Click on images to view larger radiographs and clinical pictures.
Introduction
This 29 year old man was the driver of a
pickup truck which collided head-on with another car and rolled
onto the passenger's side. The passenger was dead at the
scene. The driver was found with his body outside the
driver's side window and head inside the truck, caught around
the seatbelt. Paramedics applied a KED and semirigid
C-spine collar at the scene and he was brought to the closest
hospital. IV Steroids were instituted for a suspected
C-spine injury and he was transfered to a tertiary care centre.
On arrival, his airway is patent, the
C-spine is in a semirigid collar, and he his hemodynamically
stable on 100% Oxygen. Physical examination reveals
tenderness in the mid-to-lower C-spine. Neurological
examination shows that this man has a C6 sensory and motor
level. There is no rectal tone and a negative
bulbocavernosus reflex is noted. There are no other
injuries.
Radiographs of the C-spine
A Halo is applied on admission, and
sequential weights are used to attempt a closed reduction of the
C-spine:
(After 20 Lbs)
(After 30 Lbs)
The C-spine reduces with 40 lbs weight but
the neurological deficit persists.
The patient was taken
to the operating room the following day for instrumentation.
Click on images to view radiographs and clinical pictures.
Introduction
A 35 year old man was riding his motorcycle
at 60km/hr when he was T-boned from the left by a car travelling
at the same speed. He was brought to your trauma room and
the ATLS protocol was initiated. His airway is patent, he is
conscious and hemodynamically stable. There are obvious
extremity deformities and radiographs are taken in the trauma
room. His C-spine is cleared both clinically and
radiographically. The secondary survey is performed and he
has only orthopaedic injuries:
Right Ankle - No Dorsalis Pedis pulse, 6cm
soft tissue wound with visible deformity
Left Humerus - Neurovascularly intact but
tender over olecranon
Left Distal Radius - Tender and deformed
Right Distal Radius - Tender and deformed
Management
ATLS protocol was followed and the airway
was patent. 100% Oxygen was given via non-rebreather mask, 2
large bore IVs were instituted with Ringer's
Lactate. The C-spine was immobilized in a semirigid
cervical collar and then later cleared clinically and
radiographically. The patient was hemodynamically stable
and there were no neurological injuries thanks to the helmet
which was removed by the paramedics. Our management
was as follows:
Right Ankle - Closed reduction in the
trauma room was performed and the Dorsalis Pedis pulse
returned. Tetanus Toxoid 0.5cc IM and Cefazolin IV 1g was
given.
The patient was taken to the operating room
for Irrigation and Debridement plus Open Reduction and Internal
Fixation of all fractures.
I&D plus ORIF of the Right Ankle using
two medial screws and tension banding of the lateral malleolus:
ORIF of the olecranon:
An external fixator was applied to the left
distal radius, and a plate and screws were used to fix the left
ulna. Stability through pro/supination was checked under
the image intensifier.
The left distal radius still did not have
absolute stability so two mini fragment lag screws were used in
addition to the ulnar plate and radial external fixator:
The right distal radius fracture was treated with an external
fixator:
Click on images to view larger radiographs and clinical pictures.
Introduction
This 35 year old manual labourer fell
off the back of a truck and had a heavy weight fall onto his
foot. He was initially seen in the emergency
department, had a neurovascularly intact but deformed foot,
and a closed, isolated injury to the right ankle area.
Radiographs are shown below.
Post closed reduction and splinting in the emergency room:
What is your diagnosis and management ?
This patient had a Hawkins III right talar
fracture-dislocation with an associated fibular fracture.
He underwent open reduction and internal fixation using an
anterolateral approach and initial open reduction through the
fibular fracture site. An intraoperative picture is shown
below:
It was impossible to adequately reduce the
talus through this incision so an anteromedial incision was made
to remove any soft tissue blocks to reduction. Our plan
was to perform a medial malleolar osteotomy for access to the
medial ankle joint. However, after the skin and
subcutaneous tissue dissection, the deltoid ligament was
completely town. An intraoperative picture of this
incision is shown below with the Howarth Elevator in the
fracture site:
Provisional fixation was carried out using
Kirschner Wires under direct visualization through both
incisions. Intraoperative radiographs were obtained (shown
below):
Is this an adequate reduction ?
What is your next step in management ?
Although the reduction was adequate, there
were K-wires were in the subtalar joint. Optimally, a
large fragment cancellous screw would be used for fixation over
the guide wire. However, the bone quality of the talar
head was poor and there would not be enough bone to gain an
adequate purchase for screws. Therefore, we revised the
K-wire fixation of the talus, applied a plate to the fibula, and
an external fixator across the ankle and subtalar joints.
What is your postoperative management ?
This patient was seen in the clinic two
weeks postoperatively for staple removal. Our plan is to
keep him nonweightbearing for twelve weeks with immobilization
of the ankle and subtalar joints via the external fixator.
Clinical and radiographic follow-up will be required to confirm
or disprove revascularization of the talus.
Click on images
to view radiographs and clinical pictures.
Introduction
This 68 year old right-hand dominant woman
was climbing down a set of stairs when she tripped and fell off
the sixth step from the bottom onto her outstretched right
hand. She felt immediate pain in her right shoulder and
elbow, and was seen in the emergency department. She
sustained a closed, isolated injury to her right shoulder and
radiographs (shown below) were done to confirm this injury.
She was given a diagnosis of a right humeral fracture at the level
of the surgical neck. Treatment consisted of a Velpeau
sling. She was discharged home in the sling and sent for
follow-up to the orthopaedic clinic four days later.
Right Shoulder Radiographs in the Emergency Room
Four days after presentation in the
emergency room, this lady was seen in the fracture clinic.
She was wearing a Velpeau sling and complained of pain in her
right shoulder out of proportion to the injury previously
diagnosed. Her arm was in neutral flexion-extension,
neutral abduction-adduction, and fully internally rotated.
She had pain and tenderness over the anterior and posterior
right proximal humerus. Neurovascular examination of the
right upper extremity was normal. Radiographs were
reviewed from the emergency room and repeated on the day of her
fracture clinic visit (below). These included an
anteroposterior view, transscapular lateral view, and axillary
view of the right shoulder.
What is your diagnosis ?
What is your next step in the management
of this patient ?
This patient has a right shoulder posterior
fracture-dislocation. There is a humeral fracture at the
surgical neck and a displaced fracture of the greater tuberosity.
Since she was four days post injury, she was taken to the
resuscitation area of the emergency room and a closed reduction
under IV sedation and analagesia was carried out. The
patient was placed supine on the floor with assistants providing
countertraction to hold her body to the floor during
reduction. The right shoulder was fully adducted and
flexed to 45 degrees. The right elbow was flexed to 90
degrees and fully internally rotated to unlock the humeral head
from the posterior aspect of the glenoid. Gentle
longitudinal traction was applied until a clunk was felt by the
orthopaedic surgeon and assistant. At this point the
shoulder was fully abducted, placed in neutral
flexion-extension, and full external rotation. This
yielded a greater range-of-motion in the internal-external
rotation plane than pre-reduction. With the arm held in
this position, new radiographs were taken (below).
What is your definitive management of this
patient ?
The reduction (confirmed on all three
views) was successful. The patient was placed in a cast
with her right shoulder in neutral flexion-extension, neutral
abduction-adduction, and full external rotation.
Radiographs were taken again to confirm that the surgical neck
fracture had not displaced, the greater tuberosity fragment had
not migrated into the subacromial space, and the shoulder had
not dislocated posteriorly during cast application.
What is your postoperative management of
this patient ?
The patient will be left in this external
rotation cast for 6 weeks. We plan to see her in fracture
clinic weekly for the first three weeks to examine her and
radiographically document the position of the humeral head in
the glenoid fossa, as well as the fracture fragments.
Click on images
to view radiographs and clinical pictures.
Introduction
This 82 year old lady slipped and fell while
she was pushing her shopping cart across an icy parking lot.
She was unable to get up from her fall and was taken to
hospital. In the emergency room, she complained of pain in
both legs. She was neurovascularly intact, had deformities
of both thighs, and there were no open injuries. Examination
of both hips, ankles, and feet were normal. The pelvis was
stable and nontender. Radiographs were obtained after
splinting her legs (below).
Radiographs of the Right Femur in the Emergency Room
Radiographs of the Left Femur in the Emergency Room
What is your diagnosis and management ?
This patient has a comminuted supracondylar
left femoral fracture and an oblique fracture of the right femur
at the junction of the middle and distal thirds. There is
also an undisplaced oblique fracture of the right femur in the
distal third. In the emergency department, bilateral
Thomas splints were applied and after informed consent was
obtained, the patient was taken to the operating room for
fixation of both fractures. The original plan was to
perform a closed intramedullary nailing of the right femur and
an open reduction and internal fixation with an eight-hole,
95-degree dynamic condylar screw on the left side.
However, due to the undisplaced oblique diaphyseal right femoral
fracture, management of that femur was revised to open reduction,
cerclage wiring of the distal femoral fragment, and fracture
fixation with a 12-hole 95-degree dynamic condylar screw over
the cerclage wires (below).
Postoperative Radiographs of Both Femora
What is your postoperative management ?
Postoperatively, the two Jones Bandages and
Hemovac drains were removed at the 48-hour mark. We plan
to limit activity to bed-to-chair assisted transfers only for
six weeks to three months.
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