Orthopedic

Podcast 506: Seymour Fracture

Contributor:  Don Stader, MD

Educational Pearls:

  • Seymour fracture is an eponym for a Salter-Harris I/II fracture of the distal phalanx of the finger or toe in children, associated with a nailbed injury
  • These may present and subtle as a subungal hematoma with a fracture on x-ray but carry a significant risk of complications
  • While in adults a hammer-finger deformity indicates an avulsion injury of the extensor tendon, in children it can indicate disruption of the growth plate. This is coupled with disruption of the proximal nail bed. 
  • Because these fractures affect the growth plate, they can lead to arrest of the growth plate or chronic osteomyelitis
  • These injuries require orthopedic consultation for possible debridement and fixation

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast # 498: Ortho Tips

Author: Susan Ryan, DO

Educational Pearls:

  • General orthopedic principles:
    • Examine above and below the injury
    • Document neurovascular status
    • X-ray imaging typically requires three different views
  • Fracture description should include name the bone, location of fracture, degree of displacement, and if it is closed or open
  • Osgood-Schlatter (tibia) and Sever’s (calcaneus) disease are apophyseal injuries caused by ligaments that are “stronger” than the bones they attach to
  • When looking for scaphoid injuries, get extra (turned) views of the wrist. Remember that the scaphoid has a reverse blood flow and is prone to avascular necrosis
  • Acute carpal tunnel syndrome can occur in forearm fractures. Again, don’t forget your neuro exam.
  • Distal radial-ulnar joint (DRUJ) injuries are caused by tears in the ligaments that stabilize the wrist. They cause chronic pain with pronation and supination.
  • Posterior effusions in the elbow in the 90 degree view nearly always indicate a fracture
  • Lisfranc injuries are commonly missed, especially if the mechanism is perceived as low energy. Look for the “fleck sign”, which is an avulsion fracture at the base of 2nd metatarsal
  • Syndesmotic injuries of the ankle (a high ankle sprain) can be identified through the squeeze test
  • Knee dislocations are neurovascular emergencies

Podcast # 495: Trauma in the Elderly 

Author: Rachel Brady, MD

Educational Pearls:

  • Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury
  • Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs.
  • Image elderly patients with head injury aggressively since they are at high risk of intracranial bleeds
  • Be sure to ask about anticoagulation use. Up to 15% of asymptomatic head injury patients  on warfarin will have intracranial bleeds on CT.
  • Be on the lookout for unstable C-spine injuries such as type II odontoid fractures
  • Central cord syndrome is a possibility with any neck extension injury
  • Rib fractures are common, with mortality increasing greatly with more than 2 ribs involved
  • The elderly are more prone to musculoskeletal injuries due to loss of bone density
  • Always discuss goals of care with these patients

References

Rathlev NK, Medzon R, Lowery D, Pollack C, Bracken M, Barest G, Wolfson AB, Hoffman JR, Mower WR. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med. 2006 Mar;13(3):302-7. doi: 10.1197/j.aem.2005.10.015. PubMed PMID: 16514123.

Keller JM, Sciadini MF, Sinclair E, O’Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012 Sep;26(9):e161-5. doi: 10.1097/BOT.0b013e3182324460. PubMed PMID: 22377505.

Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma.2000 Jun;48(6):1040-6; discussion 1046-7. doi: 10.1097/00005373-200006000-00007. PubMed PMID: 10866248.

Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, Joseph B. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014 Mar;76(3):894-901. doi: 10.1097/TA.0b013e3182ab0763. Review. PubMed PMID: 24553567.

Brooks SE, Peetz AB. Evidence-Based Care of Geriatric Trauma Patients. Surg Clin North Am. 2017 Oct;97(5):1157-1174. doi: 10.1016/j.suc.2017.06.006. Review. PubMed PMID: 28958363.

Podcast # 435 : UCL Injury

Author: Ryan Circh, MD

Educational Pearls:

  • Ulnar collateral ligament injury is often called gamekeeper’s thumb or skier’s thumb
  • Can results from traumatic deviating the thumb radially (abduction)
  • Poor rabbits
  • Have a low threshold for referral to hand surgery for follow up – treatment for minor injuries can be conservative but more severe require surgery to preserve function
  • This injury should be placed in a thumb spica splint
  • Radiographs are often negative unless an avulsion fracture is present

Editor’s note: to test for UCL injuries, I like this.

References:

Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015 Jan;34(1):117-26. doi: 10.1016/j.csm.2014.09.004. Epub 2014 Oct 11. Review. PubMed PMID: 25455399.

Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014 Feb;6(1):1-7. doi: 10.1111/os.12084. Review. PubMed PMID: 24590986.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast #403: Meniscus Lock

Author: Mark Hinton, MD

Educational Pearls:

 

  • Meniscus lock can occur with a tear leading to inability to extend the knee
  • Treatment can include an intra-articular joint block followed by straightening
  • Medial meniscus injuries are more common

 

References:

Allum RL, Jones JR. The locked knee. Injury. 1986 Jul;17(4):256-8. PubMed PMID: 3770920.

Critchley IJ, Bracey DJ. The acutely locked knee–is a manipulation worth while? Injury. 1985 Jan;16(4):281-3. PubMed PMID: 3967919.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast #382: Shoulder Separations

Author:  Ryan Circh, MD

Educational Pearls:

  • A “shoulder separation” is when the clavicle separates from the scapula – also referred to as an acromio-clavicular (AC) separation
  • Diagnosis is clinical: pain over AC joint, pain with adduction, and difficulty raising harm past horizontal
  • Early range of motion can be critical for recovery

References:

Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med. 1998 Jan-Feb;26(1):137-44. Review. PubMed PMID: 9474415.

Monica J, Vredenburgh Z, Korsh J, Gatt C. Acute Shoulder Injuries in Adults. Am Fam Physician. 2016 Jul 15;94(2):119-27. Review. PubMed PMID: 27419328.

Podcast #374: Iliac Artery Endofibrosis

Author:  Sue Chilton, MD

Educational Pearls:

  • An unusual cause of leg pain that can mimic sciatica/claudication
  • Predominantly occurring in high endurance athletes, particularly cyclists and runners
  • More common in men
  • Check supine ABIs 1 minute after activity in the ED: a value < 0.5 is 80% sensitive

 

References:

Mansour A, Murney S, Jordan K, Laperna L. Endofibrosis: an unusual cause of leg pain in an athlete. J Sports Med Phys Fitness. 2016 Jan-Feb;56(1-2):157-61. Epub 2015 Jul 3. PubMed PMID: 26140352.

Peach G, Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchliffe RJ. Endofibrosis and kinking of the iliac arteries in athletes: a systematic review. Eur J Vasc Endovasc Surg. 2012;43(2):208–17.

Podcast #317: Elbow Dislocation

Author: John Winkler, M.D.

Educational Pearls:

-Lower mechanisms of injury have a lower chance of an associated fracture or major ligament injury.

-One major concern is having a fracture fragment in the joint (can lead to chronic arthritic pain).

 -Evaluation should involve checking the neurovascular status of the arm and reduce the fracture as soon as possible. Immobilize arm in a sling and consult orthopedics if there is intra-articular involvement.

References:

https://orthoinfo.aaos.org/en/diseases–conditions/elbow-dislocation/

Mehta, JA; Bain, GI. (2004). Elbow dislocations in adults and children. ?Clinics in Sports Medicine.? 23(4):609-27.

Podcast #312: SCIWORA

Author: Sam Killian, M.D.

Educational Pearls:

  • Spinal cord injury without radiographic abnormality (SCIWORA) is a diagnosis defined as traumatic injury to spine with clinical sx of traumatic myelopathy (paraplegia, paresthesias, FND) without radiographic abnormalities.
  • Term was established in  1970’s before MRI and accounted for about 15% of injuries at the time (mainly children). Today SCIWORA accounts for about 10% of spinal injuries.
  • Belief is that injury causes subtle movement of the spinal cord from its natural position with resultant contusion or ischemia with subsequent deficits.
  • Treatment involves prolonged immobilization (up to 12 weeks).

 

References:

Walecki, J. (2014). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) ? Clinical and Radiological Aspects. Polish Journal of Radiology,79, 461-464. doi:10.12659/pjr.890944

Podcast #294: Rhabdomyolysis

Author: Michael Hunt, M.D.

Educational Pearls

  • Rhabdomyolysis is caused by the destruction of skeletal muscle that leads to the release of myoglobin, which causes renal failure. It presents with pain and weakness in the affected muscle, as well as dark urine.
  • Diagnosis is made with creatinine kinase levels
  • It can happen to extreme athletes after competition, but the most common presentation is in people who fall and are immobilized for long periods of time.
  • Other causes include burns, crush injuries, viral infections (influenza), bacterial infections (Legionella), and medications (statins in adults, propofol in kids)
  • Treatment is aggressive fluids

References: Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis ? an overview for clinicians. Critical Care. 2005;9(2):158-169. doi:10.1186/cc2978.

 

Stay up to date by
joining our mailing list!