Rosen & Barkin's 5-Minute Emergency Medicine Consult (711 page)

• Fractures to the thumb sometimes occur in children.
  
• Consider nonaccidental trauma.
  
• Do not neglect appropriate pain management in children.
  

• Immobilize the thumb pending definitive evaluation.
  
• Neurovascular exam with 2-point discrimination.
  

Radiography as noted below

• Plain radiography of affected areas
  
• Avoid testing stress of thumb MP joint, as in testing for gamekeeper thumb, until all plain radiography is complete.
  

• Extra-articular fracture of the base of the thumb metacarpal
  
• Scaphoid fracture
  
• Gamekeeper thumb: Ulnar collateral ligamentous injury
  

TREATMENT

• Dress open wounds.
  
• Immobilize hand and wrist with thumb in neutral position.
  
• Elevate and apply cold to reduce swelling.
  
• Age-appropriate social management
  

Immobilize thumb pending definitive evaluation.

• Thumb spica splint with the thumb in neutral position, as if holding a beverage can
  
• Splint instructions should be provided to patient.
  
• Angulated extra-articular fractures of the 1st metacarpal require reduction. Can tolerate up to 30° of angulation. Angulation >30° requires another attempt at reduction or orthopedics’ consultation.
  
• Distal phalangeal fractures require DIP splint in extension for 3–4 wk.
  

Pain control with oral analgesic preparations

FOLLOW-UP

Open fracture, presence of multiple trauma, or other more serious injuries

• Counsel the patient that there is a strong likelihood of the need for operative repair for 1st metacarpal injuries.
  
• Closed injuries: Referral, splinting, and explain frequent need for operative fixation
  

72-hr orthopedic referral

Due to tendon insertions, fractures at the base of thumb are often unstable and frequently require operative fixation

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  Aust Fam Physician.
  2011;40(6):394–396.
  
• Capo JT, Hall M, Nourbakhsh A, et al. Initial management of open hand fractures in an emergency department.
  Am J Orthop (Belle Mead NJ)
  . 2011;40(12):E243–E248.
  
• Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries.
  J Hand Surg Am.
  2009;34(5):945–952.
  
• Haughton D, Jordan D, Malahias M, et al. Principles of hand fracture management.
  Open Orthop J.
  2012;6:43–53.
  
• Leggit JC, Meko CJ. Acute finger injuries: Part II. Fractures, dislocations, and thumb injuries.
  Am Fam Physician.
  2006;73(5):827–834.
  
• Lyn E, Mailhot T. Hand.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  7th ed. John A. Marx. Philadelphia, PA: Mosby-Elsevier; 2010:489–524.
  

CODES

• 816.00 Closed fracture of phalanx or phalanges of hand, unspecified
  
• 816.01 Closed fracture of middle or proximal phalanx or phalanges of hand
  
• 816.02 Closed fracture of distal phalanx or phalanges of hand
  

BASICS

• Synonym: Tibial condylar fracture
  
• Fracture or depression of the proximal tibial articulating surface
  
• Valgus or varus force applied in combination with axial loading onto tibial plateau
  

• Type 1:
  
  • Split fracture of the
    lateral
    tibial plateau
    without
    depression of the plateau
    
• Type 2:
  
  • Split fracture
    and
    depression of
    lateral
    tibial plateau
    
  • Associated with lateral meniscus injury
    
• Type 3:
  
  • Central depression of the
    lateral
    plateau
    
  • Injuries may be unstable
    
• Type 4:
  
  • Split of the
    medial
    tibial plateau
    
  • Can cause damage to other structures:
    
    • Popliteal vessels
      
    • Peroneal nerve
      
    • MCL
      
    • Lateral meniscus
      
    • Lateral collateral ligament
      
    • Cruciate ligaments
      
    • Tibial spines
      
    • Compartment syndrome
      
• Type 5:
  
  • Bicondylar tibial plateau fracture
    
  • Same associated injuries as type 4
    
• Type 6:
  
  • Bicondylar,
    grossly comminuted fracture of the plateau
    
  • Diaphyseal–metaphyseal dissociation
    
  • Same associated injuries as types 4 and 5
    

• Mechanism of injury:
  
  • Types 1 & 2 from a valgus force with axial loading, generally a low-energy injury
    
    • Associated with contact sports, twisting motions (e.g., skiing) or classically, pedestrians struck by a vehicle bumper
      
  • Type 3 are low-energy injuries in osteopenic bone
    
  • Types 4–6 are high-energy injuries usually from motor vehicle/cycle collisions and falls from height causing medial plateau fractures
    
    • Associated with neurovascular injuries
      
• Age associated
  
  • Type 1: Younger patients with cancellous bone of the plateau resists depression.
    
  • Types 2 & 3: Depression fractures seen in osteopenic older bones
    

Tibial plateau fractures are rare in children because of the dense cancellous bone of the tibial plateau

DIAGNOSIS

• Painful swollen knee
  
• Inability to bear weight
  
• Knee effusion (hemarthrosis)
  
• Active and passive range of motion limited
  
• Tender along the proximal tibia and joint line
  
• Possible varus or valgus deformity of the knee
  
• Possible joint instability due to associated ligamentous injury
  

• Hit to lateral knee
  
• Fall from a height with axial load
  
• Twisting injury
  

• Decision tools for the use of radiography:
  
  • Ottawa knee rules (highly sensitive): Knee radiographs are indicated if
    any
    of the following are present:
    
    • Age >55 yr
      
    • Tenderness of the fibular head
      
    • Inability to flex to 90°
      
    • Isolated patellar tenderness
      
    • Inability to transfer weight for 4 steps both immediately after the injury and in the ED
      
    • Limping is allowed.
      
  • Pittsburgh knee rule (highly sensitive and specific): Knee radiographs are indicated in fall or blunt trauma when the following are present:
    
    • Age <12 or >55 yr
      
    • Inability to bear full weight for 4 steps in the ED
      
    • Limping is
      not
      allowed
      
    • Pittsburgh knee rule should be applied with caution to patients <18 yr old
      
• Neurovascular exam:
  
  • High-energy mechanism carries risk for neurovascular injury and compartment syndrome
    
  • Watch for unrelenting pain, muscle weakness, tense muscle swelling, hypesthesia or anesthesia, pain with passive stretch of muscles
    
  • Check popliteal, posterior tibial, and dorsalis pedis pulses
    
  • Check integrity of peroneal nerve:
    
    • Ankle and great toe dorsiflexion
      
    • Sensation in dorsal web space between great and 2nd toes