Tag Archives: orthopedic

Scaphoid Fracture – Can PoCUS disrupt the traditional ‘splint and wait’ pathway?

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PoCUS Fellow Pearl

Dr. Melanie Leclerc, CCFP-EM

MSK PoCUS Fellow

Dalhousie University Department of Emergency Medicine

 

Reviewed & Edited by Dr David Lewis (@e_med_doc)

All case histories are illustrative and not based on any individual

 

Case:

A 37 year old, right hand dominant, carpenter presents to your local ED with a complaint of right wrist pain. He was on a step-stool and lost his balance earlier today. He fell landing on his outstretched arm and had an acute-onset of radial-sided wrist pain. He denies any other injury. There are no neurologic complaints.

On exam, there is no visible deformity. The skin is closed and there is some swelling noted. The patient is tender over the anatomic snuff box as well as volarly over the scaphoid. There is pain noted with axial loading of the thumb. There is no other tenderness. ROM is within normal limits. The limb is distally neurovascularly intact.

X-rays are normal.

An occult scaphoid fracture is suspected. At this institution, patients with suspected occult scaphoid fracture are placed in a thumb spica splint and referred to the local hand surgeon to be seen in ~10-14 days for repeat assessment and X-ray.

Can Point of Care Ultrasound change this traditional “splint and wait” patient pathway?

 

Background:

Scaphoid fracture is a common presentation to the Emergency Department accounting for approximately 15% of all wrist injuries and 70% of carpal fractures. Up to 30% of the time, radiographs at initial presentation appear normal making fracture a commonly missed injury for Emergency physicians. A failure to recognize this injury can lead to chronic pain and functional impairment for patients. Particularly, fractures of the proximal pole (most distant to the blood supply) can lead to avascular necrosis (AVN) at high rates. Non-union can lead to scaphoid non-union advanced collapse (SNAC wrist) which can perpetuate further degenerative changes throughout the carpus. This can cause a significant impact on quality of life and occupation. Early detection of fracture could expedite fixation and possibly results in better outcomes. Further study in this area is needed.

 

Anatomy:

The scaphoid bone lies in the radial aspect of the proximal carpal row. It’s unique shape (“twisted peanut”), lends to easy recognition. It articulates proximally with the distal radius, distally with the trapezium, and on its’ ulnar aspect with the lunate to form the scapho-lunate interval. The blood supply to the scaphoid is unique in that the majority of it is retrograde. The dorsal carpal branch of the radial artery supplies the bone from distal to proximal. A small proportion of the blood supply originates at the proximal end. The boundary between the two supplies creates a “watershed” area prone to non-union and AVN.

 

Classification of Fractures:

Scaphoid fractures are classified by location. These regions are the proximal, middle and distal thirds which account for 20%, 75%, and 5% of the fractures respectively. The stability of fractures is determined by the displacement (>1mm) and angulation (scapholunate angle >60 and radiolunate angle >15). The Hebert Classification as endorsed by Traumapedia can be found below.

 

Traditional Imaging:

Imaging of these suspected injuries varies. Traditionally serial X-rays were used, but have been found to be poorly sensitive even several weeks after injury. Bone scan has also been used as an alternative due to it’s high sensitivity, but has poor specificity and provides no further information regarding the nature of the fracture. CT is relatively sensitive and specific and provides information for pre-operative planning. MRI is considered the gold standard, but is difficult to obtain in a timely manner in Canada.

Bäcker HC, Wu CH, Strauch RJ. Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures. J Wrist Surg. 2020 Feb;9(1):81-89. doi: 10.1055/s-0039-1693147. Epub 2019 Jul 21. PMID: 32025360; PMCID: PMC7000269.

 

PoCUS Technique:

  • Linear probe

  • Consider waterbath, gel standoff pad, or bag of IV fluid

  • Scan with the wrist ulnarly deviated

  • Scan in the longitudinal and transverse orientations of volar, lateral and dorsal aspects

  • Place the probe in longitudinal orientation dorsally over lister’s tubercle of the radius and scan distally until the scaphoid is visualized in the snuff box. Scan radial to ulnar.

  • Rotate to the transverse orientation and scan through proximal to distal

  • Volarly, in the transverse plane, identify the tendon of the flexor carpi radialis (this lies radial to the easily identifiable palmaris longus tendon on exam). The scaphoid is found deep to this. Scan proximal to distal.

  • Rotate to the longitudinal orientation and scan radial to ulnar

 

 

Video Demonstration:

 

 

Findings:

  • Cortical disruption

  • Periosteal elevation

  • Hematoma

 

The Evidence:

  • Early advanced imaging (CT or MRI) compared to initial 2 week immobilisation proved more cost effective and had better patient oriented outcomes (ie. missed work).(7)
  • A systematic review and meta analysis of moderate to high quality studies published in 2018 found that ultrasound had a mean sensitivity of ~89% and specificity of ~90% for detection of occult scaphoid fractures.(1)
  • Similar results were also reported by another systematic review in 2018.(8)
  • Pocus was shown to have a comparable sensitivity to CT for occult scaphoid in a systematic review published in 2020.(2)

 

Limitations:

  • Only useful if positive
  • Operator experience dependent
  • US probe and frequency dependant
  • Potential for false positives due to injury of nearby structure causing hematoma
  • Potential for false positives in context of arthritis or remote trauma

 

Bottom line:

  • Useful if positive
  • Still need definitive test to further delineate fracture (ie: for operative planning)
  • Could expedite CT
  • Could expedite specialist follow-up
  • May improve ER physician diagnostic certainty
  • May improve patient trust and compliance with splinting
  • Further study is needed

 

Case Conclusion:

Scaphoid cortical disruption was visualized using PoCUS. After discussion with the hand surgeon, a CT Scan of the wrist was performed which confirmed a minimally displaced waste fracture of the scaphoid. The patient was splinted and seen the next day in clinic for discussion regarding operative management.

 

Further Review:

 

 

 

References

  1. Ali M, Ali M, Mohamed A, Mannan S, Fallahi F. The role of ultrasonography in the diagnosis of occult scaphoid fractures J Ultrason 2018; 18: 325–331.
  2. Bäcker HC, Wu CH, Strauch RJ. Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures. J Wrist Surg. 2020 Feb;9(1):81-89.
  3. Bakur A. Jamjoom, Tim R.C. Davis. Why scaphoid fractures are missed. A review of 52 medical negligence cases, Injury, Volume 50, Issue 7, 2019, Pages 1306-1308.
  4. Carpenter CR et al. Adult Scaphoid Fracture. Acad Emerg Med 2014; 21(2): 101-121.
  5. Gibney B, Smith B, Moughty A, Kavanagh EC, Hynes D and MacMahon PJ American Journal of Roentgenology 2019 213:5, 1117-1123
  1. Jenkins PJ, Slade K, Huntley JS, Robinson CM. A comparative analysis of the accuracy, diagnostic uncertainty and cost of imaging modalities in suspected scaphoid fractures. Injury. 2008;39:768–774.
  2. Karl, John W. MD, MPH1; Swart, Eric MD1; Strauch, Robert J. MD1 Diagnosis of Occult Scaphoid Fractures, The Journal of Bone and Joint Surgery: November 18, 2015 – Volume 97 – Issue 22 – p 1860-1868.
  3. Kwee, R.M., Kwee, T.C. Ultrasound for diagnosing radiographically occult scaphoid fracture. Skeletal Radiol 47, 1205–1212 (2018).
  4. Malahias MA, Nikolaou VS, Chytas D, Kaseta MK, Babis GC. Accuracy and Interobserver and Intraobserver Reliability of Ultrasound in the Early Diagnosis of Occult Scaphoid Fractures: Diagnostic Criteria and a Way of Interpretation. Journal of Surgical Orthopaedic Advances. 2019 ;28(1):1-9.
  5. Mallee WH, Wang J, Poolman RW, Kloen P, Maas M, de Vet HCW, Doornberg JN. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database of Systematic Reviews 2015, Issue 6.
  6. Mallee, W.H., Mellema, J.J., Guitton, T.G. et al. 6-week radiographs unsuitable for diagnosis of suspected scaphoid fractures. Arch Orthop Trauma Surg 136, 771–778 (2016).
  7. Melville, D., Jacobson, J.A., Haase, S. et al. Ultrasound of displaced ulnar collateral ligament tears of the thumb: the Stener lesion revisited. Skeletal Radiol 42, 667–673 (2013).
  8. Meyer, P., Lintingre, P.-F., Pesquer, L., Poussange, N., Silvestre, A., & Dallaudiere, B. (2018). Imaging of Wrist Injuries: A Standardized US Examination in Daily Practice. Journal of the Belgian Society of Radiology, 102(1), 9.
  9. Mohomad et al. 2019. Accuracy of the common practice of doing X-rays after two weeks in detecting scaphoid fractures. A retrospective cohort study. Hong Kong Journal of Orthopaedic Research 2019; 2(1): 01-06.
  10. Neubauer J, Benndorf M, Ehritt-Braun C, et al. Comparison of the diagnostic accuracy of cone beam computed tomography and radiography for scaphoid fractures. Sci Rep 2018; 8:3906.
  11. Ravikant Jain, Nikhil Jain, Tanveer Sheikh, Charanjeet Yadav. 2018. Early scaphoid fractures are better diagnosed with ultrasonography than X-rays: A prospective study over 114 patients, Chinese Journal of Traumatology, Volume 21, Issue 4, Pages 206-210.
  12. Senall, JA, Failla, JM, Bouffard, JL. 2004. Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. J Hand Surg Am, 29:400-405.
  13. https://essr.org/content-essr/uploads/2016/10/wrist.pdf
  14. http://www.bonetalks.com/scaphoid
  15. https://radiopaedia.org/articles/scaphoid-fracture
  16. https://sketchymedicine.com/2014/07/scaphoid-bone-anatomy-and-fractures/
  17. https://radiopaedia.org/cases/scaphoid-fracture-11?lang=gb
  18. https://www.orthobullets.com/hand/6034/scaphoid-fracture
  19. https://meeting.handsurgery.org/abstracts/2018/EP15.cgi
  20. https://www.researchgate.net/figure/Bone-scintigraphy-patient-C-of-the-hands-the-patient-with-a-scaphoid-fracture-on-the_fig4_50399987
  21. https://www.youtube.com/watch?v=7pCXiRQMRKo&t=5s&ab_channel=UltrasoundPod
  22. https://litfl.com/terry-thomas-sign
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Fascia Iliaca Nerve Block

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Hip Broke? Hip Block. Use of the fascia iliaca nerve block for analgesia in hip fractures.

Resident Clinical Pearl (RCP) July 2020

Luke Edgar, BScH MD

PGY1 Family Medicine Integrated Emergency Medicine

Dalhousie Saint John

 

Reviewed by Dr. David Lewis

Background

Hip fractures are a common and painful injury diagnosed and treated in the emergency department, with elderly patients representing the majority of cases. Advanced age, comorbidities, and increased sensitivity to side effects from systemic analgesia all pose challenges to achieving adequate pain control.1,2 Additionally, NSAID use in the elderly is frequently contraindicated due renal, cardiac, and gastrointestinal comorbidities as well as drug interactions. In elderly patients, both undertreated pain and opioid analgesia can precipitate delirium.3

Regional nerve blocks for the indication of hip and femoral neck fractures have been shown to reduce pain and need for IV opiates.1 Contraindications include infection over the injection site, patient refusal, and allergy to local anesthetic. Additionally, patients at risk for compartment syndrome (such as those with a concomitant ipsilateral tibial plateau fracture) should be selected cautiously as they may not reliably have increased pain after block.4

There are three main techniques described for regional nerve blocks to provide analgesia for hip and femoral neck fractures.1

  • Fascia Iliaca Nerve Block: Insert a needle through the fascia lata and fascia iliaca, to infiltrate dilute local anesthetic into the fascial compartment which diffuses to block the femoral, lateral femoral cutaneous, and obturator nerves.
  • Femoral Nerve Block: At the level of the femoral triangle, infiltrate local anesthetic around the femoral nerve.
  • 3-in-1 Femoral Nerve Block: At the level of the femoral triangle, infiltrate local anesthetic around the femoral nerve while applying pressure distal to the injection site, encouraging local anesthetic to track superiorly to block the femoral, lateral femoral cutaneous, and obturator nerves.

Figure 1. Lower limb peripheral nerve sensory distribution.5 Circled in red are the nerves blocked using the fascia iliaca technique. Cutaneous distribution of the obturator nerve is not depicted but consists of a small area on the proximal medial thigh.

Technique

Table 1. Supplies and equipment for performing a fascia iliaca nerve block

Table 2. Steps to complete a fascia iliaca nerve block6

Table 3. One person technique  – Steps to complete a fascia iliaca nerve block

Figure 2. Video demonstrating the sonoanatomy of the right femoral triangle. From lateral to medial, femoral nerve, artery and vein (NAVel), labeled with yellow, red, and blue arrows, respectively.

Figure 3. Sonoanatomy of the right femoral triangle, transverse view for the fascia iliaca nerve block.

Figure 4. Sonoanatomy of the right femoral triangle demonstrating ultrasound-guided needle placement using an in-plane technique. Note two pops should be felt as the needle crossed the two fascial planes.

 

For a visual review of these steps and ultrasonographic landmarks, please see the following videos and webpage by EM Ottawa, 5 Minute Sono, and NYSORA:

EM Ottawa

5 Minute Sono

NYSORA

Ultrasound-Guided Fascia Iliaca Block

 

Complications

Serious complications of this procedure are rare, but present.

  • Local Anesthetic Systemic Toxicity (LAST) as a complication of inadvertent intravenous or intra arterial anesthetic injection.7
    1. Incidence is 8 – 30 in 100,0008
    2. Manifestations typically occur within 20 minutes of injection (although onset can be as late as >1 hr) and are primarily neurologic and cardiovascular in nature. Neurologic effects include perioral numbness, metallic taste, mental status change or anxiety, muscle twitches and visual changes, followed by loss of consciousness and seizure. Cardiovascular effects are hypertension and tachycardia followed by arrhythmias, bradycardia, hypotension and cardiac arrest.
    3. Treatment is with intravenous lipid emulsion therapy (Intralipid 20%) 1.5 mL/kg bolus followed by 0.25 mL/kg/min, Maximum total dose 12 mL/kg. Contact your poison control centre if you suspect LAST.
    4. Prior to performing a fascia iliaca block, confirm availability of intralipid within your department to be used in the event of this rare complication.
  • Femoral Nerve injury secondary to intrafascicular injection
    1. Incidence 2-30/100,0008
    2. Most symptoms of paresthesias, numbness, and weakness resolved after several months in the event of this complication8
  • Other complications include infection, nerve block failure, injury secondary to numbness/weakness of limb, and allergy to the local anesthetic.

 

Take Home Message

Femoral nerve blocks are recommended for hip and femoral fractures to reduce pain and opioid analgesia requirements. Given that poor pain control and opioid analgesia are risk factors for delirium in elderly patients, hip blocks may also reduce rates of delirium (further study required). A fascia iliaca block with 20 cc of 0.5% bupivacaine is a well described technique with very few contraindications. To reduce the risk of complications, these blocks should be completed using sterile technique under ultrasound guidance with the help of an assistant. Hip broke? Hip block.

 

 

References

  • Ritcey B, Pageau P, Woo M, Perry J. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM 2015;18(1):37-47.
  • Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency department crowding on the management of pain in older adults with hip fractures. J Am Geriatr Soc. 2006;54(2):270-5.
  • Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58(1):76-81.
  • Erak M, EM Ottawa Grand Rounds. Ah, that feels better! The Use of Nerve Blocks in the ED. 2016. https://emottawablog.com/2016/10/ah-that-feels-better-the-use-of-nerve-blocks-in-the-ed/. Accessed July 25, 2020.
  • Gray H. 1918. Nerve supply of the leg. Anatomy of the Human Body. Image retrieved from https://en.wikipedia.org/wiki/Nerve_supply_of_the_human_leg. Accessed July 24, 2020
  • Woo M. How to perform the Ultrasound Guided Femoral Nerve Block. EM Ottawa. 2018. https://youtu.be/_OugsPA4rxY Accessed July 25, 2020.
  • Warren L, Pak A. Local anesthetic systemic toxicity. UpToDate. 2019. uptodate.com/contents/local-anesthetic-systemic-toxicity. Accessed July 25, 2019.
  • Helman, A, Morgenstern, J, Spiegel, R, Lee, J. Regional Nerve Blocks for Hip Fractures. Emergency Medicine Cases. August, 2018. https://emergencymedicinecases.com/regional-nerve-blocks-hip-fractures/. Accessed July 25, 2020.
  • Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J of Ultrasound in Emergency Medicine 2012;43(4):692-697.

 

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Ultrasound guided hematoma block for distal radius fractures

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Ultrasound guided hematoma block for distal radius fractures

Resident Clinical Pearl (RCP) September 2019

Robert Dunfield – PGY1 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. Kavish Chandra

 

Mr. JG, a 34 year old male snowboarder, presents to your busy emergency department after a snowboarding accident. He suffered a fall onto his left outstretched hand after hitting a jump that was approximately one foot high. Radiograph shows a closed distal radius fracture with significant  dorsal angulation.

Figure courtesy of Dr Pir Abdul Ahad Aziz, Radiopaedia.org, rID: 47908

Tonight is a busy shift and you’re working in a resource-limited department with very few staff. In speaking with the patient, he’s nervous about the prospect of procedural sedation and would prefer to not be “put to sleep to fix [his] wrist”. Luckily, your department recently purchased an ultrasound machine and the patient consents to a hematoma block prior to reduction.

What is a hematoma?

Following the initial impact that causes a fracture, the initial stage of bone healing involves a hematoma formation. In simple terms, a hematoma is a large blood clot that collects at the fracture site. Hematomas are rich in vascular supply and are the site of eventual soft callus formation; they’re the result of bony blood supply being disrupted at the site of the defect

 

Stages in Fracture Repair. The healing of a bone fracture follows a series of progressive steps: (a) A fracture hematoma forms. (b) Internal and external calli form. (c) Cartilage of the calli is replaced by trabecular bone. (d) Remodeling occurs.1

 

Hematoma blocks as an alternative to procedural sedation?

Compared to procedural sedation, hematoma blocks can be done safely when procedural sedation is not an option or is contraindicated. They also offer an alternative option for analgesia when an emergency department is busy and resources are lacking to safely perform procedural sedation.2

  • Procedural sedation requires a period of recovery after the procedure, hematoma blocks do not necessitate traditional post procedural recovery.3
  • Evidence that suggests post-procedure analgesia is similar in hematoma block patients compared to patients who undergo procedural sedation.4
  • Hematoma blocks are a form of local anaesthesia that can be used when reducing simple, closed distal long bone fractures, like the distal radius fracture in this case. They can also be performed to provide analgesia for nondisplaced fractures.2

 

Prior to the advent of bedside ultrasound, hematoma blocks were dependent on external anatomy landmarking, using “step-off” site of the bony deformity as the landmark for injection. This can be difficult, however, in fractures where swelling, habitus, or deformity can distort the anatomy of the hematoma.2 This is where ultrasound plays a role in identifying the deformity and therefore improves the precision of hematoma injection.

Contraindications to hematoma block include allergy to the anaesthetic being used, if the fracture is open, if there is cellulitis overlying the site of the fracture, and/or if there is a neurovascular deficit on exam of the affected limb.5

 

Performing  a hematoma block under US guidance

Mr. JG requires reduction of his distal radius fracture. Due to his uneasiness with procedural sedation, combined with the busy and resource-strained nature of your emergency department, a hematoma block under ultrasound guidance is performed.

 

  • Gain informed consent: The initial step in performing a hematoma block is similar to all medical procedures in that the patient undergoing the procedure should be informed of the risks associated with hematoma blocks and fracture reduction. These include, although rare, compartment syndrome, local anesthetic toxicity, acute carpal tunnel syndrome, and temporary paralysis of the upper limb6. Remember that maximum dose of lidocaine without epinephrine is 5mg/kg.
  • Reassess the neurovascular integrity of the limb: Prior to injecting the hematoma block, ensure you have confirmed neurovascular integrity of that limb.
  • Grab the supplies you’ll need: The following list is limited to the supplies needed for your hematoma block and does not include the supplies needed for fracture reduction and casting.
    • Ultrasound machine with a linear transducer probe
    • Tegaderm transparent film
    • Sterile lubricating jelly
    • Sterile skin marker
    • Sterile gloves
    • Chlorhexidine swabs x 3
    • 16G Needle (for drawing up analgesia)
    • 20G or 22G Needle (for injecting analgesia)
    • 10mL syringe
    • 1% lidocaine (approximately 10mL)
  • Landmark the hematoma using point of care ultrasound: Trace the bone’s cortex on the dorsal aspect of the forearm from the proximal aspect of the fracture towards the fracture site until you reach an interruption in the cortex of the radius (see below). Mark that site with your marker for injection.

Left: Sagittal image of left radius outlining an interruption in the radial cortex at the site of the hematoma. Right: Same image, edited to identify anatomy.8 Edited by Robert Dunfield PGY1-Dalhousie

  • Clean the site and prepare other materials: Clean the site with chlorhexidine swabs x 3. Allow it to dry while you prepare the remainder of your equipment. Draw up your 10mL of 1% lidocaine with the 16G needle and then change the needle to your 20 or 22G needle. A longer needle may be needed to reach the site of the hematoma.
  • Prepare your transducer: Clean your linear transducer and then put on your sterile gloves. With the help of an assistant apply the sterile tegaderm film to the liner transducer and place sterile lubricating jelly on the probe.
  • Insert needle under US guidance: Using the probe to visualize the site of the hematoma, simultaneously begin to insert the needle in a caudal fashion toward the hematoma, visualizing the needle in the long axis. Use the ultrasound image to follow the needle’s insertion.

Injection of hematoma block under ultrasound guidance.6 Modified by Robert Dunfield PGY1-Dalhousie

  • Inject the lidocaine: Inject 10mL of 1% lidocaine into the hematoma.
  • Give time for analgesia to take effect: Allow 5 to 10 minutes of time to allow the analgesia to take full effect, then reassess neurovascular integrity.
  • Proceed with the reduction.
  • Added note: It’s possible for distal radius fractures to have an associated ulnar styloid fracture, which will require repeating the same steps as described above, only at the side of the ulnar fracture.

 

Summary:

    • Hematoma blocks under ultrasound guidance can be done on certain distal long bone fractures that lack any contraindications
    • Use the ultrasound probe to trace the bone’s cortex and identify the site of the hematoma, then insert the needle into the hematoma under the guidance of your linear transducer.
    • Confirm needle placement into the hematoma by aspiration and inject 10mL of 1% lidocaine into the hematoma.
    • Allow 5 to 10 minutes of analgesia onset before reducing the fracture.
    • Remember to reassess the limb’s neurovascular integrity before and after the procedure.

Copyedited by Kavish Chandra

 

Resources:

  1. Rice University. Anatomy and Physiology. Chapter 6.5: Bone Repair. https://opentextbc.ca/anatomyandphysiology/chapter/6-5-fractures-bone-repair. Accessed: September 03, 2019. Last updated: unknown.
  2. Gottlieb M and Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. Journal of Emergency Medicine. 2015;48(3):310-312.
  3. Alerhand S and Koyfman A. Ultrasound-Guided Hematoma Block. emDocs.net. http://www.emdocs.net/ultrasound-guided-hematoma-block/. Accessed: September 07, 2019. Last updated: December 21, 2014.
  4. Fathi M, Moezzi M, Abbasi S, Farsi D, Zare MA, Hafezimoghadam P. Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial. Emerg Med J. 2015;32:474-477.
  5. Reichman EF. Emergency Medicine Procedures. Second Edition. 2013:Chapter 125 Hematoma Blocks.
  6. Emiley P, Schreier S, Pryor P. Hematoma Blocks for Reduction of Distal Radius Fractures. Emergency Physicians Monthly. https://epmonthly.com/article/hematoma-blocks-for-reduction-of-distal-radius-fractures/. Accessed: September 14, 2019. Last updated: February 2017.
  7. Beaty JH and Kasser JR. Rockwood and Wilkins’ Fractures in Children. Chapter 3: Pain Relief and Related Concerns in Children’s Fractures, pp61-63.
  8. EM Cases and POCUS Toronto. POCUS Cases 4: Distal Radius Fracture. https://emergencymedicinecases.com/video/pocus-cases-4-distal-radius-fracture/. Accessed: September 14, 2019. Last updated: July 2018.
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MSK Injuries – X-Ray Pitfalls

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ED Rounds – June 2019

Dr. George Xidos

  • 10-20% of ED visits are for musculoskeletal injuries
  • Unfortunately, most common cause of litigation in Canada
  • Pitfalls include missed injuries, failure to recognise
  • significance of injuries, inadequate initial management, and
  • failure to refer to appropriate specialists in a timely manner

Fundamentals:

● Complete hx : mechanism of injury, age, risk factors

● Accurate physical (e.g. there is more to the wrist exam than checking the “snuffbox” and more to the ankle exam than included in the Ottawa rules)

● X ray studies:

○ 20% of MSk litigation involves failure to order X rays in the first place

○ Ensure adequate quality of films (e.g. proper lateral views of hands, wrists and elbows) and order additional views if required

○ Be acutely aware of common locations for occult fractures: scaphoid, radial head, hip, talar dome, tibial plateau etc.

○ Most commonly missed fracture is the second fracture.

 

Download (PDF, 53KB)

 

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A Crushing Case – Compartment Syndrome

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A Crushing Case – Compartment Syndrome

Resident Clinical Pearl (RCP) March 2019

Mark McGraw– PGY1 FMEM Dalhousie University, Saint John NB

Reviewed and edited by Renee Amiro and Dr. David Lewis.

Case Part 1

Its early afternoon during your ortho call shift and you get a call from emerge staff saying that they have two patients coming with potentially significant injuries when a piece of equipment rolled over during transport. EMS has informed them that one has a broken ankle. When you arrive to the ED he tells you they are just getting the patient’s pain under control and ordering x-rays.

You head to the room to see the patient, a large burly 35 y/o with an obviously deformed R ankle. His exam is otherwise unremarkable at this time, he has good cap refill to the toes, sensation to the web space, dorsum/plantar and medial/lateral surfaces of the foot is intact and he is able to move his toes. On palpation his lower leg compartments are firm but not hard. An x-ray is done at bedside and shows a Weber Type B fracture of the fibula. His pain seems to be increasing as you speak with him and he has no significant past medical history. He tells you he was loading a piece of equipment when it got away from them and rolled over his leg pinning him momentarily, so he was hanging off a piece of equipment by the leg. Your exam is limited by pain and you ask the nurse if she can give the patient some more pain medication and you’ll return as soon as you see the other patient.

Clinical Pearl: Compartment Syndrome

Compartment Syndrome occurs when the pressure within a muscle compartment exceeds the pressure needed to adequately perfuse tissue. It is considered a true orthopedic emergency and delays in diagnosis and treatment can result in the loss of a patient’s life or limb

Anatomy/Pathophysiology

-Muscle compartments are bound by bone or fascia, two restrictive tissues that create a relatively fixed volume compartment with a very limited ability to compensate for any increase in fluid volume.

-When a traumatic or pathological process results in increased fluid within a muscle compartment the pressure within the compartment increases. This increase in pressure results in reduced arteriovenous pressure gradient (reduced arterial pressure and increased venous pressure) that impairs tissue perfusion within the compartment.

  • As the pressure rises within the compartment capillary flow declines resulting in an enhanced local blood vessel permeability which further increases compartment pressures. If pressures continue to rise tissue ischemia and necrosis will develop.
  • Time for tissue necrosis to occur will vary from patient to patient it can occur in as little as 3 hours and most literature suggests that a fasciotomy must be performed within 4 hours of the onset of ACS to prevent irreversible damage.2

 

 

Signs and Symptoms

Compartment syndrome is a true orthopedic emergency and early recognition of its clinical signs is critical in preventing irreversible tissue damage, rhabdomyolysis, and limb loss.

  1. Pain out of proportion
  2. Pain with passive stretch
  3. Paresthesia
  4. Pain at rest
  5. Paresis

 

  • Severe pain out of proportion to the examination and pain with passive stretching are the first symptoms of ACS to occur. While the early signs are 97% specific for ACS they are only 19% sensitive in the absence of other findings.

  • The combination of pain with passive stretch, paresthesia, and pain with rest has been reported to be 93% sensitive and if paresis is present the sensitivity increases to 98%1. Unfortunately, paraesthesia and paresis are late findings of ACS and delaying the diagnosis until they are present can result in unacceptable delays in treatment. Once a motor nerve deficit has occurred patients will rarely recover function after fasciotomy.

Diagnosis 1

  • Normal compartment pressures are between 8 and 10mmHg in adults and 10-15mmHg in children.
  • 30mmHg is diagnostic for compartment syndrome and should prompt an orthopedic referral when combined with clinical symptoms of compartment syndrome.
  • An alternative is to calculate a differential compartment pressure for an individual patient as factors such as hypertension, peripheral vascular disease and patient medication can cause a large variance in individuals compartment pressures.
  • Differential compartment pressure is calculated by the diastolic blood pressure minus the intra-compartmental pressure if this is under 20mHg then fasciotomy is indicated.
  • If the patient is alert and able to elevate the affected limb, serial examinations over a two-hour period may prevent unnecessary fasciotomies. This should be done in consultation with your orthopedic colleagues.

 

Measuring compartment pressures

Devise: dedicated compartment manometer (Stryker Intra-Compartmental Pressure Monitor) or by using IV tubing and an ART line transducer attached to a long needle.

Who is most at risk of developing compartment syndrome?

  1. Fractures represent 70% of all cases5.
  2. Fractures of the tibial diaphysis account for 40% of all cases in North America.
  3. Open fractures of the tibia are still high risk for compartment syndrome because the opening is insufficient to relieve the compartment pressure associated with the fracture.6

Management of potential compartment syndrome in the ED

  1. Supplemental oxygen if indicated
  2. Remove all cast material, clothing or wraps around the limb
  3. Elevate the limb to the level of the hear
  4. Apply ice to the affected limb if the compartment syndrome is secondary to trauma.
  5. Definitive treatment is a surgical fasciotomy.

 

Case Part 2

You return to see the patient and nursing staff tell you they are unable to get the patients pain under control despite significant amounts of narcotics.

The examination of the lower leg is repeated and the compartments of the leg feel the same however the patient is unable to move his toe. He reports significant pain on passive flexion and extension of the great toe. You call your staff to inform her of the change in the patient and that you are concerned about compartment syndrome and she requests compartment pressure measurements using the Stryker Kit. The senior resident performs the compartment pressure measurements with you and you record pressures of 14, 14 and 25mmHg.

In discussion with the staff you decide to leave the leg on a posterior slab unwrapped, at the level of the heart, and with ice applied 20 on 20 off and perform serial examinations. The serial examinations are unremarkable and the patients pain becomes manageable. The patient is brought to the OR approximately 5 hours later for ORIF of his distal fibula. Compartment pressures are repeated in the OR and were 12, 10, 32 mmHg. An ORIF is performed and you perform serially examinations on the patient q1h overnight. The patient is discharged the following day

Case Follow Up

The patient had significant leg pain on discharge and subsequently presented to the ED on POD#7 for significant leg swelling. Ultrasound was performed to rule out DVT and the patient was discharged for follow up in clinic. He did not go on to develop any further complications.

 

Bottom Line

Compartment syndrome is an important not to miss diagnosis. It should be considered in any hard to control limb pain, especially when associated with fracture.

 

References

  1. 1.Duckworth, A. D., & McQueen, M. M. (2017). The Diagnosis of Acute Compartment Syndrome: A Critical Analysis Review. JBJS Reviews, 5(12), e1. https://doi.org/10.2106/JBJS.RVW.17.00016
  2. Long, B., Koyfman, A., & Rdms, M. G. (2019). Clinical Review. Journal of Emergency Medicine, (December 2018), 1–12. https://doi.org/10.1016/j.jemermed.2018.12.021
  3. McQueen, M. M., & Court-Brown, C. M. (1996). Compartment monitoring in tibial fractures. The pressure threshold for decompression. The Journal of Bone and Joint Surgery. British Volume, 78(1), 99–104.
  4. McQueen, M. M., Duckworth, A. D., Aitken, S. A., Sharma, R. A., & Court-Brown, C. M. (2015). Predictors of Compartment Syndrome After Tibial Fracture. Journal of Orthopaedic Trauma, 29(10), 451–455. https://doi.org/10.1097/BOT.0000000000000347
  5. Stella, M., Santolini, E., Sanguineti, F., Felli, L., Vicenti, G., Bizzoca, D., & Santolini, F. (2019). Aetiology of trauma-related acute compartment syndrome of the leg : A systematic review. Injury, (2018). https://doi.org/10.1016/j.injury.2019.01.047
  6. Strohm, P. C., & Su, N. P. (2004). Acute compartment syndrome of the limb, 1221–1227. https://doi.org/10.1016/j.injury.2004.04.009
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EM Reflections – December 2018

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Thanks to Dr. Joanna Middleton for leading the discussions this month

Edited by Dr David Lewis 

Dr. Middleton’s Tips:

  1. Lower extremity fractures that require reduction – consider posterior slab with a stirrup rather than a circumferential cast.  
  2. 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.
  3. 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.
  4. 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.
  5. Episodes of hypotension in trauma patients should trigger a re-evaluation of a patient and bleeding should always be considered.
  6. Cross table lateral can help if you are unsure if the hip is out of joint.
  7. 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.

Application of BK Backslab SplintDownload

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

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EM Reflections – January 2018

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Thanks to Dr Joanna Middleton for leading the discussion this month and providing these tips and references.

Edited by Dr David Lewis 

 

  1. Occult Fractures of the Upper Limb

  2. Door to Needle/Balloon Times

  3. Mycotic Aneurysms

  4. CME Quiz

Occult Fractures of the Upper Limb

In patients (particularly the elderly)who present with upper limb pain following a fall or other trauma, be careful not to miss an occult fracture. Localization may be impaired by dementia, acute confusion or other soft tissue injuries. Commonly missed fractures of the upper limb include:

  • Clavicle fracture
  • Supracondylar fracture
  • Radial Head/Neck fracture
  • Buckle fractures of the radius/ulna
  • Scaphoid fracture
  • Carpal dislocation
  • Any impacted fracture

Impacted fractures of the humeral neck may still allow some shoulder joint movement. Pain can be referred to the elbow (just as some hip injuries have pain referred to the knee).

When a fracture is strongly suspected ensure that the entire bone is included in the radiograph. If localization is impaired consider obtaining radiographs of the entire limb, starting with the most symptomatic area. Also follow the old mantra – “include the joint above and below” when ordering radiographs for suspected fracture.

Commonly missed fractures in the ED

Misses and Errors in Upper Limb Trauma Radiographs

 

Strategies to reduce door to ballon time

Delays in door to balloon time for the treatment of STEMI have been shown to increase mortality.

 

 

JACC 2006 Click on here for full text

 

BMJ 2009 – Click here for full text

 

This evidence has led to an international effort to establish strategies that can reduce door to balloon times

This rural program in the USA published their strategy for reducing door to ballon times below 90mins over a 4 year period. https://www.sciencedirect.com/science/article/pii/S0735109710043810. Their strategies included the following:

2005
• Community hospital physicians visited by interventional cardiologist with recommendations to:

∘ Perform ECG within 10 min of arrival for chest pain patients

∘ Communicate with PCI center physicians via dedicated STEMI hotline

∘ Treat and triage patients without consulting with primary physicians

∘ Give aspirin 325 mg chewed, metoprolol 5 mg IV × 3 when not contraindicated, heparin 70 U/kg bolus without infusion, sublingual nitroglycerin or optional topical nitropaste without routine intravenous infusion, and clopidogrel 600 mg PO

∘ Eliminate intravenous infusions of heparin and nitroglycerin.

2006
• Nurse coordinator hired to oversee program and communicate with emergency department personnel at all referring hospitals.

• Recommendations for medications listed above were formally endorsed for all STEMI patients.

• Formal next-day feedback provided to referring hospitals, including diagnostic and treatment intervals and patient outcomes.

• Quarterly “report cards” issued to each referring hospital emergency department.

2007
• PCI hospital emergency physicians directly activated the interventional team (instead of discussing it first with the interventional cardiologist on call).

• A group page was implemented for simultaneous notification of all members of the interventional team and catheterization laboratory staff of an incoming STEMI patient.
ECG = electrocardiogram; IV = intravenous; PCI = percutaneous coronary intervention; PO = by mouth; STEMI = ST-segment elevation myocardial infarction.

 

However recent commentaries have highlighted the pitfall of this metric

 

The Challenges and Pitfalls of Door-to-Balloon Time as a Performance Metric

https://www.medscape.com/viewarticle/537538

 

and further evidence has shown no improvement in mortality despite reducing door to balloon times. However, it should be noted that these centres were already achieving < 90 min.

http://www.nejm.org/doi/full/10.1056/NEJMoa1208200

This may be a result of multiple confounding factors:

total ischemic time may be a more important clinical variable than door-to-balloon time

it has been suggested that the association between door-to-balloon time and mortality may be affected by an “immigration bias” – healthier patients are likely to have shorter door-to-balloon times than are sicker patients with more complex conditions, for whom treatment may be delayed because of the time needed for medical stabilization

 

Whilst strategies to ever reduce door to balloon times may not be the correct focus to reduce overall mortality, it is clear that the presence of significant delays (>90mins) is associated with increased mortality.

 

Mycotic Aneurysms

Any kind of infected aneurysm, regardless of its pathogenesis. Such aneurysms may result from bacteremia and embolization of infectious material, which cause superinfection of a diseased and roughened atherosclerotic surface.

 

Aneurysmal degeneration of the arterial wall as a result of infection that may be due to bacteremia or septic embolization 

  • Symptoms:  pulsatile mass, bruit, fever
  • Risk Factors:  arterial injury, infection, atherosclerosis, IV drug use
  • #1 cause = staph, #2 = salmonella

Download (PDF, 1.14MB)

 

 

CME QUIZ

EM Reflections - Jan 18 - CME Quiz

EM Reflections – Jan 18 – CME Quiz

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Elb-‘ow’! Does my patient with an elbow injury require an x-ray?

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Elb-‘ow’! Does my patient with an elbow injury require an x-ray?

Resident Clinical Pearl (RCP) – December 2017

Allyson Cornelis R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Why should you care?

Trauma to the upper extremity can result in injury to the various components of the elbow joint and associated anatomical structures. Important neurovascular structures associated with the elbow joint are the brachial artery, radial artery, ulnar artery, median, radial, and ulnar nerve¹. Elbow injuries causing fracture increase the likelihood of neurovascular damage. If fractures are missed, this may result in further damage and complications including prolonged functional limitations to the joint, nerve damage causing distal functional decline, and potential vascular compromise to the limb more distal to the injury.

Tintinalli’s Comprehensive Guide to Emergency Medicine.2

Functionally, the elbow has two primary movements: flexion/extension, and supination/pronation¹.

Fractures at the elbow may occur at the distal humerus (supracondylar, epicondylar, condylar, trochlea, and capitellum fractures), the proximal ulna (coronoid process, olecranon fractures), and the proximal radius (radial head fractures)¹. Of these, radial head fractures are the most common. Common mechanisms for these injuries include falling on an outstretched hand and direct blows to the elbow.

 

How do I know if my patient requires an X-ray for their elbow pain?

There is a rule for that! The elbow extension rule!

Simply stated: If a patient with an elbow injury is able to fully extend their elbow, they are unlikely to have a fracture and do not require imaging³.

The “how to”:

  1. Provide analgesia to patients
  2. Have patient seated with supinated arms
  3. Have patient flex shoulder to 90 degrees
  4. Ask patient to fully extend elbow to either the point of locking or the same level of extension as contralateral side

Of course, no rule is perfect, and the patient should be reassessed later if the following occur

  • Can no longer fully straighten elbow
  • Pain is getting worse
  • Cannot use their arm as previous

The patient should have imaging at the current visit if:

  • Patient is unreliable for follow up
  • If olecranon fracture is possible

 

The evidence³

Of 1740 patients presenting within 72 hours of traumatic elbow injury, 31% had a fracture³. In adults with the ability to fully extend their elbow following trauma, there was a 2% chance they had a fracture. In adults unable to fully extend their elbow following trauma, there was a 48% chance they had a fracture.

In children able to fully extend their elbow following trauma, there was a 4% chance they have a fracture, and in children unable to fully extend their elbow following trauma, there was a 43% chance they had a fracture³.

 

Bottom Line: Patients presenting with elbow trauma and an inability to extend their elbow fully require radiography. Those able to fully extend their elbow do not require imaging unless follow up is unreliable, an olecranon fracture is suspected. Caution should be exercised with assessment in children.

 

Addendum: 

Consider adding PoCUS to your clinical assessment of elbow injuries. Elbow joint effusions are very easily visualized. The presence of a joint effusion in a patient with elbow pain following trauma is a significant finding and warrants further investigation with radiography. Some studies have shown PoCUS to be more sensitive than x-ray in diagnosing occult elbow fractures.

 

Download (PDF, 2.87MB)

 

References

(1) Appleboam, A., Reuben, AD., Benger, JR., Beech, F., Dutson, J., Haig, S., Lloyd, G. (2008). Elbow extension test to rule out elbow fracture: Multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. British Medical Journal, 337:a2428.

(2) Tintinalli, JE. (2016). Cardiogenic Shock (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 1816-1817). New York: McGraw-Hill.

(3) Sheehan, SE., Dyer, GS., Sodickson, AD., Ketankumar, IP., Khurana, B. (2013). Traumatic elbow injuries: What the orthopedic surgeon wants to know. Radiographics, 33(3), 869-884.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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