Emergency Medicine Review of Extremity Injuries *not medical advice, not official, prepared as review material, personal slides not those of my employer

1. Ortho (extremities) review
Rachel Solnick PGY4
Yale EM

2. What is it, what do you do next
• 7 yr old jumped off 5 ft ladder, unable to
bear weight

3. Sneaky Salter Harris V

4. What is it, what do you do next
• 1 yo baby crying more
than normal after an
afternoon at grandmas
house
• You notice she seems to
wince more when you
squeeze her R knee

5. What fracture types make you concerned for
child abuse?
• ….

6. Consider child abuse for ANY fx, in particular
• Bucket handle aka
metaphyseal corner fx
• From whiplash
• (often tib / femur)
• Mid shaft ( requires sig
force)
• Humerus
• Tibia
• Vertebral compression
• Rib fx (lat or posterior)

7. What’s going on? Whats the ED treatment?
• 32 M playing football and was tackled, jammed finger on ground

8. Boutonniere deformity:
• extensor tendon central slip
• could also be from arthritis
• splint in Proximal PIP EXTENSION
• (if you dont, could become permanent )

9. What is it, what to do
• 14 yr old playing basketball and it jammed him in the hand

10. Mallet finger-
• extensor tendon rupture or avulsion fx at base distal phalanx, forced
flexion of DIP
• Splint Distal DIP extension

11. Mallet and Boutonnieres recap
• The part that is bent, splint it so its extended

12. What is it? What to do?
• 45 M drunk, assaulted, signed
out to you as a sobriety then
reassess
• 8 hours later he complains his
hand hurts and doesn’t work
• PE: Cant flex 4th finger DIP , can
feel a lump in volar palm
•

13. Jersey finger- Surgery!
• avulsion of the FDP at DIP joint
• Depending on how bad the injury is, may need prompt repair within 7
days – few weeks
• tendon retracts to palm and can be palpated, needs within 7 – 10 days
• If its palpated PIP/ DIP can wait a few weeks, if theres a fx that needs pining
first

14. What to do now?
• 38 M smashed his finger in the car door 3
days ago, it still hurts but is getting better
• What do do?

15. Subungal hematomas
• Subungal hematoms with pain can be trephinated if injury Under 48
hr, after the hematoma probably already clotted
• if theres small nailbed lac, if the nail is intact you dont have to remove
the nail

16. What to do? How to fix?
• 23 M punched someone
face, co R hand pain, there is
open skin on his fourth
knuckle
• PE: bent fist shows

17. Boxer fracture with rotational deformity
• How to reduce?
• place finger parallel to
ground, Flex MCP 90
degrees, press down on
metacarpal shaft and upward
on the phalange
• You give him TDAP and
unasyn

18. What to do?
• 79 year skiing in the Alps
complaining thumb pain
• He also went hunting and
twisted the necks of many a
poor fowl
• PE: ttp ulnar thumb MCP,
bends over 20%

19. UCL tear, game keepers thumb
• Torn Ulnar Collateral ligament
• Thumb spica splint
• If > 20 degrees valgus varus instability, or if lesion
as shown in xr, will also need OR

20. Ah, continuity of care….what to do next?
• Our upstanding
gentleman did not fill
his augmentin rx and
now comes back 5
days later complaining
of finger pain
• PE: flexed, sausage-
like, pain w extension,
tenderness along volar
surface

21. Tenosynovitis
• Knavel sign ( he had all the cardinal signs)
• Call ortho for debridement
• Start on IV Abx

22. FOOSH MANIA AHEAD!!!

23. What’s this?
What to check
on exam?

24. Colles fracture
• Distal radius fx dorsal displacement
• ASSESS MEDIAN NERVE
• (volar displacement is Smiths)

25. Bartons fracture
• distal radius fx w dislocation
of radiocarpal joint
• require OR exfix

26. Whats this, treatment?

27. Triquetrum fx
• Triquetrum is second most frequently fx!
• put in volar splint
• ALSO…..
• Scaphoid is first most commonly fx
• Snuff box ttp even if neg xr
• What splint do you put it in?

28. Whats this, treatment?

29. Scapholunate dislocation
• MC ligamentous injury hand
• Thumb spica

30. Whats this…pst its COMMONLY MISSED!!
What to check on exam?

31. Perilunate dislocation
• Progression of scapholunate
dissociation
• Pie sign (due to rotation)
• High energy w poor functional
outcomes
• Perilunate- lunate stays but all carpal
bones are displaced
• Median nerve injured in 25% pt (
lunate dislocates into carpal tunnel)
• NEEDS OPERATIVE MANAGEMENT!!!

32. What about this?

33. Lunate dislocation
• Carpal bones aligned lunate
displaced
• Same stuff as last slide applies,
this is worse progression

34. ED management perilunate/ lunate
• Immediately reduce, early
operative referral
• Traction (finger trips,
elbow 90 flexed, 10 lbs
traction x 15 min)
• wrist extension, traction,
and flexion of wrist w
volar pressure to
rearticulate lunate
• Sugar tong

35. Whats this, what to check on exam?

36. Monteggia fx
• Ulnar fx, radial head dislocation
• Assess radial nerve !!

37. Whats this? What to check on exam?

38. Galeazzi fx
• radius fx, ulnar joint dislocation
• assess ulnar nerve

39. What type shoulder dislocation?

40. Inferior dislocation
• high complication rate, assoc w severe rotator cuff injuries and
neurovasc compromise

41. What’s going on here, what’s their
presentation?

42. Posterior dislocation
• 5% of shoulder dislocations (95% ant)
• Held in adduction and internal rotation ( opposite of ant)

43. Whats this
called?
What nerve
should you
assess?
What other
injuries/
sequela
should you
be aware
of?

44. Tibial plateau fx
• Assess deep peroneal nerve
• big toe dorsal webspace
sensation,
• foot drop
• Watch for compartment
syndrome
• Check for ACL/ meniscal tears
• ORIF (usually)

45. Whats going on

46. Maisonneuve fx
• Squeeze calf of every ankle injury pt
• eversion injury --> proximal fibula and medial mal
• tear of the distal tibiofibular syndesmosis and the interosseous
membrane
• usually splinting is enough, if syndesmosis needs realignment then
ORIF is needed

47. What else to do?

48. Pilon/ plafond fracture
• comminuted distal tibia fx from axial force, talus pushes onto tibial
plafond.
• High energy--Check for associated injuries ( fibia, calcaneus, vert
body, pelvis)
• usually ORIF

49. What is it? What to do?
• Twist foot going down stairs

50. Jones fx
• Jones fx high risk for complication if
untreated, many require ORIF, after
ortho consult may discharge home w
NWB and splint
• if over 15mm then its metatarsal shaft
fx not jones
• if its just avulsion at base its pseudo
jones (hard sole shoe /WBAT)

51. Whats wrong here?
• 32 M tackled in football, foot pain

52. Example 2

53. Mechanism

54. Super obvious example

55. Lisfranc fx
• Lisfranc joint base 1-2 metatarsal and
cuneiform
• Most require ORIF
• Initial xr often normal (get WB XR)
• CT also helpful
• Often missed! Delayed dx = deformity,
function loss
• CHECK DP PULSE (could be transected)
• Posterior splint, NWB w likely ORIF in 7d

56. SLR notes…
• When doing SLR, pt complains of pain to mid thigh, is this + SLR?
• NO ( only past knee)
• SLR on opposite leg causes pain in effected leg, is this + SLR?
• YES, even more specific
• SLR causes pain at <30 degrees what should you think of?
• Spondylolishtesis, tumor, abscess

67. • Femoral-
• hip flexion, knee
extension
• patellar reflex
• Sensation- Ant thigh

68. • sciatic nerve-
• knee flexion,
plantarflexion
• sensation plantar
foot

69. • common peroneal- lat
calf and dorsum foot,
ankle dorsi plantar flex

71. • Deep peroneal -
• Sensory 1-2 toe
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