ORTHOPEDIC
PRINCIPLES
William Beaumont Hospital
Department of Emergency Medicine
FRACTURES IN KIDS
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Salter Harris Classification
1. Injuries to epiphyseal growth plate result from
compressive or shearing forces
2. The weak cartilaginous growth zone
separates before tendons or bones
3. If unsure, get comparison views
4. Type I and V not always evident on x-ray, so
immobilize if clinically suspect fracture
NAME THAT SALTER HARRIS
FRACTURE
Salter Harris Classification
Mnemonic “ ME ”
A
B
C
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 - ie drawer sign (ankle, knee)
Check the neurovascular status of the extremity distal
to the site of injury.
Neurovascular compromise requires emergent
reduction of the fracture or dislocation
Is the fracture open – high risk of osteomyelitis
- consult Ortho early
Signs of compartment syndrome – Five P’s
COMPARTMENT SYNDROME
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Ischemic injury to the muscles and nerves in a particular
closed fascial compartment
Caused by edema in a closed compartment.
This leads to:
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Decreased venous return
Eventual decreased arterial flow
Commonly seen with tibia or forearm fractures
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Most commonly seen in lower extremity compartments
Anterior> lateral > deep posterior> posterior
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Upper extremities: deep flexor compartment
COMPARTMENT SYNDROME
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Fractures not necessary
Can occur with excessive muscle contractions, crush
injury, circumferential burns, prolonged
compression (ie. drug 0D)
Earliest and most reliable sign is referred pain to the
compartment with passive stretch of the ischemic
muscle group (ie plantar foot flexion causing pain in
the anterior leg compartment)
COMPARTMENT SYNDROME
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Signs
1. burning, poorly localized pain disproportionate to injury
2. pain on active or passive stretch of muscles
3. paresthesias in distribution of nerves
4. pallor – late and ominous sign
5. pulselessness – late and ominous sign
6. skin color, temperature, cap refill, and distal pulses
are important to document but are unreliable monitors
for compartment syndrome because the pressure needed to
produce compartment syndrome are well below arterial
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Diagnosis – hand held device for measuring compartment
pressure
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- pressures > 30mmHg are abnormal
Treatment – immediate fasciotomy
NERVE INJURIES
ACCOMPANYING ORTHO
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
XRAY EVALUATION
Rule of two's
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Minimal of 2 views perpendicular to each other when possible
Include 2 joints - the joint above and the joint below
Include 2 limb comparison views
Variant anatomy - ie. sesamoid bones
Particularly important to assess growth plates in kids
2 sets of x-rays
a. Prereduction and postreduction films
Obtain prereduction x-rays unless neurovascular compromise
b. Possible repeat x-ray in 7-10 days for suspected occult fractures
(ie scaphoid fractures)
Is the fracture intraarticular? – increased risk of subsequent arthritis
Are the fragments distracted?
Is there a joint dislocation?
TREATMENT PRINCIPLES
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The first priorities remain ABCs
Obvious fractures should NOT deter one from
following the ABCs.
Hypovolemic shock possible secondary to fractures
1. Pelvic fracture
2. Secondary to multiple fractures
3. Worsened by third spacing
loss of ECF as edema in injured soft tissue
seen with crush injuries
Possible blood loss secondary to specific fractures
1. Pelvic fracture - 2 Liters
2. Femur fracture - 1.5 Liters
3. Tibia or humerus fracture - 0.5 Liters
TREATMENT PRINCIPLES
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Immobilize the joint proximal and distal to the fracture
For joint injuries, immobilize the affected joint only
Always reassess neurovascular status after
immobilization or manipulation
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
Consider analgesia and/or sedatives prior to attempting
reduction -> propofol, etomidate, etc.
Cervical Spine Injuries
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MVC account for 50%, falls 20%, sports 15%
C spine fractures are classified as stable or unstable
and by the mechanism of injury (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 Xray
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Always count vertebrae – if you don’t see all of C7 and
the C7-T1 interface the film is inadequate
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The Key – integrity of the anterior cervical line,
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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
Cervical Spine Injury
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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
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Unstable fractures: C1 (Jefferson burst), odontoid,
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C2 (Hangman), flexion tear drop, bilateral facet
dislocation
 Stable fractures: wedge fracture, Clayshoveler’s
fracture, transverse process fracture, vertebral body
burst fracture, unilateral facet dislocation
Jefferson Burst Fracture
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Burst fracture of C1 ring
Axial loading force on the
occiput such as diving into
shallow water, falling from a
height.
Lateral displacement of the
lateral masses
Unstable fx, but often no
neuro deficit because the
ring widens when it fractures
limiting cord compression
Hangman Fracture
Hangman’s Fracture
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The result of a head on MVC where the skull is
thrown into extreme hyperextension as a result
of abrupt deceleration.
Bilateral fractures of the pedicles of C2 create
an unstable fracture
Spinal cord damage is minimal because the
bilateral fractures allow the spinal cord to
decompress.
Odontoid fracture
15% of all C spine fractures
 Result of 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 Teardrop Fracture
Flexion Tear Drop Fracture
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Flexion and axial loading forces cause avulsion
of anteroinferior portion of vertebral body.
Unstable fracture
Involves injury to anterior and posterior
longitudinal ligaments creating spinal instability
Often associated with spinal cord damage
Extension Tear Drop
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As with flexion teardrop fracture, extension teardrop fracture
also manifests with a displaced anteroinferior bony fragment.
The anterior longitudinal ligament pulls fragment away from
the inferior aspect of the vertebra because of sudden
hyperextension.
A true avulsion, in contrast to the flexion teardrop fracture in
which the fragment is produced by compression of the
anterior vertebral aspect due to hyperflexion
Common after diving accidents and tends to occur at lower
cervical levels
Associated with the central cord syndrome due to buckling of
the ligamentum flavum into spinal canal during the
hyperextension
Extension Tear Drop Fracture
Wedge Fracture
Wedge Fracture
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With a pure flexion injury, a longitudinal pull is
exerted 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.
On xray, the anterior border of the vertebral body
has diminished height and increased concavity along
with increased density due to bony impaction.
The prevertebral soft tissues are swollen.
Stable fracture
Burst Fracture
Burst Fracture
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Downward compressive force is transmitted to lower levels
in the cervical spine -> The body of the cervical vertebra
can shatter outward, causing a burst fracture.
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This fracture involves disruption of the anterior and
posterior longitudinal ligaments
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Xray - a vertical fracture line in the frontal projection and
protrusion of the vertebral body anteriorly and posteriorly.
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Posterior protrusion of the fracture may extend into the
spinal canal and be assoc with anterior cord syndrome.
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Burst fractures always require a CT or MRI to document
amount of retropulsion.
Clayshoveler’s Fracture
Clayshoveler’s Fracture
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Abrupt flexion of neck combined with
muscular contraction of upper body/neck
muscles causes avulsion of C6 or C7
spinous process.
Also a result of a direct blow to neck
Seen best on lateral c spine xray
Stable fracture
Any questions about
the cervical spine?
Let’s Move On
UPPER EXTREMITY INJURIES
SHOULDER DISLOCATION
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98% are anterior
Mechanism: abduction and external rotation with a posterior
force (line backer injury)
SSx: squared shoulder, held in abduction/external rotation,
anterior shoulder appears full
Check axillary nerve function
motor - abduction of arm
- Deltoid muscle (unable to do from pain)
sensory - sergeant stripe distribution
Treatment – closed reduction by hanging weight, scapular
manipulation, traction/countertraction
2% are posterior -> common cause = seizure
X Ray – light bulb sign
ANTERIOR SHOULDER
DISLOCATION
FOREARM FRACTURES
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Monteggia's 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
Fat Pad Sign
normal anterior fat pad
abnormal fat pad
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 xray
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WRIST FRACTURES
COLLES fracture
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Distal radius fracture with dorsal displacement of the distal
fragment
Mechanism: fall on an outstretched hand
Swan neck or dinner fork deformity
Treatment
non-displaced -> volar splint
displaced or angulated -> urgent orthopedic referral
SMITH’S fracture or “reverse Colles”
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distal radius fracture with volar displacement of the distal
fragment
Mechanism – fall backwards on outstretched hand, direct
blow
Treatment - same as Colles
COLLES’ FRACTURE
SMITH’S FRACTURE
EXAM OF THE INJURED HAND
Tendon examination of the hand
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Flexor Digitorum Profundis
 Flex DIP joint against resistance, while blocking
MCP and PIP action
Flexor Digitorum Superficialis
 Flex MCP joint - block other digits
With partial tendon laceration - may be able to flex or
extend, but will be weak or painful
For most injuries, immobilize fingers with MCP flexed
and PIP partially extended – position of function
(holding a can)
EXAM OF THE INJURED HAND
Hand - sensory exam
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Ulnar: tip of little finger
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Median: tip of middle finger or volar pad of index
finger
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Radial: 1st dorsal web space
Hand- motor exam
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Ulnar: abduct (spread) fingers against resistance,
injury causes a claw hand
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Median: oppose thumb (recurrent branch) injury
causes thenar eminence muscles to atrophy giving the
hand an “apelike” appearance
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Radial: extend wrist, injury causes wrist drop
Boxer’s fracture
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5th metacarpal fracture, less common 4th
metacarpal
Mechanism: punching
Be suspicious of any laceration over the knuckles
– often the result of fist hitting mouth, have a
high incidence of infection, and need to be
treated with antibiotics
Treatment: Ulnar gutter splint to the PIP joint
If laceration over MCP joint consider human bite
injury
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: injure central band of the extensor
hood
Diagnosis: painful, swollen PIP joint
tenderness over PIP joint fixed flexion of PIP
and hyperextension of DIP, unable to extend
PIP
Treatment: splint only the PIP joint in
extension
BOUTONNIERE DEFORMITY
CARPAL BONE INJURIES
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Scaphoid fracture of the wrist
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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
SCAPHOID FRACTURE
Mammalian Bites
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Dog bites are large superficial crush injuries
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Cat bites are usually puncture wounds that penetrate into
tendons and joints, often on the hand
Human bites are usually fight bites or closed fist injuries found
over the metacarpal joint with high rate of infection, over 60%
involve tendon
Bacteriology -
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Dog - often polymicrobial but Pasteurella multocida most
common (found in 25-50%)
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Cat - P multocida found in 70-90% of cats oral cavity
Human - Eikenella corrodens also Staph and Strep
Treatment
Prophylaxis with Augmentin or Cefuroxime
 Bactrim as alternate or Pen allergy
 Bite wounds of face & scalp can be sutured
 Do not suture puncture wounds,
contaminated or infected wounds, wounds
more than 12 hours old, or clenched fist
injuries
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OK, let’s move down
LOWER EXTREMITY INJURIES
PELVIC FRACTURE
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The pelvis is a ring structure, so if see 1 fracture you need to check for
another
Pelvic fractures are associated with bladder rupture or membranous
urethral injuries in 7-25% of cases -> higher incidence with symphysis
pubis fracture
Do retrograde cystourethrogram if:
1. High riding boggy prostate
2. Blood at urethral meatus
Most common cause of death in patients with pelvic fracture is
hemorrhagic shock
X Ray findings predictive of need for transfusion :
1. open book fracture
2. displacement of pelvic fracture .5 cm or more
PELVIC FRACTURES
LOWER EXTREMITY INJURIES
HIP DISLOCATION
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80-90% are posterior high energy injury
Mechanism - strike knee on dash, while leg flexed and adducted
Patient presents with the leg flexed, adducted, shortened, and internally
rotated with knee resting on opposite thigh
Associated injuries include:
Patellar fracture
Sciatic nerve (peroneal branch) - unable to dorsiflex great toe
Femoral vessels – common with anterior dislocation
Treatment: immediate attempt at closed reduction
Complication: avascular necrosis of femoral head
 incidence: 40% -> reduction of hip within 6 hours of dislocation
significantly reduces incidence of avascular necrosis
HIP DISLOCATION
HIP DISLOCATION
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
LOWER EXTREMITY INJURIES
TIBIAL PLATEAU FRACTURE
 High energy injury in younger age group
(like fall from height or MVA)
 Low energy injury from a compressive force on
osteoporotic bones
 Complications:
popliteal artery injury
 lateral condyle fx can cause peroneal nerve injury
 assoc. ligamentous injuries in 20-25% -> ACL, MCL
 compartment syndrome seen within 24-48 hrs
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TIBIAL PLATEAU FRACTURE
LOWER EXTREMITY INJURIES
KNEE DISLOCATION
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Dislocation described based on position of tibia in
relation to femur
Considered high energy injury
Anterior dislocation most common type and caused by
hyperextension of knee
Posterior dislocation from direct trauma to flexed knee
(ie. MVA - dashboard injury)
Initial evaluation may not reveal obvious deformity
because of spontaneous reduction -> so grossly unstable
knee treated as if dislocation occurred
LOWER EXTREMITY INJURIES
KNEE DISLOCATION
Complications:
1) Vascular injury to popliteal artery
• crucial to document DP & DT pulses – highly
predictive of arterial injury when diminished or absent
• diagnose with arteriogram
• early revascularization within 6 hours decreases risk of
amputation
2) Peroneal nerve injury
• check sensation on dorsum of foot
• dorsiflex the ankle
KNEE DISLOCATION
ACHILLES TENDON RUPTURE
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Usually occurs in middle aged men –> weekend warrior
Mechanism is sudden, forced dorsiflexion of the foot
 strong push off like runner accelerating from start
position
 basketball player going for a lay-up.
Risk factors – RA, SLE, gout, fluoroquinolones, steroid
use or injection
Feel pop or sharp pain at the back of the ankle
Visible or palpable defect and/or swelling of tendon
Thompson’s Test – assess the integrity of Achilles tendon
Surgery is the treatment of choice with 90% rate of return to
pre-injury activity
Thompson’s Test
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To assess the integrity of the Achilles tendon
Patient prone, squeeze calf muscle
Absence or weakened plantar flexion of foot
confirms rupture
THE END