Emergency Medicine Orthopedics Review

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Posterior hip dislocation

Necessary XR views include an AP pelvis. CT scan should also be obtained to look for acetabular fractures, loose intra-articular fracture bodies or femoral head fractures. Reduction should occur within 6 hours due to avascular necrosis risk. The patient should be admitted to the hospital with orthopedic consultation for need for operative fixation.

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Extension Teardrop fracture

One of the unstable C-spine fractures. This is a avulsion fracture associated with anterior longitudinal ligament injury secondary to a severe flexion or extension injury. A small triangular avulsion fracture is seen at the insertion point of the ALL. These patients all require a cervical CT. Complications include central cord syndrome due to the ligamentum flavum buckling during hypertension. The posterior body can also be displaced backwards into the spinal canal. 

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Hangman’s Fracture

One of the unstable C-spine fractures. Caused by hyperextension injury causing C2 to displace anterior over C3 (blue arrow) often due to bilateral C2 pedicle fractures. Pre-vertebral soft tissue swelling is noted suggesting disruption of the anterior longitudinal ligament (orange arrow). Pars interarticularis fractures are also noted by the red arrow. These patients are at risk for disruption of the posterior longitudinal ligament. This fracture typically heals with immobilization. 

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Atlantoaxial or Atlanto-occipital instability

One of the unstable C-spine injuries. The occipital condyles become displaced from the superior C1 facets. This is sometimes referred to as an internal decapitation. Patients can be apneic on the scene and it is often a fatal injury. Disruption of the alar ligaments which attach the dens to the skull base or the transverse ligament, which holds the dens in place, may cause bony displacement and spinal cord compression. 

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Bilateral Facet Dislocation

One of the unstable C-spine fractures. Radiographic features include anteior displacement of the effected vertebral body greater than 50%. Typically associated with anterior and posterior ligament complex disruption. Unilateral facet dislocation may only lead to 25% displacement. At risk for injuring anterior and posterior longitudinal ligament, disk, vertebral arteries, and spinal cord

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Jefferson Fracture

One of the unstable C-spine fractures. This is a burst fracture of C1 due to excessive axial loading where fractures occur through both the anterior and posterior arches. Radiographic findings on the odontoid view include lateral displacement of C1 relative to C2. Most patients do well with immobilization in a hard cervical collar. Complications include transverse ligament rupture, which is suggested by C1 lateral masses greater than 7mm wide. CT angiography is recommended if there is suspicion of vertebral artery injury. 

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Odontoid (dens) fracture, Type III

One of the unstable C-spine fractures. It occurs secondary to an extreme flexion or extension injury such as whiplash in a MVC. The odontoid process, also called the dens, is critical for C2/C1 articulation and allows for the large range of cervical motion our necks exhibit.  A type I fracture is an avulsion injury at the tip where the transverse ligament is intact , a type II fracture is a break at the base of the dens and a type III fracture extends into the body of C2 vetebrae Type I and III fractures typically only require a hard collar for 6 weeks. Type II is more unstable and may require a cervical Halo or a pin to keep the odontoid from having worsening displacement. 

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Burst Fracture

Burst fractures occur when the vertebrae is compressed under extreme traumatic forces. Unlike a simple compression fracture, multiple vertebral columns are involved and can subsequently “retropulse” fragments from the middle column backwards into the spinal cord. 

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Chance Fracture

Also referred to as “seatbelt fractures” or “flexion-distraction fractures” that involve all three spinal columns. The anterior and middle spinal column is “flexed” while the posterior spinal column is “distracted.” They are considered unstable spinal fractures. Radiographic fractures include a anterior compression fracture of the vertebral body with a transverse fracture through the posterior spinal elements. Patients with evidence of spinal cord injury on CT or MRI scan and symptoms of spinal cord compression require surgery. Patients without neurological symptoms may be managed more conservatively with bracing, though this is more controversial. 

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L1 Vertebral Compression Fracture

Vertebral compression fractures commonly occur in elderly, osteoporotic patients. It’s estimated that 25% of people over age 70 and 50% of patients over age 80 will suffer this type of fracture. Most fractures are managed with pain control medications and rest with a gradual return to activity. If pain medications are unsuccessful, a back brace (TLSO brace) can take pressure off the fractured bone to reduce pain symptoms. Surgery is not required since vertebral compression fractures are stable and unlikely to get worse. However, if a patient’s pain does not improve after 6 weeks, a procedure called kyphoplasty is considered. During kyophoplasty, a balloon is inserted into the compressed vertebrae, inflated and then a cement like material is injected to fill the space. It is also important to treat the underlying osteoporosis with calcium, bisphosphanates and Vitamin D to prevent recurrent fractures. 

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Femur fracture

Very high mechanism injury. Necessary XR views include an AP and lateral of the femur and hip. These patients are at risk for femoral artery injury and compartment syndrome so ABI should be checked. They are also at risk for pudendal nerve injury and ipsilateral femoral neck fracture. Patients are placed in traction to relief the discomfort of the fragmented edges rubbing as well as keep the nerves and blood vessels from being kinked in the tissue. Treatment is emergent operative fixation so these patients should be admitted to the hospital.

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Subtrochanteric femur fracture

This is a common site of pathological fractures. These patients are at greater risk for compartment syndrome compared to trochanteric or neck fractures. Treatment is operative repair. 

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Intertrochanteric femur fracture

Typically occurs due to a slip and fall in an elderly patient. It is the most common type of femur fracture. There is a high risk of injury to the superficial femoral artery. Treatment is surgical repair. 

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Femoral neck fracture

Most commonly occur in an elderly patient who slips and falls. Necessary XR views include an AP of the pelvis, cross table lateral of the hip and AP/lateral of the entire femur. It is uniquely complicated by osteonecrosis of the femoral head. Treatment is emergent operative fixation so these patients should be admitted to the hospital.

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Knee Dislocation

The knee can dislocate in any plane as well as rotationally. It is classified based on displacement of the tibia. It is always associated with a significant mechanism of injury and subsequent severe soft tissue injury (ACL/PCL rupture). Necessary XR views include an AP and lateral to look for avulsion fractures. Treatment is immediate reduction and assessment of the popliteal artery with ABI. If ABIs are < .9 on the injured leg then CT angiogram of that extremity is warranted. Evaluate for injury to the peroneal nerve, which dorsiflexes the ankle and provides sensation to the dorsum of the foot. Place patient in a posterior splint with immobilization in 15-30 degrees of flexion. These patients are typically admitted to the hospital for serial neurovascular exams and consideration for surgical stabilization of ligamentous tears. 

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Tibial shaft fracture

Fracture of the middle third of the tibia. The majority need surgery. However, if there is < 5 degrees angulation and <10 degrees of rotational malalignment the leg can be casted. Many people opt for surgery as the healing time is faster. The bone can be stabilized with a metal plate to hold the bone in position or intramedullary nailing (which has a smaller incision/less injury to the soft tissue.)

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Tibial plateau fracture

It can occur on the lateral (most common), medial or both sides of the knee. The main concern is preserving the knee cartilage. Because it takes  a large amount of force to compress or split the tibia there is often associated ligamentous or meniscal injury. X-rays are sufficient for simple fractures. Comminuted tibial plateau fractures may require a CT scan to better characterize the fragmentation. Simple non-displaced fractures typically don’t require surgery. More complex fractures with uneven cartilage line will require a plate and screws to align the fragments.