POTD Trauma Tuesday: Name that fracture!

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A 36-year-old man presents by ambulance following a motorcycle crash. He told the EMTs that he lost control and fell sideways, bracing his fall with his outstretched right hand. His R arm looks deformed but is neurovascularly intact. An xray is obtained.

xray potd.png



What’s the name of this one again?!

Galeazzi fracture! Named after an Italian surgeon from Milan.

What is it? a fracture-dislocation of the distal third of the radius associated with dislocation-subluxation of the distal radial ulnar joint, or DRUJ.

Why do we care? With Galeazzi fractures, there is a high risk of malunion, loss of function, infection, and chronic pain in adult patients. For this reason, surgical management with internal fixation and possible open reduction is required. The repair should occur promptly, so the emergency physician or another clinician should contact the orthopedic consultant emergently to coordinate care.

What about in peds? Emergent orthopedic consultation is still required but interestingly, in children, some Galeazzi fractures are treated conservatively with closed reduction by an orthopedic surgeon. Disruption of the DRUJ can be subtle, so a high suspicion should be maintained when a patient presents with a fracture of the distal third of the radius.

Pearls of the Peal:

* Look for fracture-dislocation of the distal radius and ulna after a fall onto an outstretched arm. This injury can’t be missed: it requires immediate orthopedic involvement.

* Skin tenting associated with the Galeazzi fracture-dislocation puts the patient at risk for skin necrosis and conversion to an open fracture.

Wasn’t there some way to remember this compared to other one?? Why, yes! See below:


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Sources:

Comic: Medcomic.com

Xray and clinical information: PEER IX

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POTD: Trauma Tuesdays. Le Forte Fractures

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Inservice is over but let’s keep the review of Le Forte Fractures going strong!

Interesting historical fact: Named after French Surgeon Rene Le Forte. He described fracture classifications are based on experiments conducted in 1900 by dropping bricks on cadavers and observing the pattern of fractures.

I included the words for description of the fractures but pictures are truly best.

·       Le Fort I: the gist: palate. across both maxillae above the dentition.

o   More wordy: The fracture extends through the piriform aperture superior to the maxillary alveolar ridge, then propagating through the anterior, medial, and posterolateral maxillary sinus walls.

·       Le Fort II: the gist: nose + palate. starts in the maxilla laterally but extends more superiorly into the orbital floor.

o   More wordy: The fracture involves the posterolateral maxillary sinus wall and anterior maxillary wall, extending through the inferior orbital rim into the orbital floor, medial orbital wall, and the region of the nasofrontal suture.

·       Le Fort III: The gist: craniofacial separation. completely separates the facial bones from the skull. Transverses zygomatic arches laterally. Buzz word: CSF rhinorrhea.

o   More wordy: The fractures extend through the nasal bridge, medial orbital wall, posterior orbital floor, and lateral orbital wall near the frontozygomatic suture. The zygomatic arch is always fractured as well.

In general: All of these patients are going to have severe swelling, possible airway obstruction. All will need OMFS consult, IV abx, surgical management and admission.

Sources:

LIFL: https://litfl.com/le-fort-facial-fractures-eponymictionary/

ENT trauma handbook published 2017 written by the American Academy of Otolyngology- Head and Neck surgery

Photo: https://emedicine.medscape.com/article/434875-overview

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POTD: Trauma Tuesdays - Concussions

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Clinical scenario:

A 16-year-old boy presents after hitting his head in a collision with another player during a soccer game. He denies loss of consciousness but complains of a moderate headache, nausea, and difficulty concentrating. 

Which of the following represents appropriate next steps in management?

A. Admit the patient to the hospital for overnight observation

B. Clear the patient to play after 48 hours if his symptoms resolve

C. Discharge with instructions to get follow-up care and not return to play

D. Order a head CT to rule out the presence of an intracranial bleed or swelling

The correct answer is C. 

Concussions

What is a concussion?

The term "concussion" is often used in the medical literature as a synonym for mild TBI but more specifically describes a pathophysiological state that results in the characteristic symptoms and signs that individuals may experience after a mild TBI. 

Symptoms

Rapid-onset short-lived neurologic function impairment that resolves on its own. These symptoms reflect functional disturbance rather than structural injury.

concussion symptoms.png

Diagnosis

If one or more of the following:

  • Symptoms, including somatic (headache, nausea, off balance), cognitive (“ in a fog,” slow), or emotional (rapidly changing)

  • Physical signs, such as loss of consciousness, amnesia, although LOC is not required

  • Behavior changes, such as irritability

  • Cognitive impairment, such as slowed reaction times

  • Sleep disturbance, such as insomnia

Evaluation

  • Concussion is a clinical diagnosis, and there are a variety of sideline assessment tools (that are outside the scope of the ED) that include measurements of orientation, symptoms, gross cognition, and physical examination findings (e.g. Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), computerized neurocognitive testing, and the Sport Concussion Assessment Tool version 5 (SCAT5 or Child-SCAT5)).

  • Physical exam should include: 

    • assessment of the cervical spine (+/- immobilization with c-collar if cervical spine injury suspected)

    • detailed neurologic assessment (including mental status, cognitive functioning, and gait/balance)

    • structural brain imaging (i.e. CT scan or MRI) if concern for structural injury (e.g. acute brain bleed)

Discharge Precautions

This is arguably the most important part of your role in the concussed patient. Thankfully, the CDC has a ton of great literature on the subject.

Pediatric Care Packets:

  1. Pediatric Discharge Instructions

  2. Symptom-Based Recovery Tips

  3. Pediatric Care Plan

Adult Care Packets:

  1. Adult Concussion Fact Sheet

  2. Adult Concussion Brochure

  3. Adult Care Plan

References:

PEER IX

http://www.emdocs.net/concussion-update/?fbclid=IwAR3KSyGMyb-55DTXUWRkTXRLBurnrvULl2zPhZb4xIyiJH8_idVktsaDTJA

https://www.uptodate.com/contents/acute-mild-traumatic-brain-injury-concussion-in-adults?search=concussion&sectionRank=3&usage_type=default&anchor=H25&source=machineLearning&selectedTitle=1~79&display_rank=1#H25

https://www.cdc.gov/HeadsUp/

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