Episode 60: Emergency Orthopaedics

Author: Eoghan Colgan  @eoghan_colgan
Special Guest: Arun Sayal @arunsayal1

02/06/20

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Guest Bios

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Dr. Arun Sayal is an emergency physician, who works in the Fracture Clinic, and is an associate professor in the Department of Family and Community Medicine at the University of Toronto. He works at North York General Hospital, a busy community teaching hospital in Toronto. There he has worked in the ED since 1993 and has run a weekly Minor Fracture Clinic for the past 12 years. With pearls learned from orthopedic surgeons, he created and developed CASTED in 2008. CASTED is a series of hands-on orthopedic courses that have been presented over 250 times across Canada. Dr Sayal has won over a dozen teaching and CPD awards at the local, university and national levels, including the PARO Award and the CFPCs CPD Award for providing its members with an outstanding educational experience.

Show Notes

Dr Arun Sayal is an Emergency Physician from Toronto with a keen interest in orthopaedics. He has run a fracture clinic in his hospital for 12 years, and assists the orthopaedic surgeons in theatre. In this episode, Arun shares some of the tips and pearls he has learned from the orthopaedic specialists, which will guide emergency physicians to better manage cases that are ‘common, commonly missed, and commonly mismanaged’.

TAKE-HOME POINTS

  1. History Taking

    • Force involved

    • Mechanism: the way the force was applied

    • What happened afterwards

    • Previous injuries

    • Age and comorbidity

  2. Physical Examination

    • Helps to narrow the differential, especially if a normal xray

    • Not done to cause pain but to find the cause of the pain

    • Look, Feel, Move

    • Special tests have limited value in ED

    • Site of tenderness is reliable – injury is below (skin/soft-tissue or bone)

  3. Xrays:

    • An xray alone is not enough, just like an ECG or CT head is not enough

    • It’s a valuable tool but not perfect but enhanced greatly by a pre-test probability you can create from a good history and physical exam.

    • Normal xrays: think SCARED OF

      • Septic

      • Compartment syndrome

      • Abuse

      • Referred pain / Report (20% missed by radiologists)

      • Operative soft tissue injury

      • Fracture not seen on xray

    • Fracture: ask yourself, is it:

      • Comminuted (harder to hold in position)

      • Involve Joint: lead to arthritis if not aligned properly

      • Shifted: unstable

      • Oblique/spiral – easier to move

  4. ED Management

    • Fractures:

      • Obtain normal alignment

      • Maintain normal alignment

    • Non-Fractures: determining when to worry

      • The more worried we are from the history and physical, the more likely we are to immobilise and get followed up

  5. Disposition:

    • What is your ROAD MAP:

      • What is the personality of the injury: history/physical/xray

      • What is the personality of the patient: age and comorbidity

Things we might miss:

  • Wrist sprain: other significant soft tissue injuries such as:

    • Scaphoid-lunate ligament injury

    • DRUJ injury

  • Knee Sprain:

    • Quads rupture, dislocated knee (spontaneoiusly reduced). Occult fractures

  • Ankle sprain:

    • Subtle fractures: posterior malleolus, subtle widening of mortice etc

  • Kids elbows

    • 25% of fractures can be lateral condyle fracture or medial epicondyle fracture

links

Access the CASTED Course on Continulus at: https://www.continulus.com/courses/casted/

Users of St Mungo’s can get 25% off the course using coupon

CASTED25

A summary video of the online CASTED course

Free tutorial from the onlineCASTED course

Hannah BellTP6, TP2, TC1Comment