Rosen & Barkin's 5-Minute Emergency Medicine Consult (712 page)

• Plain radiography:
  
  • Tibial plateau view:
    
    • Anteroposterior (AP) view angled at 10–15° of flexion to evaluate the tibial spines, fracture lines extending into the joint, and depressions
      
  • Sunrise view of the patella:
    
    • Useful in identifying fractures of the patella not visualized on AP or lateral views
      
  • Cross-table lateral view:
    
    • To evaluate the medial plateau and reveal lipohemarthrosis (fat–fluid level)
      
  • Oblique view:
    
    • To identify fractures not apparent on other films and provide more information on fracture patterns
      
  • Pay attention to areas of ligamentous attachment where avulsion fractures may take place:
    
    • Medial and lateral femoral condyles
      
    • Tibial spine (intercondylar eminence)
      
    • Fibular head
      
• CT used to reveal occult fracture(s) not seen on plain film & further characterize known fracture
  
• MRI used for identifying soft tissue injuries (ligamentous and meniscal injuries)
  
• Arteriography helpful in localizing the injured area but should not delay revascularization and is indicated if:
  
  • High-energy mechanism
    
  • Schatzker type 4, 5, or 6 fracture
    
  • Alteration in distal pulses
    
  • Expanding hematoma
    
  • Bruit
    
  • Injury to anatomically related nerves
    

• Arthrocentesis to look for fat globules and bone marrow elements indicative of intra-articular fracture:
  
  • Indication to do procedure: Effusion present without fracture on plain radiographs
    
• Compartment pressure measurements are indicated if:
  
  • Pain not over fracture site
    
  • Pain on passive stretch
    
  • Paresthesias
    
  • Decreased distal pulses
    
  • Intracompartmental pressures >30 mm Hg are an indication for emergent orthopedic consultation
    

• Knee dislocation
  
• Proximal fibular fracture
  
• Femoral condyle fracture
  
• Patellar fracture
  
• Tibial subcondylar fracture
  
• Tibial tuberosity fracture
  
• Tibial spine fracture
  
• Cruciate ligament tears
  
• Collateral ligament tears
  
• Meniscal tears
  

Include oblique views as part of routine radiography

TREATMENT

Cautions:

• In high-energy mechanisms, associated major injuries take precedence
  
• Immobilize to prevent further neurologic or vascular injury
  

• Stabilization of the multiple-injury trauma patient
  
• Long leg splint in full extension
  
• Ice
  
• Elevation
  
• Frank dislocations with vascular compromise may need immediate reduction in ED
  

• Nonweight bearing
  
• Pain control
  
• Nondisplaced fractures or minimally displaced (<8 mm)
  lateral
  plateau fractures without ligamentous injury:
  
  • Aspiration of hemarthrosis and injection of local anesthetic
    
  • Exam for ligamentous instability
    
  • If knee is
    stable:
    
    • Compressive dressing
      
    • Ice and elevation for 48 hr
      
    • No weight bearing/crutches
      
  • Knee is
    unstable
    if fracture is causing vascular injury or compartment syndrome
    
    • Urgent orthopedic consultation is warranted in the unstable knee
      
• Open fractures:
  
  • Remove contaminants
    
  • Apply moist sterile dressing
    
  • Assess tetanus immunity
    
  • Antibiotics
    
  • Early administration of antibiotic, within 2–3 hr
    
  • Orthopedics consult for early surgical débridement
    

Open fractures: Aminoglycoside + Cephalosporin

• Cefazolin: 2 g IV (peds: 50 mg/kg)
  
• Gentamicin: 2–5 mg/kg IV (peds: 2.5 mg/kg)
  
• Tetanus toxoid if indicated
  
• Vancomycin: 1 g IV loading dose (peds: 10 mg/kg) if penicillin allergic
  

FOLLOW-UP

• Open fractures for débridement, irrigation, and IV antibiotics
  
• Comminuted, bicondylar fractures for traction
  
• High-energy mechanisms for observation of neurovascular status and development of compartment syndrome; may occur 24 or more after injury
  
• Pain control
  

Nondisplaced or minimally displaced, stable fractures of the lateral plateau

Orthopedic follow-up:

• Long leg splint with ice, elevation, and nonweight-bearing status of affected joint
  

• Consider popliteal artery injury with high-energy mechanisms of injury
  
• Lipohemarthrosis (blood and fat globules) on arthrocentesis, is pathognomonic for intra-articular knee fracture
  
• Tibial plateau fractures, Segond fractures, and Salter–Harris 1 fractures are easily missed on plain knee radiographs
  

• Berkson EM, Virkus WW. High-energy tibial plateau fractures.
  J Am Acad Orthop Surg.
  2006;14(1):20–31.
  
• Fields KB, Eiff P, Grayzel J. Proximal tibial fractures in adults.
  UpToDate.com
  . Nov 2012.
  
• Patrick B, et al. Towards evidence based emergency medicine: PRIVATE best BETs from the Manchester Royal Infirmary. BET1: Predicting the need for knee radiography in the emergency department: Ottawa or Pittsburgh rule?
  Emerg Med J.
  2012;29:77–78.
  
• Skaggs DL, Friend L, Alman B, et al. The effect of surgical delay on acute infection following 554 open fractures in children.
  J Bone Joint Surg Am.
  2005;87(1):8–12.
  
• Yao K, Haque T. The Ottawa knee rules – a useful clinical decision tool.
  Aust Fam Physician.
  2012;41(4):223–224.
  
• Zeltser DW, Leopold SS. Classifications in brief: Schatzker classification of tibial plateau fractures.
  Clin Orthop Relat Res.
  2013;471:371–374.
  

CODES

• 823.00 Closed fracture of upper end of tibia alone
  
• 823.10 Open fracture of upper end of tibia alone
  

BASICS

Tibia

• 80% have associated fibular fractures
  
• Open (24% are open) vs. closed
  
• Extent of soft tissue damage
  
• Gustilo–Anderson classification of open fractures:
  
  • Type I:
    
    • Wound <1 cm
      
    • Little soft tissue damage
      
    • No crush injury
      
  • Type II:
    
    • Wound >1 cm
      
    • Moderate soft tissue damage
      
    • Little or no devitalized soft tissue
      
  • Type III—severe soft tissue injury:
    
    • A—adequate soft tissue coverage of bone
      
    • B—tissue loss/periosteal stripping
      
    • C—neurovascular injury requiring surgery
      
• Anatomic location:
  
  • Proximal, middle, or distal 3rd
    
  • Articular extension
    
• Displacement
  
• Degree of shortening
  
• Angulation
  
• Configuration:
  
  • Spiral, transverse, or oblique
    
  • Comminuted, with butterfly fragment or multiple fragments
    

Fibula

• Proximal:
  
  • Associated with peroneal nerve injury
    
  • Disruption of ankle syndesmosis (Maisonneuve fracture)
    
• Middle
  
• Distal
  

• 3rd most common long bone fracture in children
  
• 2nd most common long bone fracture in nonaccidental trauma (usually apophyseal or metaphyseal corner)
  
• Nonphyseal fracture patterns:
  
  • Compression (torus): Distal metaphysis
    
  • Incomplete tension–compression (greenstick)
    
  • Plastic/bowing deformity of fibula may occur.
    
  • Complete fractures
    
• Physeal fracture patterns:
  
  • Tibial shaft fractures may extend to the physis in Salter–Harris II pattern.