We’ve Got A Bone To Pick

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We’ve Got a Bone to Pick .Pearls, Pitfalls & High-Yield OrthopedicsEducational ObjectivesUpon hearing & assimilating this program, clinician will bebetter able to:1. Identify each section of long-bone anatomy;2. Identify & describe various types of fractures, including transverse,oblique, spiral, comminuted & segmental;3. Correctly diagnose & describe pediatric fractures, including greenstick,buckle, & growth plate fractures using Salter-Harris classification;4. Identify & describe from radiographs common hand/wrist fractures,ankle/foot fractures, different types of hip fractures, common spinefractures & common shoulder fractures;5. Institute appropriate treatments for each of demonstrated fractures.David J. Heath, DO, MS, ATC, FAAEMFacility Medical Director, Emergency MedicineSaint Joseph-London HospitalAdjunct Clinical Professor, LMU-DCOMDavid.Heath@LMUnet.eduSystematic Approach to PE History– It’s ALL about that history! Observation– Abnormalities & symmetryLong BoneAnatomy Palpation– Temperature, tenderness Range of Motion– PROM & AROM Strength– Full & equal Special TestsHOPRSS– “Provocative” tests4561

Description of Fractures Open v. closed– Open bone exposed– Closed overlying soft tissue intactFractureNomenclature Location (be precise)– Left v. right– Anatomic orientation Proximal/distal, medial/lateral, anterior/posterior– Anatomic landmarks & name of bone Lines7– See next slide8Position & AlignmentLines of Fractures Degree of fracture Transverse– Complete v. incomplete– Right angles to long axis Oblique Rotation– Diagonal to long axis– Fragments rotated relative to each other– Interval v. external Spiral– Rotational force to shaft Angulation Comminuted– Loss of ANATOMICAL alignment in angular fashion– Valgus v. varus– Bone 2 fragments Segmental– Free floating central component– At least 2 fx lines present Displacement/shortening9– Loss of AXIAL alignment– Fragments shifted relative to each otherDescribe rotation,angulation &displacement bydirection of DISTALsegment! 10Descriptive Modifiers Position overall � Extends/involves articular surface Impaction/distraction– Shortening or widening– NO loss of alignment Pathologic– Suspected w/ trivial trauma Skeletal maturity– Growth plates present11122

Greenstick FractureBuckle (Torus) Fractures Incomplete angulated w/ cortical breech to oneside of bone Usually mid-diaphyseal Treatment Compression-type force applied to relatively soft,immature bone Incomplete fracture– Bulging of cortex– Trabecular compression 2* axial loading to long axis– Commonly involve distal radial metaphysis– Splint w/ F/U to ortho Treatment13– Volar fx Splint molded in EXTENSION– Dorsal fx Removable Velcro splintSolely relying onradiology report14Salter-Harris Fxs6%75%Infants � I to VSALTRSalter-Harris Fractures Demographics– Most common age 10 to 16 (80%)– Mostly males (2* delayed skeletal maturity)Hand & Wrist Physis (growth plate)– Composed of cartilage cells (not seen on XR)– Weaker than supporting ligaments Blood supply to GP from epiphysis– ñ epiphyseal injury ñ growth disturbances– Type I least growth disturbance– Type V most growth disturbance17183

19VOLARDORSALScaphoid Fracture Rare in kiddos Pain in snuffbox & ulnar deviation Imaging– 1st XR 14% missed– 2nd XR in 7 days– Bone scan to confirm dxMost common carpal fx(62-87% of all wrist fxs) Complication– High risk of AVN Treatment– Nondisplaced thumb spica splintScaphoid Blood Supply Scaphos peanutLunate & Perilunate Dislocations Lunate– MC carpal bone to dislocate– Volar swelling w/ palpable mass– Treatment Immediate reduction w/ surgical repair Perilunate– Dorsal swelling w/ palpable mass– TreatmentDORSALVOLAR Immediate reduction w/ surgical repair244

LunateDislocationPiece of Pie SignSpilled Teacup Sign Abnormal triangularappearance of lunateon AP XRAbnormal volardisplacement & tilt ofdislocated lunate25LunateDislocation26Lunate & Perilunate rs FractureBoxersFracture Fracture to neck of 5th metacarpal w/ volar angulation MOI– Punching injury TreatmentAlways suspect“Fight Bite”– Closed reduction ulnar gutter splint– Close F/U for loss of reduction29RotationaldisplacementUNACCEPTABLE!305

Colles’ Fracture Most common fracture in adults 50 yo “Dinner fork” deformity– Distal radius at metaphysis– Dorsal displacement– Ulnar styloid fracture common Treatment– Closed reduction cast x 6-8 wks– Intraarticular requires surgeryComplication Median nerve injury31Colles’Fracture32SmithFracture34Smith Fracture “Reverse” Colles’ fracture– Volar displacement of distal radius Associated median nerve and flexor tendon injury Treatment– Closed reduction33Triquetrum FractureTriquetral Fracture Most common dorsal chip fracture of wrist Pain on dorsum of wrist & ulnar styloid Painful to flexion2nd most commoncarpal fracture35VOLARDORSAL6

Upper Forearm FracturesGaleazzi Fracture Distal 1/3 radial fx, usually dorsal angulation Disrupted DRUJ Complication Galeazzi– DRUJ hurts, radial head does not Monteggia– Ulnar nerve injury– DRUJ painless, RH painful Treatment– ORIF Essex-Lopresti– BOTH DRUJ & RH painfulDRUJ confidently foundvia Lister’s tubercle 37GaleazziRadial fxUlnar fxMonteggiaMonteggia FractureEssex-Lopresti Fracture Apex of ulna fx points in direction of radial headdislocation Treatment– ORIF38GaleazziRadial fxUlnar fxMonteggia Radial head fractureDislocation of DRUJInterosseous membrane disruptionTreatment– ORIF generally needed3940Shoulder AnatomyThe Shoulder41427

Shoulder AnatomyShoulder AnatomySITS SupraspinatusInfraspinatousTeres minorSubscapularis43Clavicle Fractures44Clavicle Fractures Most common bone fractured in children Middle 1/3– Most commonly fractured (75-80%) Distal 1/3– Associated w/ ruptured coracoclavicular jt significant medial elevation Treatment– Nondisplaced sling x 3-4 wks à 3-4 wks, AROM– Displaced 100% (nonunion 4.5%) ORIF45Clavicle FracturesHumeral Shaft Fracture Medial 1/3– Uncommon– Requires STRONG forces– Search for associated injuries Most common associated injury radial nerveMedial 1/3 Considerintrathoracictrauma!– Injured in 20% cases– Most improve w/o intervention– Supination weak 2* radial innervation Indications for surgery––––46 ComplicationsDisplaced distal thirdOpenBilateralNeurovascular injury– R/O brachial artery injury Treatment47– Sling & swathe IF no nerve injury!– Nerve injury surgery488

Humerus Fractures Proximal humerus fracture– Injury to axillary nerve à deltoid fxn– Common w/ falls in elderly Midshaft distal fracture– Injury to radial nerve à wrist extension 1st web space– Consider PATHOLOGICAL fracture TreatmentProximalHumeralFracture49– Sling & swath x 4 wks, early ROM– Surgery compound fx or head displacement50Hip AnatomyTheHip5152Hip AnatomyAnterior53MedialPosteriorLateral549

Hip FracturesHip Fractures Intertrochanteric– Most common type Femoral neck– Common in elderly females– Complication aseptic necrosis Subtrochanteric– High energy injury in youngFemoral Neck Position Short ER ABDIntertrochanteric Position55 Short ER56Types of Hip chantericBase l NeckFracture596010

The Foot & Ankle62Weber ClassificationMaisoneuvve Fracture External ankle rotation– Mortis often open or unstable– Rupture of medial deltoid ligament– Proximal fibular fxBewarelitigation 2*peroneal nerveinjury Treatment– ORIFWeber AWeber BWeber C Inferior to tibiotalar jointNo syndesmosis disruptionUsually stableReduction castOccasional ORIF Level to tibiotalar jointPartial syndesmosisdisruptionVariable stabilityMay require ORIFAbove tibiotalar jointSyndesmosis disruptionUnstableMedial fx deltoid63ORIF64Bohler’s AngleCalcaneal Fractures Most common tarsal bone fx MOI compression 2* fall– Lumbosacral fxs– Contralateral calcaneus Bohler’s angle– Normal 20-40 – Decreased fracture656611

5th Metatarsal Fracture Pseudo-Jones (styloid) fracture– Avulsion fx of base of 5th metatarsal (peroneus brevis)– Inversion injury– TreatmentJones Fracture Distal to styloid processof 5th metatarsal Walking boot WB as tolerated Jones fracture– Transverse fx of proximal diaphysis– Common in athletes– TreatmentJones HIGH risk ofmalunion w/ running/jumping sports ORIF or castConsider even w/NORMAL XR!6768Lisfranc InjuryLisfranc Injury Disruption of 2nd metatarsal & Lisfranc ligament ?– Unstable 1mm between bases of 1st & 2nd metatarsal2nd Metatarsal Planar ecchymosis sign1st Metatarsal– Bruising in plantar aspect of midfootLisfranc joint TreatmentLisfrancjointcomplex– Nondisplaced 1mm NWB splint1st, 2nd & 3rdcuneiformsCuboid Reeval at 2 wks progressive WB x 6 wks– Displaced unstable & surgeryPain w/ torsion ofmidfoot 69HomolateralIsolatedDivergentUnstable Cervical Fxs Jefferson fx– Burst fx to ring of C1– Axial loading force (diving)TheCervicalSpine Bilateral facet dislocation––––Severe flexion injury50% subluxation of superior VBBoth ant/post ligament disruptionTypically in lower C-spine Odontoid fx (types 2 & 3)71– Dens of axis (C2)7212

Unstable Cervical FxsUnstable Cervical Fxs AA or AO dislocation Teardrop fx– Typically fatal– Head detached from spine– More common in kiddos– Hyperextension injury– Sudden pull of ALL intoant/inf aspect of VB(usually C2) Hangman C2 pedicular fx– Hyperextension injury– Chin hits dashboard in MVC– Ant C2 VB dislocation bilateral C2 pars interarticularis7374Thank you!Stable Cervical FxsDavid J. Heath, DO, MS, ATCCell: 865-585-0621Email: David.Heath@LMUnet.edu More common than unstable fxs––––Wedge fxProcess fx (SP &TP)Unilateral facet dislocationVertebral burst fx (excluding C1) All other fxs considered unstable or potentiallyunstable75Abbreviated References1.2.3.4.5.6.Babcock O’Connell C. A Comprehensive Review for the Certification andRecertification Examinations for PAs. 5th Ed. 2014Diamond MA. Davis’s PA Exam Review: Focused Review for the PANCE &PANRE. 1st Ed. 2008.Dietrich A et al. Carol Rivers’ Preparing for the Written Board Exam in EM.6th Ed. Ohio ACEP. 2014.Herbert M. Hippo PANCE/PANRE Board Review for the PA.Rhee JV. PA Board Review: Certification and Recertification. 2nd Ed.Paulk DP & Agnew D. JB Review: PA Review Guide. 2010.http://www.aapa.org/twocolumn.aspx?id 1306#review books13

Pseudo-Jones (styloid) fracture – Avulsion fx of base of 5th metatarsal (peroneus brevis) – Jones FractureInversion injury – Treatment Walking boot WB as tolerated Jones fracture – Transverse fx of proximal diaphysis – Jones HIGH risk of Common in athlet

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