Chapter 28. orthopedic emergencies

CURRENT Diagnosis & Treatment Emergency Medicine, 7e
Chapter 28. Orthopedic Emergencies
Royce Coleman, MD; Alison Reiland, MD
Immediate Management of Life-Threatening Injuries
Patients with orthopedic injuries and musculoskeletal disorders constitute a large portion of patients presenting to the Emergency Department. All
trauma patients should be managed initially in the same manner, with similar guiding principles of trauma care regardless of their underlying injuries.
Orthopedic injuries may be dramatic, but they should not draw attention away from more critical elements of initial patient assessment and treatment.
The emergency physician must assess the patient and manage injuries and based on the immediate threat to survival, evaluating each trauma patient
with the primary survey, which consists of assessing the airway, breathing, circulation, disability, and exposure (ABCDEs) (Table 28–1).
Table 28–1. Potential Blood Loss from Closed Fractures.
Site Amount (L)
Pelvis 1–5+
Femur 1–4
Spine 1–2
Leg 0.5–1
Arm 0.5–0.75
Once the primary survey has been addressed, proceed to the secondary survey, which should be a thorough, but rapid physical examination from head
to toe to assess for all injuries. With cervical spine precautions in place, logroll the patient, assess the posterior scalp, and examine the entire spine for
tenderness or step-off deformities. Perform a digital rectal examination to evaluate for sphincter tone, gross blood, or abnormal prostate position.
When evaluating the pelvis for stability, apply gentle anteroposterior and lateral compression. Visualize and go through range of motion of all joints
and document all lacerations, abrasions, and contusions. Physical examination of orthopedic injuries includes inspection for deformity, color change,
palpation for tenderness, range of motion, and assessment of neurovascular status. At this time, consider reduction of certain orthopedic
emergencies such as a dislocated hip, knee, or any fracture or dislocation in which vascular compromise is present (Figure 28–1). Delayed reduction
may lead to avascular necrosis, or other complications; therefore, if possible, reduce fractures and dislocations with neurovascular compromise
before transferring the patient.
Figure 28–1.
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may lead to avascular necrosis, or other complications; therefore, if possible, reduce fractures and dislocations with neurovascular compromise
before transferring the patient.
Figure 28–1.
Technique of manual traction to align an angulated fracture and correct deformity.
Traumatic Amputations
Essentials of Diagnosis
Sharp, guillotine injuries are best candidates for reimplantation
Keep amputated part clean, moisten with saline, and put on ice
Do not allow part to freeze
Cooling will help increase viability of amputated part up to 12–24 hours
General Considerations
Patients incurring traumatic amputations should be considered for reimplantation surgery. Young healthy patients with sharp, guillotine injuries
without crushing or avulsion damage are the best candidates for successful reimplantation. However, it is best to consider all patients as potential
candidates, care for the amputated part, and make appropriate consultations or arrange for transfer.
Clinical Findings
Symptoms and Signs
The patient presents with an amputated digit or limb.
X-Ray Finding
Although this diagnosis is made clinically, X-rays often help delineate exactly where the injury occurred, or if underlying fractures or dislocations exist.
Treatment
The amputated part should be kept clean, wrapped in a sterile dressing, moistened with sterile saline, placed in a plastic bag, and put on ice. Do not
use dry ice or allow the amputated part to freeze. Cooling the amputated part will increase the viability from 6–8 hours to approximately 12–24 hours.
The injury should be treated as an open fracture, with appropriate use of antibiotics and tetanus prophylaxis.
Disposition
Patients with limb amputations usually require consultation with an orthopedic, plastic, or trauma surgeon. These patients should be admitted for
further surgical management, neurologic and vascular evaluation, and monitoring of blood loss. Patients with small digit amputations may be
managed in the emergency department and discharged with appropriate close follow-up.
Lloyd MS, Teo TC, Pickford MA et al: Preoperative management of the amputated limb. Emerg Med J 2005;22(7):478–480 [PubMed: 15983081] .
Compartment Syndrome
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Patients with limb amputations usually require consultation with an orthopedic, plastic, or trauma surgeon. These patients should be admitted for
further surgical management, neurologic and vascular evaluation, and monitoring of blood loss. Patients with small digit amputations may be
managed in the emergency department and discharged with appropriate close follow-up.
Lloyd MS, Teo TC, Pickford MA et al: Preoperative management of the amputated limb. Emerg Med J 2005;22(7):478–480 [PubMed: 15983081] .
Compartment Syndrome
A potentially devastating and subtle complication of orthopedic injuries is the development of a compartment syndrome. Although predominantly
occurring in the lower extremities, a compartment syndrome can potentially occur anywhere in the body with a restricting compartment. Compartment
syndromes are caused by compromised blood flow due to increased hydrostatic pressure in a closed tissue space. The lower leg has four
compartments: anterior, lateral, posterior, and deep posterior. Trauma below the knee can lead to progressive swelling with eventual decreased blood
flow from vascular compression as well as neurologic compromise. The immediate threat is to the viability of the tissue and nerves, but late findings
can include permanent posttraumatic muscle contracture, infection, rhabdomyolysis, and renal failure.
Clinical Findings
The classical findings associated with compartment syndrome are pallor, pulselessness, pain, paresthesias, and poikilothermia. Pain on passive
stretching of the muscle groups and the subjective complaint of pain out of proportion to the physical findings are important findings. Decreased or
absent pulses are a late and ominous sign, and the presence of a pulse does not exclude compartment syndrome. Delays in recognition of
compartment syndrome are more likely to occur in sedated patients or in those with head injuries than in other patients due to altered mental status.
The diagnosis can be confirmed by measuring intracompartmental pressures with a Stryker pressure monitor or with a needle connected to an arterial
line pressure monitor, although noninvasive methods such as ultrasound are being studied. Levels above 30 mm Hg are abnormal and lead to necrosis
of nerve and muscle.
Treatment
Initial interventions include immobilization and removal of any constricting bandages or splints, as well as being conscious of possible rhabdomyolysis
and renal failure. Intracompartmental pressures greater than 30 mm Hg generally require immediate intervention with fasciotomy, preferably by a
surgeon.
Disposition
Patients with compartment syndrome require hospitalization for definitive surgical management.
Shadgan B, Menon M, O'Brien PJ et al: Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma 2008;22(8):581–587
[PubMed: 18758292] .
General Orthopedic Principles
Fractures and Dislocations
Precise language exists to describe fractures, allowing relevant information to be communicated. The terms closed or open designate whether the skin
and soft tissue overlying the fracture site are intact. The exact anatomic location should be included in the description including the name of the bone,
side of the body, and standard reference points. Degrees of displacement and angulation should be described in terms of the distal structure's
relationship to the more proximal part of the body. Additional modifiers include descriptions such as comminuted (fracture in more than two
fragments), impacted (collapse of one fragment of bone onto another), transverse (fracture line at right angle to long axis of the bone), oblique
(fracture line with angle other than right angle), and spiral (fracture line encircles the shaft of a long bone secondary to rotational forces). The term
valgus refers to a deformity in which the described part is angled away from the body, whereas varus denotes angling toward the midline. An avulsion
fracture occurs when a ligament or tendon pulls a fragment of bone away. Pathologic fractures occur in weakened areas of bone as seen with
osteomalacia, cysts, carcinomas, and Paget disease. The possibility of a pathologic fracture should be considered when fractures occur with minimal
trauma. Stress fractures occur most commonly in the lower extremity and are seen with repetitive trauma (eg, from prolonged marching or running).
Stress fractures may be subtle, may be missed on initial radiographs, and may require a bone scan or other imaging modality to make the diagnosis.
Dislocations are complete disruptions in the normal relationship of the articular surfaces of the bones making up a joint. They may be associated with
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relationship to the more proximal part of the body. Additional modifiers include descriptions such as comminuted (fracture in more than two
fragments), impacted (collapse of one fragment of bone onto another), transverse (fracture line at right angle to long axis of the bone), oblique
(fracture line with angle other than right angle), and spiral (fracture line encircles the shaft of a long bone secondary to rotational forces). The term
valgus refers to a deformity in which the described part is angled away from the body, whereas varus denotes angling toward the midline. An avulsion
fracture occurs when a ligament or tendon pulls a fragment of bone away. Pathologic fractures occur in weakened areas of bone as seen with
osteomalacia, cysts, carcinomas, and Paget disease. The possibility of a pathologic fracture should be considered when fractures occur with minimal
trauma. Stress fractures occur most commonly in the lower extremity and are seen with repetitive trauma (eg, from prolonged marching or running).
Stress fractures may be subtle, may be missed on initial radiographs, and may require a bone scan or other imaging modality to make the diagnosis.
Dislocations are complete disruptions in the normal relationship of the articular surfaces of the bones making up a joint. They may be associated with
fractures. Dislocations should be described by the relationship of the distal bone to the more proximal bone. A subluxation is an incomplete
dislocation.
Pediatric fractures are distinguished from adult fractures due to difference in the bones of children, which are generally less dense and have increased
compliance. A Greenstick fracture refers to an angulated fracture in which the cortex and periosteum are only disrupted on one side of the bone. Torus
fractures (also called cortical or buckle fractures) involve a buckling of the cortex. Physeal, or growth plate injuries in children are described by the
Salter–Harris classification (Figure 28–2).
Figure 28–2.
Salter–Harris classification of growth plate injuries.
Type I Injuries
The epiphysis is separated from the metaphysis without radiographic evidence of metaphyseal or epiphyseal fracture. If significant displacement is not
present, type I injuries may be difficult to diagnose on initial radiographs and should be suspected if there is point tenderness over an epiphysis.
Thickening of the growth plate and soft tissue swelling may be the only signs evident on X-rays. If an injury is suspected but cannot be identified on the
initial films, immobilization and orthopedic follow-up are recommended.
Type II Injuries
Type II injuries are the most common physeal injuries and most often seen in older children over 10 years. The fracture line travels through the physis
and is associated with an oblique fracture of the metaphysis on the opposite side from where the force was applied. The metaphyseal fragment is
referred to as the Thurston–Holland sign. Growth disturbances usually do not occur with types I and II injuries.
Type III Injuries
Type III injuries comprise a vertical fracture of the epiphysis perpendicular to the physis, extending into the growth plate. This type of injury is
uncommon and most frequently occurs at the distal tibial epiphysis. To avoid the potential of growth plate arrest, the fracture must be appropriately
reduced to maintain proper blood supply. Reduction is accomplished most commonly with operative fixation. If surgery is not performed, frequent
rechecks and follow-up radiographs are recommended to ensure that the fracture does not become displaced after immobilization.
Type IV Injuries
Unlike types I–III, type IV injuries are the result of compressive rather than rotational or shearing forces. Vertical splitting of the epiphysis occurs,
extending through the physis and metaphysis and most commonly involves the distal humerus. Type IV injuries require surgical repair, and growth
plate arrest may occur even with operative fixation.
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Type III injuries comprise a vertical fracture of the epiphysis perpendicular to the physis, extending into the growth plate. This type of injury is
uncommon and most frequently occurs at the distal tibial epiphysis. To avoid the potential of growth plate arrest, the fracture must be appropriately
reduced to maintain proper blood supply. Reduction is accomplished most commonly with operative fixation. If surgery is not performed, frequent
rechecks and follow-up radiographs are recommended to ensure that the fracture does not become displaced after immobilization.
Type IV Injuries
Unlike types I–III, type IV injuries are the result of compressive rather than rotational or shearing forces. Vertical splitting of the epiphysis occurs,
extending through the physis and metaphysis and most commonly involves the distal humerus. Type IV injuries require surgical repair, and growth
plate arrest may occur even with operative fixation.
Type V Injuries
Type V injuries, which are rare, are the result of crushing forces applied to the epiphysis at the area of the physis. When seen, they occur most often at
the distal tibia and the knee. Because no fracture is visible, these injuries are frequently missed on initial radiographs and are often diagnosed on
follow-up visits after the shortening, and angular deformity secondary to growth plate arrest is evident. Nontraumatic causes include osteomyelitis and
epiphyseal aseptic necrosis. Treatment consists of immobilization and close orthopedic follow-up.
Eponyms
Even though emergency physicians are likely to be comfortable using the many eponyms that exist to describe fractures, such as Colles, Monteggia,
Galeazzi, it is probably more efficient to provide orthopedic consultants with an anatomic description using the above terminology.
Sprains and Strains
Sprains are injuries to ligaments and may be associated with a fracture. The following grading system is used to describe the severity of the injury:
Grade I—Incomplete tear. Swelling and ecchymosis may be present. Immobilization and conservative care are indicated.
Grade II—Significant incomplete tear. Swelling and ecchymosis are usually present as is some laxity in the joint. Immobilization and orthopedic
follow-up are indicated.
Grade III—Complete disruption. The joint is unstable. Orthopedic consultation is indicated for possible surgical repair.
When assessing joint instability, remember that joint effusions, guarding, and muscle contractions may complicate the initial clinical examination. If
there is any question, a period of immobilization and follow-up examination are indicated. A strain is an injury to the muscle-musculotendinous unit.
Strains are also graded according to severity. Most only require immobilization and conservative management; however, surgical repair may be
necessary, and orthopedic consultation or referral should be obtained if indicated.
Splinting
Splints are a basic part of orthopedic care and should be applied to suspected or confirmed fractures to attempt to avoid and further damage to
muscle, nerves, vessels, and skin. They are used to stabilize the injury, provide some amount of pain relief, and help prevent further injury. Some
splints are designed to be temporary, such as those applied in the field by emergency medical services personnel. These splints should ideally stabilize
the joint above and below the suspected injury. Attempting to correct deformities before obtaining radiographs is not recommended, unless vascular
compromise is suspected.
Splints are often applied in the emergency department before the patient is discharged or admitted and are left in place until more definitive
orthopedic care is instituted. All physicians should be experienced in splinting. Even if the splint is to be applied by a technician, the physician should
ensure that the splint is adequately padded and the limb is stabilized in an appropriate position before the patient is discharged. In addition, the
physician should reevaluate and document the limb's neurovascular status after any reduction or splinting procedure. Use of circumferential plaster
(ie, casts) is strongly discouraged in the emergency department. In almost all orthopedic injuries, soft tissue swelling worsens after discharge,
potentially leading to significant neurovascular compromise if a cast has been applied in the emergency department.
Procedural Sedation
Before a fracture or dislocation is reduced, adequate analgesia and muscle relaxation must be provided. The best way to accomplish fracture or
dislocation reduction is with sedation using either intravenous or intramuscular agents. Emergency departments should have specific policies in place
for the administration and monitoring of patients undergoing sedation. The goal is to provide sufficient sedation for the procedure without having to
administer general anesthesia.
Although controversial, most authorities recommend that before sedating a patient, ensure that the patient has fasted for 4–6 hours prior to the
procedure. Necessary equipment includes at least one functioning venous catheter, continuous pulse oximetry, cardiac monitor, suction, airway
intubation equipment, and a bag-valve mask. Mallampati oropharynx assessment and consideration of the patient's American Society of
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Procedural Sedation
Before a fracture or dislocation is reduced, adequate analgesia and muscle relaxation must be provided. The best way to accomplish fracture or
dislocation reduction is with sedation using either intravenous or intramuscular agents. Emergency departments should have specific policies in place
for the administration and monitoring of patients undergoing sedation. The goal is to provide sufficient sedation for the procedure without having to
administer general anesthesia.
Although controversial, most authorities recommend that before sedating a patient, ensure that the patient has fasted for 4–6 hours prior to the
procedure. Necessary equipment includes at least one functioning venous catheter, continuous pulse oximetry, cardiac monitor, suction, airway
intubation equipment, and a bag-valve mask. Mallampati oropharynx assessment and consideration of the patient's American Society of
Anesthesiologists (ASA) categorization should be determined before beginning the procedure to ensure that the emergency physician can manage any
potential airway complications resulting from sedation. In general, only ASA class I or II patients (those without serious systemic comorbid diseases)
should undergo procedural sedation in the emergency department. ASA class III or IV patients should optimally receive treatment in the operating
room.
Most authors recommend that patients being sedated in the emergency department receive supplemental oxygen regardless of initial oxygen
saturation. The goal is to maintain an oxygen saturation above 90% at all times. It is important to remember, however, that pulse oximetry only
measures oxygen saturation and does not provide any information regarding the patient's ventilation. Many clinicians now routinely utilize end-tidal
CO2 monitoring as a measure of ventilation in order to prevent hypoxemia. Many agents are available for procedural sedation. Ideally, medications
should be short acting. Etomidate, 0.15mg/kg has a profound and short-lived action, which should be sufficient for most procedures. It has been
reported to cause adrenal suppression, the clinical significance of which is unknown and is currently not approved for use in children. Propofol has
gained widespread use in emergency medicine procedural sedation because of its rapid onset, titratable sedation effect, and quick recovery period. It
also has the added advantage of antiemetic properties, which in theory would reduce the risk of aspiration during sedation. Ketamine provides distinct
advantages for sedation in certain circumstances and is used commonly in children. It is effectively administered in both intravenous and
intramuscular routes. It provides excellent sedation without as much risk of oversedation and hypoventilation. An alternative is the combination of
agents such as midazolam and fentanyl. Be aware that a potential side effect of fentanyl is chest wall rigidity (at higher doses or with rapid boluses),
which may prohibit bag-mask ventilation and may necessitate paralyzation and intubation. It is important to remember that with the use of any
sedative, airway support through airway maneuvers or assisted ventilation may be needed. Adequate documentation by trained nursing staff is
necessary, and sedated patients should be monitored until they can ambulate and tolerate fluids by mouth.
Cotton BA, Guillamondegui OD, Fleming SB et al: Increased risk of adrenal insufficiency following etomidate exposure in critically injured patients.
Arch Surg 2008;143(1):62–67 [PubMed: 18209154] .
Zed PJ, Abu-Leban RB, Chan WW et al: Efficacy and patient satisfaction of propofol for procedural sedation and analgesia in the emergency
department: a prospective study. CJEM 2008;10(3):196 [PubMed: 18072987] .
Child Abuse
Unfortunately, child abuse remains a major problem in our society, with physical abuse affecting 2–5% of children in the United States. Skeletal
injuries sometimes occur with abuse and may represent significant morbidity to the patient. Certain fracture patterns are commonly seen in abuse,
particularly multiple fractures in varying stages of healing. Clinical suspicion of abuse should remain high whenever injured children receive treatment,
particularly if fractures are found in very young patients, especially less than 3 years of age.
Clinical Findings
The approach to diagnosis should be the same as for all trauma patients. Keys to potential abuse may be evident in the history, such as history
inconsistent with the injuries seen or delays in seeking care (may be evidenced by callus formation at a fracture site seen on X-rays). Physical findings
may include pattern injuries, old bruises, and multiple fractures in various stages of healing.
Remember that significant force is required to produce fractures in the spine, scapula, and sternum. Rib fractures are uncommon in children except in
the setting of abuse, and chest radiographs should be examined carefully to identify these injuries. Spiral fractures have long been identified as red
flags to alert the emergency physician of possible abuse. This is particularly true of humeral and femoral fractures in the very young; however, spiral
fractures of the tibia (Toddler's fracture) may be seen with accidental injuries. Another common injury pattern in abuse is a chip fracture of the
metaphysis. Pulling and twisting forces may also result in a tearing of the periosteum and cartilage at the growth plate of long bones, scapulae, and
clavicles.
Treatment
Treatment of specific injuries is described below. Careful documentation is encouraged.
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Remember that significant force is required to produce fractures in the spine, scapula, and sternum. Rib fractures are uncommon in children except in
the setting of abuse, and chest radiographs should be examined carefully to identify these injuries. Spiral fractures have long been identified as red
flags to alert the emergency physician of possible abuse. This is particularly true of humeral and femoral fractures in the very young; however, spiral
fractures of the tibia (Toddler's fracture) may be seen with accidental injuries. Another common injury pattern in abuse is a chip fracture of the
metaphysis. Pulling and twisting forces may also result in a tearing of the periosteum and cartilage at the growth plate of long bones, scapulae, and
clavicles.
Treatment
Treatment of specific injuries is described below. Careful documentation is encouraged.
Disposition
Obtain appropriate pediatric, orthopedic, and social services consultations while the patient is still in the emergency department. If the patient's safety
is in question, he or she should be admitted to the hospital or taken in to protective custody by social services until all questions have been answered
and the safety of the home environment is assured. All physicians are required to report suspected child abuse.
Management of Specific Orthopedic Injuries
Shoulder Girdle Injuries
Sternoclavicular Joint Dislocations
Chest wall deformity
Sternoclavicular tenderness
Sternal X-rays or computed tomography (CT) aids in diagnosis
May be associated with mediastinal injuries
Dislocations of the sternoclavicular joint (SCJ) are the least commonly dislocated major joint and are associated with motor vehicle collisions or sports
injuries. Anterior dislocations are most common and occur secondary to anterolateral force applied to the shoulder with a rolling movement. Posterior
dislocations are associated with crushing forces applied to the chest, and 25% of posterior dislocations are associated with injuries to the superior
mediastinal structures. The severity of the injury may be graded as follows:
Grade I—Mild sprain of the sternoclavicular and costoclavicular ligaments.
Grade II—Subluxation of the SCJ, may be anterior or posterior; associated with rupture of the sternoclavicular ligament with the costoclavicular
ligament remaining intact.
Grade III—Complete dislocation.
Clinical Findings
Symptoms and Signs
The diagnosis can often be made clinically. Tenderness, swelling, and deformity to the SCJ will be present. Patients typically use the unaffected arm to
support the affected arm across the chest. Posterior dislocations can also present with dysphagia, dyspnea, dysphonia, or upper extremity weakness.
X-Ray Findings
Plain radiographs, including anteroposterior, oblique, and 40° cephalic tilt views aid in the diagnosis. A CT scan may be necessary and is indicated in all
cases of posterior dislocations to evaluate for mediastinal injuries.
Treatment
Obtain orthopedic consultation for both anterior and posterior dislocations. Anterior dislocations may be reduced in the emergency department using
procedural sedation by placing a rolled towel or sheet between the scapulae and applying traction to the affected arm. A posterior dislocation may
need operative repair, and early orthopedic or trauma surgery consultation is appropriate because compression of critical upper mediastinal
structures such as the great vessels and trachea may occur.
Disposition
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Plain radiographs, including anteroposterior, oblique, and 40° cephalic tilt views aid in the diagnosis. A CT scan may be necessary and is indicated in all
cases of posterior dislocations to evaluate for mediastinal injuries.
Treatment
Obtain orthopedic consultation for both anterior and posterior dislocations. Anterior dislocations may be reduced in the emergency department using
procedural sedation by placing a rolled towel or sheet between the scapulae and applying traction to the affected arm. A posterior dislocation may
need operative repair, and early orthopedic or trauma surgery consultation is appropriate because compression of critical upper mediastinal
structures such as the great vessels and trachea may occur.
Disposition
Patients with anterior dislocations may be discharged in a sling and swathe. Even if the reduction is successful, the joint is often unstable and the
clavicular head may dislocate again. However, because the purpose of the reduction is often more cosmetic than functional, even if reduction is
unsuccessful the patient may be discharged with immobilization in a sling and orthopedic follow-up. Posterior dislocations may be reduced with
traction and adduction; however, patients should be managed in consultation with a specialist and most likely will require admission.
Clavicle Fractures
Clavicle deformity
X-rays confirm diagnosis
Most heal with conservative management
Clinical Findings
Symptons and Signs
The most common mechanism causing a clavicle fracture is a direct blow to the shoulder. Often the clavicle is deformed, and some swelling,
tenderness, and occasionally crepitus are present.
X-Ray Findings
Most clavicle fractures are easily seen with a clavicle series.
Treatment
Treat open fractures with antibiotics and orthopedic consultation. For closed clavicle fractures, treatment typically involves pain control,
immobilization with a sling, or sling and swathe.
Disposition
Most clavicle fractures heal uneventfully. Factors associated with nonunion include marked initial displacement or shortening. Patients with closed
fractures may be discharged with orthopedic follow-up. Patients with open fractures require hospitalization for further management.
Acromioclavicular Joint Injuries
Deformed and tender acromioclavicular joint (ACJ)
May be confused with clavicle injury
X-ray may confirm diagnosis
Acromioclavicular joint injuries most commonly result from a direct fall onto the shoulder and account for 25% of all dislocations of the shoulder
girdle. These injuries are graded according to severity:
Type I—Sprain, minimal tear of the acromioclavicular (AC) ligament.
Type II—small tear of AC ligament, widened joint space, coracoclavicular distance maintained.
Type III–VI—Complete disruption of AC ligament, coracoclavicular ligament, and muscle attachments. In type III injuries, the clavicle is displaced
upward, in type IV the clavicle displaces posteriorly into the trapezius, and in type V the clavicle is displaced superiorly. Type VI is rare and the
clavicle displaces inferiorly.
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Acromioclavicular joint injuries most commonly result from a direct fall onto the shoulder and account for 25% of all dislocations of the shoulder
girdle. These injuries are graded according to severity:
Type I—Sprain, minimal tear of the acromioclavicular (AC) ligament.
Type II—small tear of AC ligament, widened joint space, coracoclavicular distance maintained.
Type III–VI—Complete disruption of AC ligament, coracoclavicular ligament, and muscle attachments. In type III injuries, the clavicle is displaced
upward, in type IV the clavicle displaces posteriorly into the trapezius, and in type V the clavicle is displaced superiorly. Type VI is rare and the
clavicle displaces inferiorly.
Clinical Findings
Symptoms and Signs
Patients should be examined in the sitting position. Often a deformity at the ACJ will be present, with swelling, tenderness, and occasionally crepitus.
X-Ray Findings
X-rays should include anteroposterior, axillary, and 15° cephalic tilt views. Stress views are no longer recommended. Classically, separation between
the acromion and the clavicle is seen in grade II and grade III injuries. Additionally, since the coracoclavicular ligament is disrupted in a grade III injury,
the distal clavicle is elevated in relation to the acromion.
Treatment
Types I and II injuries are treated conservatively with a sling. Type III injuries have traditionally been treated with surgical repair; however, conservative
management has been used more recently with good results.
Disposition
Most patients may be discharged home. All patients should receive orthopedic referral for follow-up examination.
Mazzocca AD, Arciero RA, Bicos J: Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med 2007;35(2):316–329 [PubMed:
17251175] .
Scapula Fractures
Pain and tenderness over scapula
May be associated with more severe intrathoracic injuries
X-ray (with axillary views) confirms diagnosis
Fractures of the scapula are uncommon, accounting for approximately 1% of all fractures. Fractures usually are secondary to direct blows or to crush
injuries. Because the scapula is well protected by muscle, the presence of a fracture indicates a significant mechanism of injury and warrants
evaluation for other potential injuries to the lung, chest wall, humerus, and clavicle. Acromion process and coracoid process fractures have been
associated with brachial plexus injury. Scapula fractures can be classified as follows:
Type I—Fracture of coracoid process, acromion process, or scapular spine.
Type II—Fracture of the scapular neck.
Type III—Intra-articular fracture involving the glenoid fossa.
Type IV—Fracture of the body of the scapula (most common).
Clinical Findings
Symptoms and Signs
The patient will present with pain and tenderness over the scapula. A hematoma and crepitus may also be appreciated. The patient will usually hold
the affected arm close to the body.
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Type II—Fracture of the scapular neck.
Type III—Intra-articular fracture involving the glenoid fossa.
Type IV—Fracture of the body of the scapula (most common).
Clinical Findings
Symptoms and Signs
The patient will present with pain and tenderness over the scapula. A hematoma and crepitus may also be appreciated. The patient will usually hold
the affected arm close to the body.
X-Ray Findings
Fractures may be subtle on plain radiographs. Always obtain an axillary view to help identify fractures involving the glenoid, acromion, and coracoid
processes. In some instances, CT scanning may be necessary to identify subtle or intra-articular fractures. In children, the physis of the acromion may
be seen on X-rays. In approximately 3% of individuals, this structure remains unfused (os acromiale) and can be mistaken for a fracture.
Treatment
The majority of isolated scapula fractures are managed conservatively with a sling and swath and pain management. Intra-articular fractures such as
those involving the glenoid often require surgical stabilization.
Disposition
Significantly displaced fractures rarely may require surgical repair; patients with such fractures should be admitted. Patients with isolated scapular
fractures may be discharged with close follow-up.
Rotator Cuff Injuries
Pain and decreased motion of shoulder
Positive drop-arm test
Plain X-ray of little value
Arthrogram or magnetic resonance imaging (MRI) will confirm diagnosis
The rotator cuff comprises four muscles: the subscapularis (internal rotation), the infraspinatus and teres minor (external rotation), and the
supraspinatus (adduction). Acute tears are commonly seen with falls, either directly onto the shoulder or on an outstretched hand, but may also occur
in the setting of lifting heavy objects although most tears are chronic. Rotator cuff tears occur more commonly in middle-aged to elderly males and
usually involve the dominant arm.
Clinical Findings
Symptoms and Signs
The patient complains of pain and decreased motion. Point tenderness over the greater tuberosity or a palpable defect may be seen. Rotator cuff tears
may be evaluated by the drop arm test by passively abducting the arm to 90° and then applying pressure to the distal forearm. With significant acute
tears, this will cause the patient to drop his or her arm.
X-Ray Findings
Plain radiographs are usually of little use but should be obtained to rule out occult fractures. Superior displacement of the humeral head may be seen
in complete tears but is not diagnostic.
Treatment
Provide adequate analgesia and a sling for comfort.
Disposition
Outpatient follow-up with scheduling of an arthrogram or MRI scan may be necessary to confirm the diagnosis. Patients may be discharged with
orthopedic follow-up.
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in complete tears but is not diagnostic.
Treatment
Provide adequate analgesia and a sling for comfort.
Disposition
Outpatient follow-up with scheduling of an arthrogram or MRI scan may be necessary to confirm the diagnosis. Patients may be discharged with
orthopedic follow-up.
Shoulder Dislocations
Shoulder deformity, pain, and decreased movement
Majority are anterior dislocations
Anteroposterior, Y and axillary view X-rays confirm diagnosis
Perform thorough nerve examination
The shoulder is the most commonly dislocated major joint in the body. Most (approximately 95%) of these injuries are anterior dislocations and are
often easily diagnosed clinically; however, in muscular individuals the clinical presentation may be less obvious. Posterior dislocations are much less
common and are usually associated with violent muscle contractions as seen with seizures and electrocutions but may also occur with falls on a flexed,
internally rotated arm. Posterior dislocations are often missed clinically and may also be difficult to identify on standard anteroposterior X-rays.
Inferior dislocations (Luxatio erecta) have been described as a type of anterior dislocation and are rare. This occurs when the humeral head is forced
below the inferior rim of the glenoid fossa.
Clinical Findings
Symptoms and Signs
The patient usually holds the arm in adduction and the elbow flexed close to the body. Pain occurs with the least amount of movement. The glenoid
fossa may be palpable. A complete neurologic and vascular examination of the extremity is of paramount importance. Axillary nerve function should be
assessed by checking the sensation in the lateral aspect of the shoulder and testing deltoid motor function. Examine radial, ulnar, and median nerve
distributions thoroughly prior to sedation and reduction. Document brachial and radial pulses. In inferior dislocations, clinically the patient will hold
the arm locked overhead and abducted with the elbow flexed. This type of dislocation may also be associated with injury to the axillary artery and
neuropraxis of the brachial plexus.
In posterior dislocations, the patient usually holds the affected arm against the chest in adduction and internal rotation. Abduction and external
rotation are severely limited. The posterior shoulder may be prominent when viewed from above; however, this finding may be difficult to recognize,
particularly in muscular individuals.
X-Ray Findings
Obtain a shoulder series, including a scapular Y-view (Figure 28–3), which can help diagnose the direction of dislocation. Axillary views are often the
most helpful if any doubt exists about the diagnosis. X-rays will also help identify associated fractures. A Hill-Sachs deformity (impaction of the
posterolateral humeral head) may occur with dislocation. A fracture of the anteroinferior glenoid rim (Bankart fracture) may be seen with anterior
dislocations. Bankart fractures may be subtle and identified only on CT scans.
Figure 28–3.
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posterolateral humeral head) may occur with dislocation. A fracture of the anteroinferior glenoid rim (Bankart fracture) may be seen with anterior
dislocations. Bankart fractures may be subtle and identified only on CT scans.
Figure 28–3.
Sketch of view on tangential lateral X-ray shows the body of the scapula in its narrowest aspect. If the patient is poorly positioned, the medial and
lateral borders are not superimposed. Normally, the humeral head shadow lies directly over that of the glenoid, which may be hard to see. The position
of the glenoid is indicated by the confluence of the scapular spine, the body of the scapula, and the coracoid process. A dislocated humeral head lies
anterior or posterior to this point.
Treatment
Some controversy exists over the need to obtain X-rays prior to reduction of shoulder dislocations. We do not generally recommend bypassing X-rays
at this time unless vascular compromise is present. In patients with chronic recurrent dislocations, the dislocations may occur without significant
trauma; in this setting, consider reducing the shoulder before obtaining radiographs.
Emergency physicians should be comfortable with numerous reduction methods. The patient will often require sedation prior to the procedure and
good muscle relaxation is key to successfully reductions. We prefer the external rotation–adduction technique for reduction. With the patient in an
upright position, the extremity is externally rotated while gentle traction and adduction are applied at the elbow. This technique is associated with a
low risk of injury and does not require a great deal of force, as do the other methods. The traction–countertraction method—in which an assistant
applies countertraction with a sheet and in-line traction of the upper extremity—requires some physical strength (Figure 28–4). Do not try to pull the
humerus into place. Instead place traction on the arm until the muscles fatigue and the humeral head slides in. The Stimson method achieves
reduction by attaching weight to the wrist with the dislocated arm hanging over the bed to provide traction, but this method requires about 20–30
minutes. In scapular manipulation, reduction is performed by repositioning the glenoid fossa rather than the humeral head by rotating the inferior tip
of the scapula medially while stabilizing the superior and medial edges. After reduction, reevaluate neurovascular status and immobilize the shoulder
with a sling and swath. Obtain postreduction X-rays.
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Emergency physicians should be comfortable with numerous reduction methods. The patient will often require sedation prior to the procedure and
good muscle relaxation is key to successfully reductions. We prefer the external rotation–adduction technique for reduction. With the patient in an
upright position, the extremity is externally rotated while gentle traction and adduction are applied at the elbow. This technique is associated with a
low risk of injury and does not require a great deal of force, as do the other methods. The traction–countertraction method—in which an assistant
applies countertraction with a sheet and in-line traction of the upper extremity—requires some physical strength (Figure 28–4). Do not try to pull the
humerus into place. Instead place traction on the arm until the muscles fatigue and the humeral head slides in. The Stimson method achieves
reduction by attaching weight to the wrist with the dislocated arm hanging over the bed to provide traction, but this method requires about 20–30
minutes. In scapular manipulation, reduction is performed by repositioning the glenoid fossa rather than the humeral head by rotating the inferior tip
of the scapula medially while stabilizing the superior and medial edges. After reduction, reevaluate neurovascular status and immobilize the shoulder
with a sling and swath. Obtain postreduction X-rays.
Figure 28–4.
Method of producing traction on dislocated humerus and countertraction on thorax for reduction of shoulder dislocation.
Disposition
Discharge patients with adequate analgesia such as nonsteroidal anti-inflammatory drugs or opiates and orthopedic follow-up in 2–3 days. If any
neurologic findings are present, such as a wrist drop, obtain orthopedic consultation while the patient is still in the emergency department. Most of
these neurologic findings are caused by a neuropraxia and usually improve over time.
Baykal B, Sener S, Turkan H: Scapular manipulation technique for reduction of traumatic anterior shoulder dislocations: experiences of an academic
emergency department. Emerg Med J 2005;22(5): 336–338 [PubMed: 15843700] .
Kocher MS, Waters PM, Micheli LJ: Upper extremity injuries in the pediatric athlete. J Sports Med 2000;30(2):117 [PubMed: 10966151] .
Owens S, Itamura JM: Differential diagnosis of shoulder injuries in sports. Orthop Clin North Am 2001;32(3):393 [PubMed: 11888134] .
Ruotolo C, Nottage WM: Surgical and nonsurgical management of rotator cuff tears. Arthroscopy 2002;18(5):527 [PubMed: 11987065] .
Upper Extremity Injuries
Humerus Fractures
Frequent in elderly patients
Pain, deformity, and decreased mobility at shoulder
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Upper Extremity Injuries
Humerus Fractures
Pain, deformity, and decreased mobility at shoulder
X-ray confirms diagnosis
Conservative management
Humerus fractures frequently occur in elderly women with a history of osteoporosis and the classic mechanism of injury involves a fall on an
outstretched hand. In the Neer classification system, categories include two, three, and four part fractures.
Clinical Findings
Symptoms and Signs
The patient usually presents with deformity at the shoulder and commonly holds the affected arm close to the body. It is important to assess vascular
status because the brachial artery lies in proximity to the distal humeral shaft and associated arterial injury may be present. Assess for radial nerve
injury and wrist drop, particularly with humeral shaft fractures.
X-Ray Findings
X-rays show these injuries clearly. Proximal humerus fractures with some impaction are the most common type.
In younger patients, look for signs of a unicameral cyst or other pathologic causes of fracture.
Treatment
Conservative management is generally the rule, especially in the elderly. Minimally displaced fractures constitute the majority of injuries. These
patients do well with a splint, sling, and swathe (Figure 28–5), or sling and swathe alone, and adequate analgesia.
Figure 28–5.
Posterior plaster splint with sling and swathe for immobilization of elbow or forearm injuries. Abundant cast padding is first wrapped around the arm.
The posterior plaster must be reinforced medially and laterally to the elbow, but neither padding nor plaster should constrict the antecubital fossa.
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Conservative management is generally the rule, especially in the elderly. Minimally displaced fractures constitute the majority of injuries. These
patients do well with a splint, sling, and swathe (Figure 28–5), or sling and swathe alone, and adequate analgesia.
Figure 28–5.
Posterior plaster splint with sling and swathe for immobilization of elbow or forearm injuries. Abundant cast padding is first wrapped around the arm.
The posterior plaster must be reinforced medially and laterally to the elbow, but neither padding nor plaster should constrict the antecubital fossa.
Disposition
Patients should have orthopedic follow-up in 3–4 days. We recommend obtaining orthopedic consultation for any young person with humeral or
humeral shaft fractures while the patient is still in the emergency department. If there is displacement of a humeral shaft fracture, a hanging or gravity
splint may be applied. Occasionally these patients may undergo open reduction and internal fixation (ORIF). The most common complication of
proximal humerus fractures is a “frozen shoulder,” or adhesive capsulitis, which can be prevented with early rehabilitation.
Supracondylar Fractures
Occurs after FOOSH
Elbow deformity, pain, and decreased mobility
Posterior fat pad on lateral X-ray is highly suggestive
May have high morbidity
Mandatory orthopedic consultation
Supracondylar fractures are of the distal humerus and classically occur in children, usually age 5–10, who fall on an outstretched hand with
hyperextension at the elbow. If not managed properly, supracondylar fractures may predispose to serious morbidity, including complications such as
Volkmann ischemic contracture.
Clinical Findings
Symtoms and Signs
Patients usually present complaining of elbow pain and arm swelling. A neurologic and vascular examination is important and must include notation of
the function of the anterior interosseous nerve, which is a purely motor nerve serving the flexor pollicis longus, flexor digitorum profundus, and the
pronator quadratus. With anterior interosseous nerve dysfunction, a patient may be unable to make an “OK sign” with the thumb and index finger and
may be unable to make a fist or flex the wrist.
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Volkmann ischemic contracture.
Clinical Findings
Symtoms and Signs
Patients usually present complaining of elbow pain and arm swelling. A neurologic and vascular examination is important and must include notation of
the function of the anterior interosseous nerve, which is a purely motor nerve serving the flexor pollicis longus, flexor digitorum profundus, and the
pronator quadratus. With anterior interosseous nerve dysfunction, a patient may be unable to make an “OK sign” with the thumb and index finger and
may be unable to make a fist or flex the wrist.
X-Ray Findings
Supracondylar fractures may be subtle and at times may be suspected only by the presence of a posterior fat pad sign on a lateral elbow X-ray.
Comparison views of the uninjured elbow may be of benefit if a fracture is suspected but not immediately apparent.
Treatment
All supracondylar fractures require orthopedic consultation and generally these fractures should not be reduced by emergency physicians.
Disposition
Disposition is as per orthopedic consultation. Open reduction is often required and admission is recommended for displaced fractures.
Elbow Injuries
Deformity, pain, and decreased range of motion
Assess for ulnar nerve injury
Anteroposterior and lateral X-rays are confirmatory
Consider fracture if posterior fat pad is present
No X-ray needed for a simple nursemaid's elbow
Elbow injuries usually occur from a direct blow to the elbow, causing immobility at the elbow joint. The patient generally holds the arm in flexion, and a
moderate amount of swelling is present. Both fractures and dislocations may occur. Neurovascular status and range of motion testing are important,
as patients who cannot fully extend their elbow have a higher possibility of having a fracture. It is important to assess ulnar nerve function by testing
sensation of palmar aspect of the fifth digit and motor function of interossei muscles of the hand because of its proximity to the elbow.
X-rays should include anteroposterior and lateral views. Always look for the presence of fat pads. A small anterior fat pad can sometimes be normal;
however, the presence of a posterior fat pad is abnormal and should alert the clinician to a fracture, such as a radial head fracture in adults or a
supracondylar fracture in children. Even if a fracture is not visualized on X-ray, treat the injury as though an occult fracture is present.
Olecranon Fractures
Olecranon fractures may occur by direct trauma or less commonly by contraction of the triceps while the elbow is flexed.
Clinical Findings
Symptoms and Signs
Pain, limited range of motion, a palpable defect or crepitus may be present. Another physical finding includes inability to extend the elbow against
force.
X-Ray Findings
Plain X-rays should be sufficient to confirm the diagnosis.
Treatment
Most fractures may be treated with a long arm posterior splint with the elbow flexed at 90°, sling, and orthopedic follow-up. Displaced fractures
(greater than 2-mm separation) or the presence of an ulnar nerve injury mandates acute orthopedic consultation.
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force.
X-Ray Findings
Plain X-rays should be sufficient to confirm the diagnosis.
Treatment
Most fractures may be treated with a long arm posterior splint with the elbow flexed at 90°, sling, and orthopedic follow-up. Displaced fractures
(greater than 2-mm separation) or the presence of an ulnar nerve injury mandates acute orthopedic consultation.
Disposition
Patients who do not meet criteria for surgery may be discharged home as long as orthopedic follow-up can be obtained in 1–2 days.
Radial Head Fractures
Radial head fractures may occur by either direct trauma or more commonly by an indirect mechanism such as a fall on an outstretched hand. Damage
to the articular surface of the capitellum and collateral ligament can also occur.
Clinical Findings
Symptoms and Signs
The patient presents with pain, particularly on supination or pronation, and with limited range of motion. Elbow extension may be limited by joint
effusion.
X-Ray Findings
It is often difficult to see a definitive fracture on plain X-rays. As mentioned previously, the presence of a fat pad (especially posterior) should raise
suspicion for an occult fracture.
Treatment
Simple radial head fractures are treated conservatively with analgesics and a simple sling. We recommend contacting an orthopedist for comminuted
radial head fractures.
Disposition
Patients may be discharged with immobilization, pain control, and orthopedic follow-up.
Elbow Dislocations
The elbow is the second most commonly dislocated major joint. Generally, the radius and ulna are displaced together and the dislocation is described
as the relationship of the ulna to the humerus, such as posterior (which is most common), anterior, medial, or lateral. The most common mechanism is
a fall, and associated fractures occur frequently.
Clinical Findings
Symptoms and Signs
The patient often holds the elbow in 45° of flexion, and a deformity at the olecranon is usually visible. Because of the location of the brachial artery and
median nerve, the patient's neurovascular status should be assessed and documented initially and reassessed frequently.
X-Ray Findings
Examine plain radiographs for the presence of associated fractures.
Treatment
If neurovascular compromise is present, perform reduction as soon as possible. Reduction can be achieved by applying traction to the wrist distally,
while the humerus is stabilized (Figure 28–6). Another technique involves applying traction at the wrist while the patient lies on his or her abdomen
with the affected limb hanging off the bed. After appropriate analgesia and sedation, most dislocations can be reduced in a few minutes. These injuries
should be reassessed for neurovascular injury and then placed in a long arm splint with the elbow in flexion and sling (see Figure 28–5).
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X-Ray Findings
Examine plain radiographs for the presence of associated fractures.
Treatment
If neurovascular compromise is present, perform reduction as soon as possible. Reduction can be achieved by applying traction to the wrist distally,
while the humerus is stabilized (Figure 28–6). Another technique involves applying traction at the wrist while the patient lies on his or her abdomen
with the affected limb hanging off the bed. After appropriate analgesia and sedation, most dislocations can be reduced in a few minutes. These injuries
should be reassessed for neurovascular injury and then placed in a long arm splint with the elbow in flexion and sling (see Figure 28–5).
Figure 28–6.
Reduction of posterior elbow dislocation by applying manual traction on the forearm while an assistant stabilizes the humerus. If radial or lateral
displacement is present, it must be corrected before reduction is completed by flexion of the elbow.
Disposition
Most patients may be discharged with adequate analgesia and orthopedic follow-up, as well as instructions to watch for signs of vascular impairment.
Subluxation of the Radial Head
Radial head subluxation (nursemaid's elbow) is a common injury, accounting for as many as 25% of elbow injuries in children. This injury usually
occurs in the 1–3-year-old age group but may be seen up to school age and rarely in early teenagers. Subluxation occurs secondary to longitudinal
traction on the arm while the elbow is extended and the arm pronated. This allows fibers of the annular ligament to slip between the radial head and
the capitellum.
Clinical Findings
Symptoms and Signs
Generally no deformity is seen, but the child will hold the arm in passive pronation with slight flexion at the elbow. Some tenderness is present over the
radial head, and the child characteristically refuses to use the arm. Although subluxation of the radial head is a common injury, obtain a thorough
history to allay concerns about potential child abuse.
X-Ray Findings
Some authors suggest that if the clinician is confident with the mechanism of injury and the physical examination, radiographs need not be obtained
prior to reduction; however, others assert that X-rays should always be obtained to rule out other potential injuries. X-rays should be obtained if the
child does not resume use of the arm after reduction.
Treatment
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Generally no deformity is seen, but the child will hold the arm in passive pronation with slight flexion at the elbow. Some tenderness is present over the
radial head, and the child characteristically refuses to use the arm. Although subluxation of the radial head is a common injury, obtain a thorough
history to allay concerns about potential child abuse.
X-Ray Findings
Some authors suggest that if the clinician is confident with the mechanism of injury and the physical examination, radiographs need not be obtained
prior to reduction; however, others assert that X-rays should always be obtained to rule out other potential injuries. X-rays should be obtained if the
child does not resume use of the arm after reduction.
Treatment
Once the diagnosis is made, reduction is usually easily performed by stabilizing the elbow with one hand and, while applying gentle pressure on the
radial head, supinating the forearm and flexing the elbow. Often a click or snap will be heard. The majority of patients regain normal use of the arm
within minutes. Immobilization with a sling has been suggested; however, most patients will not comply, and if the reduction is successful, the sling
likely will not make much difference.
Disposition
Unsuccessful or recurrent subluxations require outpatient orthopedic consultation.
Forearm Fractures
Pain and deformity present
X-rays are confirmatory
Assess for concomitant dislocations
Forearm fractures may occur secondary to varied mechanisms but are commonly seen with direct blows or falls on an outstretched hand. The site of
injury determines the physical findings. Carefully examine the patient for function of the radial, median, and ulnar nerves. Assess, document, and later
reassess distal pulses and tendon function. Clinical suspicion for development of a compartment syndrome should be high and appropriate
assessment performed. As noted earlier in this chapter, it is probably more useful to describe the injury anatomically; however, the forearm is an area
where many common eponyms for fractures exist, for example,
Colles' fracture—Transverse fracture of distal radius with dorsal angulation; most common wrist fracture seen in adults.
Smith fracture—Transverse fracture of the metaphysis of the distal radius with volar displacement.
Barton fracture—Oblique, intra-articular fracture of the distal radius, with dorsal displacement of the distal fragment along with dorsal carpus
subluxation.
Hutchinson (chauffeur's) fracture—Intra-articular fracture of the radial styloid.
Monteggia fracture—Ulna fracture with radial head dislocation.
Galeazzi fracture—Fracture of distal third of radius associated with dislocation of the distal radioulnar joint.
Treatment
Nondisplaced fractures are generally treated conservatively with a sugar-tong (U-shaped) splint (volar and dorsal splint from distal metacarpals going
around the elbow) and orthopedic follow-up.
Disposition
Displaced fractures warrant orthopedic consultation to determine the appropriate method (open vs closed) and timetable for reduction. Displaced
forearm fractures in children should be seen by the orthopedist in the emergency department.
Appelboam A, Reuben AD, Benger JR et al: Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observation study
of diagnostic accuracy in adults and children. BMJ 2008;337:a2428 [PubMed: 19066257] .
Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84-
A(4):547 [PubMed: 11940613] .
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forearm fractures in children should be seen by the orthopedist in the emergency department.
Appelboam A, Reuben AD, Benger JR et al: Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observation study
of diagnostic accuracy in adults and children. BMJ 2008;337:a2428 [PubMed: 19066257] .
Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84-
A(4):547 [PubMed: 11940613] .
Wrist and Hand Injuries
Lunate or Perilunate Dislocations
Occurs after FOOSH
Wrist swelling, pain, and tenderness
Anteroposterior and lateral X-rays of wrist are confirmatory
Look for “piece-of-pie” and “spilled teacup” signs
Lunate or perilunate dislocations usually occur from a fall on an outstretched upper extremity, causing extreme dorsiflexion.
Clinical Findings
Symptoms and Signs
Usually the patient presents with a swollen wrist, decreased mobility, and severe pain over the dorsum of the wrist. Median nerve injuries may be seen
on examination.
X-Ray Findings
The lateral wrist view is the most important X-ray with these injuries. A line drawn through the center shaft of the radius normally bisects the lunate and
capitate (Figure 28–7A). In a lunate dislocation, the radius and capitate are bisected and the lunate is displaced either dorsal or volar, giving what is
sometimes referred to as a spilled teacup appearance (Figure 28–7B and C). The anteroposterior view shows a triangular-shaped lunate bone with the
apex pointing toward the fingers, which is commonly referred to as the piece-of-pie sign. A perilunate dislocation occurs when the line drawn through
the radius bisects the lunate only and the capitate is displaced.
Figure 28–7.
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A: Normal anatomy of the wrist. Note that the proximal end of the capitate rests in the lunate concavity. A straight line drawn through the metacarpal
and capitate into the radius should bisect the lunate. The scaphoid makes an angle of 45° with the long axis of the radius. B: Lunate dislocation. Lunate
dislocates volarly. The angle between the scaphoid and the long axis of the radius is 90° instead of the normal angle of 45°. C: X-ray of volar dislocation
of lunate. (Reproduced, with permission, from Way LW (editor): Current Surgical Diagnosis & Treatment, 9th ed. Appleton & Lange, 1991.).
Treatment
This injury should be managed by providing analgesia and splinting temporarily for comfort in the emergency department. Consult an orthopedic
surgeon for anatomic realignment.
Disposition
Patients undergoing ORIF should be admitted until the surgeon addresses the injury. Patients with reducible injuries may be given a long arm splint
and sent home after arranging a treatment plan in conjunction with a surgeon.
Scapholunate Dislocations
Frequently missed injury
Anteroposterior hand X-ray confirms diagnosis
“Terry Thomas” sign (greater than 3-mm scapholunate joint space)
Usually occurring from a fall on an outstretched hand, a scapholunate dislocation is a commonly missed hand injury.
Clinical Findings
Symptoms and Signs
The patient may present with wrist swelling and decreased range of motion. Tenderness over the wrist may be present.
X-Ray Findings
An anteroposterior view of the hand normally reveals a space between the scaphoid and lunate bone of less than 3 mm. If the distance is greater than 3
mm, then a dislocation injury is present.
Treatment
A scapholunate dislocation may temporarily be treated with analgesics and a radial gutter splint.
Disposition
Refer the patient to an orthopedic surgeon for definitive repair.
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mm, then a dislocation injury is present.
Treatment
A scapholunate dislocation may temporarily be treated with analgesics and a radial gutter splint.
Disposition
Refer the patient to an orthopedic surgeon for definitive repair.
Carpal Bone Fractures
Maintain high index of suspicion
Consider scaphoid view X-rays
Treat as fracture based on clinical findings even if X-ray findings are negative
Carpal bone fractures are often missed in the emergency department and require a high index of suspicion. Usually, they occur after a fall on an
outstretched upper extremity. Neurovascular status should be carefully assessed. Often, even if a fracture is not seen, the injury should be treated as a
fracture in order to prevent long-term sequelae such as avascular necrosis seen with scaphoid or lunate (Kienböck disease) fractures due to the
tenuous blood supply of these bones. Fractures of the pisiform or the hook of the hamate can impinge on the ulnar nerve.
Clinical Findings
Symptoms and Signs
Carpal bone fractures usually lead to wrist and hand swelling with decreased mobility and pain. Tenderness is often seen over the injured area. If
tenderness is present in the anatomic snuffbox, consider a scaphoid fracture, regardless of X-ray findings, and treat the injury appropriately.
X-Ray Findings
Scaphoid and other carpal fractures may be seen on anteroposterior or dedicated scaphoid views. A triquetral fracture can often be seen on a lateral
hand view as a small dorsal avulsion. Repeat X-rays in 1–2 weeks may often reveal a fracture that was not initially seen.
Treatment
Scaphoid fractures may be treated with a thumb spica splint (Figure 28–8); other fractures may be treated with a volar wrist splint (Figure 28–9). Due to
concern for complications, including avascular necrosis, if fractures of carpal bones are suspected, they should be immobilized even if X-rays are
negative.
Figure 28–8.
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concern for complications, including avascular necrosis, if fractures of carpal bones are suspected, they should be immobilized even if X-rays are
negative.
Figure 28–8.
Thumb spica splint: a slab of plaster is applied over adequate padding and secured with a loose elastic bandage.
Figure 28–9.
Volar splint for immobilization of wrist injuries.
Disposition
Patients may be discharged with analgesics and follow-up with an orthopedist in 2–3 days.
Metacarpal Fractures
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Volar splint for immobilization of wrist injuries.
Disposition
Patients may be discharged with analgesics and follow-up with an orthopedist in 2–3 days.
Metacarpal Fractures
Hand swelling and pain
Anteroposterior and lateral hand X-rays confirm diagnosis
Assess for angulation and rotation
The most common metacarpal fracture, known as a boxer's fracture, is through the neck of the fifth metacarpal and occurs from direct trauma such as
punching an object or person. A Bennet fracture refers to an intra-articular fracture at the base of the first metacarpal. If the fracture is comminuted,
then it is usually called a Rolando fracture.
Clinical Findings
Symptoms and Signs
The patient presents with hand swelling, particularly over the dorsal surface, and tenderness over the affected bone. Assess for rotational injury by
having the patient attempt to close his or her fist. The presence of open wounds should raise the suspicion that the injury resulted from hitting teeth.
These wounds should be treated as human bites, with copious irrigation and antibiotics.
X-Ray Findings
Most metacarpal fractures should be visible on an anteroposterior or lateral view of the hand. Angulation of the fracture must be assessed in order to
determine management.
Treatment
If any manipulation is needed, give the patient appropriate analgesics; local lidocaine infiltration may suffice. Correct any rotational deformity by
gentle traction. If angulation of the metacarpal neck requires correction, it may be accomplished with gentle traction. The easiest way to remember
angulation is the 10-20-30-40 rule. These are the maximum permissable degrees of angulation that may be tolerated in the second, third, fourth, and
fifth metacarpals, respectively. Fractures involving the second, third, and fourth metacarpals may be treated with a volar wrist splint (Figure 28–10).
After reduction, boxer's fractures may be placed in an ulnar gutter splint (Figure 28–11) and Bennet fractures in a thumb spica splint (Figure 28–8).
Figure 28–10.
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fifth metacarpals, respectively. Fractures involving the second, third, and fourth metacarpals may be treated with a volar wrist splint (Figure 28–10).
After reduction, boxer's fractures may be placed in an ulnar gutter splint (Figure 28–11) and Bennet fractures in a thumb spica splint (Figure 28–8).
Figure 28–10.
Volar wrist and hand splint for immobilization of metacarpal shaft fractures and wrist injuries. A plaster slab is applied over adequate padding and
secured with a loose elastic bandage.
Figure 28–11.
Ulnar gutter splint for immobilization of injuries to the metacarpals of the fourth and fifth fingers. A plaster slab is applied to the ulnar border of the
forearm and hand over adequate padding and is then secured with a loose elastic bandage.
Disposition
After the injury is splinted, the patient may be sent home with adequate analgesia. We recommend arranging follow-up specifically for first metacarpal
base fractures because they require operative repair.
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Ulnar gutter splint for immobilization of injuries to the metacarpals of the fourth and fifth fingers. A plaster slab is applied to the ulnar border of the
forearm and hand over adequate padding and is then secured with a loose elastic bandage.
Disposition
After the injury is splinted, the patient may be sent home with adequate analgesia. We recommend arranging follow-up specifically for first metacarpal
base fractures because they require operative repair.
Phalanx Fractures and Dislocations
Finger pain, deformity, and limited mobility
Finger X-rays are confirmatory
Phalanx fractures and dislocations often result from a direct blow to the affected digit. They may have rotational deformities as well as angulation.
Clinical Findings
Symptoms and Signs
With dislocations, an obvious deformity usually is seen. Patients with fractures may present with swelling, pain, decreased mobility, ecchymosis, and
tenderness. Assess for capillary refill and sensation with two-point discrimination as well as for rotational injury.
X-Ray Findings
Plain X-rays of the hand, including anteroposterior and lateral views, often suffice. A specific finger X-ray may also be performed.
Treatment
Local anesthesia or digital blocks may be administered before manipulation. Reduction of dislocations and fractures can be managed with simple
gentle traction. Splint these injuries with aluminum finger splints.
Disposition
The patient may be discharged with analgesics and hand surgeon follow-up in 3–4 days.
Subungual Hematoma
See also Chapter 29.
Painful fingernail and hematoma under nail
May be associated with tuft fracture
Subungual hematomas usually occur from a direct blow to the nail, such as from a hammer.
Clinical Findings
Symptoms and Signs
The patient presents with a painful digit. A hematoma is easily seen under the nail.
X-Ray Findings
Anterioposterior and lateral views of the affected digit often show a distal tuft fracture.
Treatment
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Clinical Findings
Symptoms and Signs
The patient presents with a painful digit. A hematoma is easily seen under the nail.
X-Ray Findings
Anterioposterior and lateral views of the affected digit often show a distal tuft fracture.
Treatment
Subungual hematomas are exceedingly painful injuries due to pressure, which builds under the nail plate. To decompress the hematoma, trephination
is performed by using an electric cautery device. If large lacerations of the nail bed are suspected, the traditional approach has been to remove the nail,
inspect the nailbed, repair any defects. After cleaning, the avulsed nail is reinserted and sutured into place as a splint to protect the nailbed and keep
the proximal nail fold open.
Disposition
Antibiotics are needed if a nailbed injury is present with an open fracture; orthopedic follow-up should occur in 2–3 days. Simple hematomas may be
followed up by a primary-care provider in 1 week.
Boutonniere Deformity
Swan neck deformity of finger
May have avulsion fracture on X-ray
A boutonniere deformity often occurs from forced flexion at the proximal interphalangeal joint with rupture of the central slip of the extensor tendon,
causing the classic deformity.
Clinical Findings
Symptoms and Signs
The patient presents with swelling at the proximal interphalangeal joint. Decreased mobility and pain may also be present. While not present initially,
the boutonniere deformity will develop within 2–3 weeks after an injury to the central slip extensor tendon.
X-Ray Findings
Occasionally, an avulsion fracture of the middle phalanx may be seen on a lateral finger view.
Treatment
Splint the proximal interphalangeal joint in full extension for 4 weeks. Do not immobilize the distal joint.
Disposition
Discharge the patient with follow-up with a hand surgeon in 1 week. Give analgesics as needed.
Mallet Finger
Flexion of distal phalanx
May have small avulsion fracture
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Mallet Finger
Flexion of distal phalanx
May have small avulsion fracture
Mallet finger often occurs as a sports-related injury when the distal phalanx receives a direct blow. The injury is a disruption of the extensor tendon at
the site of insertion on the distal phalanx, with subsequently unopposed flexion of the distal phalanx.
Clinical Findings
Symtoms and Signs
Pain is present at the distal interphalangeal joint, and the classic mallet deformity occurs, in which the distal phalanx is flexed. If not treated acutely
with appropriate splinting, the swan neck deformity may develop characterized by hyperextension at the proximal interphalangeal joint and flexion at
the distal interphalangeal joint.
X-Ray Findings
Occasionally, a small avulsion fracture of the dorsal surface of the distal phalanx may be seen.
Treatment
Finger splints the distal interphalangeal joint in slight hyperextension. Commercially available splints can be used to reproduce this alignment.
Continuous splinting is required for at least 4–8 weeks.
Disposition
Discharge the patient with orthopedic follow-up within 3–4 days.
Ulnar Collateral Ligament Rupture
Consider in a fall while holding a ski pole
Pain and swelling at first metacarpophalangeal joint
X-ray may show small avulsion fracture of proximal phalanx
Also known as gamekeeper's or skier's thumb, ulnar collateral ligament rupture of the thumb metacarpal occurs after a forceful dislocation of the
proximal phalanx of the thumb radially with spontaneous relocation that results in rupture of the ulnar collateral ligament.
Clinical Findings
Symptoms and Signs
Pain and swelling are present over the ulnar aspect of the proximal phalanx and metacarpal of the thumb. A notable finding is weak pinching ability. On
examination, there is tenderness with no end point on stress testing of the metacarpophalangeal joint (Figure 28–12). Stress testing in the emergency
department is usually not possible in an acute injury.
Figure 28–12.
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examination, there is tenderness with no end point on stress testing of the metacarpophalangeal joint (Figure 28–12). Stress testing in the emergency
department is usually not possible in an acute injury.
Figure 28–12.
Stress examination of the thumb metacarpophalangeal collateral ligament. The ulnar side is injured more frequently. Test both sides in extension and
30° of flexion. Compare the injured digit with the uninjured thumb. Feel for a firm end point and absence of excessive laxity.
X-Ray Findings
Occasionally an avulsion fracture of the proximal phalanx may be seen.
Treatment
Apply a thumb spica splint and provide analgesics. Complete tears ultimately require surgical repair.
Disposition
Discharge with immobilization and orthopedic follow-up is needed for further repair.
Batrick N, Hashemi K, Freij R: Treatment of complicated subungual hematoma. Emerg Med J 2003;20(1):65 [PubMed: 125333376] .
Steinmann SP, Adams JE. Scaphoid fractures and nonunions: diagnosis and treatment. J Orthop Sci 2008;11(4):424–431 [PubMed: 16897211] .
Pelvic Girdle Injuries
Pelvic Fractures
High degree of mortality
May have large amount of bleeding
Consider if scrotal hematoma, urethra blood, or abnormal prostate are present
Anteroposterior films are usually confirmatory
Pelvic fractures can be devastating injuries associated with significant mortality. The mechanism of injury in the majority of fractures is a high-velocity
trauma as seen in motor vehicle collisions. Fractures may also occur with low-velocity trauma such as crush injuries and simple falls, often in elderly
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Consider if scrotal hematoma, urethra blood, or abnormal prostate are present
Anteroposterior films are usually confirmatory
Pelvic fractures can be devastating injuries associated with significant mortality. The mechanism of injury in the majority of fractures is a high-velocity
trauma as seen in motor vehicle collisions. Fractures may also occur with low-velocity trauma such as crush injuries and simple falls, often in elderly
individuals with osteoporosis. Much of the high degree of mortality may be related to the incidence of significant associated injuries. High-energy
injuries that significantly disrupt the pelvic ring commonly tear pelvic veins and arteries. Bleeding associated with these injuries can be massive with
the potential for exsanguination (Table 28–1), and patients presenting with hypotension associated with pelvic fractures have a high-mortality rate.
Clinical Findings
Symptoms and Signs
Pelvic fractures can be suggested by pain, or instability on palpation, perianal edema, pelvic edema, ecchymoses, deformities, or hematomas over the
inguinal ligament or scrotom. Traditional ATLS teaching advocates that all trauma patients (especially those with pelvic fractures) receive a digital
rectal examination to look for the presence of blood, to determine the position of the prostate, and for palpation of obvious fractures. Examination of
the penis and testes or the vagina is necessary to evaluate for associated urologic and gynecologic injuries. If a urethral injury is suspected, do not
place a urinary catheter and obtain a retrograde cystogram. If a urethral injury is present, consult with a urologist to place a suprapubic or Foley
catheter (see Chapter 26). Compression to determine pelvic stability should be accomplished with gentle anteroposterior and lateral pressure (Figure
28–13).
Figure 28–13.
Compression–distraction test for stability of the pelvic ring. If the iliac crests can be pressed together or pulled apart, the pelvis is unstable. With more
severe instability, one hemipelvis may be displaced proximally.
X-Ray Findings
X-rays should initially include an anteroposterior view. Inlet and outlet views may be helpful; however, CT scanning should be obtained to classify the
extent of injury and to plan for treatment.
Treatment
Fractures associated with disruption of the symphysis pubis (open book fractures) are frequently associated with massive bleeding into the pelvis. The
patient should be monitored continuously with attention to the circulatory status and adequate volume replacement. Application of military antishock
trousers or binders may be initiated in the prehospital setting and needs to be continued in the emergency department. A sheet wrapped around the
pelvis may also be used in an attempt to stabilize the fracture and tamponade bleeding. In some cases, the orthopedist may opt to place an external
fixator device. Some patients may need emergency ORIF or need to be transferred to radiology for arteriography and embolization.
Disposition
Obtain orthopedic consultation in all cases. Most patients will require hospitalization. Simple nondisplaced fractures of the pubic rami may be
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Treatment
Fractures associated with disruption of the symphysis pubis (open book fractures) are frequently associated with massive bleeding into the pelvis. The
patient should be monitored continuously with attention to the circulatory status and adequate volume replacement. Application of military antishock
trousers or binders may be initiated in the prehospital setting and needs to be continued in the emergency department. A sheet wrapped around the
pelvis may also be used in an attempt to stabilize the fracture and tamponade bleeding. In some cases, the orthopedist may opt to place an external
fixator device. Some patients may need emergency ORIF or need to be transferred to radiology for arteriography and embolization.
Disposition
Obtain orthopedic consultation in all cases. Most patients will require hospitalization. Simple nondisplaced fractures of the pubic rami may be
managed conservatively on an outpatient basis. Consultation with trauma surgery, urology, and gynecology may also be necessary.
Hip Injuries
Hip injuries include various fractures and dislocations. As with pelvic fractures, hip injuries in young individuals are associated with high-energy
trauma and may be seen with direct (falls) or indirect (knee-to-dashboard) forces. Elderly patients frequently sustain hip injuries with lower forces
such as a fall from standing.
Hip Fractures
Hip pain and tenderness
Frequently limb is shortened and externally rotated
Anteroposterior and lateral films are usually confirmatory
Consider CT scan or MRI if X-rays are negative and diagnosis is still suspected
Hip fractures are described anatomically as they may occur through the femoral neck, intertrochanteric, or subtrochanteric locations.
Clinical Findings
Symptoms and Signs
The patient usually complains of groin pain. Shortening of the affected leg, with abduction and external rotation, is common but may not be obvious in
cases of nondisplaced fractures. Care should be taken in the evaluation of elderly patients, because a long down time prior to obtaining help can result
in dehydration, electrolyte abnormalities, or rhabdomyolysis. There is also the potential for significant blood loss and associated injuries.
X-Ray Findings
Radiographs should include anteroposterior (with the legs in internal rotation) and lateral views. CT scanning may be necessary, particularly if
acetabular involvement is suspected.
Treatment
Immobilize the affected leg. If the fracture is closed and no neurologic deficits are present, in-line traction may be applied, such as a Hare splint, and is
often applied in the prehospital setting.
Disposition
Monitor the patient for potential ongoing blood loss. Because of the risk of avascular necrosis of the femoral head, which occurs in 20% of these
injuries, early orthopedic consultation is needed. Orthopedic consultation and admission for ORIF is warranted in the evaluation of all hip fractures.
Hip Dislocations
Pain and deformity at hip
Posterior dislocation is most common
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Disposition
Monitor the patient for potential ongoing blood loss. Because of the risk of avascular necrosis of the femoral head, which occurs in 20% of these
injuries, early orthopedic consultation is needed. Orthopedic consultation and admission for ORIF is warranted in the evaluation of all hip fractures.
Hip Dislocations
Pain and deformity at hip
Posterior dislocation is most common
Hip or pelvic X-rays are confirmatory
Patient's lower extremity is usually internally rotated and shortened
Hip dislocations are described by the relationship of the femoral head to the acetabulum. Dislocations may be accompanied by fractures of the
acetabulum or femoral head. The vast majority (80–90%) of dislocations are posterior and typically seen by indirect forces such as knee-to-dashboard
injuries in motor vehicle collisions. Anterior dislocations are less common (10–15%) and may be seen slightly more frequently in patients with hip
prostheses. Central dislocation refers to the femoral head being forced through a comminuted fracture of the acetabulum. Inferior dislocations are
rare and occur almost exclusively in young children. Dislocations of the hip are generally the result of significant force, and potential associated
injuries should be sought.
Clinical Findings
Symptoms and Signs
Clinical examination in posterior dislocations generally reveals a slightly shortened extremity, adduction, and internal rotation, with the hip and knee
in flexion. With anterior dislocations where the femoral head can dislocate medially toward the obturator foramen or laterally toward the pubis, and
findings include abduction, external rotation, and flexion of the hip.
X-Ray Findings
Obtain anteroposterior and lateral views to confirm the diagnosis and rule out associated fractures.
Treatment
Hip dislocations require urgent reduction to decrease the risk of avascular necrosis, traumatic arthritis, joint instability, and neurologic sequel.
Posterior hip dislocations are commonly reduced by the Allis technique (Figure 28–14). After adequate sedation, the patient is placed supine and an
assistant stabilizes the pelvis. The hip and knee are flexed to 90° while upward traction and slight rotation are applied. Once the dislocation is reduced,
the leg is extended.
Figure 28–14.
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assistant stabilizes the pelvis. The hip and knee are flexed to 90° while upward traction and slight rotation are applied. Once the dislocation is reduced,
the leg is extended.
Figure 28–14.
The Allis technique for reduction of posterior hip dislocation. Both hip and knee are flexed 90°. An assistant stabilizes the pelvis while the operator
pulls the femur anteriorly, rotating it slightly internally and externally to aid reduction, which is acheived mainly by firm steady traction.
An alternative method is the Stimson technique. The patient is placed prone with the leg extended over the edge of the bed. With an assistant
stabilizing the pelvis, downward traction is applied with gentle rotation. The assistant then applies pressure over the greater trochanter toward the
acetabulum.
Disposition
Once the dislocation is reduced by either method, the leg should be extended and placed in traction until postreduction X-rays can be obtained. Obtain
orthopedic consultation for all hip dislocations.
Brooks RA, Ribbans WJ: Diagnosis and imaging studies of traumatic hip dislocations in the adult. Clin Orthop 2000;377:15 [PubMed: 10943181] .
Sharma OP, Oswanski MF, Rabbi J et al: Pelvic fracture risk assessment on admission. Am Surg 2008;74(8): 761–766 [PubMed: 18705583] .
Yang EC, Cornwall R: Initial treatment of traumatic hip dislocations in the adult. Clin Orthop 2000;377:24 [PubMed: 10943182] .
Lower Extremity Injuries
Femoral Shaft Fractures
Pain and deformity of femur
May lose large amount of blood in thigh
Anteroposterior and lateral X-rays of femur are confirmatory
Clinical Findings
Fractures of the femoral shaft occur most commonly with high-energy trauma. Fractures occurring with minimal trauma should alert the emergency
physician to the possibility of a pathologic fracture.
Symptoms and Signs
As noted earlier, significant bleeding may occur secondary to femoral shaft fractures and up to 3L of blood can be lost in the thigh (see Table 28–1).
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Chapter 28. orthopedic emergencies

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