More random orthopaedic injuries in ED Dr Donna Mills FACEM Caloundra

Galeazzi # radius – often distal/medial third junctions Dislocation DRUJ FOOSH Up to 7% forearm fractures Adults – ORIF; paeds – closed reduction Cx – AIN or radial nerve palsy

Monteggia # proximal third of ulna with dislocation of radial head Hyperpronation FOOSH ORIF

Smith’s fracture reverse colle’s fracture distal fracture fragment is displaced volarly (ventrally) Fall onto flexed wrist

Barton’s intra-articular # of DR with dislocation of the radiocarpal joint Can be volar (most common) or dorsal FOOSH with wrist in volar flexion or dorsiflexion

Volar Barton’s

Dorsal Barton’s

Barton’s many fail nonoperative treatment Refer for early ortho input manipulative reduction is same as for colle’s/smith’s #

Anterior shoulder dislocation Most common Bimodal age distribution

Anterior shoulder dislocation Anterior dislocations can be further divided according to where the humeral head comes to lie: subcoracoid: most common subglenoid subclavicular intrathoracic: very rare

Anterior shoulder dislocation Surgical repair is not required for dislocation per se, but rather to treat complications and associated injuries which include:  Shoulder instability Hills-Sach’s lesion Bankart lesion damage to the axillary artery or brachial plexus intraarticular loose body

Hills-Sach’s lesion

Hills-Sach’s lesion cortical depression in the posterolateral head of the humerus results from forceful impaction of the humeral head against the anteroinferior glenoid rim when shoulder dislocated anteriorly

Bankart lesion detachment of the anterior inferior labrum from the underlying glenoid  labral only ("soft Bankart"), or involve the bony margin ("bony Bankart“)

Posterior shoulder dislocation 2-4% of presentations ~50% posterior shoulder dislocations go undiagnosed on initial presentation FOOSH onto internally rotated arm

Inferior shoulder dislocation Luxatio erecta hyper-abduction of the arm that forces the humeral head against the acromion high complication rate  

Knee dislocation Urgent reduction under PS NV Ax pre and post If compromised – urgent vascular If not – imaging (eg CTA) Admission for vascular/perfusion obs

Native Hip Dislocation Posterior (80-90%), anterior and central dislocations marker for a high force mechanism Assoc injuries Sciatic nerve (20%) AVN Vascular injury less common Urgent reduction improves outcomes

Prosthetic hip dislocation occurs in 1-4% of primary THR and up to 16% in revision cases Contributing factors: looseness of hip (improper neck length) component malposition Alcoholism

Reduction method assistant provides downward traction on the pelvis proceduralist should step up onto the bed, standing over the patient grasp the patient's leg between arm and armpit, leaving both hands free to grasps the knee use legs to effect an appropriate amount of traction use hands to internally and externally rotate hip in order to guide the hip into a reduced position 

Segond fracture Avulsion # lateral aspect of the tibial plateau ~75% of cases associated with ACL disruption result of internal rotation and varus stress Assoc extensive ligamentous injury requires surgical intervention

Tillaux fracture Salter-Harris III fractures through the anterolateral aspect of the distal tibial epiphysis occurs in older children when the medial aspect of the distal tibial growth plate has started to fuse 

Tillaux fracture Operative reduction and fixation is required when displacement is marked or unable to be eliminated with closed reduction

Pilon fracture axial loading injury which drives the talus into the tibial plafond Pilon is the French word for pestle large number of patients will have pain even after 2 years post injury

Maisonneuve fracture unstable fracture # medial tibial malleolus and/or disruption of the distal tibiofibular syndesmosis # proximal fibula shaft deltoid ligament can be frequently disrupted

Lis Franc fracture/dislocation Lis franc joint is the articulation of the 1st 3 MTs with the cuneiforms Lis franc ligament attaches the medial cuneiform to the 2nd metatarsal base on the plantar aspect of the foot. Its integrity is crucial to the stability of the Lisfranc joint.

Lis Franc fracture/dislocation Homolateral lateral displacement of the 1st to 5th metatarsals, or of 2nd to 5th metatarsals where the 1st MTP joint remains congruent Divergent  lateral dislocation of the 2nd to 5th metatarsals with medial dislocation of the 1st metatarsal  

Lis franc fracture/dislocation Some studies advocate ORIF if >2mm diastasis Others report no correlation between the degree of diastasis and the eventual functional outcome All studies indicate that timely diagnosis facilitates treatment and decreases long-term disability