Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5^th Metacarpal)

Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.

• 2^nd and 3^rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
• 4^th Metacarpal fracture <20۫ angulation allowed
• 5^th Metacarpal fracture <30۫ angulation. 
  • Studies have shown that even 30۫ angulation will decrease normal function by 20%.  
  • Normal excursion of the 5^th MCP is 15۫ to 25۫.
• No amount of rotation deformity should be allowed.

Some quick facts about Knee Injuries:

 

• The most common cause of acute traumatic hemarthrosis of the knee is an anterior cruciate ligament tear.
  • Most patients with an ACL injury will give a history of immediate pain, disability, knee swelling and audible pop.
• The most common ligament injuried in the knee is the medial collateral ligament.
• Patella dislocations
  • Usually lateral dislocations and often spontaneous reduce.
  • Hyperextend the knee to make the reduction easier.
• Dislocation of the knee:
  • Anterior is the most common and usually secondary to hyperextension
  • Popliteal artery injury is commonly seen and must be looked for.  Easy bedside test is Ankle Brachial Indexs.

 

Pediatric Strain versus Fracture

• Due to the fact that tendons are much stronger than the physeal growth plate in pre-pubescent children, one should be extremely cautious when diagnosing a strain/sprain. 
• Pre-pubescent pediatric patients should be treated as if they have a Salter Harris I fracture with an appropriate splint and close follow up.

Review of Salter Harris Fractures

1. A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened.
2. A fracture through the physeal growth plate and metaphysis.
3. A fracture through the physeal growth plate and epiphysis.
4. A fracture through the physis, physeal growth plate and metaphysis.
5. A crush injury of the physeal growth plate.

Please click here for a pictorial of Salter Harris Fractures from FP Notebook.

Low Back is one of the most common complaints that we see in the Emergency Department.  Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…).  However, most of the back pain that we will see is musculoskeletal in origin.

The American College of Physicians (ACP) and the American Pain Society (APS) recently released some joint recommendations on the evaluation of treatment of individuals with back pain.

In summary their key recommendations are:

1. Routine imaging is not required. However, diagnostic imaging and testing should be obtained for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.
2.  For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
3. Medications that have good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain).

Links to the Clinical Guidelines are listed below:

• Evaluation and Treatment
• Nonpharmacologic Therapies for Acute and Chronic Low Back Pain
• Medications for Acute and Chronic Low Back Pain

Supracondylar fractures in children: To assess the likelihood of a supracondylar fracture in a child look at the anterior humeral line. This is a line drawn down the anterior portion of the humerus on the lateral view of the elbow. This line should pass through the center of the capitellum in the distal humerus. If the line does not pass through the center there is a very high likelihood of a supracondylar fracture. Review of the Appearance of Ossification Centers in Children's Elbows CRITOE Capitellum 1 to 8 months Radial Head 3 to 5 years Medial (Internal)Epicondyle 5 to 7 years Trochlea 7 to 9 years Olecranon 8 to 11 years Lateral ( External) Epicondyle 11 to 14 yeras