General principles of fracture reduction involve axially distracting or pulling on a fracture fragment and pushing the piece back into anatomical alignment. This can be seen in the video below (automatically starts at 2:25 for the actual procedure). What if this approach doesn’t work? The fracture fragment remains immobile despite your best efforts.
Patients with rotation deformities of the fingers from a metacarpal fracture should be reduced. All fingers should normally point towards the patient’s scaphoid bone.
Metacarpal (MC) fractures are common injuries, which often spark discussions about whether they should be reduced in the ED urgently.
Here’s a quick-reference card to help guide your management decisions. These recommendations may vary slightly based on what references you use. You may need to tailor your decisions based on your regional practices.
Go to ALiEM (PV) Cards for more resources.
Thanks to Dr. Nicole Strauss at the UCSF-SFGH Orthopaedic Trauma Institute and my go-to hand expert for her input.
I am in the process of creating a PV card on metacarpal fractures, divided into anatomical areas (base, shaft, neck, head), and am realizing that the EM and orthopedic literature don’t quite agree. Actually they are quite vague on whether reductions should occur in the ED vs orthopedics clinic in the next few days.
Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED.
Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides?
Once you have significant soft tissue injury, you are automatically have a Type III fracture and should add an aminoglycoside.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
As a followup to the blog on the Captain Morgan technique for hip dislocations, I’d like to throw out another similar technique that also does NOT involve climbing up on the gurney.
Relocation of a hip joint is often quite a sight to see in the ED. A commonly taught technique is the Allis maneuver (watch the first 45 seconds of the above video from the Medical College of Georgia). It has always seemed a bit precarious to me having someone stand on the patient’s bed.
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Who loves relocating shoulder dislocations as much as I do? I know you do.
Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.
How can you improve your success rate in injecting into glenohumeral joint injection?