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AAEM NEWS
The Bare Bones — Ultrasound Assisted Fracture Reduction Joseph Zarraga, DO; Carissa Jeannette, DO; Max Cooper, MD RDMS
Figure 1: Radiographs of the distal humerus fracture, described as oblique, angulated, comminuted fracture of the distal diaphysis of the humerus. Shown as pre-and and post reduction. (a) Pre-reduction x-ray shows significant displacement, read by radiology as “a varus angulation” of the distal fragment by 43 degrees. A distance of the overriding part of the distal fragment was found to be 1.02 cm. (b) Post reduction x-ray showing significant reduction of displacement. Read by radiology as “significantly improved alignment following reduction with no significant residual angulation.”
Abstract
Case
Extremity fractures are common injures that are evaluated and treated daily in the ED.1 The vast majority of fractures require conservative management in the ED and orthopedic surgery follow up as an outpatient for definitive treatment and management. However, in cases where there is significant displacement, angulation, and or neurovascular compromise, reduction of these fractures in the ED should be promptly pursued. Point of care ultrasound (POCUS) is a readily available tool in EDs worldwide that can be useful during fracture reductions to ensure adequate reduction and overall procedural success. In this case report, we review basic steps for management of displaced fractures and how POCUS can assist in successful reduction.
A 23-year-old female with no known past medical history, presented to the ED from home for a right arm injury. Just prior to arrival, the patient states that she was wrestling with her siblings, when one of them accidentally fell on her upper arm. She states that she immediately had pain in her upper arm and near her elbow, prompting her to immediately call 911.
Intro We present a case of a distal humerus fracture with moderate displacement, angulation, and comminution. The ED course of these cases is usually straightforward, with pain control, reduction with or without sedation, and post reduction splinting being the mainstays of management. However, difficult cases tend to require multiple reduction attempts and X-rays to guide effort. These procedures can be labor-intensive, siphoning providers and resources away from the rest of the department. We demonstrate the utility of POCUS as an adjunct that can give near realtime feedback during fracture reductions, which can not only potentially lower the number of attempts, radiation exposure, and resource utilization but also allow for better overall outcomes.
Point of care ultrasound (POCUS) is a readily available tool in emergency departments worldwide that can be useful during fracture reductions to ensure adequate reduction and overall procedural success.
The Emergency Medical Service (EMS) providers called our medical command physician for clearance to administer fentanyl for analgesia, as she was in severe pain. EMS also stated that she had an obvious deformity of the distal humerus, just proximal to the elbow. Initial evaluation by medics reported no immediate neurovascular compromise, with intact sensation, motor, and pulses distal to the injury. Upon arrival to the ED, she had improvement in her pain status. EMS had placed her arm in a position of comfort and applied a temporary splint to the affected area. She was placed on the monitor and had normal vital signs. Removal of the temporary splint revealed a right arm deformity of the posterolateral aspect of the humerus, just proximal to the elbow. There was no tenting of skin, open wounds, or ecchymosis, and distal sensation, motor function, and pulses were intact. Physical exam did not reveal additional signs of trauma. X-rays were performed of the right shoulder, humerus, and elbow and demonstrated an oblique, angulated, comminuted fracture of the distal diaphysis of the humerus. The radiologist measured a varus angulation of the distal fracture fragment of 43 degrees and a distance of the overriding part of the distal fragment of 1.02 cm. She was consented for procedural sedation using propofol and ketamine. Given the amount of displacement, we brought the ultrasound to the bedside to obtain real time feedback of our reduction efforts. When the patient was adequately sedated, the dressing was removed and the displacement of the fractured humerus was measured to be 0.82 cm using a linear ultrasound probe in a longitudinal view. After one attempt at reduction, we remeasured the displacement at 0.75 cm, though the
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COMMON SENSE NOVEMBER/DECEMBER 2020
