01/09/2014

Fractures, Dislocations and History and Physical Exam

Splints Immediately upon presentation with a
dislocation or fracture, the neurovascular and
circulatory status must be checked.
Attempt to ascertain the mechanism of injury.
may alert physician to other possibly
Aliasgher Hussain, MD associated injuries as well as provide clues
as to the type of injury involved
UCLA R4 Radiographs should be obtained if fracture or
dislocation is suspected
BIMC

Imaging …and…
Know what to order and why: what information Read by check list
are you looking for? How will that information
help you manage the patient? Know the common lesions
Know what an optimal imaging series is and Know the commonly MISSED lesions
accept no less
Know a good image from a poor one and
accept only the good

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Know what to order Fracture Terminology

In majority of cases, start with a XR image • Non displaced • Articular: fracture
extends to a joint
If XR doesn‟t give you the information you need
• Pathologic: fracture
to manage the patient, go on to the next
step. The imaging modality you choose next • Displaced through a focal lesion
• Stress: repetitive
depends on the clinical problem: microtrauma, fatigue
CT: best for bone detail • Comminuted and insufficiency types
MRI: best for soft tissue and non cortex bone • Malunion: heals, but not
lesions in anatomic position
• Angulated • Delayed or nonunion:
takes too long to heal,
or doesn‟t heal at all

Fracture Types Fracture Treatment

• Ice, elevation, analgesia, and immobilization
• Reduction - imperative to align the bony fragments
for optimal healing, reduce soft tissue and
neurovascular injury
• Open fractures - IV antibiotics, such as cefazolin or
clindamycin to cover gram positives (skin flora), add
aminoglycoside such as gentamicin for severely
contaminated wounds, update Tetanus
• Know the indications for emergent orthopedic
consultation – any neurovascular injury or open
fracture

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Dislocation Treatment Reducing Fractures/Dislocation

• Assess if associated fracture 1. Knowledge of anatomy

• Reduction with adequate analgesia or
sedation
• Splinting after reduction
• If successful reduction without fracture -
Orthopedic follow-up as an outpatient
2. Analgesia and sedation
3. Slow and gentle procedure
• Radiographs should be obtained after
reduction and immobilization of a fracture or
dislocation.
• After one or two unsuccessful attempts of
reducing a dislocation (closed reduction), it is
necessary to reduce under general anesthesia
(closed) or during surgery (open reduction)

Salter Harris Fractures

Pediatric
• Fracture over
Intra- growth plate –
articular unique to Peds
Fractures • Type II most
common 75%
• Type I and II
heals well with
conservative
treatment

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Salter Harris Fractures The Upper Extremity

• Type I and II can • Shoulder
be splinted and • Humerus
referred • Elbow
• All type III • Forearm
fractures and
above will need • Wrist
emergent Ortho • Hand
referral

The Shoulder Anatomy Coracoclavicular

joint

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Shoulder X Ray Shoulder XR AP

• Optimal at least 2 Images: 1. Clavicle
– AP 2. Acromion
– Lateral Scapular (Y-View) 3. Greater Tubercle
4. Lesser Tubercle
– Alternate to Lateral is Axial
5. Humeral Neck
6. Humeral Shaft
7. Coracoid
8. Scapula
9. Ribs

Shoulder XR Lateral Shoulder XR Axial

1. Coracoid
2. Clavicle
3. Acromion
4. Humeral Head
5. Humeral Shaft
6. Scapula

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Anterior Dislocation
• Humeral head is
anterior, inferior and
medial to glenoid
• Very common injury
• Can be associated with
humerus head and
glenoid rim fractures
• Rx: Closed reduction. If
repetitive, stabilization
surgery

Anterior Dislocation reduction Traction/Counter traction

• Several methods for reduction
- Traction/counter traction
- Scapular rotation
- Abduction/traction

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Scapular Rotation Abduction/traction

Posterior Dislocation
• Uncommon <5%
• 2° to severe muscle spasm – seizure, electrocution
• Arm held in adduction and internal rotation
• Reduction with traction/counter traction method

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Shoulder Dislocation
Associated fractures:
Hill-Sachs is
compression of
posterolateral
humeral head
Bankart‟s is fracture
of anterior glenoid
lip
Will need Ortho repair

Pseudosubluxation
• Injury to shoulder
causing fluid
/hemorrhage into the
joint pushing humerus
inferior
• No anterior or posterior
dislocation on lateral
XR
• Will resolve as fluid is
reabsorbed

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AC Separation AC Separation
• Very Common • Treatment depends on extent of injury
• Normal AC joint – Type I and II sling and conservative
<10mm treatment
– Type III and above need surgical repair
• Normal CC joint
<1.3cm
• If unsure,
compare both
sides

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Clavicle Fracture Clavicle Fracture

• Traumatic • Nondisplaced
• Arm held in fractures treated
adduction, possible conservatively with
tenting or deformity splint or figure of
• 80% middle 3rd (A), eight splinting
15% lateral 3rd (B), • Displaced fractures
5% medial 3rd (C) will need Orthopedic
repair with referral in
< 1-3 days

Glenoid Fracture
• Trauma
• Shoulder held in
adduction
• Limited ROM
• Tenderness on
humeral head

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Glenoid Fracture Humerus

• Minimally • Assess location of
displaced Type I fracture and
fractures - treated degree of
conservatively displacement
• Severely
displaced or
comminuted need
surgical repair

Proximal Humerus fracture

• More common in
elderly after
FOOSH, in young
after trauma
• Arm held in
adduction with
swelling
• Tenderness over
proximal humerus
• Limited ROM

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Proximal Humerus Fracture Proximal Humerus Fracture

• Nondisplaced • Displaced
anatomic/surgical
neck, greater and
lesser tuberosity
fractures treated
with sling and
outpatient Ortho
referral
Surgical/Anatomic
neck or greater
tuberosity fracture
need reduction and
early (<1-2 days)
Ortho referral, if
unable to reduce will
need emergent
referral

Proximal Humerus Fracture

• Antomic neck
fractures in children,
comminuted,
severely displaced
with neurvascular
compromise or open
fractures need
emergent Ortho
referral

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Humeral Shaft Fracture Humeral Shaft fracture

• Traumatic • Midshaft fractures
associated with
• Pain, swelling and brachial artery and
deformity radial nerve injury
• Nondisplaced with wrist drop
fractures treated • Displaced fractures,
neurovascular
with splint and compromise or open
outpatient Ortho fractures need
referral emergent Ortho
referral

The Elbow Anatomy

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Elbow X Ray Elbow X Ray AP

a. Olecranon /
• Optimal 2 views
coranoid fossa
– AP
b. Medial epicondyle
– Lateral / trochlea
– Optional radial head-capitellum view c. Lateral epicondyle
d. Coranoid process
e. Head of radius
f. Radial tuberosity

Elbow Fat Pads

Elbow X Ray Lateral
• Small anterior fat pad
normal
• Effusion distends
capsule and displaces
fat pads
• Displaced anterior fat
pad (sail sign) or visible
posterior fat pad is
abnormal

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Elbow Fat Pads Radiocapitellar Line

• Displacement in • Line drawn along
either fat pad longitudinal axis
indicates a fracture of the radial head
• Adults - radial head and neck should
fx
pass through
• Peds -
capitellum
supracondylar fx
• Splint and Ortho • Always valid on
referral lateral film

Radiocapitellar Line Anterior Humeral Line

• Any disruption of line indicates dislocation
• A line traced
of radial head
along the anterior
cortex of the
humerus will
have at least 1/3
of the capitellum
anterior to it

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Anterior Humeral Line Ossification Centers

• If < 1/3 is anterior • C – capitellum 2yrs
to this line then a • R – Radial head 4yrs
strong probability • I – Internal (medial)
epicondyle 6yrs
of a supracondylar
• T – Trochlea 8yrs
fracture
• O – Olecranon 10yrs
• E – External (lateral)
epicondyle 12yrs

Radius Head Fracture

• Note: abnormal fat
pads. They indicate
hemarthrosis, which
means a fracture is
present
• Radius head fractures
are a common injury
• Most are treated with
sling and PT, and back
to full activity in 3 weeks
• What might happen if
the elbow is
immobilized longer?

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Radius Head Fracture

• Immobilization for
more than 3 weeks
can cause a stiff
elbow, with
permanently
restricted range of
motion

Supracondylar Fracture Supracondylar Fractures

• Traumatic
• Common pediatric
fracture, relatively
uncommon in adults
• Swollen elbow,
limited ROM with • In adults, only type 1 can be referred to
possible deformity Ortho as an outpatient after splinting
or shortened upper • In children, all observed fractures
extrmity
require emergent Ortho consult

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Lateral Epicondyle Fracture

• Traumatic
• Treat with
posterior long arm
splint and
outpatient Ortho
referral

Pediatric Fractures

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Olecranon Fracture
• Traumatic
• Swelling over
posterior elbow with
limited ROM
• Intra-articular
• > 2mm
displacement or
comminuted require
surgical repair

Monteggia Fracture
• Traumatic
• Proximal ulna
shaft fracture with
radial head
dislocation
• Emergent Ortho
referral

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Subluxation of the Radial Head Subluxation of the Radial

(Nursemaid‟s Elbow)
• Definition of subluxation =
a joint disruption in which
the joint surfaces are
maintained in some
degree of apposition.
• Description: the radial
head slips out from under
the annular ligament.
• Sudden traction of the
forearm that extends and
pronates the elbow (like
the motion of pulling a
child off the ground by
his/her wrist).
Head (Nursemaid‟s Elbow)
• Most common age
1 - 4yrs
• Minimal pain if arm is
stationary but pain is
felt upon flexing or
supinating arm
• No associated
swelling, ecchymosis,
or neurovascular
deficit
• Radiography - Normal
findings

Nursemaid‟s Elbow Reduction

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Elbow Dislocation Elbow Dislocation

• Traumatic – FOOSH • Early reduction is
• Most common crucial, delay can
dislocation in peds, increase NV or
second most common
ligamentous injury
adult
• Associated fractures • Usually requires
common procedural sedation
• Over 90% posterior
• Arm with prominent
olecranon and
shortened forearm

Elbow Dislocation
• Elbow flexed to 90
degrees and supinated,
apply posterior pressure
to the humerus while a
second operator applies
downward pressure on
the proximal forearm. A
coupling is felt and
heard as the capitellum
slides over the coronoid
process and the joint
realigns

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Forearm Shaft Fractures Forearm Shaft Fractures

• Traumatic • Displaced fractures
• Pain, swelling, require reduction
possible deformity • Adequate reduction
• Nondisplaced can be referred as
fractures treated an outpatient
with splinting and • Inadequate
outpatient Ortho reduction or
referral comminuted fracture
Greenstick Fracture requires emergent
Ortho referral

Scaphoid, lunate, triquetrum,

The Wrist
pisiform

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Trapezium, trapezoid, capitate,

hamate
Wrist X Ray
• Optimal 2 views
– AP
– Lateral
– Scaphoid views for snuffbox tenderness

Normal Wrist AP
Normal Wrist • Articular surface of
AP radius distal to ulna

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Normal Wrist AP Normal Wrist AP

• Articular surface of
radius distal to ulna
• Joint spaces uniform
width 1-2mm
• Articular surface of
radius distal to ulna
• Joint spaces uniform
width 1-2mm
• Assess 3 carpal
arcs, should remain
unbroken
– Proximal carpals
distal and proximal
– Along
capitate/hamate

Normal Wrist Lateral Normal Wrist Lateral

• Articular surface
of radius with
about 10° of volar
(palmar) tilt

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Normal Wrist Lateral Wrist Fractures

• Articular surface • FOOSH most common mechanism of injury
of radius with • Specific injuries depending on the general age of the
patient:
about 10° of volar – 4-10years – Torus fracture of the distal radial
(palmar) tilt metaphysis
• Capitate, lunate – 11-16years – Salter-Harris II fracture involving the
physeal plate
and distal radius
– 17-40years – Scaphoid fracture
should be in a – Over 40years – Colles-type fracture
straight line

Colles Fracture
• Trauma – FOOSH
• Dorsal angulation
• Easily reducible extra-
articular fractures can
be splinted with
outpatient Ortho referral
• Intra-articular or unable
to reduce will require
emergent Ortho referral

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Smith‟s Fracture
• Trauma – reverse
FOOSH
• Volar angulation
• Easily reducible extra-
articular fractures can
be splinted with
outpatient Ortho referral
• Intra-articular or unable
to reduce will require
emergent Ortho referral

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Barton‟s Fracture Barton‟s Fracture

• Trauma • Reverse Barton‟s
• Intra-articular with volar
fracture involving displacement
dorsal rim of • Associated with
distal radius ulnar and carpal
• Dorsal fractures
displacement of • Highly unstable,
radius and carpus emergent Ortho
referral

Radial Styloid Fracture

• Trauma –
FOOSH
• Stable but can be
associated with
scaphoid fx and
scapho-lunate
instability
• Splint and refer

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Torus Fracture
• FOOSH
• Buckling of the
cortex with little
displacement
• Splint and
outpatient Ortho
referral

Salter Harris II Distal Radius

• FOOSH
• Above epiphysis
into metaphysis
• Splint and
outpatient Ortho
referral

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Scaphoid Fracture
• FOOSH
• Snuff box tenderness
• Rx: Immobilize in
thumb spica cast for 6
weeks
• Risk of delayed or
nonunion and AVN;
so, if fracture
uncertain on XR get
scaphoid views

Scaphoid Fracture Scaphoid Fracture

• If fracture still uncertain on scaphoid
views immobilize and repeat XR in one
Repeat
week
film at 7
days
Initial Films

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Scaphoid Fracture MRI

• Most fractures at waist of scaphoid – 80% - at risk of MRI is about 100%
AVN and nonunion sensitive and specific
• Proximal Pole fractures – 10% but highest risk of for scaphoid fractures
AVN and nonunion But it is expensive and not
• Distal Pole – 10% low risk of AVN always readily available
• Suspected fractures and nondisplaced waist/distal So, most of the time we
pole fractures treated conservatively – splint and rely on immobilization
refer and follow-up in
• Displaced and proximal fractures need operative uncertain cases
repair – splint and urgent referral < 72hrs

Triquetrum Fractures
• Traumatic
• 2nd most common
carpal fracture
• Point tenderness
of triquetrum
• Splint and
outpatient Orth
referral

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Carpal fractures
• Scaphoid and
triquetral fractures
95%, others much
more uncommon
• The remaining
fractures can all be
treated with splint
and outpatient Ortho
referral
Hamate fracture

Galeazzi Fracture/Dislocation
• Traumatic
• Radial shaft
fracture with
dislocation of the
distal radioulnar
joint
• Unstable,
emergent Ortho
referral

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Scapholunate dislocation
• Traumatic
• Scapholunate
Ligament injury
• Point tenderness
• Splint and
outpatient Ortho
referral

Lunate Dislocation Lunate Dislocation

• FOOSH, direct • Can attempt ED
trauma reduction
• Concavity of lunate • Often difficult and
empty, radius and will require operative
capitate remain in reduction
straight line • If unable to reduce,
• Lunate appears emergent Ortho
triangular on AP – referral
normally rectangular

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Perilunate Dislocation
• High energy trauma
• Whole of carpus
except lunate
displaced dorsally
• Concavity of lunate
empty
• Radius and lunate
remain in straight
line

Perilunate Dislocation The Hand

• Associated
fractures of carpal
bones and distal
forearm common
• Highly unstable,
emergent Ortho
referral

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Hand/Finger X Ray Hand XR AP

• Optimal 2 views of entire hand when
concerned about metacarpals or multiple
phalanges
– AP
– Lateral or Oblique
• Optimal 2 views of specific digit if only area of
suspected injury
– AP
– Lateral

Hand XR Lateral

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Boxer‟s (Puncher‟s) Fracture MCP Fractures

• Any scissoring indicates malrotation
• Traumatic,
punching injury
• Fracture of neck of
5th MCP
• Need to assess for
rotation clinically
and degree of
angulation on XR

MCP Fractures - Angulation Boxer‟s Fracture

• 2nd MCP fractures cannot tolerate anything > • Attempt reduction
10° for malrotation /
• 3rd MCP fractures cannot tolerate anything > angulation
20°
• Splint and
• 4th MCP fractures cannot tolerate anything >
outpatient Ortho
30°
referral
• 5th MCP fractures cannot tolerate anything >
40°

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MCP Spiral Shaft Fracture

• Trauma
• Similar to Boxer‟s –
assess for rotation /
angulation
• Reduction, splint
and outpatient
referral
• If unable to reduce
will need emergent
referral

Fracture/Dislocation MCP
Base
• Trauma
• Loss of normal joint
space (<2mm)
• Reduction is
necessary
• Splint if satisfactory
reduction otherwise
emergent Ortho

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Thumb

Bennett‟s Fracture
• Traumatic
• Most common
thumb fx
• Intra-articular
fracture /
dislocation of base
of 1st MCP
• Unstable, emergent
Ortho referral

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Rolando‟s Fracture
• Trauma
• Similar to
Bennett‟s but is
comminuted
• Unstable,
emergent Ortho
referral

Thumb Base Fracture

• Trauma
• Extra-articular 1st
MCP fracture
• No joint
involvement,
therefore stable
• Splint and
outpatient Ortho
referral

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Gamekeeper‟s or Skier‟s Gamekeeper‟s or Skier‟s

Thumb Thumb
• Forced abduction
of thumb
• Rupture or severe
stretching of ulner
collateral ligament
• Occasionally
associated with
avulsion fracture

Gamekeeper‟s or Skier‟s Gamekeeper‟s or Skier‟s

Thumb Thumb
• Weakened grip, • Assess for
swelling, pain, and instabilty with
ecchymosis stress testing or
• Partial tears without with stress X Ray
fracture and without
significant instability
can be treated
conservatively with
splinting

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Gamekeeper‟s or Skier‟s
The Finger
Thumb
• Urgent Ortho referral:
– No end point felt on
stress testing
– Deviation of 30
degrees on stress
testing
– Deviation of more than
20 degrees compared
with the other side
– Displaced avulsion
fracture

Finger Injuries
• Small fractures in
the finger can be
very important if
they involve the
tendons

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Mallet or “Baseball” finger Mallet or “Baseball” finger

• An injury of the
extensor tendon and
fracture of dorsal base
of distal phalanx
• Caused by hyperflexion
of DIP
• Splint and outpatient
referral, occasionally
needs percutaneous
pinning

Boutonniere Deformity
• Acutely after trauma
or progressive from
arthritis
• PIP hyperflexed,
DIP hyperextended
• Usually treated
conservatively
unless avulsion
fracture seen

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Volar Plate Fractures

• Forced
hyperextension
• Only seen on lateral
view
• Can be associated
with dislocation
• Unstable – Splint
with urgent Ortho
referral

Phalanx Fracture
• Common Injury
• Midshaft phalanx fx
with minimal
displacement treat
conservatively with
splinting
• Intra-articular
require splinting and
urgent Ortho referral

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Tuft Fracture
• Crush injury
• May have
associated soft
tissue or nail bed
injuries
• Closed fx can be
splinted and treated
conservatively
• Open injuries may
need referral

Finger Dislocation
• Common injury
• If successful
reduction can
splint and
outpatient referral
• If unsuccessful or
large fracture
fragment will
need Ortho

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Finger Dislocation Splints

• Used to temporarily immobilize
fractures, dislocations, and soft tissue
injuries.
• Circumferential casts abandoned in the
ED
- increased compartment syndrome and
other complications
• Splints ideal for the ED – allow swelling
and easier to apply

Indications for Splinting Specific Splints and Orthoses

Upper Extremity Lower Extremity
• Fractures • Elbow/Forearm • Knee
• Sprains – Long Arm Posterior – Knee Immobilizer / Bledsoe
– Double Sugar - Tong – Bulky Jones
• Joint infections – Posterior Knee Splint
• Forearm/Wrist
• Tenosynovitis – Volar Forearm / Cockup • Ankle
• Acute arthritis / gout – Sugar - Tong – Posterior Ankle
• Hand/Fingers – Stirrup
• Lacerations over joints
– Ulnar Gutter • Foot
• Puncture wounds and animal – Radial Gutter – Hard Shoe
bites of the hands or feet – Thumb Spica
– Finger Splints

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Long Arm Posterior Splint Double Sugar Tong

• Indications • Indications
– Elbow and forearm injuries:
– Distal humerus fx – Elbow and forearm fx - 10
– Both-bone forearm fx prox/mid/distal radius and
– Unstable proximal radius or ulnar fx.
ulna fx (sugar-tong better)
• Doesn‟t completely eliminate – Better for most distal
supination / pronation -either forearm and elbow fx
add an anterior splint or use because limits 90
a double sugar-tong if flex/extension and
complex or unstable distal
forearm fx. pronation / supination.

Forearm Sugar Tong Forearm Volar Splint aka „Cockup‟ Splint

• Indications
• Indications
– Soft tissue hand / wrist
– Distal radius and
injuries - sprain, carpal
ulnar fx.
tunnel night splints, etc
• Prevents pronation /
supination and – Most wrist fx, 2nd -5th
immobilizes elbow. metacarpal fx.
– Most add a dorsal splint
for increased stability -
„sandwich splint‟ (B).

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Hand Splinting Radial and Ulnar Gutter

• The correct position for most
hand splints is the position of
function, or the neutral position.
• This is with the hand in the “beer
can” position: wrist slightly
extended (10-25°) with fingers
flexed
• When immobilizing metacarpal •Indications •Indications
neck fractures, the MCP joint •Fractures, phalangeal and •Fractures, phalangeal and
should be flexed to 90°. metacarpal, and soft tissue metacarpal, and soft tissue
• Have the patient hold an ace injuries of the little and ring injuries of index and long
wrap (or a beer can if available) fingers. fingers.
until the splint hardens.

Thumb Spica Finger Splints

• Indications
– Scaphoid fx - seen or
suspected (check snuffbox • Sprains - dynamic
tenderness) splinting (buddy
– De Quervain tenosynovitis. taping).
• Notching the plaster (shown) • Dorsal/Volar finger
prevents buckling when splints - phalangeal
wrapping around thumb. fx, though gutter
• Wine glass position. splints probably
better for proximal
fxs.

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The Lower Extremity The Pelvis

• Pelvis
• Hip
• Femur
• Knee
• Tibia/Fibula
• Ankle
• Foot

Pelvis Anatomy Pelvis X Ray

• Optimal 1 view
– AP
– One of the few places where a single view
is sufficient

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Pelvis X Ray Pelvis X Ray

1. Ilium 1. Main pelvic ring
2. Sacrum 1
3
3. SI Joint
2
4. Acetabulum 4
5. Inf. pubic rami 6
5 7
6. Sup. pubic rami
7. Pubic symphysis

Pelvis X Ray Pelvis X Ray

1. Main pelvic ring 1. Main pelvic ring
2. Obturator rings 2. Obturator rings
3. SI Joints – equal
size

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Pelvis X Ray Pelvis X Ray

1. Main pelvic ring 1. Main pelvic ring
2. Obturator rings 2. Obturator rings
3. SI Joints – equal 3. SI Joints – equal
size size
4. Pubic symphosis – 4. Pubic symphosis –
aligned, width < aligned, width <
5mm 5mm
5. Sacral Foramina –
arcuate lines

Pelvis X Ray Pelvic Injuries

1. Main pelvic ring • 2 distinct patient groups:
2. Obturator rings – High velocity, high energy injuries often
3. SI Joints – equal due to road traffic accidents or fall from
size height
4. Pubic symphosis – • Can be associated with major organ injuries
aligned, width < and significant bleeding; these injuries can be
life threatening
5mm
– Low Velocity, low energy injuries due to
5. Sacral Foramina –
ground level falls
arcuate lines
6. Acetabulum

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Pelvic Injuries
• Pelvic Injuries classified by mechanism:
– Lateral compression
– Anterior-posterior compression
– Vertical shear
– Combination injuries
• With all pelvic fractures need to assess
the sacroiliac complex as this indicates
stability

Isolated Pubic Rami fracture

• Low velocity –
ground level fall
• May be isolated, but
second fracture
common
• Can present like hip
fracture
• Emergent ortho
referral, treated
conservatively

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Pubic Rami Fracture

• In elderly can be
low velocity, in
younger high
velocity
• Search for other
fractures/injuries
• Emergent Ortho

Sacral Fracture
• Stress fracture in
young, trauma in older
• Subtle, need to
compare arcades
bilaterally
• Rare as isolated
fracture in trauma
• Buttock pain/LBP
• Emergent Ortho,
treated conservatively

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Severe Lateral Compression

Fracture
• High velocity
• Risk of
hemorrhage,
organ injury
• Emergent Ortho,
Trauma surgery

Lateral Compression fractures

• Transverse fracture of rami and:
– Grade I - Associated sacral compression
on side of impact (often undiagnosed) -
stable
– Grade II - Associated posterior iliac
("crescent") fracture on side of impact -
relatively stable
– Grade III - Associated
contralateral sacroiliac joint injury -
unstable

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Pubic Symphysis Diastasis

• Low to moderate
velocity
• Widening of pubic
symphysis < 2cm
• No associated SI
disruption
• Stable
• Emergent Ortho

Open Book Fracture APC Injuries

• High velocity • Grade I - Associated widening (slight) of pubic
• Disruption of pubic symphysis or of the anterior sacroiliac (SI) joint, while
symphosis and ant/post sacrotuberous, sacrospinous, and posterior SI
SI joints ligaments remain intact
• Complete dissociation • Grade II - Associated widening of the anterior SI joint
of pelvis to axial caused by disruption of the anterior SI,
skeleton sacrotuberous, and sacrospinous ligaments;
• High rate of posterior SI ligaments remain intact
hemorrhage • Grade III (open book) - Complete SI joint disruption
• Emergent Ortho and with lateral displacement and disrupted anterior SI,
Trauma surgery sacrotuberous, sacrospinous, and posterior SI
ligaments

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Vertical Shear Injury

• Fall from height
• Symphyseal
diastasis, vertical
displacement
through the SI joint,
ccasionally iliac
wing or sacrum
• Emergent Ortho and
Trauma surgery

Combined Mechanism
• Trauma
• Combination of
these injury
patterns, with
LC/VS being the
most common
• Emergent Ortho
and Trauma
surgery

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Avulsion Fracture
• Young athletes due
to repeated
contractions of
strong muscles
• No disruption of ring
so stable
• Treat conservatively
with crutches and
outpatient Ortho

Hip/Femur

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Hip Anatomy Hip X Ray

• Optimal 2 views
– AP of whole pelvis – allows comparison of
both hips and view of pubic rami fracture
which can clinically appear like hip fx
– Lateral

Hip X Ray AP Hip X Ray Lateral

1. Acetabulum • Acetabulum
2. Femoral head • Femoral Head
3. Femoral neck 1 2
• Greater 3 2 1
4 trochanter
4. Greater 3
4
trochanter • Lesser trochanter 5
5
5. Lesser • Femoral Shaft
6
trochanter
6. Femoral shaft

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Acetabular Fracture
• Trauma, high
velocity
• Can be subtle
• May need
CT/MRI
• Emergent Ortho

More obvious acetabular

fracture

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Proximal Femur Fracture Proximal Femur Fracture

• Common injury in • Classified based on:
elderly due to – Relationship to hip capsule
osteoporosis and • Intracapsular
fall • Extracapsular

• In young due to – Geographic location

• Head
high velocity
• Neck (subcapital, transcervical)
trauma
• Trochanteric
• Also known as • Intertrochanteric
“hip fracture” • Subtrochanteric

Proximal Femur Fracture Proximal femur Fracture

• Head fx rare, associted
with hip dislocation and
trauma
• Neck, inter and
subtrochanteric,
common in elderly
• Trochanteric are
avulsion fx, more
common in young
athletes

Subcapital femur fracture

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Proximal Femur Fracture Proximal Femur Fracture

Can be missed
Initial • Missed fractures
Repeat 10 days later
can lead to AVN,
non-union
• If clinically
suspected but
neg XR need
further imaging –
CT, MRI or bone
scan

Skipped Capital Femoral

Epiphysis (SCFE)
• Pediatrics
• 10-16yrs, more
common
overwieght
• Hip or knee pain
occuring over a
few days to a few
weeks

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Skipped Capital Femoral Skipped Capital Femoral

Epiphysis (SCFE) Epiphysis (SCFE)
• Due to Salter • Rare but important
Harris type • Requires emergent
physeal fracture Ortho referral
and progressive • Frog-leg films in
widening leading suspected cases
– line thru center of
to AVN
femoral neck should
go thru center of
epiphysis

Hip Dislocation
• Trauma – High
velocity
• 80-90% posterior
• Need urgent
reduction with
Ortho as
complications
common

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Hip Dislocation

Femoral Shaft Fracture The Knee

• Trauma, high
velocity
• Emergent Ortho
referral

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Knee Anatomy Knee Anatomy

ACL

PCL

MCL
LCL Meniscus

Ottawa Knee Rules Knee X Ray

• Age 55 or over • Optimal 3 views
• Isolated tenderness of the patella (no bone – AP
tenderness of the knee other than the patella) – Lateral
• Tenderness at the head of the fibula – Sunrise Patella
• Inability to flex to 90 degrees
• Majority of knee injuries are soft tissue
• Inability to weight bear both immediately and
injuries (ligaments, tendons, meniscus)
in the ED (4 steps – unable to transfer weight
twice onto each lower limb regardless of
with normal X Ray
limping).

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Knee X Ray AP Knee X Ray Lateral

Knee X Ray Sunrise Knee X Ray

1. Patella • Perpendicular line
2. Femur at lateral margin
of femoral
1
condyle should
not have more
than 5mm of tibial
2 condyle outside it

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Knee X Ray
• Distance from
tibial tubercle to
lower patella
should be same
as length of
patella ±20%

Patella Fracture Patella Fracture

• Traumatic • Operative treatment
– disruption of the
• Pain, swelling, extensor mechanism
decreased ROM – articular incongruity
• Knee with more than 2 mm
of step-off
immobilization, – > 3 mm of separation
crutches and between primary
outpatient Ortho fracture fragments
referral

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Patellar Tendon Rupture

• Traumatic athletic
injury
• Patella proximally
displaced, swelling,
unable to weight
bear
• Immobilization,
crutches and urgent
Ortho referral

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Fat-fluid Level
• Indicates intra-
articular fracture
even when not
seen on XR
• Immobilzation,
crutches and
outpatient Ortho
referral

Femoral Condyle Fracture Femoral Condyle Fracture

• Trauma – axial • Associated with
lode neurovascular
• Pain over distal injury
femur, unable to • Emergent Ortho
weight bear referral
• Supracondylar,
intercondylar, or
condylar

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Tibial Spine Fracture

• Trauma
• More common in
peds 8-14yrs
• May be associated
with ACL tear
• Immobilization,
crutches and urgent
Ortho referral

Segond Fracture
• An avulsion fracture
of the lateral tibia
margin caused by
tension on lateral
capsular ligament
• 95% association
with ACL tear and
fairly high
association with
meniscus injuries

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Segond Fracture
Immobilize the knee
Urgent but not
emergent referral to
Orthopedic surgeon
If ACL injury
confirmed, surgical
repair within 2
weeks of the injury
(for best results)
indicated

Tibial Plateau Fracture Tibial Plateau Fracture

• Traumatic, often • For most,
immobilzation, crutches
high velocity and urgent Ortho
(pedestrian hit by referral
auto) • For fractures with >
3mm articular
• Associated with depression,
ligament injury comminuted or
displaced require
• Most common emergent Ortho
laterally

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Isolated Proximal Fibula

Fracture
• Traumatic - GLF
or stress fractures
• Pain, swelling but
patient may be
able to ambulate
• Immobilize,
crutches and
outpatient Ortho

Patellar Dislocation
• Traumatic
• Often diagnosed
clinically, may not
need XR
• Reduction,
immobilize, crutches
and outpatient
referral. If unable to
reduce will need
emergent Ortho

69

Patellar Dislocation
• Grasp ankle and lateral
aspect of knee with
fingers in the popliteal
space, thumb against
lateral patella
• Push against the patella
with thumb, slowly
straighten out the leg.
As leg extends, the
patella will reduce
Physical exam
• Assess for
effusion
• Active and
passive
ROM
01/09/2014
Knee Soft Tissue Injuries
• Majority of knee injuries are to the soft
tissues and have a normal XR
• Soft tissue injuries can cause significant
instability of the knee
• Can assess stability with thorough
physical exam
• Can be immobilized and have outpatient
follow-up
Tenderness to palpation
• Patella
• Tibial tubercle
• Head of fibula
• Patellar tendon
• Quadriceps
tendon
• Joint line
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Patellofemoral exam ACL stability

• Anterior drawer test -
• Patellar tracking knee in 90 degrees of
• Apprehension test flexion
– examiner tries to push • Lachman's test knee
the kneecap off to the is in 20 degrees of
side as the knee is flexion
slowly straightened. If
the patient is suddenly
• Tibia is drawn
apprehensive as he/she anteriorly, and
feels the kneecap about asymmetric
to slip out, the test is translation is an
said to be positive. indicator of ACL
injury.

PCL stability Collateral ligaments

• Posterior drawer - opposite of the anterior drawer
test. Push in against the proximal tibia while • Medial stress for MCL
anchoring the patient‟s foot on gurney • Lateral stress for LCL
• Stressed in full
extension and at 30
degrees of flexion.
Amount of opening
compared with
opposite knee
indicates severity of
injury.

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Meniscus evaluation
• McMurray‟s test
• Apley maneuver
– axial load against the
foot or ankle,
internally and
externally rotate the
tibia against the
femur. Pain with this
motion or clicking are
positive findings.

Tib-Fib fracture
• Trauma
• If nondisplaced,
then splint and
outpatient referral
• If displaced
emergent Ortho

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Toddler‟s Fracture The Ankle

• Child 1-3 yrs,
twist and fall
• Spiral fracture
tibia
• Splint and
outpatient Ortho
referral

Ankle Anatomy Ottawa Ankle Rules

• State that an ankle xray is required only if
there is pain in the “malleolar zone” and any
of these findings:
– Bone tenderness at the posterior edge/tip of
lateral malleolus (6cm)
– Bone tenderness at the posterior edge/tip of
medial malleolus (6cm)
– Inability to weight bear, both immediately and in
the emergency department.

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Ankle X Ray
• Optimal 2 views
– AP
– Lateral

Ankle X Ray
1. Uniform joint space
(mortisse)

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Ankle X Ray Ankle X Ray

1. Uniform joint space 1. Uniform joint space
2. Talar dome smooth 2. Talar dome smooth
3. Interosseous
ligament < 6mm
when measured at
a point 1cm from
tibial plafond

Distal Fibula Fracture

• Fracture of lateral
malleolus below the
mortisse joint
(Weber A)

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Distal Fibula Fracture Distal Fibula Fracture

• Weber • Weber A (below joint):
stable, so treated by
classification cast for 6 weeks – splint
depends on and outpatient Ortho
location of fibula • Weber B (at joint)
fracture, and relatively stable – splint
and urgent Ortho
determines the • Weber C (above joint):
management considered unstable –
emergent Ortho referral

Trimalleolar Fracture
• Trauma
• Bimalleolar and
trimalleolar
fractures
considered
unstable –
Emergent Ortho

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Collateral Ligament Rupture

• Inversion or
eversion injury
• Widening of
mortisse
• Can be without
associated fracture
• Stable - splint and
outpatient referral

Interosseous Ligament
Rupture
• Widened IO
space
• Without
associated
fracture – splint
and urgent Ortho
• With fracture –
emergent Ortho

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Maisonneuve Fracture
• Severe eversion
injury
• Medial malleolus
fracture, IO
rupture and fibula
fracture
• Unstable –
Emergent Ortho

Pilon Fracture
• Trauma – Talus
driven into tibial
plafond
• Fracture of tibial
plafond extending
into metaphysis
• Unstable –
Emergent Ortho

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Talus Fracture
• Trauma
• Can be subtle, if
suspected can get CT
• Nondisplaced fractures
splint and outpatient
Ortho
• Displaced, comminuted,
assoc pilon or calcaneal
fractures – emergent
Ortho

Calcaneus Avulsion Fracture

• Trauma – sudden
twisting
• Can occur at any
muscle
attachment
• Splint and
outpatient referral

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Calcaneus Stress Fracture

• Repetitive
microtrauma
• XR usually negative
for first 2 to 3 weeks
after pain onset
• Often initially
thought to be plantar
fasciitis
• Splint and outpatient
Ortho

Calcaneal Fracture
• Trauma – axial
loding (fall, MVA)
• Pain post foot,
unable to weight
bear
• Can be subtle

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Bohler‟s Angle Bohler‟s Angle

• Line drawn from • < 30° indicates
post calcaneum calcaneal fracture
to highest
midpoint and from
highest midpoint
to highest anterior
point. Should be
>30°

Calcaneal Fracture
• Any pilon, talus or
calcaneal fracture
from high velocity
injury need to exclude
fractures spine and
other LE injuries
• Isolated,
nondisplaced
fractures splint and
outpatient Ortho

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Ankle Dislocation Ankle Dislocation

• Emergent Ortho referral
• High velocity, rare
dislocation without • Reduction Posterior dislocation:
fracture 1. Slightly flex the knee to relax the achilles
• Majority posterior tendon
2. Have an assistant apply countertraction
• Associated with
3. Grasp the forefoot with one hand and the
ligament rupture and
heel with the other hand
NV compromise
4. Slightly plantar flex the foot
• Prompt reduction 5. Apply straight downward traction on the
needed plantar flexed foot, then pull the foot forward

The Foot Foot Anatomy

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Ottawa Foot Rules Foot X Ray

• State that a foot x-ray is required only if • Optimal 3 views
there is pain in the “midfoot zone” and – AP
any of these findings: – Oblique
– Bone tenderness at the base of the 5th – Lateral
metatarsal
– Bone tenderness at the navicular
– Inability to weight bear, both immediately
and in the emergency department

Foot XR AP Foot XR Oblique

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Foot XR Lateral Foot X Ray AP

• Medial margin of the
base of the second
metatarsal should
be in line with the
medial margin of the
middle cuneiform in
this view
• 1-2 mm joint space
between base 1st
and 2nd metatarsal

Foot X Ray Oblique

• Medial margin of the
base of the third
metatarsal should
be in line with the
medial margin of the
lateral cuneiform in
this view
• 1-2 mm joint space
between middle and
medial cuneiforms

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Cuboid Fracture
• Avulsion fracture
• Rare
• Splint and
outpatient referral

Navicular Fracture
• Acute fractures rare,
rarely isolated
• Stress fractures
occur in runners
• Can be very subtle,
may need CT
• Splint and outpatient
Ortho

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Metatarsal Stress Fracture

• Runners
• Initial films often
negative, CT or
repeat films in 2-3
weeks show
callus formation
• Splint and
outpatient Ortho

Tarsal Fracture
• Acute isolated
fractures rare
• Need to carefully
assess for other
fractures,
dislocation
• Splint and
outpatient Ortho

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Lisfranc Fracture/Dislocation Lisfranc Fracture/Dislocation

• Fractures at the
base of the
metatarsals
(usually the 2nd)
accompanied by
lateral subluxation
at the tarso-
metatarsal joints
• May be subtle observe
the alignment at base of
2nd / 3rd metatarsals
with cuneiforms
• Detect widening 2-5
mm between the bases
of the 1st and 2nd
metatarsals or between
the middle and medial
cuneiforms

Lisfrance Fracture/Dislocation
• Fracture at base
of 2nd metatarsal
strongly suggests
the diagnosis
• CT if suspicion
high
• Unstable,
emergent Ortho

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Dancer‟s Fracture
• Avulsion fracture
of proximal
tuberosity
• Stable, splint and
outpatient referral

Jones Fracture
• Fracture at base of
5th metatarsal
• 1.5 – 3cm distal to
tuberosity
• More likely to need Jones

operative repair
• Splint and urgent
Ortho Dancer‟s area

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Phalanx Fracture Lower Extremity Splints

• Common injury • Knee
– Knee Immobilizer
• Heal well with – Bulky Jones
conservative • Ankle
treatment – Posterior Ankle
– Stirrup
• Buddy tape and • Foot
hard shoe, – Hard Shoe
outpatient Ortho

Jones Compression Dressing

Knee Immobilizer
- aka Bulky Jones
• Procedure • Indications
• Indications – Stockinette and – Ligament/Tendon injury
– Short term immobilization Webril.
of soft tissue and – Patellar fracture
ligamentous injuries to the – 1-2 layers of thick
cotton padding. – Tibial Plateau fracture
knee or calf.
• Allows slight flexion and – 6 inch ace wrap.
extension - may add posterior
knee splint to further
immobilize the knee.

89

Posterior Ankle Splint
• Indications
– Distal tibia/fibula fx.
– Reduced dislocations
– Severe sprains
– Tarsal / metatarsal fx
• Use at least 12-15 layers of
plaster.
• Adding a coaptation splint
(stirrup) to the posterior splint
eliminates inversion /
eversion - especially useful
for unstable fx and sprains.
01/09/2014
Stirrup Splint
• Indications
– Similiar to posterior splint.
– Less inversion /eversion
and actually less plantar
flexion compared to
posterior splint.
– Great for ankle sprains.
– 12-15 layers of plaster.
90