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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

David.Heath@LMUnet.edu

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

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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

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3

Greenstick Fracture

•  Incomplete angulated w/ cortical breech to one side of bone

•  Usually mid-diaphyseal•  Treatment

–  Splint w/ F/U to ortho

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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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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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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

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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!

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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

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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

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Smith Fracture

Triquetrum Fracture

•  Most common dorsal chip fracture of wrist •  Pain on dorsum of wrist & ulnar styloid•  Painful to flexion

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2nd most common carpal fracture

Triquetral Fracture

DORSALVOLAR

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Upper Forearm Fractures

•  Galeazzi– DRUJ hurts, radial head does not

•  Monteggia– DRUJ painless, RH painful

•  Essex-Lopresti– BOTH DRUJ & RH painful

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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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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

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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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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

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PosteriorAnterior

LateralMedial

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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

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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

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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

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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: David.Heath@LMUnet.edu

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