HWN Suggests

Must Not Miss Fractures in the ED

Undiagnosed fractures occur frequently in the Emergency Department setting, with a total miss rate of 1-3%. These missed fractures not only lead to poor patient outcomes, but also account for the second highest cost of litigation against EM docs, behind only MI. This may not seem relevant if you are lucky enough to have access to a Radiologist 24-7, however there are several injuries that will be missed if they are not included in the differential diagnosis, because even the best radiologist can’t read a film if it wasn’t ordered. This blog post will cover three ‘must not miss’ injuries to keep in mind when assessing your run-of-the-mill orthopedic injuries namely: the Maissoneuve fracture,…

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 Fracture Radiographs: A Rapid Review of Terminology

Long bone fractures in the pediatric population have specialized terminology. In children, the growth plate, or physis, is the location of development of new bone and sits between the metaphysis and epiphysis. In some long bones, such as the phalanges, the growth plate is only present at one end, while in other long bones, growth occurs at both ends.

 Occult Fractures and Dislocations

Missed occult fractures and dislocations, in general, may result in significant morbidity for the patient and law suites for you. Six cases are presented in this episode, ranging from common scaphoid fractures to rarer dislocations.

 Reduction of Common Fractures and Dislocations

Reduction of fractures includes many options, some of which are appropriate for one type of injury and some for another. The reduction can be either anatomical or non-anatomical.

Articles of Interest

Distal Radius Fractures - Pediatric

Treatment is generally closed reduction and casting for the majority of fractures. Surgical intervention is indicated for significantly displaced or angulated fractures in patients approaching skeletal maturity.

EM@3AM: Open Fracture

Treat patients with open fractures as trauma patients, looking for concomitant life-threatening injuries as well as vascular injuries and compartment syndrome from the fracture.

EM@3AM: Rib Fractures

Adults, especially elderly patients, have a high risk of complications with rib fractures.

EM@3AM: Sacral fractures

A full neurologic exam, specifically aimed at the lower nerve roots (L5-S5), is needed to find any deficits. CT may be needed to discover if there is a fracture; x-rays have poor sensitivity. Most patients are appropriate for discharge with orthopedic follow up with weight bearing ambulation as tolerated.

Open Fractures – Pearls and Pitfalls

They can range from a tiny break in the skin to limbs hanging by a small piece of skin and tissue... Diagnoses that cannot be missed include vascular compromise and compartment syndrome. Compartment syndrome teachings classically recite the 5 P’s; however, these perform poorly when studied with inadequate sensitivities. The most important clinical exam finding in these patients is pain out of proportion and pain with passive stretch of the affected area.

Pediatric Ankle Injuries

No discussion on pediatric orthopedic injuries would be complete without a review of the Salter-Harris classification. There is a lot of practice pattern variation in the management of patients with negative radiographs but growth plate tenderness on exam (i.e. the potential Salter-Harris I fracture). The Boutis et al. group has done some great work in this area, and you highlight several key studies in your excellent review of the literature. I personally feel well-supported by this emerging evidence, and my practice pattern is to place patients in a removable ankle lacer (if able to bear weight) or a pneumatic walking boot (if unable to bear weight), with crutches as needed, and outpatient follow-up with their pediatrician versus Sports Medicine, rather than Orthopedics.

Pediatric Hand Injuries, Part I: Fractures and Dislocations

One of the major differences between the pediatric and the adult skeleton is the presence of growth plates or physes. When seeing a pediatric patient with any injury to the extremity, physeal injury must always be considered. The physis is the site of ossification and longitudinal bone growth.

Radial Head Fracture

One of the most commonly missed injuries in the ED and on radiographs.

Salter-Harris Fractures

Salter-Harris Fractures refer to fractures that involve the growth plate (physis). Therefore, these fractures are applicable specifically to the pediatric population, occurring most often during periods of rapid growth (growth spurts) when the growth plate is at its weakest, close to age ranges where children tend to participate in high-risk activities (11-12 in girls and 12-14 in boys).

The Growth Plate: Anatomy and Injuries

Incidence of physeal fractures ranges from 14.8%-30% in the literature.

Tips for Catching Commonly Missed Ankle Injuries

Written from the perspective of an emergency physician who also runs a weekly minor fracture clinic, this column is intended to highlight a few key ED teaching points for commonly missed and commonly mismanaged ED orthopedic cases.

Unstable Cervical Spine Fractures

Fractures of the cervical spine are injuries that must be approached with caution. Some are stable, some are unstable, and mismanagement can lead to life-altering sequelae. Remembering which fractures fit into which category is imperative for optimum emergency department care.