by Dejvid Ahmetović and Gregor Prosen
Introduction
Most of the orthopedic injuries can be predicted considering the chief complaint, the age of the patient and the mechanism of the injury itself. Additionally, a careful physical examination and the patient’s history can often predict radiographic findings with great accuracy. If an injury is suspected by clinical examination but cannot be completely confirmed by evaluating the radiograph, the patient should be treated as if the injury is present and discharged with detailed instructions on how to look out for any additional signs of neurovascular complications, compressions, and cast care.
Injuries to the musculoskeletal apparatus include one or more of the following structures: bone, joints, ligaments, tendons and in some cases vasculature and nerves.
Simple definitions of the injuries to the musculoskeletal system include the following:
Fracture: A disruption of bone tissue, which may be caused by the application of a force that exceeds the strength of the bone tissue itself, repetitive stress to the bone tissue, or invasive processes that weakens the bone structure and integrity.
Dislocation: Complete disruption of a joint, whereby articular surfaces are forced from their normal position, which immobilizes the joint temporarily. In the case of a subluxation, there is still a partial contact of the articular surfaces.
Fractures
Orthopedic injuries commonly result from accidents and often involve otherwise healthy individuals, especially in the younger population. Accurate diagnosis and treatment are of great importance both economically and medically.
Most fractures result from excessive force applied to otherwise healthy bone tissue, resulting in disruption of the bone cortex. Disruption may occur from a variety of forces, including a direct blow, axial loading, bending forces, torque forces and combinations of these.
All fractures are either simple or multifragmentary (communited). A simple fracture (spiral, oblique or transverse), is a single circumferential disruption of any part of the diaphysis, metaphysis or articular surface. A multifragmentary fracture (communited) is any fracture with one or more completely separated fragments, which can be further classified as either wedge or complex. A wedge fracture consists of fragments that, after reduction, main fragments still have some contact between themselves; in a complex fracture, however, one or more intermediate fragments and main fragments are no longer in contact after reduction.
Description of Common Fractures
Pathologic fractures: A type of injury that results from a relatively small force applied to otherwise diseased or weakened bone, which in normal circumstances would not disrupt the cortex. Examples of such types of injuries are fractures through metastatic lesions, fractures through benign bone cyst and vertebral compression fractures in individuals with advanced osteoporosis.
Stress fractures: These types of fractures involve ‘fatigued’ bone tissue that was exposed to repetitive forces. The bone and supportive tissue did not have enough time to adequately accommodate such forces. A common example is the fracture of the metatarsal shaft in unconditioned foot soldiers and athletes. It is known as ‘march fracture.’
Salter-Harris fractures: Fractures involving the physis and cartilaginous epiphyseal plate near the ends of the long bones in still growing children and adolescents. Damage to the growth plate during growth may destroy part or all of its ability to produce new bone, thus preventing elongation of the bone, which may lead to anatomical and functional deformities.
Conveniently, the Salter-Harris fracture types can be memorized by the mnemonic SALTR.
S – (slipped), fracture plane passes all the way through the growth plate.
A – (above), Fracture passes through most of the growth plate and up to the metaphysis.
L – (lower), A fracture that passes through the growth plate and extends down through the epiphysis.
T – (through, transverse or together), A fracture passing directly through metaphysis, growth plate and epiphysis.
R – (rammed, ruined), An uncommon crushing type of injury that does not displace the growth plate but damages it by direct compression.
Open fractures: An open fracture is a fracture associated with overlying soft tissue injury, causing an open communication between the fracture or dislocation and the environment.
Reduction
Reduction of fractures includes many options, some of which are appropriate for one type of injury and some for another. The reduction can be either anatomical or non-anatomical.
Non-anatomical reduction in children is used for extra-articular fractures. Because of the remodeling potential in children, most deviations and anatomical positions will be corrected spontaneously, but only if no rotation is present. In adults, for example, fractures of the humeral shaft, deviations, and non-anatomical positions are well tolerated both functionally and cosmetically. The same applies to femoral and tibial shaft fractures when length, rotation, and axis remain the same.
Anatomical reduction in children is indicated in the case of some epiphyseal fractures, especially in those that are intra-articular because if the reduction is not perfect, the gap will be filled with callus, which can consequently cause premature closure of the growth plate. In intraarticular fractures in adults, the reduction must be anatomical, or it could lead to joint incongruity and arthrosis.
Treatment Options
General steps in fracture treatment are reduction, immobilization, and rehabilitation.
Conservative treatment involves either functional treatment or closed immobilization with or without any closed reduction. It is indicated in non-displaced fractures and when a certain degree of displacement is acceptable. Examples include clavicular, scapular and rib fractures, most stable vertebral types of fractures and pelvic fractures, also when the pelvis is stable, most extra-articular fractures in children because of their remodeling potential, and any extra-articular fractures when the anatomical position can be reached by closed reduction and maintained by closed external immobilization.
Surgical treatment involves open or closed reduction of the fracture and open or closed fixation of the bone defect. Open reduction requires surgical intervention for alignment of the fracture fragments; however, in closed reduction, the fracture is reduced by manual manipulation of the affected area. There is also a difference between internal and external fixation. The term internal fixation itself suggests that the immobilizing implant is under the skin (bone surface or intramedullary), and external fixation presents in the case when most of the fixation material is outside the skin. (With this method, the risk of infection of the fracture is minimal. It is mostly used in severe open fractures.)
Generally, the indications for surgical treatment are open fractures, displaced intra-articular fractures, avulsion fractures and all femoral shaft fractures.
Reductions of Selected Fractures
Any standard reduction procedure should include these steps
- Confirming fracture with imaging if there is no neurovascular compromise and immediate reduction is needed
- Defining the need of reduction procedure
- Explaining the procedure to the patient and getting his/her consent for reduction and sedation and analgesia. You may also prefer to use hematoma or regional blocks.
- Prepare the team and the equipment. Some fracture reductions may need more than one person if you are not using special traction devices for the reduction purpose. Prepare the post-reduction splinting/casting equipment as discussed in the Splinting / Casting chapter.
- Properly place the patient and injured extremity.
- Properly position yourself and other team members.
- Axial traction, rotation, or angulation maneuvers may be necessary for the different type of fractures. Therefore, apply proper technique accordingly.
- After the reduction, please make sure the reduction is acceptable. Therefore, you can use imaging for the confirmation.
- Stabilize the extremity as recommended in the Splinting / Casting chapter.
- If you are going to discharge the patient do not forget to give discharge instructions and arrange follow up with orthopedic clinic.
Fracture of the middle phalanx
Image shows comminuted fracture of the middle phalanx of 2nd finger.
The mechanisms;
- direct force caused by fall,
- blow from a heavy object,
- twisting force.
Pain, swelling, typical angulation because of extensor tendon are typical presentation.
Treatment is conservative in case of proper reduction. However often surgical fixation required. In general, simple axial traction is enough to align the fractured phalanx. However, keeping the fractured parts in an acceptable alignment can be difficult. Therefore, immediate splinting/casting required.
Boxer’s fracture
It is a fracture of the neck of the 4th. or 5th metacarpal. Image shows 5th metacarpal neck fracture. Swelling, pain and obvious deformity are seen in the presentation. Striking a clenched fist into an immovable object is the most common mechanism.
Treatment is conservative for acceptable angulation (30° for 5th metacarpal) after reduction, surgical with severe displacement. The reduction requires different specific maneuvers, please watch sample videos.
Colles’ fracture
Fracture of the distal radius, with dorsal displacement and volar angulation.
Swelling and reduced movement and characteristic clinical deformity named ‘dinner fork deformity’ are seen in the presentation. It is the most common wrist fracture in the elderly. Fall on an outstretched hand is the primary mechanism of injury.
Treatment options are conservative treatment with marginally displaced fractures and surgical (open reduction internal fixation (ORIF), external fixation) with severe displacement and unstable reduction.
Nightstick fracture
It is a fracture of the shaft of either radius or ulna or both.
Deformity and pain are prominent in the presentation. The name of the fracture derived from citizen trying to defend against baton or nightstick, offering forearm. Caused by direct force, blow or impact.
Treatment is the conservative/closed reduction in stable and only slightly displaced fractures. Long arm cast with elbow 90°. The surgical option is ORIF with plate fixation in unstable fractures.
Fracture of the femoral shaft
The figure shows a complex segmental fracture of the shaft.
Swelling, deformity, loss of function, pain, external rotation are presentation findings.
The mechanism is a direct or axial force of high energy. The reduction with axial traction should be applied in order to decrease pain, hemorrhage, and anatomical alignment. After the reduction, traction splint should be placed. The definitive treatment is surgical (ORIF) with plate or nail.
To learn how to apply Hare Traction Splint, please watch video.
Dislocations
Any standard reduction procedure should include these steps
-
- Confirming dislocation with imaging if there is no neurovascular compromise and immediate reduction is needed
- Defining the need for reduction procedure
- Explaining the procedure to the patient and getting his/her consent for reduction and sedation and analgesia. You may also prefer to use the intraarticular anesthetic agent.
- Prepare the team and the equipment. Many dislocation reductions may need more than one person if you are not using special traction devices for the reduction purpose. Prepare the post-reduction splinting/casting/sling equipment as discussed in the Splinting / Casting chapter.
- Properly place the patient and injured extremity.
- Properly position yourself and other team members.
- Axial traction, rotation, or angulation maneuvers may be necessary for the different type of dislocations. Therefore, apply proper technique accordingly.
- After the reduction, please make sure the joint is in normal anatomy. Therefore, you can use imaging for the confirmation.
- Stabilize the extremity as recommended in the Splinting / Casting chapter.
- If you are going to discharge the patient do not forget to give discharge instructions and arrange a follow up with the orthopedic clinic.
Reductions of Selected Dislocations
Dislocation of the interphalangeal joints of the fingers
The image shows a fracture and subluxation at the distal and fracture and dislocation at the proximal phalangeal joint.
Dislocations of the PIP joint are a common hand injury, as opposed to DIP dislocation, which is rare, because of the firm attachments of the skin and surrounding tissue to the bone.
Pain, deformity are two main characteristics at the presentation.
Axial loading and hyperextension cause the dislocation. Dislocations are usually dorsal.
Longitudinal traction and hyperextension with applying dorsal pressure to the base of the dislocated phalanx usually reduce the dislocation.
Shoulder dislocation
The images show loss of shoulder curve on the left, and X-ray of the same patient with anterior shoulder dislocation and severe Hill Sacks deformity (cortical depression in the posterolateral head of the humerus) + fracture.
Anterior glenohumeral dislocation, the most common type of shoulder dislocation. Pain and swelling are common, and normal rounded contour of the shoulder is lost. The patient is unable to move, supported with healthy arm.
The mechanism is generally a fall on the hand when in the externally rotated position. It is common in age 18-25, mostly due to sport or motorbike injury.
The majority of the cases are successfully reduced with simple maneuvers (conservative reduction). Traction and external rotation-elevation, scapular rotation, Cunningham are the most popular techniques. However, there are many other successful methods. Please do not use the Hippocrates and Kocher techniques because of their high complication rate. If the reduction is unsuccessful, it can be done under sedation or even in general anesthesia in some cases.
Hip dislocation
The images show posterior hip dislocation.
In approximately 95% femoral head is dislocated posteriorly.
In the posterior dislocation, the leg position is in flexion, adduction and internal rotation.
In the anterior dislocation, the leg is in extension, abduction and external rotation.
High-energy trauma with the flexed knee (e.g., dashboard injury).
Conservative reduction is necessary, if unsuccessful, reoccurring or any type of acetabular injury, surgical treatment is required.
References and Further Reading
- Boer PGd, Morgan SJ, Werken Cvd. Handbook : orthopaedic trauma care. Stuttgart; New York: Thieme; 2009.
- Gaillard F. Salter-Harris fractures | Radiology Reference Article | Radiopaedia.org. 2016; http://radiopaedia.org/articles/salter-harris-fractures. Accessed May 2, 2016.
- Henry K, Hugh H. Pelvic fractures | Radiology Reference Article | Radiopaedia.org. 2016; http://radiopaedia.org/articles/pelvic-fractures. Accessed May 5, 2016.
- Holmes EJ, Misra RR, ebrary Inc. A-Z of emergency radiology. A-Z series. Cambridge, UK: Greenwich Medical Media,; 2004.
- Luijkx T, Schubert R. Three column concept of spinal fractures | Radiology Reference Article | Radiopaedia.org. 2016; http://radiopaedia.org/articles/three-column-concept-of-spinal-fractures. Accessed May 4, 2016.
- Rosen P, Marx JA, Hockberger RS, et al. Rosen’s emergency medicine : concepts and clinical practice. Vol Volume I. Eighth edition. ed. Philadelphia: Elsevier/Saunders; 2014.
- Tintinalli JE, Stapczynski JS, Ma OJ, Cline D, Meckler GD, Yealy DM. Tintinalli’s emergency medicine : a comprehensive study guide. Eight edition. ed. New York: McGraw-Hill Education; 2016.