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Syndesmotic injuries....AKA High Ankle Sprains:

12/22/2014

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HPI: Middle-aged male s/p MCC.

PE:  Ecchymoses, swelling, and tenderness about ankle. Tender over proximal fibula and pain with squeezing of calf.

Figure 1: Mortise view of ankle showing widened mortise medially

Picture

Figure 2:  Leg film showing proximal fibular fracture

Picture
Ankle Sprains:
-        Divided into grades
o   I: Minor, no significant ligamentous damage. Able to bear weight.
o   II: Associated with partial ligamentous tear. Significant ecchymoses/swelling. Difficulty bearing weight.
o   III:  Associated with complete ligamentous tear. Significant functional loss and universal inability to bear weight.

-        When should we obtain radiographs?:
o   If pretest clinical suspicion is high based on mechanism of injury or patient cannot be ruled out for fracture based on Ottawa ankle rules:

Picture
Syndesmotic injuries (AKA “high” ankle sprains):
o   PE and mechanism:
  • Physical exam may have tenderness with calf squeeze, pain in syndesmosis with external rotation and dorsiflexion of foot, and translation of fibula with anterior/posterior force.
  • If mechanism of injury involves hyper-dorsiflexion or significant eversion of the ankle, and patient has tenderness of the medial malleolus, a maisonneuve fracture (proximal fibular fracture associated with syndesmotic tear and deep deltoid ligament rupture) should be suspected. Order both ankle films as well as tib/fib films.  As in patient above, Ankle film may show widened mortise, indicating joint instability.

o   Treatment:
  • Non-operative: Patient may be made NWB and placed in a boot, short-leg cast, or posterior short-leg splint + sugar tong splint. 
  • Indications for non-op management:
                  -   Syndesmotic sprain without diastasis or ankle instability
                  -   Otherwise patient needs syndesmotic screw fixation. Patient can be immobilized and follow-up as an outpatient for surgical fixation

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Supracondylar Humerus Fractures:

12/12/2014

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HPI: 7 y/o fall from monkey bars. Landed on extended shoulder + outstretched arm.

Physical exam: Obvious arm deformity. Ecchymosis over distal/medial arm. Inability to flex thumb IP joint and DIP of index finger (AIN neuropraxia). Palpable pulses. Warm extremity.
Picture
AP showing mild varus angulation    

Picture
Lateral film showing significant posterior displacement of distal portion of fracture
Picture
 Normal lateral film
Picture
Normal AP flim showing Baumann's angle: angle btw humerus and capitellar physis. This measures amount of varus/valgus deformity
Supracondylar Humerus Fractures:
Two categories:
·       Extension: Distal fragment displaced anteriorly (95% of cases).
·       Flexion: Distal fragment displaced posteriorly (5% of cases).

Four Types:
·       I: Nondisplaced: look for posterior fat pad
·       II: Displaced. Posterior cortex intact
·       III: Completely displaced
·       IV: Complete periosteal disruption with instability on flexion and extension.

Presentation:

·       Usually from fall on outstretched hand.
·       Frequently will have neurologic findings:
·       Anterior Interosseus Neuropraxia:
·       Most common neurologic finding. Particularly with extension-type fractures.
·       AIN is a branch of Median nerve.
·       Patient's cannot flex thumb IP joint or index DIP joint (Can't make an “OK” sign).
        Almost all will resolve with conservative management.

       Also have vascular compromise in approximately 1%
       Usually brachial artery compromise
       High collateral flow, so patient may have a pink, but pulseless extremity. Still requires emergent reduction.

Treatment:
       Type I: Immobilization at 90 degrees and ortho follow-up.
       Type II: Closed reduction unless displacement is minimal.
       Adequate reduction: Baumann's angle wnl, anterior humeral line transects capitellum
       Type III: High-risk for neurovascular complications. Get ortho involved. Almost always require closed reduction + pinning vs. open reduction
     Type IV: Open surgical reduction and fixation

       Indications for open reduction:
       1.) Inadequate reduction with closed techniques
       2.) Vascular injury
       3.) open fracture
       4.) Type iv fracture

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Metacarpal Fractures

12/6/2014

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HPI: Patient punched a wall

Physical exam: Right hand with significant soft tissue swelling dorsally and TTP over third metacarpal.

Picture
Picture
Metacarpal Fractures:
            General Principles
  • Divided into fractures of metacarpal head, neck, and shaft
  • Treatment is based on which metacarpal is involved and location of fx
  • Acceptable angulation varies by location (See chart below)
  • No degree of malrotation is acceptable

Acceptable Angulation

Picture
Treatment:
            Immobilization: Indications for non-operative immobilization are
1.)    Stable fracture pattern
2.)    Acceptable angulation
3.)    no rotational deformity
4.)    Shortening of less than 5mm

Splinting:
•       Fracture splints should be forearm-based and should allow for motion of the interphalangeal (IP) joints.
•       Splints should extend over the dorsal and palmar aspect of the entire metacarpal being treated.
•       Generally, the wrist should be placed in 20-30° of extension; the metacarpophalangeal (MCP) joints should be immobilized in 70-90° of flexion, with the dorsal aspect of the splint extending to the IP joints; and the volar aspect should end at the distal palmar crease.
•       Buddy taping the fingers of the involved metacarpal can aid in maintaining rotational control.




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    Disclaimer: All images and x-rays included on this blog are the sole property of CMC EM Residency and cannot be used or reproduced without written permission.  Patient identifiers have been redacted/changed or patient consent has been obtained.  Information contained in this blog is the opinion of the author and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.
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  • RESIDENCY
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    • EM GuideWire
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    • Blogs, etc. >
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      • Dr. Patel's Coding Blog
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    • Resources >
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      • PGY - 1
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