Ankle fractures

Ankle fractures:




Start with good H&P:

History:

Mechanism, height of the fall, direction of the foot inversion

Consider age, steroid use, hx of neoplasm, prior surgeries, hardware

 

Physical:

Start from the knee down, neurovascular intact, ROM, strength, severe tenderness, instability, rash/ulcers

Ottawa Ankle rules 

 

Classification of the injury: stable/unstable?

Many classifications are available but for ED we can use Closed Ring System: 

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Think of an ankle as a ring of bone and ligaments surrounding the talus consisting of the tibia, the medial malleolus and medial deltoid ligaments, the fibula and lateral ligaments and calcaneus.

 




A single disruption in the ring - stability most likely preserved

Two disruptions - think instability and will likely cause the joint to shift.

Exceptions: Lateral malleolus fracture even with no medial injury may become unstable.

Isolated syndesmosis injury

 

 

Approach to ankle injuries x-ray interpretation

Here is an EM focused summary

Look at the cortical disruption of each bone

Look at the soft tissue swelling

Look at the spaces between the bones

Look within the bones

Ask for a mortise view (no, it’s not a GOT character) in addition to the standard AP and lateral views

Look at the tib/fib, knee and base of the 5th metatarsal

Key areas:

Talar shift: look to make sure there is congruence between the clear space on either side of the talus; go further - measure the medial clear space and the lateral clear space. If they are incongruent or the medial clear space is >4mm the ankle is likely unstable.

Talar tilt: The lines in red below should be parallel. Talar tilt indicates an unstable ankle 

 


Just a few commonly missed fractures at the ED:

 

High ankle sprain: The isolated syndesmosis injury - isolated distal tibiofibular syndesmosis injury, with ligamentous disruption can result in unstable ankle injury.

Look at the tibio-fibular clear-space: Measure the gap between the tibia and fibula 1cm proximal to the tibial plafond on both the AP view and mortise view. They should be <6mm. If  >6mm, suspect a syndesmosis injury.

Tillaux fracture - fracture is an intra-articular Salter-Harris class III fracture of the distal tibia with avulsion of the anterolateral tibial epiphysis.

Remember that in children, the ligaments tend to be stronger than the growth plate. Tillaux fractures can be considered “the syndesmosis injury of children




Snowboarder’s fracture - A snowboarder’s fracture is a lateral process of the talus fracture that is commonly misdiagnosed as a simple ankle sprain. 





Lateral process of the talus fracture also known as a snowboarder’s fracture

 

 

Bottom line: 

Reassess including the if the pt is still neurovascular intact

If pt can’t ambulate get further workup

If in doubt call radiology

Persistent pain but pt wants to go hoe, splint with ortho follow up

 

 

References: CoreEM, EMDoc, Uptodate, Radiopedia










5th metatarsal fracture

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Normal Apophysis in children runs parallel to the bone.  


Dancer’s or Avulsion (pseudo-Jones) Fracture @ cuboid articulation - hard sole shoe for 4-6 weeks and weight bearing as tolerated (WBAT) with orthopedics follow up in a week

Jones Fracture @ intermetatarsal articulation - high risk of non union, pt will need a splint and non weigth bearing activity (NWB) for 6-8 weeks with orthopedics follow up


Metatarsal shaft fracture - high risk of non union, will need a splint, NWB for 10-20 weeks, with orthopedics follow up

Below is a 5 minute video by amazing Dr. Anna Pickens (former Maimo attending) for visual review of the fractures:


http://www.emdocs.net/em-in-5-5th-metatarsal-fractures/

https://youtu.be/4k1dvPdpW4E





POTD: High-Pressure Injection Injury

High-Pressure Injection Injury

·      Patients present with seemingly innocuous findings after high-pressure injection injury

·      Their condition often rapidly deteriorate

·      Substances can be paint, paint stripper, grease, oil, water or air.

·      This is a surgical emergency and early consultation is critical for surgical decompression and debridement

·      Less viscous substances can penetrate deeper with less pressure, leading to worsened outcomes, even if initially the wound may appear benign on the exterior, and even if the patient’s pain is initially minimal

·      Paint and paint thinners produce a large and early inflammatory response leading to ischemia and tissue death and the rate of associated amputation is high.

·      Initial emergency department management:

o   pain control, radiographs (look for free air), elevation, splinting, IV antibiotics, tdap, emergent hand specialist consultation

o   These injuries are not high-risk injuries for tetanus, and prophylaxis, even if indicated, therefore tdap should not delay other steps in management.

o   In fact, none of the emergency department interventions, (besides pain control), is as important as recognition of the potential severity of the injury and early consultation with a hand specialist

o   There is no amount of cleansing this wound in the ED that is recommended because the penetration is deep and this patient needs to go to the OR.

·      It is interesting to note that although digital blocks are excellent tools to relieve pain and provide anesthesia, they are not recommended in high-pressure injection injury as one of our major concerns is compartment syndrome.

o   Digital blocks can lead to an increase in compartment pressure and worsen injury/tissue ischemia. Systemic pain control is recommended.

The below picture is of a hand in the OR, you can see the initial presentation appears someone benign and once the hand is opened up, you see a lot of tissue necrosis.

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Below pictures show benign physical exam findings and some free air on xray

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Sources: Tintinalli, Rosen's Emergency Medicine, uptodate, Peer IX, ortho blog for photos: http://www.cmcedmasters.com/ortho-blog/high-pressure-injection-injuries

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POTD Trauma Tuesday: Name that fracture!

A 36-year-old man presents by ambulance following a motorcycle crash. He told the EMTs that he lost control and fell sideways, bracing his fall with his outstretched right hand. His R arm looks deformed but is neurovascularly intact. An xray is obtained.

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What’s the name of this one again?!

Galeazzi fracture! Named after an Italian surgeon from Milan.

What is it? a fracture-dislocation of the distal third of the radius associated with dislocation-subluxation of the distal radial ulnar joint, or DRUJ.

Why do we care? With Galeazzi fractures, there is a high risk of malunion, loss of function, infection, and chronic pain in adult patients. For this reason, surgical management with internal fixation and possible open reduction is required. The repair should occur promptly, so the emergency physician or another clinician should contact the orthopedic consultant emergently to coordinate care.

What about in peds? Emergent orthopedic consultation is still required but interestingly, in children, some Galeazzi fractures are treated conservatively with closed reduction by an orthopedic surgeon. Disruption of the DRUJ can be subtle, so a high suspicion should be maintained when a patient presents with a fracture of the distal third of the radius.

Pearls of the Peal:

* Look for fracture-dislocation of the distal radius and ulna after a fall onto an outstretched arm. This injury can’t be missed: it requires immediate orthopedic involvement.

* Skin tenting associated with the Galeazzi fracture-dislocation puts the patient at risk for skin necrosis and conversion to an open fracture.

Wasn’t there some way to remember this compared to other one?? Why, yes! See below:


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Sources:

Comic: Medcomic.com

Xray and clinical information: PEER IX

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POTD: Straight leg test. A leg up on clinical testing!

A little background:

Lumbar disc herniation is the most common cause of lumbar radiculopathy, or sciatica, a shooting or burning pain from the low back radiating down the posterior leg distal to the knee.

Two tests used to evaluate these symptoms are

The straight leg raise.

·       The straight leg raise test is highly sensitive but not very specific for disc herniation.

·       This is performed by lifting the leg affected by the radiating pain.

·       The patient lies supine with one leg either straight or flexed at the knee with the sole of the foot flat on the stretcher.

·       The examiner then raises the affected leg up, extended, to 30 to 70 degrees.

·       Reproduction of low back pain that radiates down the posterior affected leg at least past the knee is considered a positive result. Not just pain to the lower back, which is a common misconception.

·       The SLR test can also be performed with the patient in a sitting position, by stretching the sciatic nerve by extending the knee; the test is positive if pain radiates to below the knee.

 

The crossed straight leg raise.

·       It is highly specific (90%) for disc herniation

·       You perform the same test as the straight leg but on the unaffected leg.

·       A positive test: reproducing both the back pain + the radiation down the affected leg.

Sources: Peer IX, Tintinelli’s, Dr. Sergey Motov, Uptodate

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Hip Dislocations POD

This POD was inspired by a case that Dr. Zerzan had in the Peds ED. An 8 year old with a traumatic injury presented with hip pain and was found to have an isolated posterior hip dislocation…

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Hip dislocations!

Posterior hip dislocations (PHDs) are far more common than anterior hip dislocations

(90% - 10%). This holds true in pediatrics as well in adults.

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In a posterior dislocation, the patient presents with the extremity internally rotated and shortened.

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In anterior dislocations, patients typically present with extremity flexed, abducted, and externally rotated.

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We will focus on

posterior dislocations.

Classic presentation is with an axial load such as a knee hitting the dashboard in an MVC or other high energy mechanisms.

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Important point: in adults and children >10yo, PHDs require a high energy mechanism and will often have several associated injuries.

However in children <10yo, PHDs can be seen in lower energy mechanisms such as routine sports injuries which is why you may actually see an isolated hip dislocation in a child. There are also fewer associated acetabular fractures in pediatric PHDs than adult PHDs.

Any child PhD knows…

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..that PHDs are true emergencies!

You need to

get it reduced ASAP (within 6 hours)

to prevent complications of femoral head osteonecrosis and sciatic nerve injury. Other complications include post-traumatic arthritis, and in pediatrics, physeal injury. Incidence of recurrent dislocation is higher in pediatrics than in adults!

Reduction techniques:

The Allis Maneuver:

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The Captain Morgan:

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Video here: 

https://www.youtube.com/watch?time_continue=82&v=lQMWaFX-MeQ

Propofol is preferred agent for procedural sedation given its muscle relaxant properties if it is going to be reduced in the ED, but pediatric cases are often reduced in the OR to ensure optimal muscle relaxation and to have more options available.

It is essential to have optimal muscle relaxation in pediatrics as the growth plates can be damaged during reduction.

Open reduction should be considered if fracture-dislocation or unsuccessful closed reduction attempt.

All patients should get at least a CT to evaluate for femoral head fractures, intra-articular loose bodies/incarcerated fragments, acetabular fractures.

Children should get an MRI to evaluate for ligamentous injury as well.

If closed reduction is successful, disposition is protected weight-bearing 4-6 weeks, ortho follow up.

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Pearl of the Day: Clavicle Fractures

Clavicle Fractures - clavicle articulates with sternum proximally and acromion distally - protects adjacent lung, brachial plexus, subclavian and brachial blood vessels - mid-portion of clavicle is thinnest and does not contain ligamentous or muscular attachments - signs/symptoms: swelling, deformity, tenderness overlying clavicle; arm is slumped inward and downward; limited ROM at shoulder - diagnosis: usually standard shoulder and clavicle X-rays, but may require 45-degree cephalad tilt view or CT - management: emergent orthopedic consult for open fractures, fractures with neurovascular injuries, fractures with persistent skin tenting

Middle Third Clavicle Fractures - most common - usually managed nonoperatively - risk factors for nonunion: initial shortening > 2 cm, comminuted fracture, displaced fracture > 100%, significant trauma, female, elderly - management: immobilization with either sling or figure-of-eight brace for 4 - 8 weeks - orthopedic follow up in 2 - 3 days: high risk of malunion, severely comminuted or displaced fractures, athletes, professional impact, cosmetic concerns - orthopedic follow up in 1 - 2 weeks for conservative treatment

Distal Clavicle Fractures - type I: fracture is distal to coracoclavicular ligaments with ligaments intact - type II: fracture is distal to coracoclavicular ligaments with disruption of ligaments -> causes upward displacement of proximal aspect of clavicle - type III: intra-articular fractures through acromioclavicular joint - management: types I and III can be managed conservatively with sling immobilization and follow up in 1 - 2 weeks; type II may require operative intervention

Proximal Third Clavicle Fractures - associated with high-mechanism injuries and associated with intrathoracic trauma - diagnosis: CT (also to identify additional injuries) - management: emergent consultation for posteriorly displaced fractures that compromise mediastinal structures; immobilization for all other proximal third fractures - orthopedic follow up in 1 - 2 weeks for conservative treatment

Resources Tintinalli's Emergency Medicine, 8th Edition

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