Thanks to Dr. Joanna Middleton for leading the discussions this month
Edited by Dr David Lewis
Dr. Middleton’s Tips:
- Lower extremity fractures that require reduction – consider posterior slab with a stirrup rather than a circumferential cast.
- We have a C-arm…use it! Sending grossly deformed bony injuries to the X-ray department for imaging can result in long delays to reduction/treatment.
- Handover is high risk and is a recurrent theme in EM reflections…it shouldn’t occur as a hallway conversation in passing. Be sure to communicate what the handover physician needs to do and as the handover physician you should document completion of the task.
- Pelvic fractures can occur with low mechanism injuries, particularly in the elderly. Pelvic fractures differ from hip fractures – it raises the severity of injury and should warrant a lower threshold for CT. Pelvic fractures should have a full trauma evaluation.
- Episodes of hypotension in trauma patients should trigger a re-evaluation of a patient and bleeding should always be considered.
- Cross table lateral can help if you are unsure if the hip is out of joint.
- If you are taking over a sick patient in handover, be sure to document on the chart.
Tibial Shaft Fractures
High risk for compartment syndrome
Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°. Admission to the hospital may also be necessary to control pain and to monitor closely for compartment syndrome.
Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow early swelling to diminish. The cast should extend from the mid thigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling
Tibial shaft fractures, even distal ones, are a different animal to ankle fractures. Forces involved in injury are much greater. There is no universally accepted classification for tibial shaft fractures. Describe the following:
- Location (prox, middle, distal)
- Configuration (transverse, spiral, comminuted)
- Displacement
- Angulation
- Length
- Rotation
- Open/Closed
Ankle Classification
Type A. Fracture of the fibula distal to syndesmosis. An oblique medial malleolus fracture may also be present.
Type B. Fracture of the fibula at the level of the syndesmosis. These fractures may be stable or unstable, based upon the presence of deltoid ligament rupture or medial malleolus fracture.
Type C. Fracture of the fibula proximal to syndesmosis. These unstable fractures are generally associated with syndesmosis injuries, and may include medial malleolus fracture or deltoid ligament
Full Cast vs Splint
There is little evidence favouring splint vs cast in acute lower extremity unstable fractures. Splints are generally recommended in both reviews and textbooks, but these recommendations are not referenced. However the general consensus seems to be favouring Splint over Cast – to avoid the risk of swelling and subsequent compartment syndrome.
Roberts: Clinical Procedures in Emergency Medicine, 5th ed.
Emergency clinicians have virtually abandoned the use of circumferential casts in favor of premade commercial immobilizing devices or splints made from plaster of Paris or fiberglass. The impetus for this change is primarily related to the complications occasionally associated with circumferential casts, liability issues, and ease of application brought about by new technology. In most instances, properly applied splints provide short-term immobilization equal to that of casts while allowing for continued swelling, thus reducing the risk of ischemic injury.
Acetabular Fractures vs Hip Fractures
Hip fractures are usually low impact pathological fractures and rarely associated with hemorrhage. Acetabular fracture is a PELVIC # and they bleed……
Bleeding from bone and retroperitoneal venous plexus makes up 90%, the other 10% is arterial
Patients with acetabular fractures have a high incidence of associated injuries and a full trauma assessment should be performed.
Geriatric Acetabular Fractures
- Often low-energy trauma in osteoporotic bone
- 1/3 have associated injuries
- 33% one year mortality rate
- Judet views helpful
See this post for an approach to interpreting Pelvic X-Rays:
http://www.tamingthesru.com/blog/diagnostics/pelvic-xrays
