WASHINGTON — Recent orthopedic research challenges many standards of emergency orthopedics drawn from the archetypal textbook that every medical school uses, Gregory W. Hendey, M.D., said at the annual meeting of the American College of Emergency Physicians.
Dr. Hendey of the University of California, San Francisco, debunked several myths:
▸ Preoperative skin traction reduces the pain associated with hip fracture.
The reality: A Cochrane review from 2003 including eight randomized trials and 1,349 patients showed no benefit from either skin or skeletal traction, compared with no traction for preoperative hip-fracture pain relief.
No significant difference in pain was reported after the first night following the hip fracture in a study of 311 patients randomized to skin traction vs. no traction (Int. Orthop. 2002;26:361–4). To relieve the considerable pain that some of these patients experience, consider a femoral nerve block, advised Dr. Hendey, research director of the UCSF Fresno emergency medicine residency program. In a relatively small study, patients who received a nerve block used significantly fewer analgesics than did those who didn't receive the block.
▸ A scapula fracture is associated with life-threatening injuries and requires an extensive workup.
The reality: Previous studies have shown that a high percentage of patients with a scapula fracture have other problems, but these results may be caused by the use of trauma registries for patient selection.
In a study of 11,500 patients from two trauma centers, 92 patients with scapula fracture were compared with 81 matched controls. Although scapula fracture was significantly associated with thoracic injury (49% vs. 6%), there was no significant difference in mortality or neurovascular morbidity between the two groups (Ann. Emerg. Med. 1995;26:439–42).
▸ A boxer's fracture must be reduced and immobilized with an ulnar gutter splint.
The reality: Strength and alignment are similar in splinted and nonsplinted patients, according to several studies.
In a prospective study of 29 patients with subcapital fifth metacarpal fractures randomized to either reduction and splint or functional treatment, all the fractures healed well. The functional group recovered faster, however, with better strength and range of motion than the reduction and splint group (Scand. J. Plast. Reconstr. Surg. Hand. Surg. 1999;33:315–7).
▸ Nursemaid's elbow is best reduced with rapid supination and elbow flexion.
The reality: Most physicians learned that the way to reduce nursemaid's elbow is rapid supination and flexion. That method works, but there is a kinder, gentler way, Dr. Hendey said.
In supination, you place the thumb over the radial head, grab the wrist, supinate the forearm, and flex the elbow. However, the results of two randomized trials comparing supination with hyperpronation suggest that hyperpronation is superior. Instead of supinating and flexing, simply place the thumb over the radial head, grab the wrist, and slowly pronate.
In one study, 90 children received either supination and flexion or pronation as the first treatment, and the first-attempt success rate was significantly higher for the hyperpronation method (95% vs. 77%) (Pediatrics 1998;102:e10).
▸ A figure-of-eight dressing is a better treatment for a clavicle fracture than a simple sling.
The reality: Some physicians argue that the figure-of-eight makes sense because it may approximate any fracture fragments better than a sling. However, a study of 140 patients with a clavicle fracture who were treated with either a simple sling or figure-of-eight showed no difference in speed of recovery (Injury 1988;19:162–4).
▸ All shoulder dislocations need pre- and postreduction x-rays.
The reality: A shoulder dislocation is often so obvious that x-rays are unnecessary, although the textbook says to get one, Dr. Hendey said.
“There are now six studies in this area that say you don't need x-rays,” he said. One study of prereduction films showed that three clinical factors—age older than 40 years, first-time dislocation, or a traumatic injury—identify 98% of fractures (Acad. Emerg. Med. 2004; 11:853–8).
“If you aren't sure, of course you should x-ray it,” he said.