Student Lecture Series

ORTHOPEDICESSENTIALS
ORTHOPEDIC ESSENTIALSIN
INEMERGENCY
EMERGENCYMEDICINE
MEDICINE

A GUIDE TO EMERGENCY
DEPARTMENT
ORTHOPEDICS
 JOE BEIRNE, DO, FACOEP, FACEP
JOE BEIRNE, DO, FACOEP,
ATTENDING PHYSICIAN
EMERGENCY DEPARTMENT
FACEP
MISSOURI BAPTIST MEDICAL CENTER
ST. LOUIS, MISSOURI

MEDICAL DIRECTOR-EMS PROGRAMS

ST. LOUIS COMMUNITY COLLEGE
ST. LOUIS, MISSOURI
 ORTHOPEDIC ESSENTIALS

• Orthopedic emergencies are one of the most common

presenting complaints in emergency medicine
• Basic knowledge of orthopedic injuries, fracture patterns and
splinting techniques is essential for proper management of
these cases
• Radiographic evaluation of fractures, and being able to
describe them to the orthopedic surgeon, is paramount in
emergency medicine
• Practical knowledge of fracture physiology provides the index
of suspicion needed to diagnose an injury that might otherwise
be missed
 ORTHOPEDIC ESSENTIALS

• Fractures are the result of a significant trauma to healthy bone

• Bone cortex may be disrupted by direct trauma, axial loading,
angular forces, torque stress, or a combination of these forces
• Pathologic fractures occur from relatively minor trauma to
diseased or otherwise abnormal bone
• Pathologic process weakens the bone and renders it susceptible
to fractures by forces that, under normal circumstances, would
not disrupt the bone cortex
• Common examples include metastatic lesions, fractures
through bone cysts, vertebral compression fractures in
osteoporotic patients
 ORTHOPEDIC ESSENTIALS
• Stress fractures are the result of a “fatigue” injury
• The bone is subjected to uncustomary repetitive forces before
the bone and its supporting tissues can adapt to the forces
• Classic example is the “march fracture” in a foot soldier
(metatarsal shaft fracture)
• Pathophysiologic process that renders bone susceptible to
stress fracture has not been readily identified
• Diagnosis depends on familiarity with the fracture, as
radiographs are typically normal early in the course of the
process
• Fractures are often not seen until weeks or months have passed
since the initial injury
 ORTHOPEDIC ESSENTIALS

• Salter-Harris fractures involve the epiphysis, or cartilaginous

epiphyseal growth plate, near the ends of the long bones in
children
• Named after the two physicians who devised the classification
system for naming these fractures
• New bone material needed for elongation of bones during
growth is provided by specialized cells within the physis
• When growth is complete, transformation of the physis into
bone occurs, ultimately fusing with the surrounding bone
• Salter-Harris fractures cannot occur in adults
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• Damage to the epiphyseal plate during bone growth can

destroy all or part of its ability to produce new bone substance
• This may result in an aborted or deformed growth of bone
• The earlier a Salter-Harris fracture occurs, the more likely the
chance of a deformity will occur
• Fracture pattern is also a significant factor in the development
of deformity
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• Fracture healing physiology is described in terms of three

phases: inflammatory, reparative, and remodeling
• After the initial fracture, microvessels that cross the fracture
line are transected; this results in ischemia to the damaged
bone ends
• Damaged bone ends necrose, which triggers an inflammatory
response
• Inflammatory phase is brief, but creates the tissue environment
for the reparative phase
 ORTHOPEDIC ESSENTIALS

• The reparative phase begins with granulation tissue infiltrating

the fracture area
• Granulation tissue contains cells that secrete and form
collagen, cartilage and bone; these form the callus, which
eventually surrounds the fractured ends of the bone
• Callus is responsible for stabilizing the fractured bone ends
• As the fracture heals, the callus becomes mineralized and very
dense
• The necrotic edges of the fracture fragments are attacked by
osteoclasts, which resorb bone
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• Remodeling is the final phase of bone healing

• The bone gradually regains its original shape, contour and
strength
• Remodeling often lasts years
• Callus is resorbed, new bone laid down by osteoblasts
• The trabeculae, linear densities easily seen on normal bone, are
the end result of the physiologic process that remodels bone
and provides maximum strength in relation to the amount of
bone used
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• Success of bone remodeling depends of several factors

• Young children have greater capacity for remodeling
compared to adults
• Magnitude and direction of unreduced angulation, and fracture
location on the bone
• Youth
• Proximity of fracture to end of bone
• Direction of angulation when compared to the plane of natural
joint motion
• Decisions regarding fracture reduction require knowledge of
the physiology of bone healing and its relation to patient age
 ORTHOPEDIC ESSENTIALS

• Open, or compound fracture, is associated with

communication between the bone and external surface of the
body
• Can be as simple as a puncture wound that extends to the
bone, or a large area of bone exposure
• Osteomyelitis is the most feared complication of open fracture
• Can produce long-term morbidity, chronic pain, deformity,
antibiotic therapy, and often amputation despite all medical
interventions
• All open fractures require prompt treatment and orthopedic
consultation in the emergency department
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• Joint dislocation is defined as the displacement of the articular

surfaces of bones that normally meet at the joint
• Joint subluxation, by comparison, is when the articular
surfaces are noncontiguous, to any degree. Dislocation is the
most extreme form of subluxation
• Urgency of reducing dislocations is dependent of several
criteria
• Neurologic or circulatory compromise is the most important,
as the neurovascular bundle that lies in close proximity to the
affected joint may be compressed around the dislocation
 ORTHOPEDIC ESSENTIALS
• Duration of dislocation is another consideration. It is generally
considered an axiom that “the longer a joint is dislocated, the
more difficult the reduction will be”
• This is due to the tremendous amount of edema, muscle spasm
and soft tissue injuries that occur with the dislocation
• The most urgent dislocation you will deal with in the ED is hip
dislocation. Prolonged dislocation of the femoral head puts the
patient at high-risk of developing avascular necrosis, or AVN,
of the femoral head
• The blood supply to the femoral head is via vessels that
emerge from the acetabulum; when hip dislocation occurs,
circulation to the femoral head is disrupted
 ORTHOPEDIC ESSENTIALS

• Emergency orthopedics requires careful history taking and

physical examination
• “Just taking an x-ray” is a foolish habit to fall into, as you will
miss other significant injuries
• Pain from fractures may be referred to other areas of the body;
if you do not consider this, you will miss the injury
• Some standard radiographic series will not include special
views that can determine injuries, i.e., the scaphoid or
navicular view when a hand injury has occurred
• If you don’t order the special view, you’ll miss the injury
 ORTHOPEDIC ESSENTIALS
• The value of a good history cannot be overemphasized
• Ask the patient specific questions regarding the injury, i.e.,
what were you doing when it occurred, how did you land,
where did you feel pain, etc.
• In the case of hand injuries, ALWAYS ASK THE PATIENT
IF THEY ARE LEFT OR RIGHT HANDED!
• In falls from heights, don’t stop at the feet or ankles; consider
injuries to the tibia/fibula, femur, pelvis, and lumbar vertebrae
• General medical history should also be obtained
• Determine if the patient is on anticoagulants, any other
significant history (cardiopulmonary) that may prolong
recovery, especially if surgery is involved
 ORTHOPEDIC ESSENTIALS

• Physical examination of orthopedic injuries in the ED is based

on a simple four step process
• Inspection (deformity, swelling, discoloration)
• Assess range of motion (both active and passive) of the
affected bone, as well as consideration of the joints above and
below the injured bone
• Palpation of the injury for deformity and tenderness
• Neurovascular exam
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• The heart of emergency orthopedics is being able to interpret

radiographs
• The most important concept to grasp is this: KNOW WHAT
IS NORMAL ON A RADIOGRAPH
• If you know what is normal, then identifying abnormal
findings becomes natural
• Base your x-ray ordering on your history and physical exam,
not on where the patient hurts
• Remember: x-ray the joint above and below the injury; injuries
at proximal and distal ends of bones may both be present,
especially in long bone fractures
 ORTHOPEDIC ESSENTIALS

• Always interpret your own radiographs; if you are uncertain of

what you see, ask the radiologist for assistance
• You should have an excellent idea of what injury you
anticipate seeing on the radiographs based on the history and
physical examination
• Never consider the radiologist’s diagnosis the final word;
significant injuries may not be apparent on the initial films,
and may not be visible for up to a week post-injury.
• If you suspect the injury based on your history and exam, treat
the injury as a fracture and splint it. This is your best defense
against missed injuries!
 ORTHOPEDIC ESSENTIALS

• Describing radiographs is probably the most important skill

you need to develop
• Orthopedic surgeons rely on your description to help them
decide whether surgical or nonsurgical management is
indicated
• Knowing what you are looking at, and how to describe this to
the orthopedic surgeon over the phone, is an art form. Some
will grill you endlessly, others will know immediately what
you are describing to them
• “15 questions to ask yourself before calling the orthopedic
surgeon” will assist you in radiographic interpretation
 ORTHOPEDIC ESSENTIALS
• 1. What bone is involved?
• 2. Is there any violation of the skin at, or near the fracture site?
• If so, the fracture is considered open. Clean wounds that are
less than 1 centimeter in length are classified as minimally
open fracture.
• Wounds that are large or “dirty” (i.e., large avulsion flaps,
road rash, etc) are classified as significantly open fractures
• 3. Are there any joint dislocations?
• 4. How many fracture fragments do you see?
• Two pieces is considered a simple fracture; more than two
pieces is considered a comminuted fracture
 ORTHOPEDIC ESSENTIALS

• Multiple fragments is considered severely comminuted

• 5. Is there any angulation of the fracture? (angulation is named
for the relationship of the distal fragment to the proximal
fragment)
• If so, what degree of angulation is present? Use a goniometer
and measure the degree of angulation
• 6. If the fracture is in a pediatric patient, does it involve the
growth plate?
• 7. What part of the bone is fractured? Fractures are named
according to the “zone of thirds”, i.e., proximal, middle, distal
third of the bone shaft
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• Fractures may be present at the junction of the proximal and

middle thirds, or junction of the middle and distal thirds
• 8. What is the fracture pattern? Fractures are classified as
transverse, spiral, short oblique, long oblique, butterfly or
comminuted?
• 9. Does the fracture enter a joint?
• 10. If so, how many pieces of the joint are fractured? (simple
versus comminuted)
• 11. Is the fracture completely displaced? Displacement is
measured by determining the alignment of the fragments.
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• Displacement is measured as a percentage of the width of the

bone shaft; if the distal fragment is 25% shifted away from the
bone shaft, the displacement is considered to be 25%.
• 12. How does the fracture involve the joint? (i.e., is there good
alignment, displacement with a step-off deformity,
intraarticular fragment off of the joint line, fracture
dislocation?)
• 13. Estimate the degree of displacement and shortening.
Shortening is when the bone ends overly each other
• 14. Is there blanching of the skin? Describe the swelling at the
fracture site
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• Is the neurovascular function intact distal to the fracture site?

• When was the last meal/fluid intake?
• 15. Now, when you have answered all of these questions, call
the orthopedic surgeon.
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• Control of pain and swelling after a fracture is of paramount
importance in the emergency department
• Swelling increases pain, and may preclude placement of an
appropriate immobilization device; increased swelling also
increases the risk of pressure sores
• Start with simple therapies first! Cold and elevation are time-
proven, effective and simple
• Control pain with narcotic analgesics as needed
• Remember, narcotics are essentially useless for pain associated
with movement or manipulation of the bone fragments; a
sedative/hypnotic and narcotic combination will control the
pain of bone manipulation very well
 ORTHOPEDIC ESSENTIALS
• Remove jewelry, watches, rings, etc. when an extremity is
fractured. As swelling continues after the fracture, delayed
removal of these objects becomes almost impossible
• Any patient who may be a candidate for surgery must be kept
NPO!
• Fracture reduction can be performed in the emergency
department, after adequate control of pain and swelling
• Long-term goal is to restore normal anatomic position and
function
• Reduction also alleviates acute pain, relieves blood vessel and
nerve tension, and may restore circulation to a pulseless
extremity
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• Fracture reduction is a simple process

• Once the patient’s pain has been controlled, consider adding a
sedative hypnotic prior to the reduction
• Reduction is performed by applying gentle but steady,
longitudinal traction to the shaft of the bone
• Joint dislocation reductions are also performed in the
emergency department
• Adequate pain control is essential prior to the procedure
• Use of a rapid-acting sedative/hypnotic, such as Etomidate,
will produce a relaxed state and facilitate successful reduction
 ORTHOPEDIC ESSENTIALS

• Open fractures warrant aggressive treatment and require

admission
• Tetanus prophylaxis is mandatory
• Thorough irrigation of the wound with Shur-Clens and sterile
saline will prevent further contamination
• Early administration of antibiotics is not only mandatory, but
will prevent further contamination of the wound
• Numerous antibiotic choices exist; there is no “gold standard”
regimen
• Appropriate choices are first generation cephalosporin (i.e.,
Ancef) and aminoglycoside (i.e., Gentamicin)
 ORTHOPEDIC ESSENTIALS

• Most orthopedic injuries can be managed on an outpatient

basis
• Patients must have the injury adequately immobilized before
discharge
• Make sure each patient has a prescription for pain medication
and understands their discharge instructions
• Make sure you have arranged follow-up with the orthopedic
surgeon! The patient must also understand that it is their
responsibility to contact the orthopedist as well for further care
• If you have any doubts about the patient’s ability to provide
self-care, admit them
 SUMMARY
• Emergency orthopedics is exciting, yet challenging
• Know the anatomy of the musculoskeletal system
• Perform a thorough examination; this will guide your choice of
radiographs
• Know when to order special radiographic views to identify
specific injuries
• Be able to interpret the radiographs yourself; if you are
uncertain if there is a fracture, ask the radiologist for assistance
• Be able to describe the fracture to the orthopedist
• Have the orthopedist consult in the department for open
fractures, compartment syndromes, irreducible dislocations,
injuries that require surgery and circulatory compromise