FRACTURE

MANAGEMENT
BASICS FOR ED
 Objectives
 General Principles of Fracture Management
• Fracture Mechanisms
• Salter-Harris Fractures
• Fracture Complications
 Upper Extremity Injuries

Patrick J. Lynch, medical illustrator; C. Carl

• Shoulder
• Arm
• Forearm
• Wrist
• Hand
 Lower Extremity Injuries

Jaffe, MD, cardiologist.

• Pelvis
• Hip
• Femur
• Lower leg
• Ankle
• Foot
Wikipedia
 Types of Fractures
 Complete Fractures
• Fracture involving both cortical surfaces
 Incomplete Fractures
• Only one cortex is disrupted
• Two types:
 Torus fracture = Buckle fracture = Buckling of one
cortex
 Greenstick fracture = Break in one cortex and
bending or bowing of other cortex
 Closed Fractures
• No communication with external environment
 Open Fractures
• Communication with external environment through
break in skin and soft tissue
• High risk for infection (Osteomyelitis)
 Complete vs. Incomplete Fracture
 Complete  Incomplete
Fracture Fracture
• Torus Fracture

• Greenstick
Fracture
 Closed vs. Open Fractures
 Closed Fracture  Open Fracture
 Salter-Harris Fractures
 Epiphyseal growth plate is weaker than
supporting ligaments
• Growth Plate (Physis) is made up of cartilage cells
that are weaker than the supporting ligaments
 Salter-Harris fractures are fractures involving
long bones in children and involve the growth
plate or joint surface
• Most common in children 10-16 (80%)
• More common in males due to delayed skeletal
maturation and increased physical activity compared
with females of same age
 May lead to growth complications
• Blood supply to the growth plate comes through the
epiphysis and the worse the injury to the epiphysis,
the greater the likelihood of growth disturbances
 Fractures are categorized on scale 1-5 and
increasing number indicates increasing
potential for growth complications
Salter-Harris Classification
Complications of Fractures
 Immediate
Complications
 Intermediate

Complications
 Long Term

Complications
 Immediate Complications
 Hemorrhage
• Can be extensive especially with Pelvic Fractures
 Vascular Injuries
• Anterior Shoulder Dislocation = Axillary Artery
• Extension Supracondylar Fracture = Brachial Artery
• Posterior Elbow Dislocation = Brachial Artery
• Knee Dislocation = Popliteal Artery
 Nerve Injuries
• Anterior Shoulder Dislocation = Axillary Nerve Injury
• Humeral Shaft Fractures = Radial Nerve Injury
• Supracondylar Fracture = Medial, Radial and Ulnar Nerve
Injury
• Medial Epicondyle = Ulnar Nerve Injury
• Post Elbow Dislocation = Ulnar/Medial Nerve Injury
• Olecranon = Ulnar Nerve Injury
• Acetabular Fracture = Sciatic Nerve Injury
• Posterior Hip Dislocation = Sciatic Nerve Injury
• Anterior Hip Dislocation = Femoral Nerve Injury
• Knee Dislocation = Peroneal/Tibial Nerve Injury
• Lateral Tibial Plateau Fracture = Peroneal Nerve Injury
 Soft Tissue/Visceral Injuries
Intermediate/Long Term Complications
 Intermediate Complications
• Compartment Syndrome
• Fat Embolism Syndrome
 Long-Term Complications
• Reflex Sympathetic Dystrophy
• Volkmann’ s Ischemic Contracture
• Non-union
• Avascular Necrosis
• Angulation Deformities
• Infection
• Joint Stiffness
• Post-traumatic Ossification or Arthritis
 Compartment Syndrome
 Results from crush injury and fractures to
long bones – distal radius, tibial shaft
 Swelling and bleeding in compartment
increases pressure to above that able to
maintain normal perfusion of affected area
 Most common = Anterior Tibial Compartment
 Symptoms = Pain, Pallor, Paresthesias,
Pulseness, Paralysis (5 P’ s)
 Diagnosis = Compartment Pressures
• Indication for surgery = 40-50 mmHg
 Treatment = Fasciotomy
THE SHOULDER AND UPPER ARM
 Joint Injuries
 Sternoclavicular Joint
Injuries
 Acromioclavicular Joint

Injuries
 Glenohumeral Joint

Dislocation
 Sternoclavicular Joint Injuries
1
Sternoclavicular Ligament

2
Costoclavicular Ligament
 Sternoclavicular Joint Injuries
 Classification
• 1st Degree = Sprain = Partial tear of sternoclavicular
and costoclavicular ligaments with mild subluxation
• 2nd Degree = Subluxation = Complete tear of
sternoclavicular ligament with partial tear of
costoclavicular ligament
 Clavicle subluxates from the manubrium on x-ray
• 3rd Degree = Dislocation = Complete tear of both
sternoclavicular and costoclavicular ligaments with
complete dislocation of clavicle from the manubrium
 Anterior = Most common
 Posterior = True Emergency – 25% will have concurrent
life-threatening injuries to adjacent mediastinal
structures
 Mechanism of Injury
• Direct force over sternoclavicular joint (posterior
dislocation)
• Fall onto shoulder with anterior or posterior
dislocation
 Sternoclavicular Joint Injuries
 Signs/Symptoms
• Tenderness and pain over joint
• Pain with movement of shoulder
• Patients with posterior dislocation = shortness of
breath, dysphagia or choking due to compression of
mediastinal structures
 X-rays = Regular x-rays or CT for extensive
injuries
 Treatment
• 1st Degree = Sling x 3-4 days, Analgesia
• 2nd Degree = Figure of Eight Clavicular Strap or Arm
Sling, Orthopedic Follow-up
• 3rd Degree = Immediate Orthopedic consultation and
rapid reduction
 Posterior dislocation may require reduction in operating
theatre
 Posterior dislocation may need to be reduced with
traction on clavicle with towel clip
 Apply figure of eight strap or arm sling
 Acromioclavicular Joint
1
Acromioclavicular
Ligaments

Coracoclavicular
2
Ligaments
 Acromioclavicular Joint Injuries

 Signs/Symptoms
• Tenderness/Swelling over the joint
• Pain with movement of affected extremity
• Upward displacement of clavicle (seen with type 3 or
worse)
Acromioclavicular Separation - III
 Acromioclavicular Joint Injuries
 X-rays
• AP views of clavicle
• Stress views not commonly used anymore and do not
alter course of treatment
• Findings
 1st degree = Radiographically normal
 2nd degree = Increased distance between clavicle and
acromion (< 1 cm)
 3rd degree = Increased distance between the clavicle and
acromion (> 1 cm)
 Treatment
• Type 1 = Sling x 1-2 weeks
• Type 2 = Sling, Orthopedic referral
• Type 3 = Immobilize in sling, Prompt orthopedic
referral within 72 hours
• Type 4-6 = Sling, Prompt orthopedic referral, Likely
will require surgical management
 Glenohumeral Joint Dislocation
 Shoulder Dislocation = Most Common dislocation seen
in the ED
 Classification

• Anterior (95-97%)
• Posterior (2-4%)

 Mechanism of Injury
• Anterior = Abduction, Extension and External Rotation
• Posterior = Seizure or Electric Shock
 Fall on forward-flexed, adducted and internally rotated arm
 Signs and Symptoms
• Prominence of acromion process and flattening of normal
contour of the shoulder (anterior)
• Anterior flatness, posterior fullness and prominence of
the coracoid process (posterior)
 X-rays
• Standard Series = AP Shoulder + Transcapular lateral or
Y view
• Y view is diagnostic in posterior dislocation and
without Y view, may be missed
 Glenohumeral Joint Dislocations
 Anterior  Posterior Displacement
Dislocation • AP = Internal Rotation
• Inferior displaced of humerus = “ Light bulb
sign”
humerus
• Y view = Humeral head
displaced
 Glenohumeral Joint Dislocation
 Treatment
• Reduction using a variety of techniques
• Shoulder dislocation with associated fracture should be
referred to orthopedics for reduction
• Make sure to evaluate vascular and nerve exam post reduction
and obtain a post-reduction film
• After reduction, patient should be placed in shoulder
immobilizer and orthopedic follow-up arranged
 Complications
• Recurrence = Most common complication
 Age related (younger the patient, the more likely of a reoccurrence)
• Bony Injuries
 Hill-Sachs Deformity = Compression fracture or groove of
posterolateral aspect of humeral head
• Results from impact of humeral head on the anterior glenoid rim as it
dislocates or reduces
 Avulsion of greater tuberosity (Increased in patients > 45 y/o)
 Bankart’ s Fracture = Fracture of the glenoid lip
• Nerve Injuries
 May occur during dislocation or reduction and most neuropraxias will
recover over time
 Axillary nerve (most common) or Musculocutaneous nerve
• Rotator Cuff Tears
• Axillary Artery Injury (rare) – suspect in elderly patients
with weak pulse or rapidly expanding hematoma
 Shoulder Reduction Techniques
 External Rotation Method (Hennipen
Technique)
• Gentle external rotation
• If no success, slowly lift abduct arm,
lifting humeral head into joint
 Shoulder Reduction Techniques
 Traction-Counter traction
Shoulder Reduction Techniques
 Stimson or Hanging Weight
 Fractures
 Clavicle Fractures
 Scapular Fractures

 Humeral Fractures
 Clavicle Fractures
 Classification
• Middle 1/3
 Most common area to fracture (especially in children)
• Distal 1/3
 May be associated with ruptured coracoclavicular joint with
medial elevation
• Medial 1/3
 Uncommon, requires strong injury forces
 Consider intrathoracic injury (i.e. Subclavian Artery or Vein
Injury)
 Mechanism = Fall on outstretched shoulder or direct
clavicle trauma
 Symptoms/Signs = Pain, Swelling over fractured region
 Imaging = CXR or dedicated Clavicle films
 Treatment
• Indications for surgical repair
 Displaced distal third
 Open
 Bilateral
 Neurovascular Injury
• Treatment = Sling, Orthopedic Follow-up
 Non-operative management is successful in 90%
Clavicle Fracture
 Scapular Fractures
 High Energy Mechanism
• Look for associated injuries – chest wall/ intra
thorasic
 Classification (by location of fracture)
• Body
• Neck
• Glenoid
 Mechanism of Injury
• Direct blow to the scapula Glenoid
• Trauma to the shoulder
• Fall on outstretched arm
 Clinical Features
• Pain over back side of shoulder
• Shoulder pain increased with abduction of the arm
 Imaging
• Routine shoulder x-rays will demonstrate most
scapular fractures
• Axillary lateral view – helpful with fractures of
glenoid fossa, acromion, coracoid process Neck
• CXR – to r/o associated lung or pulmonary injury
 Treatment
• Sling immobilization x 2 weeks, Early range of Body
motion exercises
• Orthopedic referral for ORIF for severely
displaced or angulated fractures

Gray’ s Anatomy
(Wikipedia)
 Humeral Fractures
 Types
• Proximal Humerus Fractures
• Mid-shaft Humerus Fractures
Proximal Humerus Fracture
 Proximal Humerus Fractures
 Imaging = Plain film x-ray imaging
 Treatment

• One part fractures

 Immobilization with shoulder
immobilizer sling and swath,
Analgesia, Ortho follow-u

• Two/Three/Four Part fractures =

Immobilize and emergent orthopedic
referral
 Many will require surgical repair
 Mid-shaft Humerus Fractures
Typically involve middle 1/3 of the humeral
shaft
 Mechanism of Injury
•Direct Blow (Most common)
•Fall on outstretched arm or elbow
•Pathologic Fracture (especially Breast Cancer)
 Clinical Presentation
•Pain and deformity over affected region
•Associated Injuries
 Radial Nerve injury = Wrist Drop = Inability of extend
wrist, fingers, thumb, Loss of sensation over dorsal web
space of 1st digit
• Neuropraxia at time of injury will often resolve
spontaneously
• Nerve palsy after manipulation or splinting is due to nerve
entrapment and must be immediately explored by orthopedic
surgery
 Ulnar and Median nerve injury (less common)
 Brachial Artery Injury
 Mid-shaft Humerus Fractures
 Imaging = Standard x-ray imaging
 Treatment

• Most managed non-operatively

(either):
 Coaptation splint (sugar tong)

plus sling and swath

 Hanging cast

• Operative management for patients:

 Neurovascular compromise,

pathologic fractures
THE ELBOW AND FOREARM
 Elbow Injuries
 Elbow Fractures
• Supracondylar Fractures
• Olecranon Fractures
• Condylar Fractures
• Articular Surface
Fractures
• Epicondylar Fractures
 Dislocations
• Posterior Elbow
Dislocation Gray’ s Anatomy (Wikipedia)

• Anterior Elbow
Dislocation
• Radial Head Subluxation
(Nursemaid’ s Elbow)
 Radiographic Elbow Evaluation
 Elbow radiographic evaluation can be difficult
 True Lateral X-ray = Hourglass or Figure of 8 at distal Humerus
 Fat Pad Signs
• Posterior Fat Pad Sign = Never seen on normal x-ray imaging
 Indicates distension of joint capsule by effusion with likely occult
fracture
 Often associated with occult radial head fracture
• Anterior Fat Pad Sign = Small one may be present on normal x-rays
 Increased anterior fat pad (sail sign) is abnormal and may indicate
fracture
 Anterior Humeral Line
• Line drawn along anterior surface of humerus and extending through the
elbow
• Normally, transects the middle of the capitellum but with
Supracondylar fractures, transects the anterior 1/3 of the capitellum
or passes completely anterior to the capitellum
 Radial-Capitellar Line
• Line drawn through the middle of the radius
• Normally, transects the middle of the capitellum
• Abnormal line may indicate radial head dislocation or subtle fracture
 Radial Head Evaluation
• Carefully inspect the radial head.
• Fracture may be subtle and only clue may be slight cortical
irregularity
 Distal Humerus Evaluation
• Careful inspection and evaluation of anterior humeral head line
Elbow Radiographic Evaluation
 Supracondylar Fractures
• Mechanism of injury = Fall on outstretched arm
with elbow in extension

• Imaging = Distal humerus fractures and humeral

fragment displaced posteriorly
 Sharp fracture fragments displaced anteriorly
with potential for injury of brachial artery
and median nerve

• Treatment
 Emergent Orthopedic Consultation

 Non-displaced fracture = Immobilization in

posterior splint
• May be discharged home with close follow-up
 Displaced fracture = Prompt reduction with
percutaneous pin fixation or internal fixation
by orthopedic surgeon
• If vascular compromise on evaluation, ED
physician should attempt reduction
 Other Elbow Fractures
 Olecranon Fracture

• Mechanism = Direct blow to point of

Elbow
• Clinical Feature
 Swelling/tenderness over Olecranon
 Inability to extend elbow against
gravity

• Treatment
 Non operative - rare
 TBW/ Plating

 Condylar Fracture

• Distal Humerus comprised of medial

and lateral condyles, Condylar
fractures involve both the articular
surface and the non-articular surface
 Lateral condyle fractures are most
common
Elbow Dislocation
 Elbow Dislocations
 Posterior (Most Common)
• Mechanism of Injury = Fall on extended and abducted arm
• Clinical Findings = Marked swelling with posterior
prominence of Olecranon
• Imaging = Lateral view of elbow
• Associated Injuries
 Fractures (30-60% of cases)

 Ulnar or Median nerve injury

 Brachial artery injury – Consider angiography is

suspect arterial injury

• Treatment = Reduction
 Traction distally at wrist with assistant
immobilizing the humerus
 While maintaining traction, flex the elbow and apply
posterior pressure to the humerus
 Elbow will exhibit “ clunk” when reduced
 Reassess ROM of elbow and neurovascular status

 Immobilize in long-arm posterior splint in 120

degrees of flexion (i.e. full flexion)
 Observe for delayed vascular compromise
Elbow Dislocations
 Radial Head Subluxation
 Nursemaid’ s elbow = Subluxation of
radial head beneath the annular ligament
 Mechanism of injury = Longitudinal
traction on hand or forearm with arm in
pronation
 Clinical Findings = Child with arm
dangling at side and unwilling to use it
 X-rays not necessary
 Treatment = Reduction
• Thumb over radial head with concurrent
supination of forearm and flexion of elbow
• Extension and pronation (another option for
reduction)
Radial Head Subluxation
 Forearm Injuries
 Radial Head Fracture
 Galeazzi Fracture
 Nightstick Fracture
 Monteggia’ s Fracture
 Both bone Forearm Fracture
 Radial Head Fracture
 Mechanism of Injury = Fall on outstretched hand
 Clinical Finding = Tenderness and swelling over the
radial head
 Imaging
• May not be seen on initial x-ray
• Evaluate for anterior or posterior fat pad which
suggests diagnosis

 Treatment
• Non-displaced = Sling immobilization, Ortho
follow-up
• Comminuted/Displaced Fractures = Immobilization in
posterior long arm splint
 Early orthopedic referral (2-5 days) for screw
fixation or radial head excision
 Galeazzi Fracture
 Distal Radius Fracture
• Distal radio-ulnar
dislocation
 Mechanism of Injury
• Direct blow to back of
wrist
• Fall on outstretched hand
 Complication = Ulnar
nerve injury
 Treatment = ORIF
 Monteggia’s Fracture
 Proximal 1/3 Ulnar Fracture
• Dislocation of radial head
 Mechanism of Injury = Direct
blow to posterior aspect of
ulna
• Fall on outstretched hand
 Imaging = Elbow/Forearm x-
rays
• Radial head dislocation
missed in 25% of cases
• Carefully examine the
alignment of radial head
 Associated Injury = Radial
Nerve Injury
 Treatment
• ORIF (Adults)
• Closed Reduction/Splinting
(Children)
 Nightstick Fracture
 Isolated fracture of
ulnar shaft
 Mechanism - Direct blow
to ulna with patient
raising forearm to
protect face
 Treatment
• Non-displaced -
Immobilization in cast
• Displaced
 >10 degrees angulation or
displacement > 50% of ulna
 Orthopedic referral - ORIF
 Both Bone Forearm Fracture
 Fracture of both ulnar and
radius
• Usually displaced fracture
 Mechanism of Injury = Direct
blow to forearm
 Associated Injury
• Peripheral Nerve Deficits
• Development of compartment syndrome

 Treatment
• Non-displaced (rare) =
Immobilization in bivalved cast
• Displaced – ORIF
 Closed reduction may be possible
in children
WRIST AND HAND INJURIES
 Hand and Wrist Injuries
 Wrist Injuries
• Fractures
• Dislocations

 Hand Injuries
• Fractures
• Dislocations
• Tendon Injuries
• Amputated Digits
 Distal Forearm/Wrist Fractures
 Colles’ Fracture
• Transverse fracture of distal radius with dorsal
displacement of distal fragment
• Mechanism = Fall on outstretched hand
• Most common fracture in adults > 50 years old
• Exam = Classic Dinner Fork Deformity
• Associated Injuries
 Ulnar styloid fracture
 Median Nerve Injury
• Treatment
 Non-displaced Fracture
• Sugar Tong Splint, Referral to Orthopedic Surgery
 Displaced Fracture
• Prompt reduction – Finger traps and manipulation under
conscious sedation or with hematoma block
• Immobilization in Sugar tong splint
• Referral to Orthopedic Surgery
 Distal Forearm/Wrist Fractures
 Smith Fracture (Reverse Colles)
• Transverse fracture of distal radius
with volar displacement
• Mechanism = Fall on outstretched arm
with forearm in supination
• Associated Injury = Median Nerve Injury
• Treatment
 Reduction with finger traps and manipulation
 Immobilization in sugar tong or long arm
splint
 Orthopedic referral
 Distal Forearm Fractures
 Colles’  Smith Fracture
Fracture
 Wrist Fractures
 Carpal Injuries
• Scaphoid Fracture (Most Common)
 Mechanism = fall on outstretched hand
 Imaging – Initial x-rays may fail to demonstrate
fracture
• > 10% of cases
• Repeat Imaging in 2 weeks will often show fracture
 Clinical findings = tenderness in anatomical snuff
box
 Treatment
• Non-displaced or clinically suspected fracture
 Thumb spica Splint

• Displaced Fracture = ORIF

• Complications
 Avascular necrosis or proximal fragment

 Delayed union or malunion

 Wrist Fractures
 Scaphoid Fracture
 Wrist Fractures
 Carpal Fractures
• Triquetrum Dorsal Chip Fracture (2 nd most
common)
 Mechanism = Fall on outstretched hand
 Exam = Tenderness on palpation distal to ulnar styloid on
dorsal aspect of wrist, painful flexion
 Best visualized on lateral view of wrist
 Treatment = Volar splint
• Lunate Fracture
 Mechanism = Fall on outstretched hand
 Exam = Pain over mid-dorsum of wrist increased with axial
loading of 3rd digit
 Plain x-rays are often normal
 Treatment = Immobilization in thumb spica splint,
orthopedic referral
 Complications
• Kienbock’ s disease = Avascular necrosis of proximal segment
 Carpal Fractures
 Triquetrum  Carpal Bone
Fracture Review

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 Carpal Dislocations
 Mechanism of Injury = Violent
Hyperextension
 Treatment - Orthopedic Consultation
 Lunate Dislocation
• Pain, swelling and loss of flexion of wrist,
hand and arm when held in anatomic position
• X-ray
 AP View = “ Piece of Pie” sign
 Lateral View = “ Spilled teacup sign”
 Perilunate Dislocation
• May be associated with Scaphoid fracture
 Lunate vs. Peri-lunate Dislocation
 Lunate  Peri-lunate
Dislocation Dislocation
• Capitate is • Lunate is centered
centered over the over the radius
radius and the and capitate is
lunate is tilted tilted out
out
• Tea cup deformity
 Carpal Dislocations
 Scapholunate Dislocation
• Most common ligamentous injury of hand
and is commonly missed
• Pain with wrist hyperextension, snapping
sensation with radial/ulnar deviation
• Radiographic signs
 Scaphoid is foreshortened and has a dense ring
shaped image around its distal edge (signet
ring sign)
 Widening of space between the lunate/scaphoid
• > 3 mm, Terry Thomas sign

• Treatment = Thumb spica, Hand Referral

Scapholunate Dislocation
 Hand Fractures
 Distal Phalanx (15-30% of hand fractures)
• Mechanism is typically crush or shearing forces
• Classified as Tuft, Shaft or Intra-articular fractures
• Fractures at base may be associated with flexor or tendon
injuries
• Treatment is typically protective splinting (hairpin
splint or finger splint)
 Proximal and Middle Phalanx
• No tendon attachments
• Mechanism
 Direct blow = transverse or comminuted fracture
 Twisting Mechanism = Spiral fracture
• Fractures are typically stable
• Treatment
 Stable and Nondisplaced impacted or transverse fx = Buddy taping
 Stable fractures with no angulation or rotation = Radial or Ulnar
gutter splint
 Unstable fractures = Internal fixation with Kirschner wires
 Hand Fractures
 Metacarpal Fractures
• Head
 Mechanism = Direct blow or projectile injury with comminuted fracture
 If laceration is present over MCP = Suspect Fight bite
 Any displacement gives poor outcome
 Treatment = Ice, Elevation, Immobilization in soft bulky dressing,
Referral to hand surgery
• Neck (Most common)
 Mechanism = Direct impaction force
 Boxer’ s fracture = 5th MC neck fracture
 Fractures are typically unstable with volar angulation and/or
rotation
 Acceptable angulation depends on digit
• 2nd and 3rd MC < 15 degrees angulation acceptable
• 4th < 20 degrees angulation acceptable
• 5th < 40 degrees angulation acceptable
 Rotation Exam = Look for malalignment of plane of fingernails in
flexed position
 Treatment
• Anatomic reduction if unacceptable angulation or rotational deformity
• Splint with wrist in 20 degree extension and MP flexed at 90 degrees
 Hand Fractures
 Metacarpal Fractures (Cont’ d)
• Shaft
 Mechanism = Direct Blow or indirect blow with
application of a rotational force
 Rotational deformity is more common than neck
fractures
 Rotational deformity is unacceptable for 2 nd and 3rd MC
 If anatomic reduction is necessary, operative
fixation is typically required
 Treatment
• Nondisplaced fractures = gutter splint
• Displaced or angulated fractures = Elevation, Ice, Immobilization
and Consultation for reduction and follow-up
• Base
 Mechanism = Direct blow or force applied to hand
 Stable injuries
 Often associated with carpal bone fractures
 Treatment = Bulky hand dressing or volar splint
 Metacarpal Fractures
 Metacarpal  Boxer’ s
fractures Fracture

< 15o < 15o < 20o < 40o

 Hand Fractures
 Bennett’ s  Rolando’ s Fracture
Fracture • Comminuted T or Y
shaped fracture
• Intra-articular involving the joint
fracture of thumb base surface
with subluxation or • Axial loading injury
dislocation of MC joint with hand closed
• Axial loading injury • Treatment
with hand closed  Ice, Elevation
• Treatment  Immobilization in thumb
 Ice, Elevation spica splint
 Emergent Orthopedic
 Immobilization in
Consultation
thumb spica splint
• Requires ORIF
 Emergent Orthopedic  Worse prognosis
Consultation
• Anatomic reduction
necessary (ORIF)
 Intra-articular Thumb Fractures
 Bennett’ s  Rolando’ s
Fracture Fracture
 Finger Dislocation
 DIP = Uncommon
 PIP = Common
• Dorsal dislocation very common, usually due to axial load and
hyperextension
• Reduction = Distraction and slight hyperextension with
repositioning
• Splint at 30 degrees flexion for 3 weeks
• Can’ t reduce = Volar plate entrapment
 MCP
• Less common than PIP
• Mechanism is typically due to hyperextension forces that
rupture the volar plate and cause dorsal dislocation
• Simple dislocations can typically be managed with closed
reduction and splinting in flexion, referral to hand surgeon
• Complex dislocations characterized by volar plate entrapment
in joint space and makes closed reduction in these cases
nearly impossible
 Requires open reduction and repair
 Amputated Digits
 Preservation of
Amputated Digit
• Irrigate amputated part
with normal saline to
remove gross contamination
• Wrap in sterile gauze
moistened with saline
• Place in sterile water
tight container
• Store the container in ice
water
 Criteria for Re-implantation
• Young, healthy patient with
normal vital signs
• Sharply incised wound with
minimal associated tissue
destruction
• Amputated thumb
• Multiple digit amputation
• Amputation in child
LOWER EXTREMITY INJURIES
 Pelvic Fractures
 Mechanism of Injury
• Motor Vehicle Accidents
• Falls
• Crush Injuries
• Take-down injuries (Car vs. Pedestrian)
 Classification (Young Classification)
• AP Compression
 Type 1 – Disruption of pubic symphysis (< 2.5 cm), No posterior
pelvis injury
 Type 2 – Disruption of pubic symphysis (> 2.5 cm), Ligamentous
injury
 Type 3 – Complete disruption of pubic symphysis and posterior
ligamentous complex with hemipelvic displacement
• Lateral Compression
 Type 1 – Posterior Compression of SI joint without ligamentous disruption,
oblique ramus fracture
 Type 2 – Rupture of posterior sacroiliac ligament, pivotal internal
rotation of hemipelvis with crush injury to sacrum and oblique ramus
fracture
 Type 3 – Type 2 + AP compression injury to contralateral hemipelvis
 Pelvic Fractures
 Imaging = Plain film, CT imaging
• CT superior in evaluating acetabulum,
posterior arch and SI joint

• Special views
- Inlet view
- Outlet view
- Judet’s views
 Pelvic Fracture
 AP Compression  Lateral
Type Injury Compression Type
Injury
 Pelvic Fractures
 Treatment
 Associated Injuries • Evaluation for secondary
• Hemorrhage injuries
 1st cause of death from • Avoid excessive movement
pelvic fx
• Antishock pelvic clamp in
 Up to 6L of blood in
retroperitoneum
patients with evidence of
fracture and instability
 50% of patients require
transfusion • Type I – Conservative treatment
• Urethral and Bladder • Type 2 – Single Ring Fractures
 Conservative treatment
Injuries
• Type 3 – Double Ring Fractures
 Most commonly associated
injuries
 Unstable, Immobilize, External or
Internal Fixation, Orthopedic
• Vaginal Laceration or Consultation, Embolization of
hemorrhage
rupture
• Type 4 – Acetabulum fracture =
• Rectal Injuries Displaced fractures require
surgical repair
Pelvic Binder
 Hip Fractures
 Classification
• Intracapsular
 Femoral Head, Subcaptital or Neck Fracture
• Extracapsular
 Trochanteric, Intertrochanteric or Subtrochaneteric
 Clinical Presentation
• External rotation, flexion, shortened leg
• Pain with attempted ROM – especially internal/external
rotation
 Imaging
• Plain films will diagnose most hip fractures
• CT or MRI for patients with occult fracture
 Patients with negative plain films who cannot ambulate should be
examined with CT or MRI imaging
 Treatment
• Orthopedic Consultation
• ORIF
 Complications = Bleeding, Aseptic Necrosis
Hip Fracture Types
Hip Fractures
 Hip Dislocations
 Anterior Hip Dislocation (10%)
• Mechanism of Injury = Extreme abduction pushes femoral head out
through tear in anterior capsule from auto accident or fall
• Clinical Features = Slight abduction, external rotation
• Associated vascular injuries with diminished femoral or distal
pulses indicates need for immediate reduction
 Posterior Hip Dislocation (80-90%)
• Mechanism of Injury = Majority are due to auto-accidents with
direct force applied to flexed knee, pushing femoral head through
the posterior capsule
• Clinical Features = Shortened, Adducted and Internally Rotated
• Associated Physical Findings
 Acetabular or Femoral Fractures
 Sciatic Nerve Injury
 Knee Injury
 Treatment
• Early reduction to avoid Avascular necrosis of the femoral head
• Closed Reduction should be attempted in ED, operative repair if unsuccessful
 Complications
• Anterior dislocation = Femoral Artery, vein, nerve injury
• Posterior dislocation = Sciatic Nerve injury
 Hip Dislocation
 Anterior Hip  Posterior Hip
Dislocation Dislocation
 Femur Fracture
 Typically, male patients suffering fall
or MVA
 Clinical Presentation – Severe pain,
unable to bear weight
 Treatment
• Hair Traction Splint
• Orthopedic Consultation
• ORIF
 Complications
• Hemorrhage
• Neurovascular Injury
• Fat Emboli
 Ottawa Knee Rules
 Patient needs an x-ray of knee if:
• Age > 55 y/o
• Isolated tenderness of patella
• Tenderness at head of fibula
• Inability to flex 90 degrees or
inability to bear weight in the ED
(at least 4 steps)
• Rules are valid in children or adults
 Knee Dislocation
 Mechanism of Injury = Violent
trauma from MVA or vehicle
pedestrian accidents
 Classification
• Classified by direction of tibial
displacement compared with femur
• 5 types: Anterior, Posterior, Medial,
Lateral, Rotary
• Most common = Anterior and Posterior
(50-60%)
 Diagnosis
• Complete disruption of all major ligaments
• Popliteal artery injury is common (21-
32%), especially in anterior/posterior
dislocation
• Peroneal nerve injury is also common (25-
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35%) ClinicImages/Knee%20disloc..jpg
 Knee Dislocation
 Diagnostic Caveats
• Knee with complete disruption may demonstrate less
swelling and pain than a less severely injured knee
• Knee may reduce spontaneously – Any patient who presents
with grossly unstable knee following trauma should be
assumed to have a spontaneously reduced dislocation
 Clinical Management
• Immediate reduction – Longitudinal Traction
• Pulses should be checked before and after reduction
• Following reduction, knee should be immobilized in
posterior splint in 15 degrees of flexion
• Arteriogram should be performed in all patients who have
had a knee dislocation
• Immediate orthopedic and vascular surgical consultation
• Immediate surgical intervention for Popliteal artery
injuries, open dislocations and irreducible dislocations
 Patellar Fracture
 Classification
• Transverse fractures most common (50-80%)
 Mechanism of Injury
• Direct blow (e.g. dashboard injury)
• Forceful contraction of quadriceps muscle
 Clinical Presentation
• Tenderness and swelling over the patella
• Limited painful knee extension
 Imaging
• AP, Lateral X-rays
• Sunrise or skyline view
 Treatment
• Nondisplaced fracture with intact extensor mechanism =
Immobilization in full extension, Partial weight bearing and
orthopedic referral
• Displaced or loss of extensor function = Orthopedic referral
for surgical intervention
 Patellar Dislocation
 Lateral subluxation or dislocation is most
common
 Mechanism of Injury
• Sudden flexion and external rotation of tibia
on the femur with contraction of the
quadriceps
• Direct blow to the patella with knee in
flexion or extension
 Clinical Features
• Typically occurs in adolescent females with
chronic patellofemoral anatomic abnormalities
 Clinical Management
• AP and Lateral x-rays of the knee
• Reduction = Flexion of hip and gentle medial
pressure over the lateral aspect of the
patella while extending the knee
• Immobilization in full extension
• Crutches
• Orthopedic Referral
• Frequently re-occur
 Tibial Plateau Fracture
 Mechanism = Strong valgus
stress with axial loading
• Fall from height
• Auto/Pedestrian (bumper vs. knee)
 Most condylar fractures http://z.about.com/d/orth
opedics/1/0/1/2/tibialpla
involve the lateral plateau teau2.jpg

 Imaging = X-ray
• CT may be needed for diagnosis
 Complications -Vascular
complications
 Anterior tibial artery
 Popliteal artery
 Lower Leg Injuries
 Tibia Fractures
• Mechanism
 Torsional injury = Spiral fracture
 Bending force = Transverse or oblique fracture
 Direct force from crush injury
• Treatment
 Avoid Infection – Antibiotics for open fractures, emergent
ortho consult if open for subsequent OR irrigation and
debridement
 Most closed fractures that are minimally displaced can be
treated with orthopedic reduction and immobilization
 Most patients require admission for pain control and further
fracture care and monitoring for compartment syndrome
 Fibula Fractures
• Isolated fibula fractures typically result from a direct blow
• Nondisplaced fractures can be treated with immobilization with
either elastic wrap (distal fibula), knee immobilizer (proximal
fibula) or splinting if significant pain
 Lower Leg Injuries
 Tibial Fracture  Fibular Fracture
 Ankle Injuries
 Anatomy
 Ankle Fractures
 Ankle Dislocation
 Ottawa Ankle Rules
 Patients need ankle x-rays if:
• Inability to bear weight
 Either after injury or in ED
• Bony tenderness along posterior
edge of distal 6 cm of lateral or
medial malleolus
• Point tender over navicular bone
 Weber Classification
 Higher level = Greater
disruption of syndesmosis –
Greater instability
 Ankle Fractures

Tri-malleolar Fracture
Bi-malleolar Fracture
 Treatment
 Avulsion fractures with no displacement, smaller than 3
mm in diameter with no evidence of medial ligamentous
injury may be treated similarly to sprain
 All other ankle fractures require immobilization by
either cast or surgical reduction with subsequent casting
 Non-displaced fractures with normal anatomic relationship
of ankle
• Talus anatomically aligned
• Joint line has to be parallel to the ground
• Articular surface must be smooth
 Most fractures with exception of Unimalleolar will
require ORIF
 Orthopedic consultation for non-displaced ankle fractures
is based on local preference
 Displaced fractures require anatomic alignment/reduction
and orthopedic reduction
 Ankle Dislocation
 Dislocation in one of four planes
• Anterior, Posterior, Lateral, Superior (upward displacement
of talus)
 Pure ankle dislocation uncommon
• Typically associated with malleolus fractures
 Treatment
• Immediate neurovascular assessment
• Reduction immediately if evidence of neurovascular
compromise or skin tenting
• Reduction with in-line traction
• Reassess neurovascular status after reduction
 High incidence of complications
• Neurovascular Compromise
• Conversion of closed to open
• Avascular necrosis
http://www.sports-injury-
info.com/images/shauns-fractured-fibula-
compound-ankle-dislocation-playing-
baseball-warning-graphic-fracture-image-
21135429.jpg
 Foot Injuries
 Foot Anatomy
• Hind part
 Calcaneus, Talus
• Midpart
 Navicular, Cuboid,
Cuneiforms
• Forepart htt://www.e-
radiography.net/technique/foot/footlat.htmp
 Metatarsals, Phalanges
 Joints http://www.e-
radiography.net/techn
ique/foot/footdp.htm
• Hind part – Midpart
 Chopart Joint
• Midpart – Forepart
 Lis Franc Joint
 Calcaneal Fractures
 Calcaneal Fracture
• Most frequently fractures tarsal bone
• Mechanism = Compression/Axial Injury
 “ Jumper’ s Fracture”
• Exam = Swelling, tenderness, Ecchymosis of hind foot with
inability to bear weight on fracture
• Rule of 10’ s
 10% are bilateral
 10% are associated with compression fractures
• Bohler’ s Angle – Formed by intersection of two lines on the
lateral film
 Superior margin of posterior tuberosity through the superior tip of the
posterior facet
 Superior tip of the anterior process through superior tip of the
posterior facet
 Angle normally = 20-40 degrees
 Angle < 20 degrees = depressed fracture
• Treatment
 Early orthopedic consultation
 Intra-articular or displaced calcaneal fracture = Controversial
(immediate reduction vs. non-operative management)
 Non-displaced or extra-articular fracture = Ice, elevation,
immobilization in posterior splint, crutches, orthopedic follow-up
 Calcaneal Fracture
 Calcaneal
Fracture
 Lisfranc Fracture Dislocation
 Mechanism of Injury
• Axial load = Fall on the plantar flexed foot
• Compressive forces = Crush Injury
• Rotational forces = Twisting of body around foot
 Exam = Midfoot swelling and pain, Decreased ROM and
inability to bear weight
 Imaging
• Evaluate x-ray for normal alignment along the medial
aspect of the middle cuneiform with the medial aspect of
the base of the 2nd metatarsal
• 2nd Metatarsal functions as primary stabilizing force and
fracture at base of 2nd MT is indicative of disrupted
Lisfranc joint (Fleck’ s sign)
 Treatment
• Closed reduction under anesthesia or ORIF
• Orthopedic consultation in ED is required
 Lisfranc Fracture-Dislocation
 Normal Lisfranc  Fracture
Joint
 Jones Fracture
 Diaphyseal Fracture of 5th Metatarsal
 Mechanism of Injury = Forceful load applied to the
ball of the foot – Running or Jumping Sports
 Note: Dancer’ s Fracture
• Avulsion fracture at 5th MT where peroneus brevis attaches
• Inversion Injury
• Cast shoe only (Cam Walker Boot)
 Clinical findings
• Pain over 5th MT
• Delayed healing compared with avulsion fractures
 Treatment
• Emergent Orthopedic Consultation
• Non-displaced fracture = Immobilization in non-weight
bearing short leg fracture
• Displaced fractures = Surgical management
 Jones Fracture

Stress Fracture – 5th MT

Jones Fx = Diaphysial 5th MT Fx http://api.ning.com/files/WgKj

1gJknxFvrwEB9z53mRstmdstzfIdE4
Dancer’ s Fx = Avulsion of 5th MT KWzFI40-
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nesfracture.jpg