Orthopaedic principles: fractures and dislocations

Chapter 17 Orthopaedic principles


fractures and dislocations



John Raftos, Peter Locke



GENERAL PRINCIPLES



Resuscitation and detection of other injuries


Orthopaedic injuries often occur in multiply-injured patients. Resuscitation and identification and management of life-threatening injuries during the primary survey usually take precedence over the identification and management of orthopaedic injuries which should be identified and managed during the secondary survey once the patient has been stabilised. Exceptions include:


• major pelvic fractures—may cause life-threatening haemorrhage which must be controlled in the primary survey

• femoral shaft fractures—may involve 1–2 litres of blood loss and should be reduced and splinted during the primary survey.


Analgesia


(See also Chapter 13, ‘Pain management in the emergency department’.)


Most fractures and dislocations cause severe pain that requires urgent analgesia on presentation to the emergency department. Appropriate initial analgesia may include:


• inhaled nitrous oxide or methoxyflurane or intranasal fentanyl

• intravenous morphine (0.1 mg/kg for children, 2.5–5 mg aliquots for adults)

• oxycodone 5–10 mg orally

• compound oral analgesics (paracetamol plus codeine)—may be used but their efficacy is not proven

• immobilisation with a plaster slab, traction splint, Zimmer splint, sling etc

• regional anaesthesia (femoral nerve block for femoral shaft fracture).


Detection of associated injuries


A thorough knowledge of anatomy is necessary to suspect and detect injuries to tendons, nerves, blood vessels and other viscera that are commonly associated with bony injuries.



Early reduction of fractures


Some displaced fractures and dislocations should be reduced urgently to prevent serious permanent sequelae. These injuries (and their sequelae) include:


• traumatic hip dislocation (sciatic nerve injury, avascular necrosis, heterotopic calcification)

• true knee joint dislocation (popliteal artery injury with lower limb ischaemia, common peroneal nerve injury)

• supracondylar fractures of the elbow (median nerve, radial artery injury)

• elbow dislocation (ulnar nerve injury, heterotopic calcification)

• displaced pelvic fractures (ongoing haemorrhage)

• ankle fracture/dislocation (ischaemic necrosis of compressed skin, usually over one of the malleoli)

• shoulder dislocation (traction injury of the brachial plexus, axillary artery injury, recurrent dislocation).


Early reduction of dislocations


Joint dislocation causes injury to the structures supporting the joint. Prolonged dislocation increases the likelihood of recurrent dislocation. Early reduction reduces the risk of recurrent dislocation and is effective analgesia. Most patients require little or no analgesia once the dislocation has been reduced and their time in the emergency department is minimised with early reduction.



Procedural sedation for emergency department reduction of dislocations and fractures


(See also Chapter 2, ‘Securing the airway, ventilation and procedural sedation’.)


Performed by appropriately qualified emergency department specialists and registrars, procedural sedation is a safe technique for the reduction of most dislocations and the urgent reduction of some fractures in the emergency department. Ketamine is the preferred agent for use in children. A combination of propofol and fentanyl is ideal in adults because its short duration of action minimises the duration of altered consciousness and allows early discharge. Morphine plus midazolam is an adequate alternative in adults but has a longer duration of action.


Safe procedural sedation requires appropriate staffing with an airway-skilled doctor, other than the doctor who will perform the procedure, to perform the sedation and monitor the patient. ECG and oxygen saturation monitoring should be in place and advanced airway and resuscitation equipment should be at hand.



Appropriate consultation and referral


Each hospital has its own arrangements for referral of patients who need specialist orthopaedic assessment. If the patient needs orthopaedic assessment in the emergency department, then the orthopaedic registrar should be contacted. If outpatient orthopaedic referral is necessary, this is provided either at a hospital fracture clinic or in the rooms of the orthopaedic surgeon on call if there is no fracture clinic.



Injuries of the hand and wrist


(See also Chapter 18, ‘Hand injuries and care’.)


The management of hand injuries is the domain of specialist hand surgeons. Fractures of any of the bones of the hand or carpus should generally be reviewed by a hand surgeon as should any laceration of the hand or wrist with the potential for nerve or tendon injury, nail bed injuries, crush injuries, burns, hand infections and high pressure injection injuries. Arrangements for referral to a hand surgery unit will vary from hospital to hospital and should be clearly laid out in the emergency department.



UPPER LIMB INJURIES



Clavicle fracture



Assessment



• Clavicle fracture is most commonly caused by falls onto the outstretched hand, less commonly by direct force injury.

• Patients usually present with pain, tenderness and deformity, and are reluctant to move the affected arm.

• Fractures of the medial and middle thirds usually heal without sequelae. Fractures of the outer third may be complicated by delayed or mal-union.

• Plain X-rays usually adequately demonstrate clavicle fractures.


Management


Orthopaedic registrar assessment in the emergency department is necessary for:


• angulated or displaced fractures

• fractures of the outer third which may need open reduction and internal fixation.

Management of undisplaced fractures of the medial and middle thirds is:


1. a triangular sling or proprietary shoulder support

2. simple analgesia

3. referral to the fracture clinic or orthopaedic surgeon’s rooms.


Acromioclavicular (AC) subluxation/dislocation



Assessment



• This is most commonly caused by a fall onto the tip of the shoulder or an impact on the tip of the shoulder during contact sport.

• Subluxation of the AC joint is associated with rupture of the acromioclavicular ligament and generally requires symptomatic treatment only.

• Dislocation of the AC joint is associated with rupture of the acromioclavicular ligament and the stronger coracoclavicular ligament and may require open reduction and internal fixation, especially in sportspeople.

• Plain X-rays of the shoulder will show widening (subluxation) or displacement (dislocation) of the AC joint. Comparative X-rays of the normal side and weight-bearing views may help with diagnosis.


Management



• Symptomatic management (triangular sling/proprietary shoulder support, ice, simple oral analgesia) is appropriate for subluxation.

• Patients with dislocation should be referred to the fracture clinic or orthopaedic surgeon for consideration of open reduction and internal fixation.


Sternoclavicular subluxation/dislocation



Assessment



• Caused by:
• a direct blow to the sternum or medial clavicle or

• transmitted force from a blow to the posterolateral shoulder causing anterior dislocation of the clavicle or to the anterolateral shoulder causing posterior dislocation.

• Anterior dislocation of the medial clavicle causes pain and localised deformity.

• Posterior dislocation of the medial clavicle has the potential to injure or compress the trachea and the major vessels and nerves that underlie the sternoclavicular joint, causing dyspnoea, chest pain, altered sensation in the arm or vascular abnormality in the arm.

• Plain X-rays are not sensitive for sternoclavicular dislocation. CT scan should be performed for diagnosis and to detect any injury or compression of intrathoracic structures.


Management



1. All patients with sternoclavicular dislocation should be seen by the orthopaedic registrar in the emergency department.

2. Subluxations and some anterior dislocations may be treated symptomatically.

3. Posterior dislocations and most anterior dislocations will require reduction under general anaesthesia.


Anterior dislocation of the glenohumeral (shoulder) joint



Assessment



• The mechanism of injury is a forced abduction and external rotation of the arm at the shoulder or a fall onto the hand forcing the humeral head anteriorly. It occurs most frequently at sport or in the surf in young people and in falls in older people.

• Every dislocation damages the rotator cuff and/or bony structures of the shoulder and so recurrent dislocation is common. The incidence of recurrent dislocation after an initial dislocation is about 50% and increases after every subsequent dislocation, each of which tends to occur with decreasing force. The likelihood of recurrent dislocation is reduced by prompt reduction.

• The patient complains of pain in the shoulder and the arm is held immobile. Inspection usually reveals prominence of the tip of the shoulder and loss of the deltoid contour with an apparent hollow subacromially. Diagnosis may be difficult in obese individuals.

• Examine the patient for common complications of shoulder dislocation:
• circumflex axillary nerve injury with loss of sensation over the deltoid and loss of deltoid function (usually masked by pain pre-reduction)—test for sensation in the ‘nurse’s cape’ distribution over the deltoid

• fracture of the humeral head or neck—inspect the humeral head and neck and the greater tuberosity carefully on X-ray

• posterior cord brachial plexus injury with weakness of wrist extension through the radial nerve—test the function of the wrist and the hand, especially wrist extension

• axillary artery injury—palpate the radial pulse.

• Plain X-rays will identify the great majority of shoulder dislocations. The humeral head usually lies in the subcoracoid position. Look for avulsion fracture of the greater tuberosity and fracture of the humeral neck. Patients with greater tuberosity avulsion should have standard reduction. Patients with humeral neck fracture need orthopaedic consultation.

• Computerised tomography (CT) scan may be necessary for the patient with a painful immobile shoulder and inconclusive X-rays.


Management


Some emergency physicians may opt to reduce recurrent shoulder dislocations without preliminary X-rays but this cannot be regarded as standard practice.


1. Standard management for shoulder dislocation is prompt reduction in the emergency department. Reduction techniques that do not involve traction are preferred because they are said to reduce the likelihood of recurrent dislocation. Techniques include:
• The Spaso (after Spaso Miljesic) technique. With the patient supine the arm is lifted vertically with gentle traction and an assistant thumbs the humeral head while gentle external rotation is applied.

• The Stimpson technique. The patient lies prone on a bed with traction applied with weights to the extended arm.

• The Kocher manoeuvre. Countertraction is provided by an assistant with a towel in the axilla. The operator applies axial traction using the flexed forearm as a fulcrum, followed by external rotation to 90°, and then adduction of the upper arm across the chest wall and internal rotation.

• The Milch technique. With the patient supine on a bed, the arm is fully abducted and gentle external rotation is applied while an assistant thumbs the humeral head.

• The Hippocratic method. With the patient supine on a bed, place the stockinged foot in the axilla for countertraction, hold the arm at the wrist in both hands, and apply traction to the straight arm.

2. Reduction is usually heralded by a palpable ‘clunk’.

3. Once reduction has been achieved:
• Perform post-reduction X-rays to assess position and the possibility of bony injury.

• Re-examine for neurovascular injury.

• Immobilise the arm in a triangular sling/shoulder support.

• Advise the patient to avoid abduction for at least 1 week.

• Referral to the GP for follow-up is usually adequate if there is no evidence of associated fracture or neurovascular injury.

• Discuss referral to a specialist shoulder surgeon with patients with recurrent dislocation.

4. Successful reduction is generally a function of good technique and adequate sedation. The use of excessive force may result in humeral neck fracture, especially in older patients. If reduction is difficult, review the adequacy of sedation and/or seek orthopaedic assistance. Never apply excessive force.


Posterior dislocation of the glenohumeral (shoulder) joint



Assessment



• Posterior shoulder dislocation is uncommon (about 1% of all shoulder dislocations) and the diagnosis is often missed because the humeral head appears to be located on anteroposterior X-ray.

• The mechanism of injury is a forceful impact to the anterior aspect of the shoulder or tetanic muscle contraction during seizure or electric shock.

• The shoulder is painful and the patient is reluctant to move the arm which is held adducted and internally rotated.

• The shoulder joint may appear located on the anteroposterior X-ray but careful inspection will show the ‘light bulb sign’ (the usually asymmetrical appearance of the humeral head becomes symmetrical because of internal rotation) or the humeral head overlapping the glenoid. The lateral X-ray will show the head of the humerus posterior to the glenoid.


Management


Reduction under procedural sedation in the emergency department is usually successful—axial traction is applied while the arm is abducted to 90o and then externally rotated.



Humeral head and neck fractures



Assessment



• The majority of fractures of the upper humerus occur in falls onto the outstretched hand in older patients.

• Fractures most commonly involve the surgical neck of the humerus but also involve the anatomical neck, the greater and lesser tuberosities, and the articular surface, all either alone or in combination.

• The history is usually of a fall onto the outstretched hand causing pain, swelling and later bruising about the shoulder. Bruising and/or reluctance to move the shoulder may be the only clinical features in older patients with dementia.

• X-rays of the shoulder are usually diagnostic. Look for associated shoulder joint dislocation, angulation, displacement, involvement of the articular surface and displacement of the greater tuberosity.


Management



• Most patients with upper humerus fractures should be reviewed by the orthopaedic registrar in the emergency department to determine appropriate treatment:
• Surgical treatment with replacement hemiarthroplasty should be considered for adults with significant intra-articular involvement.

• Surgical treatment with closed reduction or open reduction and internal fixation should be considered for younger patients with significant displacement or angulation and for displaced avulsion fractures of the greater tuberosity.

• Epiphyseal fractures in younger patients often require closed reduction under general anaesthesia.

• Uncomplicated fractures of the neck of humerus are treated conservatively in a triangular sling/shoulder support or in a collar and cuff if there is impaction requiring gravitational reduction.

• Older patients may be significantly disabled by immobilisation of one arm. Social work involvement is necessary to make appropriate care arrangements while the disability persists. Overnight admission allows analgesia to be optimised and social arrangements to be made.


Humeral shaft fractures



Assessment



• Humeral shaft fractures are caused by direct force injuries, torsion or falls onto the outstretched hand.

• The patient presents with upper arm pain and is reluctant to move the arm which is generally supported by the other hand.

• X-rays of the upper arm are usually diagnostic. Look for displacement, angulation, and the presence of a ‘butterfly’ fragment.

• The radial nerve may be contused in the radial groove in fractures of the middle third of the humerus—always test extension of the wrist and fingers. The injury is usually a neuropraxia which will recover over 6 weeks to 6 months. Vascular injury is uncommon.


Management


The orthopaedic registrar should review all humeral shaft fractures in the emergency department.


Management includes:


1. Standard management of humeral shaft fractures is immobilisation in a ‘hanging slab’. Apply ample padding, especially around the elbow, using an appropriate width plaster slab start in the axilla and continue the slab under the flexed elbow, over the outer surface of the upper arm and well onto the shoulder. Wrap with a gauze bandage, and support in a sling or collar and cuff.

2. Some humeral shaft fractures will require open reduction and internal nail fixation. These may include those with a butterfly fragment, those associated with multiple injuries.

3. Supply appropriate analgesia and arrange review at the fracture clinic or orthopaedic surgeon’s rooms.


Supracondylar fractures of the humerus



Assessment



• Supracondylar fracture is most common in children, with peak incidence at 8 years, and is usually caused by a fall onto the outstretched hand.

• The patient presents with a painful, swollen elbow and is reluctant to use the arm which is usually supported by the other hand.

• Assessment should include a full neurovascular examination of the hand looking for complications of the fracture:
• Brachial artery injury. The brachial artery may be compressed or, in severe cases, there may be intimal damage or rupture. Check the radial pulse and capillary refill in the fingers.

• Median nerve injury. Check sensation in the radial palmar 3½ fingers and motor function in the abductor pollicis.

• Increased tissue pressure/compartment syndrome. Haemorrhage and oedema around the fracture site may cause vascular compromise that is detected by regular vascular checks of the hand and forearm.

• Volkmann’s ischaemic contracture. A disabling ischaemic injury of the muscles and nerves of the forearm, this is caused by arterial injury or compartment syndrome following supracondylar fracture.

• X-rays will demonstrate a supracondylar fracture line. Look for displacement, angulation, comminution.


Management



• Urgent orthopaedic review is needed if there is evidence of vascular compromise.

• All supracondylar fractures should be reviewed by the orthopaedic registrar in the emergency department. Those with significant displacement or angulation will need closed reduction under general anaesthesia. Those with vascular compromise will need urgent reduction and vascular surgical assessment.

• Comminuted fractures in adults may require open reduction and internal fixation.

• Undisplaced fractures without significant swelling can be managed, after orthopaedic registrar review, with a collar and cuff, oral analgesia and referral to the fracture clinic or orthopaedic surgeon’s rooms.


Elbow dislocation



Assessment



• Elbow dislocation occurs in both children and adults, usually as the result of a fall onto the outstretched hand. The radius usually dislocates posteriorly in response to forced hyper-extension.

• The patient presents with a painful, swollen elbow and is reluctant to use the arm which is usually supported by the other hand.

• Assessment should include a full neurovascular examination of the hand looking for complications of the fracture:
• Ulnar nerve injury. Check sensation in the ulnar palmar 2½ fingers and motor function in adduction and abduction of the fingers.

• Brachial artery injury. The brachial artery may be compressed or, in severe cases, there may be intimal damage or rupture. Check the radial pulse and capillary refill in the fingers.

• Median nerve injury. Check sensation in the radial palmar 3½ fingers and motor function in the abductor pollicis.

• Increased tissue pressure/compartment syndrome. Haemorrhage and oedema around the fracture site may cause vascular compromise that is detected by regular vascular checks of the hand and forearm.

• X-rays usually demonstrate the dislocation clearly. Intra-articular bone fragments are common and their origin is often unclear. Look for these carefully—they may inhibit reduction.


Management



1. Elbow dislocations are generally reduced in the emergency department under procedural sedation. Most will reduce with axial traction on the forearm which is held in 30° flexion while the assistant thumbs the olecranon process. If this is not successful, then, with traction still applied, extend the elbow to unlock the coronoid process. An intra-articular bony fragment may prevent reduction—these patients will need open reduction.

2. Test range of elbow movement post-reduction—a full, smooth range suggests successful reduction, resistance to movement suggests intra-articular bone fragment or soft tissue entrapment.

3. Post-reduction X-rays are performed to show alignment and the position of any intra-articular fragment.

4. Repeat the neurovascular examination post-reduction to ensure that none of the nerves has been entrapped in the reduction.

5. Support the reduced elbow in a long arm plaster back slab and refer to the fracture clinic/orthopaedic surgeon’s rooms for review.


Olecranon fractures



Assessment



• These fractures are caused by either a fall onto the elbow or forcible contraction of the triceps.

• There is usually pain and swelling over the olecranon.

• X-rays clearly demonstrate the fracture in most cases. Look for displacement and the position of the fracture relative to the joint.


Management



• All olecranon fractures require orthopaedic registrar review in the emergency department.

• Management usually depends on the integrity of the extensor mechanism:
• If the mechanism is intact and the fracture undisplaced, treatment consists of immobilisation in a long arm slab supported in a sling/shoulder support and review at the fracture clinic or orthopaedic surgeon’s rooms.

• If the extensor mechanism is disrupted, then open reduction and internal fixation is usually necessary.


Pulled elbow



Assessment



• Occurs in children aged 1 to 6 years when the radial head slips out from under the annular ligament as a result of axial traction when there is a sudden tug on the arm by either child or parent while the parent is holding the child’s hand.

• The parent indicates that the child is not using the affected arm which is usually held limply by the side or semi-flexed. There is often, but not always, tenderness over the radial head.

• X-rays are not necessary when the history is clear.


Management



• Reduction is achieved without anaesthetic. The operator, having gained the child’s and parent’s confidence, holds the elbow in one hand with the thumb over the radial head while the other hand fully supinates and then flexes the forearm. Reduction is usually palpable.

• The child does not usually begin to use the arm again immediately. Review about 15 minutes post-reduction usually shows that full movement has returned. No follow-up is necessary.


Radial head and neck fracture



Assessment



• These structures may be injured by direct force but the most common mechanism of injury is a fall onto the outstretched hand.

• The patient presents with pain in the elbow and pain on movement. Supination and pronation are usually limited by pain. Firm palpation over the radial head reveals tenderness.

• Most of these fractures are undisplaced and do not require manipulation.

• The outstanding feature on X-ray is a positive ‘fat pad sign’, indicating the presence of an elbow joint effusion:
• visible posterior elbow joint fat pad

• anterior bowing of the usually straight anterior fat pad

• a blood/fat level in the anterior fat pad.

• On X-rays, look for angulation in the normally smooth arc of the radial neck and intra-articular fracture of the radial head.


Management



• Undisplaced fractures of the radial head or neck are treated with triangular sling immobilisation and referral to the fracture clinic or orthopaedic surgeon’s rooms.

• Angulated fractures of the radial neck and displaced intra-articular fractures of the radial head should be reviewed by the orthopaedic registrar in the emergency department and considered for open reduction and internal fixation.


Radius and ulna shaft fracture



Assessment



• Isolated fracture of the shaft of one of the forearm bones is usually caused by direct force injury. Fractures of both bones are much more common and are caused by transmitted forces from falls onto the outstretched hand. The position of the hand and arm at the time of the fall will determine the pattern of the fractures.

• The patient presents with pain, swelling, deformity and limitation of movement of the forearm.

• X-rays will demonstrate the pattern of the fracture. Both bones are usually broken or there is a pattern of fracture of one bone with dislocation of the other (Monteggia, Galeazzi fracture/dislocations) so views that include the whole of the forearm including the elbow and wrist joints are essential. Look for angulation, displacement and comminution.


Management



• All fractures of the shaft of the radius and/or ulna should be reviewed by the orthopaedic registrar in the emergency department.

• Management depends on patient age, the site of the fracture and the degree of angulation and displacement.

• A significant proportion of radial/ulnar shaft fractures will require either closed reduction under general anaesthesia or open reduction and internal fixation.


Distal radius and ulna fracture



Colles’ fracture



Assessment



• Colles’ fracture, first described by Abraham Colles in 1814, is defined as a fracture of the distal radius within 2.5 cm of the wrist joint with dorsal and radial angulation and dorsal displacement.

• It is caused by falls onto the outstretched hand and is commonest in older women.

• The patient presents with pain, swelling and deformity (often described as ‘dinner fork’ deformity) of the wrist after a fall. There is tenderness over the distal radius.

• X-rays show a transverse fracture of the distal radius. Look for angulation, displacement, comminution, intra-articular involvement.


Management



• Management depends on the nature of the fracture:
• Fractures with minimal displacement and angulation are adequately treated by immobilisation with a short arm slab with the wrist in the neutral position.

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Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Orthopaedic principles: fractures and dislocations

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