Galeazzi and Monteggia Fractures

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Galeazzi Fracture: Definition:

-       Fracture of the shaft of radius (most commonly at the junction of the middle and distal thirds) with dislocation of distal radioulnar joint (DRUJ)

Mechanism:

- Direct wrist trauma

- Fall onto outstretched hand with forearm in pronation

Treatment:

-       Operative:

- ORIF of radius with reduction and stabilization of DRUJ. Anatomic reduction of DRUJ is required. Acute  operative treatment far superior to late reconstruction

Complications:

- Compartment syndrome: increased risk with high energy crush injuries

-       Neurovascular injury: uncommon except type III open fractures

 

Monteggia fracture:

Definition:

-       Fracture of the proximal portion of the ulna combined with dislocation of the radial head.

Epidemiology:

-       Rare in adults

-       More common in children with peak incidence between 4 and 10 years of age

Mechanism:

- Fall on an outstretched hand with the forearm in excessive pronation (hyper-pronation injury)

Prognosis:

-       If diagnosis is delayed greater than 2-3 weeks complication rates increase significantly

Treatment:

- Nonoperative

o   Closed reduction 

  • indications
  • more common and successful in children

- Operative

o   ORIF

  • indications
  • acute fractures which are open or unstable
  • comminuted fractures
  • Most Monteggia fractures in adults are treated surgically

o   IM Nailing of the ulna

  • Indications
  • transverse or short oblique fracture

Confusing right? Well... Just Remember "MuGGeR"!!

Sources: Ortho Bullets, Life in the Fastlane, InTrainingPrep

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CED

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CED stands for Clinical Event Debriefing. I am sure most of you are aware of these sessions taking place in the north/south side. These discussions are geared towards learning from a clinical case to ultimately improve patient care. Despite the fast-paced and high-volume ED where we practice it is possible to take 5 minutes to debrief a clinical case, if you follow these simple steps:

  1. Introduction:

- explain that this discussion is only going to take 5-10 minutes

- explain that this is a safe environment and that all participants will be treated with respect

- give all participants permission to leave (if they have a sick patient, a new patient, etc)

  1. Names and Roles
  2. Case Summary (provided by the team leader)
  3. +/delta

- Start with the positives! What went well? (i.e. closed loop communication, role assignment,

tone/volume, etc)

- How can we improve? (i.e. teamwork, systems, safety, etc)

  1. Develop solutions
  2. Closing Summary

What NOT to do:

https://www.youtube.com/watch?v=-aoTW420tBs

What to do:

https://www.youtube.com/watch?v=CUvrjOAEMWw

Happy debriefing!

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CCB Toxicity

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  • CCBs are divided into 2 groups:

    • Non-Dihydropyridines (Verapamil and Diltiazem) à cause a pup (heart) problem
    • Dihydropyridines (Amlodipine, Felodipine, Nifedapine, Nimodipine and Lercanidipine)à cause a pipe (vasoplegic) problem
    • However, in large overdoses receptor selectivity can be lost and the dihydropyridines can cause cariogenic shock.

 

  • Ingestion of >10 tablets of verapamil or diltiazem XR can cause life-threatening toxicity.
  • Effects are usually seen within 2 hours following standard preparations but can be delayed up to 16 hours with XR preparations.
  • Early signs of toxicity includes a rising glucose (patients are in a drug induced hypoinsulinaemic state) and lactate.
  • Typical signs include bradycardia, heart blocks and hypotension. If left untreated they can develop refractory shock and die.

Management of CCB overdose:

  1. As always, follow ABC. Intubate if the airway is compromised. However, it is important to remember to start at a 10th of your usual induction dose + push dose pressors prior to intubation if the patient is hypotensive
  2. High dose insulin is the antidote of choice. Early administration of High Dose Insulin 1unit/kg IV bolus and dextrose 50ml of 50% dextrose (paediatrics 5ml/kg of 10% dextrose to a max of 250ml). Followed by an infusion of insulin at 1 unit/kg/hour IV and a dextrose infusion. Some patients may not require additional dextrose early in the management. This will take 30-45 minutes to start working and therefore you will need other measures to manage the hypotension.
  3. Hypotension:
  4. Calcium gluconate and atropine. However, both of these agents are unlikely to work.
  5. A vasopressor such as norepinephrine will be the most effective. Start it peripherally until you get central access
  6. Ventricular pacing rarely works but in severe cases ECMO and intra-aortic ballon pump maybe considered.
  7. Decontamination:
  8. Charcoal to those who present within 1 hour of standard preparation or 4 hours for XR preparations. Whole bowel irrigation can be considered in patients who present within 4 hours of an XR preparation of 10 or more diltiazem or verapamil tablets.

Sources:

Life in the Fastlane, UpToDate

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