Posts tagged #fracture

Is Fracture Healing Impaired by NSAIDs?

Written by: Andra Farcas, MD (PGY-3) Edited by: Jessica Bode, MD (NUEM ‘19) Expert Commentary by: Matthew Levine, MD

Clinical Question:

Are we impeding our patients’ fracture healing by giving them NSAIDs?

Why is this important?

Broken bones hurt. A lot. And we want to do something about that to make our patients feel better. In the context of the current opioid crisis and the controversy of prescribing opioids, we need good non-opioid alternatives. Enter NSAIDs. Multiple studies have investigated whether nonsteroidal anti-inflammatory drugs (NSAIDs) are efficient pain relievers in multiple scenarios, including fractures, and the consensus seems to lean towards yes. However, this is not a discussion about their effectiveness but rather an attempt to finally answer the question that emergency docs seem to have different answers to: will giving patients NSAIDs for their fracture-related pain actually lead to worse outcomes in terms of fracture healing?

Mechanism of action

NSAIDs work by inhibiting the COX enzyme that catalyzes the conversion of arachidonic acid into prostaglandins. In turn, prostaglandins work as inflammatory response mediators. When a bone is fractured, the healing process involves an inflammatory response. Giving NSAIDs alters that inflammatory response by decreasing prostaglandin production. This is why it’s been proposed that giving NSAIDs to patients with bone fractures will affect their healing.

Additionally, prostaglandins also modify the expression of bone morphogenic proteins (BMPs), which are involved in the bone healing process. This is another mechanism by which NSAIDs may affect fracture healing.

What the Research Shows

There have been a multitude of animal and human studies investigating the effect of NSAIDs on bone fracture healing, mostly in the orthopedic surgery community. The chart below has short summaries of some of the ones that are most relevant to emergency medicine.

Studies with Animals

Animal studies in general tend to use mice or rats with induced long bone fractures. The animals are exposed to NSAIDs or placebo and various bone characteristics are measured at various time frames. Capello, 2013 and Utvag, 2010 showed that Ketorolac, Parecoxib, and Diclofenac had no effect on strength, stiffness, or bone mineralization in rats with tibia fractures. On the other hand, Lu, 2012 and Murnaghan, 2006 showed that Indomethacin was associated with decreased bone and cartilage formation and that Rofecoxib was associated with slower and poorer healing in mice with tibia and femoral fractures, respectively.

Studies with Humans

While studies with animals have a lot of advantages, we’re often more interested in clinical outcomes than physiological nuances. DePeter 2016 in a retrospective chart review showed no association between ibuprofen exposure in kids with various fractures and healing complications like nonunion, delayed union, or re-displacement. However, there was no specification of the timeframe of treatment, and some patients received ibuprofen in the ED while others were sent home with it without a clear defined use period. Adolphson, 1993 showed there was no significant difference in bone mineral decrease in postmenopausal women with displaced Colles’ fractures that used Piroxicam for 8 weeks after the fracture compared to women who used a placebo. Giannoudis, 2000 found greater proportion of NSAID use in patients with nonunion of a femur shaft fracture compared to those who had union and found that in patients who had union, those who used NSAIDs took longer to achieve it. Bhattacharyya 2005 found that NSAID use at 61-90 days post fracture was associated with nonunion. However, an important thing to point out is that association does not equal causation. Is it that the NSAID use caused the poor outcome? Or is it that the poor outcome was more painful and thus those patients used pain medication for longer. To that point, Bhattacharyya, 2005 also found that there was an association between opioid use at 61-90 days and nonunion.

The Conclusion

The evidence isn’t slam-dunk in either direction on whether using NSAIDs impedes the fracture healing process. There aren’t many randomized control trials to explore causation (versus association) of NSAID use with fracture healing outcome. The one RCT I could find (Adolphson, 1993) leans towards no difference in outcome between NSAID users and placebo users. My takeaway: if my patients have no other contraindications to using NSAIDs and if their pain is well-controlled with said medication, then I’m going to advise they can use it for a short term and advise them to seek medical attention if they’re still needing to use NSADs regularly a few weeks out.

Expert Commentary

As is frequently the case in medicine, confounding factors make seemingly simple questions have not-so-simple answers.

Some animal studies suggested that NSAIDS can do harm to healing fractures. Others did not. The benefit of the animal study approach is that more variables can be controlled - the site of fracture, NSAID type, dose, frequency, duration of therapy. These animals were also surely more compliant with medications and follow up than our patients. However, animal studies do not necessarily translate to human outcomes. And these animal studies were less than definitive anyway.

The human studies were also less than definitive. Human studies are difficult for many reasons. Do NSAIDS affect pediatric, adult, elderly bone healing outcomes the same? Does it matter which NSAID, how often it is taken, the dose, the duration of use, which bone is fractured? When taking all these factors into consideration, it becomes more clear just how unclear the answer to this question is.

So at the end of the day, we do what we do time and time again in medical decision making – a risk-benefit analysis:

Option 1: Give NSAIDS. Risk causing an uncertain NSAID-related complication such as poor bone healing or a known NSAID complication such as a cardiovascular/GI/renal issue. Avoid narcotics.

Option 2: Give acetaminophen. Little downside as long as the patient can follow the directions you give them or on the bottle to avoid overdosing. Avoid NSAIDS and narcotics.

Option 3: Give narcotics. Avoid complications of NSAIDS. Expose to complications of narcotics. I don’t need to list these.

Option 4: Some combination of options 1, 2, and 3 because your gestalt is telling you that acetaminophen or NSAIDS alone won’t cut it for some cases.

I have different patients that end up falling into each of those options. This also raises another question - how do NSAIDS, acetaminophen, and opiates compare to each other for control of fracture pain? These scenarios and questions again demonstrate that medicine is often not a robotic one-size-fits-all, one-answer-to-every-question field, or else Dr. Google would replace us. Until more definitive RCTs come along, you will be required to use your judgment, or as I like to call it, expertise.

Matthew Levine, MD

Associate Professor

Department of Emergency Medicine

Northwestern University

How to Cite This Post

[Peer-Reviewed, Web Publication] Farcas A, Bode, J. (2020, April 6). Clinical Question: are we impeding our patients’ fracture healing by giving them NSAIDs? [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/fx-nsaids

Can't Miss Hand and Wrist Fractures in the ED

Written by: Justine Ko, MD (NUEM PGY-3) Edited by: Spenser Lang MD (NUEM Alum ‘18 ) Expert commentary by: Matt Levine, MD

“Can’t Miss” Hand and Wrist Injuries in the ED

In the emergency department, orthopedic complaints make up a large percentage of presentations, up to 50% in the pediatric population and close to 33% in the adolescent and young adult population. Many of these injuries are uncomplicated, but an astute clinician can diagnose subtle and uncommon injury patterns. Three less common injuries are reviewed here. If found, these injuries can alter the management and disposition of the patient. Each of these injuries should be carefully assessed for on physical exam and imaging.

DISTAL RADIOULNAR JOINT (DRUJ) INJURIES

What exactly is the distal radioulnar joint and why is it important?

The distal radioulnar joint (DRUJ) consists of both the bony radioulnar articulation as well as the soft tissue components, including ligaments. It has significant contributions to the axial load-bearing capabilities of the forearm. The injury can be an isolated injury or associated with forearm fractures and should be tested for with every forearm injury as its presence can alter the disposition and even functionality of the patient.

When does it occur?

A DRUJ injury may occur, although rarely, in isolation. This is usually related to a fall on outstretched hand (FOOSH). A DRUJ injury is more often associated with a fracture. Common associations include:

Distal radial fracture (DRF)
- DRF + DRUJ = Galeazzi fracture (pictured to the right)
Ulnar styloid fracture

How should I assess for a possible DRUJ injury?

Routine AP and lateral views are poor for determining a DRUJ injury. This is largely a CLINICAL DIAGNOSIS.
Piano Key Sign: with the patient’s hand in pronation, push on the dorsal aspect of the ulnar head. Depression and rebound of the ulnar head suggest DRUJ instability
Table Top Test: have patient place hands on a table and apply force. A DRUJ injury will show dorsal depression of the ulna
Grind Test: hyperextend the wrist and axial load the forearm. A positive sign elicits pain over the joint

How does this alter management?

When associated with a fracture, operative management is often indicated and consultation with our orthopedist is warranted. When missed, a DRUJ injury will result in instability of the joint and arthrosis.

PERILUNATE AND LUNATE DISLOCATIONS

It has been reported that these injuries are missed in up to 25% of ED presentations.

How do these injuries occur?

In perilunate and lunate dislocations, the mechanism is usually hyperextension in the setting of trauma. Patients presents with hand and wrist pain/swelling.

How do I distinguish perilunate from lunate dislocations?

Lunate and perilunate dislocations can be easily confused or mistaken for each other. The key to distinguishing these injuries on imaging is the alignment between the metacarpal, carpal, and the radius/ulna bones.

In a normal lateral x-ray, these bones should all align (Figure 1, far left). In a lunate dislocation, the lunate itself is physically removed or out of line with the rest of these bones (Figure 1, far right), resulting in the classic “spilled teacup” appearance on x-ray. In a perilunate dislocation, the lunate sits in line with the radius/ulna, however the capitate/metatarsal bones are dislocated dorsally.

On an AP film, a break in Gilula’s arc/lines may be used to assess for a perilunate or lunate dislocation (Figure 2).

How Are These Injuries Treated?

In the ED, closed reduction can be attempted. If successful, definitive treatment can occur up to 7 days later. If unsuccessful, operative management is indicated. Definitive treatment involves open reduction and internal fixation.

How Would I Reduce These Injuries in the ED?

Usually, the assistance of our orthopaedic colleagues is warranted. Finger traps can be used for traction. The wrist should be extended while placing palmar pressure on the lunate. Then, with continued traction, the wrist should be gradually flexed so that the capitate falls back into place within the concavity of the lunate. Once the lunocapitate joint is reduced, the wrist can be extended in traction again for full reduction.

SCAPHOLUNATE DISSOCIATION

What is a scapholunate dissociation?

Scapholunate dissociation is caused by injury to the scapholunate ligament. Injury to this ligament can occur with acute FOOSH injury or be caused by degenerative rupture of the ligament.

How do I diagnosis it?

These patients present with radial wrist pain. On imaging, the following signs can aid in diagnosis.

Terry Thomas sign: This is seen on an AP wrist film and is indicated by a gap >3mm between the scaphoid and lunate bones

Cortical Ring sign: occurs when the scaphoid is in a flexed position, making the scaphoid tubercle more prominent. A measure distance less than 7mm between the end of the cortical ring and the proximal end of the scaphoid suggests scapholunate dissociation and instability.

How do I manage it?

In the ED, patients should be placed in a thumb spica cast for stabilization and referred to orthopaedics for follow up. Operative indication includes injury within 3 weeks and associated imaging and physical exam findings. During this time frame, the SL ligament is still viable for repair.

Expert Commentary

Great choice by Dr. Ko to highlight these injuries that are often subtle, yet important because of the comorbidities associated with missing the diagnosis.

The Galeazzi fracture is a classic EM boards question, because it is important! It was termed by Campbell as the “fracture of necessity” (modern day translation = “this needs surgery!”) in 1942 because nonoperative management was observed to be associated with recurrent ulna styloid dislocations. Hughston confirmed this is 1957, reporting that 35/38 cases treated nonoperatively had unsatisfactory outcomes.

There’s a saying in orthopedics that “the most commonly missed injury is the second injury”. The radial shaft fracture is usually obvious and can distract the clinician from the less dramatic DRUJ injury. DRUJ injury is radiographically diagnosed by:

Fracture at the BASE of the ulna styloid process (not the tip)
A widened DRUJ (a comparison x ray may be necessary), or
>5mm of shortening of the radius relative to the distal ulna.

A subtle clinical finding often associated with the Galeazzi fracture is anterior interosseus nerve injury. It is a branch of the median nerve and is purely motor, so there will be no sensory deficit or paresthesia! It manifests as loss of pinch strength between the thumb and index finger. So have the patient make the OK sign and resist as you try to open it!

Mayfield, Johnson and Kilcoyne described a pattern of carpal injury caused by wrist hyperextension, ulnar deviation and intercarpal supination in 1980. In their original research on cadavers, progressive hyperextension force was applied and resulted in a consistent, sequential, progressively more unstable intercarpal injury pattern known as the four stages of carpal instability:

Scapholunate dissociation
Perilunate dislocation
Perilunate and triquetral dislocation
Lunate dislocation

Acute scapholunate dissociation is the most common pattern of carpal instability. It occurs secondary to a tear of the scapholunate interosseus ligament. Scapholunate dissociation can also be chronic secondary to arthritic changes when there is no history of recent trauma.

X rays in lunate and perilunate dislocations are often not as clear and obvious as the diagrams used to teach these injuries. The key to realizing that there is a carpal bone dislocation is recognizing that the carpal arcs are disrupted on the AP view. The distal and proximal carpal rows should never overlap on this view. If you recognize this, you will heighten your suspicion and won’t miss these injuries, even if you cannot immediately tell the exact diagnosis.

The name perilunate dislocation has always been a pet peeve of mine. There is no perilunate bone, so this nomenclature just introduces confusion. It should simply be called a capitate dislocation, because that it what it really is.

All of these injuries, and more, are further detailed in our Ortho Teaching Files!

Matthew R. Levine, MD

Assistant Professor

Department of Emergency Medicine

Northwestern University

How to Cite this Post

[Peer-Reviewed, Web Publication] Ko J, Lang S. (2019, Aug 19). Can't Miss Hand and Wrist Fractures in the ED. [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/cant-miss-hand-and-wrist-fractures-in-the-ed/.

To learn more about the diagnosis and management of orthopedic injuries from head to toe, check out our Ortho Teaching Files!

References

Bowen WT, Slaven EM. 2014. “Evidence-based management of acute hand injuries in the emergency department.” Emergency Medicine Practice 16 (12):1-28.
“Distal Radial Ulnar Joint (DRUJ) Injuries - Trauma - Orthobullets.” n.d. Accessed March 7, 2018. https://www.orthobullets.com/trauma/1028/distal-radial-ulnar-joint-druj-injuries.
Kardashian G, CHristoforou DC, Lee SK. 2011. “Perilunate dislocations.” Bulletin of the NYU Hospital for Joint Diseases 69 (1):87-96.
“Lunate Dislocation (Perilunate Dissociation) - Hand - Orthobullets.” n.d. Accessed March 2, 2018. https://www.orthobullets.com/hand/6045/lunate-dislocation-perilunate-dissociation.
Pappou, Ioannis P., Jennifer Basel, and D. Nicole Deal. 2013. “Scapholunate Ligament Injuries: A Review of Current Concepts.” Hand (New York, N.Y.) 8 (2): 146–56. https://doi.org/10.1007/s11552-013-9499-4.
Reisler T, Therattil PJ, Lee ES. 2015 “Perilunate Dislocation.” Eplasty.
Rodner CM, Weiss APC. “Acute scapholunate and lunotriquetral dissociation.” American Society for Surgery of the Hand. 155-171.
Scalcione LR, Gimber LH, Ho AM, Johnston SS, Sheppard JE, Taijanovic MS. 2014. “Spectrum of carpal dislocations and fracture-dislocations: imaging and management.” AJR 203: 541-550.
Thomas, Binu P, and Raveendran Sreekanth. 2012. “Distal Radioulnar Joint Injuries.” Indian Journal of Orthopaedics 46 (5): 493–504. https://doi.org/10.4103/0019-5413.101031.

Posted on August 19, 2019 by NUEM Blog and filed under Orthopedics and tagged orthopedics fracture missed fractures hand injury wrist.

Ultrasound in Pediatric Distal Forearm Fractures

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Written by: Jason Chodakowski, MD (NUEM PGY-3) Edited by: Logan Weygandt, MD (NUEM ‘17) Expert commentary by: Rachel Haney, MD (NUEM ‘17)

Why use Ultrasound?

Distal forearm fractures are common fractures in the pediatric population. Although plain radiographs of the forearm are still considered the gold standard for definitive diagnosis, there is growing interest in using ultrasound for diagnosis because it provides zero radiation exposure, it can be used to guide local pain control, and it can confirm reduction success at the bedside. Ultrasound is easy to teach and provides value under circumstances when plain radiography might be unavailable (pre-hospital environment, disaster areas, or in developing countries).

A recent meta-analysis of 12 studies, which included 951 children 18 and younger, found that physician performed bedside ultrasound detected distal forearm fractures with a pooled sensitivity of 98% and a specificity of 96% when compared with the gold standard plain radiographs.[1] The pain associated with ultrasound use was also significantly less.[2]

How do I use Ultrasound?

To evaluate musculoskeletal pathology use the high-frequency linear array transducer employing the six-view ultrasound technique as shown below. You may detect a fracture as an apparent discontinuity or irregularity (divots, step-offs, distortion) of the hyperechoic and continuous bony cortex. Disruptions as small as 1mm can be detected.

Six-view technique (Herren et. al. 2015)

Distal radius fracture (emergencyultrasoundteaching.com)

Pitfalls

In children the evaluation of bones is complicated by the open physes, which may be mistaken for fractures. The difference is that physes will appear as smooth, downward-sloping curves unlike fractures, which will have abrupt step-offs.

Normal open tibial physis (Crosby et. al. 2014)

What else is Ultrasound Good For?

Confirming reductions
Ultrasound is also utilized by emergency physicians to determine successful realignment of pediatric distal forearm fractures after closed reduction.[4]

Fracture reduction (Socranksy et. al. 2016)

Achieving adequate pain control
Ultrasound can also be used to guide hematoma blocks. The hematoma block is a technique wherein the physician injects an anesthetic solution into the hematoma between the fractured bone fragments (see image below). It has been shown to be effective, safe, faster, and uses fewer resources with no significant difference in pain scores when compared to procedural sedation in both adults and children with distal forearm fractures.[6,7]

Clean skin and place a sterile cover over the transducer. Using 5-10cc of 1-2% lidocaine inject into the hematoma between the fractured bone fragments using an 18-22 gauge needle.

Visualization of needle (N) entering between fracture bone fragments (U) (emdocs.net)

Take Home Points

Ultrasound is most useful in evaluating long bone fractures such as the femur, clavicle, ribs, or distal radius and ulna.
A reliable alternative to the plain radiograph is the proper six-view method it, with the advantages of being portable and radiation-free.
Ultrasound can also be reliably used to confirm fracture reduction, as well as for guiding forearm fracture hematoma blocks.

Expert Commentary

Thank you for providing a concise summary of the utility of Point-of-care Ultrasound (POCUS) for pediatric forearm fractures.

I’d like to mention a few key points regarding the use of POCUS for pediatric fracture assessment.

If you do a lot of adult scanning and not much pediatric scanning it is important to keep in mind that children may not be as cooperative (or stationary) as adults.
- Smaller children may be afraid of the transducer therefore introducing the transducer to the patient as an object that will not hurt them is key. You should hand the probe to the patient, allow them to touch it and even scan themselves initially in order to get them more comfortable with the probe.
While the 6-view scan you describe will certainly improve sensitivity, adequate sensitivity can be achieved with a 2-view approach. Additionally, the 6-view technique may be prohibitively time-intensive in a busy Emergency Department.
- In order to increase sensitivity with the 2-view approach, always start imaging at the point of maximal tenderness, initially in the longitudinal plane with the cortex of the bone parallel to the probe surface. Slide distal and proximal to the point of tenderness. Then rotate the probe 90 degrees to view the cortex in the transverse plane. Fractures are noted as cortical disruptions or step-offs. Fractures are most visible on POCUS when the fracture line is perpendicular to the angle of insonation.
Another key pearl is to use copious gel in order to optimize the focal point of the image. The focal zone on the screen is the part of the image with the highest resolution secondary to convergence of the US beams. The focal point can be changed depending upon your machine, but is typically no more shallow than about 1-cm below the probe surface, therefore if you place a good layer of gel about 1cm thick, you will place the cortext of the bone at the optimal focal point. Using copious gel is also important in reducing any potential discomfort caused by pressure from the probe.
- If gel is a limited resource, you can use a water bath as well.
While POCUS is a wonderful tool, especially for fracture detection, I want you to keep in mind that the sensitivity of POCUS for fractures is the highest (low-mid 90s) for the diaphysis of long bones (femur, humerus, radius and ulna). Sensitivity is significantly lower for detecting fractures of other bones and fractures near joint lines secondary to the curvilinear nature of the metaphysis as well as the presence of cartilaginous epiphyseal plates in children.
- While POCUS can supplant the use of radiography in austere environments, in a well-resourced emergency department, POCUS should be an adjunct to radiography. In this setting, POCUS can have utility in patients in whom you suspect occult fracture despite negative XRs or for real-time fracture reduction assessment before sedation wears off. Unless you are a pediatric POCUS expert, I would order XR’s as usual for a pediatric patient you suspect has a fracture. In the meantime- continue scanning patients with normal anatomy and documented fractures in order to develop your POCUS expertise! Happy Scanning!

Rachel Haney, MD

NUEM ‘17

Ultrasound Fellow at Massachusetts General Hospital

How To Cite This Post

[Peer-Reviewed, Web Publication] Chodakowski J, Weygandt L. (2019, April 28). Ultrasound in pediatric distal forearm fractures. [NUEM Blog. Expert Commentary by Haney R]. Retrieved from http://www.nuemblog.com/blog/us-for-fracture

References

Douma-den Hamer, Djoke, et al. "Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis." PloS one 11.5 (2016): e0155659.
Chaar-Alvarez FM, Warkentine F, Cross K, et al. Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department. Pediatr Emerg Care 2011; 27:1027.
Herren C, Sobottke R, Ringe MJ, et al. Ultrasound-guided diagnosis of fractures of the distal forearm in children. Orthop Traumatol Surg Res 2015; 101:501.
Dubrovsky, Alexander Sasha, et al. "Accuracy of ultrasonography for determining successful realignment of pediatric forearm fractures." Annals of emergency medicine 65.3 (2015): 260-265.
Socransky, Steve, et al. "Ultrasound-Assisted Distal Radius Fracture Reduction." Cureus 8.7 (2016).
Fathi, M. et al. Ultrasound-guided hematoma block in distal radius fracture reduction: a randomized clinical trial. Emerg Med J. 2014 Jul 12.
Bear, David M., et al. "Hematoma block versus sedation for the reduction of distal radius fractures in children." The Journal of hand surgery 40.1 (2015): 57-61.

Posted on April 29, 2019 by NUEM Blog and filed under Ultrasound and tagged pediatric ultrasound fracture MSK ultrasound POCUS.