Rosen & Barkin's 5-Minute Emergency Medicine Consult (275 page)

• Multiple acetaminophen/opioid analgesic combinations are available; see the alert below.
  
• Acetaminophen: 300 mg/codeine 30 mg (peds: 0.5–1 mg/kg codeine) PO q4–6h
  
• Acetaminophen: 500 mg/hydrocodone 5 mg PO q4–6h
  
• Acetaminophen: 750 mg/hydrocodone 7.5 mg PO q4–6h
  
• Acetaminophen: 325 mg/hydrocodone 10 mg PO q4–6h
  
• Acetaminophen: 325 mg/oxycodone 5 mg PO q6h
  
• Bupivacaine: 0.5% 0.5–1 mL per injection for intercostal nerve blocks
  
• Hydromorphone: 2–8 mg (peds: 0.03–0.08 mg/kg) PO q4–6h
  
• Hydromorphone: 1–4 mg (peds: 0.015 mg/kg) IV/IM/SC q4–6h
  
• Morphine sulfate: 0.05–0.1 mg/kg IV/IM/SC q2–6h
  
• Patient-controlled analgesia using fentanyl, hydromorphone, or morphine sulfate is effective.
  

FOLLOW-UP

All patients with flail chest should be admitted to critical care setting for close monitoring and adequate pain control.

Patients found to have flail chest, with or without pulmonary contusion, should not be discharged.

• Early pain control is key.
  
• Beware of concomitant injuries such as pulmonary contusion and pneumothorax.
  
• Elderly patients have significantly poorer outcomes.
  

• Eckstein M, Henderson S. Thoracic trauma. In: Marx J, Hockberger R, Walls R, eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  , 7th ed. St. Louis, MO: Mosby; 2009.
  
• Livingston DH, Shogan B, John P, et al. CT diagnosis of rib fractures and the prediction of acute respiratory failure.
  J Trauma
  . 2008;64:905–911.
  
• Simon B, Ebert J, Bokhari F, et al. Management of pulmonary contusion and flail chest: An Eastern Association for the Surgery of Trauma practice management guideline.
  J Trauma Acute Care Surg
  . 2012;73(5 suppl 4):S351–S361.
  
• Wanek S, Mayberry JC. Blunt thoracic trauma: Flail chest, pulmonary contusion, and blast injury.
  Crit Care Clin
  . 2004;20(1):71–81.
  

CODES

807.4 Flail chest

BASICS

Injury to tarsal bones or metatarsals including calcaneus, talus, navicular, cuboid, cuneiform, and metatarsals

• Most common foot injuries are of the metatarsals and phalanges.
  
• The calcaneus is the most commonly fractured of the tarsal bones.
  
• Calcaneus fractures: Compression injury from sudden high-velocity impact to heel:
  
  • 75% are intra-articular; 50% have associated injuries:
    
    • 10% spine fractures
      
    • 25% with associated lower extremity trauma
      
    • 9% bilateral, 5% open
      
• Metatarsal fractures: Divided into stress fractures, twisting injuries, or direct trauma:
  
  • 1st metatarsal: Direct applied force
    
  • 2nd and 3rd metatarsals are most often involved in stress fractures and twisting injuries.
    
  • 5th metatarsal: Avulsion fracture (dancer’s fracture) of proximal apophysis is the most common injury.
    
  • Jones fracture: Transverse fracture of the metaphyseal–diaphyseal junction of 5th metatarsal; results from twisting while foot inverted.
    
• Talus: Caused by dorsiflexion with axial load, common snowboarder’s injury
  
• Navicular: Results from axial compression or stress fractures
  
• Cuboid and cuneiform fractures are rare and occur in conjunction with other injuries, often with tarsal–metatarsal injuries.
  
• Tarsal–metatarsal injuries (Lisfranc injuries) are high-energy injuries:
  
  • Axial load on plantar-flexed foot, or hindfoot fixed with forced foot eversion
    
  • Unstable forefoot on hindfoot
    
  • 20% go undiagnosed on initial visit.
    
  • 3 types: Convergent, divergent, and incongruent
    

• Metatarsal fractures account for 90% of foot fractures in children, usually from direct trauma:
  
  • Lesser metatarsal fractures (2–4) most common followed by base of 5th then base of 1st metatarsal.
    
  • Physeal injury may occur with proximal 1st metatarsal fractures.
    
• Other common injuries include phalangeal fractures (17%) and navicular fractures (5%).
  
• Fractures of talus or calcaneus occur with distal tibia or fibula fractures (8%).
  
• Calcaneus fractures are less likely intra-articular. Less common to have associated spine fractures.
  

DIAGNOSIS

• History of preceding trauma most common
  
• Stress fractures may present with increasing pain in the setting of repetitive activities.
  

• Ecchymosis, pain, swelling, or deformity of foot
  
• Pain with weight bearing
  
• Joint instability
  

• Physical exam of extremity is necessary to assess neurovascular status, skin integrity, gross swelling, deformity, or loss of function.
  
• Exam of spine is also essential in suspected calcaneus fractures, as there is a 10% incidence of coexistent injury.
  
• Anteroposterior/lateral and oblique views are necessary for all foot fractures.
  
• Complications:
  
  • Compartment syndrome most commonly presents as severe pain in a swollen foot:
    
    • Pressures >35 mm Hg require opening of all major foot compartments.
      
    • May have hypesthesia of plantar foot
      
    • Weak toe flexion
      
    • Late findings include claw toe deformity.
      
  • Nonunion and avascular necrosis are common complications with talar neck fractures owing to distal blood supply.
    
  • Calcaneus fractures may be accompanied by sural nerve injury; test sensation along lateral aspect of foot.
    

Special views may be needed for some fractures:

• Lisfranc fractures may require stress views with weight bearing. They may require MRI to evaluate ligamentous stability. May require CT for evaluation of small fractures if clinically suspicious
  
• Fleck sign: Pathognomonic—avulsion of ligament from 2 MT base or medial cuneiform
  
• Talar fractures may require a 45° internal oblique view. May require CT.
  
• Midfoot fractures may require an external oblique foot view.
  
• Calcaneus fractures require an axial view and may require CT:
  
  • Bohler's angle <20° suggests a compression fracture of calcaneus.
    
  • Lumbosacral spine films are necessary in all patients with calcaneus fractures.
    
• Stress fractures may require 2 wk to appear on plain films; bone scan or CT may be used to elucidate suspected fractures.
  

• Anterior effects of calcaneus and talar dome fractures can be misdiagnosed as ankle sprains.
  
• Foot contusions
  
• Freiberg disease: Osteochondrosis of 2nd metatarsal head may be mistaken for stress fracture.
  

TREATMENT

• Ice bag should be placed on affected foot and foot and ankle immobilized.
  
• All patients suspected of calcaneus fracture should have spinal immobilization; often, mechanism is fall from height >6 ft.