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Chapter 90 PEDIATRIC TRAUMA618
position (slight superior and anterior positioning of the midface) is employed to maintain a
patent airway. Infants are preferential nasal breathers, so their nares should not be occluded
with a nasogastric tube. Oral airways should be inserted only in unconscious children as they
may induce vomiting.
5. Which factors affect endotracheal intubation of a child?
A child’s larynx lies higher and more anterior in the neck, and the vocal cords have a more
anterocaudal angle; the cords may be more difficult to visualize for intubation. The narrowest
part of a child’s airway is the cricoid ring, which forms a natural seal with the endotracheal
tube. In adults, the narrowest portion is at the level of the vocal cords and a balloon is
necessary to stabilize the tube. Uncuffed tubes (using the formula 4 1 age/4 to calculate mm
of internal diameter) may be used in children younger than 8 years. However, because the size
of the airway cannot always be predicted, one may opt for a cuffed endotracheal tube (ETT)
half a size smaller to prevent any potential air leak. Insertion depth can be estimated as three
times the tube size in centimeters.
6. What are my options if I cannot endotracheally intubate the patient?
A laryngeal mask airway is considered class indeterminate by pediatric advanced life support
(PALS) guidelines. Although an option, this device may cause upper airway obstruction,
particularly in children less than 20 kg, by folding the larger epiglottis into the larynx (see
chapter on pediatric and neonatal resuscitation). In children older than 8 years of age, a
surgical cricothyrotomy can be performed. There is debate and limited evidence to support
a specific lower age limit for this procedure. Most would agree that in children younger than
6 years of age, the cricothyroid membrane is too small and structures too thin to safely
perform this procedure. In this group, a needle cricothyrotomy should be performed using a
16- to 18-gauge needle and a translaryngeal jet ventilation device. Due to limitations in
adequate ventilation with needle cricothyrotomy, the treating provider should immediately
consult with a surgeon to perform an emergent tracheostomy.
7. How do I recognize shock in a pediatric patient?
Children have an increased physiologic reserve and often maintain vitals signs in the normal
range even in the presence of compensated shock. However, young children are less able to
increase their cardiac contractility, responding to blood loss only by increasing heart rate. This
singular cardiac mechanism can result in precipitous drops in blood pressure when a critical
volume is lost. Other signs include poor skin perfusion, decreased pulse pressure, mottling of
the skin, cool extremities, capillary refill greater than 2 seconds, increased work of breathing
and a depressed level of consciousness. For children older than 1 year, the average systolic
blood pressure can be estimated as 90 mm Hg plus twice the age in years, whereas the lower
fifth percentile is estimated as 70 mm Hg plus twice the age in years. Hypotension typically
indicates a loss of . 45 % of blood volume and may be accompanied by bradycardia.
8. Name the preferred sites for venous access.
In decreasing order of preference: peripheral, intraosseous (particularly in very young critically
ill children), percutaneous femoral-subclavian-internal jugular, and saphenous vein cutdown at
the ankle. In the unstable patient, intraosseous or central venous access must not be delayed
by multiple peripheral attempts. Ultrasound-guided central line access should be utilized, as
its use results in a decreased number of access attempts, as well as fewer arterial punctures
in the pediatric population.
9. What are some considerations regarding an intraosseous line?
It is most appropriate in children younger than 6 years and allows administration of virtually
any fluid and blood product or drug. The preferred site is the proximal tibia below the tibial
tuberosity. It should not be placed distal to a fracture and should be removed when peripheral
intravenous access is secured. Complications include cellulitis, osteomyelitis, growth plate
injury, fat microembolism, compartment syndrome, and iatrogenic fractures.
Chapter 90 PEDIATRIC TRAUMA 619
10. What is a child’s normal blood volume?
80 mL/kg
11. How should I resuscitate a pediatric trauma patient?
A 30% reduction in blood volume generally is required to manifest signs of compensated
shock. The 3:1 rule (crystalloid resuscitation-to-blood loss) applies as it does in adults. For
a 20-mL/kg blood loss, 60 mL/kg should be given. Either warmed normal saline or lactated
Ringer’s solution can be given in boluses of 20 mL/kg. After 60 mL/kg, consideration should
be given to transfusing warmed packed red blood cells (10 mL/kg).
12. Why are children prone to head trauma?
A child’s body is like a dart—they lead with their head. Relative to the adult, children’s heads
are larger in proportion to their bodies.
13. Which kinds of head injuries do children get?
Compared with adults, mass lesions are less common, but cerebral edema and postinjury
seizures are more common. Hemorrhagic shock may occur secondary to blood loss in the
subgaleal or epidural space because of open cranial sutures and fontanels. Bulging sutures or
fontanelles suggest a significant brain injury and/or cerebral edema and warrant aggressive
management and neurosurgical consultation before decompensation occurs. Subdural
hemorrhages and cerebral edema are typical manifestations of abusive head trauma (also
known as shaken baby syndrome), where bridging veins are torn and shear injury occurs
from a rapid acceleration-deceleration shaking mechanism.
14. Which children need cranial imaging after head trauma?
This has been an area of considerable debate. Many algorithms have lacked sensitivity for
identifying intracranial injuries in children, while others would result in overutilization and
unnecessary exposure to radiation. In an attempt to identify patients that can be safely
discharged from the ED without imaging, the Pediatric Emergency Care Applied Research
Network (PECARN) has recently published a large series (over 42,000 patients) of children
with head injury.
n
In patients younger than 2 years of age, the following characteristics gave a negative
predictive value (NPV) of 100% (95% CI, 99.7%–100%) for clinically important brain
injuries: normal mental status, no scalp hematoma (except frontal), no loss of
consciousness or loss of consciousness less than 5 seconds, nonsevere mechanism, no
palpable skull fracture, and acting normally per parents.
n
For children older than 2 years of age, the following criteria generated an NPV of 99.95%
(95% CI, 99.81%–99.99%): normal mental status, no loss of consciousness, no vomiting,
nonsevere mechanism, no signs of basilar skull fracture, and no severe headache.
15. What is SCIWORA?
SCIWORA stands for spinal cord injury without radiographic abnormality. Children are
particularly vulnerable to this type of injury due to their horizontally situated facet joints,
incomplete spinal ossification, and immature ligamental support structures. Plain spine
radiographs are normal in two thirds of children with spinal cord injury. Therefore, in children
with evidence of a spinal cord injury and normal plain films, the provider should request
magnetic resonance imaging (MRI) and neurosurgical consultation.
16. How common is pseudo-subluxation of the cervical spine?
About 40% of children younger than 7 years demonstrate anterior displacement of the
anterior border of C2 on C3. Approximately 20% of children up to 16 years also demonstrate
pseudo-subluxation. This radiographic finding can be minimized by placing the patient in a
sniffing position. It can be differentiated from true subluxation by evaluating the line of
Swischuk; drawn along the anterior spinous processes of C1 and C3. Injury is suspected
if the line passes greater than 1.5 mm from the anterior spinous process of C2.
Chapter 90 PEDIATRIC TRAUMA620
17. How common are rib fractures in children?
Not very. The compliant chest wall allows unimpeded transmission of energy to the underlying
thoracic organs, potentially resulting in life-threatening contusions. Because of the force
required to break elastic bones in young children, two thirds of children with rib fractures
have associated organ injuries. The child’s mobile mediastinum allows tension pneumothorax
to develop more readily than in adults. Bilateral posterior rib fractures should heighten the
clinician’s suspicion for nonaccidental trauma.
18. What are predictors of pediatric intra-abdominal injuries?
Multiple investigators have attempted to identify predictors of intra-abdominal injury in
children. High-risk mechanisms for intra-abdominal injury should be taken into
consideration and include high speed motor vehicle collisions, pedestrian versus
automobiles, bicycle accidents (including handlebar injuries), and direct blows to the
abdomen. Tenderness on palpation, seatbelt bruising, and hemodynamic instability in the
field are other associated findings. Holmes et al recently published a prospectively validated
prediction instrument that identified six criteria, wherein the absence of all of the following
identified pediatric patients at low risk for intra-abdominal injury (95% sensitivity and 37%
specificity): low age-adjusted systolic blood pressure, abdominal tenderness, femur
fracture, increased liver enzyme levels (serum aspartate aminotransferase . 200 U/L or
serum alanine aminotransferase . 125 U/L), microscopic hematuria (. 5 red blood cells/
high powered field) and an initial hematocrit level , 30%. Ultimately, because no criteria
have been perfect in identifying abdominal injuries on initial evaluation of the pediatric
trauma patient, any decision algorithm cannot supplant clinical judgment in determining any
individual patient’s risk.
19. Compare and contrast the primary diagnostic modalities for evaluating
children for abdominal trauma.
CT, diagnostic peritoneal lavage (DPL), and ultrasonography are the primary diagnostic
tests. CT is appropriate in stable patients. It is the most specific of the tests, identifying
solid organ and (less accurately) hollow viscus injuries. It also evaluates the
retroperitoneum. However, it is time consuming, requires the patient to be hemodynamically
stable for transfer out of the ED, and often requires sedation in young children. DPL is
more than 95% accurate in identifying injuries, but is invasive and nonspecific. Because
most solid organ injuries can be managed nonoperatively, the finding of a hemoperitoneum
alone, without hemodynamic instability, does not warrant operative exploration. DPL is
most useful in patients who are hemodynamically unstable or in patients whose abdomen
cannot be serially evaluated, for example, if they require emergency neurosurgical or
orthopedic surgery under general anesthesia. Ultrasound is simple, rapid, repeatable, and
non-invasive. As with an adult patient, it may be used to triage unstable pediatric patients to
the operating room or to rapidly exclude the abdomen as a source of significant blood loss.
If equivocal, further imaging or diagnostic peritoneal lavage may be required, depending on
the urgency of the situation. Growing experience with focused abdominal sonography for
trauma (FAST) in children suggests that it can replace peritoneal lavage for the unstable
pediatric patient.
20. What is a handlebar injury?
An intra-abdominal injury from a direct blow (e.g., from a bicycle handlebar) to the right upper
quadrant or epigastrium. The classic finding is a pancreatic injury or duodenal hematoma, but
renal injury can occur if the impact is off midline.
21. What is the lap belt syndrome?
Ecchymoses of the abdominal wall, a flexion-distraction injury of the lumbar spine (Chance
fracture), and intestinal or mesenteric injury.
Chapter 90 PEDIATRIC TRAUMA 621
22. How much of a problem is nonaccidental trauma?
Nonaccidental trauma is the most common cause of traumatic death in the first year of life.
Fifty percent of abused children who are released to their abusers will be the victims of
repeated nonaccidental trauma, often resulting in death. Identifying victims of abuse in the
ED allows for early intervention. Historical clues to abuse include changing reports of the
traumatic event, injuries incompatible with reported mechanism, and late presentations. Very
young age (, 3 years of age and particularly , 3 months of age), developmental delay, and
parental substance abuse have all been associated with nonaccidental pediatric trauma.
1. Children are not just little adults. Providers must take into account specific anatomic
and physiologic differences when evaluating for pediatric injuries.
2. In the pediatric trauma population, head injury is the leading cause of morbidity and
mortality.
3. Unstable vital signs is a late and ominous finding in the pediatric trauma patient.
KEY POINTS: PEDIATRIC TRAUMA
BIBLIOGRAPHY
1. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support for Doctors, 8th ed.
Chicago, American College of Surgeons, 2008. Available at: www.facs.org/trauma/atls/index.html
2. Froehlich CD, Rigby MR, Rosenberg ES, et al: Ultrasound-guided central venous catheter placement
decreases complications and decreased placement attempts compared with landmark technique in patients in
a pediatric intensive care unit. Crit Cre Med 37(3):1090–1096, 2009.
3. Holmes JF, Brant WE, Bond WF, et al: Emergency department ultrasonography in the evaluation of hypotensive
and normotensive children with blunt abdominal trauma. J Pediatr Surg 36(7):968–973, 2001.
4. Holmes JF, Mao A, Awasthi S, et al: Validation of a prediction rule for the identification of children with
intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 54: 528–533, 2009.
5. Kupperman N, Holmes JF, Dayan PS, et al: Identification of children at very low risk of clinically-important
brain injuries after head trauma. Lancet DOI: 10.1016/S0140-6736(09)61558-0.
6. Mace SE, Khan N: Needle cricothyrotomy Emerg Med Clin North Am 26:1085–1101, 2008.
7. Pang D: Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurg 55:
1325–1343, 2004.
8. Partrick DA, Bensard DD, Moore EE, et al: Ultrasound is an effective triage tool to evaluate blunt abdominal
trauma in the pediatric population. J Trauma 45:57–63, 1998.
9. Soudack M, Epelman M, Maor R, et al: Experience with focused abdominal sonography for trauma (FAST) in
313 pediatric patients. J Clin Ultrasound 32:53–61, 2004.
10. Tuggle DW, Garza J: Pediatric trauma. In Feliciano DV, Mattox KL, Moore EE, editors: Trauma, ed 6, New York,
2008, McGraw-Hill, pp 987–1002.
622
MUSCULOSKELETAL TRAUMA
AND CONDITIONS OF THE EXTREMITY
CHAPTER 91
Anthony R. Sanchez II, MD, and Steven J. Morgan, MD
GENERAL PRINCIPLES
1. What are the immediate treatment priorities in an open fracture?
An open fracture is an orthopedic emergency!
As in any trauma patient, the immediate priorities are the ABCs: airway, breathing, and
circulation. Any break in the skin near a fracture site should be assumed to communicate
with the fracture until proved otherwise. After careful examination with neurologic and
vascular assessment, the wound should be cleaned of gross contamination, and a sterile
dressing applied. Direct pressure can be used for hemorrhage control. Axial realignment and
splinting immobilize the bone, decreasing blood loss and protecting the soft tissue from
further damage. Probing of the wound, wound cultures, extensive irrigation, and multiple
examinations of the wound should be avoided, owing to the increased potential for
secondary contamination and soft-tissue damage. Tetanus prophylaxis and intravenous
antibiotics are usually administered.
A first-generation cephalosporin, with or without an aminoglycoside, is used most
commonly for antibiotic prophylaxis. When open fractures occur in grossly contaminated
environments, such as barnyards, penicillin is added, secondary to the increased risk of
anaerobic organisms. Consult an orthopedic surgeon immediately.
2. What percentage of polytrauma patients have unrecognized fractures
at the time of admission?
Of patients with multiple system injuries, up to 20% have unrecognized fractures at the time
of initial assessment. In general, these do not typically involve the axial skeleton or long
bones. These unrecognized injuries are located most commonly in the hands and feet. This
important fact shows the need for repetitive examination of the multiply injured patient and
discussions with the family of the injured party regarding the potential of unrecognized
fractures.
3. What is compartment syndrome?
A condition that develops when the pressure in the confined space of the muscle
compartment exceeds the filling pressure of the venules and the arterioles supplying the
muscle, resulting in muscle ischemia and edema. This increases intracompartmental pressure,
further setting up a vicious cycle, eventually leading to necrosis of muscle and nerves.
Conditions or situations that cause an increase in the compartment contents or decrease the
expansive nature of the compartment can result in compartment syndrome. Common causes
include fracture, crush injuries, hemorrhage, postischemic swelling after repair of vascular
injury, tight-fitting casts or dressings, military antishock trousers (MAST), and circumferential
burns.
4. What are the signs and symptoms of acute compartment syndrome?
The classic diagnosis of acute compartment syndrome is indicated by the 5 Ps:
n
Pain is the earliest and most common symptom associated with compartment syndrome. It
is typically more severe than what is normally expected, based on the associated cause,
Chapter 91 MUSCULOSKELETAL TRAUMA AND CONDITIONS OF THE EXTREMITY 623
and is often exacerbated when the muscles of the involved compartment are put on stretch.
Pain is typically ischemic in nature and often not relieved by narcotics.
n
Paresthesia is another common finding but indicates a prolonged period of increased
compartment pressures.
n
Pallor, pulselessness, and paralysis are late findings, and the condition is often not
reversible at that point.
There are various methods of measuring intracompartmental pressure to obtain objective
evidence of compartment syndrome. The gold standard of diagnosis is a positive clinical
examination combined with a plausible history. Missed or delayed diagnosis of compartment
syndrome is catastrophic, warranting a high index of suspicion and early specialist consultation.
Exertional compartment syndrome is characterized by exercise-induced compartmental
pain and swelling that resolves with rest. Acute compartment syndrome may complicate this
condition. It is therefore prudent always to exclude compartment syndrome in a painful limb
due to uncertain etiology to avoid disastrous complications.
5. What are the most common sites of compartment syndrome?
The volar compartment of the forearm and the anterior compartment of the leg. The deep
posterior compartment of the leg is the site most often missed for this event. Supracondylar
fractures of the humerus in children and both-bone forearm fractures are the injuries most
commonly associated with this process in the upper extremity. Proximal tibial fractures are
the most common cause of compartment syndrome in the leg. Compartment syndrome is
also known to occur in the hands, feet, thighs, and upper arm. Fractures may or may not be
present.
6. What is the treatment of compartment syndrome?
Surgical release of the investing fascia of the compartment (fasciotomy) is the only effective
treatment for this condition. Temporary measures that may be used to prevent compartment
syndrome include elevation of the extremity to above heart level and maintenance of a normal
arteriole filling pressure by maintaining a normotensive blood pressure.
7. Describe the joint fluid analysis consistent with septic arthritis.
The fluid will appear cloudy. Other causes of cloudy fluid are gout and psuedogout. Cells per
mm
3
will be between 2,000 and 50,000 with greater than 90% being polymorphonuclear
neutrophils (PMNs). Unlike gout and pseudogout, there will be no crystals and the culture will
be positive.
8. What information should be obtained if a possible septic joint is to be
aspirated?
The fluid should be sent for Gram stain, culture, cell count, and crystals. Always remember
that if attempting to aspirate a joint with surrounding cellulitis, try to stay clear of the red,
inflamed, infected skin area so as not to seed the joint.
9. How do I diagnose a traumatic open joint?
Probing of a wound in proximity to a joint is insufficient, may increase the risk of infection,
and generally should be avoided. Radiographs of the involved joint may reveal the presence of
air in the joint, indicating joint violation. The definitive diagnosis is made by performing an
arthrogram. Sterile saline combined with a small amount of methylene blue should be injected
in the joint. A significant amount of fluid needs to be injected to distend the joint. The
traumatic wound is inspected for egress of the injected fluid. The fluid should then be
withdrawn from the joint.
10. When should I order radiographs? How many should I order?
n
Radiographs should be ordered based on the physical examination findings.
n
Radiographs should include the joints above and below the perceived area of injury.
n
Two orthogonal views always should be obtained.
Chapter 91 MUSCULOSKELETAL TRAUMA AND CONDITIONS OF THE EXTREMITY624
Obtaining radiographs should not obstruct the resuscitation process in the multiply injured
patient. In situations in which significant deformity of the limb results in vascular compromise
or devitalization of the overlying skin, radiographs should be delayed, pending emergent
realignment and splinting of the involved extremity.
KEY POINTS: MUSCULOSKELETAL TRAUMA AND CONDITIONS
OF THE EXTREMITY
1. An open fracture is an orthopedic emergency.
2. Compartment syndrome is an important diagnosis for exclusion.
3. Septic joints require immediate orthopedic attention.
HAND AND UPPER EXTREMITY
11. What is the best method to control bleeding in a hand or forearm laceration?
Direct pressure. Tourniquets are rarely necessary. The practice of blindly placing clamps into
the wound is dangerous and often can damage structures in close proximity to the offending
vessel, such as the median or ulnar nerve.
12. What metacarpophalangeal joint most commonly sustains a laceration when
an individual engages in fist diplomacy?
The third metacarpophalangeal joint because it is the most prominent knuckle when making a fist.
13. How much deformity can be tolerated in a metacarpal fracture?
Rotational deformity is not tolerated well and should be corrected. Rotation in a metacarpal
neck or shaft fracture causes the fingers to cross when the individual makes a fist. Flexion
deformity of the fracture is the most common and best tolerated. You can accept 10, 20, 30,
and 40 degrees of flexion in the index through small fingers. A greater degree of deformity is
tolerated at the small finger, secondary to the increased motion at the carpometacarpal joint.
The same is true for a thumb metacarpal fracture, in which 40° of angular deformity can be
accepted.
14. What bacterium is often associated with cat bites, and what is the antibiotic
treatment?
Pasteurella multocida. Penicillin G, co-amoxiclav (orally [PO]), or ampicillin/sulbactam
(Unasyn) (intravenous [IV]). Use doxycycline in penicillin-allergic patients.
15. What should be done with an amputated part that may be replanted?
1. Remove gross contamination by irrigating with saline.
2. Wrap the part in a saline-moistened (not soaked) sterile gauze.
3. Place the wrapped part into a sealed plastic bag or container.
4. Place the bag or container into an ice water bath.
Never put the amputated part straight onto ice!
16. List traumatic amputations that should be considered for replantation.
n
Any amputation in a child
n
Multiple finger amputations
n
Thumb
n
Hand
n
Arm
Chapter 91 MUSCULOSKELETAL TRAUMA AND CONDITIONS OF THE EXTREMITY 625
The ultimate decision always should be deferred to a hand surgery specialist. It is usually
best to defer detailed discussion of replantation with the patient or family to the consulting
specialist.
17. What is the appropriate treatment for a patient with pain in the snuffbox of the
wrist and normal radiographs after a traumatic event to the wrist?
The scaphoid is easily palpable in the anatomic snuffbox of the wrist. The snuffbox is the
space between the extensor pollicis longus and the extensor pollicis brevis. Tenderness in this
area is suggestive of a scaphoid fracture. The absence of fracture on the initial radiographs is
common. As the necrotic bone at the fracture site is resorbed, the fracture line often becomes
apparent on radiographs approximately 14 days after injury. Individuals with this condition
should be immobilized in a thumb spica splint or cast and referred to an orthopedist for
evaluation. Bone scans and magnetic resonance imaging (MRI) are not indicated in the acute
evaluation.
18. Radiographically, how can one tell the difference between an anterior and
posterior shoulder dislocation?
On an anterior-posterior (AP) radiograph, an anterior dislocation would show bony overlap in
a medial and inferior direction. An AP radiograph with a posterior shoulder dislocation shows
a vacant glenoid sign as the humeral head fails to fill most of the glenoid, which should be
present on a normal AP radiograph. There is also a positive rim sign with space between the
anterior rim of the glenoid and the humeral head exceeding 6 mm.
19. State the incidence and common causes of posterior shoulder dislocations.
Incidence is 5% of shoulder dislocations. They are most often the result of falls on an
outstretched hand. Other cause include tonic-clonic seizures, electrical shock, and
direct anterior shoulder trauma. Reduction can be accomplished with flexion of the arm to
90 degrees and adduction to disimpact the humeral head from the glenoid rim. The arm is
then externally rotated until the head has cleared the glenoid rim. A sling should be applied
in neutral to 5 to 10 degrees of external rotation and slight abduction. It is critical to avoid
internal rotation for 4 to 6 weeks.
20. What percentage of patients with first-time anterior shoulder dislocations
experience a recurrent dislocation?
Of patients aged 30 years or younger, 90% experience a recurrent dislocation. For older
patients, the percentage is lower and more variable, depending on the mechanism of injury.
21. What are the potential complications of anterior shoulder dislocation?
The axillary nerve is at risk for injury at the time of dislocation. Careful examination of the
deltoid muscle should be done to assess motor function. The axillary nerve also provides
sensation to the lateral aspect of the shoulder (regimental badge area), and sensation should
be checked in this area. In addition to axillary nerve injury, there is high incidence of a rotator
cuff tear in the first time dislocator older than age of 40.
22. How is a rotator cuff tear diagnosed?
The patient often complains of pain with overhead activity, night pain, and pain with abduction
of the arm. The patient has difficulty abducting the arm and often is unable to lift the arm
above the level of the shoulder. With the shoulder in 90-degree abduction, 30-degree forward
flexion, and maximal internal rotation, the patient cannot resist against downward pressure on
the extremity (supraspinatus strength test). A drop test is done in the same manner with the
arm simply at 90-degree abduction. The patient is not able to lower the arm slowly from
90-degree abduction. When these conditions exist, it is important to differentiate a rotator cuff
tear from subacromial impingement (condition that irritates the rotator cuff). Inject 10 mL 1%
lidocaine in the subacromial space. If the patient obtains pain relief and still cannot initiate
abduction, the diagnosis of rotator cuff tear is confirmed.
Chapter 91 MUSCULOSKELETAL TRAUMA AND CONDITIONS OF THE EXTREMITY626
23. How is a posterior sternoclavicular dislocation diagnosed?
Radiographs are generally nondiagnostic. Computed tomography (CT) scan is the most
sensitive diagnostic modality.
24. Describe the significance of anterior versus posterior dislocation of a
sternoclavicular joint.
n
Anterior dislocations are not associated with major complications and are treated easily
with a sling.
n
Of posterior sternoclavicular dislocations, 25% are associated with complications,
including rupture or compression of the trachea; esophageal occlusion or rupture; lung
contusion; and laceration or occlusion of the superior vena cava, subclavian vein, or artery.
Reduction of posterior sternoclavicular dislocation should be done only in the operating
room, with a cardiothoracic surgeon immediately available.
25. What is the most common neurological deficit seen with a humeral shaft fracture?
The radial nerve may be stretched (neurapraxia) or rarely lacerated (neurotmesis). This
condition typically occurs with fractures involving the distal one third of the humerus.
Disability includes inability to extend the wrist and fingers at the metacarpophalangeal joints
and numbness on the dorsum of the radial side of the hand. Interphalangeal extension,
representing ulnar and median nerve function, is preserved. Triceps function is preserved
because it is innervated by branches of the radial nerve proximal to the radial groove.
26. What is the difference between a nightstick fracture and a Monteggia
fracture?
n
A fracture of the ulna (typically the proximal one third) with a radial head dislocation is a
Monteggia fracture. This fracture occurs as a result of a fall on an outstretched hand with
associated valgus force on the extremity. The treatment requires internal fixation of the ulna
fracture.
n
A nightstick fracture is a fracture of the ulna resulting from a direct blow to the shaft of the
ulna. There is no associated injury to the proximal radial ulnar humeral joint. In most cases,
these injuries can be treated by closed means and early range of motion. Nightstick
fractures with significant comminution, greater than 10 degrees of angulation or greater
than 50% displacement, may be considered for operative fixation.
27. What nerve is commonly injured in a Monteggia fracture?
The posterior interosseous nerve lies in close proximity to the neck of the radius. When the
radial head is dislocated, this nerve is often stretched, resulting in a neurapraxia and inability
to extend the thumb or wrist.
LOWER EXTREMITY AND PELVIC FRACTURES
28. Name the major complications directly related to pelvic fracture.
Hemorrhage and urologic injuries, including bladder rupture and urethral tear. (See Chapter 88.)
29. What is the mortality rate in patients with open pelvic fracture?
Mortality has decreased from 50% in the 1980s to 10% to 25% due to a move toward a
multidisciplinary approach and advances in critical care.
30. What are the incidence and mechanism of injury in posterior hip dislocation?
Greater than 80% are posterior and result from a force directed posteriorly to a flexed knee, as
occurs when the knee strikes the dashboard in a motor vehicle crash.
31. What are the complications of posterior hip dislocation?
n
Sciatic nerve deficit is found in about 10% of patients, resulting in weakness or loss of
hamstring function in the thigh and all of the muscles of the leg.
Chapter 91 MUSCULOSKELETAL TRAUMA AND CONDITIONS OF THE EXTREMITY 627
n
Avascular necrosis occurs in 10% to 15% of patients but increases almost to 50% if
reduction is delayed beyond 12 hours.
n
Even with prompt reduction, 20% of patients develop osteoarthritis.
n
The risk of recurrent dislocation is increased during early rehabilitation following traction.
32. How is posterior hip dislocation differentiated clinically from a femoral neck
fracture or intertrochanteric femoral fracture?
Both result in lower extremity shortening. In posterior hip dislocation, the hip is flexed,
adducted, and internally rotated. This is often referred to as the position of modesty. With a
femoral neck or intertrochanteric fracture, the lower extremity is not flexed but is shortened,
abducted, and externally rotated.
33. How much blood loss can be expected with a fracture of the femoral shaft?
500 to 1500 mL
34. How are femoral shaft fractures best stabilized in the ED?
Longitudinal traction, involving a self-contained traction unit. Most emergency providers carry
these and can place them in the field or ambulance. Traction should not be left in place for
more than 2 hours without frequent neurovascular checks because of the potential for
compartment syndrome and vascular compromise. A second option is placement of a distal
femoral traction pin and in-line traction connected to the bed or gurney. A proximal tibial pin
may also be used provided there is no knee injury. Conventional splinting is ineffective.
35. Why do patients with hip pathology present with knee pain?
A patient with a hip problem may complain only of pain to the anterior distal thigh and medial
aspect of the knee. The knee and the hip share a common innervation through the obturator
nerve. Always suspect a hip problem in a patient who complains of knee pain without
corresponding findings on physical examination. Careful examination of the knee and hip, with
appropriate radiographs of the hip, is necessary to complete the evaluation.
36. Name the most common injury associated with traumatic hemarthrosis of the
knee joint.
Anterior cruciate ligament rupture. If fat globules are noted in the joint aspiration fluid, the
possibility of an associated intra-articular fracture should be pursued.
37. Name the ligament most commonly associated with an inversion ankle sprain.
Anterior talofibular ligament. The calcaneofibular ligament can also be injured in more severe
sprains.
38. Describe the treatment for ankle sprains.
Ankle sprains are treated by the RICE protocol: Rest, Ice, Compression, and Elevation.
Early protected weight bearing with crutches and an early range-of-motion program
should be instituted. More severe sprains may require a short period of immobilization.
39. Discuss the Ottawa rules regarding radiographs of the ankle.
The Ottawa rules were developed from a large study done in Ottawa, Canada, which examined
the necessity of routine ankle radiography in the assessment of patients with ankle injuries. It
was determined that radiographs are not required when the following conditions are met:
n
The examiner is experienced.
n
The patient does not have significant deformity of the ankle.
n
The examination is consistent with an ankle sprain.
n
There is no tenderness on examination over the medial or lateral malleolus (palpate
posteriorly from the tip of the malleolus to 6 cm proximally).
n
The patient was able to bear weight on the injured ankle immediately after the injury or in
the ED.