orthopedics pda

8/3/2019 Orthopedics PDA

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2/12

History

identifying data chief complaint history of present illness

mechanism of injurydescription of pain: OPQRST (Onset, Provoking/Palliative factors,

Quality/Quantity, Radiation, Site, Timing)acute vs. chronic symptomsinflammatory symptoms morning stiffness, tenderness, swelling, warmth,

rednessdegenerative symptoms increased with activity, decreased with restmechanical symptoms locking, giving way (knee)constitutional symptoms: fever, chills, night sweats, fatigue, anorexia, weight losslifestyle effects/ADLsreferred symptoms: shoulder pain from heart or diaphragm, arm pain from

neck, leg pain from back, back pain from kidney, aortic aneurysm, duodenalulcer, pancreatitis

review of systems past medical history

orthopedic history: injuries, fractures, investigations (x-ray, CT, MRI), surgerycancer historyother: medical illnesses, surgeries

medication + allergies time of last meal and beverage (only if surgery is likely within next 24 hours)

Physical Examination

look: general observation of movement, SEADS feel: palpate soft tissue, bone and joint line for tenderness, temperature, deformity,

effusion and joint laxity move: active then passive range of movement (ROM) for affected joint(s) and joints

above and below, palpate for crepitus neurovascular tests

pulse (palpate, Doppler)sensation (fine touch, pinprick in dermatomal distribution)

reflexes (grade 0 ^ 4)

power (0 ^ 5) special tests: refer to each subsection


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Investigations

plain x-ray: anteroposterior (AP), lateral, oblique(s) CT: for bony anatomy not well visualized with x-ray MRI: soft tissue evaluation (meniscus, ligaments, tendons, intervertebral discs) arthrography: injection of radio-opaque dye into joint followed by x-ray, CT or MRI

(e.g. rotator cuff tear) nuclear medicine scan: nonspecific test to show areas of increased bony production

(tumour, fracture, infection)technetium (bone scan): osteoblastic activity and increased blood flowgallium: chronic inflammation and infection

fluoroscopy: real-time static or dynamic visualization (e.g. intraoperative fracturemanagement)

ultrasound: helps to identify cysts, rotator cuff tears, ligament injuries (requires skilledoperator)

myelography: injection of radio-opaque dye into epidural space to outline spinal cordand roots

aspiration: aspirate fluid from joint for analysis nerve studies

electromyelography (EMG): intramuscular needle electrodes to evaluate muscleunits

nerve conduction studies (NCS): latency suggests nerve abnormalities

Fractures General Principles


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Fracture Description

open versus closed (refer to Orthopedic Emergencies, OR5) neurovascular status location along the length of the bone

diaphysis (proximal 1/3, middle 1/3, distal 1/3)metaphysisepiphysis (extra-articular, intra-articular)

pattern of fracturetransverse high energy, direct forceoblique angular and rotational forcespiral rotational forcecomminuted (? 3 fragments) fracture

undisplaced versus displacedundisplaced no change in alignment or relationship of the bone on either side

of the fracturedisplaced

angulated described by apex; varus/valgus; or distal fragment translated described by percent of bone width and

direction rotated by clinical exam only shortened due to overlap or impaction


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Management of Fractures

airway, breathing, and circulation (ABCs), primary survey and secondary survey(ATLS protocol)

establish that the patient is stable rule out other fractures/injuries range of all joints is determined, ligaments are

stressed and neurovascular evaluations are performed rule out open fracture take an AMPLE history allergies, medications, past medical history, last meal,

events surrounding injury analgesia splint fracture to prevent further soft tissue injuries imaging reduction

closed reduction apply traction in the long axis of the limb reverse the mechanism that produced the fracture

indications for open reduction NO CAST (see side bar)other indications include

failed closed reduction cannot cast or apply traction due to site (hip fracture) pathologic fractures potential for improved function with open reduction with internal

fixation (ORIF)potential complications

infection non union implant failure new fracture

re-check neurovascular status after reduction stabilization

external stabilization splints; casts; traction, external fixator

internal stabilization percutaneous pinning; extramedullary fixation(screws, plates, wires); intramedullary fixation (rods)

post reduction imaging DVT prophylaxis (for pelvic and hip fractures) rehabilitation: to avoid joint stiffness

isometric exercises to avoid muscle atrophyROM for adjacent jointscontinuous passive movement (CPM) following rigid fixation of fracture

allows joint motion to prevent stiffness for intra-articular fracturesonce cast/splint removed and fracture healed ^ resistive muscle strengthening

follow-up: evaluate bone healing


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Fracture Healing

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 1. Stages of Bone Healing

Evaluation of Healing: Tests of Union clinical: no longer tender to palpation or angulation stress x-ray: trabeculae cross fracture site, visible callus bridging site

Fracture Complications

Table 1. Fracture Complications

Early Late

compartment syndrome* mal/nonunion

neurological injury avascular necrosis (AVN)

vascular injury osteomyelitis

infection heterotopic ossification (HO)

implant failure post-traumatic arthritis

reflex sympathetic dystrophy (RSD)

Local

fracture blisters

(vitamin C 500 mg QD may incidence)

sepsis

deep vein thrombosis (DVT)

pulmonary embolus (PE)

actue respiratory distress

syndrome (ARDS)

Systemic

hemorrhagic shock

* see Orthopedic Emergencies, OR7

Avascular Necrosis (AVN; Osteonecrosis)

Definition disruption of blood supply to bone resulting in ischemia occurs in bones extensively covered in cartilage which rely on intra-osseous blood

supply (femoral head) or in bones with a distal proximal blood supply (proximalpole of scaphoid, body of talus, femoral head)

Risk Factors steroid use chronic alcohol use post-traumatic fracture/dislocation septic arthritis sickle cell disease storage disease (e.g. Gauchers disease) dysbarism (Caissons disease the bends) idiopathic (Chandlers disease)


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Orthopedic Emergencies

Multiple Long Bone Fractures and

Unstable Pelvic Fracture

Etiology high energy trauma generally multiple lower extremity and/or pelvic fractures may be associated with spinal injuries or life threatening injuries

Clinical Presentation local swelling, tenderness, deformity of the hips and instability of the pelvis with

palpation

Investigations

routine views of pelvis: AP, inlet, outlet and Judet (Iliac oblique and obturator oblique)views, push-pull views to assess rotational and vertical instability(see Table 14 for classification of pelvic fractures)

x-ray AP and lateral of all long bones suspected to be injured

Management ABCs assess genitourinary injury (rectal exam/vaginal exam mandatory) external or internal fixation of all fractures

Complications hemorrhage life threatening acute respiratory distress syndrome (ARDS)

fat embolism syndrome pulmonary embolism bladder/bowel injury neurological damage obstetrical difficulties persistent sacro-iliac joint pain post-traumatic arthritis of the hip with acetabular fractures

Open Fracutre (Gustilo Classification)

Definition

fracture with communication with the external environment

Management if neurovascular status is impaired, reduce ASAP obtain culture and cover with sterile dressing tetanus inoculation IV antibiotics (Table 2) splint fracture (alleviates pain, prevents further tissue, nerve or vessel damage) NPO and prepare for OR operative irrigation and debridement within 6 hours to decrease risk of infection open reduction and stabilization of the fracture wound usually left open to drain


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re-examine, with possible repeat I&D in 48 hours and closure if appropriate

Complications osteomyelitis soft tissue damage neurovascular injury

blood loss nonunion


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Septic Joint

Etiology most commonly caused by S. aureus consider Neisseria gonorrhoreae in sexually active patients

most common route of infection is hematogenous

Clinical Presentation localized joint pain, erythema, warmth, swelling with pain on active and passive ROM,

inability to bear weight, fever

Investigations x-ray (to r/o osteomyelitis), ESR, WBC, blood cultures joint aspirate (WBC > 80,000 with > 90% neutrophils, protein level > 4.4 mg/dL;

glucose level


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Compartment Syndrome

Definition increased interstitial pressure in an anatomical compartment (forearm, calf) where

muscle and tissue are bounded by fascia and bone (fibro-osseous compartment) withlittle room for expansion

interstitial pressure exceeds capillary perfusion pressure leading to muscle necrosis(in 4-6h) and eventually nerve necrosis

Etiology intracompartmental: fracture (particularly tibial fractures, pediatric supracondylar

fractures, and forearm fractures), crush injury, revascularization extracompartmental: constrictive dressing (circumferential cast), circumferential burn

Physical Examination 5 Ps (see side bar)

Investigation compartment pressure monitoring (normal = 0 mmHg; urgent ? 30 mmHg or within

30 mmHg of diastolic BP)

Treatment remove constrictive dressings (casts, splints) elevate limb definitive treatment: fasciotomy to release compartments

Complications rhabdomyolysis, renal failure, Volkmanns ischemic contracture


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Cauda Equina Syndrome

Etiology most frequent cause is large central disc herniation

Clinical Presentation progressive neurological deficit presenting withsaddle anesthesiadecreased anal tone and reflexfecal incontinenceurinary retention

Managment emergency decompression will cause permanent urinary/bowel incontinence if

untreated

Hip Dislocation

reduce hip dislocations ASAP (ideally within 6 hours) to risk of AVN of the femoralhead

1. ANTERIOR HIP DISLOCATION (rare)

Etiology blow to knee with hip widely abducted

Clinical Features shortened, abducted, externally rotated limb

Treatment closed reduction under GA (Allis reduction maneuver) post-reduction CT to assess joint congruity

2. POSTERIOR HIP DISLOCATION

Mechanism severe force to knee with hip flexed and adducted (e.g. knee into dashboard in MVC)

Clinical Features shortened, adducted and internally rotated limb

Treatment closed reduction under GA (Bigelow maneuver) ORIF if unstable, intra-articular fragments or posterior wall fracture post-reduction CT to assess joint congruity and fractures traction x 6 weeks

3. CENTRAL HIP DISLOCATION

Etiology traumatic injury where femoral head is pushed through acetabulum toward pelvic

cavity


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COMPLICATIONS FOR ALL HIP DISLOCATIONS post-traumatic arthritis AVN fracture of femoral shaft or neck

sciatic nerve palsy in 25% (10% permanent) heterotopic ossification (HO) damage to femoral head

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