Category: Orthopedics
Keywords: High Pressure, Injection, Injury (PubMed Search)
Posted: 6/20/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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High Pressure Injection Injuries:
Hogan CJ, Ruland RT: High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma 20:503, 2006
Category: ENT
Keywords: Mandible, Dislocation, Unified, Hand (PubMed Search)
Posted: 6/13/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Manibular Dislocations:
Some authors also recommend using rolled guaze to hold the patient's mouth shut so that they do not inadvertantly dislocate their jaw a second time if they happen to yawn while awakening from their sedation.
Cheng D. Unified hands technique for mandibular dislocation. J Emerg Med. Mar 19 2009.
Category: Orthopedics
Keywords: shoulder, dislocation, treatment (PubMed Search)
Posted: 6/7/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Shoulder Dislocations -- Treatment
McNeil NJ. Postreduction management of first-time traumatic anterior shoulder dislocations. Ann Emerg Med. Jun 2009;53(6):811-813.
Category: Orthopedics
Keywords: Nursemaid, Radial head, dislocation (PubMed Search)
Posted: 5/30/2009 by Michael Bond, MD
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Nursemaid Elbow:
It is typically taught that the way to reduce a nursemaid's elbow is to hold the elbow at 90 degrees, then firmly supinate and flex the elbow. Place your thumb over the radial head and apply pressure as you supinate.(Taken from Sean Fox's Pearl on 7/20/2007)
However, there is a growing body of evidence that is showing that hyperpronating the forearm actually has a higher success rate on first attempt, is easier to perform, and is associated with less pain then supinating the forearm. The overall reducation rates where similar for both methods.
The hyperpronation method consists of hyperpronating the forearm and then flexing the elbow. Since the child tends to already hold their arm in partial pronation, the hyperpronation technique tends to need less force and has been associated with less pain.
Bek D, Yildiz C, Kose O, Sehirlioglu A, Basbozkurt M. Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial. Eur J Emerg Med. Jun 2009;16(3):135-138.
Green DA, Linares MY, Garcia Pena BM, Greenberg B, Baker RL. Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion or forced pronation. Pediatr Emerg Care 2006; 22:235–238.
Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics 1998; 102:e10.
Category: Orthopedics
Keywords: Elbow Dislocation (PubMed Search)
Posted: 5/23/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Elbow Dislocation
Quick clinical clues that the elbow is dislocated:
Category: Orthopedics
Keywords: Trimallelor Fracture (PubMed Search)
Posted: 5/16/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Trimallelor Fractures:
Bimallelor fracture involve both the medial mallelous of the tibia and the distal fibula. The third malleloi is the posterior tip of the articular surface of the tibia. Can result in instability in the posterior and lateral directions along with external rotation.
Some indications for Open Reduction Internal Fixation when the posterior mallelous is fractured are:
Category: Orthopedics
Posted: 5/9/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Knee Dislocations:
Are relatively rare injuries, but can result in loss of the limb if missed. Patients will sometimes say they dislocated their knee when they actually mean their patella, so a good history where they describe what their knee looked like, and what they were doing at the time will help differentiated the two.
Some signs that you are dealing with a spontanously reduced knee dislocation are:
The loss of limb is due to unrecognized injury to the popiteal artery which as be estimated to occur 7-45% of the time.
If you would like to see some videos of knee injuries in the making follow this link www.csmfoundation.org/Educational_Lower_Extremity.html
Category: Orthopedics
Keywords: radius, fracture, colles, smith, barton, chauffer (PubMed Search)
Posted: 5/2/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Distal Radius Fractures
Category: Orthopedics
Keywords: Phalanx, fracture, treatment (PubMed Search)
Posted: 4/25/2009 by Michael Bond, MD
(Updated: 6/27/2009)
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Category: Airway Management
Keywords: Le Fort, fracture, facial (PubMed Search)
Posted: 4/19/2009 by Michael Bond, MD
(Updated: 8/28/2014)
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The French Surgeon Rene Le Fort first described these facial fracture patterns. Reportedly he made the observations after dropping numerous skulls from the wall of a castle. This might be why we don't see pure Le Fort fractures in our patients most of the time as they are not likely to be falling off castle falls head first.
The classic fracture patterns are:
http://radiographics.rsnajnls.org/cgi/content-nw/full/26/3/783/F15
Category: Misc
Keywords: G6PD, Deficiency (PubMed Search)
Posted: 4/11/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Glucose-6-Phosphate Dehydrogenase Deficiency
Also make sure that you are not G6PD deficiency if you are eating with Hannibal Lecter as Fava beans and other legumes can also cause an episode of hemolysis.
A good reference for G6PD deficiency is http://g6pddeficiency.org/index.php
Category: Orthopedics
Keywords: Radial, Head, Fracture (PubMed Search)
Posted: 4/3/2009 by Michael Bond, MD
(Emailed: 4/4/2009)
(Updated: 8/31/2024)
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Radial Head Fractures:
Radial head fractures are more common in adults, where radial neck fractures are more common in children. Remember to look for fat pads to help make the diagnosis if it is not obvious on plain films. On plain films, a line drawn down the middle of the radial head should always line up with the capitellum of the humerus. If this does not occur the radial head is dislocated and/or fracture.
Orthopaedics use the Mason classification to help guide treatment, and break down fractures into 3 different types.
Category: Orthopedics
Keywords: Hamate, Fracture, (PubMed Search)
Posted: 3/28/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Hamate Fractures:
Walsh JJ 4th. Bishop AT. Diagnosis and management of hamate hook fractures. Hand Clinics. 16(3):397-403, viii, 2000 Aug.
Category: Orthopedics
Keywords: Lunate, Dislocation, Perilunate (PubMed Search)
Posted: 3/20/2009 by Michael Bond, MD
(Emailed: 3/21/2009)
(Updated: 8/31/2024)
Click here to contact Michael Bond, MD
Lunate Dislocation and perilunate dislocation are broken down into 4 stages that relates to the progressive disruption of the carpal ligaments due to hyperextension and ulnar deviation of the wrist:
For a good indepth review of lunate and perilunate injuries please read the article by Andy Perron with this attached link.... doi:10.1053/ajem.2001.21306
If you are interested in seeing some xray examples please visit LearningRadiology.com
Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic Pitfalls in the ED: Lunate and Perilunate Injuries Am J Emerg Med 2001;19:157-162
Category: Orthopedics
Keywords: Child Abuse, Fracture (PubMed Search)
Posted: 3/15/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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A lot of what is taught about fracture patterns in abused children has been extrapolated from post-mortem studies which is a different population then what you will see in the Emergency Department. The study referenced did a metanalysis of all the literature in an attempt to determine what fractures suggest abuse and looked at all comers that had fractures. Some of the patterns they were able to extrapolate are:
Patterns of Skeletal Fractures in Child Abuse: Systemic Review. BMJ, Alison M Kemp et al. 2008;337:a1518
Category: Orthopedics
Keywords: Galeazzi, Fracture (PubMed Search)
Posted: 3/7/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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The Galeazzi Fracture:
To see a photo of a Galeazzi fracture please visit the Learning Radiology Website by clicking on the following link:
http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow157lg.jpg
Category: Orthopedics
Keywords: Ottawa, Ankle, Knee, Foot (PubMed Search)
Posted: 2/28/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Most people are familiar with the Ottawa Ankle Rules, but there are also Ottawa Knee and Foot rules. The Ottawa rules help to limit the number of x-rays you may need in patients that present with ankle, foot or knee pain after an injury.
The Ottawa Ankle Rule
An ankle x-ray is only needed if there pain in the mallelolar area and any of the following:
The Ottawa Foot Rule
A foot x-ray is only needed if there is pain in the midfoot and any of the following:
The Ottawa Knee Rule
A knee x-ray is only needed for knee injury patients when they have any of the following:
Category: Vascular
Keywords: AV fistulas, bleeding (PubMed Search)
Posted: 2/21/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Bleeding AV Fistulas
It is not an uncommon complaint for dialysis patients to present with bleeding from their fistula. They can lose a large amount of blood in a short period of time if not treated promptly, and if treated too agressive their fistula can clot off. Some tips on how to control the bleeding.
Most of the bleeding occurs at the site that the needle puntured the fistula. If it is due to an ulcer eroding into the fistula these tips may not be effective.
I typically check a CBC and coags. Once the bleeding is controlled observe the patient for awhile [typically the hour to hour and half to get the labs back] and then road test them with a walk around the Emergency Department to ensure it does not start bleeding again.
Category: Orthopedics
Keywords: Ankle Sprain, Treatment (PubMed Search)
Posted: 2/14/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Ankle sprains are typically treated with a short period of immbolization and then functional exercises are prescribed to rehabilitate the ankle. A study published in the Lancet this week might just change that. Lamb et al looked at 584 people with severe ankle sprains (unable to weight bear 3 days out from injury) that were randomized to be treated with a 10 day below knee cast, Aircast, Bledshoe Shoe or Tubular Compression dressing (similar to Ace Wrap). Those that were treated with the Cast and Aircast had quicker return to function and less disability at 3 months. There was no increased risk of DVTs in the cast group.
A commentary in the same issue points out that severe ankle sprains are associated with:
Based on this article I think it is prudent to treat all patients with severe Ankle Sprains with a prolonged period of forced immobilzation (Posterior Splint, Short Leg Cast or Aircast). I would also recommend the Aircast be used to prevent recurrent sprains especially if the patient is involved in sports that require jumping (Basketball, Volleyball) where the risk of reinjury is higher.
Mechanical supports for acute, severe ankle sprain:a pragmatic, multicentre, randomised controlled trial
S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*. Lancet 2009; 373: 575–81
Immobilisation for acute severe ankle sprain [Commentary] Hertel J. Lancet 2009; 373: 524-526
Category: Trauma
Keywords: Epinephrine, Lidocaine, Fingers, (PubMed Search)
Posted: 2/7/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Lidocaine with Epinephrine and it use on Fingers and Toes
It has been taught for a long time that Lidocaine with Epinephrine should not be used on fingers, toes, ears and nose [There has to be a kid's song in there somewhere] due to the risk of vasoconstricition/vasospasm and possible digitial infarcation.
The short story is that this practice is not supported by the literature, and there are now numerous publications that have shown that lidocaine with epinephrine is safe for use on the finger tips. It turns out the the original case reports were submitted with procaine and epinephrine and not lidocaine with epinephrine. Most of the cases of digital infarction where with straight procaine that is now thought to have been contaiminated or too acidic pH close to 1 when injected.
The effects of epinephrine last approximately 6 hours. This time is well within the accepted limit of ischemia for fingers that has been established in digitial replanation.
So why use Lidocaine with Epinephrine:
Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. Jan 2007;119(1):260-266.