 30° of dorsal angulation, even though the apex of the angle formed by the fragments is pointing in the opposite direction from that in the preceding figures. If there is a possibility of ambiguity in the description, specifying the direction of deviation of the distal fragment can usually resolve it.

Depending on the anatomic area involved, direction of angulation may be expressed as radial or ulnar, dorsal or volar, anterior or posterior, or lateral or medial.

Zen Seeker Tintinalli 1743

Angulation is expressed in terms of two parameters: direction and amount (fig 259-4).  Quantifying the angulation is relatively simple.  The physician need only estimate the amount of “unbending” (expressed in degrees) that would be required to make the fragments parallel.

             Describing the direction of angulation is more difficult because the terminology is less consistent among clinicians.  Generally, when a fracture is near the midshaft of a long bone, the direction of angulation is the direction of the apex of the angle formed by the two fragments.  Figures 259-4A and B both represent 30° of dorsal angulation.  When a fracture is located near the end of a bone, however, angulation is described in terms of the direction the terminal fragment is deviated.  Figure 259-4C also represents 30° of dorsal angulation, even though the apex of the angle formed by the fragments is pointing in the opposite direction from that in the preceding figures.  If there is a possibility of ambiguity in the description, specifying the direction of deviation of the distal fragment can usually resolve it.

            Depending on the anatomic area involved, direction of angulation may be expressed as radial or ulnar, dorsal or volar, anterior or posterior, or lateral or medial.

Anonymous Tintinalli, pgs. 1744-5

See Fig. 259-4 to best understand this concept.  Angulation is expressed in terms of two parameters: direction and amount.  Quantifying the angulation is relatively simple.  The physician need only estimate the amount of “unbending” (expressed in degrees) that would be required to make the fragments parallel.

Describing the direction of angulation is more difficult because the terminology is less consistent among clinicians.  Generally, when a fracture is near the midshaft of a long bone, the direction of angulation is the direction of the apex of the angel formed by the two fragments.  When a fracture is located near the end of a bone, however, angulation is described in terms of the direction the terminal fragment is deviated.  If there is a possibility of ambiguity in the description, specifying the direction of deviation of the distal fragment can usually resolve it.

Depending on the anatomic area involved, direction of angulation may be expressed as radial or ulnar, dorsal or volar, anterior or posterior, or lateral or medial.

VB. Tintinalli pg 1174

Described in terms of direction and amount. 

Amount-  estimated by degrees needed to bring bone to parallel position. 

Direction- depending on area involved, direction may be expressed as radial or ulnar, dorsal or volar, anterior or posterior, or lateral or medial.  When Fx is near end of bone, angulation described in terms of direction of terminal fragment deviation.

Anonymous Tintinalli p. 1744

Angulation is expressed in terms of two parameters: direction and amount (Fig. 259-4). Quantifying the angulation is relatively simple. The physician need only estimate the amount of “unbending” (expressed in degrees) that would be required to make the fragments parallel. Describing the direction of angulation is more difficult because the terminology is less consistent among clinicians. Generally, when a fracture is near the midshaft of a long bone, the direction of angulation is the direction of the apex of the angle formed by the two fragments. Fig 259-4A and B both represent 30 degrees of dorsal angulation. When a fracture is located near the end of a bone, however, angulation is described in terms of the direction the terminal fragment is deviated. Fig C also represents 30 degrees of dorsal angulation, even though the apex of the angle formed by the fragments is pointed in the opposite direction from that in the preceding figures. If there is a possibility of ambiguity in the description, specifying the direction of deviation of the distal fragment can usually resolve it. Depending on the anatomic area involved, direction of angulation may be expressed as radial or ulnar, dorsal or volar, anterior or posterior, or lateral or medial.

Anonymous Tintinalli pg.1744

Angulation- it is expressed in two parameters: direction and amount.  To quantify the angualtion the provider needs to estimate the amount of “unbending” (expressed in degrees) that would be required to make the fragments parallel.  Describing the direction is a bit more difficult.  When a fracture is near the midshaft of a long bone, the direction of angulation is the direction of the apex of the angle formed by the two fragments.(see fig 259-4, pg. 1744)

When the fracture is located near the end of the bone the angulation is described in terms of the direction of the terminal fragment is deviated.  

11.    Describe what is meant by rotation and how it is assessed.

Zen Seeker Tinitinalli EM Fifth Edition

ROTATIONAL DEFORMITY

Rotational deformity—the extent to which the distal fracture fragment is twisted on its own axis relative to the proximal fragment—is generally not measurable on x-ray and sometimes not even radiologically apparent. This element of fracture description depends on physical examination. Its detection is particularly important in the phalanges of the fingers, where, if rotational deformity goes unrecognized and uncorrected, the affected finger will always be malaligned when the hand is closed.

Anonymous Tintinalli pg. 1745

Rotational deformity is the extent to which the distal fracture fragment is twisted on its own axis relative to the proximal fragment. Often not able to be assessed by x-ray. This is most often assessed by physical exam.

Jennyb Tintinalli p 1745

         I believe the question is referring to rotational deformity.  Rotational deformity is the extent  to which the distal fracture is twisted on its own axis relative to the proximal fragment.   Sometimes it is not radiologically apparent, and is only apparent through physical exam.

Vb. Tintinalli pg 1745

Extent to which a fracture fragment is twisted on its own axis relative to the proximal fragment.

Anonymous Tintinalli p. 1745

Rotational deformity-the extent to which the distal fracture fragment is twisted on its own axis relative to the proximal fragment-is generally not measurable on x-ray and sometimes not even radiologically apparent. This element of fracture description depends on the physical examination. Its detection is particularly important in the phalanges of the fingers, where, if rotational deformity goes unrecognized and uncorrected, the affected finger will always be malaligned when the hand is closed.

Anonymous Tintinalli pg.1745

Rotational deformity is the extent to which the distal fracture fragment is twisted on its own axis relative to the proximal fragment.  This is generally not measurable on x-ray and sometimes not even radiologically apparent.  Assessment depends on physical examination.

 12.   Be able to identify the type of Salter fracture if shown the drawings in Tintinalli Fig. 259-6.

Zen Seeker Tinitinalli EM Fifth Edition

Epiphyseal fractures based on Salter-Harris classification.

SALTER FRACTURES

The physiology of Salter fractures—fractures involving the epiphyseal plate at the end of the long bone of a growing child—has already been discussed. Salter fractures are classified into five types, based on the pattern of the fracture line. Because the type generally correlates with the potential for future growth disturbance (and, consequently, with the aggressiveness of treatment required), the ability to classify such injuries based on their x-ray appearance is important. 

Perhaps the easiest way to remember the Salter classification system is to think of these injuries not in terms of where the fracture line runs, but in terms of what has been broken off. Figure 259-5 illustrates the anatomy involved. Table 252-2 describes the five types of Salter fractures, which are illustrated in Fig. 259-6. The potential for growth disturbance is least for type I and increases with the classification number, the worst prognosis being associated with type V injuries.

Type I and type V Salter fractures may be radiologically undetectable. Type I injuries usually involve little or no separation of the epiphysis from the rest of the bone, and the lucent fracture line is not visible along the equally lucent epiphyseal plate. If the epiphysis and plate slip transversely along the end of the shaft, the abnormal position will be seen on x-ray, but slippage does not always occur. Diagnosis of acute Salter I fractures is usually clinical, based on the presence of swelling and tenderness in the region of the physis.

Type V injuries may be evident only retrospectively, when growth disturbance first begins to appear. At time of initial presentation, however, a history of a significant axial loading force, coupled with significant tenderness in the area of the epiphyseal plate, should suggest the possibility of a type V injury. Such children should be immobilized and referred for orthopedic follow-up.

Anonymous Fig. 259-6.

Once again a picture is worth a thousand words. In general, this type of fx involves the growth plates + there are 5 classifications that are illustrated + explained in Tintinalli p.1745.

Jennyb Tintinalli p 1745

            Here’s a description of the drawings on page 1745

Salter Type                             What is Broken Off

            I                                   The entire epiphysis

            II                                  The entire epiphysis with a portion of the metaphysis

            III                                A portion of the epiphysis

            IV                                A portion of the epiphysis& a portion of the metaphysis

            V                                 Nothing broken off, a compression fracture of the plate 

Vb. Tintinalli pg 1745

Affecting the epiphyseal plate at bone ends of growing children.

Type:

I-           entire epiphysis

II-        entire epiphysis with a portion of the metaphysic

III-      portion of epiphysis

IV-     portion of the epiphysis with a portion of the metaphysic

V-        nothing “broken off”.  Compression injury of the epiphyseal plate.

Anonymous Tintinalli p. 1745

Fractures involving the epiphyseal plate at the end of a long bone of a growing child. Salter fractions are classified into five types:

I.                    The entire epiphysis is broken off.

II.                 The entire epiphysis with a portion of the metaphysic is broken off.

III.               A portion of the epiphysis is broken off.

IV.              A portion of the epiphysis with a portion of the metaphysic is broken off.

V.                 Nothing “broken off,” compression injury of the epiphyseal plate.

Anonymous Tintinalli fig. 259-6, pg.1745

Salter fractures involve the epiphyseal plate at the end of long bones in a growing child.  There are five classifications of Salter fractures based on fracture lines:

Type 1- The entire epiphysis is broken off.

Type 2- The entire epiphysis with a portion of the metaphysis is broken off.

Type 3- A portion of the epiphysis is broken off.

Type 4- A portion of the epiphysis with a portion of the metaphysis is broken off.

Type 5- Nothing is broken off.  Compression injury of the epiphyseal plate.

13.    Explain the importance of reducing a fracture deformity and how it is done when the fracture is near the midshaft of a long bone.

Zen Seeker Tinitinalli EM Fifth Edition

Reducing Fracture Deformity

The long-term purpose of reducing significant deformity associated with fractures is, of course, restoration of normal appearance and function of the extremity. However, there are also short-term reasons for reducing deformity early in the patient´s course, including (1) alleviating pain, (2) relieving the tension on nerves or vessels that may be stretched as they pass over the deformity, (3) eliminating or significantly minimizing the possibility of inadvertently converting a closed fracture to an open one when the skin is tented by a sharp bony fragment, and (4) restoring circulation to a pulseless distal extremity.

After the patient has been sedated, deformity at or near the midshaft of a long bone is usually easy to reduce with gradual, steady longitudinal traction. Any rotational deformity should be corrected only after the angular component has been addressed and should be performed while traction is maintained. If reduction is performed as a definitive procedure prior to immobilization, attention to rotational deformity is particularly important because of its profound effect on ultimate function. As discussed earlier, rotational deformity is much easier to appreciate by examining the patient than by examining the x- ray.

The nearer the deformity is to a joint, the more difficult it may be to correct and the more specialized the reduction maneuver may have to be. Who performs the procedure, the emergency physician or the orthopedist, is determined by a variety of circumstances, some of which may be specific to the particular practice environment. When deformity is associated with circulatory deficit, a true emergency exists, and the anticipated delay until reduction should be considered.

Anonymous Tintinalli, pp. 1746.

a)      Alleviating pain

b)      Relieving the tension on nerves or vessels that may be stretched as they pass over the deformity

c)      Eliminating or significantly minimizing the possibility of inadvertently converting a closed fracture to an open one when the skin is tented by a sharp bony fragment.

d)      Restoring circulation to a pulseless distal extremity.

-After the patient has been sedated, deformity at or near the midshaft of a long bone is usually easy to reduce with gradual, steady longitudinal traction.  Any rotation deformity should be corrected only after the angular component has been addressed and should be preformed while traction is maintained.

Jennyb Tintinalli p. 1746

         The long term importance of reducing a fracture is for the restoration of normal appearance and function of the extremity.  Short term reasons are:

         1.  Alleviate pain

         2.  Relieve tension of nerves or vessels that may be stretched over the deformity.

         3.  Minimize inadvertent conversion of a closed fracture to an open one.

         4.  Restore circulation to a pulseless extremity.

         Given a deformity near the midshaft of a long bone, the patient should be sedated then the fracture can be reduced with gradual steady longitudinal traction.

Vb. Tintinalli pg 1746

Reduction is done to restore normal appearance and function of extremity, alleviate pain, relieve tension on nerves or vessels, prevent further damage or advancement of closed fracture to open fracture, restoring circulation.

Anonymous

1. Restoration of normal appearance and function

2. alleviating pain

3. reliving tension on nerves and vessels that are stretched over the deformity

4. eliminating or minimizing the chance of converting a closed fracture into an open one

5. restoring circulation to a pulseless extremity.

To reduce a mid shaft fracture, the patient is sedated and gradual, steady longitudinal traction is applied. Rotational deformity is corrected after the angular component is addressed and while traction is being maintained.

Anonymous Tintnalli pg.1746

The long-term purpose of reducing a significant deformity associated with a fracture is restoration of normal appearance and function of the extremity.

The short term reasons are: alleviating pain, relieving the tension on nerves or vessels that may be stretched as they pass over the deformity, eliminating or minimizing the possibility of converting a closed fracture to an open fracture, and restoring circulation to a pulseless distal extremity.

How is it done?

Sedate the patient, then reduce with gradual, steady longitudinal traction.  Any rotational deformity should be corrected only after the angular component has been addressed.  The nearer the deformity is to a joint, the more difficult it may be to correct.

14.    List (do not describe) 5 conditions that should prompt orthopedic consultation while the patient is still in the ED.

Zen Seeker Tinitinalli EM Fifth Edition

ORTHOPEDIC CONSULTATION IN THE EMERGENCY DEPARTMENT

In many cases, such as hip fracture or both-bone fracture of the forearm, the need for hospital admission and/or orthopedic consultation in the emergency department is obvious. In some situations, however, differences of opinion may exist among emergency physicians, as well as among orthopedists, as to whether the patient needs to be seen by an orthopedist in the emergency department, or whether the patient may be treated in preliminary fashion and referred for subsequent definitive orthopedic management. Even patients with injuries that may ultimately require surgical repair, such as an unstable ankle fracture, may sometimes be immobilized and discharged for prompt orthopedic follow-up.

Some entities or situations that may warrant orthopedic consultation while the patient is still in the emergency department are discussed below.

Compartment Syndrome

The physiology and potentially catastrophic consequences of compartment syndrome are described later in this chapter. In cases of known or suspected compartment syndrome, orthopedic consultation should be obtained promptly. Emergency surgical intervention may be required to try to avert permanent tissue damage and muscle contracture.

Irreducible Dislocation

The emergency physician may sometimes be unable to reduce a dislocation, even with the aid of nerve block or pharmacologic sedation. While technique is certainly a factor, there may be other reasons closed reduction cannot be accomplished, such as the interposition of soft tissues or the presence of associated fractures. Orthopedic consultation should be sought in such cases. Timely reduction, which may sometimes only be achieved surgically, can help minimize the complications (and shorten the pain) resulting from a dislocated joint.

Circulatory Compromise

Circulatory deficit resulting from musculoskeletal injury warrants prompt orthopedic consulation. Even if circulation has been restored by the emergency physician through the correction of deformity, the orthopedist may wish to investigate the integrity of the involved vessels, and should at least be contacted in order to discuss the case.

Open Fracture

As mentioned earlier, some open fractures need to be treated aggressively in the operating room. Other types, such as those involving the phalanges, may often be irrigated in the emergency department and referred for follow-up. If there is any question, a discussion with an orthopedist can result in a mutually agreeable plan of care.

Injuries Requiring Surgical Repair

While some musculoskeletal injuries require operative intervention as soon as possible, others may be treated on a delayed basis. In many cases, orthopedists differ in their preferred approach to the timing of surgery. Orthopedic consultation, at least by telephone, is indicated in cases of musculoskeletal injury that the emergency physician believes may need operative fixation or repair. The orthopedist may then exercise his or her choice to admit the patient right away, or to see the patient in timely follow-up and schedule surgery at that time

Anonymous Tint 1746-1747

Compartment syndrome

Irreducible dislocation

Circulatory compromise

Open Fracture

Injuries requiring Surgical Repair

Jennyb Tintinalli p. 1746-1747

         1.  Compartment Syndrome

         2.  Irreducible Dislocation

         3.  Circulatory Compromise

         4.  Open Fracture

         5.  Injuries requiring surgical repair 

Vb. Tintinalli pg 1746

Hip Fx/ bilat both-bone Fx of forearm/ need for admission/ compartment syndrome/ irreducible dislocation/ circulatory compromise/ open Fx/ injuries requiring surgical repair.

Anonymous

1. compartment syndrome

2. irreducible dislocation

3. circulatory compromise

4. open fracture

5. injuries requiring surgical repair

Anonymous Tintinalli pgs.1746-1747

a.       compartment syndrome

b.      irreducible dislocation

c.       circulatory compromise

d.      open fracture

e.       injuries requiring surgical repair

15.    Identify which types of injuries should be immobilized, what determines whether plaster or fiberglass is used, and advantages of fiberglass.

Zen Seeker Tinitinalli EM Fifth Edition

IMMOBILIZATION TECHNIQUES

Immobilization is indicated not only for fractures but also for dislocated joints that have been reduced. When a joint becomes dislocated, the ligaments that had provided it with stability are disrupted, and the joint is susceptible to redislocation until healing has occurred.

Whether plaster or fiberglass is used in the dressing depends on a number of factors, including the emergency physician´s preference, the philosophy of the orthopedic community, the needs of the patient, and the hospital´s resources. Fiberglass has the advantages of being lightweight, fast setting, and resistant to damage by moisture (although most splint dressings contain additional bandaging materials that need to be kept dry). Ultimately, the physician should use the material he or she is most comfortable with and can use most skillfully with best results.

Anonymous . Tint p. 1747

Identify which types of injuries should be immobilized: Fractures and dislocated joints that have been reduced. (dislocations disrupt the stabilizing ligaments and the joint is susceptible to redislocation until healing has occurred)

What determines whether plaster or fiberglass is used: practitioner preference, the philosophy of the orthopedic community, needs of the patient, facility resources. Ultimately, use the material you are most comfortable with and can achieve the best results with.

Advantages of fiberglass:  lightweight, fast setting, and resistant to moisture - although splint dressings contain bandage material that needs to be kept dry

Jennyb Tintinalli p. 1747

Immobilization is indicated not only for fractures but also for joints that have been reduced.  Whether fiberglass or plaster is used depends on a number of factors including physician preference, philosophy of the orthopedic community, the needs of the patient, and the hospitals resources.  Fiberglass has the advantage of being lightweight, fast setting, and resistant to damage by moisture.

VB. Tintinalli pg 1747

Immobilization indicated for Fx and dislocations requiring reduction.

Choosing fiberglass or plaster depends on physician preference, needs of patient, resources.

Fiberglass has advantage of being lightweight, fast setting, and resistant to damage by moisture.

Anonymous

• Fractures and reduced dislocations which have disrupted ligaments that could allow for re-dislocation should be immobilized. 

• Fiberglass VS plaster depends on:

1.      physician preference

2.      philosophy of the orthopedic community

3.      needs of the patient

4.      resources of the hospital

Anonymous Tintinalli pg.1747

Immobilization is indicated not only for fractures but also for dislocated joints that have been reduced.  When a joint is dislocated, the ligaments that provide stability are disrupted, and the joint is susceptible to redislocation.  

Whether plaster or fiberglass is used depends on: the emergency physician’s preference, philosophy of the orthopedic community, the needs of the patient, and the hospitals resources.

Advantages of fiberglass are it is lightweight, fast setting, and resistant to damage by moisture.

16.    Be able to recognize the following splints if shown a picture:

         a.            Long-arm ulnar gutter

         b.            Sugar-tong

         c.            Short-arm ulnar gutter

         d.            Thumb spica

         e.            Knee immobilizer

         f.             Posterior ankle

         g.            Inflatable ankle stirrup

Zen Seeker Tinitinalli EM Fifth Edition

Long-arm ulnar gutter splint.

Sugar-tong splint.

Short-arm ulnar gutter splint.

Thumb spica splint.

Knee immobilizer.

Posterior ankle mold.

A and B. Inflatable ankle stirrup.

Anonymous Tintinalli, pp 1748-1751

Pam    Tintinalli, See pp 1749 - 1751

Jenn Emergency Med. Study Guide, pg 1748-1752

a.      Long-arm ulnar gutter:  Plaster splint that maintains the elbow in flexion, usually at 90 .  The splint begins on the ulnar surface of the hand at the metacarpal heads and extends along the ulnar surface of the forearm, past the apex of the elbow, to a spot high on the lateral surface of the upper arm opposite and below the axillary crease.  It should be supplemented w/a sling.

b.      Sugar-tong:  Plaster splint that prevents motion of the wrist and elbow, including pronation-supination.  The upper extremity is placed in sling position.  It begins on the extensor aspect of the hand at the level of the metacarpal heads and extends along the extensor aspect of the forearm, and ultimately to the palmar aspect of the hand, ending at the level of the metacarpal heads.  It is wrapped in place w/gauze and often topped off w/a compression bandage.  It should be supplemented w/a sling.

c.      Short-arm ulnar gutter:  This plaster splint immobilizes the wrist and ulnar half of the hand.  It extends along the ulnar surface of the hand and forearm, beginning just proximal to the tip of the fifth finger and ending high onto the forearm.  The splint should be wide enough to encompass the fourth and fifth rays on both the extensor and palmar aspects of the hand.  The splint is wrapped in place w/the fourth and fifth fingers bound together, separated by a thin layer of padding to prevent maceration of the skin.  The metacarpophalangeal joints and interphalangeal joints should be positioned in gentle flexion.  The dressing should be supplemented w/a sling.

d.      Thumb spica:  Plaster dressing immobilizes the wrist and thumb.  The term spica applies to any dressing that encompasses a main trunk plus one or more of its branches, in this case, the forearm plus the thumb

e.      Knee immobilizer:  A removable device that wraps around the upper and lower leg and maintains the knee in a fully or almost fully extended position.  The splint contains longitudinal metal struts and is fastened w/Velcro straps.

f.       Posterior ankle:  Plaster splint that immobilizes the ankle.  It begins beneath the metatarsal heads, runs along the plantar aspect of the foot, and continues up the back of the lower leg, ending at high calf. 

g.      Inflatable ankle stirrup:  It is equipped w/valves and tubes to allow the addition or removal of air, although it usually comes optimally pre-inflated.  The ankle stirrup is essentially a “sugar-tong” splint held in place by Velcro straps.  It prevents eversion and inversion but does not limit ankle plantarflexion or dorsiflexion.  It is removable by the patient for purposes of bathing or when not bearing wt.

Anonymous

• Long-arm ulnar gutter

• Sugar-tong

• Short-arm ulnar gutter

• Thumb spica

• Knee immobilizer

• Posterior ankle

• Inflatable ankle stirrup

Anonymous Titntinalli  1748-51

Anonymous Tintinalli 1748-1750

a.       Long-arm ulnar gutter- splint maintains the elbow in flexion, usually at 90 degrees.

b.      Sugar tong- Prevents motion of the wrist and elbow, including pronation and supination.

c.       Short-arm ulnar gutter- Immobilizes the wrist and ulnar half of the hand.

d.      Thumb spica- Immobilizes the wrist and thumb.

e.       Knee immobilizer- maintains the knee in a fully or almost fully extended position.

f.        Posterior ankle- immobilizes the ankle.

g.       Inflatable ankle stirrup- used for ankle sprains and minor avulsion fractures.

17.    Identify the type of injuries that are treated with the following splints:

         a.            Long-arm ulnar gutter

         b.            Sugar-tong

         c.            Short-arm ulnar gutter

         d.            Thumb spica

         e.            Knee immobilizer

         f.             Posterior ankle

         g.            Inflatable ankle stirrup

Zen Seeker Tinitinalli EM Fifth Edition

LONG-ARM ULNAR GUTTER SPLINT

This is a plaster splint that maintains the elbow in flexion, usually at 90° (Fig. 259-9). The upper extremity is placed in sling position (elbow flexed and palm facing the abdomen). The splint begins on the ulnar surface of the hand at the metacarpal heads and extends along the ulnar surface of the forearm, past the apex of the elbow, to a spot high on the lateral surface of the upper arm just opposite and below the axillary crease. It should be supplemented with a sling.

The most common error associated with fashioning this dressing is insufficient length. If the splint is not carried far enough above the elbow, it will not be able to exert enough leverage to prevent motion of the joint.

The long-arm ulnar gutter is useful for injuries about the elbow, including radial head fractures, nondisplaced supracondylar humeral fractures, and reduced dislocation of the elbow.

SUGAR-TONG SPLINT

This is a plaster splint that prevents motion of the wrist and elbow, including pronation-supination (Fig. 259-10). The upper extremity is placed in sling position, as described above. The splint begins on the extensor aspect of the hand at the level of the metacarpal heads and extends along the extensor aspect of the forearm, around the elbow and humeral condyles onto the flexor aspect of the forearm, and ultimately to the palmar aspect of the hand, ending at the level of the metacarpal heads. It is wrapped in place with gauze and often topped off with a compression bandage. It should be supplemented with a sling.

Proper length of the sugar-tong dressing is important. Too short a splint will fail to immobilize the wrist. If the dressing is too long, it will impair motion of the metacarpophalangeal joints, leaving them stiff and making the fingers more susceptible to swelling due to immobility.

The sugar-tong splint is appropriate for fractures about the wrist or distal forearm. Some orthopedists use it as a definitive dressing after reduction of wrist fractures.

THUMB SPICA

This plaster dressing immobilizes the wrist and thumb (Fig. 259- 12). The term spica applies to any dressing that encompasses a main trunk plus one or more of its branches, in this case, the forearm plus the thumb. It is used for fractures of the scaphoid or for fractures of the thumb metacarpal or proximal phalanx.

A thumb spica can be fashioned from a single wide plaster splint, but a more effective and better-looking dressing can be made from two separate splints. The wrist piece runs along the extensor aspect of the hand and forearm beginning at the metacarpal heads and ending just short of the elbow. The more narrow thumb piece, approximately 2 in wide, extends from the tip of the thumb (which has been padded separately), along the outer aspect of the thumb metacarpal, and onto the extensor aspect of the forearm, well overlapping the first splint. Along their area of contact, the two splints are molded into each other, with no padding between them, to form a sturdy dressing. The plaster is wrapped in place with gauze, and a compression wrap may be added at the physician´s discretion. The dressing is supplemented with a sling.  

While the plaster is setting, optimal position can be achieved by keeping the wrist in neutral position and having the patient oppose the tips of the thumb and index fingers in the form of an “OK” sign. This preserves thumb-index pinch function, minimizing the patient´s incapacitation. It also avoids reproducing the position of injury in the case of scaphoid fractures, which are typically caused by forced dorsiflexion of the wrist.

KNEE IMMOBILIZER

This is a removable device that wraps around the upper and lower leg and maintains the knee in a fully or almost fully extended position (Fig. 259-13). The splint contains longitudinal metal struts and is fastened with Velcro straps.

The knee immobilizer is useful for a variety of injuries, including fracture of the lateral or medial tibial plateau, fracture or subluxation of the patella, meniscal injuries (provided the patient´s knee is not locked in partial flexion), and ligamentous strains or tears.

POSTERIOR ANKLE MOLD

This is a plaster splint that immobilizes the ankle (Fig. 259-14). It begins beneath the metatarsal heads, runs along the plantar aspect of the foot, and continues up the back of the lower leg, ending at high calf. The splint is used for severe ankle sprains or for stable ankle fractures, such as minimally displaced fractures of the distal fibula. Unstable fractures, such as those involving more than one malleolus or widening of the medial joint space (disruption of the deltoid ligament), may be supplemented by a sugar-tong component running down one side of the leg, beneath the heel, and up the other side. Where the two components overlap, they are molded together. The additional component helps minimize inversion-eversion of the ankle. Even more stability is provided by continuing the posterior splint past the back of the knee to high posterior thigh, using wider plaster for this area. With the knee slightly flexed, rotational motion at the ankle will be prevented as well.

While the plaster is setting, the ankle should be maintained in a position as close as possible to neutral, that is, at 90° to the leg. This maintains the width of the ankle joint and may allow the patient to regain range of motion more quickly after the dressing is removed. Because most patients with ankle injuries tend to keep the ankle plantar flexed, the physician will usually have to maintain passive dorsiflexion by exerting gentle pressure with a palm beneath the sole of the foot. An exception to the 90° principle is immobilization for rupture of the Achilles tendon. Patients with this injury should be immobilized in plantar flexion to reduce tension on the tendon.

ANKLE STIRRUP

Like the posterior mold, the commercially available inflatable ankle splint (Fig. 259-15A and Fig. 259-15B) is useful for ankle sprains and minor avulsion fractures. It is equipped with valves and tubes to allow the addition or removal of air, although it usually comes optimally pre-inflated. Printed instructions are typically included, describing the method of determining and creating the proper degree of inflation and also describing rehabilitation exercises for the patient.

The ankle stirrup is essentially a “sugar-tong” splint held in place by Velcro straps. It prevents eversion and inversion but does not limit ankle plantarflexion or dorsiflexion. It is removable by the patient for purposes of bathing or when not bearing weight.

If the patient does remove the splint temporarily, a common error when re-applying it is to fail to unwrap the Velcro straps completely, specifically, to leave the straps attached posteriorly, so that the splint is “hinged” along its posterior aspect, like a “book.” This may result in the foot´s persistently slipping forward and out of the splint. The clinician may wish to instruct the patient that the proper way to re-apply the splint is to unwrap the straps all the way around, so that the sides fall apart bilaterally, with the foot pad acting as the “hinge” on the plantar aspect (Fig. 259-16). The foot can then be positioned on the lower pad, and the sides brought together to adequately grasp the medial and lateral aspects of the ankle and lower leg. The final step is to wrap the straps about the posterior and anterior aspects of the dressing.

Anonymous

Long-arm ulnar gutter – Useful for injuries about the elbow, including radial head fractures, nondisplaced supracondylar humeral fractures and reduced dislocation of the elbow.

Sugar-tong- appropriate for fractures about the wrist or distal forearm. Some use it as a definitive dressing after reduction of wrist fractures.

Short-arm ulnar gutter- Useful for fractures of the proximal phalanx of the ring or little finger, or for fractures of the fourth or fifth metacarpal (including “boxer’s fracture”).

Thumb spica- Useful for fractures of the scaphoid or for fractures of the thumb metacarpal or proximal phalanx.

Knee immobilizer- Useful for a variety of injuries, including fracture of the lateral or medial tibial plateau, fracture or subluxation of the patella, meniscal injuries (provided the patient’s knee is not locked in partial flexion) and ligamentous strains or tears.

Posterior ankle- Used for severe ankle sprains or for stable ankle fractures, such as minimally displaced fractures of the distal fibula. Unstable fractures, such as those involving more than one malleolus or widening of the medial joint space may be supplemented by a sugar-tong component running down one side of the leg.

Inflatable ankle stirrup- Useful for ankle sprains and minor avulsion fractures. Tintinalli pp 1748-1751

Pam    Tintinalli, pp 1749 -1751           

a.       Long-arm ulnar gutter:  The long-arm ulnar gutter is useful for injuries about the elbow, including radial head fx’s, nondisplaced supracondylar humeral fx’s, and reduced dislocation of the elbow.

b.      Sugar-tong:  Useful for fx’s about the wrist or distal forearm.  Some orthopedists use it as a definitive dressing after reduction of wrist fx’s.

c.       Short-arm ulnar gutter:  Useful for fx’s of the proximal phalanx of the ring or little finger, or for fx’s of the fourth or fifth metacarpal (including the common “boxer’s fx”). 

d.      Thumb spica:  Used for fx’s of the scaphoid or for fx’s of the thumb metacarpal or proximal phalanx.

e.       Knee immobilizer:  Useful for a variety of injuries, including fx of the lateral or medial tibial plateau, fx or subluation of the patella, meniscal injuries (provided the pt’s knee is not locked in partial flexion), and ligamentous strains or tears.

f.        Posterior ankle:  Used for severe ankle sprains or for stable ankle fx’s, such as minimally displaced fx’s of the distal fibula.  Unstable fx’s, such as those involving more than one malleolus or widening of the medial jt space (disruption of the deltoid ligament), may be supplemented by a sugar-ton component running down one side of the leg, beneath the heal, and up the other side.

g.       Inflatable ankle stirrup:  Like the posterior mold, the commercially available inflatable ankle splint is useful for ankle sprains and minor avulsion fx’s. 

 Jenn Emergency Med. Study Guide, pg 1748-1752

a.      Long-arm ulnar gutter:  The long-arm ulnar gutter is useful for injuries about the elbow, including radial head fractures, nondisplaced supracondylar humeral fractures, and reduced dislocation of the elbow.

b.      Sugar-tong:  The sugar-tong splint is appropriate for fractures about he wrist or distal forearm.

c.      Short-arm ulnar gutter.  The short-arm ulnar gutter is useful for fractures of the proximal phalanx of the ring or little finger, or for fractures of the fourth or fifth metacarpal.

d.      Thumb spica:  It is used for fractures of the scaphoid or for fractures of the thumb metacarpal or proximal phalanx.

e.      Knee immobilizer:  The knee immobilizer is useful for a variety of injuries, including fracture of the lateral or medial tibial plateau, fracture or subluxation of the patella, meniscal injuries (provided the patient’s knee is not locked in partial flexion), and ligamentous strains or tears.

f.       Posterior ankle:  The splint is used for severe ankle sprains or for stable ankle fractures, such as minimally displaced fractures of the distal fibula.

g.      Inflatable ankle stirrup:  Is useful for ankle sprains and minor avulsion fractures. 

Anonymous Tintinalli 1747

•        Long-arm ulnar gutter: Radial head fracture, non-displaced supracondylar humeral fractures, and reduced dislocation of the elbow.

•        Sugar-tong: fractures above the wrist or distal forearm, may be used as a definitive dressing after reduction of wrist fractures.

•        Short-arm ulnar gutter: Fractures of the proximal phalanx of the ring finger or for fractures of the fourth or fifth metacarpal including the common boxer’s fracture.

•        Thumb spica: fractures of the scaphoid or the thumb metacarpal or proximal phalanx

•        Knee immobilizer: Fractures of the lateral or medial tibial plateau, fracture or subluxation of the patella, meniscal injuries (provided the patients knee is not locked in partial flexion), and ligamentous strains or tears.

•        Posterior ankle: Severe ankle sprains, stable ankle fractures, minimally displace fractures of the distal fibula, with the addition of sugar tongs down one side and up the other, unstable fractures of multiple malleolus or  widening of the medial joint space (disruption of the deltoid ligament) eversion-inversion of the ankle.

•        Inflatable ankle stirrup: ankle sprains and minor avulsion fractures.

Anonymous Tintinalli 1748-1750

a.      Long-arm ulnar gutter- used for injuries about the elbow, including radial head fractures, non-displaced supracondylar humeral fractures, and reduced dislocation of the elbow.

b.      Sugar tong- used for fractures about the wrist or distal forearm.  Some orthopedists use it as a definitive dressing after reduction of wrist fractures.

c.       Short-arm ulnar gutter- used for fractures to the proximal phalanx of the ring or little finger, or for fractures of the 4^th or 5^th metacarpal.

d.      Thumb spica- used for fractures of the scaphoid or for fractures of the thumb metacarpal or proximal phalanx.

e.      Knee immobilizer- used for fracture of the lateral or medial tibial plateau, fracture or subluxation of the patella, meniscal injuries, and ligamentous strains or tears.

f.        Posterior ankle- used for severe ankle sprains or for stable ankle fractures, such as minimally displaced fractures of the distal fibula.

g.      Inflatable ankle stirrup- used for ankle sprains and minor avulsion fractures.

18.    Identify the patient who needs crutches and describe the ideal crutch height. 

Zen Seeker Tinitinalli EM Fifth Edition

ADJUNCTS TO AMBULATION

Crutches

Crutches should be used by patients who can bear no weight at all on an injured lower extremity. Ideal crutch height is one hand width below the axillae. The grip bar should be adjusted to a height at which the elbows are still mildly flexed while supporting the body weight. The patient should be instructed to bear the pressure of the pads against the sides of the thorax rather than in the axillae, or brachial plexus injury might result (crutch palsy).

Any of several crutch gaits may be prescribed. With a two-point gait, the patient advances the crutches first, and then brings the well leg up to the crutches (“swing-to” gait) or just past the crutches (“swing-through” gait). With a three-point gait, the crutches and the injured extremity are all advanced together, and then the well extremity is advanced to meet them. The three-point gait results in slower forward progression than does the two-point gait, but requires less energy. Partial weight- bearing or no weight-bearing may be prescribed for the injured extremity, regardless of the gait used.

The method for negotiating stairs is similar for the two- and three-point gaits. Ascending stairs, the patient advances the well extremity up to the next step, followed by the crutches and the injured extremity. Descending stairs, the crutches are lowered first.

Anonymous

Patients who can bear no weight at all on an injured lower extremity should use crutches.  Ideal crutch height is one hand width below the axillae. The grip bar should be adjusted to a height at which the elbows are still mildly flexed while supporting the body weight. Tintinalli p. 1751

Pam    Tintinalli, p 1751

         Crutches should be used by pts who can bear no weight at all on an injured lower extremity.  Ideal crutch height is one hand width below the axillae.  The grip bar should be adjusted to a height at which the elbows are still mildly flexed while supporting the body wt.    

 Jenn Emergency Med. Study Guide, pg 1748-1752

Crutches should be used by patients who can bear no wt. at all on an injured lower extremity.

Ideal crutch ht. is one hand width below the axillae.  The grip bar should be adjusted to a ht. at which the elbows are still mildly flexed while supporting the body wt.

Anonymous

Patients who can bear no weight at all on an injured lower extremity. Ideal height is one hand with below the axilla, with the grip bars adjusted to slight flexion while bearing the body weight.

Anonymous Tintinalli 1751

Crutches should be used on patients who can bear no weight at all on an injured lower extremity.

Ideal crutch height is one hand width below the axillae (armpit).

19.    Explain why and how canes and walkers are used.

Zen Seeker Tinitinalli EM Fifth Edition

Walkers and Canes

Most elderly or infirm patients do not have the strength to use crutches safely. For them, a walker or cane is more suitable. Unfortunately, these devices are more appropriate for partial weight-bearing than for full non–weight-bearing conditions. Elderly patients who can bear no weight at all on an injured extremity may require initial bed rest and subsequent rehabilitation. 

The technique for using a walker is essentially intuitive, with the patient simply lifting it and placing it a short distance ahead, then advancing up to it. By contrast, the technique for using a cane tends to be counterintuitive. Most patients instinctively hold a cane on the same side as the injured extremity. In fact, when the cane is held in the hand on the well side, much less strength is required to maintain balance, resulting in an easier and less awkward gait. The patient should be instructed to advance the cane (held on the well side) and the injured extremity simultaneously, then advance the noninjured extremity to meet them.

Anonymous

Used for partial weight-bearing when lower extremity is injured.

Walker – patient simply lifts and places the walker a short distance ahead and advances up to it.

Cane – the cane is held in hand on the uninjured side and patient is instructed to advance the cane and the injured extremity at the same time and then advance the well extremity to meet them.

Pam    Tintinalli, p. 1751

            Most elderly or infirm pts do not have the strength to use crutches safely.  For them, a walker or can is more suitable.  Unfortunately, these devices are more appropriate for partial wt-bearing than for full non-wt-bearing conditions.  Elderly pts who can bear no wt at all on an injured extremity may require initial bed rest and subsequent rehabilitation.  The technique for using a walker is essentially intuitive, with the pt simply lifting it and placing it a short distance ahead, then advancing up to it.  By contrast, the technique for using a cane tends to be counterintuitive.  Most pts instinctively hold a cane on the same side as the injured extremity.  In face, when the cane is held in the hand on the well side, much less strength is required to maintain balance, resulting in an easier and less awkward gait.  The pt should be instructed to advance the cane (held on the well side) and the injured extremity simultaneously, then advance the noninjured extremity to meet them.

Jenn Emergency Med. Study Guide, pg 1748-1752

Most elderly or infirm patients do not have the strength to use crutches safely.  For them, a walker or can is more suitable.  Unfortunately, these devices are more appropriate for partial wt-bearing than for full non-wt-bearing conditions.  The technique for using a walker is essentially intuitive, w/the patient simply lifting it and placing it a short distance ahead, then advancing up to it.  By contrast, the technique for using a cane tends to be counterintuitive.  Most patients instinctively hold a cane on the same side as the injured extremity.  In fact, when the cane is held in the hand on the well side, much less strength is required to maintain balance, resulting in an easier and less awkward gait.  The patient should be instructed to advance the cane and the injured extremity simultaneously, then advance the noninjured extremity to meet them.

Anonymous Tintinalli p. 1751

• Used for partial weight-bearing when lower extremity is injured.

• Walker – patient simply lifts and places the walker a short distance ahead and advances up to it.

• Cane – the cane is held in hand on the uninjured side and patient is instructed to advance the cane and the injured extremity at the same time and then advance the well extremity to meet them.

Anonymous Tintinalli 1751-1752

Walkers and canes are used with patients that do not have the strength to use crutches.  An example being the elderly and infirm. However, these devices are more appropriate for partial weight bearing.

The technique used for the walker is usually intuitive.  The patient lifts the walker and places it a short distance, then advances to it.

With a cane, the patient should be instructed to advance the cane (held on the uninjured side) and the injured extremity simultaneously, then advance the non-injured extremity to meet them.

20.    List several instructions to send home with the patient following a fracture or sprain.

Zen Seeker Tinitinalli EM Fifth Edition

DISCHARGE INSTRUCTIONS

Continuous elevation of the injured part usually helps minimize swelling and pain. However, most individuals do not share the physician´s knowledge that, to be effective, elevation must be above the level of the heart. Patients with an injured lower extremity often sit at home or at work with the leg resting on a chair, thinking they are complying with instructions. The patient should understand that the benefits of elevating a lower extremity can only be achieved in a recumbent or near- recumbent position, with the leg supported higher than the rest of the body.

Patients discharged in a lower-extremity plaster dressing should be cautioned not to rest the heel on the floor or any other hard surface. Plaster takes about 24 h to fully set. During this time, prolonged pressure on the heel can gradually create an indentation that may cause significant discomfort or even a pressure sore. This is not a consideration with fiberglass, which sets immediately. 

If an upper-extremity sugar-tong dressing has been applied, the patient should be instructed to work the fingers (wiggle or wave) as much as possible to minimize stiffness and swelling. The sugar-tong splint should allow full flexion of the metacarpophalangeal joints.

Patients should be advised to watch the fingers or toes for excessive swelling, decreased sensation, or cyanosis, and to be alert for a significant increase in pain. Any of these signs or symptoms warrant a return to the emergency department or prompt evaluation by the follow-up physician.

When crutches, a cane, or a walker is supplied, instruction for use should be provided, and the patient´s ability to navigate with such aids should be verified.

Anonymous Tintinalli p. 1752

-Continuous elevation of the injured part usually minimize swelling and pain, elevation must be above the level of the heart. Especially w/ lower extremities

-Lower Extremity: plaster dressing should be cautioned not to rest the heel on the floor or any other hard surface. Plaster takes about 24 h. to fully set; prolonged pressure on the heel can gradually create an indentation that may cause significant discomfort or even a pressure sore.

-Upper extremities: if a sugar-tong dressings has been applied the pt should be instructed to work the fingers (Wiggle or wave) as much as possible to minimize stiffness and swelling. The sugar-tong splint should allow full flexion of the metacarpophalangeal joint.

Pts should be advised to watch the fingers and toes for excessive swelling, decreased sensation, or cyanosis, and to be alert for a significant increase in Pain.

-Any of this signs or symptoms warrants a return to the ER or prompt evaluation by a F/U physician.

-When crutches, a cane, or a walker is supplied, instructions for use should be provided, and the pt’s ability to navigate w/ such aids should be verified

Pam    Tintinalli, p.1752

            Continuous elevation of the injured part usually helps minimize swelling and px.  However, most individuals do not share the physician’s knowledge that, to be effective, elevation must be above the level of the heart.  Pts with an injured lower extremity often sit at home or at work with the leg resting on a chair, thinking they are complying with instructions.  The pt should understand that the benefits of elevating a lower extremity can only be achieved in a recumbent or near-recumbent position. 

            Pts discharged in a lower-extremity plaster dressing should be cautioned not to rest the heel on the floor or any other hard surface.  Plaster takes about 24 h to fully set.  During this time, prolonged pressure on the heel can gradually create an indentation that may cause significant discomfort or even a  pressure sore.  This is not a consideration with fiberglass, which sets immediately.

            If an upper-extremity sugar-tong dressing has been applied, th ept should be instructed to work the fingers as much as possible to minimize stiffness and swelling.  The sugar-tong splint should allow full flexion of the MCP jts.

            Pts should be advised to watch the fingers or toes for excessive swelling, decreased sensation, or cyanosis, and to be alert for a significant increase in pain.  Any of these signs will warrant a return to the ER or prompt evaluation by the follow-up physician.

            When crutches, a cane, or a walker is supplied, instruction for use should be provided, and the pt’s ability to navigate with such aids should be verified.

Jenn Emergency Med. Study Guide, pg 1748-1752

•        Continuous elevation of the injured part usually helps minimize swelling and pain.  To be effective, elevation must be above the level of the heart.  The patient should understand that the benefits of elevating a lower extremity can only be achieved in a recumbent or near-recumbent position, w/the leg supported higher than the rest of the body.

•        Patients discharged in a lower-extremity plaster dressing should be cautioned not to rest the heel on the floor or any other hard surface.  Plaster takes about 24h to fully set.  During this time, prolonged pressure on the heel can gradually create an indentation that may cause significant discomfort or even a pressure sore.  This is not a consideration w/fiberglass, which sets immediately.

•        If an upper-extremity sugar-tong dressing has been applied, the patient should be instructed to work the fingers (wiggle or wave) as much as possible to minimize stiffness and swelling.

•        Patients should be advised to watch the fingers or toes for excessive swelling, decreased sensation, or cyanosis, and to be alert for a significant increase in pain.  Any of these signs or symptoms warrants a return to the emergency dept. or prompt evaluation by the follow-up physician.

•        When crutches, a cane, or a walker is supplied, instruction for use should be provided, and the patient’s ability to navigate w/such aids should be verified.

•        Follow-up:  There is no universally prescribed follow-up interval for specific injuries.  Generally, patients’ w/unreduced fractures or injuries that require future surgical intervention should be seen w/in a few days.  Sometimes the situation may be discussed w/the follow-up physician and an appt. arranged while the patient is still in the emergency dept.  Alternatively, the emergency physician may instruct the patient to contact the follow-up physician or clinic as soon as possible.

Anonymous   Tintinalli p. 1752

• Continuous elevation of the injured part usually minimize swelling and pain, elevation must be above the level of the heart. Especially w/ lower extremities

• Lower Extremity: plaster dressing should be cautioned not to rest the heel on the floor or any other hard surface. Plaster takes about 24 h. to fully set; prolonged pressure on the heel can gradually create an indentation that may cause significant discomfort or even a pressure sore.

• Upper extremities: if a sugar-tong dressing has been applied the pt should be instructed to work the fingers (Wiggle or wave) as much as possible to minimize stiffness and swelling. The sugar-tong splint should allow full flexion of the metacarpophalangeal joint.

• Pts should be advised to watch the fingers and toes for excessive swelling, decreased sensation, or cyanosis, and to be alert for a significant increase in Pain.

• Any of this signs or symptoms warrants a return to the ER or prompt evaluation by  F/U with a physician.

• When crutches, a cane, or a walker is supplied, instructions for use should be provided, and the pt’s ability to navigate w/ such aids should be verified

Anonymous Tintinalli 1752

a.       Continuous elevation of the injured part higher than the rest of the body to minimize swelling.

b.      If discharged in a lower extremity plaster dressing do not rest heal on the floor or any other hard surface.  Plaster takes about 24 hours to fully set.

c.       If an upper extremity sugar tongue was placed the patient should work/wiggle fingers as much as possible to minimize stiffness and swelling.

d.      Watch fingers or toes for excessive swelling, decreased sensation, or cyanosis, and to be alert for significance increase in pain.  If so f/u with physician.

e.       When crutches, a cane or walker is used provide instructions on use, and make sure the patient can use them.

21.    Briefly discuss neurologic deficits associated with musculoskeletal injury.

Zen Seeker Tinitinalli EM Fifth Edition

COMPLICATIONS

Complications associated with musculoskeletal injury may be early or delayed, and may occur minutes, days, weeks, or even months later.

Neurologic Deficit

Neurologic injury resulting from long-bone fractures or joint dislocations is usually due to traction or pressure on a peripheral nerve or a nerve plexus. Such complications usually manifest themselves early. Recovery may take hours, days, or weeks. Sometimes they are irreversible. Prompt reduction of deformity can often prevent, eliminate, or mitigate the effects of neurologic involvement, but is not a guarantee against permanent deficit.

Anonymous Injury usually due to traction or pressure on a peripheral nerve or a nerve plexus. Usually manifest early. Recovery can take hours, days, weeks or injury may be irreversible. Prompt reduction of deformity can often prevent, eliminate or mitigate the effects of neurologic involvement, but are not a guarantee against permanent deficit. Tintinalli, p. 1752

*I know this answer seems overly vague, but this is pretty much verbatim from Tint.

Kim B/Tintinalli pg.1752

 Neurologic injury resulting from long bone fractures or joint dislocations is usually due

 to traction or pressure on a peripheral nerve or a nerve plexus.  Such complications

 usually manifest themselves early.  Recovery may take hours days, or weeks.

  Sometimes they are irreversible.  Prompt reduction of deformity can often prevent,

 eliminate, or mitigate the effects of neurologic involvement, but is not a guarantee

 against permanent deficit. 

Anonymous Tintinalli, p. 1752

Injury is usually due to traction or pressure on a peripheral nerve or a nerve plexus. Usually manifests early. Recovery can take hours, days, weeks or injury may be irreversible. Prompt reduction of deformity can often prevent, eliminate or mitigate the effects of neurologic involvement, but are not a guarantee against permanent deficit.

Anonymous Tintinalli 1752

Neurologic deficit is usually due to traction or pressure on a peripheral nerve or nerve plexus.  These complications usually manifest themselves early.  Recovery may take hours, days or weeks.  Sometimes they are irreversible.  Prompt reduction can prevent, eliminate, or mitigate the effects of neurological involvement, but is not a guarantee against permanent deficit.   

22.    Identify the classic signs of compartment syndrome: the 5 Ps.

Zen Seeker Tinitinalli EM Fifth Edition

Compartment Syndrome

The limbs are divided into “compartments” by longitudinal partitions of fascia. Each compartment is a closed space, whose fascial borders are firm and relatively unyielding. With musculoskeletal injury, either a direct blow or a fracture, there may be extravasation of blood, swelling of muscle tissues, and impairment of venous flow within a given compartment. Eventually, this leads to increased pressure, which can compromise circulatory perfusion of the muscles and nerves in that compartment. If the tissues remain ischemic for a sufficient period of time, irreversible necrosis and permanent neurologic damage and muscle contracture can occur.9  

Clinical evidence of ongoing compartment syndrome is a true emergency, requiring expeditious diagnosis and aggressive treatment, sometimes surgical fasciotomy, to try to prevent permanent disability.

Early diagnosis of compartment syndrome is typically presumptive, based on index of suspicion. Classic signs of compartment syndrome, the five “P´s,” have been described: pain, pallor, paralysis, pulselessness, and paresthesias. The problem is that, by the time all these signs are present, irreversible damage has almost always occurred. The emergency physician should be alert for the earliest sign of impending compartment syndrome, which is pain.

Fassil   Tintinalli  1838-1839,  The 5 Minute Emergency Medicine Consult  pg. 252

•  Compartment syndromes are due to increased pressure within closed tissue spaces that compromises the flow of blood through nutrient capillaries in muscles and nerves.

•  In page 252 above, the book has “6 P’s”: pain, pressure, paresis, paresthesia, pulses present

Anonymous Tintinalli pg. 1752

Pain, pallor, paralysis, pulselessness, paresthesias

Pain - earliest sign, due to ischemia - deep continuous, poorly localized, unlike fx px and extremely difficult to control.

In upper extremity -  pain exacerbated by passive extention of Pts. fingers.

In lower extremity   - usual pain exacerbating maneuver = passive flexion of toes.

Kim B/Tintinalli pg. 1752 

 Pain, Pallor, paralysis, pulselessness, and paresthesias

 The problem is that by the time all of these signs are present, irreversible damage has

 almost always occurred.  The emergency room physician should be alert for the

 earliest sign of impending compartment syndrome which is pain.

Anonymous Tintinalli pg. 1752

Pain, pallor, paralysis, pulselessness, paresthesias

Pain - earliest sign, due to ischemia - deep continuous, poorly localized, unlike fx px and extremely difficult to control.

In upper extremity - pain exacerbated by passive extension of Pts. fingers.

In lower extremity - usual pain exacerbating maneuver = passive flexion of toes.

Anonymous Tintinalli1752-1753

Pain, pallor, paralysis, pulselessness, and parasthesias.

23.    Describe how the pain of compartment syndrome differs from that of a fracture.

Zen Seeker Tinitinalli EM Fifth Edition

Although some degree of pain is normally associated with fractures, it can usually be relieved by reduction, immobilization, and customary doses of oral or parenteral analgesics. Contrary to this is the pain associated with compartment syndrome, which is due to ischemia. It is perceived by the patient as deep, continuous, and poorly localized, and, unlike typical fracture pain, is extremely difficult to control, even with large and frequent doses of parenteral analgesics. In the upper extremity, the pain is typically exacerbated by passive extension of the patient´s fingers. In the lower extremity, the usual exacerbating maneuver is passive flexion of the toes.

Other early signs of still-reversible compartment syndrome are tight swelling and tenseness along one aspect of an extremity, and paresthesias or hypesthesia in the area of skin served by the cutaneous nerve contained within the affected compartment. Unfortunately, none of these signs occurs consistently. However, they are sufficiently common that, when any of them is present (most commonly uncontrollable pain), the possibility of an evolving compartment syndrome should be considered and surgical consultation obtained. Patients with altered mental status, in whom pain and paresthesias cannot be relied upon as early indicators of compartment syndrome, need to be monitored for physical signs such as tenseness of the affected area, skin cyanosis (early) or pallor (late), and impaired circulatory status.

In some emergency departments, a percutaneous manometer is available to measure intracompartmental pressure. Under normal circumstances, the pressure should be close to zero. Pressures of 30–40 mm Hg usually indicate the need for fasciotomy. Once the pressure equals or exceeds the patient´s diastolic blood pressure, perfusion of the tissues within the compartment is physiologically impossible, and fasciotomy may be indicated even in the presence of a palpable peripheral pulse.

Fassil  Medical surgical Nursing 5th ed  pg 1786

•  The earliest sign of a developing compartment syndrome is a progressive pain distal to the injury that is not relieved by the usual analgesics.

Anonymous p1752

Although some degree of pain is normally associated with fractures, it can usually be relieved by reduction, immobilization, and customary doses of oral or parenteral analgesics.  Contrary to this is the pain associated with compartment syndrome, which is due to ischemia.  It is perceived by the pt as deep, continuous, and poorly localized, and, unlike typical fracture pain, is extremely difficult to control, even with large and frequent doses of parenteral analgesics.

Kim B/Tintinalli pg.1752

 Fractures:  Although some degree of pain is associated with fractures, it can usually be

 relieved by reduction, immobilization, and customary doses of oral or parental

 analgesics. 

 Compartment Syndrome: Pain associated with compartment syndrome, which is due to

 ischemia.  It is perceived by the patient as deep, continuous, and poorly localized, and

 unlike typical fracture pain, is extremely difficult to control, even with large and frequent

 doses of parental analgesics. 

Anonymous Tintinalli p1752

Although some degree of pain is normally associated with fractures, it can usually be relieved by reduction, immobilization, and customary doses of oral or parenteral analgesics.  Contrary to this is the pain associated with compartment syndrome, which is due to ischemia.  It is perceived by the pt as deep, continuous, and poorly localized, and, unlike typical fracture pain, is extremely difficult to control, even with large and frequent doses of parenteral analgesics.

Anonymous Tintinalli 1753

Fracture pain can generally be relieved by reduction, immobilization and analgesics.  Pain associated with compartment syndrome is due to ischemia.  It is perceived by the patient as a deep, continuous, and poorly localized.  The pain is extremely difficult to control, even with large and frequent doses of parenteral analgesics.  In the upper extremity the pain is worsened by passive extension of the patient’s fingers.  In the lower extremity, passive flexion of the toes makes the pain worse.

24.    Discuss the relative seriousness of fractures in the pediatric population compared to the adult population.

Zen Seeker Tinitinalli EM Fifth Edition

Anonymous Squire’s 448, Tintinalli 1744

Pediatric fractures differ from adult fractures.  Young bones are more pliable than older ones, therefore fractures may occur in children that result in bending of the bone, buckling of the cortex (torus fracture), or bending on the concave side of the bone combined with an incomplete fracture of the convex side(greenstick fracture).  Epiphyseal plate fractures are also common in children and are produced by the same forces that can cause a dislocation in an adult.   Epiphyseal fractures correlate with the potential for future growth disturbance, so they need to be treated aggressively.

25.    State the most common fracture seen in children.

Zen Seeker Tinitinalli EM Fifth Edition

CLAVICLE FRACTURE

The clavicle, extending from the scapular acromion process to the manubrium sterni, serves as the sole skeletal connection between the upper extremity and the trunk and absorbs all medial forces imposed upon the upper arm. The clavicle consists of a double curve in the horizontal plane. Viewed from the front, the medial two-thirds is convex, while the lateral one-third is concave. The junction between the two curves represents its structurally weakest area and most frequently fractured site. The clavicle is the most commonly fractured bone in children.

Clavicle fractures may occur in the newborn as a result of shoulder compression during a difficult delivery. In the older infant, toddler, or child, the usual mechanism of fracture is a fall onto an outstretched hand or elbow or onto the side of a shoulder. Often, in younger children, the fracture is of the incomplete, or greenstick, type. A direct blow to the clavicle may also cause a fracture.

Diagnosis of clavicular fracture is facilitated by its subcutaneous location and the ease of its palpation on examination. Newborns with clavicle fractures may not be symptomatic. When they are symptomatic, it may come in the form of “pseudoparalysis,” or nonuse of the ipsilateral upper extremity. Alternatively, parents or health care providers may notice the bone callus at 2 to 3 weeks of age, indicative of a fracture previously unappreciated.

Older infants and children with clavicular fractures have pain on attempted range-of-motion movement of the neck or upper extremity. Soft tissue swelling, point tenderness, and bone crepitance are indicative of the fracture site. In view of the close proximity of the clavicle to the subclavian vessels and lung, careful assessment of the circulation to the ipsilateral upper extremity and chest auscultation are important. Anteroposterior radiographs of the clavicle and shoulder are principally useful in excluding other associated skeletal injuries, particularly those involving the proximal humerus and scapular prominences. Dislocations of the sternoclavicular joint, particularly posterior dislocations of the proximal clavicle, are optimally visualized by lordotic views.

Care of the child with a clavicle fracture is principally directed toward comfort and analgesia for the child. The child´s future bone growth and the modeling potential confer great healing and restorative capability to the fractured clavicle. Even displaced fractures nearly always heal well, whether or not strict anatomic reduction is accomplished in the emergency department. 

“Figure-of-eight” shoulder abduction restraints are available in various sizes and can be offered to children outside infancy. Application should ensure a snug, symmetrical fit without excessive tightness or pinching. As is the case with the application of any orthopedic appliance, subsequent assessment of the child´s neurovascular status in the upper extremities is mandatory. Some children, however, complain of greater discomfort with the figure-of-eight restraint than without. In such instances, the use of an upper extremity sling-and-swathe or shoulder immobilizer will offer adequate protection from the discomfort associated with shoulder and upper extremity movements.

Children with either type of immobilizing or restraint device are encouraged to wear the restraint day and night for 2 weeks, followed by daytime use for another 2 to 3 weeks. Oral analgesia sufficient to ensure the child´s comfort is of paramount importance. Follow-up care can be arranged through the child´s primary care physician or an orthopedic surgeon.

Fassil   Tintinalli   909

•        The clavicle is the most commonly fractured bone in children.

Kim B/Tintinalli pg.

The clavicle is the most commonly fractured bone in children. 

Anonymous Current Ped. Diag.& Treat. Pgs.803-804

Epiphyseal fractures, torus factures, greenstick fractures, fracture of the clavicle, and supracondylar fractures of the humerus.

26.    Be able to identify a radiographic imaging technique other than plain x-rays to further substantiate the presence of a fracture i.e., bone scan, CT, or MRI.

Zen Seeker Tinitinalli EM Fifth Edition

KIM R.  Pg 363 SQUIRES 

CT can show the FX lines better than plain films and can identify even the subtle cortical abnormalities of nondisplaced FXs.  A bone scan would show increased uptake of isotope at the site where the nondisplaced FX was located.    But CT is preferable to the bone scan because CT can show the FX lines in greater detail and the position and orientation of FX fragments better than any imaging procedure.  CT is especially helpful in showing FX in the position of the skeleton where the bony anatomy is complex, such as the spine, pelvis and hips, face, shoulder girdle, and foot.  (It can be performed quickly without uncomfortable positioning of the pt, and with less radiation exposure). 

MR imaging does not show FX lines or fragments as well as CT because there is no MR signal from cortical bone.  BUT MR can show bony injuries, such as BONE BRUISES, that do not involve cortical bone disruption but produce hemorrhage and edema within the bone marrow space.   

Kate Squire's pp. 362-363
When clinical exam suggests a fracture and the plain films are negative, pt. must be examined with a second imaging procedure, usually CT and sometimes bone scan. CT can show fracture lines better than plain film and can ID subtle abnormalities of nondisplaced fractures.  Bone scan would show increased uptake of isotope at site of fracture, but CT is still better because it shows detailed fracture lines, position and orientation of fracture fragments.  CT shows fractures in complex bone anatomy and it is quick (pt. less uncomfortable) and provides less radiation.  MR doesn't work as well because no MR signal from cortical bone.  But MR can show bone injuries like bruises. 

Anonymous Squire’s 362-365

Cat Scan- can show the fracture lines better than plain films and can identify even the subtle cortical abnormalities of non-displaced fractures.  A CT is especially helpful in showing fractures in portions of the skeleton where the bony anatomy is complex.(spine, pelvis, hips, face, shoulder girdle, foot)

Bone Scan- will show increased uptake of isotope at the site where the non-displaced fracture was located, however, a CT is preferred over a bone scan because it can show the fracture lines in greater detail and the position and orientation of fracture fragments better than any imaging procedure.

MRI-  does not show fracture lines or fragments as well as CT because there is no MR signal from cortical bone.  But MR can show bony injuries such as bone bruises, that do not involve cortical bone disruption but produce hemorrhage and edema w/in the marrow space.