Sport, person-on-person physical violence, motor and other vehicle smashes, “accidents” (I believe there is no such thing as an accident), anger and frustration often result in people attending the ED for management of bone and joint injuries.
I mention anger and frustration and will deal with it first because these emotions cause a lot of bone injuries. Believe it or not, a week rarely goes by when we don’t see at least one or two people with “boxer’s fractures”. This is a break through the far end of the fifth metacarpal which is the long bone in the hand right behind the little finger. Sure, many we see are inflicted by the victim punching another person on the hard bones of the face or skull. We just have to accept that as a fact of modern life. The hard-to-believe bit is that we frequently see this bone, and others in the hand, broken by the owner punching a wall or other solid, immobile object in anger or frustration. Most often seen in young males in their late teens but occasionally seen in young women as well.
According to a set of clearly defined criteria, some of these fractures we deal with by splinting the hand, others we send to plastic surgeons or orthopaedic specialists for treatment. These latter patients have bone that is significantly displaced and /or the broken bit is angulated more than fifteen degrees. They may require open surgery or internal splinting with wire or fine steel pins. Given the nature of the injury the skin is often broken which then makes the injury a compound fracture. That is, there is an open wound through which bacteria can gain access to the broken bones and cause bacterial osteo-myelitis. This is a very nasty situation with the potential for very serious complications. I don’t pursue the causes of the anger or frustration but I often wonder just what compels young people to punch a fist with full force into a brick or solid timber wall.
The flip side of the boxer’s fracture is the broken nose or jaw. Some patients have all three. We don’t get too excited about broken noses unless there is severe displacement of the bones. Even then the patient’s are usually booked into an outpatient clinic in a week or more for review after the swelling has gone down. Disfiguring fractures are put back into place. Minor fractures left alone.
Jaw fractures can be a worry. The jaw most commonly breaks in two places and it is a trap into which young players often fall. These fractures usually result in the jaws being wired together until the fractures heal. CT scans are much more reliable with face fractures and we rarely do plain x-rays looking for fractures of the face. This turned out to be a good thing for a little old lady I recently treated. She had tripped on the hose on the garden path and fell forward striking here face on the gravel. She had not lost consciousness and seemed only to have abrasions to her nose and the tip of her jaw. But she did complain of an earache. Examination of the ear revealed nothing abnormal. I was acutely aware that pain from the temporo-mandibular joint (the jaw joint) can often be felt in the ear but her joint was not tender and she had a full range of movements without pain. I requested a CT scan and, lo and behold, there was a severe fracture of the jaw. That part of the jaw that fits into the socket in the skull bones, just in front of the ear, had snapped off completely and was displaced out of the socket. The dear old soul had to be dispatched off to the facio-maxilliary surgeons.
Little Jason was a six year old boy brought in by his parents after falling over backwards and his left upper arm striking the edge of the gianormous back pack tiny kids appear compelled to wear to school every day. He was very distressed and obviously suffering a lot of pain which, he indicated, was in his left upper arm. There was no deformity and no bruising but he was very tender when I gently felt around the mid-shaft of his humerus, (the bone in the upper arm). I was sure he had a fracture even though the mechanism was not consistent with that.
We gave him a good dose of oral analgesic, (pain killer), then waited until it kicked in before sending him off for an x-ray. I got the images up on our computer screen as soon as they became available. Sure enough, there was a comminuted fracture through the mid-shaft of the humerus with considerable displacement of the fractured bone ends. This mean there was not just a simple break through the bone but that it was shattered. Not only that but the cortex of the bone appeared abnormally thin and there was the appearance of empty space within the bone.
I nipped around to x-ray and grabbed the radiologist just before he knocked off for the day. He confirmed my findings and announced that there was, indeed, a large bone cyst at the point of the fracture. In technical terms we were then dealing with a pathological fracture, that is, a fracture with an underlying disease involved. The good news was that the cyst was benign, not malignant.
I rang the orthopaedic registrar at a teaching hospital and he advised me to send the boy up immediately. We put a plaster-of-paris back slab splint on his arm to keep it immobile, and his parents elected to drive him up. I heard no more until, a few months later, his parents brought him in again after a fall. Parents and patient were convinced he had broken the same arm again. It had transpired that, the night of the original fracture, the orthopaedic consultant on call had advised they wait for a few months and let the fracture heal itself – which that type of fracture does – but to then let him perform a bone graft that would permit the arm to develop normally and prevent further fractures. He had sternly warned patient and parents to be careful to prevent another fracture in the interim. So, on the second occasion I saw him he had fallen onto the same arm, it hurt and all were convinced it had broken again. X-rays disproved that. We could easily see the original fracture but it had thick, healing callous around it and the broken ends were not displaced from their original positions.
We applied another plaster-of- paris splint and sent him home. I gave them a letter and the new x-rays and advised they get back to the orthopaedic specialist. In fact they already had an appointment within the next week. I haven’t seen him since.
At the other end of the age spectrum are those with osteoporosis and prone to falling. Just about every Monday morning two or three ambulances will roll in each with an elderly patient, usually from a nursing home, and a history of falling and a painful hip. The ambulance officers usually splint the affected led by tying it to the other. When we remove the ties the affected leg is obviously shorter than the other and the foot will be turned, usually, outwards. These are classical signs of a fractured neck of femur- the femur being the thigh bone - and it snaps at the hip joint. X-rays confirm the clinical diagnosis.
We often do a femoral nerve block by injecting local analgesic into the femoral nerve in the groin. This relieves the pain. It is necessary to insert a catheter into the bladder and leave it there to control the flow of urine into a bag. We immobilise the legs again and arrange transfer to a teaching hospital where surgery will be performed to repair the fracture. The patient will most often be up and about and back in the nursing home within a few days.
On occasions patients with fractured NOF – neck of femur – or other fractures, sustain the injury in their home. These people, all too often, live alone and it is obvious to one and all that they really should not live alone. They may be dirty, disheveled, underweight, dehydrated and often confused. When asked, the ambulance officers will report the house to be sadly untidy especially in the case of elderly men who live alone. When the next of kin arrive – usually an adult off-spring of the patient – they hasten to reassure us that they try their hardest to look after the parent and have repeatedly but unsuccessfully tried to persuade them to move to accommodation where care and support is provided. We have no cause to doubt them and need to reassure them that they have no reason to feel guilty.
With the presenting injury managed and under control I will often take it upon myself to have a quiet chat with the patient and suggest the time may have come to seriously consider alternative accommodation. The spectre of “a nursing home” and horror stories of many years since may be raised. Many, though, realise just how precarious their existence has become; with others the prime concern is inconvenience to their children. My next move will be to suggest to patient and next of kin that our hospital social worker can be very helpful at times like this and seek their permission to ask that good lady to attend. Expert at dealing with such crises at such times, the social workers invariably set the family on the right track to explore the options and help them make rational decisions.
Another fracture common in seniors is Colle’s fracture of the wrist. The patient usually trips and falls onto the outstretched hand breaking the radius just short of the wrist and displacing the broken fragment backwards. This almost invariably requires intervention to get the bone back into near-normal position and alignment. Once-upon-a-time this was always done under general anaesthetic in the operating theatre. Now it is usually done under local anaesthetic in the ED. A plaster of Paris splint is applied and the patient goes home with an appointment for orthopaedic follow up in due course.
In younger people the same mechanism of falling onto outstretched hand often results in a fracture of a small bone in the wrist joint – the scaphoid. Even though there is a classical injury history with classical symptoms and clinical signs it is often difficult to diagnose in the early stages because the fracture line will not clearly show on x-rays for ten to fourteen days. Most of us in ED, whenever we suspect such a fracture, will immobilise the wrist in plaster of Paris and arrange repeat x-rays and review in two weeks.
Even though this is a small bone it is an important bone. And this complicates matters because its blood supply comes from an artery than runs backwards onto the bone. That is, the artery branches off its parent at a point past the scaphoid and runs into the bone at its furthermost point. Fractures of the scaphoid most commonly run across the mid-point waist of the bone hence can disrupt the blood supply to the near half which may suffer ischaemic necrosis (death from lack of blood) and crumple up. The end result of this is severe arthritis and limitation of function of the wrist joint.
While we are discussing the upper limb – fractures of the clavicle (collar bone) are common especially in the young. (Young can mean not as old as me; but here let’s say in those under forty.) Falls from horses, motor bikes, push bikes, fences, monkey bars and swings often result in a fractured clavicle. And so do person to person collisions as occur in many contact sports such as Aussie Rules footy. This fracture , traditionally, was considered to be of no great significance and treated with a collar and cuff sling and analgesics. (The collar and cuff was preferred to the full arm sling because it allows the weight of the arm to pull the broken ends back into position.) The Generation Y orthopaedic specialists seem to be taking a different view of this fracture. They are doing “open reduction and fixation” – that is – operating to get the bone pieces back into place and holding them there with plates and screws. Some use a large, ugly screw that looks like an auger and is screwed in to the bone marrow.
There are advantages to the surgical approach. Normal function is returned quicker and, because the broken bones ends are immobilised sooner, there is less pain. The flip side is risk. Immediately behind the clavicle runs the brachial artery and vein and, a bit further away, the brachial plexus or bundle of nerves. These organs supply the arm. Without suggesting that any surgeon is careless, operating on the clavicle requires meticulous care to avoid damage to any of the afore-mentioned structures the consequences of which could be disastrous.
Just at the tip of the clavicle in the shoulder lies the shoulder joint and this is commonly dislocated. The ball shaped upper end of the humerus bone in the upper arm fits into a shallow socket called the glenoid cavity formed by three parts of the shoulder blade aka the scapulla. The humerus can be dislocated in front of the glenoid cavity, behind it or below it and it is very difficult to determine, on x-rays, which way it has gone or even if it has gone at all. That is, if you do not know of the Mercedes Sign. Picture the symbol of the Mercedes-Benz motor company – a circle with three equally spaced radii. OK? Well, if you take an x-ray of the shoulder from the side the three parts of the scapula forming the glenoid cavity resemble the mercedes Sign inverted. Overlying it is the humeral head. If the centre of the head overlies the centre of the cavity the shoulder is not dislocated. The location of the centre of the humeral head relative to the centre of the Mercedes symbol tells us if it is dislocated and if so if it is to the front, behind or below. This is important as it dictates what manoeuvres are necessary to get it back in place.
As a bit of an aside, we have all heard of Mercedes Benz and, perhaps Daimler-Benz. Karl Benz built and patented the first petrol-powered automobile in 1886. Gottlieb Daimler added a petrol engine to a stage coach later in 1886. In 1926 the Daimler-Benz Motor Company was formed and all of their product vehicles were to be called Mercedes-Benz. So, who was Mercedes? She was, in fact, the daughter of one Emil Jellinek who was a member of the board and who had some racing cars built to his specifications. He insisted that the engine be named the Mercedes… and the rest is history.
All of that has precious little to do with the Emergency Department other than that motor vehicles provide us with a great deal of work although not a lot from Mercedes per se – probably because, in Australia, their smash numbers are statistically insignificant. And now, let’s move on to another bone.
Calcaneus is the name given to the heel bone. It is commonly broken in falls from heights with the victim landing upright. A favourite of roof carpenters who fall and people who slip off the rungs of ladders landing on their feet, as well as drunks, or the adventurous, jumping onto solid ground from heights. In fact, in the literature, they are sometimes referred to as “Lover’s Fractures” because they could, presumably, result from a lover leaping from a bedroom window to escape an enraged spouse – honestly! The bone is usually impacted into itself but the fracture can be difficult to see on x-rays. CT scans give better results. The clinical clues to diagnosis are severe pain, with the patient being unable to bear any weight on the affected foot, swelling, bruising and severe tenderness. Often (7%) both heels are smashed.
These fractures present challenges to the orthopaedic surgeons – into whose care most of these patients are referred. Surgery is usually required to attempt to dis-impact the crushed bones and get them back into as normal position as possible. 70% of these fractures run into the adjacent ankle joint and even good repair may still results in severe arthritis in the ankle. Not at all a nice fracture to have and we do see our fair share of them presenting to ED.
Sport – a variety of physical activities, undertaken by many and passively but passionately followed by many more Australians, provides us with much of our bone and joint emergencies. I have never seen any statistical research results of studies into what sport costs the nation but I would venture to suggest it would be astronomical. Joint injuries are most common especially ankles and knees. Football of any type and netball/basketball are the prime contenders for ignominy.
Inversion injuries, commonly known a rolled ankles, roll into ED with monotonous regularity on Saturdays and Sundays. The ankle is usually very painful, tender and swollen around the lateral malleolus - the bony protuberance on outer side of the ankle. Careful examination will usually differentiate between a sprain, in which the ligaments holding the lower leg onto the foot are torn, and a fracture in which bones are broken. These ankles are usually x-rayed because it is difficult to exclude an avulsion fracture – where ligaments are torn out of the bone or a fragment of bone is ripped away.
Ankle fractures demand a plaster of Paris back slab and orthopaedic specialist consultation in due course. Sprains are occasionally also treated with a plaster of Paris back slab but usually just supported with an elastic tube or bandage. We advise ICE – Ice packs, Compression and Elevation for the first day or two. Non-steriodal anti-inflammatory medications are often prescribed along with analgesics and we advise the use of crutches until the victim can bear weight without pain.
Aussie Rules footy and netball cause more than their fair share of knee injuries. In netball, the rule that requires the player to catch a ball and immediately turn through 180 degrees before throwing it to another player is an abomination. It is difficult to imagine a mechanism more effective at screwing up knees. And the Aussie Rules player who takes a spectacularly high mark is just as likely to inflict a spectacular injury on a knee when he touches down.
A very common knee injury is a torn meniscus – the meniscus being the rim of cartilage that forms a rather inefficient shock absorber between femur and tibia (thigh bone and shin bone.) There is one on each side of each knee. The classic mechanism of tearing it is twisting the knee when it is under pressure just as the netball player does and so does the Aussie Rules player twisting and turning on the run. In days that have fortunately long gone the treatment of a torn meniscus was to operate and remove it. The end result of that, all too often, was serious osteo-arthritis on the knee with bone scraping on bone and necessitating knee replacement surgery. The modern treatment is still surgery but a far more sophisticated operation done via an arthroscope to nibble away only the damaged edges of the meniscus.
The rite of passage for the modern footballer now seems to be torn cruciate ligaments demanding knee reconstruction. It is not uncommon for us to see patients with new knee injuries and proudly proclaiming that they have had one or more previous knee reconstructions. They seem to think the operation can be done over and over with each one giving them another season – or part thereof –on the field. Their ultimate fate might best be demonstrated by the chap I met in a caravan park recently. Ten years or more younger than me he hobbled about the place with great difficulty and in considerable pain. “Aussie Rules!” he explained. “Both knees reconstructed twice and both replaced last year.” I gave him a chair, which he accepted very gratefully, and a can and we had an interesting chat about footy.
Mind you, not all knee injuries are due to sport. Just recently a Good Samaritan brought in a chap who had fallen off his bike and injured a knee. He could not put any weight on the knee at all and was in severe pain. We gave him something for the pain and he explained that his bike wheel got caught in a groove between road and kerb, at low speed, but he fell side ways. As he fell he put his leg out to break his fall but it all went pear-shaped and he finished up on the ground with agonizing knee pain. The Samaritan had him with us within fifteen minutes of the fall.
His knee was grossly swollen and impossible to examine formally but I did determine he was extremely tender around the outer side of the knee. Because the knee had swollen so quickly it was reasonable to assume it was bleeding inside. Testing the cruciates and collateral ligaments was impossible but the knee cap and patella tendon appeared intact.
At first scrutiny the x-rays appeared unremarkable. Very close examination using the eye of faith suggested there was a fracture through the boney protuberance on the tibial plateau to which the anterior cruciate ligament attaches. (The tibial plateau is the wide surface at the top of the tibia through which the thigh bone transfers the body weight to the lower leg, ankle and foot.) This situation demanded a CT scan even though they are not as reliable as PET scans at revealing knee damage especially to the ligaments. But we don’t have a PET scanner so off he went to the CT machine.
The pictures confirmed a fracture through the anterior cruciate insertion. However, I was surprised to find a crush fracture of the tibial plateau on the inner side. Serious stuff! The causative mechanism was the knee trying to bend sideways when his foot was in contact with the ground as he fell. Of course the knee will not bend sideways but the forces produced were enough for the thigh bone to crush the tibia. The unfortunate patient had to be admitted to hospital for management by an orthopaedic surgeon.
Broken ribs are a common consequence to fighting but there are other causes of course. They are not considered to be terribly important, (other than to the suffering patient), and are most commonly treated with rest and analgesia. In the olden days we strapped the chest with elastoplast but too many patients developed pneumonia so that fell out of favour. (The strapping stopped the fracture end from moving but also stopped the lung from inflating which leads to pneumonia.)
Rib fractures are difficult to see on x-rays unless the fractured ends overlap or are otherwise displaced. However, most doctors do ask for x-rays any way. It helps to diagnose a pneumothorax, haemothorax or flail chest. A pneumothorax is free air in the chest outside the lung. A displaced rib fracture can tear the lung allowing air to escape. A haemothorax is free blood in the chest caused by the same mechanism. They can co-exist. A flail chest is caused by one or more ribs fracturing in two places which is not uncommon. This upsets the respiratory process and when the patient inhales the affected part of the chest wall moves inward when it would normally move outward. If several adjacent ribs have flail segments the paradoxical movement can seriously compromise the patient’s breathing.
Spinal fractures vary from life threatening fractures of the neck to relatively minor fractures of those bits of vertebrae that stick out to offer attachment for muscles. The serious stuff is always sent off to the specialist management hospitals. The not-so-serious may be treated in the local hospital or even in the home. Any suspicion of spinal fracture is always regarded and assessed very carefully. And so it is with skull fractures also. They are all treated very seriously and often require surgery to correct bleeding inside the skull or even heroic surgery to remove bone to allow the brain to swell – and then putting the bone back when the swelling goes down.
Pelvic fractures are usually a consequence of severe trauma and are often associated with injury to intra-abdominal organs. The pelvis – like the jaw – will usually fracture in two places rather than one. Uncomplicated pelvic fractures are most often treated with rest in bed with appropriate analgesia. Others require surgical intervention to reduce and immobilise the fractures. (Reduce means to get displaced bones back into normal or near normal position.)
And now that we’ve broken just about every bone in the body that part of the journey ends.