Orthopedics Toronto Notes

8/17/2019 Orthopedics Toronto Notes

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Essential Med Notes 2015 Orthopedics OR1

Tomas Gregory, Michel Saccone, and Ian Whatley, chapter editors

Khaled Ramadan, Karim Virani, and Vahagn Karapetyan, associate editors

Alexa Bramall, EBM editor

Dr. Michael Blankstein, Dr. Nathaniel Nelms, Dr. Markku . Nousiainen, and

Dr. Herbert P. von Schroeder, staff editors

OrthopedicsOR

Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Basic Anatomy Review . . . . . . . . . . . . . . . . . . . 2

Differential Diagnosis of Joint Pain . . . . . . . . . 4

Fractures – General Principles . . . . . . . . . . . . . 5Fracture DescriptionManagement of FracturesFracture HealingGeneral Fracture Complications

Articular Cartilage . . . . . . . . . . . . . . . . . . . . . . . 6

Orthopedic X-Ray Imaging . . . . . . . . . . . . . . . . 7

Orthopedic Emergencies . . . . . . . . . . . . . . . . . 8Trauma Patient WorkupOpen FracturesCauda Equina SyndromeCompartment SyndromeOsteomyelitisSeptic Joint

Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Shoulder DislocationRotator Cuff DiseaseAcromioclavicular Joint Pathology

Clavicle FractureFrozen Shoulder

Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Proximal Humeral FractureHumeral Shaft Fracture

Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Supracondylar FractureRadial Head FractureOlecranon FractureElbow DislocationEpicondylitis

Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Radius and Ulna FractureMonteggia FractureNightstick FractureGaleazzi Fracture

Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Colles’ FractureSmith’s FractureComplications of Wrist FracturesScaphoid Fracture

Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PL22

Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Fractures of the SpineCervical Spine

Thoracolumbar Spine

Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Pelvic Fracture

Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Hip DislocationHip FractureArthritis of the HipHip Dislocation after Total Hip Arthroplasty

Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Femoral Diaphysis FractureDistal Femoral Fracture

Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Evaluation of KneeCruciate Ligament TearsCollateral Ligament TearsMeniscal TearsQuadriceps/Patellar Tendon RuptureDislocated Knee

Patella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Patellar FracturePatellar DislocationPatellofemoral Syndrome

Tibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Tibial Plateau FractureTibial Shaft Fracture

Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Evaluation of Ankle and Foot ComplaintsAnkle FractureLigamentous Injuries

Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Talar FractureCalcaneal FractureAchilles TendonitisAchilles Tendon RupturePlantar Fasciitis (Heel Spur Syndrome)Bunions (Hallux Valgus)Metatarsal Fracture

Pediatric Orthopedics . . . . . . . . . . . . . . . . . . . . 39Fractures in Children

Stress FracturesEvaluation of the Limping ChildEpiphyseal InjurySlipped Capital Femoral EpiphysisDevelopmental Dysplasia of the HipLegg-Calvé-Perthes Disease (Coxa Plana)Osgood-Schlatter DiseaseCongenital Talipes Equinovarus (Club Foot)Scoliosis

Bone Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Benign Active Bone TumorsBenign Aggressive Bone TumorsMalignant Bone Tumors

Common Medications . . . . . . . . . . . . . . . . . . . 47

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48


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OR2 Orthopedics Acronyms/Basic Anatomy Review Essential Med Notes 2015

Basic Anatomy Review

Figure 1. Median, musculocutaneous, and ulnar nerves: innervation of upper limb muscles

Musculocutaneous

nerve

Median

nerve

Ulnar

nerve

Lateral cutaneous

nerve of forearm

(sensory)

Pronator teres

Pronator teres

Brachialis

Flexor carpi radialis

Palmaris longus

Flexor digitorumsuperficialis

Flexor digitorumprofundus(lateral 2,3, digits)

2, 3 lumbricals

Palmar sensorybranches of mediannerve

Flexor pollicislongus

Pronatorquadratus

Thenarmuscles

Biceps brachii

Coracobrachialis

C5

C6

C7

C8

T1

C7

C8

T1

Medial cutaneous

nerve of the arm

(sensory)

Flexor digitorumprofundus(medial 4,5 digits)

Flexor carpiulnaris

Medial cutaneous

nerve of the forearm(sensory)

Dorsal cutaneousbranch (sensory)

Palmar cutaneousbranch (sensory)

Adductorpollicis

Dorsalinterossei

4,5lumbricals

Superficial terminalbranches (sensory)

Palmar interossei

Palmar is brevisHypothenar muscles

ANTERIOR VIEW © L o r i W a t e r s 2 0 0 5

Acronyms

AC acromioclavicularACL anterior cruciate ligamentAIN anterior interosseous nerveAP anterior posteriorARDS acute respiratory distress syndromeAVN avascular necrosis

CA coracoacromialCC coracoclavicularCRPS complex regional pain syndromeDDH developmental dysplasia of the hipDRUJ distal radioulnar jointDVT deep vein thrombosisEtOH ethanol/alcohol

FAI femoroacetabular impingementFOOSH fall on outstretched handGA general anestheticHO heterotopic ossificationI&D incision and drainageIM intramedullaryLCL lateral collateral ligamentMCL medial collateral ligamentMT metatarsalMTP metatarsophalangealMVC motor vehicle collisionNVS neurovascular statusNWB non-weight bearing

OA osteoarthritisORIF open reduction internal fixationPCL posterior cruciate ligamentPE pulmonary embolismPIN posterior interosseous nerveRA rheumatoid arthritisROM range of motionRSD reflex sympathetic dystrophySCFE slipped capital femoral epiphysisSLAP superior lateral, anterior posteriorSN sensitivityTHA total hip arthroplasty# fracture


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Essential Med Notes 2015 Basic Anatomy Review Orthopedics OR3

Figure 2. (Left) Blood supply to the upper limb (Right) Axillary and radial nerves: innervation of the

upper limb

Table 1. Sensory and Motor Innervation of the Nerves in the Upper and Lower Extremities

Nerve Motor Sensory Nerve Roots

Axillary Deltoid/Teres Minor Lateral Upper Arm (Sergeant’s Patch) C5, C6

Musculocutaneous Biceps/Brachialis Lateral Forearm C5, C6

Radial TricepsWrist/Thumb/Finger Extensors

Lateral Dorsum of the HandMedial Upper Forearm

C5, C6, C7, C8

Median Wrist Flexors and AbductorsFlexion of the 1st-3rd Digits

Volar Thumb to Radial half of 4th Digit C6, C7

Ulnar Wrist Flexors and AdductorsFlexion of the 4th-5th Digits

Medial ForearmMedial Dorsum and Volar of Hand(Ulnar half of 4th and 5th Digit)

C8, T1

Tibial Ankle Plantar FlexionKnee FlexionGreat Toe Flexion

Sole of Foot L5, S1

Superficial Peroneal Ankle Eversion Dorsum of Foot L5, S1

Deep Peroneal Ankle Dorsiflexion and InversionGreat Toe Extension

1st Web Space L5, S1

Sural Lateral Foot S1, S2

Saphenous Anteromedial Ankle L3, L4

© L o r i W a t e r s 2 0 0 5

Axillary nerve

Upper cutaneousnerve of the arm(sensory)

Brachioradialis

Deltoids

C5C6

C7C8

Extensor carpiradialis longusExtensor carpiradialis brevis

Posteriorinterosseousnerve

Radial nerve

Abductorpollicis longus

Abductorpollicis brevis

Subscapularis

Teres major

Latissimusdorsi

Supinator

Extensor carpi ulnaris

Extensor digiti minimi

Extensor digitorum

Extensor indicis

AxillarySubclavian

Thoracoacromial

Lateral thoracic

Subscapular

Brachialartery

Superior ulnarcollateral

Inferior ulnarcollateral

Anterior and posteriorulnar recurrent

Ulnar

Anterior interosseous

Deep palmar arch

Superficial palmar arch

Radial

Radialrecurrent

Profundabrachii

Circumflexhumeral

Posterior

Anterior

Superficialradial nerve(sensory)

POSTERIOR VIEWANTERIOR VIEW

Triceps brachii (long head)

Triceps brachii (medial head)


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OR4 Orthopedics Basic Anatomy Review/Differential Diagnosis o Joint Pain Essential Med Notes 2015

Figure 3. Nerves and arteries of lower limbs

Differential Diagnosis of Joint Pain

Figure 4. Intrinsic vs. extrinsic joint pain

© B

a r b a r a B r e h o v s k y 2 0 1 2

Common iliac artery

Femoral nerve

Internal iliac arteryExternal iliac artery

Profunda femoris artery

Femoral artery

Anterior tibial artery

Dorsalis pedis artery

Deep circumflex iliac artery

Superficial circumflex iliacartery

Lateral circumflex femoralartery

Descending branchFemoral artery

Hiatus in adductor magnus

Popliteal artery

Posterior tibial arteryAnterior tibial artery

Plantar artery

Medial plantar artery

Lateral plantar artery

Lateral circumflexfemoral arteryMedial circumflexfemoral artery

Profunda femoris artery

Medial cutaneousnerve of the thigh

Lateral cutaneous nerve ofthe thigh

Obturator nerve

Intermediate cutaneousnerve of the thigh

Common fibular(peroneal) nerve

Saphenous nerve

Deep fibular (peroneal)nerve

Superficial fibular(peroneal) nerve

Superior gluteal nerve

Inferior gluteal nerve

Sciatic nerve

Posterior cutaneousnerve of the thigh

Tibial nerveCommon fibular(peroneal) nerve

Sural nerve

Calcaneal branch

Lateral plantar nerve

Medial plantar nerve

ANTERIOR VIEW POSTERIOR VIEW

ExtrinsicIntrinsic

Joint Pain

GeneralizedFibromyalgia,

dermatomyositis

Referred PainFrom nearby

organs or tissue

NeurologicNerve root

compression, HZV

ArticularArthritis, neoplasm,

trauma

Non-articularBursitis, tendonitis,

myositis


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Essential Med Notes 2015 Fractures – General Principles Orthopedics OR5

Fractures – General Principles

Fracture Description

1. Integrity of Skin/Soft Tissue

• closed: skin/sof tissue over and near racture is intact• open: skin/sof tissue over and near racture is lacerated or abraded, racture exposed to outside

environment signs: continuous bleeding rom puncture site or at droplets in blood are suggestive o anopen racture

2. Location • epiphyseal: end o bone, orming part o the adjacent joint• metaphyseal: the flared portion o the bone at the ends o the shaf• diaphyseal: the shaf o a long bone (proximal, middle, distal)• physis: growth plate

3. Orientation/Fracture Pattern• transverse: racture line perpendicular to long axis o bone; result o direct high energy orce

• oblique: angular racture line; result o angular or rotational orce• butterfly: racture site ragment which looks like a butterfly• segmental: a separate segment o bone bordered by racture lines; result o high energy orce• spiral: complex, multi-planar racture line; result o rotational orce, low energy• comminuted/multi-ragmentary: >2 racture ragments• intra-articular: racture line crosses articular cartilage and enters joint• avulsion: tendon or ligament tears/pulls off bone ragment; ofen in children, high energy• compression/impacted: impaction o bone; typical sites are vertebrae or proximal tibia• torus: a buckle racture o one cortex, ofen in children (see Figure 51, OR39)• greenstick: an incomplete racture o one cortex, ofen in children (see Figure 51, OR39)• pathologic: racture through bone weakened by disease/tumor

4. Displacement• nondisplaced: racture ragments are in anatomic alignment• displaced: racture ragments are not in anatomic alignment

• distracted: racture ragments are separated by a gap (opposite o impacted)• impacted: racture ragments are compressed, resulting in shortened bone• angulated: direction o racture apex, e.g. varus/valgus• translated/shifed: percentage o overlapping bone at racture site• rotated: racture ragment rotated about long axis o bone

Figure 6. Fracture types

Management of Fractures

• ABCs, primary survey and secondary survey (ALS protocol) rule out other ractures/injuries rule out open racture (see sidebar, OR6)

• AMPLE history: Allergies, Medications, Past medical history, Last meal, E vents surroundinginjury consider pathologic racture with history o only minor trauma

• analgesia• imaging• splint extremity

E

B

C

DF

G

H

IJ K

A

A. Transverse

B. Oblique

C. Butterfly

D. Segmental

E. Spiral

F. Comminuted

G. Shifted

H. Angulated

I. Rotated

J. Avulsion

K. Impacted

© Carly Vanderlee 2011

X-Ray Rule of 2s2 sides = bilateral2 views = AP + lateral2 joints = joint above + below2 times = before + after reduction

Varus/Valgus AngulationVarus = Apex away from midlineValgus = Apex toward midline

Figure 5. Schematic diagram ofthe long bone

Proximalepiphysis

Diaphysis

Distalepiphysis

Spongybone

Articularcartilage

Epiphyseal line

Periosteum

Compact bone

Medullarycavity

Metaphysis

DisplacementRefers to position of the distal fragmentrelative to the proximal fragment

Quick Nerve Exam“Thumbs Up”: PIN (Radial Nerve)“OK Sign”: AIN (Median Nerve)“Spread Fingers”: Ulnar Nerve

Reasons for Splinting• Pain control

• Reduces further damage to vessels,nerves, and skin

• Decreases risk of inadvertentlyconverting closed to open fracture

• Facilitates patient transport


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OR6 Orthopedics Fractures – General Principles/Articular Cartilage Essential Med Notes 2015

1. obtain the reduction (or appropriate IV sedation see able 28, OR47) closed reduction

apply traction in the long axis o the limb reverse the mechanism that produced the racture reduce with IV sedation and muscle relaxation (fluoroscopy can be used i available)

indications or open reduction “NO CAS”

other indications include– ailed closed reduction– not able to cast or apply traction due to site (e.g. hip racture)– pathologic ractures– potential or improved unction with ORIF

ALWAYS re-check NVS afer reduction and obtain post-reduction x-ray 2. maintain the reduction

external stabilization: splints, casts, traction, external fixator internal stabilization: percutaneous pinning, extramedullary fixation (screws, plates, wires),

IM fixation (rods) ollow-up: evaluate bone healing

3. rehabilitate to regain unction and avoid joint stiffness

Fracture Healing

Figure 8. Stages of bone healing

Evaluation of Healing: Tests of Union• clinical: no longer tender to palpation or stressing on physical exam• x-ray: trabeculae cross racture site, visible callus bridging site on at least 3 o 4 cortices

General Fracture Complications

Table 2. General Fracture Complications

Early Late

Local Compartment syndromeNeurological injuryVascular injuryInfection

Implant failureFracture blisters

Mal-/non-unionAVNOsteomyelitisHO

Post-traumatic OAJoint stiffness/adhesive capsulitisCRPS type I/RSD

Systemic SepsisDVTPEARDS secondary to fat embolismHemorrhagic shock

Articular Cartilage

Properties

• 2-4 mm layer covering ends o articulating bones, provides nearly rictionless surace• avascular (nutrition rom synovial fluid), aneural, alymphatic• composed o: collagen (90% is type II; gives tensile strength), water, proteoglycans (gives

compressive strength), and chondrocytes

Normal Healing

Weeks 0-3 Hematoma, macrophages surround fracture site

Weeks 3-6 Osteoclasts remove sharp edges, callus forms within hematoma

Weeks 6-12 Bone forms within the callus, bridging fragments

Months 6-12 Cortical gap is bridged by bone

Years 1-2 Normal architecture is achieved through remodelling

Figure 7. Heterotopic ossificationof femoral diaphysis after femurfracture and IM nailing

Avascular NecrosisIschemia to bone due to disrupted bloodsupply; commonly in bones coveredby cartilage or with distal to proximalblood supply

Fracture BlisterFormation of vesicles or bullae thatoccur on edematous skin overlying afractured bone

Heterotopic OssificationThe formation of bone in abnormallocations (e.g. in muscle), secondary topathology

Indications for Open Reduction

NO CASTNon-unionOpen fractureNeurovascular CompromiseIntra-Articular fractureSalter-Harris 3,4,5PolyTrauma


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Essential Med Notes 2015 Articular Cartilage/Orthopedic X-Ray Imaging Orthopedics OR7

ARTICULAR CARTILAGE DEFECTS

Etiology• overt trauma, repetitive minor trauma (such as patellar maltracking); common sports injury • degenerative conditions such as early stage OA or osteochondritis dissecans

Clinical Features

• similar to symptoms o OA (joint line pain with possible effusion, etc.)• ofen have predisposing actors, such as ligament injury, malalignment o the joint (varus/ valgus), obesity, bone deficiency (AVN, osteochondritis dissecans, ganglion bone cysts),inflammatory arthropathy, and amilial osteoarthropathy

• may have symptoms o locking or catching related to the torn/displaced cartilage

Investigations• x-ray (to rule out bony deects and check alignment)• MRI• diagnostic arthroscopy (treatment is ofen guided by what is seen during arthroscopy)

Table 3. Outerbridge Classification of Chondral Defects

Grade Chondral Damage

I Softening and swelling of cartilage

II Fragmentation and fissuring


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OR8 Orthopedics Orthopedic X-Ray Imaging/Orthopedic Emergencies Essential Med Notes 2015

Table 4. Orthopedic X-Ray Imaging (continued)

Site Injury X-Ray Views

Knee Knee dislocationFemur/tibia #Patella #Patella dislocationPatella femoral syndromeTibia shaft #

AP standing, lateralSkyline – tangential view with knees flexed at 45° to see patellofemoraljoint

Ankle Ankle # APLateralMortise view: ankle at 15° of internal rotation

Foot Talar #Calcanial #

APLateral

Spine Compression #Burst #Cervical spine #

AP spineAP odontoidLateralObliqueSwimmer’s view: lateral view with arm abducted 180° to evaluate C7-T1junction if lateral view is inadequateLateral flexion/extension view: evaluate subluxation of cervical vertebrae

Orthopedic Emergencies

Trauma Patient Workup

Etiology• high energy trauma, e.g. MVC, all rom height• may be associated with spinal injuries or lie-threatening visceral injuries Clinical Presentation• local swelling, tenderness, deormity o the limbs, and instability o the pelvis or spine• decreased level o consciousness, hypotension/hypovolemia

• consider involvement o EtOH or other substances Investigations• trauma survey (see Emergency Medicine, ER5)• x-rays: lateral cervical spine, AP chest, AP pelvis, AP and lateral o all bones suspected to be

injured• other views o pelvis: AP, inlet, and outlet; Judet views or acetabular racture (or classification

o pelvic ractures see able 19, OR26)

Treatment• ABCDEs and initiate resuscitation or lie threatening injuries• assess genitourinary injury (rectal exam/vaginal exam mandatory)• external or internal fixation o all ractures• DV prophylaxis

Complications• hemorrhage – lie threatening (may produce signs and symptoms o hypovolemic shock)• at embolism syndrome (SOB, hypoxemia, petechial rash, thrombocytopenia, and neurological

symptoms)• venous thrombosis – DV and PE• bladder/urethral/bowel injury• neurological damage• persistent pain/stiffness/limp/weakness in affected extremities• post-traumatic OA o joints with intra-articular ractures• sepsis i missed open racture

Open Fractures

Definition• ractured bone and hematoma in communication with the external environment Emergency Measures• removal o obvious oreign material• irrigate with normal saline i grossly contaminated

33% of patients with open fractureshave multiple injuries

Orthopedic Emergencies

VON CHOPVascular compromiseOpen fractureNeurological compromise/cauda equinasyndromeCompartment syndromeHip dislocation

Osteomyelitis/septic arthritisUnstable Pelvic fracture

Buck’s TractionA system of weights, pulleys, andropes that are attached to the end of

a patient’s bed exerting a longitudinalforce on the distal end of a fracture,improving its length, alignment, androtation

Antibiotics for Preventing Infection in Open LimbFractures

Cochrane DB Syst Rev 2004;1:CD003764Purpose: To review the evidence regarding theeffectiveness of antibiotics in the initial treatment ofopen fractures of the limbs.Methods: Randomized or quasi randomizedcontrolled trials comparing antibiotic treatment withplacebo or no treatment in preventing acute woundinfection were identified and reviewed. Data wereextracted and pooled for analysis.Results: Eight studies (n=1,106) were reviewed.The use of antibiotics had a protective effect againstearly infection compared with no antibiotics orplacebo (RRR=0.43, 95% CI 0.29, 0.65; ARR=0.07,95% CI 0.03=0.10).Conclusions: Antibiotics reduce the incidence ofearly infections in open fractures of the limbs.


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Essential Med Notes 2015 Orthopedic Emergencies Orthopedics OR9

• cover wound with sterile dressings• immediate IV antibiotics• tetanus toxoid or immunoglobulin as needed• reduce and splint racture• NPO and prepare or OR (blood work, consent, ECG, CXR)

operative irrigation and debridement within 6-8 h to decrease risk o inection traumatic wound ofen lef open to drain but vacuum-assisted closure dressing may be used re-examine with repeat I&D in 48 h

Table 5. Gustilo Classification of Open Fractures

GustiloGrade

Length ofOpen Wound

Description Prophylactic Antibiotic Regimen

I 10 cm IIIA: Extensive soft tissue injury with adequateability of soft tissue to cover woundIIIB: Extensive soft tissue injury withperiosteal stripping and bone exposure;

inadequate soft tissue to cover woundIIIC: Vascular injury/compromise

As per Grade IIFor soil contamination, penicillin is added forclostridial coverage

*Any high energy, comminuted fracture, shot gun, farmyard/soil/water contamination, exposure to oral flora, or fracture >8 h old is immediately classified as Grade III

Cauda Equina Syndrome

• see Neurosurgery, NS26

Compartment Syndrome

Definition• increased interstitial pressure in an anatomical compartment (orearm, cal) where muscle and

tissue are bounded by ascia and bone (fibro-osseous compartment) with little room or expansion• interstitial pressure exceeds capillary perusion pressure leading to muscle necrosis (in 4-6 h)and eventually nerve necrosis

Etiology• intracompartmental: racture (particularly tibial shaf ractures, pediatric supracondylar

ractures, and orearm ractures), crush injury, ischemia-reperusion injury• extracompartmental: constrictive dressing (circumerential cast, poor positioning during

surgery), circumerential burn

Figure 9. Pathogenesis of compartment syndrome

Clinical Features• pain with active contraction o compartment• pain with passive stretch• swollen, tense compartment

• suspicious history

• 5 Ps: late sign – do not wait or these to develop to make the diagnosis!

Increased pressure from bloodand intracompartmental swelling

Decreased venous drainage

Decreased lymphatic drainage

Intracompartmental pressuregreater than perfusion pressure

Muscle andnerve anoxia

Acidosis Muscle and

nerve necrosis

Transudation into tissue

surrounding compartment

Leaky basementmembranes

5 Ps of Compartment Syndrome

Pain: out of proportion for injury and notrelieved by analgesics

• Increased pain with passive stretchof compartment muscles (mostspecific sign)

Pallor: late finding

ParesthesiaParalysis: late findingPulselessness: late finding

Cauda equina syndrome is a surgicalemergency

Controversies in Initial Management of OpenFracturesScand J Surg 2014;103(2):132-137Study: Literature review examining the initialmanagement of open fractures. 40 studies included.Findings:

• A first generation cephalosporin (or clindamycin)should be administered upon arrival. In general,24 h of antibiotics after each debridement issufficient to reduce infection rates.

• Although cultures are taken from delayed (>24h) or infected injuries, it may not be necessary toroutinely take post-debridement cultures in openfractures.

• Open fractures should be debrided as soon aspossible although the “6-hr rule” is not generallyvalid.

• Wounds should be closed within 7 d once softtissue has stabilized and all non-viable tissueremoved.

• Negative pressure wound therapy (NPWT) hasbeen shown to decrease infection rates in openfractures.


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OR10 Orthopedics Orthopedic Emergencies Essential Med Notes 2015

Investigations• usually not necessary as compartment syndrome is a clinical diagnosis• in children or unconscious patients where clinical exam is unreliable, compartment pressure

monitoring with catheter AFER clinical diagnosis is made (normal = 0 mmHg; elevated≥30 mmHg or ≤30 mmHg o diastolic BP)

Treatment

• non-operative remove constrictive dressings (casts, splints), elevate limb at the level o the heart

• operative urgent asciotomy 48-72 h post-operative: wound closure ± necrotic tissue debridement

Complications• rhabdomyolysis, renal ailure secondary to myoglobinuria• Volkmann’s ischemic contracture: ischemic necrosis o muscle, ollowed by secondary fibrosis

and finally calcification; especially ollowing supracondylar racture o humerus

Osteomyelitis

Etiology• most commonly caused by Staphylococcus aureus• mechanism o spread: hematogenous (most common) vs. direct-inoculation vs. contiguous

ocus• risk actors: recent trauma/surgery, immunocompromised patients, DM, IV drug use, poor

vascular supply, peripheral neuropathy

Clinical Presentation• symptoms: pain and ever• on exam: erythema, tenderness, edema common ± abscess/draining sinus tract; impaired

unction/WB

Diagnosis• see Medical Imaging, MI24

• workup includes: WBC and diff, ESR, CRP, blood culture, aspirate culture/bone biopsy

Table 6. Treatment of Osteomyelitis

Acute Osteomyelitis Chronic Osteomyelitis

IV antibiotics 4-6 wk; started empirically and adjusted afterobtaining blood and aspirate cultures± surgery (I&D) for abscess or significant involvement± hardware removal (if present)

Surgical debridementAntibiotics: both local (e.g. antibiotic beads) and systemic (IV)

Septic Joint

Etiology• most commonly caused by Staphylococcus aureus in adults• consider coagulase-negative Staphylococcus in patients with prior joint replacement• consider Neisseria gonorrhoeae in sexually active adults and newborns• most common route o inection is hematogenous• risk actors: age >80 yr, DM, RA, prosthetic joint, recent joint surgery, skin inection/ulcer,

IV drug use, alcoholism, previous intra-articular corticosteroid injection

Clinical Presentation• inability/reusal to bear weight, localized joint pain, erythema, warmth, swelling, pain on active

and passive ROM, ± ever Investigations• x-ray (to rule out racture, tumor, metabolic bone disease), ESR, CRP, WBC, blood cultures• joint aspirate: WBC >80,000 with >90% neutrophils, protein level >4.4 mg/dL, joint glucose

level


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Essential Med Notes 2015 Shoulder Orthopedics OR11

Shoulder

Shoulder Dislocation

Prognosis

• recurrence rate depends on age o first dislocation: 40 yr = 2-4%

Specific Complications• rotator cuff or capsular tear, shoulder stiffness• injury to axillary nerve/artery, brachial plexus• recurrent/unreduced dislocation (most common complication)

Investigations• anterior dislocation x-rays (AP, trans-scapular, axillary views)• posterior dislocation x-rays (AP, trans-scapular, axillary) or C scan

Table 7. Anterior and Posterior Shoulder Dislocation

Anterior Shoulder Dislocation (>90%) Posterior Shoulder Dislocation (5%)

MECHANISM

Abducted arm is externally rotated/hyperextended,or blow to posterior shoulder

Involuntary, usually traumatic; voluntary, atraumatic

Adducted, internally rotated, flexed arm

FOOSH

3 Es (epileptic seizure, EtOH, electrocution)

Blow to anterior shoulder

CLINICAL FEATURES

Symptoms Pain, arm slightly abducted and externally rotatedwith inability to internally rotate

Pain, arm is held in adduction and internal rotation;external rotation is blocked

Shoulder Exam “Squared off” shoulder

Positive apprehension test: patient looksapprehensive with gentle shoulder abduction andexternal rotation to 90o since humeral head is

pushed anteriorly and recreates feeling of anteriordislocation (see Figure 13)

Positive relocation test: a posteriorly directedforce applied during the apprehension testrelieves apprehension since anterior subluxation isprevented

Positive sulcus sign: presence of subacromialindentation with distal traction on humerusindicates inferior shoulder instability (see Figure 13)

Anterior shoulder flattening, prominent coracoid,palpable mass posterior to shoulder

Positive posterior apprehension (“jerk”) test: withpatient supine, flex elbow 90° and adduct, internally

rotate the arm while applying a posterior forceto the shoulder; patient will “jerk” back with thesensation of subluxation (see Figure 13)

Note: the posterior apprehension test is used totest for recurrent posterior instability, NOT for acuteinjury

NeurovascularExam Including

Axillary nerve: sensory patch over deltoid anddeltoid contraction

Musculocutaneous nerve: sensory patch on lateralforearm and biceps contraction

Full neurovascular exam as per anterior shoulderdislocation

RADIOGRAPHIC FINDINGS

Axillary View Humeral head is anterior Humeral head is posterior

Trans-scapular 'Y'View

Humeral head is anterior to the center of the“Mercedes-Benz" sign

Humeral head is posterior to center of “Mercedes-Benz" sign

AP View Sub-coracoid lie of the humeral head is mostcommon

Partial vacancy of glenoid fossa (vacant glenoidsign) and >6 mm space between anterior glenoidrim and humeral head (positive rim sign), humeralhead may resemble a lightbulb due to internalrotation (lightbulb sign)

Hill-Sachs andBony BankartLesions

± Hill-Sachs lesion: compression fracture ofposterior humeral head due to forceful impaction ofan anteriorly dislocated humeral head against theglenoid rim (see Figure 12)

± bony Bankart lesion: avulsion of the anterior

glenoid labrum (with attached bone fragments)from the glenoid rim (see Figure 12)

± reverse Hill-Sachs lesion (75% of cases): divot inanterior humeral head

± reverse bony Bankart lesion: avulsion of theposterior glenoid labrum from the bony glenoid rim

Factors Causing Shoulder Instability• Shallow glenoid• Loose capsule• Ligamentous laxity

Frequency of Dislocations:• Anterior shoulder > Posterior shoulder

The glenohumeral joint is the mostcommonly dislocated joint in the bodysince stability is sacrificed for motion

Figure 10. Shoulder joints

1

2345

6

7 8 9

1. Manubrium2. Sternoclavicular joint3. Clavicle4. Coracoid process5. AC joint6. Acromion7. Humerus8. Glenohumeral joint9. Scapula

© J

a s o n R a i n e

Figure 11. Mercedes-Benz

© K

a j e a n d r a R a v i c h a n d i r a n 2 0 1 2

Coracoid

process

Acromion

Scapula

Humerus

Posterior Shoulder DislocationUp to 60-80% are missed on initialpresentation due to poor physical examand radiographs

There are 4 Joints in the Shoulder:glenohumeral, AC, sternoclavicular (SC),scapulothoracic

Shoulder passive ROM: abduction –180°, adduction – 45°, flexion – 180°,extension – 45°, int. rotation – level ofT4, ext. rotation – 40-45°


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OR12 Orthopedics Shoulder Essential Med Notes 2015

Table 7. Anterior and Posterior Shoulder Dislocation (continued)

Anterior Shoulder Dislocation (>90%) Posterior Shoulder Dislocation (5%)

TREATMENT

Closed reduction with IV sedation and musclerelaxation

Traction-countertraction: assistant stabilizes torso

with a folded sheet wrapped across the chest whilethe surgeon applies gentle steady traction

Stimson: while patient lies prone with arm hangingover table edge, hang a 5 lb weight on wrist for15-20 min

Hippocratic method: place heel into patient’s axillaand apply traction to arm

Cunningham's method: low risk, low pain; if notsuccessful try above methods

Obtain post-reduction x-rays

Check post-reduction NVS

Sling x 3 wk (avoid abduction and externalrotation), followed by shoulder rehabilitation(dynamic stabilizer strengthening)

Closed reduction with sedation and musclerelaxation

Inferior traction on a flexed elbow with pressure on

the back of the humeral head

Obtain post-reduction x-rays

Check post-reduction NVS

Sling in abduction and external rotation x 3 wk,followed by shoulder rehabilitation (dynamicstabilizer strengthening)

Figure 13. Shoulder maneuvers

Rotator Cuff Disease

• rotator cuff consists o 4 muscles that act to stabilize humeral head within the glenoid ossa Table 8. Rotator Cuff Muscles

Muscle Muscle Attachments Nerve Supply Muscle Function

Proximal Distal

Supraspinatus Scapula Greater tuberosity of humerus Suprascapular nerve Abduction

Infraspinatus Scapula Greater tuberosity of humerus Suprascapular nerve External rotation

Teres Minor Scapula Greater tuberosity of humerus Axillary nerve External rotation

Subscapularis Scapula Lesser tuberosity of humerus Subscapular nerve Internal rotation and adduction

SPECTRUM OF DISEASE: IMPINGEMENT, TENDONITIS, MICRO OR MACRO TEARS

Etiology• impingement: “painul arc syndrome”, compression o rotator cuff tendons (primarilysupraspinatus) and subacromial bursa between the head o the humerus and the undersurace oacromion, AC joint, and CA ligament

leads to bursitis, tendonitis, and i lef untreated, can lead to rotator cuff thinning and tear Figure 14. Muscles of the rotator cuff

Subscapularis

Joint capsule

Scapular bodyTeres minor

Coracoidprocess

Acromion

ACligament

© A

n d r e e a M

a r g i n e a n u 2 0 1 2

Infraspinatus

Supraspinatus

Anterior apprehension sign

© L o r i W a t e r s 2 0 0 5

© Lori Waters 2005

Sulcus sign

Posterior apprehension sign

© L o r i W a t e r s 2 0 0 5

© T a b b y L u l h a m 2 0 1 0

Traction-Countertraction

Figure 12. Posterior view ofanterior dislocation causingHill-Sachs and Bankart lesions

© M

a r y S i m s 2 0 0 3

Bankart

Hill-Sachs


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Essential Med Notes 2015 Shoulder Orthopedics OR13

• anything that leads to a narrow subacromial space glenohumeral muscle weakness leading to abnormal motion o humeral head scapular muscle weakness leading to abnormal motion o acromion acromial abnormalities such as congenital narrow space or osteophyte ormation

Clinical Features• night pain and difficulty sleeping on affected side• pain worse with active motion; passive movement generally permitted• weakness and loss o ROM especially between 90°-130° (e.g. trouble with overhead activities)• tenderness to palpation over greater tuberosity• rule out bicep tendinosis: Speed and Yergason’s tests; SLAP lesion: O’Brien’s test

Table 9. Rotator Cuff Special Tests

Test Examination Positive Test

Jobe’s Test Supraspinatus: place the shoulder in 90° of abduction and 30° offorward flexion and internally rotate the arm so that the thumb ispointing toward the floor

Weakness with active resistancesuggests a supraspinatus tear

Lift-off Test Subscapularis: internally rotate arm so dorsal surface of hand restson lower back; patient instructed to actively lift hand away fromback against examiner resistance (use Belly Press Test if too painful)

Inability to actively lift hand away fromback suggests a subscapularis tear

Posterior-Cuff

Test

Infraspinatus and teres minor: arm positioned at patient’s side in90° of flexion; patient instructed to externally rotate arm against the

resistance of the examiner

Weakness with active resistancesuggests posterior cuff tear

Neer’s Test Rotator cuff impingement: passive shoulder flexion Pain elicited between 130-170° suggests impingement

Hawkins-Kennedy Test

Rotator cuff impingement: shoulder flexion to 90° and passive internalrotation

Pain with internal rotation suggestsimpingement

Painful ArcTest

Rotator cuff tendinopathy: patient instructed to actively abductthe shoulder

Pain with abduction >90° suggeststendinopathy

Figure 15. Rotator cuff tests

Lift-off test

Posterior cuff test © T

a b b y L u l h a m 2 0 1 0

© E

r i n D u f f 2

0 0 9

© T

a b b y L u l h a m 2 0 1 0

130-170º

Jobe’s test

Neer’s test

Hawkins-Kennedy test

Ruling in Rotator Cuff Tears – 98%probability of rotator cuff tear if all3 of the following are present:• Supraspinatus weakness• External rotation weakness• Positive impingement sign(s)

Diagnosis of rotator cuff tears. Lancet 2001;357:769-770

Screening Out Rotator Cuff Tears• No night pain (SN 87.7%)• No painful arc (SN 97.5%)• No impingement signs (SN 97.2%)• No weakness

Returning to the bedside: Using the history andphysical examination to identify rotator cuff tears JAM Geri Soc 2000;48:1633-1637

Rotator Cuff Muscles

SITSSupraspinatusInfraspinatusTeres minor

Subscapularis

Does this Patient with Shoulder Pain haveRotator Cuff Disease? The Rational ClinicalExamination Systematic Review JAMA 2013;310:837-847Study: 5 studies of sufficient quality including30-203 shoulders and a prevalence of RCD rangingfrom 33-81%.Results/Conclusions: Among pain provocationtests, a positive painful arc test had the greatestspecificity and sensitivity (SP 81%, SN 71%)Among strength tests, a positive external rotationlag test and internal rotation lag test were the mostaccurate for full-thickness tears (SP 47%, SN 94%;SP 97%, SN 83% respectively). The internal rotationlag test was therefore also the most accurate foridentifying patients without a full-thickness tear.A positive drop arm test is helpful to identifypatients with RCD (SN 24%, SP 93%).


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OR14 Orthopedics Shoulder Essential Med Notes 2015

Investigations• x-rays: AP view may show high riding humerus relative to glenoid, evidence o chronic

tendonitis• MRI: coronal/sagittal oblique and axial orientations are useul or assessing ull/partial tears and

tendinopathy ± arthrogram: geyser sign (injected dye leaks out o joint through rotator cuff tear)• arthrogram: see ull thickness tear, difficult to assess partial thickness tears

Treatment and Prognosis• mild (“wear”) treatment is non-operative (physiotherapy, NSAIDs)

• moderate (“tear”) non-operative treatment ± steroid injection

• severe (“repair”) impingement that is reractory to 2-3 mo physiotherapy and 1-2 injections may require arthroscopic or surgical repair, i.e. acromioplasty, rotator cuff repair

Acromioclavicular Joint Pathology

• 2 main ligaments attach clavicle to scapula: AC and CC ligaments

Mechanism• all onto shoulder with adducted arm (all onto tip o shoulder) Clinical Features• palpate step deormity between distal clavicle and acromion (with dislocation)• pain with adduction o shoulder and/or palpation over AC joint• limited ROM

Investigations• x-rays: AP, Zanca view (10-15° cephalic tilt), axillary ± stress views (10 lb weight in patient’s

hand) Treatment• non-operative (most common): sling 1-3 wk, ice, analgesia, rehabilitation

• operative indications: AC and CC ligaments are both torn and/or clavicle displaced posteriorly procedure: number o different approaches involving AC/CC ligament reconstruction or

screw/hook plate insertion

Table 10. Rockwood Classification of Acromioclavicular Joint Seperation

Grade Features Treatment

I Joint sprain, absence of complete tear of either ligament Non-operative

II Complete tear of AC ligament, incomplete tear of CCligament, without marked elevation of lateral clavicularhead

Non-operative

III Complete tear of AC and CC ligaments, >5 mmelevation at AC joint, superior aspect of acromion is

below the inferior aspect of the clavicle

Most non-operative, operative if laborer or high levelathlete

Will heal with step deformity, although most fullyfunctional in 4-6 mo

IV-VI Based on the anatomical structure the displaced clavicleis in proximity with

Operative in most cases

Clavicle Fracture

• incidence: proximal (5%), middle (80%), or distal (15%) third o clavicle• common in children (unites rapidly without complications) Mechanism• all on shoulder (87%), direct trauma to clavicle (7%), FOOSH (6%)

Clinical Features• pain and tenting o skin• arm is clasped to chest to splint shoulder and prevent movement

Treatment• evaluate NVS o entire upper limb

Associated Injuries with ClavicleFractures• Up to 9% of clavicle fractures are

associated with other fractures (mostcommonly rib fractures)

• Majority of brachial plexus injuriesare associated with proximal thirdfractures

Pneumothorax or pulmonary contusionare potential complications of severe ACjoint dislocation


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Essential Med Notes 2015 Shoulder/Humerus Orthopedics OR15

• medial and middle third clavicle ractures figure-o-eight sling x 1-2 wk early ROM and strengthening once pain subsides i ends overlap >2 cm consider ORIF

• distal third clavicle ractures undisplaced (with ligaments intact): sling x 1-2 wk displaced (CC ligament injury): ORIF

Specific Complications (see General Fracture Complications, OR6)• cosmetic bump usually only complication• shoulder stiffness, weakness with repetitive activity • pneumothorax, brachial plexus injuries, and subclavian vessel (all very rare)

Frozen Shoulder (Adhesive Capsulitis)

Definition• disorder characterized by progressive pain and stiffness o the shoulder usually resolving

spontaneously afer 18 mo

Mechanism• primary adhesive capsulitis

idiopathic, usually associated with DM usually resolves spontaneously in 9-18 mo

• secondary adhesive capsulitis due to prolonged immobilization shoulder-hand syndrome: CRPS/RSD characterized by arm and shoulder pain, decreased

motion, and diffuse swelling ollowing MI, stroke, shoulder trauma poorer outcomes

Clinical Features• gradual onset (wk to mo) o diffuse shoulder pain with:

decreased active AND passive ROM pain worse at night and ofen prevents sleeping on affected side increased stiffness as pain subsides: continues or 6-12 mo afer pain has disappeared

Investigations• x-rays may be normal, or may show demineralization rom disease

Treatment• Freezing Phase

active and passive ROM (physiotherapy) NSAIDs and steroid injections i limited by pain

• Tawing Phase manipulation under anesthesia and early physiotherapy

arthroscopy or debridement/decompression

Humerus

Proximal Humeral Fracture

Mechanism• young: high energy trauma (MVC)• elderly: FOOSH rom standing height in osteoporotic individuals

Clinical Features• proximal humeral tenderness, deormity with severe racture, swelling, painul ROM, bruising

extends down arm later

Investigations• test axillary nerve unction (deltoid contraction and skin over deltoid)

• x-rays: AP, trans-scapular, axillary are essential• C scan: to evaluate or articular involvement and racture displacement

Classification• Neer classification is based on 4 racture ragments (see Neer Classification sidebar, OR16)• displaced: displacement >1 cm and/or angulation >45°

Greater tuberosity

Lesser tuberosity

Anatomical neck

Surgical neck

Figure 16. Fractures of theproximal humerus

Conditions Associated with an

Increased Incidence of AdhesiveCapsulitis:• Prolonged immobilization (most

significant)• Female gender• Age >49 yr• DM (5x)• Cervical disc disease• Hyperthyroidism• Stroke• Myocardial infarction• Trauma and surgery


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OR16 Orthopedics Humerus/Elbow Essential Med Notes 2015

• the Neer system regards displacement, not the racture line, as meeting criteria or a 'part' in theclassification scheme

• ± dislocated/subluxed: humeral head dislocated/subluxed rom glenoid

Treatment• treat osteoporosis i needed• non-operative

nondisplaced - broad arm sling immobilization begin ROM in 7-10 d to prevent stiffness

minimally displaced - closed reduction with sling immobilization x 2 wk, gentle ROM• operative

ORIF (anatomic neck ractures, displaced, associated dislocated glenohumeral joint) hemiarthroplasty may be necessary, especially in elderly

Specific Complications (see General Fracture Complications, OR6)• AVN, axillary nerve palsy, malunion, post-traumatic arthritis

Humeral Shaft Fracture

Mechanism• direct blows/MVC (most common), FOOSH, twisting injuries, metastases (in elderly)

Clinical Features• pain, swelling, ± shortening, motion/crepitus at racture site• must test radial nerve unction beore and afer treatment: look or drop wrist, sensory

impairment dorsum o hand Investigations• x-rays: AP and lateral radiographs o the humerus including the shoulder and elbow joints

Treatment• in general, humeral shaf ractures are treated non-operatively• non-operative (most common)

± reduction; can accept deormity due to compensatory ROM o shoulder hanging cast (weight o arm in cast provides traction across racture site) with collar and cuff

sling immobilization until swelling subsides, then Sarmiento unctional brace, ollowed byROM

• operative indications: open racture, neurovascular injury, unacceptable racture alignment,

polytrauma, segmental racture, pathological racture, “floating elbow” (simultaneousunstable humeral and orearm ractures), intra-articular

ORIF: plating (most common), IM rod insertion, external fixation Specific Complications (see General Fracture Complications, OR6)• radial nerve palsy: expect spontaneous recovery in 3-4 mo, otherwise send or EMG• non-union: most requently seen in middle 1/3• decreased ROM• compartment syndrome

Elbow

Supracondylar Fracture

• most common in pediatric population (peak age ~7 yr old), rarely seen in adults• racture o the distal 1/3 o humerus just proximal to capitulum and trochlea, usually transverse• AIN injury commonly associated with extension type

Mechanism• >96% are extension injuries via FOOSH (e.g. all off monkey bars);


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Essential Med Notes 2015 Elbow Orthopedics OR17

Treatment• reduction indications: evidence o arterial obstruction, unacceptable angulation, displaced

(>50%)• non-operative

nondisplaced: long arm plaster slab in 90o flexion x 3 wk• operative

indications: displaced, vascular injury, open racture

requires percutaneous pinning ollowed by limb cast with elbow flexed 30°, involves ≥1/3 of the radial head, or if≥3 mm of joint incongruity exists

3 Comminuted fracture Radial head excision ± prosthesis

4 Comminuted fracture with posteriorelbow dislocation

Radial head excision ± prosthesis

Specific Complications (see General Fracture Complications, OR6)• myositis ossificans• recurrent instability (i MCL injured and radial head excised)

Olecranon Fracture

Mechanism

• direct trauma to posterior aspect o elbow (all onto the point o the elbow)

Clinical Features• ± loss o active extension due to avulsion o triceps tendon

Investigations• x-rays: AP + lateral (require true lateral to determine racture pattern)

Treatment• non-displaced (2-3 wk

© Desmond Ballance 2006

Anterior Humeral Line

Radio-Capitellar Line

Capitellum

Radial Head

Figure 19. Lateral view of elbow

Elbow DislocationThe radio-capitellar line refers to animaginary line along the longitudinal axisof the radius that passes through thecenter of the capitellum regardless ofthe degree of elbow flexion; if the radio-capitellar line does not pass through thecenter of the capitellum a dislocationshould be suspected

Terrible Triad• Radial head fracture• Coronoid fracture• Elbow dislocation

Anterior fat pad

Posterior fat pad

Figure 18. X-ray of fat pad sign

Mason Class 2 Radial Head FractureCT reconstruction provides the bestdetail and ability to appreciate theanatomic orientation of the fracturepattern, enhancing surgical planning andprognosis

The anterior humeral line refers to animaginary line drawn along the anterior

surface of the humeral cortex thatpasses through the middle third of thecapitellum when extended inferiorly.In subtle supracondylar fractures theanterior humeral line is disrupted,typically passing through the anteriorthird of the capitellum


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OR18 Orthopedics Elbow/Forearm Essential Med Notes 2015

Mechanism• elbow hyperextension via FOOSH or valgus/supination stress during elbow flexion• usually the radius and ulna are dislocated together, or the radius head dislocates and the ulna

remains ("Monteggia")• 90% are posterior/posterolateral, anterior are rare and usually devastating Clinical Features• elbow pain, swelling, deormity

• flexion contracture• ± absent radial or ulnar pulses Treatment• assess NVS beore reduction: brachial artery, median and ulnar nerves (can become entrapped

during manipulation)• closed reduction under conscious sedation (post-reduction x-rays required)• Parvin’s method: patient lies prone with arm hanging down; apply gentle traction downwards on

wrist, as olecranon slips distally, gently lif up the arm at elbow to reduce joint• long-arm splint with orearm in neutral rotation and elbow in 90° flexion• early ROM (


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Essential Med Notes 2015 Forearm Orthopedics OR19

Monteggia Fracture

• more common and better prognosis in the pediatric age group when compared to adults

Definition• racture o the proximal ulna with radial head dislocation and proximal radioulnar joint injury

Mechanism• direct blow on the posterior aspect o the orearm• hyperpronation• all on the hyperextended elbow

Clinical Features• decreased rotation o orearm ± palpable lump at the radial head• ulna angled apex anterior and radial head dislocated anteriorly (rarely the reverse deormity occurs)

Treatment• adults: ORIF o ulna with indirect radius reduction in 90% o patients• splint and early post-operative ROM i elbow completely stable, otherwise immobilization in

plaster with elbow flexed or 6 wk • pediatrics: attempt closed reduction and immobilization in plaster with elbow flexed or Bado

ype I-III, surgery or ype IV

Specific Complications (see General Fracture Complications, OR6)• PIN: most common nerve injury; observe or 3 mo as most resolve spontaneously • radial head instability/redislocation• radioulnar synostosis

Nightstick Fracture

Definition• isolated racture o ulna without dislocation o radial head

Mechanism• direct blow to orearm (e.g. holding arm up to protect ace)

Treatment• non-displaced: below elbow cast (x 10 d) ollowed by orearm brace (~8 wk)• displaced: ORIF i >50% shaf displacement or >10° angulation

Galeazzi Fracture

Definition• racture o the distal radial shaf with disruption o the DRUJ• most commonly in the distal 1/3 o radius near junction o metaphysis/diaphysis• 3x more common than Monteggia racture

Mechanism• hand FOOSH with axial loading o pronated orearm

Investigations• x-rays shortening o distal radius >5 mm relative to the distal ulna widening o the DRUJ space on AP dislocation o radius with respect to ulna on true lateral

Treatment• ORIF o radius; aferwards assess DRUJ stability by balloting distal ulna relative to distal radius• i DRUJ is stable and reducible, splint or 10-14 d with early ROM encouraged• i DRUJ is unstable, ORIF or percutaneous pinning with long arm cast in supination x 6 wk

Fracture of distal radius

DRUJ

Dislocation of ulna © D

e s m

o n d B a l l a n c e 2 0 0 6

Figure 22. Galeazzi fracture

For all isolated radius fractures assessDRUJ to rule out a Galeazzi fracture

© C

h e s l e y S h e p p a r d

Figure 21. Nightstick fracture

© J

o e y T r a u t m a n n 2 0 0 7

Figure 20. Monteggia fracture


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OR20 Orthopedics Wrist Essential Med Notes 2015

Wrist

Colles’ Fracture

Definition

• extra-articular transverse distal radius racture (~2 cm proximal to the radiocarpal joint) withdorsal displacement ± ulnar styloid racture

Epidemiology• most common racture in those >40 yr, especially in women and those with osteoporotic bone Mechanism• FOOSH Clinical Features• “dinner ork” deormity • swelling, ecchymoses, tenderness Investigations• x-ray: AP and lateral wrist

Treatment• goal is to restore radial height, radial inclination (22°), volar tilt (11°) as well as DRUJ stability

and useul orearm rotation• closed reduction (think opposite o the deormity):

hematoma block (sterile prep and drape, local anesthetic injection directly into racture site)or conscious sedation

closed reduction: 1) traction with extension (exaggerate injury), 2) traction with ulnardeviation, pronation, flexion (o distal ragment – not at wrist)

dorsal slab/below elbow cast or 5-6 wk x-ray x 1 wk or 3 wk and at cessation o immobilization to ensure reduction is maintained

• obtain post-reduction films immediately; repeat reduction i necessary, consider externalfixation or ORIF i ailure o adequate closed reduction

Smith’s FractureDefinition• volar displacement o the distal radius (i.e. reverse Colles’ racture) Mechanism• all onto the back o the flexed hand Treatment• usually unstable and needs ORIF• i patient is poor operative candidate, may attempt non-operative treatment• closed reduction with hematoma block (reduction opposite o Colles’)• long-arm cast in supination x 6 wk

Complications of Wrist Fractures

• most common complications are poor grip strength, stiffness, and radial shortening• distal radius ractures in individuals


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Essential Med Notes 2015 Wrist/Hand/Spine Orthopedics OR21

Scaphoid Fracture

Epidemiology• common in young men; not common in children or in patients beyond middle age• most common carpal bone injured• may be associated with other carpal or wrist injuries (e.g. Colles' racture)

Mechanism• FOOSH: impaction o scaphoid on distal radius, most commonly resulting in a transverseracture through the waist (65%), distal (10%), or proximal (25%) scaphoid

Clinical Features• pain with wrist movement• tenderness in the anatomical “snuff box”, over scaphoid tubercle, and pain with long axis

compression into scaphoid• usually nondisplaced

Investigations• x-ray: PA, lateral, scaphoid views with wrist extension and ulnar deviation x 2 wk• ± C or MRI• bone scan rarely used• note: a racture may not be radiologically evident up to 2 wk afer acute injury, so i a patient

complains o wrist pain and has anatomical snuff box tenderness but a negative x-ray, treat asi positive or a scaphoid racture and repeat x-ray 2 wk later to rule out a racture; i x-ray stillnegative order C or MRI

Treatment• early treatment critical or improving outcomes• non-displaced (


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OR22 Orthopedics Spine Essential Med Notes 2015

Fractures of the Spine

• see Neurosurgery, NS32

Table 13. Fracture Type and Column Involvement

Fracture Type Column Failure Stable/Unstable Mechanism

Compression Anterior Stable Compression

Burst Anterior, middle ± Unstable High-energy axial loading + flexion

Fracture-Dislocation Anterior, middle, posterior Unstable Significant force applied to spine (flexion, extension,distraction, rotation, shear or axial load)

Flexion-Distraction Middle, posterior ± Unstable MVC (lap belt only) causing flexion and distraction(Chance fracture)

Cervical Spine

General Principles• C1 (atlas): no vertebral body, no spinous process• C2 (axis): odontoid = dens• 7 cervical vertebrae; 8 cervical nerve roots• nerve root exits above vertebra (i.e. C4 nerve root exits above C4 vertebra), C8 nerve root exits

below C7 vertebra• radiculopathy = impingement o nerve root• myelopathy = impingement o spinal cord Special Testing• compression test: pressure on head worsens radicular pain• distraction test: traction on head relieves radicular symptoms• Valsalva test: Valsalva maneuver increases intrathecal pressure and causes radicular pain Table 14. Cervical Radiculopathy/Neuropathy

Root C5 C6 C7 C8

Motor Deltoid

BicepsWrist extension

Biceps

Brachioradialis

Triceps

Wrist flexionFinger extension

Interossei

Digital flexors

Sensory Axillary nerve (patch overlateral deltoid)

Thumb and index finger Middle finger Ring and little finger

Reflex Biceps BicepsBrachioradialis

Triceps Finger jerk

X-Rays for C-Spine• AP spine: alignment• AP odontoid: atlantoaxial articulation• lateral

vertebral alignment: posterior vertebral bodies should be aligned (translation >3.5 mm isabnormal)

angulation: between adjacent vertebral bodies (>11° is abnormal) disc or acet joint widening anterior sof tissue space (at C3 should be ≤3 mm; at C4 should be ≤8-10 mm)

• oblique: evaluate pedicles and intervertebral oramen• ± swimmer’s view: lateral view with arm abducted 180° to evaluate C7-1 junction i lateral

view is inadequate• ± lateral flexion/extension view: evaluate subluxation o cervical vertebrae Differential Diagnosis of C-Spine Pain• neck muscle strain, cervical spondylosis, cervical stenosis, RA (spondylitis), traumatic injury,

whiplash, myoascial pain syndrome

C-SPINE INJURY• see Neurosurgery, NS33

Thoracolumbar Spine

General Principles• spinal cord terminates at conus medullaris (L1)• individual nerve roots exit below pedicle o vertebra (i.e. L4 nerve root exits below L4 pedicle)

Canadian C-Spine RuleUsed to guide imaging for alert(GCS = 15) and stable patients withsuspected C-spine injuryObtain radiography if:• Age ≥65• Paresthesia in the extremities• Inability to rotate neck >45° to the

left and right• Dangerous mechanism of injury

(e.g. high speed MVC, fall fromelevation >5 ft, etc.)

Canadian CT Head and C-Spine (CCC) Study Group.Canadian C-Spine Rule Study for alert and stabletrauma patients. I. Background and rationale.CJEM 2002;4:84-90

C-Spine X-Ray in TraumaMust see C7-T1

Compression

Burst

Fracture-dislocation © K

i m b e r l y C h i n

Figure 28. Compression, burst, anddislocation fractures

Canadian Cervical Spine Rule Compared withComputed Tomography: A Prospective Analysis

J Trauma 2011;71:352-355Study: 3,201 blunt trauma patients screened withCCS. All patients received complete C-spine CT.Results: 192 patients with C-spine fracture and3,009 without fracture on CT. The sensitivity ofCCS was 100% (192/192) and specificity 0.6%(18/3009) with a PPV of 6.03% (192/3182) and NPVof 100% (18/18).Conclusions: CCS is very sensitive but not specificto determine the need for subsequent radiographicevaluation after blunt trauma.


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Essential Med Notes 2015 Spine Orthopedics OR23

Special Tests• straight leg raise: passive lifing o leg (30-70o) reproduces radicular symptoms o pain radiating

down posterior/lateral leg to knee ± into oot• Lasegue maneuver: dorsiflexion o oot during straight leg raise makes symptoms worse or, i leg

is less elevated, dorsiflexion will bring on symptoms• emoral stretch test: with patient prone, flexing the knee o the affected side and passively

extending the hip results in radicular symptoms o unilateral pain in lumbar region, buttock, or

posterior thigh

Table 15. Lumbar Radiculopathy/Neuropathy

Root L4 L5 S1

Motor Quadriceps (knee extension + hipadduction)Tibialis anterior (ankle inversion+ dorsiflexion)

Extensor hallucis longusGluteus medius (hip abduction)

Peroneus longus + brevis (ankleeversion)Gastrocnemius + soleus (plantarflexion)

Sensory Medial malleolus 1st dorsal webspace andlateral leg

Lateral foot

Reflex Knee (patellar) Medial hamstring* Ankle (Achilles)

Test Femoral stretch Straight leg raise Straight leg raise

*Unreliable

Differential Diagnosis of Back Pain1. mechanical or nerve compression (>90%)

degenerative (disc, acet, ligament) peripheral nerve compression (disc herniation) spinal stenosis (congenital, osteophyte, central disc) cauda equina syndrome

2. others (50 yrIV drug useNeuromotor deficits

All trauma patients with suspectedC-spine injury require immediateimmobilization of C-spine at scene ofaccident with spine board, C-collar, andsandbags


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OR24 Orthopedics Spine Essential Med Notes 2015

SPINAL STENOSIS• definition: narrowing o spinal canal 6 mo

Table 17. Differentiating Claudication

Neurogenic Vascular

Aggravation With standing or exerciseWalking distance variable

Walking set distance

Alleviation Change in position (usually flexion, sitting, lying down) Stop walking

Time Relief in ~10 min Relief in ~2 minCharacter Neurogenic ± neurological deficit Muscular cramping

Figure 30. Approach to back pain

MECHANICAL BACK PAIN• definition: back pain NO due to prolapsed disc or any other clearly defined pathology• clinical eatures

dull backache aggravated by activity morning stiffness no neurological signs

• treatment: symptomatic (analgesics, physiotherapy)• prognosis: symptoms may resolve in 4-6 wk, others become chronic

LUMBAR DISC HERNIATION• definition: tear in annulus fibrosus allows protrusion o nucleus pulposus causing either a

central, posterolateral, or lateral disc herniation, most commonly at L5-S1 > L4-5 > L3-4• etiology: usually a history o flexion-type injury• clinical eatures

back dominant pain (central herniation) or leg dominant pain (lateral herniation) tenderness between spinous processes at affected level muscle spasm ± loss o normal lumbar lordosis neurological disturbance is segmental and varies with level o central herniation

motor weakness (L4, L5, S1) diminished reflexes (L4, S1) diminished sensation (L4, L5, S1)

positive straight leg raise positive Lasegue test bowel or bladder symptoms, decreased rectal tone suggests cauda equina syndrome due to

central disc hernation – surgical emergency

• investigations: MRI, consider a post-void residual volume to check or urinary retention; post- void >100 mL should heighten suspicion or cauda equine syndrome• treatment

Back Pain

Back Dominant Leg Dominant

Constant

InflammatoryMechanical

Intermittent Constant

Disc Herniation (lateral)Intermittent

Spinal Stenosis

Disc Herniation (central) Facet Joint

Sciatica• Most common symptom of

radiculopathy (L4-S3)• Leg dominant, constant, burning pain• Pain radiates down leg ± foot• Most common cause = disc

herniation

©

R y o S a k a i 2 0 0 7

Spondylolysis

Spondylolisthesis(anterior displacement)

Figure 31. Spondylolysis,spondylolisthesis

MRI abnormalities (e.g. spinal stenosis,disc herniation) are quite common inboth asymptomatic and symptomaticindividuals and are not necessarilyan indication for intervention withoutclinical correlation

Figure 32. “Scottie dog” fracture

Neurogenic claudication is position

dependent; vascular claudication isexercise dependent


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Essential Med Notes 2015 Spine/Pelvis Orthopedics OR25

symptomatic extension protocol (physiotherapy)

NSAIDs 90% resolve in 3 mo; surgical discectomy reserved or progressive neurological deficit,

ailure o symptoms to resolve within 3 mo, or cauda equina syndrome due to central discherniation

SPONDYLOLYSIS• definition: deect in the pars interarticularis with no movement o the vertebral bodies• etiology

trauma: gymnasts, weightlifers, backpackers, loggers, laborers• clinical eatures: activity-related back pain, pain with unilateral extension (Michelis' test)• investigations

oblique x-ray: “collar” break in the “Scottie dog’s” neck bone scan C scan

• treatment: activity restriction, brace, stretching exercise

SPONDYLOLISTHESIS

• definition: deect in pars interarticularis causing a orward slip o one vertebra on anotherusually at L5-S1, less commonly at L4-5

• etiology: congenital (children), degenerative (adults), traumatic, pathological, teratogenic• clinical eatures: lower back pain radiating to buttocks

Table 18. Classification and Treatment of Spondylolisthesis

Class Percentage of Slip Treatment

1 0-25% Symptomatic operative fusion only for intractable pain

2 25-50 Same as above

3 50-75 Decompression for spondylolisthesis and spinal fusion

4 75-100 Same as above

5 >100 Same as above

Specific Complications• may present as cauda equina syndrome due to roots being stretched over the edge o L5 or

sacrum

Pelvis

Pelvic Fracture

Mechanism• young: high energy trauma, either direct or by orce transmitted longitudinally through the

emur• elderly: all rom standing height, low energy trauma• lateral compression (most common), vertical shear, or anteroposterior compression ractures

Clinical Features• local swelling, tenderness• deormity o lower extremity• pelvic instability

Investigations• x-ray: AP pelvis, inlet and outlet views, Judet views (obturator and iliac oblique or acetabular

racture) 6 cardinal radiographic lines o the acetabulum: ilioischial line, iliopectineal line, tear drop,roo, posterior rim, anterior rim

• C scan useul or evaluating posterior pelvic injury and acetabular racture

Figure 33. Pelvic columns

© E

m i l i e M c M a h o n 2 0 0 5

Posterior

column

Anterior

column

Possible Radiological Findings:• Pubic rami fractures: superior/inferior• Pubic symphysis diastasis: common

in AP compression (N=5 mm)• Sacral fractures: common in lateral

compression• SI joint diastasis: common in AP

compression (N=1-4 mm)• Disrupted anterior column

(iliopectineal line) or posterior column(ilioischial line)

• “Teardrop” displacement: acetabularfracture

• Iliac, ischial avulsion fractures• Displacement of the major fragment:

superior (VS), open book (APC),bucket handle (LC)

Figure 34. Illustration of the Tileclassification of pelvic fractures

© S

e l i n e M

c N a m e e

Type AStable Avulsion Fracture

Type BOpen Book

Type CUnstable Vertical Fracture


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OR26 Orthopedics Pelvis/Hip Essential Med Notes 2015

Classification Table 19. Tile Classification of Pelvic Fractures (see Figure 34)

Type Stability Description

A Rotationally stableVertically stable

A1: fracture not involving pelvic ringA2: minimally displaced fracture of pelvic ring (e.g. ramus fracture)

B Rotationally unstableVertically stable B1: open bookB2: lateral compression – ipsilateralB3: lateral compression – contralateral

C Rotationally unstableVertically unstable

C1: unilateralC2: bilateralC3: associated acetabular fracture

Treatment• ABCDEs• assess genitourinary injury (rectal exam, vaginal exam, hematuria, blood at urethral meatus)

i involved, the racture is considered an open racture• stable ractures: non-operative treatment, protected weight bearing• emergency management

IV fluids/blood

pelvic binder/sheeting external fixation vs. emergent angiography/embolization ± laparotomy (i FAS/DPL positive)

• indications or operative treatment unstable pelvic ring injury disruption o anterior and posterior SI ligament symphysis diastasis >2.5 cm vertical instability o the posterior pelvis

Specific Complications (see General Fracture Complications, OR6)• hemorrhage (lie-threatening) • injury to rectum or urogenital structures• obstetrical difficulties, sexual and voiding dysunction• persistent SI joint pain

• post-traumatic arthritis o the hip with acetabular ractures• high risk o DV/PE

Hip

Hip Dislocation

• ull trauma survey (see Emergency Medicine, Initial Patient Assessment/Management , ER2)• examine or neurovascular injury PRIOR to open or closed reduction• reduce hip dislocations ASAP (ideally within 6 h) to decrease risk o AVN o the emoral head• hip precautions (no extreme hip flexion, adduction, internal or external rotation) or 6 wk

post-reduction

• see Hip Dislocation afer Total Hip Arthroplasty , OR28

ANTERIOR HIP DISLOCATION• mechanism: posteriorly directed blow to knee with hip widely abducted• clinical eatures: shortened, abducted, externally rotated limb• treatment

closed reduction under conscious sedation/GA post-reduction C to assess joint congruity

POSTERIOR HIP DISLOCATION• most requent type o hip dislocation• mechanism: severe orce to knee with hip flexed and adducted

e.g. knee into dashboard in MVC

• clinical eatures: shortened, adducted, internally rotated limb• treatment

closed reduction under conscious sedation/GA only i associated emoral neck racture ORIF i unstable, intra-articular ragments or posterior wall racture post-reduction C to assess joint congruity and ractures i reduction is unstable, put in traction x 4-6 wk

Rochester Method to ReduceDislocations

• Patient lying supine with hip and kneeflexed on injured side• Surgeon stands on patient’s injured side• Surgeon passes one arm under

patient’s flexed knee, reaching to placethat hand on patient’s other knee (thussupporting patient’s injured leg)

• With other hand, surgeon graspspatient’s ankle on injured side,applying traction, while assistantstabilizes pelvis

• Reduction via traction, internalrotation, then external rotation oncefemoral head clears acetabular rim

Figure 35. Rochester method

2. Internal rotation

3. External rotation

© Janet SM Chan 2009

1. Traction

Up to 50% of patients with hipdislocations suffer fractures elsewhereat the time of injury


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Essential Med Notes 2015 Hip Orthopedics OR27

CENTRAL HIP DISLOCATION (rare)• traumatic injury where emoral head is pushed medially through acetabulum

COMPLICATIONS FOR ALL HIP DISLOCATIONS• post-traumatic OA• AVN o emoral head• racture o emoral head, neck, or shaf

• sciatic nerve palsy in 25% (10% permanent)• HO• thromboembolism – DV/PE

Hip Fracture

General Features• acute onset o hip pain• unable to weight-bear• shortened and externally rotated leg• painul ROM

Figure 36. Subcapital, intertrochanteric, subtrochanteric fractures

Table 20. Overview of Hip Fractures

Fracture Type Definition Mechanism Special ClinicalFeatures

Investigations Treatment Complications

Femoral Neck(Subcapital)

Intracapsular(See GardenClassification, Table 21)

Young: MVC, fall from heightElderly: fall from standing,rotational force

Same as general X-ray: AP hip, AP pelvis,cross table lateral hip

DVT, non-union, AVN

IntertrochantericStable: intactposteromedial cortexUnstable: non-intactposteromedial cortex

Extracapsular fractureincluding the greater andlesser trochanters andtransitional bone betweenthe neck and shaft

Same as femoral neckfractureDirect or indirect forcetransmitted to theintertrochanteric area

Ecchymosis at backof upper thigh

X-ray: AP pelvis,AP/lateral hip

Closed reductionunder fluoroscopythen dynamic hipscrew or IM nail

DVT, varusdisplacement ofproximal fragment,malrotation, non-union, failure offixation device

Subtrochanteric Fracture begins ator below the lesser

trochanter and involvesthe proximal femoral shaft

Young: high energy traumaElderly: osteopenic bone +

fall, pathological fracture

Ecchymosis at backof upper thigh

X-ray: AP pelvis, AP/lateralhip and femur

Closed/openunder fluoroscopy

then plate fixationor IM nail

Malalignment, non-union, wound infection

Table 21. Garden Classification of Femoral Neck Fractures

Type Displacement Extent Alignment Trabeculae Treatment

I None "Incomplete" Valgus orneutral

Malaligned Internal fixation to prevent displacement(valgus impacted fracture)

II None Complete Neutral Aligned Internal fixation to prevent displacement

III Some Complete Varus Malaligned Young: ORIFElderly: hemi-/total hip arthroplasty

IV Complete Complete Varus Aligned Young: ORIFElderly: hemi-/total hip arthroplasty

© S e a n W a n g 2 0 0 7

Normal joint Subcapital fracture Intertrochantericfracture

Subtrochantericfracture

DVT Prophylaxis in Hip FracturesLMWH (i.e. enoxaparin 40 mg SC bid),fondaparinux, low dose heparin onadmission, do not give


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OR28 Orthopedics Hip Essential Med Notes 2015

Figure 37. Garden classification of femoral neck fractures

Arthritis of the Hip

Etiology• OA, inflammatory arthritis, post-traumatic arthritis, late effects o congenital hip disorders, or

septic arthritis Clinical Features

• pain (groin, medial thigh) and stiffness aggravated by activity• morning stiffness >1 h, multiple joint swelling, hand nodules (RA)• decreased ROM (internal rotation is lost first)• crepitus• ± fixed flexion contracture leading to apparent limb shortening (Tomas test)• ± rendelenberg sign Investigations• x-ray

OA: joint space narrowing, subchondral sclerosis, subchondral cysts, osteophytes RA: osteopenia, erosion, joint space narrowing, subchondral cysts, symmetric joint space

narrowing• blood work: ANA, RF

Treatment• non-operative: weight reduction, activity modification, physiotherapy, analgesics, walking aids• operative: realign = osteotomy; replace = arthroplasty; use = arthrodesis• complications with arthroplasty: component loosening, dislocation, HO, thromboembolism,

inection, neurovascular injury, limb length discrepancy• arthroplasty is standard o care in most patients with hip arthritis

Hip Dislocation after Total Hip Arthroplasty

Etiology• HA that is unstable when hip is flexed, adducted and internally rotated, or extended and

externally rotated (avoid flexing hip >90° or crossing legs or ~6 wk afer surgery)

Epidemiology• occurs in 1-4% o primary HA and 10-16% o revision HAs• risk actors: neurological impairment, post-traumatic arthritis, revision surgery, substance abuse Treatment• external abduction splint to prevent hip adduction• constrained acetabular component or recurrent dislocation i no issue with position o acetabular/emoral implants + knee immobilizer

Complications• sciatic nerve palsy in 25% (10% permanent)• HO

DVT Prophylaxis in Elective THA(continue 10-35 d post-operative)Fondaparinux, low molecular weightheparin, or coumadin

© G

l o r i a S i t u 2

0 0 3

Type I Type II Type III Type IV

Figure 38. Distal femoral fractures

© P

a u l B e l l e t r u t t i 2 0 0 3

Supracondylar

Intercondylar

Condylar


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Essential Med Notes 2015 Femur Orthopedics OR29

Femur

Femoral Diaphysis Fracture

Mechanism

• high energy trauma (MVC, all rom height, gunshot wound)• in children, can result rom low energy trauma (spiral racture)

Clinical Features• shortened, externally rotated leg (i racture displaced)• inability to weight-bear• ofen open injury, always a Gustilo III (see able 5, OR9)

Investigations• AP pelvis, AP/lateral hip, emur, knee

Complications• hemorrhage requiring transusion• at embolism leading to ARDS

• extensive sof tissue damage• ipsilateral hip dislocation/racture (2-6%)• nerve injury

Treatment• stabilize patient• immobilize leg• ORIF with anterograde or retrograde IM nail, external fixator or unstable patients, open

ractures, or highly vascular areas, or plate and screws or open growth plates within 24 h• early mobilization and strengthening

Distal Femoral Fracture

Mechanism• direct high energy orce or axial loading• three types in addition to classification as intra-articular or extra-articular

Clinical Features• extreme pain• knee effusion (hemarthrosis)• shortened, externally rotated leg i displaced• neurovascular deficits can occur with displaced racture

Treatment• ORIF i displaced or intra-articular; may choose to manage non-operatively i nondisplaced or

incomplete racture• early mobilization and strengthening

Complications (see General Fracture Complications, OR6)• emoral artery tear• popliteal artery injury • nerve injury • extensive sof tissue injury• angulation deormities

© J

e n n P l a t t 2 0 0 4

1

2

3

4

5

6

1. Posterior horn of lateral meniscus

2. Anterior horn of lateral meniscus

3. PCL

4. ACL

5. Posterior horn of medial meniscus

6. Anterior horn of medial meniscus

Figure 39. Diagram of the right

tibial plateau

It is important to rule out ipsilateralfemoral neck fracture as they occurin 2-6% of femoral diaphysis fracturesand are reportedly missed in 19-31%of cases


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OR30 Orthopedics Knee Essential Med Notes 2015

Knee

Evaluation of Knee

Common Complaints

• general orthopedic history• also inquire about common knee symptoms

locking: mechanical block to extension torn meniscus/loose body in joint

pseudo-locking: limited ROM without mechanical block effusion, muscle spasm afer injury, arthritis

painul clicking (audible) torn meniscus

giving way: instability cruciate ligament or meniscal tear, patellar dislocation

Special Tests of the Knee• anterior and posterior drawer tests

demonstrate ACL and PCL, respectively

knee flexed at 90°, oot immobilized, hamstrings released i able to sublux tibia anteriorly (anterior drawer test), then ACL may be torn i able to sublux tibia posteriorly (posterior drawer test), then PCL may be torn

anterior drawer test or ACL: 3.8 positive likelihood ratio, 0.30 negative likelihood ratio• Lachmann test

demonstrates torn ACL hold knee in 10-20° flexion, stabilizing the emur try to sublux tibia anteriorly on emur similar to anterior drawer test, more reliable due to less muscular stabilization or ACL: 25.0 positive likelihood ratio, 0.1 negative likelihood ratio

• Tessaly test demonstrates meniscal tear patient stands flat ooted on one leg while the examiner provides his or her hands orbalance. Te patient then flexes the knee to 20° and rotates the emur on the tibia medially

and laterally three times while maintaining the 20° flexion positive or a meniscal tear i the patient experiences medial or lateral joint line discomort or medial meniscus: 29.67 positive likelihood ratio, 0.11 negative likelihood ratio or lateral meniscus: 23.0 positive likelihood ratio, 0.083 negative likelihood ratio

• posterior sag sign demonstrates torn PCL may give a alse positive anterior draw sign flex knees and hips to 90°, hold ankles and knees view rom the lateral aspect i one tibia sags posteriorly compared to the other, its PCL is torn

• pivot shif sign demonstrates torn ACL start with the knee in extension internally rotate oot, slowly flex knee while palpating and applying a valgus orce

normal knee will flex smoothly i incompetent ACL, tibia will sublux anteriorly on emur at start o maneuver. During

flexion, the tibia will reduce and externally rotate about the emur (the “pivot”) reverse pivot shif (start in flexion, externally rotate, apply valgus and extend knee) suggests

torn PCL composite assessment or ACL: 25.0 positive likelihood ratio, 0.04 negative likelihood ratio composite assessment or PCL: 21.0 positive likelihood ratio, 0.05 negative likelihood ratio

• collateral ligament stress test palpate ligament or “opening” o joint space while testing with knee in ull extension, apply valgus orce to test MCL, apply varus orce to test LCL repeat tests with knee in 20° flexion to relax joint capsule opening only in 20° flexion due to MCL damage only opening in 20° o flexion and ull extension is due to MCL, cruciate, and joint capsule damage

• tests or meniscal tear

joint line tenderness joint line pain when palpated palpate one side at a time and watch patient's eyes or meniscal tear: 0.9 positive likelihood ratio, 1.1 negative likelihood ratio

crouch compression test joint line pain when squatting (anterior pain suggests patelloemoral pathology)

Figure 41. Anterior and posterior

drawer test

© T

a b b y L u l h a m 2 0 1 0

Anterior Drawer Test

Posterior Drawer Test

Figure 42. McMurray test

Examination for Medial

Meniscal Tear

Examination for Lateral

Meniscal Tear © T

a b b y L u l h a m 2

0 1 0

© Inessa Stanishevskaya 2012

Patellartendon

Patella

ACL

LCL

Distalpatellarligament(cut)

Lateral

meniscus

Proximal patellarligament

(cut)

PCL

Medial

meniscus

MCL

Figure 40. Knee ligament andanatomy

6 Degrees of Freedom of the Knee

• Flexion and extension• External and internal rotation• Varus and valgus angulation• Anterior and posterior glide• Medial and lateral shift• Compression and distraction

On physical exam of the knee, do notforget to evaluate the hip


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Essential Med Notes 2015 Knee Or

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