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Trauma ITE ReviewThree peaks for trauma deathsFirst (immediate death)Massive head injury, high C-spine injury, cardiac laceration, aortic rupture, laceration of other great vessels, airway obstructionSecond (Minutes to few hours) “Golden hour”Subdural/epidural hematoma, ruptured spleen/lacerated liver, multiple injuries with hypovolemic shock, fracture of pelvis or multiple long bones, hemopneumothorax, tension pneumothorax, cardiac tamponade, massive hemothroax, aortic dissection/ruptureThird (days to weeks)Multisystem organ failure, systemic inflammatory response syndromePrimary surveyAirway and C-spineIf patient can speak, airway is intactNoisy respirations: partial obstructionGag reflex depressed/absent or secretions pooling: airway poorly protectedIntubate with collar loosened and inline precautions; collar restricts mouth opening to 20 mm or lessBreathingRate, depth, pattern of respiration; supplemental O2, pulse oxTension pneumo: needle thoracostomy followed by tubeSucking chest wound: sterile occlusive dressing taped on three sidesCirculation and hemorrhage controlPulse quality, rate, regularity; skin color, capillary refill, LOCLarge bore IVs, warmed crystalloid, cardiac monitorDirect pressure for external bleedingWrap unstable pelvic fractures with sheetPericardiocentesis for tamponadeED thoracotomyDisabilityPupil size, reactivity, symmetryLevel of consciousnessAVPU (qualitative): Alert, responds to vocal stimuli, responds to painful stimuli, unresponsiveGCS (quantitative): Eye opening, verbal response, motor responseIntubate for GCS <= 8Exposure: undress, warm blanketsHemorrhagic shockClass I hemorrhage: blood volume loss 0-15% (0-750 ml)Normotensive, slight tachycardia (<100)Treat with crystalloidsClass II hemorrhage: blood volume loss 15-30% (750-1500 ml)Tachypnea, tachycardia >100, narrow pulse pressure, delayed capillary refill, mild anxiety, slight decreased urine outputTreat with crystalloidsClass III hemorrhage: blood volume loss 30-40% (1500-2000 ml)Tachypnea, tachycardia >120, decreased systolic BP, delayed capillary refill, decreased urine output, altered mental statusTreat with crystalloids and bloodClass IV hemorrhage: blood volume loss >40% (>2 liters)Obvious shock, tachycardia >140, decreased systolic BP, extremely narrow pulse pressure, scant urine output, delayed capillary refill, confusion, lethargyTreat with crystalloids and bloodHead InjuriesLeading cause of death and disability in trauma patientsAssume cervical spine injury existsSuspect in: intoxicated, headache, sensory changes, LOC, persistent amnesia, skull fx, lateralized weakness, abnormal pupillary functionGCS: Mild (14-15), Moderate (9-13), Severe (3-8)ConcussionBrief loss of neurologic function, headache, +/- vomiting, amnesia, no focal findings, CT negativePost-concussive syndrome (headache, irritability, dizziness, depression, loss of memory, inability to concentrate)—outpatient workupDiffuse axonal injuryProlonged coma, +/- posturing, +/- autonomic dysfunction, no mass lesion on CT (may see punctate hemorrhages); mortality 33%Cerebral contusionConfusion, obtunded, coma, +/- focal deficitsVisible on CT (frontal and temporal lobes); coup vs contrecoupDelayed complications: cerebral edema, intracerebral hematomaEpidural hematomaInjury—LOC--lucid interval (<30%)--coma--fixed, dilated ipsilateral pupil and contralateral hemiparesisTranstentorial herniation compresses CN III and corticospinal tractArterial bleed (middle meningeal artery)CT: lens-like, biconvex lesion (does not extend beyond cranial sutures). Associated parietal or temporal fx (80%)Mortality 0-20%Subdural hematomaMore common than epidural; significant intrinsic brain damageMild headache, confusion, lethargy, comaBleeding from bridging veins (brain atrophy more susceptible)CT: crescent shaped lesion (can extend beyond cranial sutures)Mortality for acute subdurals: 30-60%Skull fracturesLinear, non-depressed—no treatmentDepressed—may be operativeOpen skull fx—operative“Egg shell”—evaluate for child abuseBasilar skull fx—CSF rhinorrhea, “ring sign” on filter paper, Battle’s sign, raccoon eyes, hemotympanumCan compress cranial nerves (most commonly VII)Increased intracranial pressureSx: headache, N/V, decreasing LOC, progressive deficit, Cushing reflex (hypertension, bradycardia), CN VI paresis, papilledema, herniationMost rapid mechanism for lowering ICP is hyperventilation (to 30-35 mm Hg); causes vasoconstriction of cerebral vasculatureHerniation Uncal herniation: most common; unilateral mass pushes medial temporal lobe through tentorial incisura; ipsilateral pupil dilation and fixation (CN III), respiratory rate (Cheyne-Stokes), coma, posturing, apnea, deathCentral herniation: mass effect compresses brainstem-- results in progressive loss of brainstem function; decreased LOC and increased RR or Cheyne-Stokes (thalamic, upper brainstem compression)—posturing, loss of oculovestibular reflexes (pontine compression)—flaccidity, apnea (medullary compression)Cerebellar tonsillar herniation: downward displacement of tonsils through foramen magnum leads to medullary compression; pinpoint pupils and flaccid quadriplegia (compression of corticospinal tracts) and then apnea, circulatory collapseUpward transtentorial herniation: expanding posterior fossa lesion; LOC rapidly declines, pinpoint pupils from compression of pons; downward conjugate gaze with absence of vertical eye movementsENT TraumaAuricular hematoma: drain and apply compressive dressing to prevent “cauliflower ear”; reassess in 24 hoursTM perforation: penetrating object, loud noise, infection, lightning strike, rapid changes in pressureExam shows tear; immobility of TM on bulb insufflationTx: heal spontaneously; keep ear dryCan have hearing loss, N/V, vertigo, facial palsy (suggests injury to ossicles, labyrinth, temporal bone)Nasal bone fractures: most common facial fractureImaging not necessaryENT for reduction once swelling improves; gross angulation reduced in EDNasal septal hematoma: bluish-purple, grapelike swelling of septumNeed vertical I&D to prevent “saddle-nose” deformity due to avascular necrosisPack, anti-staph antibiotics, ENTLe Fort fractures- usually occur in combinationDiagnose by grasping upper alveolar ridge and note which part of the midface movesI: horizontal fracture of maxilla at level of nasal floor; allows movement of alveolar ridge and hard palateII: pyramidal fracture with apex just above bridge of nose and extends laterally and inferiorly through infraorbital rims; allows movement of maxilla, nose, infraorbital rimsIII: complete craniofacial disruption; involves zygoma, infraorbital rims, maxilla; dishpan faceBeware of the cervical spine and airwayAvoid NG tube with midface fracturesMandibular fractures: second most common facial fractureRinglike structure: two or more fractures in 50%Most common fracture sites: condyle, body, angleSx: tenderness, deformity, sublingual hematoma, asymmetry, deviation TOWARD the side of fx; tongue blade testDx: Panorex (most useful), CTMandibular dislocationTrauma, yawning, laughingBilateral: anterior open bite Unilateral: jaw displaced AWAY from side of dislocationReduction: thumbs on posterior molars and push mandible downward and posteriorTripod fracture: fracture of zygomatic arch, zygomaticofrontal suture, and infraorbital foramen. Also, lateral wall of maxillary sinus and orbital floorSx: flattening of cheek, periorbital swelling, ecchymosis, diplopia, palpable step-off of inferior orbital rim, anesthesia of cheek, upper teeth, lip and gumDental fracturesEllis I: enamel fractured; no pain, no hot/cold sensitivity; elective followupEllis II: enamel fractured and dentin exposed; hot/cold sensitivity present; followup within 24 hours<12 yrs: calcium hydroxide paste covered by aluminum foil>12 yrs: dressing for comfortEllis III: enamel fractured, both dentin and pulp exposed; pink dot; severe pain; immediate dental referral; moist cotton covered by tin foilAlveolar fractures: considered open fractures; need prophylactic antibioticsAvulsed teethPermanent tooth: rinse with saline and replace; do not brush-will remove periodontal ligamentViability decreases 1% for every minute out of socketCan also transport in Hank’s solution or milkPrimary tooth: 6 months to 5 years; do not replaceOcular Trauma UV keratitisProlonged UV exposure: arc welding, reflected sunlight (snow blindness), artificial sunlight (tanning bed)Sx: 6-12 hrs after exposure; severe pain, photophobia, FB sensation, tearing, blepharospasm, decreased visual acuityDx: multiple pinpoint epithelial surface irregularities on fluorescein stainingTx: topical cycloplegic, ointment, oral pain meds; no topical anesthetic because can increase risk of corneal ulcerationTraumatic iritis1-4 days post traumaSx: tearing, photophobia, decreased visual acuityDx: consensual photophobia, ciliary flush, miotic pupil, cells and flareTx: topical cycloplegic (paralyzes ciliary body which dilates pupil—prevents formation of posterior synechiae); topical steroidOrbital floor fracture (blow-out fracture)Pain and diplopia on upward gaze (entrapment of inferior rectus and inferior oblique), enophthalmos, hypesthesia in distribution of infraorbital nerve, subcutaneous orbital emphysemaBest seen on Water’s viewAir-fluid level in maxillary sinus, “tear-drop” sign (prolapse of orbital tissue into maxillary antrum), clouding of maxillary sinus, orbital emphysemaMedial orbital wall fractureEpistaxis, emphysema of lids/conjunctiva, limited lateral gaze (entrapment of medial rectus)Clouding of ethmoid sinus, orbital emphysemaTx of orbital fx: exclude associated ocular injuries, decongestants, antibiotics, avoid Valsalva, ophtho Chemical burns: Alkali (liquefaction necrosis) worse than acid (coagulation necrosis)Tx: copious irrigation until pH neutral, topical cycloplegic, antibiotic ointment, oral analgesics, followupLid lacerationsSuperficial can be repaired with 6-0 or 7-0 nonabsorbableRefer: lacrimal canaliculi, levator muscle/tendon (ptosis), canthal tendons, orbital septum (fat protrusion), lid marginsCorneal abrasionSx: pain, FB sensation, tearing, photophobia, conjunctival injectionEvert lids to look for FBTx: cycloplegic, topical antibiotic, oral analgesics; avoid eye patch (especially if vegetable matter or contacts)Corneal rust ringCan remove FB after topical anesthetic with 25 gauge needleCan be referred for removal of rust ring the next dayGlobe perforationBell’s phenomenon: commonly located in inferior aspect of globe b/c of eyeball rolling upward and outward in response to eye closureSx: teardrop/irregular pupil, flattening of anterior chamber, black iris pigment at wound edges, decreased visual acuityDx: Seidel test (fluorescein stain flows from laceration in “riverlike” pattern because of aqueous humor leakage)Tx: DO NOT check IOP, metal eye shield, NPO, tetanus, IV abx, analgesicsSuccinylcholine increases IOPHyphemaBleeding into anterior chamber from blood vessels of ciliary body or irisSx: eye pain, photophobia, blurred visionExamine in sitting position so blood will layer out in anterior chamberTx: HOB 45°, metal eye shield, avoid eye movement, NO ASA or NSAIDs; beta-blockers, alpha-agonists, carbonic anhydrase inhibitors (avoid CAI in sickle cell)Complications: rebleeding 2-5 days later, secondary glaucoma, corneal stainingRetrobulbar hematomaExtreme blunt or deep penetrating traumaSx: proptosis, decreased vision, pain, limited mobility, increased IOP, afferent pupil defectTx: lateral canthotomyNeck InjuriesMost common cause of death for penetrating trauma is exsanguinationVascular injury occurs in 25% penetrating neck wounds (IJ, carotid artery)Historically, all injuries that penetrate platysma explored surgically; no longer trueZones of the neckZone I: base of neck to cricoid cartilageStructures at risk: subclavian vessels, brachiocephalic veins, common carotid arteries, aortic arch, jugular veins, trachea, esophagus, lung apices, cervical spine, spinal cord, and cervical nerve rootsAngiography needed to determine integrity of thoracic outlet vesselsPositive angio may necessitate thoracotomyZone II: cricoid cartilage to angle of mandibleStructures at risk: carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus, cervical spine and spinal cordMost common location for penetrating traumaEasily accessible surgicallySome recommend CT angiography or carotid duplex ultrasonographyZone III: angle of mandible to base of skullStructures at risk: salivary and parotid glands, esophagus, trachea, vertebral bodies, carotid arteries, jugular veins, and major nerves (including cranial nerves IX-XII)Difficult to expose surgicallyAngiography to assess internal carotid and intracerebral circulationSpine InjuriesSpinal cord ends at L2Cross –table lateral must visualize all 7 cervical vertebrae and the C7-T1 interspaceKnow NEXUS criteriaJefferson fracture: C1 ring blowout. Axial load injury. Seen on open –mouth odontoid view.Odontoid fractures:swelling anterior to C2 on lateral film. Abnormalities on open-mouth odontoid:Type I: tip of the densType II: traverses dens at junction of body of C2Type III: involves vertebral body of C2Hangman’s fracture: bipeduncular fracture of C2; extension injuryFacet dislocationsUnilateral (flexion-rotation) or bilateral (flexion)Anterior displacement of superior vertebral body relative to the adjoining inferior vertebral bodyClay shoveler’s fracture: flexion avulsion fx of spinous process of C6-T3 (C7 most common). Flexion injury or direct blow to spinous processFlexion teardrop fracture: significant disruption of posterior ligaments and anterior cord syndromeChance fracture: transverse fx through vertebral body from flexion about axis anterior to vertebral columnMVCs when only lap belt wornAssociated with retroperitoneal and abdominal visceral injuriesFracture-dislocations: extreme flexion or severe blunt trauma to spine-- disruption of posterior elements (pedicles, facets, laminae)Often complete neuro deficitSpinal Cord SyndromesAnterior cord syndromeFlexion injuryLoss of function of anterior two thirds of cordComplete loss of motor function, pain, and temperature below level of injuryPreservation of posterior column functions of vibration and positionCentral cord syndromeHyperextension injury in patients with degenerative spurring or congenital narrowingWeakness greater in the arms than legsGood prognosisBrown-Sequard syndromePenetrating injury hemisects cordIpsilateral motor paralysis, loss of proprioception and vibration with contralateral loss of pain and temperatureGood prognosisCauda equina syndromeInjury to lumbar, sacral, coccygeal nerve roots causing peripheral nerve injuryMotor/sensory loss in lower extremities, bladder dysfunction (most consistent), bowel dysfunction, saddle anesthesia, decreased rectal tone, weakness in dorsiflexion of great toeNeurogenic shockLoss of neurologic function and accompanying autonomic toneFlaccid paralysis, loss of reflexes, loss of urinary and rectal tone, bradycardia (may need atropine or pacemaker), hypotension (IVF, may need dopamine or phenylephrine), hypothermia, ileusSCIWORASpinal Cord Injury Without Radiographic AbnormalitiesKids more susceptible because greater elasticity of cervical structuresBrief episode of upper extremity weakness or paresthesias with delayed development of neuro deficits; obtain MRIThoracic TraumaTension pneumothoraxRespiratory distress, hypotension, tachycardia, PEA, tracheal deviation away, distended neck veins, ipsilateral absent breath sounds, ipsilateral hyperresonanceNeedle thoracostomy followed by tube thoracostomySimple pneumothoraxDecreased breath sounds, hyperresonance, dyspneaDiagnosis on expiratory CXRMay observe up to 25%; always consider chest tube if transport by airTube thoracostomyOpen pneumothoraxIf opening 2/3 diameter of trachea, air moves through chest wall defectSterile occlusive dressing taped on three sidesChest tube in area distantFlail chestContiguous rib fx in multiple places—paradoxical movement of chest wallDo not wrap chestPulmonary contusionMost common potentially lethal chest injuryDirect chest wall traumaDyspnea, tachypnea, tachycardia, chest wall tenderness/ecchymosis, rib fxCXR findings localized to site of injury; usually present on arrival and always within 6 hoursTx: O2, pulmonary hygiene, pain control; may require intubation (ventilation with good lung down)Pneumonia most common complicationHemothoraxCXR requires 200-300 ml; blunting of costophrenic angle on upright filmDiminished breath sounds, dullness to percussion, decreased tactile fremitusMost need tube thoracostomyThoracotomy: blood loss >1500 ml in initial drainage, persistent bleeding requiring continuous transfusion, hypotension or decompensation, blood loss >200 ml for 2-4 hours, 50% hemorrhageMyocardial contusionHigh-speed deceleration; heart (usually RV) strikes sternumECG (neither sensitive nor specific): sinus tachycardia, multiple PVCs, atrial fibrillation, bundle branch block (usually RBBB), ST-T wave changes2D Echo: impaired regional systolic function, increased end-diastolic wall thicknessTraumatic myocardial infarctionCoronary artery occlusion by arterial spasm, intimal tear, thrombosis or compression from adjacent hemorrhage and edemaPre-existing CAD at greatest riskThrombolytics contraindicatedPericardial tamponadePenetrating trauma most commonRapid deceleration of blood filled ventricles during early systole or late diastole—rents/tears/lacerations of rigid myocardial wall—impending myocardial rupture60-100 ml blood in pericardiumBeck’s triad: hypotension, JVD, muffled heart tonesDecreased pulse pressure, rising CVP, Kussmaul’s sign, pulsus paradoxusElectrical alternans, PEA, pericardial fluid on USTx: pericardiocentesis, open thoracotomyTraumatic aortic ruptureSudden decelerationMost occur at ligamentum arteriosum (point of greatest aortic fixation) just distal to left subclavianRetrosternal pain, dyspnea, harsh systolic murmur, upper extremity htn, decreased/absent femoral pulses, ischemic pain of extremities, paraplegiaCXR findingsWidening of superior mediastinumObliterated/indistinct aortic knob (most reliable)Deviation of trachea and/or esophagus to rightDepression of left mainstem bronchus > 40 degrees below horizontalObliteration of space between pulmonary artery and aortaLeft apical pleural capMultiple rib fracturesWidening and/or displacement of paratracheal stripe to rightWidening of left or right paraspinous stripeFractures of first or second ribs or scapulaAbdominal InjuriesBlunt trauma: Spleen most commonly injured organ; followed by liverPenetrating trauma: Liver most commonly injured organ; followed by small bowelGSW: high incidence of peritoneal cavity penetration and intraperitoneal injury; most require laparotomyStab wounds: low incidence of intraperitoneal injuries; exploration, diagnostic laparoscopyMost common location of stab wound: LUQSolitary lap belt: jejunal injuries and mesenteric lacerationsUltrasoundInitial diagnostic modality for hemodynamically stable and unstable patients with blunt traumaAdvantages: noninvasive, detects intra-abdominal/pericardial/pleural fluid, rapid, safe, portable, doesn’t interfere with resuscitation, no contrast, specificDisadvantages: can miss bowel and retroperitoneal injuries, cannot differentiate fluids, impaired in obese, operator-dependentUnstable pt + positive USlaparotomyStable patient + positive USCTUnstable patient + negative USrepeat US or DPLStable patient + negative USobservationCTStudy of choice for hemodynamically stable patients with blunt trauma, GU trauma, suspected retroperitoneal injuriesAdvantages: noninvasive, gives information on specific organ injury, diagnose retroperitoneal and pelvic organsDisadvantages: contrast, more time than DPL, expert interpretation, high false negative rate (can miss diaphragm, pancreas, bladder, bowel injuries)Normal VS + normal USCT can be deferredNormal VS + positive UCT DPLIdentify intra-abdominal bleeding or bowel injury that requires immediate laparotomy in unstable patient if FAST not available or inconclusiveAdvantages: rapid, readily available, sensitiveDisadvantages: invasive, misses retroperitoneal/diaphragm/isolated hollow viscus injuries, less specificOnly contraindication to DPL is an indication for laparotomyGenitourinary TraumaRenal injuryFlank ecchymosis, lateral abdominal tenderness or mass, hematuria, fracture of lower posterior ribs or lumbar vertebraeDeceleration injury can cause pedicle injury—can cause uncontrolled hemorrhage, renal ischemia, exsanguinationDx: IVP, CTUrethral injuryMost common mechanism: straddle injuryPerineal pain, inability to void, gross hematuria, blood at urethral meatus, perineal swelling/ecchymosis, absent/high-riding/boggy prostateDx: retrograde urethrogramDo not place foley catheterBladder injuryExtraperitoneal: full bladder poked by pelvic fx; nonsurgical tx; foley for 1-2 weeksIntraperitoneal: surgical tx; full bladder ruptures with urine spillage into peritoneumDx: CT cystography, retrograde cystographyAsymptomatic microscopic hematuriaNot good predictor of GU tract injury; amount of blood does not correlate with severity of injuryNo tx; close follow-up and repeat UAPenile fractureSudden tear in tunica albuginea with rupture of corpora cavernosumSnapping noise and immediate detumescenceTesticular disruptionFall or kick to scrotum; swollen, ecchymotic scrotum, absent testisTrauma in PregnancyMost common cause of non-obstetric maternal death during pregnancyMVC, interpersonal violence, fallsFetal survival depends on maternal survival; management should be directed at resuscitation of motherMost common cause of fetal death: maternal death; abruption is secondReview normal physiologic changes of pregnancy (increased HR, decreased BP, increased plasma volume, physiologic anemia, increased WBC, hyperventilation, uterine flow comprises 20% cardiac output)LR better than NS for resuscitationPosition patients on left side; backboard tilted 15°>20 weeks should undergo continuous cardiotocographic monitoringUterine ruptureFree intraperitoneal air, extended fetal extremities, abnormal fetal positionPlacental abruptionVaginal bleeding, abdominal pain, uterine tenderness, expanding fundal height, maternal shock, fetal distress, DICDetected 50% by USChest tubes: never below 4th ICSDPL: open, supraumbilical techniqueRhogam: mini dose (50 mcg) if < 12 weeks; standard dose (300 mcg) if > 12 weeksPerimortem C-section: fetal prognosis improves with advanced gestational age; maternal improvement may be from relief of aortocaval compression by fetus; best result if done within 5 minutes of maternal loss of vitalsCompartment SyndromeSix P’s: pain out of proportion to injury (earliest), paresthesias, paralysis, pallor, palpable tenseness and tenderness, pulselessness (latest)Most consistent exam finding: loss of two-point discriminationΔP < 30 indication for fasciotomy (ΔP=DBP-CP)Keep extremity level or slightly elevatedMost commonly seen with tibial fracturesDrowning10-15% are dry (no aspiration, laryngospasm with closed glottis)Co-morbidities: hypothermia, hypotension, C-spine injuriesDeath usually due to hypoxiaCXR normal, generalized pulmonary edema, perihilar pulmonary edemaMost common cause of dysrhythmia is hypoxiaMost reliable prognostic indicators: duration of submersion and resuscitationElectrical ShockConduction system changesCardiac: asystole, v fib (most common cause of death in acute phase)CNS: respiratory, apnea, seizures (nerves have highest conductive capacity)Thermal tissue damageCutaneous burns and muscle injuryMuscle injury—rhabodmyolysis—renal failureBlunt traumaShock can throw victimTetanic contractions—scapular fractures, shoulder dislocationsMost common entrance site is hand and skull; most common exit site is heelCleanse, tetanus, check for compartment syndrome, never debride, beware of traumatic cataractsLip burns: delayed bleeding from labial artery 3-14 days later when eschar separatesHospitalize: high-voltage (>1000 V) burns, low-voltage (<1000 V) burns with sx (dysrhythmias, chest pain, cutaneous findings, abnormal urine)Discharge: Asymptomatic patients with low-voltage injuries after period of observation and cardiac monitoringExtent of cutaneous injury in no way correlates with the amount of underlying tissue damageRhabdomyolysisMuscle pain, weakness, tenderness, +/- hypotension/AKI/shockElevated CPK, myoglobinuria (+blood on dipstick but no RBCs on microscopy)Hypocalcemia (63%), hyperkalemia (40%)Maintain urine output 1.5-2.0 ml/kg/hrIV fluids, mannitol, lasix, alkalinization of urine with sodium bicarbonateThermal BurnsInhalation injury: facial burns, singed facial and nasal hair, oropharyngeal inflammation, carbon deposits in oropharynx, carbonaceous sputum, fire exposure in confined space, circumferential burns of neck. Early intubation.Rule of Nines; Rule of PalmsParkland Formula: Fluid 24 hrs = 4 x weight (kg) x %BSA; First half in 8 hrs; second half next 16 hoursGuide resuscitation based on urine output: adults 0.5-1 ml/kg/hr, kids 1-2 ml/kg/hrGeneral Orthopedic PrinciplesDefinitions:Torus (buckle) fracture: bulging of one cortex; from compressive forces; usually involves metaphyseal regionGreenstick fracture: break in one cortex (convex) and bending/bowing of other cortex (concave)Complete fracture: involves both corticesClosed (simple) fracture: no communication with external environmentOpen (compound) fracture: communication with external environmentPathologic fracture: secondary to underlying disease process (cyst, tumor, osteogenesis imperfecta, scurvy, rickets, Paget’s)Stress fracture: bone fatigue secondary to repeated stress (metatarsals, navicular, distal tibia/fibula, femoral neck)Dislocation: displacement of bone from normal position so that there is complete disruption of articular surfaceSubluxation: partial dislocation where there is incomplete disruption of articular surfaceSalter-Harris Classification (SALTR)I (Slip): fracture through epiphyseal plate; xrays may be normalII (Above): fracture of metaphysis with extension through epiphyseal plate (most common)III (Lower): fracture of epiphysis with extension into epiphyseal plateIV (Through): fracture through metaphysis, epiphysis, and epiphyseal plateV (Rammed): crush fracture of epiphyseal plate; xrays may be normalCommon associationsAnterior shoulder dislocation: axillary artery injuryExtension supracondylar fracture: brachial artery injuryPosterior elbow dislocation: brachial artery injuryKnee dislocation: popliteal artery injuryAnterior shoulder dislocation: axillary or musculocutaneous injuryHumeral shaft injury: radial nerve injuryExtension supracondylar fracture: median, radial, ulnar nerve injuryMedial epicondylar fracture: ulnar nerve injuryPosterior elbow dislocation: ulnar, median nerve injuryOlecranon fracture: ulnar nerveAcetabular fracture: sciatic nervePosterior hip dislocation: sciatic nerve injuryAnterior hip dislocation: femoral nerve injuryKnee dislocation: peroneal and tibial nerve injuryLateral tibial plateau fracture: peroneal nerve injuryLong-term complicationsReflex sympathetic dystrophyVolkmann’s ischemic contractureNonunionAvascular necrosis (femoral head, proximal scaphoid, capitate, talus)Angulation deformitiesInfectionJoint stiffnessPost-traumatic ossificationSternoclavicular Joint InjuriesMechanismDirect force on SC joint (posterior dislocation)Fall onto shoulder (anterior or posterior)Sx: tenderness, swelling, pain with movement of arm and lateral compression of shoulders; SOB, dysphagia, choking with posterior dislocationsFirst degree (sprain): partial tear of sternoclavicular and costoclavicular ligaments without clavicular subluxationTreat with slingSecond degree (subluxation): complete tear of sternoclavicular ligament plus partial tear of costoclavicular ligament with subluxation of clavicleTreat with figure-of-eight clavicular strap or slingThird degree (dislocation): complete tear of both sternoclavicular and costoclavicular ligaments with dislocation of clavicle. Anterior > posteriorTreatment: extend, abduct, traction to arm while assistant pushes (anterior) or pulls with a towel clip (posterior)Posterior: 25% have life-threatening injuries to adjacent structures (pneumothorax, compression/laceration of esophagus, trachea, great vessels)Acromioclavicular SeparationMechanism: fall on shoulder with arm adducted; FOOSHSx: tenderness, swelling, pain with movementFirst degree/Type I (sprain): partial tear of AC ligament without subluxation of clavicle; coracoclavicular ligament intactXray normalTx: sling for 1-2 weeksSecond degree/Type II (subluxation): complete tear of AC ligament with subluxation of clavicle; coracoclavicular ligament incompletely tornDistance b/t acromion and inferior aspect of distal clavicle increased by < ? width of clavicle (1cm)Tx: sling until pain subsidesThird degree/Type III (dislocation): complete tears of AC and coracoclavicular ligaments with dislocation of clavicleDistance b/t acromion and distal aspect of clavicle increased by > ? width of clavicle (1 cm)Tx: immobilization vs surgicalFourth degree/Types IV-VI (displacement): displacement of distal clavicle posteriorly (type IV), superiorly (V), or inferiorly (VI)Tx: surgical fixationShoulder DislocationMost common dislocation seen in the EDAnterior (95-97%)Mechanism: abduction, extension and external rotationTypes: subcoracoid (most common), subglenoid, subclavicular, intrathoracicExam: prominence of acromion process and flattening of normal contour; arm held in slight abduction and external rotation; unable to place palm on uninjured shoulderComplicationsRecurrence-most commonHill-Sachs deformity: up to 50%; compression fracture of posterolateral humeral head from impaction on the anterior glenoid rimAvulsion of greater tuberosity (15%)Bankart’s fracture: fracture of anterior glenoid lip (10-20%)Most nerve injuries are neuropraxias and recover well over timeAxillary nerve injury: sensory loss over lateral shoulder and weakness in shoulder abduction (deltoid) (14%)Musculocutaneous nerve injury: weakness of forearm flexors and supinators; sensory loss along dorsum of forearmBrachial plexus injuriesRotator cuff tearsAxillary artery injuryReduction: Stimson (hanging weight), scapular manipulation, traction-countertraction, external rotation, Milch forward elevation (Kocher maneuver and Hippocratic technique no longer recommended)Posterior (2-4%)Mechanism: seizure, electric shock; fall on forward-flexed, adducted, internally rotated arm; direct blow to anterior shoulderMost commonly missed major dislocation of the bodyDx best with axillary or Y viewExam: anterior flatness, posterior fullness, prominence of coracoid process; arm held internally rotated and in adductionComplicationsFracture of posterior rim of glenoid fossaReversed Hill-Sachs: fracture of anteromedial aspect of humeral headLesser tuberosity fxRecurrenceNeurovascular complications uncommonReduction: ORInferior (luxatio erecta)Arm held elevated at 180°; humeral head palpated along lateral chest wallAlways accompanied by detachment of rotator cuffSuperiorExtreme force in superior and anterior directionArm held against body in slight internal rotationRotator Cuff TearsTendinous insertions of following muscles that attach to the greater and lesser tuberosities of the humerus: Subscapularis, supraspinatus (most frequently torn), infraspinatus, teres minorMechanismAcute: forceful abduction of arm against significant resistance (FOOSH), fall on shoulder, heavy liftingChronic: 90%; subacromial impingement and decreased blood supply to tendonsSx: often male in forties or older; pain over anterior shoulder; weak, painful abduction; positive “drop-arm” test; tenderness on palpation of supraspinatus on greater tuberosityX rays normal or degenerative changes; if complete tear, superior displacement of humeral headTx: slingScapular FracturesMechanism: direct blow to scapula, trauma to the shoulder, high speed MVC, FOOSHAssociated injuries present in up to 98%Rib fracturesLung injury (ptx, hemothorax, contusion)Shoulder (clavicle, rotator cuff, dislocation)Neurovascular (brachial plexus, axillary artery or nerve, subclavian artery, suprascapular nerve)Vertebral compression fxArm and shoulder held adducted against body and pain over back of shoulder; pain increases with abduction of armTx: slingHumeral FracturesProximal humerus fracturesMechanism: FOOSH (most common), direct blow to lateral armElderly, osteoporotic women; holding arm in adductionNeer Classification (according to amount of displacement of >1cm of anatomic neck, surgical neck, greater tuberosity, lesser tuberosity)One part: no displacement (sling only)Two part: displacement of only one segmentThree part: displacement of two fragments from the remaining proximal humerusFour part: displacement of all four segments ComplicationsAdhesive capsulitis (frozen shoulder)Neurovascular (brachial plexus, axillary nerve, axillary artery); especially with surgical neck fracturesPosterior shoulder dislocations (with fx of lesser tuberosity because of muscle contraction of subscapularis muscle); anterior and posterior dislocations with three and four part fxAvascular necrosis of the humeral head (anatomical neck fractures, four part fractures, fractures of articular surfaces)Humeral shaft fracturesMechanism: direct blow (most common), FOOSH, pathologicUsually involves middle thirdAssociated injuries-radial nerve (wrist drop)If present at time of injury, likely neuropraxia and resolvesIf present after manipulation, due to nerve entrapmentCan also have ulnar nerve, median nerve, brachial artery injuryTreatment: coaptation splint plus sling; hanging castComplications: delayed union, adhesive capsulitisElbow FracturesFat pad signsPosterior fat pad: never seen on normal x-ray; indicates distention of joint capsule by effusion (hemarthrosis) and likely fractureAnterior fat pad: may be present on normal x-rays; superior and anterior displacement suggests fractureAnterior humeral lineLine drawn along anterior surface of humerus and extending through the elbow transects the middle of the capitellumWith supracondylar extension fx, transects the anterior third of the capitellum or passes completely anteriorSupracondylar fracturesUsually kids <15 yearsExtension fractures: most commonFOOSH with elbow in extension/hyperextensionDistal humeral fragment displaced posteriorly, fracture fragments anteriorlyCan injure brachial artery, median nerve; also radial and ulnar nerve injuryCan result in compartment syndrome (Volkmann’s ischemia) and later Volkmann’s ischemic contractureTx: nondisplaced- immobilized in posterior splint with elbow flexed 90°; displaced-operativeFlexion fracturesDirect blow to posterior aspect of flexed elbowDistal humeral fragment displaced anteriorly; frequently open fxUlnar nerve injuryTx: nondisplaced-splint; displaced-operativeElbow DislocationsPosterior dislocationsMost common elbow dislocationFall on extended/hyperextended and abducted armMarked swelling with 45° flexion and posterior prominence of olecranonAssociated injuries: elbow fractures, ulnar or median nerve, brachial arteryTx: reductionTraction distally at wrist, flex elbow and apply posterior pressure to distal humerus; “clunk” will be heardLong-arm posterior splint in 120° flexionAnterior dislocationsBlow to olecranon with elbow in flexionForearm elongated and supinated while elbow held in full extensionMuch higher incidence of vascular impairment than posteriorRadial head subluxation (nursemaid’s elbow)Kids <5 yrs Abrupt longitudinal traction on hand or forearm with arm in pronation pulls annular ligament over radial headArm dangling at side, unwilling to move; elbow flexed and arm held in passive pronation; resistance to supinationX-rays normalReduction: supination method or hyperpronation methodRadial and Ulnar InjuriesRadial head fractureFOOSHTenderness, swelling over radial head; pain increased with supinationCheck for distal radioulnar dissociation (Essex-Lopresti lesion)If nondisplaced, may not be visible on x-rayBulging anterior fat pad sign or posterior fat pad signTx: nondisplaced-sling; displaced-immobilize with long arm posterior splintGaleazzi fractureFracture of distal radial shaft with distal radioulnar dislocationDirect blow to back of wrist or FOOSH in forced pronationNightstick fractureIsolated fracture of shaft of ulnaDirect blow to subcutaneous border of ulna when patient raises forearm to protect face from a blowMonteggia’s fractureFracture of the proximal third of ulna with dislocation of radial headDirect blow to posterior aspect of ulna, FOOSH with forearm in forced pronationUlnar fracture often obvious on x-ray; radial head dislocation missed in 25%Hand and Wrist InjuriesFight bitesMost commonly third MCPDo not suturePathogens: anaerobes (Eikenella, strep), S. aureus, NeisseriaHigh pressure injection injuriesHigh rate of amputation and infectionTravels down tendon sheath, damages flexor tendonFactors affecting prognosis:Location of entry woundQualities of substance (low viscosity, corrosive, paint solvents most damage)Velocity of injection Duration of exposure Tx: splint, elevate, antibiotics, immediate hand consult; no digital blocks!!Scaphoid fracturesMost common carpal fractureFOOSHX-rays negative in up to 10%Tenderness in anatomic snuff box, pain referred to snuff box with longitudinal compression of thumb or supination of hand against resistanceThumb spica splintComplicationsAvascular necrosis of proximal fragment (blood supply comes distally to proximally). The more proximal the fracture, the greater the riskDelayed union, malunion, nonunionTriquetrum dorsal chip fractureSecond most common carpal fractureFOOSH, direct blow to dorsum of handTenderness immediately distal to ulnar styloid on dorsal wristTx: volar splintLunate fractureThird most common carpal fractureFOOSHPain, tenderness over middorsum of wrist increased by axial compression of third metacarpalX-rays often normalThumb spica splintComplication: avascular necrosis of the proximal segment (Kienbock’s disease)Lunate dislocationViolent hyperextensionMay dislocate volarly (most common) or dorsallyPain, swelling, marked loss of flexion with wrist, hand and arm held in anatomic positionAP view: lunate normally squarish but becomes triangular when dislocated (piece of pie sign). Foreshortening of wrist and loss of normal space between capitate and lunateLateral view: displacement of lunate volarly relative to capitate (spilled teacup sign)Perilunate dislocation (most common wrist dislocation)Violent hyperextension+/- scaphoid dislocation or fractureLunate remains in anatomic position relative to forearm while capitate displaced dorsally due to disarticulation of capitolunate jointScapholunate dislocationPain with wrist hyperextension and snapping sensation when wrist deviated in either radial or ulnar directionAP film: scaphoid foreshortened and has dense ring-shaped image around distal edge (signet ring sign); widening >3mm between lunate and scaphoid (Terry Thomas sign)Lateral film: angle between scaphoid and lunate is increased (>60°)Metacarpal neck fracturesUsually from punch with clenched fistProximal fragment angulates in dorsal direction; distal fragment angulates in volar directionAmount of angulation acceptable varies with mobility of involved metacarpal; the greater the mobility, the greater the degree of angulation toleratedLittle finger (boxer’s fracture): 40°Ring finger: 20°Index and long fingers: <=15°Any rotational deformity must be correctedBennett’s fractureIntraarticular fracture at base of first metacarpal (CMC joint)Caused by punchingRolando’s fractureY or T shaped intraarticular fracture at base of first metacarpal (CMC joint)Worse prognosis than Bennett’sGamekeeper’s or skier’s thumbTear of ulnar collateral ligamentAcute, forceful deviation of thumbTenderness along ulnar aspect of thumb, worst at MCP joint; weak grasp and pinchColles’ fractureTransverse fracture of metaphysis of distal radius with dorsal displacement of distal fragmentFOOSH“Dinner fork” deformity of wristCan have associated ulnar styloid fracture (60%), median nerve injurySmith’s fractureTransverse fracture of metaphysis of distal radius with volar displacement of distal fragmentFOOSH with forearm in supination; direct blow to dorsum of distal radius or wrist with hand flexed and forearm pronatedGarden spade deformityCan have associated median nerve injuryFlexor tendon injuries are worse than extensor tendon injuriesMallet fingerExtensor tendon laceration or disruption at DIP jointUnable to extend DIP joint activelyMechanism: blow to tip of extended finger producing sudden, forced flexionComplication: “swan neck deformity” hyperextension of PIP joint and mallet flexion deformity of DIP joint (b/c increased extension forces on PIP; produced by proximal and dorsal migration of the lateral bands)Boutonniere deformityRupture of central slip of extensor tendon at PIPFlexion of PIP joint and hyperextension of DIP jointMechanism: direct blow to (or laceration of) PIP joint or forced flexion of the PIP joint against resistanceMay take 1-2 weeks to developAmputationsDigits have better tolerance for ischemia (8 hrs) than limbs (4-6 hrs)Reimplantation: sharply incised with minimal damage, thumb, multiple digits, hand/forearm, childPelvic FracturesClassification by mechanism (Young-Burgess system): lateral compression, anteroposterior (AP) compression, vertical shearMost common cause of death is hemorrhage; retroperitoneal space can accommodate 6 liters of bloodAssociated injuries: urethra, bladder, vagina, nerves, diaphragm, rectum, thoracic aortaContrast extravasation on CT 80-90% sensitive for arterial bleedingHip InjuriesAnterior hip dislocation (10% of hip dislocations)Mechanism: extreme abduction causes femoral head to be pushed out through tear in anterior capsule (MVC, fall, blow to back while squatting)Limb is abducted, externally rotated, flexedComplications: femoral nerve (decreased quad function, decreased DTR at knee, decreased sensation on anteromedial thigh), femoral artery or veinPosterior (80-90%)Mechanism: direct force to flexed knee (hitting dashboard) causes femoral head to be pushed out through posterior capsuleLimb is shortened, adducted, internally rotatedComplications: sciatic nerve (decreased muscle function below knee, decreased ability to flex knee, decreased sensation on posterolateral leg and sole of foot)Early reduction of all hip dislocations necessary to prevent avascular necrosis of the femoral headHip fracturesClassification: intracapsular (femoral head and neck) or extracapsular (trochanteric, intertrochanteric, subtrochanteric)Extracapsular fractures more likely to result in disrupted vascular supply and subsequent avascular necrosis Femoral neck fx: leg is shortened, abducted, slight external rotationIntertrochanteric fx: leg is shortened and in marked external rotationNegative x-rays do not rule out fracture; may need CT, MRI, bone scanKnee InjuriesOttawa Knee Rules—obtain xrays if any of the following:Age >55 yrsIsolated tenderness of the patella (no other bony tenderness)Tenderness at head of fibulaInability to flex 90?Inability to bear weight both immediately and in the ED for 4 stepsQuadriceps mechanism ruptureOne of the following injuries: quadriceps tendon rupture (patella baja), patellar tendon rupture (patella alta), patellar fracture, avulsion of tibial tuberosityCan stand but cannot walk or extend kneeDiffuse swelling around knee and palpable defectKnee dislocationClassified according to direction of tibial displacement relative to femur: anterior, posterior, medial, lateral, rotaryAnterior and posterior most commonPresentationComplete disruption of all major ligaments plus meniscal injuryPopliteal artery injury (anterior and posterior)Peroneal nerve injury-- paresthesia of dorsal foot, reduced foot dorsiflexion, decreased sensation between first and second toes (seen most with medial and posterolateral)Tibial nerve injuryProximal tibial fractureMay relocate spontaneously; assume spontaneously-reduced dislocation when patient presents with grossly unstable kneeTreatmentImmediate reduction and immobilize in posterior splint in 15° flexionCheck popliteal, dorsalis pedis, tibialis posterior pulses before and afterCheck peroneal and tibial nerves before and afterCT angiography or standard angiography strongly consideredImmediate surgery: popliteal artery injury (repair within 6 hrs), open dislocation, irreduciblePatellar subluxation/dislocationMechanism: sudden flexion and external rotation of tibia on femur with concomitant contraction of quads; direct blow to patella with knee in flexion or extensionLateral subluxation most commonReduction by flexing hip and applying medially-directed pressure over lateral patellaImmobilize in full extension; NWBPatellar fractureInjury to extensor mechanism of kneeMechanism: direct blow (most common); forceful contraction of quadriceps muscleTransverse fractures most commonSx: tenderness and swelling over patella and limited, painful knee extension (if extensor mechanism intact) or inability to extend knee (if extensor mechanism torn)TreatmentNondisplaced, extensor mechanism intact: immobilize in full extension, partial weight bearingDisplaced >3mm, loss of extensor function: surgicalLower Leg InjuriesFour compartments of the lower leg: anterior, lateral (peroneal), deep posterior, superficial posteriorAnterior compartment syndrome usually seen with fractures of the proximal tibiaAnkle InjuriesOttawa Ankle Rules—obtain xrays if any of the following:Inability to bear weight both immediately and in the ED for 4 stepsBone tenderness along distal 6cm of posterior edge of tibia or tip of medial malleolusBone tenderness along distal 6cm of posterior edge of fibula or tip of lateral malleolusSprains: classified based upon clinical presentation and degree of instabilityFirst degree: mild tenderness, minimal swelling, no instability or functional loss, able to bear weight, no abnormal motionTx: immobilize in protective device (air cast, brace, splint)Second degree: moderate swelling and tenderness, moderate functional loss, increased pain with stress testingTx: if mild, same as first degree; if severe, splint immobilization (sugar tong or posterior mold)Third degree: marked tenderness, egg-shaped swelling over affected ligaments, significant functional loss, inability to bear weight, resistance to motion of the foot, positive stress testTx: splint immobilization; surgeryMaisonneuve fractureProximal fibular fracture in association with rupture of deltoid ligament or avulsion fracture of medial malleolus at insertion site of distal talofibular ligamentHistory of eversion injury and significant medial malleolar tenderness and swellingAchilles tendon ruptureOccurs in sedentary, middle-aged males engaging in weekend athletic activitiesMechanism: forceful dorsiflexion of foot with ankle relaxed; direct trauma to taut tendon; extra stretch applied to taut tendonSx: sudden excruciating pain at back of ankle; heard or felt a “pop” or “snap”Exam: swelling of distal calf, palpable defect in tendon, weak plantar flexionThompson test: normally, squeezing calf produces plantar flexion of foot; with complete tear, will not occurTx: immobilize in posterior splint in plantar flexionFoot InjuriesOttawa Foot Rules—obtain xrays if any of the following:Inability to bear weight both immediately and in the ED for 4 stepsBone tenderness at base of 5th metatarsalBone tenderness at navicular boneCalcaneus fracturesMost commonly fractured tarsal boneAlso called Lover’s fractureMechanism: compression injury (fall from height and landing on feet)Exam: swelling, tenderness, ecchymosis of hindfoot; inability to bear weight10% bilateral, 10% with fractures of lumbar spine, 26% with other injuries to lower extremitiesDx: Bohler’s angle <20°Lisfranc’s fracture-dislocationMechanism: axial load (fall on plantar-flexed foot), compressive forces (crush injury), rotational forces (twisting of body around fixed foot)Exam: significant midfoot swelling and pain, decreased ROM, inability to bear weight, +/- paresthesias of midfootDx: fracture through base of second metatarsal (Fleck’s sign), separation between base of first and second metatarsalsJones fractureTransverse fracture of proximal diaphysis of fifth metatarsalMechanism: forceful load applied to ball of foot laterally (pivot)Tx: NWB, immobilizationComplications: delayed union, nonunionPseudo-Jones fractureDancer’s fractureAvulsion fracture of the base of the fifth metatarsalTx: post-op shoeHeals better than Jones fracture ................
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