Rosen & Barkin's 5-Minute Emergency Medicine Consult (238 page)

Appropriate splinting

Immobilization to prevent further injury before taking radiographs is essential.

• Orthopedic consultation is recommended for all but nondisplaced, stable fractures, which can generally be splinted with 24–48 hr orthopedic follow-up.
  
• Fractures generally requiring orthopedic consultation:
  
  • Transcondylar, intercondylar, condylar, epicondylar fractures
    
  • Fractures involving articular surfaces such as capitellum or trochlea
    
• Supracondylar fractures:
  
  • Type 1 can be handled by ED physician with 24–48 hr orthopedic follow-up.
    
  • Elbow may be flexed and splinted with posterior splint.
    
  • Types 2 and 3 require immediate orthopedic consult.
    
  • Reduce these in ED when fracture is associated with vascular compromise.
    
• Anterior dislocation:
  
  • Reduce immediately if vascular structures compromised.
    
  • Then flex to 90° and place posterior splint.
    
• Posterior dislocation:
  
  • Reduce immediately if vascular structures compromised.
    
  • Then flex to 90° and place posterior splint.
    
• Radial head fracture:
  
  • Minimally displaced fractures may be aspirated to remove hemarthrosis; instill bupivacaine (Marcaine) and immobilize.
    
  • Other types should have orthopedic consult.
    
• Radial head subluxation:
  
  • In 1 continuous motion, supinate and flex elbow while placing slight pressure on radial head.
    
  • Hyperpronation technique is possibly more effective—while grasping the patient’s elbow the wrist is hyperpronated until a palpable click is felt.
    
  • Often will feel click with reduction
    
  • If exam suggests fracture but radiograph is negative, splint and have patient follow up in 24–48 hr for re-evaluation.
    
• Medial/lateral epicondylitis:
  
  • Severe cases can be splinted.
    
  • Rest, heat, anti-inflammatory agents
    

• Conscious sedation is often required to achieve reductions; see Conscious Sedation.
  
• Ibuprofen: 600–800 mg (peds: 5–10 mg/kg) PO TID
  
• Naprosyn: 250–500 mg (peds: 10–20 mg/kg) PO BID
  
• Tylenol with codeine no. 3: 1 or 2 tabs (peds: 0.5–1 mg/kg codeine) PO q4–6h; Do not exceed acetaminophen 4 g/24h
  
• Morphine sulfate: 0.1 mg/kg IV q2–6h
  
• Hydromorphone 5 mg/Acetaminophen 300 mg
  
• Acetaminophen do not exceed 4 g/24h
  
• Vicodin: 1–2 tabs PO q4–6h
  

FOLLOW-UP

• Vascular injuries, open fractures
  
• Fractures requiring operative reduction or internal fixation
  
• Admit all patients with extensive swelling or ecchymosis for overnight observation and elevation to monitor for and decrease risk for compartment syndrome.
  

• Stable fractures or reduced dislocations with none of the above features
  
• Splint and arrange orthopedic follow-up in 24–48 hr.
  
• Uncomplicated soft tissue injuries
  

• Failure to appreciate that a posterior fat pad sign is abnormal.
  
• Always check for neurovascular injury with injuries about the elbow, especially with dislcoations, pre- and postreduction.
  
• Always educate parents of a child with a supracondylar fracture about the signs and symptoms of compartment syndrome.
  

• Carson S, Woolridge DP, Colletti J, et al. Pediatric upper extremity injuries.
  Pediatr Clin North Am
  . 2006;53(1):41–67.
  
• Carter SJ, Germann CA, Dacus AA, et al. Orthopedic pitfalls in the ED: Neurovascular injury associated with posterior elbow dislocations.
  Am J Emerg Med
  . 2010;28(8):960–965.
  
• Chasm RM, Swencki SA. Pediatric orthopedic emergencies.
  Emerg Med Clin North Am
  . 2010;28(4):907–926.
  
• Falcon-Chevere JL, Mathew D, Cabanas JG, et al. Management and treatment of elbow and forearm injuries.
  Emerg Med Clin North Am
  . 2010;28(4):765–787.
  
• McCarty LP, Ring D, Jupiter JB. Management of distal humerus fractures.
  Am J Orthop (Belle Mead NJ)
  . 2005;34(9):430–438.
  

CODES

• 812.41 Closed supracondylar fracture of humerus
  
• 813.05 Closed fracture of head of radius
  
• 959.3 Elbow, forearm, and wrist injury
  

BASICS

• Electricity is the flow of electrons through a conductor, across a gradient, from high to low concentration
  
• Nature and severity of electrical injuries depend on the voltage, current strength and type, resistance to flow, and duration of contact
  
• Ohm law: Voltage (V) = current (I) × resistance (R):
  
  • Voltage is directly proportional to current and is inversely proportional to resistance.
    
  • High-voltage (>600 V) and low-voltage sources:
    
    • Telephone lines: 65 V
      
    • Household general circuit: 110 V
      
    • Electrical range or dryer: 220 V
      
    • Household power lines: 220 V
      
    • Subway 3rd rail: 600 V
      
    • Residential trunk line: 7,620 V
      
    • Industrial electrical power line: 100,000 V
      
  • Household devices can contain a transformer stepping up a seemingly low-voltage source to high voltage:
    
    • Microwave, television, computer
      
  • Resistance (R) is determined by the current’s pathway through the body:
    
    • Nerves, muscles, blood vessels have low resistance and are better electrical conductors than are bone, tendon, fat
      
    • Water and sweat on skin decrease resistance; calloused skin increases resistance
      
    • More resistance means less flow, and more conversion to heat
      
  • Current is measured in amperes (I) and is a measure of the amount of energy flowing through an object:
    
    • “Let go” current is the max. current a person can grasp and release before muscle tetany inhibits letting go
      
    • Household general circuit: 15–30 A
      
    • Tingling sensation/perception: 0.2–2 mA
      
    • Pain: 1–4 mA
      
    • Average child “let go” current: 3–5 mA
      
    • Adult “let go” current: 6–9 mA; higher for men than women
      
    • Skeletal muscle tetany current: 16–20 mA
      
    • Respiratory muscle paralysis: 20–50 mA
      
    • Ventricular fibrillation: 50–120 mA
      
• Alternating current (AC):
  
  • Electron flow rhythmically reverses direction:
    
    • Homes and offices in US use standard 60 Hz
      
  • Can produce continuous tetanic muscle contraction, loss of voluntary control of muscles, prolonged contact
    
  • More dangerous than direct current (DC)
    
  • More likely to result in ventricular fibrillation at household current level:
    
    • Stimulation can continue through T-wave period of cardiac cycle
      
• DC:
  
  • Continuous electron flow in 1 direction
    
    • Defibrillators and pacemakers, industrial sources
      
  • Large, single muscle spasm tends to throw victim from source:
    
    • Increased risk of traumatic blunt injuries
      
    • Shorter duration of exposure
      
  • More likely to result in asystole
    
• Trimodal distribution of electrical injuries:
  
  • Toddlers (household outlets and cords)
    
  • Teenagers (risk-taking behavior)
    
  • Adults (work-related injuries)
    

Types of electrical injury:

• Direct contact causing tissue destruction:
  
  • Electrothermal burn may cause skin or deep tissue coagulation necrosis
    
  • Minor visible injuries may be misleading for extensive deep tissue injury
    
  • Location of damage is point of contact with source and point of contact with ground
    
• Flame:
  
  • Burns from burning clothing or other substances
    
• Electrical arc indirect contact:
  
  • Burns from the heat of a high-voltage arc (a flash burn) that passes electricity through air
    
  • May cause thermal and flame burns
    
  • Flash burns usually result in superficial partial-thickness burns
    
• Primary electrical phenomena:
  
  • Cardiac arrhythmias
    
  • Muscle contractions and tetany
    
• Secondary injury from trauma:
  
  • Supraphysiologic muscle contraction
    
  • Fall or being thrown
    

DIAGNOSIS