Rosen & Barkin's 5-Minute Emergency Medicine Consult (713 page)

• High- vs. low-energy injury
  
• Amount of soft tissue injury is prognostic and determined by the degree of energy involved.
  
• Indirect force—frequently low-energy trauma:
  
  • Rotary and compressive forces often result in oblique and spiral fractures.
    
• Skiing, fall, child abuse
  
• Direct force—high-energy trauma:
  
  • Direct blow to leg often results in transverse and comminuted fractures.
    
• Pedestrian vs. auto, motor vehicle crash (MVC):
  
  • Bending force over a fulcrum often produces comminution with a wedge-shaped butterfly fragment.
    
• Skier’s boot top, football tackle, MVC
  

• Bicycle spoke injury:
  
  • Foot and lower leg get caught between frame and wheel spoke
    
  • Crush injury is the primary problem.
    
  • Initial benign appearance of the soft tissues is often deceiving:
    
    • Full-thickness skin loss can occur in days.
      
  • Orthopedic surgery consultation should be obtained for all spoke-injury patients with associated fractures.
    
• Toddler fracture:
  
  • Spiral fracture involving the distal 3rd of the tibia with intact fibula secondary to rotational force (turning on planted foot)
    
  • Age range is 9 mo–6 yr, most often when learning to walk.
    
  • Fractures in midshaft or more transverse are suggestive of nonaccidental trauma.
    

DIAGNOSIS

• History of trauma
  
• Pain is usually immediate, severe, and well localized to the fracture site.
  

• Visible or palpable deformity at the fracture site
  
• Significant soft tissue damage with high-energy trauma
  
• Inability to bear weight if tibia involved:
  
  • May be able to walk if isolated fibular fracture
    
• Foot drop on affected leg from injury to the peroneal nerve as it wraps around the fibular head
  
• Compartment syndrome
  

• Rely on parents for historical information.
  
• Child may present limping with no obvious deformity.
  

• Careful assessment of soft tissues
  
• Careful neurovascular exam (compare with contralateral side)
  
• Examine for associated injuries.
  
• Completely expose patient and put into gown.
  
• Assessment for compartment syndrome
  

Include creatine phosphokinase levels if concerned about compartment syndrome

• Anteroposterior and lateral views of the leg, knee, and ankle
  
• Bone scan at 1–4 days for toddler fracture and stress fractures if radiographs unrevealing
  
• CT scan for complex fracture pattern to evaluate for rotational malalignment
  
• CT or MRI for pathologic fracture
  
• MRI for stress fractures may be necessary.
  

Compartment pressures:

• Pressures >30 mm Hg are an indication for orthopedic consultation and fasciotomy.
  
• Delta P or difference between diastolic BP and compartment pressure <20 is indicative of compartment syndrome
  
• Repeated pressure measurements over time, taken within 5 cm of fracture site, are necessary.
  

Oblique radiograph to detect nondisplaced fractures

• Stress fracture
  
• Pathologic fracture
  
• Osteomyelitis
  

• Sarcoma
  
• Pathologic fracture
  
• Osteomyelitis
  
• Nonaccidental trauma
  

TREATMENT

• Look for associated injuries in high-energy mechanisms.
  
• Assess for neurologic or vascular compromise.
  
• Adequate immobilization is essential to prevent further injury.
  

• Manage airway and resuscitate as indicated.
  
• Life-threatening injuries take precedence.
  
• Immobilize extremity.
  
• Apply ice
  
• Strict NPO
  
• Pain control
  

• Closed fractures:
  
  • Gentle attempt at reduction if fracture is displaced (do not attempt multiple reductions; may increase risk for compartment syndrome).
    
  • Immobilization:
    
    • Well-padded long leg posterior splint
      
    • Knee in 10–20° of flexion
      
  • Avoid circumferential cast.
    
  • If pain persists after immobilization, suspect:
    
    • Compartment syndrome
      
    • Avoid elevation of leg in suspected compartment syndrome; it lowers perfusion to the extremity.
      
    • Nerve compression
      
  • Crutches
    
• Open fractures:
  
  • Remove contaminants and cover wound with moist, sterile dressing.
    
  • Antibiotics
    
  • Tetanus prophylaxis
    
  • Immobilization with well-padded long leg posterior splint
    
  • Immediate orthopedic surgery consultation for débridement and fracture fixation
    
• Isolated fibular fracture:
  
  • Usually treated symptomatically:
    
    • Padded splint
      
    • Elevation
      
    • Ice
      
    • No weight bearing until swelling resolves
      
  • Crutches if not bearing weight
    

• Gram-positive cocci coverage for open fractures: Cefazolin 2 g loading dose then 1 g (peds: 50 mg/kg/d) IV/IM q8h
  
• Gustilo–Anderson type III, add gram-negative rod coverage: Gentamicin 3–5 mg/kg (peds: 2.5 mg/kg) IV q8h
  
• Farming accident, add
  Clostridium
  spp coverage: Penicillin G 10 million IU (peds: 250,000–400,000 IU/kg/d) IV q6h
  
• Tetanus 0.5 mL IM and tetanus immune globulin 250 U IM as indicated by the type of wound and the number of primary immunizations
  
• If penicillin allergic: Vancomycin 1 g (peds: 10 mg/kg) IV q12h
  

FOLLOW-UP

• Multiple trauma
  
• High-energy mechanism
  
• Soft tissue involvement
  
• Risk for compartment syndrome
  
• All open fractures
  
• Displaced, angulated, transverse, shortened, comminuted, and otherwise unstable fractures
  
• Intra-articular involvement
  
• Neurovascular compromise
  
• Inadequate pain control
  
• Pathologic fracture
  
• Nonaccidental trauma in children
  

• Minimally displaced fracture with low-energy injury mechanism
  
• Close orthopedic follow-up
  
• Return parameters for compartment syndrome in a reliable patient
  
• If fracture is >48 hr old, compartment syndrome is unlikely to develop; if it has not occurred, discharge criteria may be more liberal.
  

• Most pediatric fractures are treated with long leg cast for 4–6 wk.
  
• Nondisplaced and minimally displaced fractures in adults may be treated with long leg cast and closed reduction.
  
• Open contaminated fractures may be treated with external fixation and débridements.
  
• Treatment with intramedullary nail allows for early mobilization and weight bearing as tolerated.
  
• Kirschner wires are sometimes used in the treatment.
  

• High incidence of associated injuries in high-energy trauma:
  
  • Associated injuries commonly include:
    
    • Femoral fractures (“floating knee injury”)
      
    • Head trauma
      
    • Spine fractures
      
  • Deep venous thrombosis occurs in 10–25% of patients following tibial fracture.
    

• Browner BD. Fractures of the tibial shaft. In:
  Skeletal Trauma.
  4th ed. Philadelphia, PA: WB Saunders Co.; 2008.
  
• Green NE, Swiontkowski MF. Fractures of the tibia and fibula. In:
  Skeletal Trauma in Children
  . Philadelphia, PA: Elsevier; 2008.
  
• Newton EJ, Love J. Emergency department management of selected orthopedic injuries.
  Emerg Med Clin North Am
  . 2007;25(3):763–793, ix–x.
  
• Park S, Ahn J, Gee AO, et al. Compartment syndrome in tibial fractures.
  J Orthop Trauma
  . 2009;23(7):514–518.