Snapshot A healthy 25-year-old man is brought to the ED after falling out of a second-floor window. He is supported by two friends. All appear to be inebriated with injected conjunctiva. The patient complains that his right thigh is in pain. He reports having landed on his feet. Primary survey is unremarkable. Blood pressure is 100/60 mmHg, pulse is 80/min, respirations are 18/min, and SaO2 is 99% on RA. On physical exam, he cannot passively or actively move his right leg without wincing in pain. AP and lateral radiographs of his right femur reveal an isolated oblique diaphyseal fracture. Radiographs of his other femur, knees, hip, and lumbar spine are unremarkable. Urine drug screen is positive for marijuana. Pain medications are provided and closed reduction with a splint is applied. The patient is admitted to the orthopedics service. Introduction Orthopedic trauma can be part of any high-energy mechanism (MVC, fall) spinal and/or visceral injuries may coexist in ED setting, goal is to quickly diagnose or rule out life or limb threatening injuries non-threatening fractures can be reduced and immobilized pain relief and proper follow-up are crucial for appropriate discharge Life and Limb-Threatening Orthopedic Injuries All of the following are appropriate reasons for emergent surgical consultation Life-threatening pelvic fracture massive long bone injuries (high risk of fat emboli) vascular injury proximal to knee and/or elbow traumatic amputations Limb-threatening compartment syndrome associated with tibial plateau fractures login to view 1 more bullet open fractures knee dislocation can injure the popliteal artery requires immediate reduction then evaluation of arterial injury fracture proximal to knee and/or elbow crush injuries fracture/dislocation of ankle Classification of Fractures Fractures are described by integrity of skin, location, fracture pattern, and displacement integrity of skin/soft tissue closed or open (blood or fat droplets at puncture site) location epiphyseal, metaphyseal, diaphyseal orientation/fracture pattern (see image below) transverse login to view 2 more bullets oblique login to view 2 more bullets spiral login to view 2 more bullets comminuated login to view 1 more bullet avulsion login to view 2 more bullets impacted login to view 2 more bullets fissure login to view 1 more bullet greenstick login to view 1 more bullet torus login to view 2 more bullets displacement refers to distal fragment in or not in anatomic alignment with proximal fragment varus: apex away from midline valgus: apex toward midline fractures of the fingers and hand fractures of the distal phalanx login to view 2 more bullets Imaging Radiographs lateral cervical spine, AP chest, pelvis AP and lateral of all injured bones studies Primary and secondary survey with resuscitation SEADS inspection: Swelling, Erythema, Atrophy, Deformity, Skin changes increased pain with passive stretch, or pain out of proportion to injury suggests compartment syndrome palpate all bones/joints and actively move joints that affected and those above/below assess vascular and neurological statuses distal to injury treatment For all life and limb-threatening injuries, surgical consult (general, vascular, orthopedics) Fracture management includes reduction to maintain bone alignment and integrity reduction can be closed or open closed reduction login to view 3 more bullets open reduction login to view 3 more bullets reduction is maintained via external or internal stabilization external stabilization login to view 1 more bullet internal stabilization login to view 1 more bullet physical rehabilitation and therapy are needed to regain function and avoid joint stiffness Goal of open fracture management is to minimize risk of osteomyelitis gross debris removal, irrigation with normal saline, and sterile dressing tetanus prophylaxis with toxoid or immunoglobulin as needed intravenous antibiotics for at least 3 days first-generation cephalosporins for gram-positives login to view 1 more bullet aminoglycosides for gram-negatives penicillin added if soil-contaminated for Clostridium perfringens reduce and splint fracture NPO for definitive surgical irrigation and debridement in 6-8 hours