Transcript Orthopaedic injuries in the ED

More random orthopaedic
injuries in ED
Dr Donna Mills
FACEM
Caloundra
Galeazzi
 # radius – often distal/medial third
junctions
 Dislocation DRUJ
 FOOSH
 Up to 7% forearm fractures
 Adults – ORIF; paeds – closed
reduction
 Cx – AIN or radial nerve palsy
Monteggia
 # proximal third of ulna with
dislocation of radial head
 Hyperpronation FOOSH
 ORIF
Smith’s fracture
 reverse colle’s fracture
 distal fracture fragment is
displaced volarly (ventrally)
 Fall onto flexed wrist
Barton’s
 intra-articular # of DR with
dislocation of the radiocarpal joint
 Can be volar (most common) or
dorsal
 FOOSH with wrist in volar flexion or
dorsiflexion
Volar Barton’s
Dorsal Barton’s
Barton’s
 many fail nonoperative treatment
 Refer for early ortho input
 manipulative reduction is same as for
colle’s/smith’s #
Anterior shoulder dislocation
 Most common
 Bimodal age distribution
Anterior shoulder dislocation
 Anterior dislocations can be further
divided according to where the
humeral head comes to lie:
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
subcoracoid: most common
subglenoid
subclavicular
intrathoracic: very rare
Anterior shoulder dislocation
 Surgical repair is not required for
dislocation per se, but rather to treat
complications and associated injuries which
include:

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
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
Shoulder instability
Hills-Sach’s lesion
Bankart lesion
damage to the axillary artery or brachial plexus
intraarticular loose body
Hills-Sach’s lesion
Hills-Sach’s lesion
 cortical depression in the
posterolateral head of the humerus
 results from forceful impaction of the
humeral head against the
anteroinferior glenoid rim when
shoulder dislocated anteriorly
Bankart lesion
 detachment of the anterior inferior
labrum from the underlying glenoid
 labral only ("soft Bankart"), or
involve the bony margin ("bony
Bankart“)
Posterior shoulder dislocation
 2-4% of presentations
 ~50% posterior shoulder dislocations
go undiagnosed on initial presentation
 FOOSH onto internally rotated arm
Inferior shoulder dislocation
 Luxatio erecta
 hyper-abduction of the arm that
forces the humeral head against
the acromion
 high complication rate
Knee dislocation
 Urgent reduction under PS
 NV Ax pre and post
 If compromised – urgent vascular
 If not – imaging (eg CTA)
 Admission for vascular/perfusion obs
Native Hip Dislocation
 Posterior (80-90%), anterior and
central dislocations
 marker for a high force mechanism
 Assoc injuries
 Sciatic nerve (20%)
 AVN
 Vascular injury less common
 Urgent reduction improves outcomes
Prosthetic hip dislocation
 occurs in 1-4% of primary THR and
up to 16% in revision cases
 Contributing factors:
 looseness of hip (improper neck length)
 component malposition
 Alcoholism
Reduction method
 assistant provides downward traction on
the pelvis
 proceduralist should step up onto the bed,
standing over the patient
 grasp the patient's leg between arm and armpit,
leaving both hands free to grasps the knee
 use legs to effect an appropriate amount of
traction
 use hands to internally and externally rotate hip
in order to guide the hip into a reduced position
Segond fracture
 Avulsion # lateral aspect of the tibial
plateau
 ~75% of cases associated with ACL
disruption
 result of internal rotation and varus
stress
 Assoc extensive ligamentous injury
requires surgical intervention
Tillaux fracture
 Salter-Harris III fractures through the
anterolateral aspect of the distal tibial
epiphysis
 occurs in older children when the
medial aspect of the distal tibial
growth plate has started to fuse
Tillaux fracture
 Operative reduction and fixation is
required when displacement is
marked or unable to be eliminated
with closed reduction
Pilon fracture
 axial loading injury which drives the
talus into the tibial plafond
 Pilon is the French word for pestle
 large number of patients will have
pain even after 2 years post injury
Maisonneuve fracture
 unstable fracture
 # medial tibial malleolus and/or
disruption of the distal tibiofibular
syndesmosis
 # proximal fibula shaft
 deltoid ligament can be frequently
disrupted
Lis Franc fracture/dislocation
 Lis franc joint is the articulation of
the 1st 3 MTs with the cuneiforms
 Lis franc ligament attaches the
medial cuneiform to the 2nd
metatarsal base on the plantar aspect
of the foot. Its integrity is crucial to
the stability of the Lisfranc joint.
Lis Franc fracture/dislocation
 Homolateral
 lateral displacement of the 1st to 5th
metatarsals, or of 2nd to 5th metatarsals
where the 1st MTP joint remains
congruent
 Divergent
 lateral dislocation of the 2nd to 5th
metatarsals with medial dislocation of
the 1st metatarsal
Lis franc fracture/dislocation
 Some studies advocate ORIF if >2mm
diastasis
 Others report no correlation between
the degree of diastasis and the
eventual functional outcome
 All studies indicate that timely
diagnosis facilitates treatment and
decreases long-term disability