Evaluation of Skeletal Trauma - Dr. Osborne

Evaluation of Skeletal Trauma Upper and Lower ExtremitiesDr. Edward Osborne

Dr. Ed Osborneo BSc. MSc. Queen’s University 1983 – 1989o MD University of Toronto 1989 - 1993o Family Practice since 1996o Lakeridge Health Bowmanville/Oshawa 1996o Scarborough General Hospital 2005o University of Toronto Lecturer 2004o Queen’s University Assistant Professor 2007o Boomer’s Sports Medicine Clinic 2008

Dr. Ed OsborneDisclosures:• I AM NOT A RADIOLOGIST!• I AM NOT A ORTHOPAEDIC SURGEON!• Within the past 5 years received consulting and speaker fees from Purdue, Nycomed Canada Inc., Janssen-Ortho, AstraZeneca,and Pfizer

Goals• Understanding the injury• Proper imaging evaluation• Fracture Description

When are skeletal films not necessary in the trauma?• Just because we “can” image doesn’t mean we “should” image…• Consider $$, radiation• Wastes patient’s, tech’s and radiologist’s time

Having the proper history is crucial so that the correct body part is imaged! “MECHANISM OF INJURY”

Mechanism of injury• Describe accident• Amount of force (High speed, fall, etc…)• Type of force (Direct, twisting, etc…)• What happened after the accident?• What does it look like now?• What can the joint do?

Imaging principles in trauma: Rule of 2’s• 2 views: AP and lateral• 2 radiographs: compare with normal/book• 2 joints: include the joints above and below fracture• 2 sides: both limbs Only if needed (in children with open epiphyses)• 2 occasions: some non-displaced fractures will not be visible for 10-14 days

Fracture Description: Definitions• Fracture – complete disruption in the continuity of a bone• Dislocation – complete disruption of a joint, articular surfaces are no longer in contact• Subluxation – minor disruption of a joint, where some articular contact remains

Fracture types: Incomplete or Complete• Complete – Goes through entire cortex• Incomplete – involves a portion of cortex - Children >> Adults 1. Torus / buckle 2. Greenstick 3. Plastic

Buckle

Greenstick Fracture

How fractures are described…• Direction of fracture line• Number of fragments• Relationship of fragments• Open or closed - Clinical evaluation for integrity of overlying skin

Direction of fracture line• Transverse (simple) – Perpendicular to long axis of bone – Caused by force perpendicular to shaft

Direction of fracture line• Oblique – Force applied in same direction as long axis of bone

Direction of fracture line• Longitudinal – along long axis of bone

Direction of fracture line• Spiral – Fx plane rotates along long axis of bone – Planting foot in hole

Number of fragments• 2 fragments – simple fracture• > 2 fragments – comminuted fracture * Segmental – 2 fracture lines isolate a discrete segment * Butterfly – wedge-shaped separate fragment formed at the apex of the force S

Relationship of fragments• Displacement – Described by position of distal fracture fragment relative to proximal fragment – Off-set of fragments described by direction and degree Direction – anterior, posterior, lateral or medial Degree – percentage of shaft width or cm/mm

Relationship of fragments• Angulation – Relationship of long axes of fracture fragments – Described by direction of displacement of distal fracture fragment Anterior / posterior Varus / valgus

Angulation• Varus – distal fragment points toward body midline (apex points away)• Valgus – distal fragment points awayfrom body midline (apex points toward)

Relationship of fragments• Shortening – complete loss of contact of bone ends

Joint Disruption• Dislocation vs. Subluxation – Complete disruption vs. Partial – Articular surface: no contact vs. some

Case 1• 25 year-old male falls on out-stretched hand• Complains of shoulder pain radiating to the elbow• ? Standing? Running? From a height• Physical exam – ? Deformity? Active movement? Pulse? Sensation? Passive movement?

Case 1• Obvious shoulder deformity – AP Shoulder – AP Glenohumeral view – Opitional views: Y or Axillary

Anterior dislocation (95%) Normal shoulder

Normal shoulder Posterior dislocation (5%)

Case 1• Only finding is that patient is unable to extending elbow completely then order elbow views only• AP View• Lateral (90° flexion)

Case 1• Obvious swelling and pain in elbow with limited movement• Fractions and dislocation often occur in combination• If no obvious fracture, look for posterior fat pad or sail sign

Fat PadsDL Fracture

Case 2• 20 year-old snowboarder• Complains of wrist pain• ? Wrist guards ? Speed ? Jumps ? Past injuries• Examination – Obvious deformity / decreased motion wrist – Good pulse – Normal sensation

Case 2• Wrist x rays:

Colles’ Fracture 17% of all fractures in ER

Case 2• 20 year-old snowboarder with wrist guards• Forearm fractures – Monteggia: ulnar # and radius DL – Galeazzi: radius # and unla DL “MUGR (mugger)”

Case 2• 20 year-old snowboarder• Wrist pain• No obvious deformity and no swelling• Only tender area is base of thumb, posterior.• “Snuffbox”

Scaphiod fracture• Easily missed• Most common carpal fracture• FOOSH• Scaphiod view needed to be certain• If uncertain – treat as fracture and reassess

Scaphiod fracture H C Tqm S L

Case 3• 52 year-old female twists ankle• Walks into ER with a limp and complains of lateral R ankle pain• Patient states: “Just came in for an x-ray; I don’t need to see anyone.”• Ankle x-rays > 10% all ER x-rays – 20% positive Who needs an x-ray? Ottawa ankle rules

Ottawa Ankle Rule• Bony tenderness at the posterior or inferior edge of either malleolus (distal 6cm of tibia and fibula)• Unable both to weight bear immediately after injury and walk four steps in A&E department

Imaging of ankle injuries• AP – ankle mortise and malleoli• Lateral – nondisplaced spiral/oblique fractures - Talus in profile - Should include MT• Internal oblique – evaluate ankle mortise

Case 3• 60 year-old walking into ER complaining of ankle• Examination no tenderness of ankle NO X-RAY

Case 3• Twisted ankle, unable to weight bear in ER or prior and tender lateral malleolus

Case 3• Twisted ankle, unable to weight bear, tender at base of fifth.

Navicular Fracture•Twisted Ankle•Not walking•Tender medial side

Case 4• 70 year-old lady hit by car while crossing street at a corner (low speed)• Not weight-bearing.• Swollen R knee• Tender R knee• Decreased flexion

Knees• Most x-rays of knee in ER normal• Ottawa decision rule for acute knee injury• 98 - 100% sensitive for fracture• Age 55 or older• Tenderness at head of fibula• Isolated tenderness at patella• Inability to flex at 90°• Inability to bear weight immediately following injury and in ER (4 steps)

Knees: Radiographic views• AP – weight-bearing surfaces of tibiofermoral joint• Oblique views – obliquely oriented fractures of tibial plateau or fermoral condyles• Lateral view – soft tissues, extensor mechanism, joint effusion

Tibial Fracture

Tibial Plateau fracture• Often radiographically subtle• Twisting injury from fall or pedestrain hit by car• Most patients > 50 yrs.• 80% involve lateral plateau (valgus stress)• Oblique films useful

Tibial Plateau fracture• MRI for occult fractures

Hip Dislocations / Fractures• AP view of pelvis• Oblique / frog-leg view of proximal femur• Groin lateral view of hip

Oblique or Frog-Leg View1. Acetabular fossa.2. Head femoral.3. Greater trochanter.4. Lesser trochanter.5. Femur.6. Obturator foramen.7. Inferior pubic ramus.8. Superior pubic ramus.9. Sacrum.10. Iliac wing.

Hip Dislocation• Significant force• Often associated with other fractures• Orthopedic emergency• High chances of complications (AVN)• Posterior dislocation most common• MVA, sports, fall from height

Hip Dislocation

Hip Fractures• May be minimal trauma• Passive motion often painless• Classic description shortened and rotated laterally• Accurate and early diagnosis• Prognosis influenced by degree of displacment

Case 5• 70 year-old female complains of R hip pain after slipping and falling on icy driveway• Cannot weight-bear• No obvious deformity• Good distal pulses and sensation

Case 5• Intracapsular (x2) … subcapital usual• Extracapsular

Case 6• 80 year-old falls and comes in for suture of forehead laceration• No loss of consciousness• Complains of R hip pain when weight- bearing only• No shortening or rotation• Full range of motion, both hips• Pain on palpation of pelvis only

Pelvic Fractures• Stable (2/3) – Single break in pelvic ring• Unstable (1/3) – Two or more fractures in pelvic ring – Usually MVA Views AP, inlet/outlet, Judet view, Lateral

Pelvis AP View

Inlet/Outlet Views

Judet View

Case 6• 80 year-old lady with pelvic pain on palpation

Case 6

Unstable!

Summary• Take time to understand the mechanism• Examine the patient• Order the proper x-ray• Describe the abnormality (fracture, dislocation, subluxation)• Manage the injury

Evaluation of Skeletal Trauma - Dr. Osborne

by Nurse Practitioners' Association of Ontario on Aug 03, 2011

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Evaluation of Skeletal Trauma - Dr. Osborne — Presentation Transcript