orthopedic essentials in emergency medicine

Student Lecture Series

ORTHOPEDIC ESSENTIALS IN EMERGENCY MEDICINE

ORTHOPEDIC ESSENTIALS IN EMERGENCY MEDICINE

A GUIDE TO EMERGENCY DEPARTMENT ORTHOPEDICS

JOE BEIRNE, DO, FACOEP, FACEP

JOE BEIRNE, DO, FACOEP, FACEPATTENDING PHYSICIAN

EMERGENCY DEPARTMENTMISSOURI BAPTIST MEDICAL CENTER

ST. LOUIS, MISSOURI

MEDICAL DIRECTOR-EMS PROGRAMS ST. LOUIS COMMUNITY COLLEGE

ST. LOUIS, MISSOURI

ORTHOPEDIC ESSENTIALS

• Orthopedic emergencies are one of the most common presenting complaints in emergency medicine

• Basic knowledge of orthopedic injuries, fracture patterns and splinting techniques is essential for proper management of these cases

• Radiographic evaluation of fractures, and being able to describe them to the orthopedic surgeon, is paramount in emergency medicine

• Practical knowledge of fracture physiology provides the index of suspicion needed to diagnose an injury that might otherwise be missed


• Fractures are the result of a significant trauma to healthy bone• Bone cortex may be disrupted by direct trauma, axial loading,

angular forces, torque stress, or a combination of these forces• Pathologic fractures occur from relatively minor trauma to

diseased or otherwise abnormal bone• Pathologic process weakens the bone and renders it susceptible

to fractures by forces that, under normal circumstances, would not disrupt the bone cortex

• Common examples include metastatic lesions, fractures through bone cysts, vertebral compression fractures in osteoporotic patients


• Stress fractures are the result of a “fatigue” injury• The bone is subjected to uncustomary repetitive forces before

the bone and its supporting tissues can adapt to the forces• Classic example is the “march fracture” in a foot soldier

(metatarsal shaft fracture)• Pathophysiologic process that renders bone susceptible to

stress fracture has not been readily identified• Diagnosis depends on familiarity with the fracture, as

radiographs are typically normal early in the course of the process

• Fractures are often not seen until weeks or months have passed since the initial injury


• Salter-Harris fractures involve the epiphysis, or cartilaginous epiphyseal growth plate, near the ends of the long bones in children

• Named after the two physicians who devised the classification system for naming these fractures

• New bone material needed for elongation of bones during growth is provided by specialized cells within the physis

• When growth is complete, transformation of the physis into bone occurs, ultimately fusing with the surrounding bone

• Salter-Harris fractures cannot occur in adults


• Damage to the epiphyseal plate during bone growth can destroy all or part of its ability to produce new bone substance

• This may result in an aborted or deformed growth of bone• The earlier a Salter-Harris fracture occurs, the more likely the

chance of a deformity will occur• Fracture pattern is also a significant factor in the development

of deformity


• Fracture healing physiology is described in terms of three phases: inflammatory, reparative, and remodeling

• After the initial fracture, microvessels that cross the fracture line are transected; this results in ischemia to the damaged bone ends

• Damaged bone ends necrose, which triggers an inflammatory response

• Inflammatory phase is brief, but creates the tissue environment for the reparative phase


• The reparative phase begins with granulation tissue infiltratingthe fracture area

• Granulation tissue contains cells that secrete and form collagen, cartilage and bone; these form the callus, which eventually surrounds the fractured ends of the bone

• Callus is responsible for stabilizing the fractured bone ends• As the fracture heals, the callus becomes mineralized and very

dense• The necrotic edges of the fracture fragments are attacked by

osteoclasts, which resorb bone


• Remodeling is the final phase of bone healing• The bone gradually regains its original shape, contour and

strength• Remodeling often lasts years• Callus is resorbed, new bone laid down by osteoblasts• The trabeculae, linear densities easily seen on normal bone, are

the end result of the physiologic process that remodels bone and provides maximum strength in relation to the amount of bone used


• Success of bone remodeling depends of several factors• Young children have greater capacity for remodeling

compared to adults• Magnitude and direction of unreduced angulation, and fracture

location on the bone• Youth• Proximity of fracture to end of bone• Direction of angulation when compared to the plane of natural

joint motion• Decisions regarding fracture reduction require knowledge of

the physiology of bone healing and its relation to patient age


• Open, or compound fracture, is associated with communication between the bone and external surface of the body

• Can be as simple as a puncture wound that extends to the bone, or a large area of bone exposure

• Osteomyelitis is the most feared complication of open fracture• Can produce long-term morbidity, chronic pain, deformity,

antibiotic therapy, and often amputation despite all medical interventions

• All open fractures require prompt treatment and orthopedic consultation in the emergency department


• Joint dislocation is defined as the displacement of the articular surfaces of bones that normally meet at the joint

• Joint subluxation, by comparison, is when the articular surfaces are noncontiguous, to any degree. Dislocation is the most extreme form of subluxation

• Urgency of reducing dislocations is dependent of several criteria

• Neurologic or circulatory compromise is the most important, as the neurovascular bundle that lies in close proximity to the affected joint may be compressed around the dislocation


• Duration of dislocation is another consideration. It is generally considered an axiom that “the longer a joint is dislocated, the more difficult the reduction will be”

• This is due to the tremendous amount of edema, muscle spasm and soft tissue injuries that occur with the dislocation

• The most urgent dislocation you will deal with in the ED is hip dislocation. Prolonged dislocation of the femoral head puts the patient at high-risk of developing avascular necrosis, or AVN, of the femoral head

• The blood supply to the femoral head is via vessels that emerge from the acetabulum; when hip dislocation occurs, circulation to the femoral head is disrupted


• Emergency orthopedics requires careful history taking and physical examination

• “Just taking an x-ray” is a foolish habit to fall into, as you will miss other significant injuries

• Pain from fractures may be referred to other areas of the body; if you do not consider this, you will miss the injury

• Some standard radiographic series will not include special views that can determine injuries, i.e., the scaphoid or navicular view when a hand injury has occurred

• If you don’t order the special view, you’ll miss the injury


• The value of a good history cannot be overemphasized• Ask the patient specific questions regarding the injury, i.e.,

what were you doing when it occurred, how did you land, where did you feel pain, etc.

• In the case of hand injuries, ALWAYS ASK THE PATIENT IF THEY ARE LEFT OR RIGHT HANDED!

• In falls from heights, don’t stop at the feet or ankles; consider injuries to the tibia/fibula, femur, pelvis, and lumbar vertebrae

• General medical history should also be obtained• Determine if the patient is on anticoagulants, any other

significant history (cardiopulmonary) that may prolong recovery, especially if surgery is involved


• Physical examination of orthopedic injuries in the ED is based on a simple four step process

• Inspection (deformity, swelling, discoloration)• Assess range of motion (both active and passive) of the

affected bone, as well as consideration of the joints above and below the injured bone

• Palpation of the injury for deformity and tenderness• Neurovascular exam


• The heart of emergency orthopedics is being able to interpret radiographs

• The most important concept to grasp is this: KNOW WHAT IS NORMAL ON A RADIOGRAPH

• If you know what is normal, then identifying abnormal findings becomes natural

• Base your x-ray ordering on your history and physical exam, not on where the patient hurts

• Remember: x-ray the joint above and below the injury; injuries at proximal and distal ends of bones may both be present, especially in long bone fractures


• Always interpret your own radiographs; if you are uncertain of what you see, ask the radiologist for assistance

• You should have an excellent idea of what injury you anticipate seeing on the radiographs based on the history and physical examination

• Never consider the radiologist’s diagnosis the final word; significant injuries may not be apparent on the initial films, and may not be visible for up to a week post-injury.

• If you suspect the injury based on your history and exam, treat the injury as a fracture and splint it. This is your best defense against missed injuries!


• Describing radiographs is probably the most important skill you need to develop

• Orthopedic surgeons rely on your description to help them decide whether surgical or nonsurgical management is indicated

• Knowing what you are looking at, and how to describe this to the orthopedic surgeon over the phone, is an art form. Some will grill you endlessly, others will know immediately what you are describing to them

• “15 questions to ask yourself before calling the orthopedic surgeon” will assist you in radiographic interpretation


• 1. What bone is involved?• 2. Is there any violation of the skin at, or near the fracture site? • If so, the fracture is considered open. Clean wounds that are

less than 1 centimeter in length are classified as minimally open fracture.

• Wounds that are large or “dirty” (i.e., large avulsion flaps, road rash, etc) are classified as significantly open fractures

• 3. Are there any joint dislocations?• 4. How many fracture fragments do you see?• Two pieces is considered a simple fracture; more than two

pieces is considered a comminuted fracture


• Multiple fragments is considered severely comminuted• 5. Is there any angulation of the fracture? (angulation is named

for the relationship of the distal fragment to the proximal fragment)

• If so, what degree of angulation is present? Use a goniometerand measure the degree of angulation

• 6. If the fracture is in a pediatric patient, does it involve the growth plate?

• 7. What part of the bone is fractured? Fractures are named according to the “zone of thirds”, i.e., proximal, middle, distal third of the bone shaft


• Fractures may be present at the junction of the proximal and middle thirds, or junction of the middle and distal thirds

• 8. What is the fracture pattern? Fractures are classified as transverse, spiral, short oblique, long oblique, butterfly or comminuted?

• 9. Does the fracture enter a joint? • 10. If so, how many pieces of the joint are fractured? (simple

versus comminuted)• 11. Is the fracture completely displaced? Displacement is

measured by determining the alignment of the fragments.


• Displacement is measured as a percentage of the width of the bone shaft; if the distal fragment is 25% shifted away from the bone shaft, the displacement is considered to be 25%.

• 12. How does the fracture involve the joint? (i.e., is there good alignment, displacement with a step-off deformity, intraarticular fragment off of the joint line, fracture dislocation?)

• 13. Estimate the degree of displacement and shortening. Shortening is when the bone ends overly each other

• 14. Is there blanching of the skin? Describe the swelling at thefracture site


• Is the neurovascular function intact distal to the fracture site?• When was the last meal/fluid intake?• 15. Now, when you have answered all of these questions, call

the orthopedic surgeon.


• Control of pain and swelling after a fracture is of paramount importance in the emergency department

• Swelling increases pain, and may preclude placement of an appropriate immobilization device; increased swelling also increases the risk of pressure sores

• Start with simple therapies first! Cold and elevation are time-proven, effective and simple

• Control pain with narcotic analgesics as needed• Remember, narcotics are essentially useless for pain associated

with movement or manipulation of the bone fragments; a sedative/hypnotic and narcotic combination will control the pain of bone manipulation very well


• Remove jewelry, watches, rings, etc. when an extremity is fractured. As swelling continues after the fracture, delayed removal of these objects becomes almost impossible

• Any patient who may be a candidate for surgery must be kept NPO!

• Fracture reduction can be performed in the emergency department, after adequate control of pain and swelling

• Long-term goal is to restore normal anatomic position and function

• Reduction also alleviates acute pain, relieves blood vessel and nerve tension, and may restore circulation to a pulselessextremity


• Fracture reduction is a simple process• Once the patient’s pain has been controlled, consider adding a

sedative hypnotic prior to the reduction• Reduction is performed by applying gentle but steady,

longitudinal traction to the shaft of the bone• Joint dislocation reductions are also performed in the

emergency department• Adequate pain control is essential prior to the procedure• Use of a rapid-acting sedative/hypnotic, such as Etomidate,

will produce a relaxed state and facilitate successful reduction


• Open fractures warrant aggressive treatment and require admission

• Tetanus prophylaxis is mandatory• Thorough irrigation of the wound with Shur-Clens and sterile

saline will prevent further contamination• Early administration of antibiotics is not only mandatory, but

will prevent further contamination of the wound• Numerous antibiotic choices exist; there is no “gold standard”

regimen• Appropriate choices are first generation cephalosporin (i.e.,

Ancef) and aminoglycoside (i.e., Gentamicin)


• Most orthopedic injuries can be managed on an outpatient basis

• Patients must have the injury adequately immobilized before discharge

• Make sure each patient has a prescription for pain medication and understands their discharge instructions

• Make sure you have arranged follow-up with the orthopedic surgeon! The patient must also understand that it is their responsibility to contact the orthopedist as well for further care

• If you have any doubts about the patient’s ability to provide self-care, admit them

SUMMARY

• Emergency orthopedics is exciting, yet challenging• Know the anatomy of the musculoskeletal system• Perform a thorough examination; this will guide your choice of

radiographs• Know when to order special radiographic views to identify

specific injuries• Be able to interpret the radiographs yourself; if you are

uncertain if there is a fracture, ask the radiologist for assistance• Be able to describe the fracture to the orthopedist• Have the orthopedist consult in the department for open

fractures, compartment syndromes, irreducible dislocations, injuries that require surgery and circulatory compromise

orthopedic essentials in emergency medicine

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