Chapter 267: Initial Evaluation and Management of Orthopedic Injuries

Musculoskeletal trauma involves injury to one or more of the following structures:

Bone: A unit of the skeleton composed of the hardest variety of connective tissue. Bones give shape and support to the body. In addition to surrounding and protecting vital organs, they serve as points of attachment for the muscles of the limbs, making movement possible.

Joint: The area where two or more bones articulate with one another. Joints are usually classified in terms of the amount of motion permitted at the articulation. Most joints of the extremities are synovial joints, which allow the greatest amount of motion.

Ligament: A bundle of connective tissue forming part of the fibrous capsule surrounding a joint and attached to it. Every joint of the extremities is reinforced by two or more ligaments, whose purpose is to stabilize the joint by confining its movements to specific planes and preventing movement beyond physiologic limits.

Tendon: The fibrous structure connecting a voluntary muscle to bone, cartilage, or ligaments. Tendons enable muscles to effect motion in the joint or body area to which they are attached.

Orthopedic injuries to these structures include the following:

Fracture: A disruption of bone tissue. Fractures may be caused by: (1) an application of force exceeding the strength of the bone, (2) repetitive stress, or (3) an invasive process that undermines the bone's integrity.

Dislocation: Complete disruption of a joint, such that the articular surfaces of the bones that comprise the joint are no longer in contact with one another.

Subluxation: Partial disruption of a joint, in which some degree of contact between the articular surfaces remains.

Fracture-dislocation or fracture-subluxation: Disruption of a joint combined with fracture of at least one of the bones involved in the articulation.

Strain: A tearing injury to muscle fibers resulting from excessive tension or overuse.

Sprain: A tearing injury to one or more ligaments of a joint, which occurs when the joint is forced beyond the limits of its normal planes of motion.

Properly assessing and treating bony injuries in the ED requires an understanding of the physiologic processes by which fractures are created and by which they heal. Practical knowledge of fracture pathophysiology may provide the index of suspicion needed to diagnose an injury that might otherwise be missed. It also may help prevent or minimize complications and sometimes may form the basis for advising the patient regarding the outlook for recovery of function.

TYPES OF FRACTURES

Although fractures are sometimes classified in terms of the mechanism that created them, they also may be described in terms of the physiology involved.

"Common" Fractures

Most fractures are the result of significant trauma to healthy bone. The bony cortex may be disrupted by a variety of forces, including a direct blow, axial loading, angular (bending) forces, torque (twisting stress), or a combination of these.

Pathologic Fractures

Fractures that result from relatively minor trauma to diseased or otherwise abnormal bone are termed pathologic fractures. In such cases, a preexisting process has weakened the bone and rendered it susceptible to fracture by forces that, under normal circumstances, would not disrupt the cortex. Common examples of such injuries are fractures through metastatic lesions, fractures through benign bone cysts, and vertebral compression fractures in patients with advanced osteoporosis. Numerous other disease processes may render an individual susceptible to pathologic fracture. Because these injuries often are not associated with a history of significant trauma, subtle pathologic fractures may go undetected unless there is a clinical index of suspicion.

Stress Fractures

Bone may undergo a "fatigue" fracture by being subjected to repetitive forces before the bone and its supporting tissues have had adequate time to accommodate to such forces. An example is a metatarsal shaft fracture in unconditioned foot soldiers ("march fracture"). Radiographs often are negative early in the clinical course of stress fractures. The initial diagnosis may be presumptive, based solely on the history and findings of point tenderness or localized swelling. Days or weeks may pass before the fracture line or new bone formation becomes visible radiographically.

Salter (Epiphyseal Plate) Fractures

Fractures involving the physis, the cartilaginous epiphyseal plate near the ends of the long bones of growing children, were originally classified by Salter and Harris¹ and are commonly called Salter fractures. New bony material needed for the elongation of bones during growth is provided by specialized cells within the physis. When growth is completed, the physis transforms from cartilage into bone, ultimately fusing with the bone surrounding it, and disappearing as a distinct entity. By definition, Salter fractures cannot occur in fully grown adults.

Damage to the epiphyseal plate during a child's growth may destroy part or all of its ability to produce new bone substance, resulting in aborted or deformed growth of the limb. The potential for growth disturbance from an epiphyseal plate injury is related to the number of years the child has yet to grow (the older the child, the less time remains for deformity to develop) and to the pattern of the fracture line through the epiphyseal area. Classification of Salter fractures and their clinical implications are discussed in the section Describing Radiographs in this chapter.

FRACTURE HEALING

An understanding of the short- and long-term aspects of bone healing helps decision making regarding fracture reduction, treatment modality, and the prognosis for regaining function or being left with residual deformity. Fracture healing consists of three phases: inflammatory, reparative, and remodeling, each of which blends into the next, with some degree of overlap between them.² When a fracture occurs, the microvessels crossing the fracture line are severed, depriving the damaged bone ends of their blood supply. As a result, the bone ends gradually necrose, triggering a classic inflammatory response in which neutrophils, macrophages, and lymphocytes migrate to the area. The proteins and peptides (collectively termed cytokines) released by these cells promote revascularization.³ This early phase is brief but creates the tissue environment for the most predominant aspect of fracture healing, the reparative phase.

Granulation tissue soon begins to infiltrate the area.⁴ Within the granulation tissue are specialized cells capable of forming collagen, cartilage, and bone—the ingredients of callus. Callus gradually surrounds the fractured ends and stabilizes them, becoming more densely mineralized with time.

Meanwhile, the necrotic edges of the fragments are removed by osteoclasts, cells whose function is to resorb bone. That is why some "hairline" fractures do not appear on a radiograph until days after injury. Invisible initially, the diagnostic fracture line appears only after necrotic bone has been resorbed from the area.

The final phase of bone healing, the remodeling phase, is the longest, sometimes lasting years. Remodeling is the tendency of bone gradually to regain its original shape and contour. During this phase, superfluous portions of callus are resorbed, and new bone is laid down along the natural lines of stress. These layers, easily visible on radiographs of normal bone, are the bony trabeculae. The formation of trabecular bone is a physiologically efficient process providing maximum strength relative to the amount of bone material used.

The anticipated degree of remodeling after a fracture is related to a number of factors. Predictors of satisfactory remodeling include youth, proximity of the fracture to the end of the bone (but not involving the epiphyseal plate), the amount of angulation, and the extent to which the direction of angulation coincides with the plane of natural joint motion.

Clinical decisions regarding the aggressiveness of fracture reduction are directly linked to knowledge of bone-healing physiology. Some angulation near the end of a long bone, for example, may be more accepTable than the same amount of angulation near the midshaft. In the wrist, dorsal or volar angulation has a better prognosis than does ulnar or radial angulation because the natural plane of wrist motion is dorsal to volar. Mild angulation in a 2-year-old child may be left to remodel on its own, whereas the same amount of angulation in an adult may require correction.

OPEN FRACTURE

An open fracture is a fracture associated with overlying soft tissue injury, creating communication between the fracture site and the skin. Although this term may convey the image of grossly exposed bone, the term is equally applicable to any puncture wound extending to the depth of an underlying fracture. Such puncture wounds may be created by external forces or may occur from within, when a sharp bone fragment transiently protrudes through the skin before receding back beneath the surface.

A potential major complication of open fracture is osteomyelitis. Once established, osteomyelitis may result in months or years of pain, disability, medical therapy, surgical procedures, and, in some cases, amputation. Although osteomyelitis may sometimes be unavoidable, it is less likely when treatment is prompt and meticulous.

Open fractures are usually classified by their severity, based on the extent of overlying tissue disruption, lack of bone coverage, kinetic energy of the injuring force, and evidence or likelihood of significant contamination. Irrespective of these factors, any open fracture should be promptly and carefully treated.

SUBLUXATION AND DISLOCATION

Subluxation is a condition in which the articular surfaces of a joint are nonconcentric to any degree. Dislocation is the most extreme form of subluxation. A joint is dislocated when the articular surfaces of the bones that normally meet at the joint are completely out of contact with one another. The urgency of reducing a dislocation is based on several factors. One is the potential for neurologic or circulatory compromise. The neurovascular bundle passing close to the affected joint may become "kinked" around the dislocation. This may result in neurologic or vascular deficit that might be temporary if the deformity is reduced promptly but irreversible if treatment is delayed. Another consideration is that the longer a joint has been dislocated, the more difficult it may be to reduce and the less sTable the reduction is likely to be. This is probably due, at least in part, to edema, muscle spasm, and other tissue changes that increase over time.

Dislocation of the hip also carries the potential for avascular necrosis of the femoral head. The necrosis occurs because much of the blood supply to the femoral head is delivered through vessels that emerge from the acetabulum. When the joint is dislocated, circulation to the femoral head is disrupted. At some point, the vascular insult becomes irreversible, and bony necrosis results. Although aseptic necrosis may occur despite the clinician's best efforts, its likelihood increases with the delay until reduction.

NEUROVASCULAR INJURY

Any injury associated with neurologic or vascular compromise should be addressed as soon as possible. The longer such a deficit goes untreated, the longer it is likely to persist and the greater the possibility that it will be irreversible. In some cases, reducing a deformity by means of longitudinal traction is all that is necessary to restore circulation or nerve function.

PRELIMINARY SPLINTING

Effective splinting of an injured extremity is important for several reasons: (1) it reduces pain, (2) it reduces damage to nerves and vessels by preventing them from being compressed between the fracture fragments or being stretched by angulation at the fracture site, (3) it reduces the chance of inadvertently converting a closed fracture to an open one should a sharp bone fragment poke its way through the skin, and (4) it reduces the pain associated with patient transport by minimizing motion of the fracture fragments.

PREHOSPITAL SPLINTING DEVICES

Many splinting modalities are available to EMS personnel. These may range from sophisticated devices, such as vacuum splints containing small beads that conform to the extremity when air is removed, to simpler techniques such as cardboard or pillow splints, or padded IV boards.

Sling and Swath

For injuries of the wrist or forearm, consider using a sling to supplement the splint, because optimal immobilization includes the joint above and the joint below the fracture, and a sling helps keep the elbow at rest.

For suspected injuries to the shoulder, humerus, or elbow, a sling-and-swathe arrangement works well. This method involves applying a sling, then binding the affected arm to the thorax with a gauze wrap. An exception to this principle is immobilization of patients with suspected anterior dislocation of the shoulder. Many patients with this injury have difficulty adducting the forearm, and forcibly binding it to the thorax may be painful. A simple sling is adequate in such cases. Injuries to the ankle may be immobilized in a pillow or well-padded cardboard splint. If a fracture of the tibial shaft or knee is suspected, the device should extend well above the knee to immobilize the joint above and the joint below the fracture.

Splints

Some injuries warrant special splints, such as a winch-mechanism traction apparatus for femoral shaft fractures. Although such a device does not immobilize the hip (the joint above the fracture), the traction component makes this unnecessary. If a traction device is not available, then both the hip and knee should be immobilized. One method of accomplishing this is to bind the legs together, then bind the patient to a backboard from ankles to thorax with folded sheets or towels beneath the lower legs (but not the feet) to ease pressure on the heels.

Other types of splints exist, but their use is controversial. InflaTable plastic splints, for example, may be used for injuries to the ankle or wrist but sometimes are used inappropriately for fracture of the humerus or femur. Because these devices normally do not extend sufficiently proximally, they provide inadequate immobilization for such injuries. Also, overinflating the device may impair circulation. If the inflaTable splint cannot be dented by moderate thumb pressure, it is probably overinflated. InflaTable splints should not be applied over clothing, because wrinkles in the clothing may cause pressure sores in swollen and vulnerable tissue.

Also controversial are nonmalleable aluminum splints, because they are based on the "one size fits all" principle, which some clinicians interpret as "this size fits none." Malleable aluminum splints are preferable, as they can be made to conform more closely to the contour of the extremity, even accommodating some degree of deformity. If used, aluminum splints of either type should be well padded, because their hard surface may cause pressure sores. Like any splint, they should immobilize the joint above and the joint below the fracture when used for long-bone injuries. For example, an above-knee splint is indicated for suspected fracture of the tibial shaft. Aluminum splints should be removed promptly once a fracture is diagnosed or ruled out. If a fracture is confirmed, replace the splint with an alternative immobilization dressing before the patient leaves the ED, because aluminum splints may cause pressure sores even when padded.

Military Antishock Trousers

Another controversial device is military antishock trousers. This device may be used during ambulance transport of patients with already diagnosed pelvic ring fracture, or for patients with a clinically apparent femoral fracture when a traction device is not at hand, as the device immobilizes the joints above and below the fracture. Some EMS systems also advocate its use for patients with bilateral femur fractures even when traction is available, because of the anatomic difficulty of applying two traction splints. However, military antishock trousers are cumbersome to apply, their efficacy is not firmly established, and they can possibly contribute to compartment syndrome, fluid and electrolyte imbalance, and circulatory impairment.^5,6

REDUCING DEFORMITY IN THE FIELD

Many EMS programs do not recommend prehospital reduction of deformity for an injured extremity, as injudicious manipulation may convert a pure dislocation to a fracture-dislocation. Even if a fracture had already existed, there would be no way to prove it was not caused by the manipulation. One circumstance in which prehospital reduction of obvious fracture to the shaft of a long bone may be justified is a nonpalpable distal pulse. In the absence of a common standard, the indications for reduction of deformity by prehospital personnel remain at the discretion of the supervising EMS program.

The importance of a careful history and physical examination cannot be overstated. Orthopedic diagnosis is sometimes thought of as being as simple as taking a radiograph of the painful area. Although imaging is an important adjunct, it is not the ultimate diagnostic resource. The pain of a fracture or a dislocation may be referred to another area. For example, patients with disruption of the sternoclavicular joint or fracture of the humeral shaft may complain only of shoulder pain. If the radiograph is based solely on where the patient reports discomfort, then the injured part might not be included on the film. Imaging decisions should be based not only on the chief complaint, but also on systematic palpation, observation of subtle deformity or significant point tenderness, and mechanism of injury.

Some fractures or dislocations may be demonstrated only by special radiographic views, which are not part of the standard series for that body part. Such views will never be ordered unless the clinician has already formulated a presumptive diagnosis based on the history and physical findings.

Some injuries might not be radiographically apparent on the first day, regardless of what views are taken. Common examples are fracture of the scaphoid, nondisplaced fracture of the radial head, and stress fracture of a metatarsal. The classic radiographic signs accompanying these injuries, such as the fat-pad sign of the elbow, are not always conveniently present, but mechanism, history, and findings suggesting the injury often are. CT or MRI may allow early diagnosis of fractures that are not radiographically evident. However, such tests are not always available or feasible on the day of injury. In such cases, the diagnosis of fracture may be purely clinical until 7 to 10 days post-trauma, when enough bony resorption has occurred at the fracture site to reveal a lucency on plain radiographs.

HISTORY

The value of the history in cases of orthopedic trauma is often underestimated. Knowing the precise mechanism of injury may be the key to diagnosing some fractures or dislocations. For example, a history of shoulder injury combined with the complaint of dysphagia may be the only clue to the existence of posterior sternoclavicular dislocation. This entity, which causes pressure on mediastinal structures, often can be demonstrated only by CT and may result in severe complications if treatment is delayed. Table 267-1 provides other examples of mechanisms that may lead the clinician to suspect, or presumptively treat for, specific injuries. This is by no means a definitive or exhaustive list. Some of the mechanisms described may produce injuries other than those mentioned. Conversely, the injuries may be produced by mechanisms in addition to those listed.

Some musculoskeletal injuries or conditions may not necessarily be associated with a history of direct trauma. Occult fracture of the hip in an osteoporotic individual, occult stress fracture of a metatarsal in someone who has recently done an unusual amount of walking, and slipped capital femoral epiphysis in a preteenager or young adolescent are examples of injuries in which symptoms may be gradual and insidious in onset, unrelated to an isolated traumatic event. Exquisite tenderness to palpation or pain on weightbearing or passive range of motion suggests the possibility of an occult or easily missed fracture. Depending on the index of suspicion, further studies, such as a bone scan or MRI, may be indicated to exclude significant pathologic conditions before the patient is allowed to resume weightbearing.

History taking should not necessarily be limited to orthopedic issues. Depending on the situation, a general medical history should be obtained because it may have implications for further workup, the potential for complications, or ultimate prognosis for recovery of function. Relevant issues may include a history of heart disease or neurologic disease, taking anticoagulant medication, falling due to syncope or transient hemiparesis, or an unsteady baseline gait that cannot withstand further impairment.

PHYSICAL EXAMINATION

Essential components of the examination for musculoskeletal trauma are (1) inspection for swelling, discoloration, or deformity; (2) assessment of active and passive range of motion of the joints proximal and distal to the injury; (3) palpation for tenderness or deformity; and (4) assessment of neurovascular status.

Inspection and Range of Motion

Gross deformity along the shaft of a long bone is pathognomonic for fracture. Deformity at a joint, loss of range of motion, and severe pain at rest suggest the presence of a dislocation or fracture near the joint. An exception is posterior dislocation of the shoulder, which, although intensely painful, might not be accompanied by obvious deformity, although the humeral head may be palpable posteriorly.

Palpation

When gross deformity is not present, presumptive diagnosis strongly depends on findings noted on palpation. Palpation may disclose areas of bony step-off and the precise location of point tenderness.

The palpation examination should be done systematically and consistently from one patient to the next. The area palpated should extend well beyond the location of pain described by the patient, as the pain may be referred. For example, when an injured patient complains of shoulder pain, palpation should begin at the sternoclavicular joint, then proceed along the clavicle onto the acromioclavicular joint, then onto the humeral head and along the entire humeral shaft. In addition, the scapula should be palpated for tenderness, and the posterior aspect of the shoulder should be palpated for any unnatural prominence or fullness that might suggest posterior dislocation of the humeral head. Injury to any of these areas may be reported by the patient as "pain in the shoulder." Only a meticulous palpation examination may protect the clinician from being misled by referred pain and missing a crucial diagnosis.

Neurovascular Assessment

When injury involves an extremity, as opposed to the vertebral column, sensorimotor testing should be performed on the basis of peripheral nerve function, rather than nerve root and dermatomal distribution (Figure 267-1). In the upper extremity, the radial, median, and ulnar nerves should be tested. When the shoulder is anteriorly dislocated, two additional nerves, the axillary (supplying sensation to the lateral aspect of the shoulder) and the musculocutaneous (supplying sensation to the extensor aspect of the forearm), also should be checked. In the lower extremity, examination of the saphenous (sensory only), peroneal, and tibial nerves should be performed. Neurologic deficit is important to document early, particularly before the patient has undergone any significant manipulation or reduction maneuvers.

Assess vascular status early. The sooner circulatory compromise is identified and addressed, the better the chance of avoiding tissue ischemia or necrosis. Injuries such as dislocation of the knee (tibiofemoral joint), fracture-dislocation of the ankle, and displaced supracondylar fracture of the elbow in children may be associated with vascular disruption, with resulting circulatory impairment.

IMAGING

The joints above and below a fracture should generally be imaged because injury at the proximal or distal joint may coexist with long-bone fractures. Injuries that may require special views or advanced imaging modalities in order to be visualized include acromioclavicular separation, fracture of the scaphoid, posterior shoulder dislocation, and sternoclavicular dislocation.

The use of bedside US has been reported for pediatric clavicle and forearm fractures and long-bone fractures. However, US for these purposes is operator dependent and has not replaced traditional diagnostic imaging.^7,8,9,10

Children who have sustained trauma at or near a joint may need comparison studies of the opposite extremity to differentiate fracture lines from normal epiphyseal plates or ossifying growth centers. This is particularly true of the pediatric elbow, which typically exhibits six ossification centers sequentially as the child grows.

Although the clinician may be tempted to base diagnostic and treatment decisions on the radiologist's report, this is not advisable for at least two reasons. First, a negative radiologic report does not exclude significant injury. Fracture of the radial head, scaphoid, or metatarsal shaft, for example, may be undetecTable on radiographs initially, even when special views are taken. Second, the terminology used by radiologists to describe malposition of fracture fragments or disrupted joints often differs from the terminology used by orthopedists. Because the emergency physician may confer with an orthopedist regarding the initial management of a patient, and because this interaction commonly involves describing the radiographic appearance of an injury, it is important that the two physicians "speak the same language."

DESCRIBING RADIOGRAPHS

As more hospitals convert from film-based to digital imaging, orthopedic consultants are increasingly likely to be able to examine a patient's imaging studies by remote access. In the absence of such technology, proper management of the patient may depend on the emergency physician's ability to convey the radiographic appearance of the injury to the consultant. In such cases, the narrative often will influence the orthopedist's decision regarding the need for hospital admission and whether surgical versus nonsurgical management is warranted. In essence, the emergency physician should be able to transmit a virtual copy of the radiograph by means of verbal description.

There are a number of ways to characterize the appearance of fractures. The method presented below is intended to be the most practical from the standpoint of communicating with an orthopedic consultant.

Open Versus Closed

Although not a radiologic finding per se, whether a bony injury is open or closed is an important consideration and should be conveyed to the orthopedist at the outset. The implications of open fracture are of such significance that this factor alone may determine the patient's immediate care or ultimate disposition.

Location of the Fracture

Typical reference points used by orthopedists to describe the location of a fracture along the shaft of a long bone are the midshaft, the junction of the proximal and middle thirds, and the junction of the middle and distal thirds. Any fracture more proximal or distal than these locations may be described in terms of its distance, in centimeters, from the bone end.

When a fracture extends into the adjacent joint, it is termed intra-articular. Intra-articular fractures have special significance because disruption of the joint surface may warrant surgery to restore the joint's contour and prevent subsequent traumatic arthritis. This feature of a fracture line, if present, constitutes important information.

Anatomic bony reference points should be cited when applicable. A fracture just above the condyles of the distal humerus or femur, for example, is termed a supracondylar fracture. A fracture running from the greater to the lesser trochanter of the proximal femur is an intertrochanteric hip fracture, whereas a fracture just below the trochanters is subtrochanteric, a fracture just above them is said to involve the femoral neck, and a higher fracture just below the femoral head is referred to as subcapital. The area at or proximal to the coronoid process of the ulna is the olecranon and should be referred to as such, rather than simply the "proximal ulna." Other bony landmarks include the radial head at the elbow, radial styloid at the wrist, and the greater tuberosity of the humeral head. Numerous additional examples exist.

Orientation of the Fracture Line

The most common orientations of fracture lines are illustrated in Figure 267-2. Torus and greenstick fractures occur almost exclusively in young children, whose bones are more pliable than those of adults. Note the segmental fracture, which is commonly described incorrectly as a comminuted fracture. To an orthopedist, the term comminuted implies splintering or shattering. A single, large, free-floating segment of bone between two well-defined fracture lines is a segmental fracture.

Displacement and Separation

The term displacement may be used in either of two ways. In the broadest sense, it pertains to any deviation from anatomic position or alignment. Used more precisely, displacement refers to the extent to which fracture fragments are nonconcentric or offset from each other. The magnitude of displacement may be expressed in terms of direct measurement (e.g., 4-mm displacement) or in terms of the percentage of the width of the bone (e.g., 50% displacement, complete displacement). The direction of displacement is based on the position of the distal fragment relative to the proximal fragment.

Displacement should not be confused with separation, which is the distance two fragments have been pulled apart. Figure 267-3 illustrates principles of displacement and separation.

Shortening

Shortening, expressed in millimeters or centimeters, is the amount by which a bone's length has been reduced. Shortening may occur by impaction (telescoping of the fragments into one another) or by the overlap of two completely displaced fragments (Figure 267-4). The latter is referred to by some orthopedists as overriding. Because a radiograph affords no depth perception, a fracture that appears impacted on one view needs to be visualized at an angle 90 degrees from the first to differentiate it from a fracture whose ends are completely displaced and overriding. Depending on the location of the fracture and the age of the patient, shortening may have long-range functional implications and may have to be corrected by closed manipulation or by surgery.

Angulation

Angulation is described in terms of two parameters: degree and direction (Figure 267-5). Quantifying the angulation is relatively simple. One need only estimate the amount of "unbending" (expressed in degrees) that would be needed to make the fragments parallel.

Conveying the direction of angulation may be more difficult because the terminology is less consistent among clinicians. In general, when a fracture is near the midshaft of a long bone, the direction of angulation is the direction of the apex of the angle formed by the two fragments. (Figures 267-5A and 267-5B illustrate 30 degrees of dorsal angulation.) When a fracture is near the end of a bone, however, angulation is described in terms of the direction the terminal fragment is deviated. Thus Figure 267-5C also shows 30 degrees of dorsal angulation, even though the apex of the angle formed by the fragments is pointing in the opposite direction from that in the preceding figures. If there is a possibility of ambiguity in the description, specifying the direction of deviation of the distal fragment usually can resolve it.

Depending on the anatomic area involved, direction of angulation may be expressed as anterior or posterior, lateral or medial, radial or ulnar, or dorsal or volar.

Rotational Deformity

Rotational deformity—that is, the extent to which the distal fracture fragment is twisted on its own axis relative to the proximal fragment—is generally not apparent on radiographs. This element of fracture description depends on physical examination. Its detection is particularly important in the phalanges of the fingers, where, if rotational deformity goes unrecognized and uncorrected, the injured finger will permanently be malaligned when the hand is closed.

Fracture Combined With Dislocation or Subluxation

Injuries near a joint may involve dislocation or subluxation combined with a proximate fracture. An example is fracture of one or more ankle malleoli, together with partial or complete displacement of the talus from beneath the tibia. These are significant injuries, often requiring surgical intervention. If, in describing the injury, the clinician emphasizes the fracture component but expresses the dislocation or subluxation as mere "displacement," then the full severity may not be appreciated by the orthopedist. Such injuries should be described as fracture-dislocations or fracture-subluxations.

Salter-Harris Fractures

Salter and Harris classified fractures involving the epiphyseal plate at the end of the long bone of a growing child into five types based on the pattern of the fracture line. Because the type generally correlates with the potential for future growth disturbance (and, consequently, with the aggressiveness of the treatment warranted), the ability to identify the fracture type based on its radiographic appearance is important.

Perhaps the easiest way to remember the Salter-Harris classification system is to think of these injuries not in terms of where the fracture line runs, but in terms of what has been broken off. Figure 267-6 illustrates the anatomy involved. Table 267-2 lists the five types of Salter-Harris fractures, which are illustrated in Figure 267-7. The potential for growth disturbance is least for type I and increases with the classification number, with the worst prognosis being associated with type V injuries.

Type I and type V Salter fractures may be radiographically undetectable. Type I injuries usually involve no transverse displacement and little or no separation of the epiphysis from the rest of the bone. Also, the lucent fracture line is not visible within the equally lucent epiphyseal plate. Diagnosis of acute Salter type I fractures is usually presumptive, based on the presence of swelling and tenderness in the region of the physis.

Type V injuries may be evident only retrospectively, when growth disturbance first begins to appear. At the time of initial presentation, however, a history of a significant axial loading force, coupled with significant tenderness in the area of the epiphyseal plate, should suggest the possibility of a type V injury. Such injuries should be immobilized and referred for orthopedic follow-up.

CONTROL PAIN AND SWELLING

Initiate measures to reduce swelling early. Severe swelling not only intensifies the pain of injury but also may delay the application of a definitive immobilization dressing and may make the skin more susceptible to pressure sores. Although sometimes regarded as trivial modalities, the application of cold and elevation are often quite effective in keeping swelling to a minimum or at least halting its progression. Jewelry, watches, or rings that may cause compression or constriction as an extremity swells should be removed.

Give analgesics as necessary. If the patient is relatively comforTable at rest, medication may not be required. Even narcotic analgesics may have minimal effect on the pain of movement or manipulation unless combined with other CNS–acting agents.

WITHHOLD ORAL INTAKE

Any patient who might be a candidate for prompt surgical fixation, manipulation, or any other procedure under general anesthesia or procedural sedation should not be allowed to eat or drink from the moment of arrival until the need for, and timing of, such a procedure has been ascertained.

REDUCE FRACTURE DEFORMITY

The long-term purpose of reducing significant deformity associated with fractures is restoration of normal appearance and function of the extremity. However, there are also short-term benefits to reducing deformity early: (1) alleviating pain, (2) relieving the tension on nerves or vessels that may be stretched as they pass along the deformity, (3) eliminating or significantly minimizing the possibility of inadvertently converting a closed fracture to an open one when the skin is tented by a sharp bony fragment, and (4) restoring circulation to a pulseless distal extremity.

After the patient has been appropriately sedated, deformity at or near the midshaft of a long bone is usually reduced with gradual, steady, longitudinal traction. Any rotational deformity should be corrected only after the angular component has been addressed and should be performed while traction is maintained.

The nearer a deformity is to a joint, the more difficult it may be to correct and the more specialized the reduction maneuver may have to be. When deformity is associated with circulatory deficit, a true emergency exists, and the anticipated delay until reduction should be considered.

REDUCE DISLOCATIONS

The techniques used to reduce specific dislocations are discussed in subsequent chapters. In general, prereduction radiographs are advisable when there has been significant trauma, unless time is crucial because circulation is threatened. Radiographs are needed because dislocations and fracture-dislocations may have a similar appearance on physical examination, but the techniques used to treat them may be very different.

Of course, there are circumstances in which the potential benefits of a prereduction radiograph may be outweighed by the associated expenditure of time and money. For example, a prereduction radiograph may be omitted in a patient with a history of multiple recurrent dislocations of the shoulder who presents with history, signs, and symptoms typical of another recurrence in the absence of significant trauma.

After a reduction maneuver, postreduction radiographs are valuable for confirming the success of the procedure, as well as for providing documentation, in the event that the joint redislocates after the patient is discharged from the ED.

INITIAL MANAGEMENT OF OPEN FRACTURES

Open fractures warrant prompt and meticulous attention. The most important elements in the treatment of open fractures, aside from tetanus prophylaxis that applies generally to any wound, are irrigation, debridement, and antibiotics as soon as is practical.¹¹

Early administration of antibiotics can prevent or reduce the clinical consequences of bacterial contamination in open fractures.^12,13 Consequently, initiate antibiotic therapy promptly in the ED. There is no standard antibiotic regimen. An accepted approach, but by no means the only regimen in use, is a first-generation cephalosporin, with the addition of an aminoglycoside when the wound is >10 cm with severe soft tissue injury and loss of bone coverage.^14,15 Some studies advocate the use of ciprofloxacin as an alternative to a cephalosporin.¹⁶ When there is significant contamination by plants or soil, consider the addition of penicillin (or metronidazole, clindamycin, or vancomycin for penicillin-allergic patients) for anaerobic coverage. Aerobic and anaerobic wound cultures may be obtained before antibiotics are administered, although the value of pretreatment cultures for open fractures is controversial.¹⁷

To lower the infection rate, not only antibiotics but also generous irrigation and adequate debridement are necessary to reduce bacterial contamination and colonization.¹⁸ The purposes of debridement and irrigation are (1) to expose the wound in order to allow better identification of the limits of injury and facilitate inspection for foreign material; (2) to identify and remove clots, debris, and nonviable tissue; and (3) to reduce bacterial contamination and make the wound more resistant to the effects of any residual contamination. (See chapter 40, Wound Preparation, for complete discussion of wound irrigation.)

Debridement and irrigation of minor wounds overlying a fracture sometimes may be performed in the ED. When tissue damage is moderate or severe, debridement and irrigation are typically performed in the operating room.

In many cases, such as fracture of the hip, the need for hospital admission and/or orthopedic consultation in the ED is obvious. In some situations, however, differences of opinion may exist regarding whether the patient needs to be seen by an orthopedist in the ED or whether the patient may be treated in preliminary fashion and referred for definitive orthopedic management. Even patients with injuries that ultimately may require surgical repair, such as an unsTable ankle fracture, sometimes may be immobilized and discharged with a referral for prompt orthopedic follow-up.

COMPARTMENT SYNDROME

In cases of known or suspected compartment syndrome, obtain prompt orthopedic consultation. Emergency surgical intervention may be required to try to avert permanent tissue damage and muscle contracture. The physiology and potentially catastrophic consequences of compartment syndrome are described in the section Complications later in this chapter and in chapter 278, Compartment Syndrome.

IRREDUCIBLE DISLOCATION

The emergency physician sometimes may be unable to reduce a dislocation, even with the aid of a nerve block or procedural sedation. Although technique is certainly a factor, there may be other reasons closed reduction cannot be accomplished, such as the interposition of soft tissues within the joint or the presence of an associated fracture. Orthopedic consultation should be sought in such cases. Timely reduction, which sometimes can be achieved only surgically, may help minimize the complications (and shorten the duration of pain) resulting from a dislocated joint.

CIRCULATORY COMPROMISE

Circulatory deficit due to musculoskeletal injury warrants prompt orthopedic consultation. Even if circulation has been restored by the emergency physician through the correction of deformity, the orthopedist may wish to investigate the integrity of the involved vessels and should at least be contacted to discuss the case.

OPEN FRACTURE

Some open fractures need to be treated aggressively in the operating room. Other types, such as those involving the phalanges, often may be irrigated in the ED and referred for follow-up. If there is any question, a discussion with the orthopedist may result in a mutually agreeable plan of care.

INJURIES REQUIRING SURGICAL INTERVENTION

Whereas some musculoskeletal injuries require operative intervention as soon as possible, others may be treated on a delayed basis. In many cases, orthopedists differ in their preferred approach to the timing of surgery. Orthopedic consultation, at least by telephone, is indicated in cases of musculoskeletal injury that the emergency physician believes may require operative fixation or repair. The orthopedist may then exercise the option to admit the patient or to see the patient in timely follow-up and schedule any necessary surgery at that time.

Immobilization is indicated not only for fractures, but also for dislocated joints that have been reduced. When a joint becomes dislocated, the ligaments that had provided its stability are disrupted, and the joint is susceptible to redislocation until healing has occurred.

The materials most commonly used for orthopedic immobilization are plaster of Paris (calcium sulfate) and fiberglass fabric combined with a polyurethane resin. Fiberglass has the advantages of being lightweight, fast setting, and resistant to damage by moisture. However, it is not as malleable as plaster, so it might not conform as well to the contour of the limb. This may be an issue when the purpose of the dressing is not only to provide immobilization but also to maintain the position of the fragments once a displaced fracture has been reduced.

Whether plaster or fiberglass is used for immobilization depends on a number of factors, including the emergency physician's preference, the philosophy of the orthopedic community, the needs of the patient, and the hospital's resources.

PRINCIPLES OF SPLINTING

The chemical reactions that cause plaster or fiberglass to set are initiated by contact with water. The higher the water temperature, the faster the materials harden. However, these reactions are exothermic, meaning they liberate heat. The faster the setting process, the more heat is generated. Therefore, the temperature to which the skin ultimately is exposed will be the additive result of the water temperature and the heat released by the chemical reaction. For this reason, severe burns may occur when plaster or fiberglass has been immersed in mildly hot water, even though the temperature of the water itself would not be sufficient to cause such burns. Although there is no universally prescribed ideal water temperature, a safe practice is to make the water room temperature. If steam is visible, the water is certainly too hot.

To avoid irritation and to minimize the potential for pressure sores, plaster or fiberglass dressings should include several layers of padding over the skin. When non-prepadded longitudinal plaster splints are used, cast padding has to be applied separately. The padding does not necessarily have to be circumferential. Several layers of longitudinal padding will effectively protect the skin as long as they exceed the width and length of the splinting material. The best way to ensure this is to fashion the dry splint first, then measure the padding over it. Longitudinal splints may be fashioned from fixed-length plaster strips, from plaster rolls normally used to create circumferential casts, or from prepadded material with plaster or fiberglass enclosed. The splint should be long enough to provide the leverage needed to immobilize the injured joint. To immobilize the elbow, for example, a splint should begin distal to the wrist and extend high up the lateral arm, almost to the level of the humeral neck. To immobilize the ankle effectively, a splint should extend from beneath the metatarsal heads to the proximal calf. If the fracture is along the midportion of a distal extremity (i.e., the forearm or the lower leg) rather than at a joint, the splint should be long enough to immobilize the joint above and the joint below the fracture.

NON-PREPADDED PLASTER

When a splint is fashioned from plaster rolls, determine the length of the splint by measuring out a single layer along the extremity according to the principles described previously. Then, on a flat surface, unroll the plaster back and forth over itself to make a multilayered splint. If fixed-length plaster strips are used instead of rolls, the only way their length can be customized is to shorten them, so an adequate length should be selected at the outset and trimmed as necessary. In either case, the splint should be at least 12 layers thick for an adult. Even more layers should be used for children, who typically remain as active as possible and have little regard for protecting the dressing.

When the dry splint has been prepared, measure out several layers of padding over it, making the padding longer and wider than the plaster. After setting the padding aside, grip each end of the splint and immerse it in water, keeping it submerged until bubbling stops (indicating that water has been fully absorbed into the interstices of the material). Then withdraw the splint and remove the excess water by sliding the compressed thumb and index finger along the length of the plaster on each edge. (Use a stripping motion, rather than crumpling or wringing out the dressing, or much of the plaster may be lost.)

The next step, frequently overlooked, is to lay the splint on a flat surface and massage the layers into one another so that they fuse together. This creates a strong dressing that is solid on cross-section. A splint whose separate layers are still visible on cross-section is much weaker.

The padding should now be laid on the plaster and the dressing applied to the extremity, with the padded surface against the skin. When two plaster segments are used, as for a thumb spica or a posterior ankle mold with an additional transverse "sugar tong" component, no padding should be interposed between the segments. Rather, they should be molded into each other where they overlap. An assistant can hold the splint against the extremity while it is wrapped in place with gauze bandage. The assistant should use the palms, rather than the fingertips, when holding the splint in place. Hardened finger dents may cause irritation or even pressure sores. When a compressive effect is desired, an elastic bandage may be wrapped over the gauze. (If an elastic bandage is wrapped directly onto plaster without an interposed layer of gauze, it will set into the plaster and may lose most of its compressive function.)

While the plaster is setting, the affected joint may need to be held in a particular position. Again, use the palms, rather than the fingers, for reasons already described. Once the setting process is well under way, the position of a joint should not be changed, or the dressing may crack and become functionally useless. If the joint has gradually migrated from the desired position, the clinician must decide to accept the current position or remove the dressing and start over. There is no need to feel hesitant about the latter course. Patients generally appreciate a desire for perfection by their clinician.

PREPADDED MATERIAL

Some plaster or fiberglass splinting products are manufactured with the immobilization material already enclosed in padding, either as strips of predetermined length or as rolls from which splints may be cut to the desired length. Precut strips come packaged in air-tight foil. When a roll is used, the cut end is sealed with a tight clip to protect the exposed material. (Even when not immersed in water, fiberglass may set within 10 to 15 minutes, simply from exposure to moisture in the air.)

Prepadded material is fast and convenient to use because the layers are already in place and the padding need not be applied separately. However, the potential disadvantages are that the thickness of the dressing cannot be customized, and the material does not lend itself to applying two overlapping segments, because they cannot be molded into each other to create a sturdy dressing. If these issues are not a consideration, then prepadded material is a reasonable choice.

TYPES OF IMMOBILIZATION DRESSINGS

The more common immobilization dressings used in the ED are discussed next and are summarized in Table 267-3.

Shoulder Immobilizer

This is a removable Velcro^®-fastened device that keeps the arm in "sling position" but allows less mobility than a sling (Figure 267-8). A wide band wraps around the thorax. Two cuffs are attached to the thoracic piece: one on the lateral side, which grasps the upper arm, keeping the shoulder adducted; and one anteriorly, which holds the wrist to the chest, keeping the shoulder internally rotated. This dressing is suiTable for fractures about the shoulder girdle, including clavicle and well-positioned humeral neck fractures, and for reduced shoulder dislocations.

A shoulder immobilizer is also commonly used for acromioclavicular separations, although from a mechanical standpoint, the ideal dressing for this injury is one that exerts upward pressure on the elbow and downward pressure on the clavicle to bring the clavicle and acromion back into alignment. Commercial versions of such dressings exist, but they are cumbersome to apply and uncomforTable to wear, leading to noncompliance. A shoulder immobilizer (or sling and swathe) is an accepTable alternative dressing.

Arm Sling

Although it does not provide rigid immobilization, a sling (Figure 267-9) may be used as an adjunct to other splinting techniques for a variety of upper extremity injuries to enhance comfort, reduce motion, and provide some degree of support and elevation to the upper extremity. In some cases, as for nondisplaced fracture of the radial head, it may be used alone, without the need for supplementary immobilization.

Clavicle Strap (Figure-of-Eight Bandage)

The figure-of-eight clavicle strap is mentioned only as a historical note. This dressing had long been considered the appropriate immobilization method for fracture of the clavicle, but in fact it is fairly ineffective at maintaining alignment of the fracture fragments and produces no difference in clinical outcome compared with a simple sling.²⁰ In addition, the clavicle strap may be awkward to apply, may require frequent readjustment, may cause problems related to pressure on the brachial plexus, and is often uncomforTable for the patient. A shoulder immobilizer or sling is a much better choice.

Long-Arm Gutter Splint

A long-arm gutter splint immobilizes the elbow (Figure 267-10). The upper extremity is placed in "sling position" (elbow flexed about 90 degrees and palm facing the abdomen). The splint begins on the ulnar surface of the hand at the metacarpal heads and extends along the ulnar surface of the forearm, past the elbow, to a spot high on the lateral surface of the upper arm just opposite and below the axillary crease. It should be supplemented with a sling.

The most common error associated with fashioning this dressing is insufficient length. If the splint is not carried far enough above the elbow, it will not exert enough leverage to prevent motion of that joint.

The long-arm gutter is useful for injuries about the elbow, including displaced radial head fracture, supracondylar humeral fracture, and reduced dislocation of the elbow.

Sugar-Tong Splint

The sugar-tong is a splint that prevents motion of the wrist and elbow, including pronation-supination (Figure 267-11). The upper extremity is placed in "sling position," as described in the preceding section Long-Arm Gutter Splint. The splint begins on the extensor aspect of the hand at the level of the metacarpal heads and runs along the extensor aspect of the forearm, around the elbow and humeral condyles, onto the flexor aspect of the forearm, and ultimately to the palmar aspect of the hand, ending at the level of the metacarpal heads. It is wrapped in place with gauze and often topped off with an elastic compression bandage. It should be supplemented with a sling.

Proper length of the sugar-tong dressing is important. Too short a splint will fail to immobilize the wrist. If the dressing is too long, it will impair motion of the metacarpophalangeal joints, leaving them stiff and making the fingers more susceptible to swelling due to immobility.

The sugar-tong splint is appropriate for fractures about the wrist or distal forearm. Some orthopedists use it as a definitive dressing after reduction of wrist fractures.

Cock-Up Wrist Splint (to Be Avoided)

A cock-up splint extends from the distal forearm to the proximal portion of the hand and maintains the wrist in a dorsiflexed position. It should not be used for fractures of the wrist or carpals because injuries to those areas usually are caused by forceful dorsiflexion, and a cock-up splint reproduces the position of injury, imposing considerable pain in the process. Generally, fractures about the wrist are immobilized in neutral position. Colles fractures may sometimes be immobilized in palmar flexion after reduction.

Cock-up splints may be useful in some situations not related to trauma, such as to immobilize the wrist for tendinitis or to support it in the case of wrist drop due to radial nerve palsy. In such instances, passive dorsiflexion of the wrist is indicated to preserve grip strength.

Short-Arm Gutter Splint

A short-arm gutter splint immobilizes the wrist and the ulnar or radial half of the hand (Figure 267-12). The ulnar gutter, for example, extends along the ulnar surface of the hand and forearm, beginning just proximal to the tip of the fifth finger and ending high on the forearm. It should be wide enough to encompass the fourth and fifth rays (phalanges and metacarpals) on the extensor and flexor aspects of the hand. The splint is wrapped in place so that the fourth and fifth fingers are bound together, with a thin layer of padding between them to prevent maceration of the skin. The metacarpophalangeal joints and interphalangeal joints are positioned in gentle flexion. The dressing may be supplemented with a sling.

The short-arm ulnar gutter is useful for fracture of the proximal phalanx of the ring or little finger or for fracture of the fourth or fifth metacarpal (including the common "boxer's fracture"). The counterpart of this splint, the short-arm radial gutter, is designed in similar fashion but extends along the radial surface of the hand and forearm and is used for comparable injuries of the index or middle rays. It can be fashioned with a hole that allows the thumb to pass through, or by splitting the distal end so the two halves can be run along the extensor and volar aspects of the index and middle rays while the thumb remains free.

Thumb Spica Splint

A thumb spica immobilizes the wrist and the thumb (Figure 267-13). The term spica applies to any dressing that encompasses a main trunk plus one or more of its branches—in this case, the forearm plus the thumb. It is used for fracture of the scaphoid or for fracture of the thumb metacarpal or proximal phalanx.

A thumb spica may be fashioned from one wide splint that runs along the thumb and radial aspect of the wrist and forearm, but an even more effective dressing can be made from two separate non-prepadded plaster splints. The wrist piece runs along the extensor aspect of the hand and forearm, beginning at the metacarpal heads and ending just short of the antecubital crease. The more narrow thumb piece, approximately 2 in. wide, extends from the tip of the thumb, along the outer aspect of the thumb metacarpal, and onto the extensor aspect of the forearm, well overlapping the first splint. Along their area of contact, the two splints are molded into each other, with no padding between them, to form a sturdy dressing. The plaster is wrapped in place with gauze, and a compression wrap may be added at the clinician's discretion. The dressing may be supplemented with a sling.

This technique is not suiTable for prepadded splints with plaster or fiberglass already enclosed, as the two pieces cannot be molded into one another, which compromises the structural integrity of the dressing. When prepadded material is used, a single wide splint encompassing the thumb must suffice.

While the dressing is setting, optimal position may be achieved by keeping the wrist in neutral position and having the patient oppose the tips of the thumb and index finger in the form of an "OK" sign. This preserves thumb-to-index pinch function, so as to minimize the patient's incapacitation. The neutral position of the wrist also avoids reproducing the position of injury in the case of scaphoid fracture, which is typically caused by forced dorsiflexion.

Knee Immobilizer

The knee immobilizer is a removable circumferential device that extends from the thigh to just above the ankle (Figure 267-14). The splint contains longitudinal struts that, in some cases, may be repositioned as needed, and is secured with Velcro^® straps.

A knee immobilizer maintains the knee in extension, the position of maximum stability. The device is useful for a variety of injuries, including fracture of the lateral or medial tibial plateau, fracture of the patella, meniscal injuries (provided the knee is not locked in partial flexion), and ligamentous strains or tears.

Use of an immobilizer for more than a few days in the elderly or for more than a week or two in young patients may result in painful stiffness of the knee joint. For that reason, orthopedic follow-up should occur within approximately 7 days. If immobilization is indicated beyond that point, the orthopedist may replace the original device with a cast brace or other orthosis that allows controlled and progressive range of motion.

Motion and Strength Exercises for the Knee Joint stiffness and instability due to quadriceps weakness may occur rapidly when the knee is immobilized. Patients wearing an immobilizer should be encouraged to remove the device periodically and perform the following exercises:

1. Passive flexion: While sitting on a flat surface, grasp the ends of a towel draped beneath the sole of the foot and pull upward, creating as much knee flexion as possible without undue pain.

2. "Gravity-assisted" flexion: While sitting on the edge of a bed or chair, support the knee in extension, with the well foot beneath the ankle of the injured extremity, then gradually lower the supporting foot so the injured knee "drops" into flexion. When tolerance is reached, bring the knee back into extension.

3. Quadriceps strengthening: While lying supine with a pillow beneath the knee, actively bring the knee to full extension in a straight leg raise, then relax.

Each of these exercises should be performed as multiple repetitions several times a day.

Posterior Ankle Mold

The posterior ankle mold is used to immobilize the ankle (Figure 267-15). It begins beneath the metatarsal heads, runs along the plantar aspect of the foot, and continues up the back of the lower leg, ending at high calf. The splint is used for fractures or severe sprains of the ankle. Support may be supplemented by a transverse sugar-tong component running down the lateral side of the lower leg, beneath the heel, and up the medial side. Where the two components overlap, they are molded together. (Non-prepadded plaster should be used in this situation). The transverse component helps minimize inversion and eversion of the ankle. Even more stability is provided by continuing the posterior splint past the back of the knee to the high posterior thigh, using wider splinting material for this area. With the knee slightly flexed, rotational motion at the ankle also will be prevented.

While the dressing is setting, the ankle should be maintained in a position as close as possible to neutral dorsiflexion—that is, at 90 degrees to the leg. This may facilitate regaining range of motion after the dressing is removed. Because most patients with ankle injuries tend to keep the ankle plantarflexed, the clinician usually will have to counteract this by exerting gentle pressure with a palm beneath the metatarsal heads. An exception to the 90-degree principle is immobilization for rupture of the Achilles tendon. Patients with this injury should be immobilized in plantar flexion to reduce tension on the tendon.

Ankle Stirrup

Easier to apply and less cumbersome for the patient than a posterior mold, the ankle stirrup (Figures 267-16A and 267-16B) is useful for sTable ankle sprains and for sTable lateral malleolus fractures. The ankle stirrup is essentially an air-padded "sugar-tong" splint held in place by Velcro^® straps. Unlike the posterior mold, this device is intended for use in conjunction with weightbearing. It limits inversion more effectively than taping but allows normal plantarflexion and dorsiflexion. This feature and the graduated compressive effect of the air-filled bladders may result in less swelling and edema, less joint stiffness, and a faster return to comforTable ambulation than is typically observed after rigid immobilization.²¹

The stirrup may be removed for purposes of bathing or when not bearing weight. If the patient does remove the splint temporarily, a common error when reapplying it is to fail to unwrap the straps completely—specifically, to leave the straps attached posteriorly, so that the splint is "hinged like a book" along its posterior aspect. This may result in the foot persistently slipping forward and out of the splint. The clinician may wish to instruct the patient that the proper way to reapply the splint is to unwrap the straps all the way around, so that the sides fall apart bilaterally, with the heel pad acting as the "hinge" on the plantar aspect (Figure 267-17). The foot may then be positioned on the lower pad, and the sides reapplied to the medial and lateral aspects of the ankle and lower leg. The final step is to rewrap the straps around the dressing.

Motion and Strength Exercises for the Ankle Exercises to restore range of motion, stability, and balance should be started as soon as possible after an ankle injury.

1. Active dorsiflexion and plantarflexion: When performed supine with the foot well elevated, this exercise may also enhance lymphatic drainage, thereby reducing swelling.

2. Passive dorsiflexion: One method for performing this exercise is to stand with the palms braced against the wall, then to bend the knee toward the wall while keeping the heel flat on the floor.

3. Eversion, dorsiflexion, and plantarflexion against resistance: This exercise may be accomplished by manually applying a counterforce with a stretchable elastic cord (commercially available). Standing on the toes is another means of resistive plantarflexion.

Each of these exercises should be performed as multiple repetitions several times a day.

Hard-Soled Shoe

A hard-soled shoe is a removable "sandal" with wrap-around sides usually secured with Velcro^® and a flat, nonflexible sole (Figures 267-18A and 267-18B). This device is intended to allow weightbearing by patients with toe fractures or certain types of metatarsal fractures. The firm sole prevents the toes from bending and provides support for the forefoot. Although immobilization dressings may be warranted for some metatarsal fractures, the hard-soled shoe is an accepted treatment modality for fracture of the second, third, fourth, or proximal fifth metatarsal.^22,23

Pneumatic Walking Brace

The pneumatic walking brace is a device that provides firm support about the foot, ankle, and lower leg. It is available in high-top or short-top varieties. The high-top walker (Figure 267-18C), which extends almost to the knee, is suiTable for injuries such as moderate to severe ankle sprains or for sTable fractures of the foot or ankle. Short-top walkers extend just above the ankle joint and may be used for phalangeal or sTable metatarsal fractures.

The term pneumatic refers to the fact that the inner lining of the brace is inflatable. Though non-pneumatic models are available, the pneumatic component has at least two advantages. It provides added compression, which helps reduce swelling and pain, and allows the walker to conform more closely to the contour of the extremity, which enhances immobilization.

CRUTCHES

Crutches should be used by patients who can bear little or no weight on an injured lower extremity. Ideal crutch height is one hand width below the axilla. The grip bar should be adjusted to a height at which the elbows are mildly flexed while supporting the body weight. The patient should be instructed to bear the pressure of the pads against the sides of the thorax rather than in the axillae, or brachial plexus injury (crutch palsy) might result.

Any of several crutch gaits may be prescribed. The most common is the three-point gait, in which the patient keeps the injured extremity off the ground, advances both crutches simultaneously, then brings the well leg to a point between the crutches ("swing-to" gait) or just past them ("swing-through" gait). Alternatively the patient may use a two-point gait, in which one crutch and the opposite extremity are advanced together followed by the other crutch and extremity, or a four-point gait, in which one crutch is advanced, then the opposite extremity, then the other crutch, then the remaining extremity. The two- and four-point gaits are slower in forward progression than the three-point gait but require less arm and wrist strength. They should be used only for patients who are able to bear some weight on the injured extremity. To ascend stairs, the patient advances the well extremity up to the next step, followed by the crutches and the injured extremity. To descend stairs, the crutches are lowered first.

WALKERS AND CANES

Most elderly or infirm patients do not have the strength needed to use crutches safely. For them, a walker or a cane is more suitable. Unfortunately, these devices are more appropriate for partial weightbearing than for nonweightbearing conditions. Elderly patients who can bear no weight at all on an injured extremity may require initial bedrest or use of a wheelchair and subsequent rehabilitation.

The technique for using a walker is essentially intuitive, with the patient simply lifting it and placing it a short distance ahead and then advancing toward it. In contrast, the technique for using a cane tends to be counterintuitive. Many patients instinctively hold a cane on the same side as the injured extremity. In fact, when the cane is held in the hand on the well side, less strength is required to maintain balance, resulting in a less awkward gait. The patient should be instructed to advance the cane (held on the well side) and the injured extremity simultaneously, and then advance the noninjured extremity to meet them.

Elevation of the injured part usually helps minimize pain and swelling. Elevation must be above the level of the heart to be effective. Patients with an injured lower extremity often sit at home or at work with the foot resting on a stool or chair, thinking they are complying with instructions. The patient should understand that the benefits of elevating a lower extremity can be achieved only in a recumbent or near-recumbent position, with the leg supported higher than the rest of the body.

Patients discharged in a lower-extremity plaster dressing should be cautioned not to rest the heel on the floor or any other hard surface during the first day, as plaster takes about 24 hours to fully set. During this time, prolonged pressure on the heel might create an indentation that could cause significant discomfort or even a pressure sore. This is not a consideration with fiberglass, which sets almost immediately.

If an upper-extremity sugar-tong dressing has been applied, the patient should be instructed to work the fingers (wiggle or wave) as much as possible to minimize stiffness and swelling. The sugar-tong splint should extend to, but not beyond, the metacarpal heads, so as to allow full flexion of the metacarpophalangeal joints.

Patients should be advised to monitor the fingers or toes for excessive swelling, decreased sensation, or cyanosis and to be alert for a significant increase in pain. Any of these signs or symptoms warrants a return to the ED or prompt evaluation by the follow-up physician.

When crutches, a cane, or a walker is supplied, instruction for use should be provided, and the patient's ability to navigate with such aids should be verified.

Complications associated with musculoskeletal injury may be early or delayed and may occur minutes, days, weeks, or even months later.

NEUROLOGIC DEFICIT

Neurologic injury resulting from long-bone fracture or joint dislocation is usually due to traction or pressure on a peripheral nerve or a nerve plexus. Such complications usually manifest themselves early. Recovery may take hours, days, or weeks. Sometimes, the injury is irreversible. Prompt reduction of deformity often may prevent, eliminate, or mitigate the effects of neurologic involvement, but it is not a guarantee against permanent deficit.

VASCULAR INJURY

Peripheral vessels that run close to a joint sometimes may be compressed or disrupted when the joint becomes dislocated, as, for example, with dislocation of the ankle or knee (tibiofemoral joint). Loss of peripheral pulses or poor to absent capillary refill calls for expeditious reduction of deformity. Even after reduction, evidence of significant vascular injury may be delayed. Patients who experience tibiofemoral dislocation, for example, often undergo routine postreduction angiography to verify the integrity and patency of the popliteal vessels, regardless of whether a circulatory deficit has been observed clinically.

COMPARTMENT SYNDROME

After a fracture or a direct blow to an extremity, there may be extravasation of blood, swelling of muscle tissues, and impairment of venous flow within one or more fascial compartments. The resulting increase in pressure within the limb may lead to circulatory compromise, neurologic damage, and muscle necrosis, known collectively as compartment syndrome. This is a surgical emergency, and early recognition is crucial. Compartment syndrome is discussed further in chapter 278, Compartment Syndrome.

DELAYED AND LATE COMPLICATIONS

Patients who have sustained a fracture may be at risk for pulmonary fat embolus, usually originating from the marrow of a large bone, such as the femur. If fat embolism occurs, it is typically within the first few days after injury, rather than the first hours. This event may have a variable effect on pulmonary function, ranging from mild distress to severe or even fatal respiratory failure.

The most delayed complications of fracture include nonunion, malunion (healing with deformity), joint stiffness, traumatic arthritis, avascular necrosis of bone, and, in the case of open fracture, osteomyelitis.

There is no universally prescribed follow-up interval for specific injuries. Orthopedists differ in their opinions regarding how soon patients should be seen. In general, patients with unreduced fractures or injuries that may require surgical intervention should be seen within a few days.

Sometimes the situation may be discussed with the follow-up physician and an appointment arranged while the patient is still in the ED. Alternatively, the emergency physician may instruct the patient to contact the follow-up physician or clinic as soon as possible. If the name of the injury is written on the discharge instruction sheet, the patient can convey it at the time of the call. This information may help the follow-up physician decide when the patient should be seen.

Acknowledgments: The author wishes to thank the following: Eleanore Denton Rhodes, AMI, for original artwork, and Joe Driscoll for original photography.