Category: Orthopedics
Keywords: Klein's line, slipped capital femoral epiphysis (PubMed Search)
Posted: 11/7/2009 by Michael Bond, MD
(Updated: 8/31/2014)
Click here to contact Michael Bond, MD
Slipped Capital Femoral Epiphysis (SCFE)
SCFE can present as hip, thigh or knee pain in the young adolescent. Risk factors include hypogonadism, hypothyroidism, hypopituiratism, and obesity. One way to make the diagnosis is to obtain a AP view of the pelvis and draw a line(Klein's line) along the superior border of the neck of the femur. This line should intersect the femoral epiphysis. If it does not the diagnosis of SCFE can be made.
However, this is only about 40% sensitivity. Green et al recently published a study that demonstrated that if you measure the distance from Klein's line and the lateral edge of the femoral epiphysis on both sides, and the difference between the two is more than 2mm you can make the diagnosis of SCFE more accurately and sooner.
FIGURE 1. Measurement methods on an anterior-posterior radiograph of a right slipped capital femoral epiphysis. White lines indicate Klein’s line for each hip. A and B, indicate maximum epiphyseal width lateral to Klein’s line. As A is 2mm narrower than B, the right (A) hip qualifies as a slip using our modification but not Klein’s original definition.
Green DW, Mogekwu N, Scher DM, Handler S, Chalmers P, Widmann RF. A modification of Klein's Line to improve sensitivity of the anterior-posterior radiograph in slipped capital femoral epiphysis. J Pediatr Orthop. Jul-Aug 2009;29(5):449-453.
Category: Orthopedics
Keywords: Wound, Irrigation, Fibroblast (PubMed Search)
Posted: 10/31/2009 by Michael Bond, MD
(Updated: 7/16/2024)
Click here to contact Michael Bond, MD
Wound Irrigation
A recent article by Thomas et al showed that any concentration of betadiene and hydrogen peroxide used to irrigate a wound was more toxic to fibroblasts (required for wound healing) then it was to bacteria. Low concentrations of chlorhexidine remained bactericidial while having minimal affects on fibroblasts.
WIth the addition of this study the routine practice of soaking a wound in betadiene or hydrogen peroxide should be abandoned. Good irrigation with normal saline or even tap water is all that is really needed to decontaminiate a wound. If a bactericidal agent is needed then low concentrations of chlorhexidine should be used.
Thomas, GS. Mechanisms of Delayed Wound Healing by Commonly Used Antiseptics. J Trauma 2009; 66:82-91
Category: Orthopedics
Keywords: winged scapula, trapezius, serratus anterior, long thoracic nerve (PubMed Search)
Posted: 10/18/2009 by Dan Lemkin, MS, MD
(Emailed: 10/24/2009)
(Updated: 7/16/2024)
Click here to contact Dan Lemkin, MS, MD
Winged scapula is caused by muscular injury or damage to corresponding muscular innervation. Mechanism can be due to blunt or penetating thoracic trauma.
Clinical findings include
Treatments
Category: Orthopedics
Keywords: Scaphoid Fracture, CT (PubMed Search)
Posted: 10/17/2009 by Michael Bond, MD
(Updated: 7/16/2024)
Click here to contact Michael Bond, MD
Snuff Box Tenderness:
It has become the standard of care that individuals with snuff box tenderness, or pain with axial loading of the thumb, be placed in a thumb spica splint for 1-2 weeks until follow up x-rays can be done. This is done to rule out an occult scaphoid fracture. However, this practice can be hugely inconvenient to the patient and result in some atrophy of their forearm.
An alternative approach is to obtain a CT scan through the wrist to look specifically at the scaphoid bone. If the CT scan is negative you can send them home with some pain control, RICE (Rest, Ice, Compression, Elevation) treatment and let them use thier thumb. No splint is needed. If it is positive then you can splint them and have them follow up with orthopedics or hand surgery.
Category: Orthopedics
Keywords: AC Joint, Separation, Dislocation (PubMed Search)
Posted: 9/26/2009 by Michael Bond, MD
(Updated: 7/16/2024)
Click here to contact Michael Bond, MD
AC Joint Dislocations
The acromioclavicular (AC) Joint is commonly injured when a person falls onto their shoulder.
The AC Joint consists of three ligaments:
Injuries to this joint are classified as Type I – Type VI and involve sprain or tears of the AC or CC ligaments
Category: Orthopedics
Keywords: Monteggia's Fracture (PubMed Search)
Posted: 8/1/2009 by Michael Bond, MD
Click here to contact Michael Bond, MD
Monteggia's Fracture
Wheeless' Textbook of Orthopaedics http://www.wheelessonline.com/ortho/monteggias_fracture
Category: Orthopedics
Keywords: jones fracture,foot fracture,malunion (PubMed Search)
Posted: 6/21/2009 by Dan Lemkin, MS, MD
(Emailed: 7/18/2009)
(Updated: 7/18/2009)
Click here to contact Dan Lemkin, MS, MD
Jones fracture
Presented with persistant foot pain from
Jones fracture malunion.
http://www.wheelessonline.com/ortho/jones_fracture
http://www.wheelessonline.com/ortho/avulsion_frx_of_base_of_5th_metatarsal
Category: Orthopedics
Keywords: Blast, hand, injuries (PubMed Search)
Posted: 7/5/2009 by Michael Bond, MD
Click here to contact Michael Bond, MD
Blast Injuries:
In honor of the 4th of July holiday, here is a quick pearl about blast injuries.
Philipson MR, Southern SJ. The blast component of firework injuries--not to be underestimated. Injury. 2004:35; 1042-1043.
Category: Orthopedics
Keywords: Metacarpal, Fracture, Growth, Plate (PubMed Search)
Posted: 6/28/2009 by Michael Bond, MD
(Updated: 7/16/2024)
Click here to contact Michael Bond, MD
Metacarpal Fractures and Growth Plates:
The growth plates on metacarpals are on the distal end of the bone, except for the 1st metacarpal which is on the proximal end near the carpal bones.
Don't mistake this for a fracture line, however, make sure you get comparison views if they are tender over the area, as this can help you diagnosis a Salter Harris Type 1 fracture.
Category: Orthopedics
Keywords: High Pressure, Injection, Injury (PubMed Search)
Posted: 6/20/2009 by Michael Bond, MD
(Updated: 7/16/2024)
Click here to contact Michael Bond, MD
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: Orthopedics
Keywords: shoulder, dislocation, treatment (PubMed Search)
Posted: 6/7/2009 by Michael Bond, MD
(Updated: 7/16/2024)
Click here to contact Michael Bond, MD
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
Click here to contact Michael Bond, MD
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: 7/16/2024)
Click here to contact Michael Bond, MD
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: 7/16/2024)
Click here to contact Michael Bond, MD
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: 7/16/2024)
Click here to contact Michael Bond, MD
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: 7/16/2024)
Click here to contact Michael Bond, MD
Distal Radius Fractures
Category: Orthopedics
Keywords: Phalanx, fracture, treatment (PubMed Search)
Posted: 4/25/2009 by Michael Bond, MD
(Updated: 6/27/2009)
Click here to contact Michael Bond, MD
Category: Orthopedics
Keywords: Radial, Head, Fracture (PubMed Search)
Posted: 4/3/2009 by Michael Bond, MD
(Emailed: 4/4/2009)
(Updated: 7/16/2024)
Click here to contact Michael Bond, MD
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: 7/16/2024)
Click here to contact Michael Bond, MD
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: 7/16/2024)
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