Tag Archives: orthopedics

The Hand: An Expedited Examination and Key Points Regarding ED Diagnoses

Authors: Alin Gragossian, DO (EM Resident Physician, Drexel University), Matthew A. Varacallo, MD (Orthopedics Resident Physician, Drexel University), and Richard J. Hamilton, MD (EM Professor and Chair, Drexel University) // Edited by: Erica Simon, DO (@E_M_Simon) & Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

A 31-year-old male, the victim in a low-speed MVC versus pedestrian, arrives to the trauma bay via EMS. As the stretcher rolls by you see an alert patient, yelling in pain. A c-collar is in place, and a splint supports what appears to be a mangled right hand and an open right forearm fracture. As your trauma team hurriedly connects monitors, you note initial VS: HR 110, BP 132/96, RR 14, SpO2 98% RA.

You’re reassured by your primary survey: ABCs are intact; the radial and ulnar pulses of both upper extremities are palpable. Your secondary survey is significant for what appears to be a serious injury to the dorsal aspect of the distal right upper extremity: a large skin avulsion revealing extensor tendons of the hand and an open distal radius fracture.

CT imaging and radiographs demonstrate that the patient is without additional injuries, save those identified on your exam. After administering analgesia, cefazolin, and updating a tetanus, the patient wheels off to the OR for washout, re-approximation, and repair. As you complete the trauma paperwork, you replay the hand examination in your mind.  Was there anything that your team overlooked?

If it’s been a while since you’ve treated a patient with a hand complaint, let’s review some high-yield material.

Epidemiology

Hand complaints represent nearly 12% of injury-related visits to ED setting.1,2 Trauma involving the hands imparts a significant burden on healthcare systems given the frequent requirement for referral, and potential necessity for surgical intervention. According to a 2009 study of 134 patients presenting for the evaluation of hand lacerations secondary to electric saws, mean treatment costs per injury (including hospitalization) were $30,704, with an average loss of 64 productive work days.3 As limitations in dexterity can significantly impact activities of daily living and quality of life, the early identification and treatment of neurovascular, tendon, and bone injuries of the hand are paramount.4

History & Physical

History
When obtaining a history, question patients regarding the type of injury (burn, laceration, injection injury, etc.), the mechanism, time elapsed between injury and evaluation, and the possibility of occupational exposures. Hand dominance, prior hand injury, and prior hand surgeries should be documented.5

Physical Exam
Table 1 offers a quick reference guide for use when performing muscle and tendon function evaluation of the hand and wrist.6,7

Table 1. Muscle and Tendon Function of the Hand and Wrist
Table 1. Muscle and Tendon Function of the Hand and Wrist

Nerves
Examination of the hand should include an assessment of nerve function:

Median Nerve

  • Motor: thumb abduction and opposition => test by asking the patient to place his hands in anatomic position.  Apply resistance to the thumbs while prompting the patient to move them towards the ceiling.
  • Sensory: innervates the central aspect of the palm and terminates distally in the radial 3.5 digits of the hand => test sensation by assessing two-point discrimination. Normal two-point discrimination is 5mm at the volar fingertips. Sensory testing should be repeated 2-4 times on each side of each digit.5,6

Radial Nerve

  • Motor: thumb extension => test the patient’s thumb extension against resistance.
  • Sensory: the superficial branch of the radial nerve and its terminal branches provide sensation to the central and radial aspects of the dorsum of the hand, and the dorsal-radial aspect of the thumb => test sensation by performing two-point discrimination on the dorsum of the thumb.5,6

Ulnar Nerve

  • Motor: innervates the adductor pollicis muscles and controls thumb adduction => test by asking the patient to cross her fingers, or abduct her fingers against resistance.
  • Sensory: provides sensation to the dorsal-ulnar aspect of the hand and into the fingertips of the fourth and fifth digits => test ulnar nerve sensation by assessing two-point discrimination of the fourth and fifth digits.5,6
Figure 1. Cutaneous Nerve Supply of the Hand O’Rahilly R. Basic Human Anatomy: Chapter 10: The Hand. 2008. Available from: https://www.dartmouth.edu/~humananatomy/about/credits.html
Figure 1. Cutaneous Nerve Supply of the Hand
O’Rahilly R. Basic Human Anatomy: Chapter 10: The Hand. 2008. Available from: https://www.dartmouth.edu/~humananatomy/about/credits.html

Vascularity

The radial and ulnar arteries perfuse the hand. The radial artery forms the deep palmar arch, and the ulnar artery forms the superficial palmar arch.5,7 Vascularity may be evaluated through palpation (temperature and pulses), Doppler (if required), and capillary refill. While some advocate the use of the Allen’s test during the vascular examination, it is important to note that this test lacks sensitivity and specificity as findings vary according to the time employed (e.g. – injury transecting the radial artery may initially present with a normal Allen’s test, however subsequent radial artery vasospasm and thrombosis may result in an later abnormal Allen’s test), and operator experience.8

Alignment

When it comes to hand injuries, malrotation resulting from fracture is an indication for ED reduction. When the fingers are flexed, a cascade directed towards the scaphoid tubercle should be observed (Figure 2). If abnormalities in alignment are identified, radiographs and consultation are advised.

Figure 2. Assessment of Malrotation Steinman S. Seattle Children’s Hospital Finger Fractures: Don’t Forget the Malrotation. 2017. Available from: http://www.seattlechildrens.org/healthcare-professionals/resources/case-studies/finger-fractures-dont-forget-rotation/
Figure 2. Assessment of Malrotation
Steinman S. Seattle Children’s Hospital Finger Fractures: Don’t Forget the Malrotation. 2017. Available from: http://www.seattlechildrens.org/healthcare-professionals/resources/case-studies/finger-fractures-dont-forget-rotation/

Special Examinations

Carpal Tunnel

Tinel’s and Phalen’s tests may be utilized to assess for the presence of carpal tunnel syndrome. A positive Tinel’s sign is elicited when the examiner taps the median nerve as it passes through the carpal tunnel, eliciting a report of paresthesias in median nerve distribution. A positive Phalen’s test occurs when paresthesias are experienced in median nerve distribution after > 60 seconds of maximum wrist flexion.8

Ulnar Motor Weakness

Froment’s test identifies ulnar nerve motor dysfunction (specifically, a weakness of the adductor pollicis). The patient is instructed to grasp a thin object between the thumb and radial aspect of the index finger.   If the examiner is able to remove the thin object, or the patient flexes the IP joint (flexing the flexor pollicis longus, innervated by the anterior interosseous nerve) to increase the grasping force, the test is said to be positive. If the patient simultaneously hyperextends the first metacarpophalangeal joint, this is said to be a positive Jeanne’s test, again indicating ulnar motor weakness.9

Figure 3. Froment's Test Ujash S. Physical Exam of the Hand. 2017. Available from: http://www.orthobullets.com/hand/6008/physical-exam-of-the-hand#
Figure 3. Froment’s Test
Ujash S. Physical Exam of the Hand. 2017. Available from: http://www.orthobullets.com/hand/6008/physical-exam-of-the-hand
Figure 4. Positive Jeanne's Test Ujesh, S. Physical Exam of the Hand. 2017. Available from: http://www.orthobullets.com/hand/6008/physical-exam-of-the-hand
Figure 4. Positive Jeanne’s Test
Ujesh, S. Physical Exam of the Hand. 2017. Available from: http://www.orthobullets.com/hand/6008/physical-exam-of-the-hand

Imaging

In the ABCs of Emergency Radiology, Chan and Touquet offer a number of excellent recommendations on the basics of ED radiographs:

The Rules of Two:1

  • Two views: one view is one too few
  • Two joints: image the joint above and below a long bone
  • Two sides: compare the other side if unsure of pathology
  • Two abnormalities: look for a second abnormality
  • Two occasions: compare current films and old films (if available)
  • Two visits: repeat films before and after procedures
  • Two specialists: if possible, obtain a formal radiology report
  • Two examination modalities: US, CT, or MRI should be considered as appropriate to the clinical scenario

Speaking of imaging, ultrasound is quickly becoming a popular mechanism for identifying foreign bodies. Prior to the employment of US, epidemiological studies estimate that nearly 38% of non-radiopaque foreign bodies went unidentified during initial ED encounters (1982 publication).11 A recent study by Saboo and colleagues demonstrated sensitivities of 94–98% for ultrasound detection of both radiolucent and radiopaque foreign bodies (n =123 patients, 7.5 MHz transducer).12 As US may be difficult to perform on the small surfaces of the hands, a water bath may be utilized with a high frequency linear transducer to generate high resolution images.

Figure 5. Water Bath for Hand US Lin, Michelle. Tricks of the Trade: Underwater Ultrasonography. 2011. Available from: https://www.aliem.com/2011/tricks-of-trade-underwater/
Figure 5. Water Bath for Hand US
Lin, Michelle. Tricks of the Trade: Underwater Ultrasonography. 2011. Available from: https://www.aliem.com/2011/tricks-of-trade-underwater/

Urgent or Emergent  Surgical Intervention

The following offers a review of hand conditions requiring urgent or emergent ED attention.

 Acute Compartment Syndrome

Compartment syndrome of the hand is relatively uncommon, but may occur secondary to trauma, insect bites, snake bites (2-8%13), high-pressure injection, contrast infusion, and crush injuries.12 The hand is anatomically separated into ten compartments; those most commonly at risk for the development of elevated intra-compartmental pressures include: the interossei (dorsal and palmar), the thenar and hypothenar, the adductor, and the finger compartments.14 Symptoms associated with acute compartment syndrome are classically characterized as the “six Ps” – pain, pallor, paresthesias, poikilothermia, pulselessness, and paralysis. The most reliable indicator is pain out of proportion to physical examination findings.12 It is paramount that fasciotomy be performed within 8 hours of the onset of symptoms as axonal and myocyte damage may be irreversible outside of this time frame.15-17

Replantation

Replantation, the surgical reattachment of a finger, hand, or arm that has been severed, is a topic best discussed with the orthopedic/hand specialist –  patient outcomes depend upon the skill of the surgical team, patient co-morbidities, and the extent of the injury.18 Primary indications for replantation after trauma include amputations to the thumb at any level, involvement of multiple digits, amputations through the palm, amputations at or proximal to the wrist, and almost all amputated parts in the pediatric patient.18 Consideration for replantation should be given for individual digit amputations distal to the insertion of flexor digitorum superficialis, ring avulsion injuries, and amputations through or above the elbow.18

Primary contraindications to replantation include patients with severe vascular disorders, crush injuries, or injuries with mangling of the severed limb.18

Flexor tenosynovitis

 Flexor tenosynovitis is an infection of the flexor tendon sheath that is characterized by Kanavel’s Signs: finger held in flexion, pain with passive extension, pain with palpation of the flexor tendon sheath, and fusiform swelling.19 Flexor tenosynovitis may result from minor trauma as the distance from the volar dermis to the flexor sheath is 1-2 millimeters.19 If suspected, initiate broad-spectrum antibiotic therapy, and consult for surgical intervention.19

High-Pressure Injection Injuries

Patients utilizing high-pressure injection equipment often present to the ED for the evaluation of an injury to the non-dominant hand (equipment most commonly held in the dominant hand).20,21 Injury severity is dependent upon the force of injection, volume of material injected, and the composition of the material injected.20 While injuries may initially appear relatively benign, specialty consultation is a must as tracking of the injected material may ultimately result in gross contamination of subcutaneous tissue and deep muscle. Upon ED arrival, imaging should be performed to assess for the presence of foreign bodies, and parenteral antibiotic therapy initiated.20,21 In terms of morbiditiy, as compared to all other finger injuries, those due to high-pressure injection are three times as likely to require amputation.19

Pearls:

  • A rapid hand exam can be performed in the following manner:
    • As the patient make an “OKAY” sign with thumb and first finger (median nerve). Spread the fingers apart maximally (ulnar nerve). Dorsiflex the wrist fully (radial nerve). These can be combined into an OKAY sign with remaining fingers spread apart and the wrist dorsiflexed to get an all-in-one motor exam.
    • Check sensation of the median and ulnar nerve by testing two-point discrimination at the index and small finger pads respectively. Radial nerve sensation can be tested over the dorsum of the thumb.
  • For carpal tunnel syndrome, perform Tinel’s and Phalen’s tests. Remember, a positive test occurs when the patient reports paresthesias in median nerve distribution.
  • Acute compartment syndrome must go to the OR within 8 hours of onset.
  • Kanavel’s Signs are key physical exam findings for flexor tenosynovitis: finger held in flexion, pain with passive extension, pain with palpation of the flexor tendon sheath, and fusiform swelling.
  • Beware of high-pressure injection injuries. They look more benign than they truly are, and warrant a careful physical examination of the hand and consultation.


References / Further Reading:

  1. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010;(26):1-31.
  2. Maroukis BS, Chung KC, MacEachern M, Mahmoudi E. Hand trauma care in the United States: a literature review. Plastic and Recon Surg. 2016 Jan; 137(1): 100e-111e.
  3. Hoxie SC, Capo JA, Dennison DG, Shin AY. The economic impact of electric saw injuries to the hand. J. Hand Surg. 2009 Jun; 34A: 886-889.
  4. Soucacos P. Indications and selection for digital amputation and replantation. J Hand Surg Br. 2001;26(6):572–581.
  5. Tintinalli J, Stapczynski J, Cline D, Ma OJ et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th edition. McGraw-Hill Education / Medical; 2015.
  6. Chung KC. Hand and Wrist Surgery. Elsevier Health Sciences; 2012.
  7. Morton DA, Foreman K, Albertine KH. eds. The Big Picture: Gross Anatomy New York, NY: McGraw-Hill; 2011.
  8. Jarvis MA, Jarvis CL, Jones PR, Spyt TJ. Reliability of Allen’s test in selection of patients for radial artery harvest. Ann Thorac Surg. 2000;70(4):1362-5.
  9. Ujash S. Physical Exam of the Hand. 2017. Accessed 15 March 2017. Available from: http://www.orthobullets.com/hand/6008/physical-exam-of-the-hand#
  10. Chan O and Touquet R. General Principles: How to Interpret Radiographs. In ABC of Emergency Radiology. 3rd 2013. West Sussex, UK. Wiley-Blackwell Publishing.
  11. Lewis D, Jivraj A, Atkinson P, Jarman R. My patient is injured: identifying foreign bodies with ultrasound. Ultrasound. 2015;23(3):174-80.
  12. Saboo S, Saboo SH, Soni SS, et al. High-resolution sonography is effective in detection of soft tissue foreign bodies. J Ultrasound Med 2009; 28: 1245–9.
  13. Anz A, Schweppe M, Halvorson J, Bushnell B, Sternberg M, Andrew Koman L. Management of venomous snakebite injury to the extremities. J Am Acad Orthop Surg. 2010 Dec; 18(12): 749-59.
  14. Chandraprakasam T and Kumar R. Acute compartment syndrome of forearm and hand. Indian J Plast Surg. 2011; 44(2):212-218.
  15. Oak NR, Abrams RA. Compartment Syndrome of the Hand. Orthop Clin North Am. 2016;47(3):609-16.
  16. Whitesides TE, Heckman MM. Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg 1996;4(4):209–18. 21.
  17. Von keudell AG, Weaver MJ, Appleton PT, et al. Diagnosis and treatment of acute extremity compartment syndrome. Lancet. 2015;386(10000):1299-310.
  18. Sabapathy SR, Venkatramani H, Bharathi RR, Bhardwaj P. Replantation surgery. J Hand Surg Am. 2011;36(6):1104-10.
  19. Ong YS, Levin LS. Hand infections. Plast Reconstr Surg. 2009;124(4):225e-233e.
  20. Eroglu O, Sari E, Vural S, Coskun F. Warning: This may be as dangerous as firearm injuries; “grease-gun injury”: A case report. The Pan African Medical Journal. 2015;20:40. doi:10.11604/pamj.2015.20.40.5892.
  21. Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma. 2006;20(7):503-11.

MEDICAL MALPRACTICE INSIGHTS: Don’t miss a posterior shoulder dislocation

Author: Chuck Pilcher, MD, FACEP (Editor, Med Mal Insights) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Here’s the second monthly post from Medical Malpractice Insights – Learning from Lawsuits, a free monthly opt-in email newsletter. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits.

Chuck Pilcher MD, FACEP, Editor, Med Mal Insights

Don’t miss a posterior  shoulder dislocation

Critical thinking makes the diagnosis easy

Facts: A 42 yo well-dressed businessman presents to the ED with pain in his left shoulder after slipping and falling on his outstretched arm on a wet sidewalk about 2 hours earlier. He has no prior history Screen Shot 2017-02-16 at 9.31.17 PMof shoulder problems. Exam shows very limited and painful ROM with the shoulder held in adduction and internal rotation. There is a normal appearing “deltoid bulge” indicating no anterior dislocation. An impacted humeral head fracture is suspected. An x-ray is read by both the ED physician and the radiologist as normal. The patient is placed in a sling and discharged to follow up with an orthopedic surgeon. Two days later the orthopod finds the patient has a posterior dislocation The patient notifies the ED. The hospital’s Risk Management Department goes into action.

Plaintiff: My pain and limited ROM was way off the scale compared to a minor sprain. Both the ED doc and the radiologist misread my x-rays. You should have suspected a posterior shoulder dislocation and done a CT scan. Your failure to recognize this caused me more pain, time off, and medical expenses. We need to talk.

Defense: You’re right. We’re sorry. We want to make this right.

Result: The orthopedic surgeon was gracious. The ED physician and radiologist both called the patient and apologized. After discussions with the patient (a forgiving and reasonable gentleman), his attorney, and the hospital risk management department, an agreement was reached to forgive all bills, pay his expenses for relocating the shoulder and therapy, compensate him for time loss from work, plus a small amount for pain, suffering, and inconvenience. The total amount was under $100,000, split between the radiologist, the ED physician, and the hospital. The patient recovered nicely.

Takeaway:

  • Saying you’re sorry helps, along with having a good relationship with your backup docs and risk management department.
  • Posterior shoulder dislocations are uncommon but commonly missed.
  • FOOSH is the typical mechanism, with seizures second.
  • Pain and limited ROM are impressive – as one can imagine. The patient just hurts too much for nothing to be wrong. This alone should trigger the “critical thought”: “Could this be a posterior dislocation?”
  • The shoulder is usually held in adduction and internal rotation.
  • The humeral head on x-ray may be internally rotated and appear as a “lightbulb on a stick,” but it may also be read as normal.
  • High index of suspicion required. A CT will make the diagnosis, especially if one suspects a humeral head fx and finds none..

Screen Shot 2017-02-19 at 9.22.53 PM

http://eorif.com/Shoulderarm/Images/Shoulder-dislocationP1.jpg

References/Further Reading:

  1. Lightbulb on a stick image: http://eorif.com/Shoulderarm/Images/Shoulder-dislocationP1.jpg
  2. Posterior Shoulder Dislocation. Life in the Fastlane (blog). Mike Cadogan http://lifeinthefastlane.com/posterior-shoulder-dislocation/ (includes excellent x-ray images)

“There are no mistakes, save one: the failure to learn from a mistake.” – Robert Fripp

Septic Arthritis

Originally published at Pediatric EM Morsels on August 28, 2015. Reposted with permission.

Follow Dr. Sean M. Fox on twitter @PedEMMorsels

We have discussed several entities that may lead to a child limping. We have covered osteomyelitis, plantar punctures, and toddler’s fractures.  We have also touched upon Osgood Schlatter’s Disease, SCFE, osteosarcoma and even Growing Pains. Now let us review a topic that always crosses our minds when considering the painful extremity: Septic Arthritis.

Septic Arthritis: Basics

  • Septic arthritis is an infection in the joint space and synovial fluid.
  • Can occur by hematogenous spread of bacteria or direct inoculation.
  • High Risk populations = children less than 2 years of age, immunocompromised, and patients without functional spleens
  • Complications:
    • Capsule damage
    • Chronic arthritis
    • Osteonecrosis
    • Growth Arrest
    • Sepsis

Septic Arthritis: Presentation

  • Fever
    • Although no/low fever noted in up to 20% of cases!
  • Joint pain, swelling, and erythema
    • Pain with passive range of motion!
    • Limps or refuses to bear weight on limb.
  • 80% of cases in children involve the lower limbs
    • Knee involved in 40% of cases
    • Hip involved in 20% of cases

Septic Arthritis: The Bugs

  • Staph aureus = most common organism across all ages
    • MRSA has become more prevalent [Young, 2011]
    • Group B Strep is 2nd most common
  • Special Population considerations:
    • Infants:
      • E. Coli
    • Young Children (<4 years)
      • Klingella kingae (notoriously difficult to culture)
      • Hemophilus influenza B has become less prevalent since HiB vaccination.
    • Immunocompromised:
      • Klingella kingae
      • Streptococcus pneumoniae (especially with HIV infection)
    • Sickle Cell Disease:
      • Salmonella (although, S. Aureus is still most common)
    • Sexually Active:
      • N. Gonorrhea – most common cause of polyarticular infections in sexually active patients

Septic Arthritis vs. Toxic Synovitis

  • Despite the name, toxic synovitis is the self-limited, benign inflammation of the joint that gets treated symptomatically.
  • Unfortunately, the presentation of toxic synovitis can be difficult to differentiate from septic arthritis, particularly when involving the hip joint.
    • Atraumatic 
    • Acute pain
    • Limp / refuses to bear weight
    • Fever
  • The treatment strategies and potential outcomes are quite different for the two conditions, so differentiating between them is critical… although challenging. (again, your job isn’t easy)

Septic Arthritis: Kocher’s Criteria

  • In 1999, Kocher et al published retrospective data from cases that presented to their facility from 1979-1996 due to “acutely irritable hip.”
  • Through a logistic regression analysis of 168 patients, they devised a probabilityalgorithm to help differentiate between septic arthritis and toxic synovitis.
  • There was no single lab test that was able to differentiate between the two entities. [Kocher, 1999]
  • Kocher’s Criteria: [Kocher, 1999]

    • Predictors associated with risk of Septic Arthritis
      • Fever
      • Non-weight-bearing
      • ESR = 40 or more
      • Serum WBC = 12,000 or more
    • Probability of Septic Arthritis based on number of Predictors
      • 0 Predictors – <0.2 %
      • 1 Predictor – 3.0%
      • 2 Predictors – 40.0%
      • 3 Predictors – 93.1%
      • 4 Predictors – 99.6%
  • Use this information wisely… not blindly.
    • May not apply to your patient.
      • Not hip pain?
      • Any underlying high-risk factors?
      • Clinical Decision Rules typically have diminished performance in different populations other than the derivation group. [Kocher, 2004]
    • Must balance the risk of false-positives vs false-negatives.
      • At what point does risk of missing septic arthritis outweigh the morbidity of joint aspiration? [Kocher, 1999].
        • 0 or 1 Predictors – close follow-up / observation
        • 2 Predictors – Aspiration via fluoroscopy/ultrasound
        • 3 or 4 Predictors – Aspiration in OR with likely arthrotomy and drainage.

Morals of the Morsel

  • Septic Arthritis needs to be higher on your differential than Toxic Synovitis.
  • Appreciate the diagnostic challenge inherent in the evaluation.
  • NO SINGLE TEST WILL DIAGNOSE OR RULE-OUT SEPTIC ARTHRITIS. [Dodwell, 2013]
  • Anticipate what tool (ex, Kocher Criteria) your consultants will likely use, but know their limitations.
  • 2 Predictors is more reassuring than 3, but still comes with increased risk.
    • Having Fever and being Non-Weight Bearing with normal labs can still be associated with Septic Arthritis!
  • Your pretest probability has to be taken into account, like always.
  • Don’t forget to give some analgesics!  
    • The child who is now weight-bearing after NSAIDs just became less concerning and it may be better to arrange close followed-up rather than ordering a bunch of non-specific lab tests.

References

Montgomery NI1, Rosenfeld S. Pediatric osteoarticular infection update. J Pediatr Orthop. 2015 Jan;35(1):74-81. PMID: 24978126. [PubMed] [Read by QxMD]

Dodwell ER1. Osteomyelitis and septic arthritis in children: current concepts. Curr Opin Pediatr. 2013 Feb;25(1):58-63. PMID: 23283291. [PubMed] [Read by QxMD]

Gill KG1. Pediatric hip: pearls and pitfalls. Semin Musculoskelet Radiol. 2013 Jul;17(3):328-38. PMID: 23787987. [PubMed] [Read by QxMD]

Young TP1, Maas L, Thorp AW, Brown L. Etiology of septic arthritis in children: an update for the new millennium. Am J Emerg Med. 2011 Oct;29(8):899-902. PMID:20674219. [PubMed] [Read by QxMD]

Yuan HC1, Wu KG, Chen CJ, Tang RB, Hwang BT. Characteristics and outcome of septic arthritis in children. J Microbiol Immunol Infect. 2006 Aug;39(4):342-7. PMID:16926982. [PubMed] [Read by QxMD]

Kocher MS1, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004 Aug;86-A(8):1629-35. PMID: 15292409.[PubMed] [Read by QxMD]

EM Cases: Hand Emergencies

Originally published at EM Cases – Visit to listen to accompanying podcast . Reposted with permission.

Follow Dr. Anton Helman on twitter @EMCases

Ep29-Hand-Emergencies

Written Summary and blog post by Clarie Heslop, edited by Anton Helman January, 2013

Fight Bites & Boxer Fracture

Suspect a “fight bite” when there is a laceration over an MCP joint. 10% of “fight bites” develop septic arthritis;these injuries need prophylactic antibiotics. For metacarpal fractures, assess for rotation & compare to contralateral hand:

  1. Phalanxes should point to the scaphoid in a closed fist (image below, left), or
  2. Look head on at the fingertips for rotation of fingernails, or
  3. Looking for scissoring with MCP in flexion (image below, right).

Reduce if rotation is present!

rotational deformity

Rotational deformity of the 5th digit: note that the 5th digit does NOT point towards the scaphoid

Metacarpal Fracture Acceptable angulation

40° for 5th MC, 30° for 4th MC, 20° for 3rd MCP, and 10° for 2nd. Reduce if greater angulation is present.

Pearls for Boxer Fracture Reduction

  • Provide good anesthesia (i.e. ulnar nerve block).
  • Consider using finger-traps for traction. Reduce by pushing dorsally on the distal bone fragment while providing counter pressure on proximal fragment, and immobilize in position of safety (MCP 90′ flexion, IP extension).
  • Early follow-up (<7 days) in clinic to confirm stability is necessary.

Tendon injuries

Have a high index of suspicion.

  • Inspect & test function of tendon against minimal or no resistance.
  • For <50% extensor tendon injury, a splint may be sufficient.
  • Our experts suggest ED physicians may repair extensor tendons cut >50% if ends are easily visible and easily opposed.
  • Use a single horizontal mattress suture and splint the hand.
  • All flexor tendon and all complex extensor tendon injuries should be splinted and seen by plastics in <7 days.

Skin Lacerations

Is suturing indicated? Simple hand lacerations <2 cm in healthy individuals have the same outcome without sutures. Digital nerve block: Single palmar injection of 2-3mL of 1% xylocaine at the base of the digit just distal to the proximal skin crease. Irrigation: Use 19g needle with 35cc syringe to irrigate copiously with saline or even tap water, under pressure.

Gamekeeper’s Thumb or Skier’s Thumb

Mechanism: Valgus force to abducted thumb. Exam: point of maximal tenderness is usually over the volar/ ulnar aspect of 1st MCP. Pincer grasp often painful with partial tears.

  • Assess stability by applying radial stress to the distal thumb while immobilizing the proximal thumb and compare to contralateral thumb.

gamekeeper's thumb

If >30′ deviation, assume instability. Get an X-ray to rule out avulsion # of proximal phalanx. For a partial injury, a 6-week splint may heal the tendon, but a complete tear requires surgery, so surgical exploration is often necessary for cases where a partial tear cannot be confirmed. All patients should be placed in a thumb spica splint and seen early for follow up (7 days) as nonunion of a complete tear requires extensive reconstruction.

gamekeepers

Gamekeeper’s thumb with fracture

High Pressure Injection Injury

Injury Liquid under high pressure causes severe injury when injected into the hand by: 1) Direct dissection of tissue planes and tissue ischemia, 2) Cytotoxicity of materials, and 3) Possible secondary infections. These injuries can result in extensive damage and lead to amputation. Don’t be fooled: these can appear benign but pain, pallor, and edema progress like a hand “compartment syndrome”. If history suggests a high pressure injection, contact plastics urgently for definitive exploration and debridement. X-ray can help determine the extent of injury.

high pressure injection injury

High pressure injection injury

Flexor Tenosynovitis

4 cardinal signs (Kanavel signs):

  1. Finger held in slight flexion,
  2. Fusiform swelling of the digit,
  3. Tender along tendon sheath, &
  4. Pain with passive extension.
flexor tenosynovitis

Flexor tenosynovitis

Time is key because adhesions can form and permanently disable the digit. These must be urgently evaluated by plastic surgery, treated with IV antibiotics, and often admitted for either close monitoring, or urgent surgical irrigation and drainage. Start antibiotics, splint and elevate the hand, and refer to plastics.

Hook of the Hamate Fracture

Mechanism – either FOOSH, or an impact of a club or racket forced into the palm. Hook of the hamate fractures may not be seen on usual Xray views of the hand. The “carpal view” (supinated lateral view) should be ordered if suspicious about this fracture, and/or if pain is felt over the hypothenar eminence.

hook of the hamate

carpal view

Carpal View for hook of the hamate

Not all hamate fractures appear on Xray. Some need further imaging (CT), and nonunion is very common. Excision of the fracture fragment is often necessary if there is nonunion. If a fracture is seen, immobilize the hand (in a volar slab, with MCP joints in flexion) and refer for follow-up within 4 weeks.

Paronychia

peronychia

  • Paronychia (nail edge infections, image at right) should be managed depending on the extent of the infection. A small infection without an abscess may improve with soaking the finger, and oral antibiotics.
  • However, if an abscess has formed, it needs blunt dissection with a surgical blade, elevation of the lateral nail fold (image at right) and drainage of the sulcus between the lateral nail plate and the lateral epithelium.
  • Irrigate copiously, and instruct the patient to soak the finger to keep the abscess open, or place a wick.
  • If the abscess tracks under the nail, consider wedge resection of the nail plate, or nail plate removal if the entire nail plate is involved.

peronychia

Felon

Compartments of the volar skin may form abscesses which need careful and thorough surgical decompression. See image (right). If urgent referral to a hand surgeon is not available, these must be managed in the ED. Cut and detach septae along whole length of distal phalanx nearest to the abscess site, releasing and irrigating very thoroughly. Avoid making incisions across the lateral aspect, to avoid injuring the digital nerve. After releasing all septae, swab, pack and treat with IV antibiotics, splinting, and elevation. Ensure urgent follow-up.

Tips for Hand Injuries

  • When considering when to remove sutures in the hand, leave sutures that are over areas of tension (i.e. over a joint) for longer (at least 12 days) so they heal completely.
  • If controlling bleeding is an issue, do NOT clamp any digital arteries, as the digital nerve is very nearby and hard to visualize. Use pressure, limited tourniquet and elevation to control bleeding safely.
  • Prophylactic antibiotics are indicated for for all animal bites to the hand, and for certain complex injuries (crush wounds, wounds over a joint, or for immune compromised patients).
  • If referring a hand abscess to a clinic, consider swabbing the drained fluid so MRSA status can be determined.
  • Immobilizing the PIP joint in extension can stiffen the collateral ligaments causing permanent disability, so don’t splint PIP joint for greater than 1–2 weeks unless necessary, and if splinting, ensure an early referral time. (within 1–2 weeks).

Dr. Helman, Dr. Tate and Dr. Arcand have no conflicts of interest to declare.

References

Bleeding Hand Wounds

Author: Josh Bucher, MD (EM Attending Physician and EMS Fellow, Morristown Medical Center) // Edited by: Jennifer Robertson, MD, MSEd, Alex Koyfman, MD (@EMHighAK)

Case:

A 27-year-old male with no medical problems presents to the emergency department (ED) with a chief complaint of a finger amputation. He reports he was using a circular saw when his hand slipped and the saw accidentally cut his finger. He is complaining of severe pain and a hand deformity. On exam, his left third digit has an obvious amputation at the proximal interphalangeal (PIP) joint, and the distal portion of the finger is mangled beyond repair. This site also demonstrates pulsatile and venous bleeding, both of which have not stopped with direct pressure.

Hemorrhage control:

Hemorrhage control is an important aspect of both the treatment of and evaluation of any wound. Wounds that are actively bleeding require treatment. In addition, persistent hemorrhage can make the exam very difficult, such as assessing for full tendon function and visualization.

In a 2015 article, Thai et al. published a set of guidelines on hemorrhage control of forearm arterial lacerations. This is the first set of published, evidence-based guidelines on this topic.1

Hemorrhage control should first be attempted with direct pressure. All wounds deserve an attempt with direct pressure for 5 – 15 minutes.2 In the event that 15 minutes of direct pressure does not work, other steps, as noted below, can be attempted.

First, a tourniquet can be used to attain a bloodless field. There are commercially available tourniquets made specifically for the finger, such as the T-Ring™ (http://pmedcorp.com/). This can allow you to locate a specific area of bleeding and then attempt hemorrhage control of a specific vessel. Academic Life in Emergency Medicine has a blog posting (http://www.aliem.com/trick-of-trade-hemostasis-of-finger/) and video (https://www.youtube.com/watch?v=QuogjNsjOag) about a simple technique called a “glove tourniquet,” which can be done with a simple exam glove. Both the T-Ring or glove tourniquet can be employed to attain a bloodless field.

A simple blood pressure cuff can also be used to achieve hemorrhage control. The cuff can be inflated up to 250 mm Hg in adults and 100 – 200 mm Hg in children.3 This can help achieve a bloodless field to locate areas of bleeding that require treatment. Likewise, a commercial tourniquet, such as the Combat Tourniquet™ (C-A-T; http://combattourniquet.com/), can be used to allow a bloodless field.

After the field is bloodless, care should be taken to inspect all underlying structures, including tendons, to assess if repair is needed. Furthermore, any tourniquet can be loosened to help visualize bleeding areas or vessels. When a bleeding vessel or area is located, there are several methods to repair it and stop the bleeding.

Wounds can be anesthetized with an anesthetic such as lidocaine and epinephrine. Epinephrine works by constricting blood vessels through alpha receptor stimulation. If hemostasis is not achieved, primary closure of the wound may stop the bleeding. For wounds of the hand and fingers, 5-0 or 6-0 suture size should ideally be utilized for best wound healing.4 The fear of causing digital ischemia with epinephrine is greatly exaggerated and studies have not shown any significant adverse events from using epinephrine in hand or digital wound repair.6,7

There are other methods for wound hemostasis if the above techniques are inadequate or you want to avoid sutures. Topical tranexamic acid (TXA) has been demonstrated in multiple studies to be effective in hemorrhage control. An excellent Cochrane review article by Ker et al. evaluated these studies and their positive findings of topical TXA in the cessation bleeding.5 Most of the studies were conducted in the operating room for elective surgeries, but the data can be extrapolated towards bleeding from trauma, as surgical incisions are similar to local tissue trauma.

Another option is topical thrombin. Topical thrombin is a biologic agent that cleaves fibrin into fibrinogen which leads to hemostasis. There are many biologic brand name thrombin agents that are readily available. Thrombin has been proven to be effective for surgical hemostasis, and its use can be extrapolated to the ED for traumatic wounds.8

Through any combination of the above methods, hemostasis can be achieved readily.

Case Conclusion:

Using an exam glove, a finger tourniquet is placed on the patient, and luckily, the bleeding stops. The wound is repaired with sutures and lidocaine with epinephrine is used for analgesia. The patient is discharged without complications.

References / Further Reading

  1. Thai JN, Pacheco JA, Margolis DS, et al. Evidence-based Comprehensive Approach to Forearm Arterial Laceration. The western journal of emergency medicine. 2015;16(7):1127-1134.
  2. Sharif MA Wyatt MG. Vascular trauma. Surgery. 2012;30(8):5.
  3. Kragh JF, Jr., Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. The Journal of emergency medicine. 2011;41(6):590-597.
  4. Abraham MK, Oh JS. Recent Advances in Wound Care. Trauma Reports. 2010;11(4).
  5. Ker K, Beecher D, Roberts I. Topical application of tranexamic acid for the reduction of bleeding. The Cochrane database of systematic reviews. 2013;7:CD010562.
  6. Chowdhry S, Seidenstricker L, Cooney D, et al. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plastic and Reconstructive Surgery 2010; 126 (6): 2031-34.
  7. Firoz B, Davis N, Goldberg LH. Local anesthesia using buffered 0.5% lidocaine with 1:200,000 epinephrine for tumors of the digits treated with Mohs micrographic surgery. Journal of the American Academy of Dermatology 2009; 61 (4): 639-43.
  8. Lew WK, Weaver FA. Clinical use of topical thrombin as a surgical hemostat. Biologics. 2008;2(4):593-599.

Diagnostic accuracy of ankle x-rays: How often do we miss fractures? How can we improve?

Author: Jeremy Kim, MD (EM Resident Physician, Icahn School of Medicine at Mount Sinai) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) & Justin Bright, MD (@JBright2021)

 Clinical Scenario

A 25-year-old male presents with a left ankle injury while playing basketball. There is swelling and ecchymosis diffusely with tenderness at the tip of the lateral malleolus. Should an x-ray be performed?

Background

Traumatic ankle pain is a common presenting problem to emergency departments. While sprains are the most common injuries (most common = anterior talofibular ligament), the patient still needs to be assessed for fracture.1

Since its derivation and validation in 1992, the Ottawa ankle rules are the most frequently used clinical decision tool when considering to obtain ankle x-rays.2

ottawa-ankle

Ottawa ankle rules: Ankle X-rays if pain in the malleolar zone PLUS one of the following:

  1. Bony tenderness at “A”
  2. Bony tenderness at “B”
  3. Unable to bear weight both immediately and in the ED

How often are fractures missed?

When x-rays are ordered based on the Ottawa ankle rules, multiple studies have shown sensitivity at nearly 100% in adult populations while decreasing the number of x-rays ordered by 20-40%.3,4 Similar sensitivity results are seen in pediatric populations, with near 100% sensitivity when categorizing Salter-Harris Type I as clinically insignificant due to low complication rate.5

One of the original multi-center validation studies for Ottawa ankle rules in 1995 revealed a 0.5% fracture miss rate, mostly because providers misused the clinical decision rule or in one case had difficulty assessing the grossly swollen ankle.3 However, at a similar rate, patients who underwent imaging had the x-rays initially read as negative.

image2
Mortise view
image3
Lateral view

What is the sensitivity of ankle x-rays?

The initial radiographic evaluation of the ankle involves three views (lateral, AP, and mortise). The mortise view is taken in 15-20 degrees of internal rotation with x-ray beams projecting perpendicular to the intermalleolar line. In an effort to save time and resources, some institutions use a two-view approach (lateral PLUS either AP or mortise), but this has a sensitivity of only 85-98%.7,8 Overall, the diagnostic accuracy of ankle x-rays is unknown, but one study suggests that the incidence of occult fractures is about 1% and the degree of effusion correlated with the likelihood of occult fracture.9

In high-energy, poly-trauma, evaluation for ankle injuries may be more difficult due to the presence of distracting injuries or difficulty manipulating the extremity for adequate views on x-ray. In this scenario, when compared to multi-detector CT as a gold standard, sensitivity of x-rays can be as low as 87% for calcaneal fractures, 78% for talar fractures and 25-33% for midfoot fractures.10

Why do we miss fractures?

  • Inadequate physical exam (eg. palpating incorrect areas and misusing the Ottawa ankle rules or gross swelling making palpation difficult)
  • Unreliable patient (ie. altered, distracted, or intoxicated)
  • Misinterpreting x-rays
  • Occult fracture on x-rays, requiring further imaging

How can we improve?

  • Thorough physical exam
    • Palpate posterior edge of distal 6 cm of both lateral and medial malleoli
    • Assess for associated proximal fibular fracture (Maisonneuve fracture): palpate the proximal fibula
    • Assess for syndesmotic ligament injury. Squeeze test (squeeze at mid-calf causes pain just proximal to ankle) or external rotation of foot (with tibia stabilized, causes pain at level of syndesmosis)11
    • Assess for open fracture. Check for skin breakdown.
    • Neurovascular exam
  • Review any imaging you order! You have the advantage of having examined the patient and have additional localization clues to detect fractures.
  • Consider CT imaging if concerning mechanism or if needed for surgical considerations by orthopedic colleagues (eg. Pilon fracture)
  • Instruct patient to follow-up within 1 week if no improvement in pain/ability to walk. Repeat x-rays at that time may reveal fracture
  • Excellent resource on the approach to ankle x-rays: http://radiopaedia.org/articles/ankle-radiograph-an-approach

 

References / Further Reading

  1. Tintinalli’s Emergency Medicine Manual. 7th Ed. Chapter 175: Ankle and foot injuries.
  2. Stiell I et al. Implementation of the Ottawa ankle rules. JAMA. Mar 1994; 271(11):827-32.
  3. Stiell I et al, Multicentre Ankle Rule Study Group. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. BMJ. Sept 1995; 311:594-7.
  4. Bachmann LM et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: a systematic review. BMJ. Feb 2003; 326(7386): 417.
  5. Myers A, Canty K, Nelson T. Are the Ottawa ankle rules helpful in ruling out the need for x-ray examination in children? Arch Dis Child. 2005; 90:1309-11.
  6. Radiology masterclass: Trauma x-ray / Lower limb / ankle. <http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_lower_limb/ankle_fracture_x-ray.html#top_second_img>
  7. Brandser EA et al. Contribution of individual projects alone and in combination for radiographic detection of ankle fractures. Am J Roentgenol. Jun 2000; 174(6):1691-7.
  8. De Smet AA, et al. Are oblique views needed for trauma radiography of the distal extremities? Am J Roentgenol. 1999; 172(6):1561-5.
  9. Ho K et al. Using tomography to diagnose occult ankle fractures. Ann Emerg Med. May 1996; 27(5): 600-5.
  10. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. Am J Roentgenol. Sep 2004; 183(3):615-22.
  11. Busconi BD, Stevenson JH. Sports Medicine Consult: a problem-based approach to sports medicine for the primary care physician. Lippincott: 2009.
  12. Berbaum KS et al. Impact of clinical history on radiographic detection of fractures: a comparison of radiologists and orthopedists. Am J Roentgenol. 1989; 153(6):1221-4.

EM Cases: Occult Fractures and Dislocations

Originally published at EM Cases – Visit to listen to accompanying podcast . Reposted with permission.

Follow Dr. Anton Helman on twitter @EMCases

Occult-Fractures

 

Dr. Arun Sayal and Dr. Natalie Mamen discuss the key diagnostic considerations in commonly missed occult fractures and dislocations.  They review the indications and controversies for the use of Bone Scan, CT and MRI in occult fractures and dislocations and give you some great clinical pearls to use on your next shift.

Missed occult fractures and dislocations, in general, may result in significant morbidity for the patient and law suites for you. Six cases are presented in this episode, ranging from common scaphoid fractures to rarer dislocations. Dr. Sayal & Dr. Mamen answer questions such as:  Which fractures can mimic ankle sprains and how do you avoid missing them? What are the most reliable signs of scaphoid fracture? In which occult orthopaedic injuries should we anticipate limb threatening ischemia? Which is better to diagnose occult fractures – MRI or CT? Which calcaneus fractures require surgery and which ones can be managed conservatively? and many more……

Case 1 – Occult Hip Fracture

  • 67 y.o. woman with severe COPD on long-term steroids who fell from standing height
  • Ambulating well at current time, but with groin pain

Pearls:

  • Findings suspicious for hip fracture:
    • Triad of
        1. New inability to weight bear
        2. Hip pain on axial loading of leg
        3. Inability to straight leg raise are highly specific for hip fracture
    • Groin pain
    • Percussion test:
      • Percuss patella bilaterally while listening with stethoscope on symphysis pubis. Unilateral diminished sound (due to effusion) should increase suspicion.
    • Don’t forget hip injury can present as knee pain, especially in children and elderly
  • Pelvic ring and femoral neck fractures are mutually exclusive: In a study with >100 elderly patients unable to weight bear after a fall, no patient with a fracture of the femoral neck had an associated fracture of the pelvic ring or vice versa found on MRI.
  • Imaging choices in occult hip fracture:
    • CT scan: in general, very good at identifying fractures involving bone cortex. Most studies compare 4-slice CT vs MRI and show that MRI is far superior for identifying occult hip fractures. However, newer-generation CT scans (64-slice) may be as sensitive and specific for hip fractures compared to MRI, especially when 3D reconstructions are available (no studies to confirm this yet).
    • MRI: The gold standard. Allows better look at bone marrow (trabecular bone), but might overcall certain injuries that are not clinically relevant.
    • Bone scan: Very sensitive at 48-72hrs (24hrs for newer 3-phase array scans) but not specific and poor localization, and potential for complications while patient is bedridden waiting for scan (VTE, pneumonia, pressure ulcers, delays to surgery).
    • Ultrasound: May demonstrate effusion in occult hip fracture
      • A study from Israel had 100% sensitivity for identifying post-traumatic hip fracture, but not ready for ‘prime time’
      • Safran et al. J Ultrasound Med 2009; 28:1447–1452

A proposed algorithm for suspected occult hip fracture:

    • In young patients with high-energy trauma, a fracture in the cortex will likely be seen
      • If x-rays are negative but clinical suspicion is high, move on to CT scan
    • In elderly with low-energy trauma, occult fractures are less likely to involve cortex
      • If x-rays are negative but clinical suspicion is high, move on to MRI (preferred) or 64-slice CT if MRI not available

Reference: Lakshmanan et al. J Bone Joint Surg Br, Vol 89-B, Issue 10, 1344-1346www.ncbi.nlm.nih.gov/pubmed/17957075

Case 2 – Ankle Sprain Mimics

  • 18 y.o. woman landed “funny” while snowboarding and had immediate left ankle pain
  • Very swollen inferior and anterior to the tip of fibula, with tenderness over the anterior talofibular ligament (ATFL)
  • Ankle sprain mimics:
    1. Snowboarder’s fracture (lateral process of talus)
    2. Posterior talus process fracture
    3. Achilles tendon rupture
    4. Anterior process calcaneus fracture
    5. Talar dome fracture

In snowboarder’s fracture (see image below) the feet are fixed in dorsiflexion, and the anterior foot usually everts as the snowboarder lands (very different mechanism than classic inversion ankle sprain). The fibula impacts the lateral process of the talus causing a fracture.

    • Broden’s view (Mortise view) x-ray:
    • Foot in plantar flexion; lateral aspect of the talus better visualized The plantar talus should show a “symmetric V” in normal x-ray
      • An asymmetric “V sign” indicates a displaced fracture requiring surgery
    • When in doubt, place a posterior slab and make the patient non weight-bearing until follow-up

snowboarder's-fracture

Case 3 – Occult Knee Dislocation

  • 40 y.o. male in belted MVC (frontal collision at 80km/h)
  • Severe knee pain and tenderness and limited ROM, but no deformity

Pearls of occult knee dislocation:

    • 50% self-reduce before presenting to the ED, and with distracting injuries can be easily overlooked
    • Common mechanisms: pedestrian-vs-car, contact sports injuries and knee-to- dashboard mechanism
    • 1/3rd will have neurovascular injuries, with significant morbidity
  • Knee-to-dashboard DDx:
    • Posterior hip dislocation, tibial plateau fracture, patellar fracture, knee dislocation, posterior acetabular fracture
  • Physical exam:
    • Serial neurovascular exams:
      • Distal pedal pulses +/- Doppler assessment
      • if decreased sensation in peroneal nerve distribution, assume concomitant popliteal artery injury
    • Findings suspicious for occult knee dislocation:
      • 3 out of 4 knee ligament laxity (ACL, PCL, MCL, LCL)
  • Adjuncts:
    • Ankle-Brachial Index (ABI): >90% is reassuring, and can be monitored serially
    • CT-angiogram if suspicious of vascular damage, and consult vascular
  • Complications:
    • In patients with knee dislocation associated with vascular injury, 15% will develop ischemia when repair is delayed by > 8hrs

Case 4 – Occult Scaphoid Fracture

  • 10 y.o. boy with FOOSH and lone snuff box tenderness

Pearls of occult scaphoid fracture:

  • Epidemiology: Less likely in children < 15y.o., adults > 50 y.o., 15% of fractures will be occult on initial x-rays
  • Physical exam – 3 key maneuvers for scaphoid fracture:
      1. Palpation of snuff box with wrist ulnarly deviated
      2. axial loading of thumb with pain in the anatomical snuffbox
      3. palpation of volar aspect of scaphoid with wrist radially deviated
    • 3 of 3 gives 90% risk of scaphoid fracture (70% with 2 of 3)
  • X-ray imaging for suspected scaphoid fracture:
    • Order specific scaphoid views
    • Consider clenched fist view to splay carpals, especially if tenderness is more at the lunate bone
      • Might reveal a dynamic “Terry Thomas sign” (or “David Letterman” sign) (as the gap in their teeth similar to the gap between scaphoid and lunate) if >3mm between scaphoid and lunate consistent with a scapho-lunate ligament tear

    terry thomas sign

  • In negative x-ray with high clinical suspicion:
    • Immobilization with thumb spica splint is most commonly used
    • precise position of immobilization does not effect outcome
    • Other options: CT in ED, Bone Scan at 72hrs, MRI
    • must weigh time off work/sport if immobilize vs expense and radiation exposure of early advanced imaging
  • Follow-up:
    • Longer follow-up (10-14d) necessitates longer immobilization period, but allows for more time for the fracture to reveal itself compared to shorter period (7d)
    • many scaphoid fractures take up to 16 weeks to heal

Case 5 – Posterior Shoulder Dislocation

  • 56 y.o. male found down by wife, found to have glucose of 1 by EMS
  • Holding bilateral shoulders in internal rotation, and there is resistance to external rotation attempts

Pearls

  • Epidemiology
    • 2-3% of shoulder dislocations, 15% bilateral and often missed on first visit (50-80%!)
    • Associated with 3 Es: epilepsy, ethanol and electricity
    • Mechanism: axial force with shoulder internally rotated and abducted
  • Clinical findings:
    • Prominent coracoid, and humeral head posteriorly displaced (vs. squared shoulder of anterior dislocation)
    • Patients hold arm internally rotated, and reversed Hill-Sachs lesion (engagement of humeral head on posterior glenoid rim) often prevents external rotation
  • Diagnosis:
    • Axillary view on x-ray very useful, as well as the subtle “light bulb” sign on AP (loss of asymmetry of the humeral head created by greater tuberosity due to the internal rotation of the humerus – see image below)
  • Reduction of Posterior Shoulder Dislocation:
    1. Physician’s contralateral hand puts anterior pressure on the patient’s posterior humeral head (eg, left hand on right shoulder)
    2. Physician applies gentle longitudinal downward traction of patient’s arm
    3. Assistant externally rotates patient’s arm
  • Immobilization of Posterior Shoulder Dislocation:
    • Arm hanging in neutral position, with internal or external rotation (recent studies show external rotation may be better, but impractical)
    • Length in weeks: “8 minus decade of life, to max of 3”, maybe even shorter

For an excellent evidence-based review of posterior shoulder dislocations visit Brent Thoma’s Boring EM blog

Case 6 – Occult Calcaneus Fracture

  • 29y.o. male jumped from height while under the influence of crack cocaine
  • Tender to palpation L-spine and entire bilateral extremities, ankles and feet swollen, positive pulses
  • X-rays all normal lower extremities, but multiple L-spine compression fractures

Pearls: 

  • Fall from height onto feet:
    • Look for associated injuries: spinal injuries (esp. L-spine), contralateral calcaneal fracture, and ankle fractures
    • Calcaneal injuries have high morbidity with 20% of patients debilitated at 3yrs
  • Calcaneal fracture imaging:
    • Bohler’s angle on lateral view x-ray of foot measured between the line formed by posterior tuberosity of calcaneus apex to anterior process, and line formed by apex to anterior process (see image)
    • Normal is 20-40°, <20° suggestive of compression fracture of calcaneus
    • Harris view (axial view of calcaneus)
  • Management:
    • Usually needs CT scan to determine whether fracture is extra-articular (conservative management) or intra-articular (operative management)
    • Any displacement typically requires operative repair
    • ED management centres around minimizing soft tissue swellling and preventing fracture blisters and skin sloughing, with application of a bulky compressive dressing with a posterior splint, combined with elevation and icing

Open Fractures – Pearls and Pitfalls

Authors: Richard B. Moleno, DO, MS (@rbmoleno, EM Resident Physician, UTSW/Parkland Memorial Hospital) and Michael Venezia, DO, MPH (Orthopaedic Surgery Resident Physician, Largo Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

Screen Shot 2015-12-27 at 10.38.06 PM

Background

Open fractures are something ED physicians deal with quite frequently. They can range from a tiny break in the skin to limbs hanging by a small piece of skin and tissue. Some common mechanisms by which these injuries occur include falls, motor vehicle collisions, motor vehicle versus pedestrian, and crush injuries. A thorough physical exam should be performed on all of these patients, paying special attention to mechanism of injury, examining the wound to look for contamination, and confirming intact neurovascular status. Following the primary survey, make sure to complete the secondary survey so that additional injuries are not missed. Plain films should be obtained of all injured areas, and tetanus status should be updated if indicated.

Diagnoses that cannot be missed include vascular compromise and compartment syndrome. Compartment syndrome teachings classically recite the 5 P’s; however, these perform poorly when studied with inadequate sensitivities. The most important clinical exam finding in these patients is pain out of proportion and pain with passive stretch of the affected area. Decreased two point discrimination in the affected limb can be beneficial in evaluating for compartment syndrome.  A compartment pressure >30 mm Hg raises concern, and a pressure within 30 mm Hg of the diastolic blood pressure (ΔP) indicates compartment syndrome. Immediate involvement of an orthopaedic or general surgeon should be obtained so that fasciotomies can be performed. If vascular compromise is suspected, an ankle-brachial index (ABI) should be obtained.  A normal ABI is > 0.9.  Abnormal ABIs with suspected vascular compromise should be investigated with angiography.

Traditional teachings state that all patients should receive antibiotics and go to the operating room within 6 hours for washout and/or open reduction internal fixation (ORIF).1 To better understand treatment principles, we will first review how to classify open fractures.

Screen Shot 2015-12-27 at 10.38.21 PM

Classification

The most well known grading system for open fractures is the Gustilo-Anderson classification. It is based on the size of the skin defect and degree of soft tissue injury and contamination.2

Type I – Laceration is <1cm and there is no evidence of contamination

Type II – Laceration >1cm with moderate contamination

Type III

  • A: severe soft tissue injury but adequate bone coverage, highly contaminated (5-10%)
  • B: severe soft tissue injury, massive contamination, bone is exposed, and there is periosteal stripping (10-50%)
  • C: same as IIIB but with an arterial injury requiring repair (25-50%)

You can also calculate the Mangled Extremity Severity Score (MESS) score, which estimates viability of an extremity after trauma to determine need for salvage versus empiric amputation. Patients with a MESS ≥ 7 are likely to require amputation secondary to their limb trauma. It takes into account the following:

  • Extent of skeletal and soft-tissue damage
  • Extent and severity of limb ischemia
  • Associated shock
  • Age

 

Management

Initial management of all patients should start with the ABCs. Once you arrive at circulation, you should attempt to control hemorrhage by direct pressure or a tourniquet if the patient is in severe shock or with otherwise uncontrollable bleeding. You should resuscitate the patient and correct coagulopathies with crystalloids, packed red cells, and other blood products as needed.3

Reduction of grossly deformed fractures may be attempted in the Emergency Room, primarily for neurovascular compromise and comfort of the patient. All neurovascular-compromised patients require urgent reduction and further vascular workup. A patient with an ankle-brachial index of <0.9 should be evaluated with angiography.5

All grossly contaminated wounds should be irrigated, covered in sterile saline soaked permeable dressing, and splinted. Further management is to be made at this time with consultation and imaging. Preoperative cultures have been shown to be ineffective in the quest for definitive organisms and are not recommended.

Tetanus prophylaxis and antibiotics should be initiated in all patients, with tetanus based on their prior status and antibiotics as described below.

Screen Shot 2015-12-27 at 10.38.43 PM

Antibiotics

Open fractures are significant injuries that can lead to many complications if not treated appropriately and in a timely manner. The current literature shows that in the absence of timely antibiotics, infection can occur in up to 24% of cases.5 Studies have shown that delay in antibiotic administration >3 hours can result in an increased infection rate (7.4% versus 4.7%).6

Recommended antibiotics vary based on grading of the open fracture. Gustilo-Anderson types I-II should be treated with a first generation cephalosporin, with the addition of an aminoglycoside for type III fractures. If there is any concern for clostridial exposure (e.g. farm injuries), the recommendation is to add Penicillin G. Of note, this classification is truly an intraoperative grading that cannot be accurately diagnosed in the trauma bay until the severity of soft tissue wounds has been assessed during debridement. Most institutions will err on the side of caution if there is any question of it being a higher energy fracture and cover it empirically as a type III. Currently there is no data to support prophylactic coverage of MRSA, despite the notable increase in prevalence in recent years.7

The latest literature available demonstrates that timing to antibiotic coverage is the most important determining factor in infection with regards to open fractures. Although the currently used algorithm for antibiotic regimen has not changed in many years, there have been no studies that show any alternative regimens with higher success and lower infection rates.

 

Ultimate Disposition and Treatment

All these patients need orthopedic surgery consultation. The current treatment algorithm is very controversial, as prior recommendations were for urgent irrigation and debridement within 6 hours of injury. Recent studies have shown no documented increased risk of infection with delayed irrigation and debridement beyond 6 hours.8 The current recommendation is that most grade I-II open fractures should be treated as urgent and not delayed beyond 24 hours if medically possible. General consensus for type III injuries is to provide an urgent irrigation and debridement as soon as possible. Intraoperative guidelines for irrigation have been shown to be most effective using normal saline, with the amount based on the grade of the fracture: 3L for type I, 6L for type II, and 9L for type III.9

 

References/Further Reading

  1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453-8.
  2. Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures. Lippincott Williams & Wilkins; 2010.
  3. Tintinalli J, Stapczynski J, Ma OJ et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition. McGraw-Hill; 2010.
  4. Available at: http://lifeinthefastlane.com/ortho-library/open-fractures/. Accessed October 31, 2015.
  5. Melvin, J. Stuart, et al. “Open tibial shaft fractures: I. Evaluation and initial wound management.” Journal of the American Academy of Orthopaedic Surgeons1 (2010): 10-19.
  6. Patzakis MJ, Wilkins J: Factors influencing infection rate in openfracture wounds. Clin Orthop 1989;243:36–40.
  7. Saveli, Carla C., et al. “The role of prophylactic antibiotics in open fractures in an era of community-acquired methicillin-resistant Staphylococcus aureus.” Orthopedics (Online)8 (2011): 611.
  8. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: The impact of the time factor on infection rates.Injury 2007; 38:879-889.
  9. http://www.ncbi.nlm.nih.gov/pubmed/25159242