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We’ve Got a Bone to Pick….�Pearls, Pitfalls & High-Yield Orthopedics
David J. Heath, DO, MS, ATC, FAAEMFacility Medical Director, Emergency Medicine
Saint Joseph-London HospitalAdjunct Clinical Professor, LMU-DCOM
Educational Objectives
Upon hearing & assimilating this program, clinician will be better able to:
1. Identify each section of long-bone anatomy;2. Identify & describe various types of fractures, including transverse,
oblique, spiral, comminuted & segmental;3. Correctly diagnose & describe pediatric fractures, including greenstick,
buckle, & growth plate fractures using Salter-Harris classification;4. Identify & describe from radiographs common hand/wrist fractures,
ankle/foot fractures, different types of hip fractures, common spine fractures & common shoulder fractures;
5. Institute appropriate treatments for each of demonstrated fractures.
Systematic Approach to PE• History
– It’s ALL about that history!• Observation
– Abnormalities & symmetry• Palpation
– Temperature, tenderness• Range of Motion
– PROM & AROM• Strength
– Full & equal• Special Tests
– “Provocative” testsHOPRSS
Long Bone Anatomy
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5 6
2
Fracture Nomenclature
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Description of Fractures
• Open v. closed– Open = bone exposed– Closed = overlying soft tissue intact
• Location (be precise)– Left v. right– Anatomic orientation
• Proximal/distal, medial/lateral, anterior/posterior
– Anatomic landmarks & name of bone
• Lines– See next slide 8
Lines of Fractures
• Transverse– Right angles to long axis
• Oblique– Diagonal to long axis
• Spiral– Rotational force to shaft
• Comminuted– Bone > 2 fragments
• Segmental– Free floating central component– At least 2 fx lines present 9
Position & Alignment
• Degree of fracture– Complete v. incomplete
• Rotation– Fragments rotated relative to each other– Interval v. external
• Angulation– Loss of ANATOMICAL alignment in angular fashion– Valgus v. varus
• Displacement/shortening– Loss of AXIAL alignment– Fragments shifted relative to each other 10
Describe rotation, angulation &
displacement by direction of DISTAL
segment!
Descriptive Modifiers
• Position overall• Intra/extraarticular
– Extends/involves articular surface• Impaction/distraction
– Shortening or widening– NO loss of alignment
• Pathologic– Suspected w/ trivial trauma
• Skeletal maturity– Growth plates present 11
Incomplete Pediatric Fractures
12
3
Greenstick Fracture
• Incomplete angulated w/ cortical breech to one side of bone
• Usually mid-diaphyseal• Treatment
– Splint w/ F/U to ortho
13
Buckle (Torus) Fractures
• 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
• Treatment– Volar fx = Splint molded in EXTENSION– Dorsal fx = Removable Velcro splint
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Solely relying on radiology report
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Dorsal Torus
Fracture
Salter-Harris Fxs
Separated Above Lower Through Rammed
SALTR
6% 75% 10% 10% 1%MOST
COMMONInfants & toddlers
Growth complications
ñ I to V
Salter-Harris Fractures
• Demographics– Most common age = 10 to 16 (80%) – Mostly males (2* delayed skeletal maturity)
• 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 disturbance 17
Hand & Wrist
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4
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DORSALVOLAR
Scaphoid Fracture
• Rare in kiddos• Pain in snuffbox & ulnar deviation• Imaging
– 1st XR = 14% missed– 2nd XR in 7 days– Bone scan to confirm dx
• Complication– High risk of AVN
• Treatment– Nondisplaced = thumb spica splint
Most common carpal fx (62-87% of all wrist fxs)
Scaphoid Blood Supply`
Scaphos = peanut
DORSAL VOLAR
Lunate & 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– Treatment
• Immediate reduction w/ surgical repair
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5
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Lunate Dislocation
Piece of Pie Sign• Abnormal triangular
appearance of lunate on AP XR
Spilled Teacup Sign• Abnormal volar
displacement & tilt of dislocated lunate 26
Lunate Dislocation
27
Perilunate Dislocation
Lunate & Perilunate Dislocations
DorsalVolar
Boxers Fracture
• Fracture to neck of 5th metacarpal w/ volar angulation
• MOI– Punching injury
• Treatment– Closed reduction + ulnar gutter splint– Close F/U for loss of reduction
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Always suspect “Fight Bite”
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Boxers Fracture
Rotational displacement
UNACCEPTABLE!
6
Colles’ Fracture
• Most common fracture in adults >50 yo
• “Dinner fork” deformity – Distal radius at metaphysis– Dorsal displacement– Ulnar styloid fracture common
• Treatment– Closed reduction + cast x 6-8 wks– Intraarticular requires surgery
31
Complication = Median nerve injury
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Colles’ Fracture
Smith Fracture
• “Reverse” Colles’ fracture– Volar displacement of distal radius
• Associated median nerve and flexor tendon injury
• Treatment– Closed reduction
33 34
Smith Fracture
Triquetrum Fracture
• Most common dorsal chip fracture of wrist • Pain on dorsum of wrist & ulnar styloid• Painful to flexion
35
2nd most common carpal fracture
Triquetral Fracture
DORSALVOLAR
7
Upper Forearm Fractures
• Galeazzi– DRUJ hurts, radial head does not
• Monteggia– DRUJ painless, RH painful
• Essex-Lopresti– BOTH DRUJ & RH painful
37
DRUJ confidently found via Lister’s tubercle
Galeazzi Fracture
• Distal 1/3 radial fx, usually dorsal angulation• Disrupted DRUJ• Complication
– Ulnar nerve injury • Treatment
– ORIF
38GaleazziRadial fxUlnar fxMonteggia
Monteggia Fracture
• Apex of ulna fx points in direction of radial head dislocation
• Treatment– ORIF
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GaleazziRadial fxUlnar fxMonteggia
Essex-Lopresti Fracture
• Radial head fracture • Dislocation of DRUJ• Interosseous membrane disruption • Treatment
– ORIF generally needed
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The Shoulder
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Shoulder Anatomy
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8
Shoulder Anatomy
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SITS• Supraspinatus• Infraspinatous• Teres minor• Subscapularis
Shoulder Anatomy
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Clavicle Fractures
• Most common bone fractured in children
• Middle 1/3– Most commonly fractured (75-80%)
• Distal 1/3– Associated w/ ruptured coracoclavicular jt + significant medial elevation
• Treatment– Nondisplaced = sling x 3-4 wks à 3-4 wks, AROM– Displaced > 100% (nonunion 4.5%) = ORIF 45
Clavicle Fractures
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Clavicle Fractures
• Medial 1/3– Uncommon– Requires STRONG forces– Search for associated injuries
• Indications for surgery– Displaced distal third– Open– Bilateral– Neurovascular injury
47
Medial 1/3 =Consider intrathoracic trauma!
Humeral Shaft Fracture
• Most common associated injury = radial nerve– Injured in 20% cases– Most improve w/o intervention– Supination weak 2* radial innervation
• Complications– R/O brachial artery injury
• Treatment– Sling & swathe IF no nerve injury!– Nerve injury = surgery
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9
49
Proximal Humeral Fracture
Humerus Fractures
• Proximal humerus fracture– Injury to axillary nerve à deltoid fxn– Common w/ falls in elderly
• Midshaft distal fracture– Injury to radial nerve à wrist extension + 1st web space– Consider PATHOLOGICAL fracture
• Treatment– Sling & swath x 4 wks, early ROM– Surgery = compound fx or head displacement
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The �Hip
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Hip Anatomy
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Hip Anatomy
53 54
PosteriorAnterior
LateralMedial
10
Hip Fractures
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• Intertrochanteric– Most common type
• Femoral neck– Common in elderly females– Complication = aseptic necrosis
• Subtrochanteric– High energy injury in young
Femoral Neck Position• Short + ER + ABDIntertrochanteric Position• Short + ER
Hip Fractures
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Types of Hip Fxs
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Subcapital Transcervical Base Neck
Intertrochanteric Peritrochanteric Subtrochanteric58
Left Intertrochanteric
Fracture
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Left Subcapital
Femoral Neck Fracture
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Right Subtrochanteric
Fracture
11
The Foot & Ankle
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Weber A• Inferior to tibiotalar joint• No syndesmosis disruption• Usually stable• Reduction + cast• Occasional ORIF
Weber C• Above tibiotalar joint• Syndesmosis disruption• Unstable• Medial fx + deltoid• ORIF
Weber B• Level to tibiotalar joint• Partial syndesmosis
disruption• Variable stability• May require ORIF
Weber Classification Maisoneuvve Fracture
• External ankle rotation– Mortis often open or unstable– Rupture of medial deltoid ligament– Proximal fibular fx
• Treatment– ORIF
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Beware litigation 2* peroneal nerve injury
Calcaneal Fractures
• Most common tarsal bone fx
• MOI = compression 2* fall– Lumbosacral fxs– Contralateral calcaneus
• Bohler’s angle– Normal = 20-40°– Decreased = fracture
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Bohler’s Angle
66
12
5th Metatarsal Fracture
• Pseudo-Jones (styloid) fracture– Avulsion fx of base of 5th metatarsal (peroneus brevis)– Inversion injury– Treatment
• Walking boot + WB as tolerated
• Jones fracture– Transverse fx of proximal diaphysis– Common in athletes – Treatment
• ORIF or cast 67
Jones = HIGH risk of malunion w/ running/jumping sports
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Consider even w/ NORMAL XR!
Jones Fracture• Distal to styloid process
of 5th metatarsal
Lisfranc Injury
• Disruption of 2nd metatarsal & Lisfranc ligament– Unstable ≥ 1mm between bases of 1st & 2nd metatarsal
• Planar ecchymosis sign– Bruising in plantar aspect of midfoot
• Treatment– Nondisplaced < 1mm = NWB + splint
• Reeval at 2 wks + progressive WB x 6 wks
– Displaced = unstable & surgery
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Pain w/ torsion of midfoot
Lisfranc Injury
• ?
2nd Metatarsal
1st Metatarsal
Lisfranc joint
1st, 2nd & 3rd cuneiforms
Lisfranc joint
complex
Cuboid
Homolateral Isolated Divergent
The Cervical
Spine
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Unstable Cervical Fxs
• Jefferson fx – Burst fx to ring of C1– Axial loading force (diving)
• Bilateral facet dislocation– Severe flexion injury– 50% subluxation of superior VB– Both ant/post ligament disruption– Typically in lower C-spine
• Odontoid fx (types 2 & 3)– Dens of axis (C2) 72
13
Unstable Cervical Fxs
• AA or AO dislocation– Typically fatal– Head detached from spine– More common in kiddos
• Hangman C2 pedicular fx– Hyperextension injury– Chin hits dashboard in MVC– Ant C2 VB dislocation + bilateral C2 pars interarticularis
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Unstable Cervical Fxs
• Teardrop fx– Hyperextension injury– Sudden pull of ALL into ant/inf aspect of VB (usually C2)
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Stable Cervical Fxs
• More common than unstable fxs– Wedge fx– Process fx (SP &TP)– Unilateral facet dislocation– Vertebral burst fx (excluding C1)
• All other fxs considered unstable or potentially unstable
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Thank you!David J. Heath, DO, MS, ATC
Cell: 865-585-0621Email: [email protected]
Abbreviated References1. Babcock O’Connell C. A Comprehensive Review for the Certification and
Recertification Examinations for PAs. 5th Ed. 20142. Diamond MA. Davis’s PA Exam Review: Focused Review for the PANCE &
PANRE. 1st Ed. 2008.3. Dietrich A et al. Carol Rivers’ Preparing for the Written Board Exam in EM.
6th Ed. Ohio ACEP. 2014.4. Herbert M. Hippo PANCE/PANRE Board Review for the PA.5. Rhee JV. PA Board Review: Certification and Recertification. 2nd Ed.6. Paulk DP & Agnew D. JB Review: PA Review Guide. 2010.
http://www.aapa.org/twocolumn.aspx?id=1306#review_books
