Orthopedic Principles
William Beaumont Hospital
Department of Emergency Medicine
Fractures in Kids –
Salter Harris Classification
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Injuries to epiphyseal growth plate result from
compressive or shearing force
The weak cartilaginous growth zone separates
before tendons or bones
If unsure, get comparison views
Type I and V not always evident on x-ray, so
immobilize if clinically suspect fracture
Salter Harris Classification
Mnemonic “ ME ”
What Salter-Harris type is this?
Type 2
What Salter-Harris type is this?
Type 3
What Salter-Harris type is this?
Type 3
What Salter-Harris type is this?
Type 4
What Salter-Harris type is this?
Type 1
Examination Basics
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Determine the point of maximum tenderness
Examine the joint above and below the site of injury
Check for joint stability
Check the neurovascular status
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Is the fracture open?
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Neurovascular compromise requires emergent reduction of
the fracture or dislocation
Early Ortho consult
Signs of compartment syndrome – Five P’s
Compartment Syndrome
Ischemic injury to muscles and nerves in a closed
fascial compartment
Caused by edema in a closed compartment
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Decreased venous return
Eventual decreased arterial flow
Commonly seen with tibia or forearm fractures
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Most common lower extremity compartments:
anterior > lateral > deep posterior > posterior
Most common upper extremity compartment: deep flexor
compartment
Compartment Syndrome
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Fracture not necessary
Can occur with excessive muscle contractions,
crush injury, circumferential burns, prolonged
compression (i.e. drug OD)
Earliest and most reliable sign is referred pain to
the compartment with passive stretch of the
ischemic muscle group (i.e. plantar foot flexion
causes pain in the anterior leg compartment)
Compartment Syndrome - Signs
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Pain
 burning, poorly localized, disproportionate to
injury
 pain on active or passive stretch of muscles
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Paresthesias in distribution of nerves
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Pallor – late and ominous sign
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Paralysis
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Pulselessness – late and ominous sign
Compartment Syndrome
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Diagnosis – hand held device for measuring
compartment pressure
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Pressures > 30mmHg are abnormal
Treatment – immediate fasciotomy
Associated Nerve Injuries
ORTHO INJURY
NERVE INJURY
Elbow injury
Shoulder dislocation
Sacral fracture
Acetabular fracture
Hip dislocation
Femoral shaft fracture
Knee dislocation
median or ulnar
axillary
cauda equina
sciatica
femoral
peroneal
tibial or peroneal
Radiographic Evaluation
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Rule of two's
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Minimal of 2 views perpendicular to each other when
possible
Include 2 joints
Include 2 limb comparison views
2 sets of X-rays
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Pre-reduction and post-reduction films; obtain prereduction x-rays unless neurovascular compromise
Possible repeat x-ray in 7-10 days for suspected occult
fractures (i.e. scaphoid fractures)
Radiographic Evaluation
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Is the fracture intraarticular? – increased risk
of subsequent arthritis
Are the fragments distracted?
Is there a joint dislocation?
Treatment Principles
The first priority = ABCs
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Obvious fractures should NOT deter from ABCs.
Hypovolemic shock possible secondary to
fractures
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Pelvic fracture – 2 Liters
Femur fracture – 1.5 Liters
Multiple fractures
Worsened by third spacing
Treatment Principles
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For fractures: immobilize the joint proximal and
distal
For joint injuries: immobilize the affected joint
only
Reassess neurovascular status after
immobilization or manipulation
Consider analgesia and/or sedatives prior to
attempting reduction
Treatment Principles
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Plaster splinting
Circumferential casting rarely done in the ED
for an acute fracture  evolving edema may
lead to compartment syndrome
Ice and elevate for 48 hours post injury
Healing occurs over 4-10 weeks if properly
immobilized
Cervical Spine Injuries
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Etiology:
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MVC 50%
Falls 20%
Sports 15%
Classified as stable or unstable and by injury mechanism
(flexion, extension, rotation, compression)
Anterior column – vertebra, discs, and anterior and posterior
longitudinal ligaments
Posterior column – spinal cord, pedicles, facets, spinous
processes, held together by the nuchal and capsular
ligaments, and ligamentum flavum
Let’s move on to the
specifics…
Anatomy of the Cervical Spine
Navigating the C Spine X-ray
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Count vertebrae – if you don’t see C7 and the C7-T1
interface the film is inadequate
The Key – integrity of the anterior cervical line,
posterior cervical line and spinolaminar line
Anterior cervical line maintained by anterior
longitudinal ligament
Posterior cervical line maintained by the posterior
longitudinal ligament
Spinolaminar line maintained by ligamentum flavum
Cervical Spine Xray
Unstable Cervical Spine Injuries
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An unstable C spine injury occurs when there is
disruption of the ligaments of the anterior and
posterior column elements
Chance of spinal cord injury great
Unstable Cervical Spine Injuries
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C1 (Jefferson burst fracture)
C2 (Hangman fracture)
Odontoid fracture
Flexion tear drop fracture
Bilateral facet dislocation
Jefferson Burst Fracture
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Burst fracture of C1 ring
Mechanism: axial loading force on the occiput
Diving into shallow water
 Falling from a height
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Lateral displacement of the lateral masses
Disruption of the transverse ligament
Unstable, but often no neuro deficit because the
ring widens when it fractures limiting cord
compression
Jefferson Burst Fracture
Hangman Fracture
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Mechanism: skull is thrown into extreme
hyperextension as a result of abrupt deceleration
(i.e. MVC).
Bilateral fractures of the pedicles of C2
Spinal cord damage is minimal because the
bilateral fractures allow the spinal cord to
decompress
Unstable fracture
Hangman Fracture
Odontoid Fracture
15% of all C spine fractures
 Mechanism: MVC or fall
 Type 1 – tip fracture
 Type 2 – base fracture,
unstable, most common
60% of odontoid fx
 Type 3 – thru body of C3
very unstable
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Odontoid Fracture
Flexion Tear Drop Fracture
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Mechanism: flexion and axial loading forces
cause avulsion of anteroinferior portion of
vertebral body
Involves injury to anterior and posterior
longitudinal ligaments creating spinal instability
Often associated with spinal cord damage
Unstable fracture
Flexion Tear Drop Fracture
Stable Cervical Spine Injuries
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Wedge fracture
Vertebral body burst fracture
Clay Shoveler’s fracture
Transverse process fracture
Unilateral facet dislocation
Wedge Fracture
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Mechanism: Flexion injury causes a
longitudinal pull on the nuchal ligament
complex that, because of its strength, usually
remains intact.
The anterior vertebral body bears most of the
force, sustaining simple wedge compression
anteriorly without any posterior disruption.
The prevertebral soft tissues are swollen.
Stable fracture
Wedge Fracture
Vertebral Burst Fracture
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Mechanism: Downward compressive force is
transmitted to lower levels in the C spine 
vertebra can shatter outward, causing a burst
fracture
Disruption of anterior and posterior longitudinal
ligaments
Posterior protrusion of the fracture may extend
into the spinal canal and be associated with
anterior cord syndrome
Burst fractures require a CT or MRI to
document degree of retropulsion
Vertebral Burst Fracture
Clay Shoveler’s Fracture
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Avulsion of C6 or C7 spinous process
Mechanism: Abrupt flexion of neck combined
with muscular contraction of upper body/neck
muscles; can also result from a direct blow to
neck
Seen best on lateral C spine X-ray
Stable fracture
Clay Shoveler’s Fracture
Any questions about the
cervical spine?
Let’s Move On
Anterior Shoulder Dislocations
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Mechanism: abduction and external rotation
with a posterior force (line backer injury)
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98% are anterior
Signs & Symptoms: squared shoulder, held in
abduction/external rotation, anterior shoulder
appears full
Check axillary nerve function: abduction of
arm and sensory sergeant stripe distribution
Treatment: closed reduction by hanging weight,
scapular manipulation, traction/countertraction
Posterior Shoulder Dislocations
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2% are posterior
Most common cause is from a seizure
X-ray – light bulb sign
Anterior Shoulder Dislocations
Forearm Fractures
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Monteggia fracture – fracture of the proximal
1/3 ulna with an associated radial head
dislocation
Galeazzi fracture – fracture distal 1/3 radius
with dislocation of the distal radioulnar joint
Treatment – urgent Ortho consult for
operative repair
Monteggia Fracture
Galleazzi Fracture
Significance of the Fat Pad Sign
Anterior fat pad may be seen in normal elbow
but usually is a thin strip
 Posterior fat pad sign indicates occult fracture –
in children indicates supracondylar fracture and
in adults indicates radial head fracture
 Pathophysiology – intraarticular hemorrhage or
effusion causes distention of synovium making
posterior fat pad visible on X-ray
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Fat Pad Sign
normal anterior fat pad
abnormal fat pad
Wrist Fractures – Colles Fracture
 Distal
radius fracture with dorsal displacement of
the distal fragment
 Mechanism:
 Swan
fall on an outstretched hand
neck or dinner fork deformity
non-displaced  volar splint;
displaced/angulated  ortho referral
 Treatment:
Colles Fracture
Wrist Fractures –
Smith’s Fracture
 Distal
radius fracture with volar displacement of
the distal fragment
 Mechanism:
fall backwards on outstretched
hand, direct blow
 Treatment:
same as Colles
Smith’s Fracture
Exam of the Injured Hand –
Tendon Examination
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Flexor Digitorum Profundis
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Flexor Digitorum Superficialis
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Flex DIP joint against resistance, while blocking
MCP and PIP action
Flex MCP joint - block other digits
With partial tendon laceration - may be able to
flex or extend, but will be weak or painful
Exam of the Injured Hand
Sensory exam
 Ulnar: tip of little finger
 Median: tip of middle finger or pad of index
finger
 Radial: 1st dorsal web space
Motor exam
 Ulnar: Spear fingers against resistance, injury
causes a claw hand
 Median: oppose thumb (recurrent branch)
injury causes thenar eminence muscles to
atrophy giving the hand an “apelike” appearance
 Radial: extend wrist, injury causes wrist drop
Boxer’s Fracture
5th metacarpal fracture
Mechanism: punching
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Be suspicious of any laceration over the knuckles
Often the result of fist hitting mouth
High incidence of infection, may need antibiotics
Treatment: ulnar gutter splint to the PIP joint
Boxer’s Fracture
Mallet Finger
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Mechanism: distal tip of finger is forcibly flexed,
resulting in rupture or avulsion of the lateral
expansions of the extensor hood
Diagnosis: unable to extend DIP joint; defect
may not be seen for 5-7 days
Treatment: splint DIP joint in slight
hyperextension for full 6 weeks
Mallet Finger
Boutonniere Deformity
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Mechanism: injured central band of the extensor
hood
Diagnosis:
painful, swollen PIP joint
 tenderness over PIP joint fixed flexion of PIP
 hyperextension of DIP, unable to extend PIP
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Treatment: splint only the PIP joint in
extension
Boutonniere Deformity
Carpal Bone Injuries –
Scaphoid Fractures
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Most common carpal bone fracture
Mechanism: fall on the outstretched palm
Diagnosis: snuff box tenderness or tenderness
with axial loading of thumb
Treatment: thumb spica with volar splint
Complications:
Avascular necrosis if not correctly immobilized
 Non-union, because scaphoid with unique distal
origin of blood supply
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Scaphoid Fractures
OK, let’s move down
Pelvic Fractures
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The pelvis is a ring structure, so if see 1 fracture
you need to check for another
Associated with bladder rupture or membranous
urethral injuries
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Higher incidence with symphysis pubis fracture
Retrograde cystourethrogram if:
High riding boggy prostate
 Blood at urethral meatus
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Common cause of mortality is hemorrhagic
shock
Open book fracture
 Displacement of pelvic fracture > 0.5 cm
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Pelvic Fractures
Hip Dislocations
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80-90% are posterior high energy injury
Mechanism: strike knee on dash, while leg
flexed and adducted
Presentation: leg flexed, adducted, shortened,
and internally rotated with knee resting on
opposite thigh
Associated injuries: patellar fracture, sciatic
nerve (peroneal branch), femoral vessels
Treatment: immediate attempt at closed
reduction
Complications: Avascular necrosis
Hip Dislocations
Hip Dislocations
Hip Fracture
Hip Fracture
Hip Pain – Differential Diagnosis
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Referred pain from back or knee
Herniated disc
Discitis
Toxic synovitis, bursitis, tendonitis of hip
Septic joint
Occult fracture of hip
Tumor (lymphoma)
DVT or arterial ischemia
Osteomyelitis
Slipped capital femoral epiphysis
Tibial Plateau Fracture
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High energy injury in younger age group
Fall from height
 MVC
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Low energy injury due to compressive forces on
osteoporotic bones
Complications:
Popliteal artery injury
 Lateral condyle fracture
 Ligamentous injuries
 Compartment syndrome
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Tibial Plateau Fractures
Knee Dislocation
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Described by position of tibia in relation to
femur
Considered high energy injury
Anterior dislocation most common and caused
by hyperextension of knee
Posterior dislocation from direct trauma to
flexed knee
Initial evaluation may not reveal obvious
deformity because of spontaneous reduction 
so grossly unstable knee treated as if dislocation
occurred
Knee Dislocations - Complications
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Vascular injury to popliteal artery
Crucial to document DP & DT pulses
 Highly predictive of arterial injury when diminished
or absence
 Diagnose with arteriogram
 Early revascularization within 6 hours decreases risk
of amputation
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Peroneal nerve injury
Check sensation on dorsum of foot
 Dorsiflex the ankle
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Knee Dislocations
The End