Transcript
  • 8/10/2019 Dont Miss Ortho Injuries 2

    1/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    2/77

    O"(ecti!es

    Disc%ss common orthopedic

    %rgencies and emergencies that

    are not %ncommon#ymisdiagnosed and)or initia##y

    mismanaged.

    Detai# pertinent diagnostic

    eat%res and c#inica# criteria or

    reerra# to an orthopedic

    co##eag%e.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    3/77

    Case *

    Patient is a *+ y)o soccer p#ayer ho presents tothe E- ith a pain%# orearm ater a FOOSin(%ry. e is /%ite tender to pa#pation o!er the

    pro0ima# orearm and has !isi"#e deormity. 1hes2in is intact. 3e%ro!asc%#ar e0amination isnorma#.

    -adiographs.

    Patient is p#aced in a #ong arm sp#int. Prior to discharge rom the ED or Ortho )% in the

    am, the patient comp#ains o th%m" n%m"ness.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    4/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    5/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    6/77

    Epidemio#ogyCompartment Syndrome4CS5 is a serio%s #ie and

    #im"6threatening comp#ication o e0tremity tra%ma.

    Fract%res, "%rns, cr%sh in(%ries and arteria# in(%ries

    can a## res%#t in CS.

    1hree /%arters o cases are associated ith

    ract%res7 ti"ia most common.

    Other sites inc#%de: hand7 orearm7 arm7 sho%#der7"ac27 "%ttoc2s7 thigh7 oot.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    7/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    8/77

    C#inica# AnatomyEach #im" contains a n%m"er o

    compartments at ris2 or CS.

    Upper arm: anterior4"iceps6"rachia#is5 and posterior4triceps5.

    Forearm: !o#ar4#e0ors5 and

    dorsa#4e0tensors5

    9 g#%tea#, thigh, ; in the #oer#eg.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    9/77

    Diagnosisigh inde0 o c#inica# s%spicion, ith pain o%t o

    proportion to the mechanism o in(%ry "eing the

    ha##mar2 symptom.

    Fi!e Ps: pain7 paresthesia7 paresis7 pa##or7 p%#ses.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    10/77

    -adiographic Findings

    Common ract%res associated ith ACS: ti"ia# ract%res

    s%pracondy#ar ract%res o the h%mer%s h%mera# shat

    orearm ract%res

    m%#tip#e metacarpa# or metatarsa# ract%res

  • 8/10/2019 Dont Miss Ortho Injuries 2

    11/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    12/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    13/77

    Case * Fo##o6%p

    C#inica# diagnosis o

    ACS made.

    1a2en to the O- or

    O-8F and compartment

    asciotomy.

    De#ayed s2in c#os%re.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    14/77

    Case

    Pt is a ;> y)o ma#e ith a

    history o co#on CA, ho

    presents ith a history o#o "ac2 pain and a

    history o ne onset

    "#adder incontinence.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    15/77

    Ca%da E/%inaSyndrome

  • 8/10/2019 Dont Miss Ortho Injuries 2

    16/77

    Epidemio#ogy

    ?=@ o the pop%#ation e0periences "ac2 pain at

    some point in their #i!es.

    =@ o #o "ac2 pain reso#!es in + 6* ee2s B-ed F#ag symptoms inc#%de: age o!er >=, tra%ma,

    e!er, incontinence, night pain, eight #oss,

    progressi!e ea2ness.

    Ca%da E/%ina Syndrome 4CES5 is a rare disorder,

    representing on#y =.===;@ o a## "ac2 pain patients

  • 8/10/2019 Dont Miss Ortho Injuries 2

    17/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    18/77

    Mechanism o 8n(%ry

    Us%a##y secondary to e0trinsic press%re

    rom a massi!e centra# 3P

    Other ca%ses inc#%de: epid%ra# a"scess

    epid%ra# t%mor

    epid%ra# hematoma

    tra%ma

  • 8/10/2019 Dont Miss Ortho Injuries 2

    19/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    20/77

    Diagnosis

    C#inica# diagnosis: #oss o "#adder contro#7 periana# n%m"ness7 pain

    and ea2ness in!o#!ing "oth #egs

    E!a#%ation o the %rinary post6!oid resid%a#

    !o#%me assists ith diagnosis:

    the a"sence o a post6!oid resid%a# !o#%me oo!er *==m#, essentia##y e0c#%des a diagnosis o

    CES, ith a negati!e predicti!e !a#%e o

    .@

  • 8/10/2019 Dont Miss Ortho Injuries 2

    21/77

    8maging

    P#ain i#msM-8 imaging

    o the entire spine

  • 8/10/2019 Dont Miss Ortho Injuries 2

    22/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    23/77

    Case 9

    Pt is a proessiona# oot"a## p#ayer, ide

    recei!er, ho presents to ith rist pain.

    e descri"es a FOOS mechanism oin(%ry and comp#ains o n%m"ness in the

    distri"%tion o the median ner!e.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    24/77

    Peri#%nate 8n(%ry

  • 8/10/2019 Dont Miss Ortho Injuries 2

    25/77

    Epidemio#ogy

    &rist in(%ries acco%nt

    or .>@ o a## ED

    !isits.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    26/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    27/77

    Mechanism o 8n(%ryPeri#%nate and #%nate dis#ocations res%#t rom

    hypere0tension in(%ries.

    Most common mechanism o in(%ry is a FOOS,

    o##oed "y an MA.Progressi!e 8n(%ries: Stage 8: scapho#%nate dissociation

    Stage 88: peri#%nate dis#ocation

    Stage 888: dis#ocation o the tri/%etrem

    Stage 8: #%nate dis#ocation

  • 8/10/2019 Dont Miss Ortho Injuries 2

    28/77

    C#inica# Presentationistory o high energy

    mechanism o

    hypere0tension

    Pa#pa"#e pain o!er the

    dors%m o the rist

    1enderness dista# to

  • 8/10/2019 Dont Miss Ortho Injuries 2

    29/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    30/77

    8magingPA and #atera# radiographs PA !ie:

    constant mm intercarpa# (oint space

    9 arcs degrees

    scapho#%nate 9=6+= degrees

    Stress !ies

  • 8/10/2019 Dont Miss Ortho Injuries 2

    31/77

    1reatment

    Cons%#tation ith ahand s%rgeon to

    disc%ss management

  • 8/10/2019 Dont Miss Ortho Injuries 2

    32/77

    Case ;

    Pt is a 9 y)o acti!e d%ty specia# operations

    so#dier ho presents ith persistent dorsa#

    oot pain. e stepped in a ho#e o!er a ee2ago, and has not impro!ed ith se#6care.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    33/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    34/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    35/77

    C#inica# anatomy1he second metatarsa# is the

    2eystone to the

  • 8/10/2019 Dont Miss Ortho Injuries 2

    36/77

    Mechanism o 8n(%ry

  • 8/10/2019 Dont Miss Ortho Injuries 2

    37/77

    C#inica# PresentationPresentation !aries rom a mi#d %ndetecta"#e

    s%"#%0ation to an o"!io%s ract%re dis#ocation

    Midoot pain, se##ing and diic%#ty "earing

    eight are c#inica# c#%es

    Pain ith passi!e pronation and a"d%ction o

    the oreoot ith the hindoot s%pported

    1ense se##ing may indicate a CS.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    38/77

    Diagnosis

    igh inde0 o

    s%spicion in an2#eand oot in(%ries

    Proper radiographic

    interpretation

  • 8/10/2019 Dont Miss Ortho Injuries 2

    39/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    40/77

    1reatment

    Orthopedic

    cons%#tation orpossi"#e O-8F

    8dentiy and manage

    compartmentsyndrome

    http://www.wramc.amedd.army.mil/MainFrame.cfm
  • 8/10/2019 Dont Miss Ortho Injuries 2

    41/77

    Case >

    Pt is an *? y)o oot"a## p#ayer ho presents

    ith an an2#e sprain.

    Pt has considera"#e se##ing anddemonstrates more tenderness pro0ima# to

    the A1F< in the area o the A81F #igament.

    -adiographs are negati!e or ract%re.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    42/77

    Syndesmotic An2#e

    Sprain

  • 8/10/2019 Dont Miss Ortho Injuries 2

    43/77

    Epidemio#ogyAn2#e sprains are the most common #oer e0tremity

    in(%ry in sports medicine, and constit%te >@ o a##

    sports in(%ries.

    8n one series, syndesmotic in(%ries constit%ted *I @ oan2#e sprains.

    Syndesmotic in(%ries res%#t in #onger periods o

    disa"i#ity than standard #atera# an2#e sprains.

    Syndesmotic in(%ries are not %ncommon#y associated

    ith ract%res.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    44/77

    C#inica# Anatomy

    1he syndesmotic #igaments maintain

    sta"i#ity "eteen the dista# ti"ia and i"%#a

    Anterior ti"ioi"%#ar #igament Posterior ti"ioi"%#ar #igament

    1rans!erse ti"ioi"%#ar #igament

    interosseo%s #igament interosseo%s mem"rane

  • 8/10/2019 Dont Miss Ortho Injuries 2

    45/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    46/77

    C#inica# PresentationUs%a##y the patient cannot p%t eight %pon the

    #eg.

    Pain is #ocated anterior#y a#ong thesyndesmosis.

    Acti!e mo!ement o e0terna# rotation o the

    oot is pain%#.

    Positi!e S/%eeKe 1est

    Positi!e E0terna# -otation Stress 1est

  • 8/10/2019 Dont Miss Ortho Injuries 2

    47/77

    Diagnosis

    C#inica# diagnosismechanism o in(%ry

    corre#ati!e physica#

    e0amination

    -adiographic imaging

    assists in ris2 stratiying

  • 8/10/2019 Dont Miss Ortho Injuries 2

    48/77

    8magingOttaa An2#e -%#es: AP, #atera# and mortise

    !ies sho%#d "e o"tained: tenderness o!er the #atera# and media# ma##eo#%s

    %na"#e to "ear eight or o%r steps immediate#y

    or in the ED

    Syndesmosis -adiographic Criterion

    Mortise: media# c#ear space L ;mm

    AP: ti"ioi"%#ar o!er#ap *= mm

  • 8/10/2019 Dont Miss Ortho Injuries 2

    49/77

    1reatment

  • 8/10/2019 Dont Miss Ortho Injuries 2

    50/77

    Case +

    Pt is a 9> y)o physician)mother ho hi#e

    r%nning %p the stairs, noted a pain%# pop

    in!o#!ing the #atera# oot.

    On pa#pation, she has considera"#e

    tenderness o!er the pro0ima# ith

    metatarsa#.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    51/77

    Fith Metatarsa#

    Fract%re

  • 8/10/2019 Dont Miss Ortho Injuries 2

    52/77

    Epidemio#ogy

    1he most common#y ract%red metatarsa# is

    the ith.

    1hese ract%res may res%#t rom direct or

    indirect tra%ma.

    Pro0ima# ith metatarsa# ract%res,

    hoe!er, ha!e "een the s%"(ect oconsidera"#e de"ate and contro!ersy.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    53/77

    C#inica# Anatomy1he pro0ima# ith metatarsa# consists o the

    t%"erosity, "ase, and pro0ima# shat.1%"erosity is the site o attachment o the perone%s

    "re!is and #atera# "and o the p#antar ascia.1he metaphysea#6diaphysea# (%nction is a !asc%#ar

    atershed

    1he metaphysea#6diaphysea# (%nction inc#%des

    the (oint "eteen the "ase o the ;th and >th

    metatarsa#s.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    54/77

    Mechanism o 8n(%ry

    1%"erosity ract%res ha!e a mechanism o

    in(%ry compara"#e to an an2#e sprain

    An ac%te ract%re o the metaphysea#6

    diaphysea# (%nction 4ones5 occ%rs ith a

    orce%# add%ction orce hi#e the oot is

    p#antar#e0ed e.g. st%m"#ing and catchingonese#

  • 8/10/2019 Dont Miss Ortho Injuries 2

    55/77

    C#inica# Presentation

    Pain, se##ing and an ina"i#ity to "ear eight simi#ar

    to a moderate an2#e sprain.

    8n a t%"erosity ract%re there is pinpoint pain o!er the

    "ase o the ith metatarsa#

    8n an ac%te ones ract%re the pain is dista# to the

    t%"erosity at the ract%re site

    istory o prodroma# symptoms is important to r)o

    stress ract%re

  • 8/10/2019 Dont Miss Ortho Injuries 2

    56/77

    Diagnosis1org C#assiicationA. 1%"erosity a!%#sion ract%re

    . Fract%res ithin *.> cm o the t%"erosity

    Ac%te ones Fract%re 1ype *: ear#y

    1ype : de#ayed %nion

    1ype 9: non%nion

    Stress Fract%res

    1ype *: ear#y 1ype : de#ayed %nion

    1ype 9: non%nion

  • 8/10/2019 Dont Miss Ortho Injuries 2

    57/77

    8maging

    AP, #atera# and o"#i/%e radiographs

    A!%#sion ract%res are a#most

    a#ays trans!erse

    8n a ones ract%re the ract%re #ine

    is trans!erse and e0tends into the

    (oint "eteen the "ases o the ;thand >th metatarsa#s

  • 8/10/2019 Dont Miss Ortho Injuries 2

    58/77

    1reatment

    1%"erosity ract%res rare#y need reerra#,

    %n#ess disp#aced o!er 9mm. 8nitia##y treated

    in a irm6so#ed shoe, and transitioned to aS

  • 8/10/2019 Dont Miss Ortho Injuries 2

    59/77

    Case I

    Pt is a *I y)o oot"a## p#ayer ho comes

    into the %rgent care center comp#aining o

    persistent pain ater (amming his inger on atac2#e.

    e has pain o!er the dors%m o the midd#e

    pha#yn0 o the midd#e inger.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    60/77

    P8P 8n(%riesB1he ammed Finger

  • 8/10/2019 Dont Miss Ortho Injuries 2

    61/77

    Epidemio#ogy

    Potentia##y serio%s P8P (oint in(%ries are

    common#y misdiagnosed as a simp#e sprain

    or B(ammed ingerP8P dorsa# (oint dis#ocations are the most

    common #igamento%s in(%ries o the hand

    ypere0tension is the most commonmechanism, "%t a0ia# #oading and

    hyper#e0ion are can a#so occ%r.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    62/77

    C#inica# Anatomy1he P8P (oint is a

    concentric

    "icondy#ar hinge

    (oint

    Primary sta"i#iKers

    o the P8P (oint:

    co##atera# #igaments

    !o#ar p#ate

  • 8/10/2019 Dont Miss Ortho Injuries 2

    63/77

    Mechanism o 8n(%ry

    ypere0tension stress ith #ongit%dina#

    compression res%#ts in a dis#ocation

    Forced hyper#e0ion in(%ry to e0tended

    inger can r%pt%re the e0tensor tendon

    Dorsa# dis#ocations res%#t in in(%ry to the

    !o#ar p#ate

    o#ar dis#ocations in(%re the centra# s#ip

  • 8/10/2019 Dont Miss Ortho Injuries 2

    64/77

    C#inica# Presentationigh inde0 o s%spicion

    Mechanism o in(%ry

    O"ser!ation

    Care%# pa#pationSta"i#ity testing ater

    radiographs7 acti!e and

    passi!e

    Assess acti!e and passi!e

    range o motion

  • 8/10/2019 Dont Miss Ortho Injuries 2

    65/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    66/77

    8maging

    -adiographs sho%#d "e o"tained

    prior to attempting a red%ction1r%e #atera# and AP !ies ater a red%ction7 there sho%#d "e a

    concentric red%ction o the midd#e

    pha#yn0 on the pro0ima# pha#yn0

  • 8/10/2019 Dont Miss Ortho Injuries 2

    67/77

    1reatment Sta"#e dorsa# dis#ocation

    Sp#int or 9 ee2s in 9= degrees o #e0ion, o##oed "y"%ddy taping

    reer ract%re o!er 9=@ artic%#ar s%race

    Co##atera# #igament in(%ry"%ddy taping or 9 to ; ee2s

    reer #arge a!%#sion ract%res, disp#aced L mm orartic%#ar s%race L 9= @

    E0tensor mechanism in(%ry P8P sp#int %## e0tension or + to ? ee2s

  • 8/10/2019 Dont Miss Ortho Injuries 2

    68/77

    Case ?

    Pt is a 9= y)o ema#e ho presents to yo%r

    %rgent care center ith pain o!er the

    pro0ima# th%m", on the %#nar aspect o the

    "ase.

    She had a a## hi#e s2iing the day "eore.

  • 8/10/2019 Dont Miss Ortho Injuries 2

    69/77

    S2iers 1h%m"

  • 8/10/2019 Dont Miss Ortho Injuries 2

    70/77

  • 8/10/2019 Dont Miss Ortho Injuries 2

    71/77

    C#inica# Anatomy

    1he th%m" has a !o#ar p#ate and e##

    deined co##atera# #igaments.

    1he %ni/%e eat%re o this (oint is there#ationship o the UC< to the add%ctor

    apone%rosis 4AA5, ith the add%ctor

    tight#y o!er#ying the UC degrees on stresstesting

  • 8/10/2019 Dont Miss Ortho Injuries 2

    76/77

    1reatment

    Conser!ati!e !s. S%rgica#1reatment in a th%m" spica cast)sp#int or ; to +

    ee2s: nondisp#aced ract%re o pro0ima# pha#yn0

    no ract%re7 (oint sta"#e

    S%rgica# Cons%#tation disp#aced or %nsta"#e ract%re o pro0ima# pha#yn0

    %nsta"#e (oint7 Stener #esion

  • 8/10/2019 Dont Miss Ortho Injuries 2

    77/77


Top Related