UMEM Educational Pearls - Orthopedics

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:

• Fractures from abuse predominately occurred in infants and toddlers
  • In children less than 12 one study showed that 80% of all fractures from abuse occurred in children less than 18 months old.
  • In children over 5 years old 85% of fractures are not caused by abuse
• In children under 3 years old, skull fractures were by far the most common fracture type in both abused and non-abused children.
  • However, the presense of a skull fracture only has a 1:3 chance of being from abuse.
  • Skull fractures location and type are similar between abuse and non-abuse, though multiple fractures and fractures that cross suture lines are more highly associated with abuse.
• There is a strong relationship between multiple fractures and abuse
  • 74% of abused children had two or more fractures compared to 16% of non-abused
• In the absence of a confirmed traumatic case, rib fractures have the highest probability (71%) of being caused by abuse.
• Humeral fractures have a 1:2 chance of being the result of abuse.
• Femur fracture like skull fractures have a 1:3 chance of being the result of abuse.

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The Galeazzi Fracture:

• It is a fracture of the distal to middle third of the radial shaft with dislocation of the Distal Radio-Ulnar Joint. 
• Typical mechanism of injury is a fall onto a outstretched hyperpronated forearm.
• Estimated to represent 7% of adult forearm fractures.
• This fracture requires surgical repair (Open reduction and internal fixation) in order to prevent presistant or recurrent dislocation of the distal ulnar which typically occurs with closed reduction techniques.
• Associated with injury to the Anterior interosseous nerve which is a purely motor branch of the median nerve.  Injury results in paralys of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, resulting in loss of the pinch mechanism between the thumb and index finger.

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

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:

• Bone tenderness at the posterior tip of the base of the lateral mallelous
• Bone tenderness at the posterior tip of the base of the medial mallelous
• Inability to weight bear immediately and in the Emergency Department

The Ottawa Foot Rule

A foot x-ray is only needed if there is pain in the midfoot and any of the following:

• Bone tenderness at the base of the 5th metatarsal
• Bone tenderness over the navicular
• Inability to weight bear immediately and in the Emergency Department

The Ottawa Knee Rule

A knee x-ray is only needed for knee injury patients when they have any of the following:

• Age 55 or over
• Isolated tenderness of the patella (no bone tenderness of the knee other than the patella)
• Tenderness at the head of the fibula
• Inability to flex to 90 degrees
• Inability to weight bear both immediately and in the Emergency Department (4 steps - unable to transfer weight twice onto each lower limb regardless of limping).

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:

• lower levels of physical activity levels
• recurrent ankle sprains are often reported for months and years after initial injury.
• About 30% of patients with an initial ankle sprain develop chronic ankle instability, or repetitive giving way of the ankle during functional activities.
• There is also emergent evidence to link severe and repetitive ankle sprains to increased risk of ankle osteoarthritis.

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.

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A maisonneuve fracture is a fracture dislocation resulting from external rotational forces to ankle -- through interosseous ligament to fibula.

• Proximal fibula fracture - from external rotational forces (spiral/oblique)
• Ankle components can include any of the following:
  • medial maleolus avulsion fx or deltoid ligament rupture
  • anterior talofibular ligament rupture
  • interosseous ligament rupture
  • posterior malleolar fracture

If stability is questionable, orthopedic evaluation under anesthesia is required. Additionally always consider compartment syndrome. Do not rely on Kanduval's signs (pain, paraesthesia, pallor, poikilothermia, pulselessness) - "... with the exception of pain and paraesthesia, these traditional signs are not reliable." Emergent orthopedic consultation and compartment pressure assessment should be performed. (see attached photos)

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Management of Felons

• An abscess of distal finger that involves the pulp. 
• A difficult infection to treat due to fibrous septa that divide the pulp into multiple small compartments. 
• These septa run from the periosteum to the skin increasing the risk of osteomyelitis
• Patients typically present with a lot of pain, redness, and swelling.
• Typically triggered by a puncture wound (i.e.: splinter)
• Incision and Drainage can result in a:
  
  • anesthetic finger tip
  • unstable finger pad
  • neuroma
• If you are going to drain one it is recommended that you do a volar longitudinal incision down the middle of the finger pad or a high lateral incision. 
• The high lateral incision should be at about 5 mm below the nail plate border. This distance should allow for avoiding the more volar neurovascular structures.

For good photos of the incision technique please visit the reference article listed.

Clark, DC. Common Acute Hand Infections. Am Fam Physician 2003;68:2167-76

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Mallet Finger:

A common injury resulting in a tear or avulsion of the extensor digitorium tendon inserting into  the base of the distal phalanx.  Occurs due to hyperflexion of the finger usually as of a esult of it getting jammed on a ball while playing sports.  Most can be treated non-surgically.

The distal phalanx must be kept in full extension for 6 to 8 weeks. This is one of the few times that the finger should not be splinted in the position of function.

Make sure that patient is informed that if they remove the splint and flex their finger the 6 to 8 week healing window will be reset to day 0.  These patients should not be doing ROM exercises and must wear the splint full time.

Splinting Pearls:

1. When using plaster of paris remember to use at least 10 layers for upper extremities and 15-20 layers for lower extremities.
2. Always apply the splint so that the joint above and below the fracture is immobilized.
3. On radius and ulnar fractures, a sugar tong splint will provide better immobilzation as it also prevents supination/pronation where a posterior long arm or volar splint only prevent flexion and extension.
4. Remember to make sure that the hand is placed in the position of function.
5. Though not required a stockinette provides an additional layer of skin protection and helps to make the ends of the splint looking cleaner.  It can also help hold the splint in place as you ace wrap it.
6. Finally, make sure that you document neurovascular status pre and post splint placement and if any manipulation is done you should have a follow up xray taken to ensure alignment is satisfactory.

Olecranon Bursitis is inflammation and swelling of the bursa overlying the olecranon process of the ulna.  Can result from trauma, overuse, or infection. 

Treatment can consist of:

• Aspiration:  Can be done to rule out infection [send gram stain, culture, and cell count], and be therapeutic by removing the excess fluid.
• NSAIDs
• Local injection of corticosteroids into the bursa
• Wearing of a neopryne elbow sleeve, or ace wraps to provide compression over the bursa and may help prevent reaccumulation of the fluid.

Remember aspiration has some major risks that need to be explained to the paitent:

• Infection may be introduced during the aspiration.  [Follow aseptic techniques and ensure that the skin is adequately prepped with chlorhexidine or betadiene].
• Formation of fistula tract with chronic drainage. [Use a Z or zigzap approach to minimize this complication.]
• Ulnar nerve injury.  Avoided by using a posterior lateral approach and avoiding a medial approach.

They also need to know that the fluid will likely reaccumulate.  So aspiration is not a guaranteed cure. 

When examining a knee for a meniscal injury the commonly described tests are the McMurray Test and Apley Test.  However, these tests have sensitivities of 48-68% and 41% respectfully, and specificities of 86-94% and 86-93% respectfully.  Depending on whether you are looking at the medical or lateral meniscus.

The Tessaly Test that was first described in 2005 can be performed with knee in either 5 or 20 degrees of flexion and has a senstivity of 89-92% and specificity of 96-97% when performed in 20 degrees flexion.  The test also tends to be easier to perform.

To perform the test:

1. Stand on affected leg only with the other leg held up in the air.  The examiner holds hands for balance.
2. Flex knee to be test to 20 degrees, while the other leg is held in the air
3. Internally and Externally Rotate Knee
4. Positive test is pain at medial or lateral joint line with possible locking/catching sensation

Essentially you and your patient will look like you are doing the twist as they rotate their knee with you holding their hands.

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Fracture Management:

In order to maximize billing when caring for patients with fractures two things should be done:

1. The physician does not need to place the splint, but the physican must document that they checked the splint for proper placement and alignment for it to be billed appropriately..
2. Emergency physicians also provide a lot of "definitive" care for fractures.  (i.e.: we provide the same care that the treating specialist would provide) and can bill for a higher level if this is documented properly. 
   1. For instance, if you are treating a impacted, stable distal radius fracture with a splint and pain medication this is the same definitive care the orthopedist would do as they are only going to exchange your splint for  a cast. 
   2. Another example is the treatment of rib fractures which may consist only of pain control, incentive spirometry and instructions to prevent pneumonia.
   3. In these patients, have the patients follow up more than 48 hours later.  If you document that the patient will followup in less than 48 hours, most auditors and billing companies will assume you are not providing definitive care and will not code for the higher earning RVU.

Finally,  you should obtain post-reduction x-rays on any fracture that you manipulate and document that the patient is neurovascularly intact prior to discharge.

SCAPHOID FRACTURE:

• One of the most frequently missed fractures in the ED
• Most common carpal fracture.
• 10-20% fractures are “occult”
• Significant long-term complications:
  
  • Non-union
  • Avascular necrosis
• Complications more common due to the fact the blood supply comes form from the distal end of the bone.
• The more distal the fracture, the greater risk of complications
• MR remains the best test for occult fx.

Joint Fluid Analysis:

This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain.  For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.

 To view a gout crystal click this link.

To view a pseudogout crystal. Click this link

Pearls: 

• A WBC Count >50,000 is septic arthritis until cultures are negative. 
• Due to the wide range of WBC for septic arthritis have a high index of suspicion and do not discount the diagnosis because the WBC count is only 10,000.

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Calcaneus Fractures

Normally occur due to axial loading mechanism such as:

•     Fall from height
•     Motor Vehicle collisions
•     Repetitive impacts on a hard surface such as seen with running or jumping.

Miscellanous Facts:

1. 70% of calcaneal fractures are intra-articular
2. 10-15% are associated with spinal compression fractures
3. Estimated that 7-10% will have a fracture of the contralateral foot
4. Monitor for compartment syndrome of the foot.  Deep central compartment is most commonly affected with calcaneus fractures

Pearls:

1. Strongly consider getting Lumbar Spine Films and x-rays of the opposite foot in anybody that has a calcaneus fracture.
2. Perform frequent reassessments, and do not hesitate to check compartment pressures if you suspect they might be elevated.

Hip Fractures:

Typically divided into four types:

1. Intracapsular,
   1. femoral head and neck fractures
2. Extracapsular
   1.  trochanteric,
   2. Intertrochanteric
   3. subtrochanteric fractures. 

• Non-displaced fractures, especially in osteoporotic elderly patients, may be missed on plain films. This is estimated to occur in 2-9% of cases. 
• It can take up to 72 hours for a fracture to be seen on bone scan. And it is estimated that only 80% of fractures will be seen at 24 hours.
• MRI is now the preferred imaging modality (100% sensitivity and specificity) to confirm a hip fracture when plain films are negative and equivocal. A MRI will have positive findings in as little as 4 hours after a fracture.
• Consider CT scan of the hip if MRI is not available at your center.

Here is a link to a picture with a good representation of the different types of fractures.

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  Lisfranc Fracture:

Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid.  Common current  mechanism is when a person steps into a hole and twists the foot.Originally described when a horseman would fall of their horse with their foot still trapped in a stirrup.

Diagnosis should be considered if patient has difficult weight bearing with pain on palpation over the 2^nd and 3^rd metacarpal head with an appropriate mechanism.

Pearls:

• Fracture findings on plain films may be subtle.
• Can obtain weight bearing AP views of the foot to demonstrate dislocation/fracture.
• If still suspicious consider a CT scan of the foot.

I remember being taught as a medical student that clavicle fractures could be treated conservatively.  A direct quote was "if both ends of the clavicle are in the same room it will heal".

Though conservative treatment with a sling for 6 weeks with early pendulum ROM exercises for the shoulder is appropriate for the vast majority of clavicle fractures surgery should be considered for those that have:

1. An open fracture
2. Significant angulation with tenting of the skin
3. Midshaft fractures that have overlap or displacement greater than 1 cm.
4. Displaced fractures of the distal clavicle [high rate of non-union]
5. Surgery can also be beneficial to those that do a lot of lifting or want to return to work as quick as possible.

Extensor Tendon Injuries [Mallet Finger]

• Due to jamming the finger or to use a Pittsburgh term "stoving it".
• Can result in a swan neck deformity or permanent flexion of the DIP joint.
• Due to stretching of the extensor tendon,or avulsion of the extensor tendon off the distal phalanx.
• Approximately 50% will develop a complication.
• Conservative treatment is splinting the DIP joint in full extension for 5-6 weeks. 
  • The DIP joint must not be flexed for the full treatment period.
  • If the patient does flex their DIP, the 5-6 week time frame needs to completely restart.
• Due to the high complication rate all of these patients should be referred to a hand specialist early.

Posterior Interosseous Nerve Compression Syndrome

As eluded to last week Posterior Interosseous Nerve (PIN) Compression Syndrome, a deep branch of the radial nerve, is felt to be radial tunnel syndrome with paralysis.

• Symptoms depend on whether the PIN is compressed before or after it divides into medial and lateral branches.
  • Before: Results in complete paralysis of the digital extensors, and extensor Capri ulnaris. Wrist will become dorsoradial deviated.
  • After-Medial Branch: Paralysis of extensor carpi ulnaris, extensor digiti quinti, and extensor digitorum communis
  • After-Lateral Branch: Paralysis of abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis proprius
• Common causes:
  • Synovitis and Joint Ganglions
  • Nerve compression following fracture repair
  • Idiopathic Compression can occur at these sites
    • Fibrous bands anterior to the radial head
    • Tendinous origin of Extensor Carpri Radialis Brevis
    • Arcade of Froshe –Most common, it is the tendinous proximal border of supinator
    • Distal Edge of Supinator –Least Common
• Exam:
  • Increased pain with resisted supination of the forearm
  • Supination with Wrist Flexion symptoms will likely be reproduced.
  • Pain with resisted extension of the middle finger
  • Unable to extend thumbs or fingers at MCP joints, but can extend at PIP and DIP joints

For those at the University of Maryland that got the chance to hear my lecture this week, you learned about Cubital tunnel syndrome [ulnar neuropathy], the second most common compressive neuropathy.  Carpal Tunnel syndrome remains the number one compressive neuropathy, and this pearl, for the sake of completeness, will address Radial tunnel syndrome.

Radial Tunnel Syndrome

• Believed to be due to overuse, frequently due to excessive elbow extension or forearm rotation.
• May actually just be an early stage of posterior interosseous nerve syndrome.
• Due to compression of the radial nerve as it passes a fibrous band that is attached to the radiocapitellar joint, and the tendinous origins of two muscles, extersor carpi radialis brevis and the supinator.
• Patients typically have l pain along the anteriolateral forearm.
• Pain is increased by extending the elbow and pronating the forearm.
• This syndrome is associated mostly with pain
• Weakness and numbness are not often seen.

Stay tuned for next week for Posterior Interosseous Nerve syndrome.