BASICS
Most commonly caused by assault or motor vehicle crash
SIGNS AND SYMPTOMS
Malocclusion
Floor of mouth ecchymosis
Lower lip/chin paresthesias
DIAGNOSTICS
X-ray two views or Panorex view
Maxillofacial CT preferred
TREATMENT
Referral to Oral and Maxillofacial Surgery
Prophylactic antibiotics: needed only if oral involvement (penicillin or first-generation cephalosporin, clindamycin)
Maxillary Fracture (Midface Fracture)
BASICS
Look for malocclusion
Nasal intubations and nasogastric tubes are contraindicated
Associated with significant traumatic mechanism
DIAGNOSTICS
Maxillofacial CT
Le Fort fracture classification (Figure 17.1)
• Le Fort I: transverse, through the maxilla
• Le Fort II: extends superiorly involving the nasal bridge, maxilla, lacrimal bones, orbital floor, and rim
• Le Fort III: craniofacial dissociation; involves bridge of the nose and extends posteriorly along the medial wall and floor of the orbit, lateral orbital wall, zygomatic arch to the base of the sphenoid. May involve the cribriform plate; check for cerebrospinal fluid (CSF) leak
FIGURE 17.1. Le Fort fractures of the midface. (From Auerbach PS, ed. Wilderness Medicine. 6th ed. Philadelphia, PA: Elsevier Mosby; 2011. Figure 31-18 MD Consult. Redrawn from the American Association of Oral and Maxillofacial Surgeons. Oral and Maxillofacial Surgery Services in the Emergency Department. Rosemont, IL: American Association of Oral and Maxillofacial Surgeons; 1992, With permission.)
TREATMENT
ABCs (airway, breathing, circulation), supportive, antibiotics
Plastic surgery, Oral and Maxillofacial Surgery consults
Neurosurgery consult for Le Fort III
Keep head of bed >30 degrees
BASICS
Tripod fractures (infraorbital rim, zygomaticofacial and zygomaticotemporal suture lines)
DIAGNOSTICS
Maxillofacial CT
TREATMENT
ENT, plastics consult
Delayed open reduction internal fixation
BASICS
Most involve the orbital floor and medial wall
FIGURE 17.2. CT shows a right inferior orbital fracture (blowout fracture). (Neuman ML. Orbital fractures. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate; 2014. Graphic 53238 Version 3.0. Courtesy of Mark Neuman, MD.)
SIGNS AND SYMPTOMS
Periorbital swelling and tenderness
Numbness over cheek
Can cause muscle and nerve entrapment
DIAGNOSTICS
CT with clinical findings
TREATMENT
Surgery within 24 hours, unless there is too much edema, then within 5 to 7 days
Discharge with sinus precautions and Augmentin for 7 days or azithromycin
Blowout fracture (Figure 17.2)
BASICS
The most common fracture of the face
SIGNS AND SYMPTOMS
Pain, history of trauma
Nasal deformity
Assess for septal hematoma: requires immediate evacuation to prevent necrosis
DIAGNOSTICS
Mostly clinical, can get x-ray
TREATMENT
Reduction in 5 to 7 days by plastics or ENT
BASICS
Most fractures can be diagnosed with at least two-view x-rays; however, some need CT or MRI (especially elderly with continued pain)
The neurovascular exam is essential on initial assessment and after splint placement; always document this
Orthopedic consult should be considered for fractures that are open, intra-articular, unstable, require surgical repair, or with neurovascular compromise
General treatment: pain control, elevation, immobilization, follow–up, and rehabilitation
Always examine joint above and below injury
Bone anatomy (Figure 17.3)
• Epiphysis: ends of a bone
• Physis: growth plate
• Metaphysis: upper and lower third of a bone
• Diaphysis: middle third of a bone
BASICS
Anterior: most common, arm is externally rotated and slightly abducted
Posterior: 2% to 4%, arm held in adduction and internal rotation
Inferior: 0.5%, arm held above the head, high risk for fracture and nerve damage
Complications that need ortho referral
• Humerus fracture
Hill–Sachs deformity: humeral head cortical depression
Bankart lesion: avulsion fracture
Greater tuberosity fracture
• Axillary nerve: always test on exam for injury
DIAGNOSTICS
X-ray pre- and postreduction
In some cases, there is no need for x-ray if the patient meets all of these criteria: age <40, atraumatic, and history of multiple shoulder dislocations
TREATMENT
Reduction (many techniques)
• Scapular manipulation, external rotation, traction-countertraction
Immobilization with sling and swath
Occasional surgery
Radial Ulna Fractures/Dislocation
BASICS
Colles fracture: radial styloid fracture and distal radius fracture with dorsal displacement of the distal fragment
Smith fracture: distal radial fracture with palmar displacement
Galeazzi: midshaft radius fracture with dislocation at the distal radioulnar joint
Monteggia: fracture at the junction of the proximal and middle thirds of the ulna, with an anterior dislocation of the radial head
TREATMENT
Reduce displaced fracture
Splint, ortho follow-up
FIGURE 17.3. Bone anatomy and fracture classifications. (From Beutler A, Mark Stephens. General principles of fracture management: bone healing and fracture description. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate; 2014. Graphic 56313 Version 2.0. Reproduced with permisiion from: Johnson TR, Steinback, LS. eds. Essentials of Musculoskeletal Imaging. Rosemonst, IL: Amercan Academy of Orthopedic Surgeons; 2004:40–41. Copyright 2004 American Academy of Orthopaedic Surgeons.)
DIAGNOSTICS
X-ray:
• Anterior fat pad: can be normal, but if sail shape, always indicative of fracture
• Posterior fat pad: never normal, indicative of fracture
In adults:
• Assume radial head fracture if anterior sail shape or posterior fat pad (Figure 17.4)
In children:
• Assume supracondylar fracture if anterior sail shape or posterior fat pad
TREATMENT
Sling and ortho follow-up
BASICS
Fifth metacarpal neck fracture, sometimes involves the fourth metacarpal
Mechanism is usually direct trauma to a clenched fist such as punching
Dorsal angulation of the fracture causes metacarpophalangeal joint depression (loss of the knuckle)
DIAGNOSTICS
X-ray
TREATMENT
May need reduction with a hematoma block
Ulnar gutter splint
Hand surgery follow-up
Complications
• Open fracture
Antibiotics within 6 hours to prevent osteomyelitis (cefuroxime or fluoroquinolone, consider methicillin-resistant Staphylococcus aureus coverage)
• “Fight bite”: skin tear near the metacarpal head from a tooth
Irrigation, must give antibiotic coverage
First line: Augmentin
Second line: doxycycline, Bactrim, fluoroquinolone, cefuroxime, or penicillin plus Flagyl or clindamycin
BASICS
Mechanism is usually a fall onto an outstretched hand
Classified as distal, central, or proximal
Tenderness at the radial, dorsal aspect of hand, anatomical snuff box
DIAGNOSTICS
X-ray scaphoid views
TREATMENT
Thumb spica splint
If suspected, but x-ray is negative, still splint it!
BASICS
Ulnar collateral ligament injury of the thumb
Caused by hyperextension
Common in skiers, volley ball players, goalies
TREATMENT
Thumb spica splint
BASICS
From trauma or exertion, such as, coughing
Ribs 1 to 3 associated with mediastinal injury (i.e., aorta)
Ribs 9 to 12 associated with intra-abdominal injury
Flail chest
• Three or more consecutive ribs fractured in two or more places
• “Floating” segment, paradoxical movement on inspiration
Complications
• Pneumonia
• Pneumothorax
• Hemothorax
• Respiratory failure
More rib fractures = longer ventilation duration and increased mortality
DIAGNOSTICS
Chest x-ray, ultrasound, CT
TREATMENT
Most heal in 6 weeks
Less than three rib fractures: outpatient pain control, incentive spirometry
Three or more rib fractures: inpatient, elderly with six or more admit to ICU, pain control, continuous pulse oximetry, multidisciplinary care
BASICS
Primary pneumothorax (PTX): occurs without a causing event or an underlying lung disease
• Risk factors: smoking, family history, Marfan syndrome
• Usually in early 20s to 30s
Secondary PTX: occurs with an underlying lung disease
• Risk factors: chronic obstructive pulmonary disease, cystic fibrosis, cancer, necrotizing pneumonia
Traumatic PTX: may occur with a hemothorax
Tension PTX: hypotension, tracheal deviation, elevated jugular venous pressure, requiring emergent needle decompression, and/or chest tube
SIGNS AND SYMPTOMS
Shortness of breath, tachypnea, tachycardia, hypoxia, decreased breath sounds, subcutaneous emphysema; tracheal deviation is a late finding
Hemodynamic instability may indicate a tension PTX
DIAGNOSTICS
Chest x-ray, ultrasound, CT
TREATMENT
Small (<15% volume): observation, high-flow O2 with non-rebreather face mask, repeated chest x-ray
Large (2 cm on upright posterior to anterior chest x-ray equals a 50% PTX)
• Needle decompression (14G IV catheter into the pleural space at the second intercostal space, midclavicular line)
• Chest tube (see Chapter 18 for procedure details)
VATS (video-assisted thoracoscopic surgery) pleurodesis
ABCs, supportive, smoking cessation education
BASICS
Benign to life-threatening
Examine the genital and rectum for signs of open fracture
Always perform rectal exam before Foley placement
SIGNS AND SYMPTOMS
Affected side: shortened, externally rotated, and abducted
Presentation is pathognomonic
DIAGNOSTICS
X-ray, CT (gold standard)
Complications: urethral, vaginal, or rectal injuries
TREATMENT
ABCs, pain control, resuscitation
Pelvic binder, external fixation
Orthopedic consult for open reduction internal fixation
BASICS
Posterior: most common, leg flexed and adducted
Anterior: leg abducted and externally rotated
DIAGNOSTICS
X-ray
TREATMENT
Reduction with postreduction films
BASICS
High-energy trauma
High risk for hemorrhage
DIAGNOSTICS
X-ray
TREATMENT
ABCs, pain control, resuscitation
Immobilization and traction
Ortho consult for surgery
BASICS
Most commonly from a direct blow to the lateral knee
Seen often in pedestrian struck by vehicle
DIAGNOSIS
X-ray
TREATMENT
Brace in extension, non-weight-bearing with crutches
Ortho follow-up
BASICS
Anterior talofibular ligament is most common ligament injured in sprained ankle, from inversion injury
Always examine knee looking for Maisonneuve fracture
• A spiral fracture of proximal fibula and medial malleolus associated with a tear of the distal tibiofibular syndesmosis
Ottawa ankle rules: x-rays indicated if one of the following:
• Tenderness over the medial or lateral malleolus
• Tenderness over the midfoot
• Tenderness over the base of the 5th metatarsal
• Unable to weight bear immediately and take four steps in the emergency department
DIAGNOSTICS
X-ray
TREATMENT
Short-leg posterior splint or boot
Ortho consult and surgery if unstable
BASICS
Jones: transverse fracture of the diaphyseal region of the base of the 5th metatarsal
Lisfranc: fracture/dislocation of the tarsometatarsal joint
Caution: avulsion fracture of base of 5th metatarsal concerning for malunion given peroneus brevis ligament attachment site
TREATMENT
Most nondisplaced shaft fractures of metatarsal 2 to 5 do not require reduction or casting
BASICS
Usually caused by force during physical activities that involve sudden pivoting on a foot or rapid acceleration
SIGNS AND SYMPTOMS
Patient may describe feeling struck in the back of the ankle or hearing a “pop”
Severe acute pain when pushing off with his or her foot, although the absence of pain does not rule out rupture
DIAGNOSTICS
Do not assume rupture is absent because the patient can plantar flex or walk; 20% to 30% ruptures are missed because of this assumption
Thompson test: the patient lies prone with his or her feet hanging off the end of the examination table, or kneels on a chair; clinician squeezes the gastrocnemius muscle belly while watching for plantar flexion; absence of plantar flexion when squeezing the gastrocnemius muscle marks a positive test = rupture
Clinical exam diagnosis
TREATMENT
Complete tendon rupture: ice, rest, pain control, plantar flexion splint, crutches, non-weight-bearing
Ortho consultation
Partial tendon rupture: RICE (rest, ice, compression, elevation), 3 to 6 months of conservative treatment, if failed then ortho consultation
BASICS
Increased pressure between muscle and fascia layers caused by bleeding or edema usually from trauma or burns
Results in venous congestion and arterial insufficiency
Late findings are associated with irreversible nerve and muscle damage
SIGNS AND SYMPTOMS
Swelling with tight compartments
Pain out of proportion from exam (early)
Early signs: numbness, tingling, and paresthesias
Late signs: loss of function, and decreased pulses or pulselessness
7 Ps:
• Pain
• Pallor
• Paresthesia
• Paralysis
• Poikilothermia (inability to regulate temperature)
• Pulselessness
• Pressure
DIAGNOSTICS
Handheld manometer (Stryker)
• Normal pressure is 0 to 8 mm Hg
TREATMENT
Remove all splints/casts
Do not elevate or lower the limb; it should be level with the heart
Pain control, IV fluids, treat hypotension to reduce hypoperfusion
Emergent surgery consult for fasciotomy
(see also Chapter 10, Nervous System Disorders)
BASICS
Brain ischemia is caused by decrease in cerebral perfusion pressure
If intracranial pressure sharply increases, it can result in herniation
DIAGNOSTICS
Decision to obtain head CT scan should be based upon Canadian or National Emergency X-Ray Utilization Study (NEXUS) II Head CT rules
• Canadian CT Head Rule (consider CT if yes to any of the following):
Glasgow Coma scale (GCS) <15 two hours after injury
Suspected open skull fracture
Sign of a basal skull fracture
Two or more episodes of vomiting
Age more than 65
Thirty minutes of preimpact amnesia
Dangerous mechanism
• NEXUS II CT Head Rule (consider CT if yes to any of the following):
Evidence of skull fracture
Scalp hematoma
Neuro deficit
Altered level of consciousness
Abnormal behavior
Coagulopathy
Persistent vomiting
Age more than 65
GCS
• GCS <8: severe head trauma
• GCS 9 to 13: moderate head trauma
• GCS 14 to 15: minor head trauma
Eye opening
– 4 spontaneous
– 3 to verbal commands
– 2 to pain
– 1 no response
Verbal response
– 5 oriented
– 4 confused
– 3 inappropriate
– 2 incomprehensible sounds
– 1 no response
Motor response
– 6 obeys commands
– 5 localizes to pain
– 4 flexion withdrawal
– 3 decorticate posturing
– 2 decerebrate posturing
– 1 no response
TREATMENT
ABCs
Neurosurgery consult
Keppra, Dilantin (seizure prevention)
Correct coagulopathy as indicated (fresh frozen plasma, platelet, vitamin K, profile 9)
Goal systolic blood pressure <140
Mannitol is sometimes used to decrease cerebral edema
Uncal herniation
• Most common
• Ipsilateral uncus herniation compresses cranial nerve (CN) III
• Dilated ipsilateral pupil, ptosis, nonreactive pupil
Central transtentorial herniation
• Central biphasic herniation though tentorium caused by a lesion in the vertex or frontal lobe
• Signs: altered mental status, bilateral motor weakness, pinpoint pupils that eventually become dilated and nonreactive
Cerebellotonsillar herniation
• Cerebellar tonsils herniate through the foramen magnum
• Signs: quadriplegia caused by compression of the corticospinal tracts, cardiopulmonary collapse from brainstem compression
Subdural hematoma (SDH)
• Tearing of veins between the brain and dura occurring with acceleration-deceleration
• Risk factors: people with brain atrophy (elderly, alcoholics)
• CT: concave density adjacent to the skull, crosses suture lines
Epidural hematoma (EDH)
• Bleeding between the dura and skull, usually from the middle meningeal artery
• Usually from direct trauma over the temporoparietal region
• CT: biconvex density adjacent to skull, does not cross suture lines
Subarachnoid hemorrhage (SAH)
• Most common abnormality seen on CT posttrauma
• CT: hyperdensity within subarachnoid space, prominent in the sulci or cerebral peduncles
• See SAH under Headache for more information
BASICS
Most commonly involves the temporal bone
High risk for intracranial hemorrhage
SIGNS AND SYMPTOMS
Battle sign: ecchymosis over the mastoid area
Raccoon eyes: periorbital ecchymosis
DIAGNOSTICS
Head CT
COMPLICATIONS
Temporal bone fracture
Check for CSF leak, “halo” or “ring” test, risk for meningitis
Dural tear (intracranial hemorrhage)
CN palsies
TREATMENT
Head of bed 60 degrees if concerned for CSF leak
Admission for observation and consider neurosurgery consult
BASICS
When in doubt, splint and follow up with orthopedics
May need sedation, consider ketamine
Current state and federal laws support the treatment of minors with an emergent medical condition, regardless of consent issues
Salter–Harris Fracture Classification (Based on the Growth Plate)
Type I: Separation at the physis
Type II: Above, separation at the physis with partial metaphyseal fracture
Type III: Lower, partial separation of the physis with intra-articular epiphyseal fracture
Type IV: Through, intra-articular fracture extending across the physis into the metaphysis
Type V: Everything Ruined, crush of the growth plate (Figure 17.5)
BASICS
Most common pediatric fracture
Middle-third clavicle fracture: most common (80%), treat with a sling
Distal-third clavicle fracture: sling, displaced fracture may require surgery
Medial-third clavicle fracture: sling, displaced fracture needs ortho referral for reduction, consider intrathoracic injuries
DIAGNOSTICS
X-ray
TREATMENT
Usually comfort measures, sling
Rarely surgery
BASICS
Radial head subluxation
Usually age 1 to 4
Mechanism is usually someone pulling on the child’s pronated forearm while the elbow is in extension, commonly while he or she is falling or pulling away
SIGNS AND SYMPTOMS
Child not using his or her arm and holding it close to the body
Pain with forearm supination
FIGURE 17.5. Salter–Harris fracture classification. (From Young SJ, Barnett PLJ, Oakley EA. Fractures and minor head injuries: minor injuries in children II. Med J Aust. 2005;182(12):644–648.)
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