ortho Flashcards
MC location and mechanism of compartment syndrome
i. Can occur in any extremity
1. Lower leg most common.
any kind of fracture but most frequently you see it with a crush injury
other than crush injuries, what are common etiologies of compartment syndrome
- Crush injury
- Fracture
- External compression i.e. casts that are too tight, splints, dressings.
- Bleeding/hematoma
- Burns
- Positional – overdose found down.
what do we look for with compartment syndrome? what is the BEST indicator
1 –>PAIN TO PASSIVE STRETCH
b. Paresthesias (numbness or tingling in the extremity)
c. Pain
d. Peripheral pulses absent (very late finding)
e. Paralysis (late finding)
why is an absent peripheral pulse such a late finding
compartment pressures are usually not higher than blood pressure
gold standard for dx compartment syndrome
Gold standard Diagnostic: Compartment Pressure Measurement
DIAGNOSIS = If pressures within 30mmHg of diastolic BP it is positive for compartment syndrome.
what is the pathophys of compartment syndrome exactly
muscle encapsulated in fascia and the fasica can’t expand very much
too much swelling causes pressure push inward causing increased pressure on A/V/N and damage
what is the first step in the management of compartment syndrome
- Operate immediately
a. Call attending get scheduled for OR now
fasciotomy
how can you determine the pressure with comaprtment syndrome
- Diastolic BP 88, Intracompartment pressure 68.
a. 88 – 68 = 20mm Hg Compartment syndrome.
b. Emergency Fasciotomy of all 4 compartments
c. Take intraoperative pressures to confirm release.
initial management of open fracture (up to splinting)
- ER washout, remove any visible foreign material, and cover.
- Check and apply pressure if active bleeding.
- Check neurovascular distal to the fracture. If compromised reduce and recheck.
- Splint and then prep for OR
what else do you need to do with a open fracture
WHAT DO YOU NEED TO ASK
- Apply external traction if needed.
- Start antibiotics (tobramycin, ancef) per facility protocol. We use IV Tobramycin and Ancef.
- Give Tetanus if needed.
- Make pt. NEED TO ASK–> NPO, ask last meal.
- Call your attending.
- Don’t forget the XR
Radial Nerve does what (3)
Extend elbow
supinate
and extend wrist and fingers.(wrist drop)
ulnar nerve is responsible for (2)
Flexion of 4th &5th fingers,
and adductors. (Claw hand)
medial nerve is responsible for (3)
Pronation
flexes &
abducts 1st, 2nd, 3rd fingers. (Carpal Tunnel)
Femoral Nerve
Extends knee, some hip flexion.
Hip extension is governed by what nerve
Superior Gluteal Nerve-
Sciatic/Tibial N
Flexes knee, foot, & toes. (Must find during THA)
Deep Peroneal N
Plantar flexion. (Foot Drop)
eversion of foot.
v. Superficial Peroneal N-
how do you check for vascular compramise un UE, LE
- Check skin, pulses, and capillary refill.
- Upper Ext- Radial and brachial if needed.
- Lower Ext.- Dorsalis Pedis and posterior tibial. Use Doppler if needed.
what do you need with a posterior knee dislocation
- Get CT angio of knee if posterior knee dislocation** (to look for posterior tibial artery – complications from that being torn)
management of dislocations
i. Get them reduced then no longer an emergency.
1. Always get XR before reduction
if you have a fracture of the coronoid you need to know if it is from the reduction or occured before
(hill sach’s, fx the humoral head)
where do most septic joints occur
i. Septic joint can happen in any joint. Most common in knee >50% of cases.
RF for septic joints
Risk factors include elderly immune compromised RA hx of joint replacement IV Drug users.
complications of septic joint
iii. Can Cause significant cartilage damage within 8hrs, can lead to sepsis and death.
iv. Most common cause Staph Aureus.
common pathogens with septic joint
iv. Most common cause Staph Aureus.
v. Don’t forget Neisseria Gonorrhea! (in young adults, anyone who is sexually active)
exam findings with septic joint
- Pain in absence of trauma
- Red, Hot, Swollen Joint.
- Fevers, malaise, may appear toxic.
- Inability to bear weight or tolerate passive ROM.
can’t passively move the joint–> a lot of pain
work up for septic joint (what is the study of choice and 3 others)
- WBC often elevated
- ESR
- CRP
- Joint aspiration is study of choice.
why is CRP is helpful
Most helpful as it will rise within hours of infection. (rise the fastest and falls the fastest in response to inflammation)
WBC indicative of septic joint
• WBC >50K, gram +, absence of crystals, +Cult confirms.
If low white count and a bunch of crystals think
- If low white count and a bunch of crystals think about gout
Tx for septic joint
Empiric treatment based on risk factors. Remember staph Aureus is #1 cause but think Gonorrhea in young people.
MRSA in IVDU
Pseudomonas in immune compromised (HIV, elderly, etc.).
Needs to go to surgery ASAP!!
what is a huge complicating factor for septic joint management
a. Operative irrigation and drainage.
b. In presence of hardware be prepared to do revision surgery or staged procedure if necessary.
Hardware = magnet for bacteria
cauda equina is caused by (MC) and 4 others
i. Caused by compression to nerve roots at the lumbosacral region.
Disc herniation (most common)
but also trauma/fx tumor epidural abscess or hematoma.
sxs of cauda equina
Saddle numbness, bowel and bladder incontinence, impotence, bilateral leg pain, lower extremity weakness.
exam to rule out cauda equina
- Muscle atrophy
- Lower ext. weakness
- Absence of pin prick sensation at perianal region.
- Lack of rectal tone or voluntary contracture.
- Lack of anal wink ;)
study of choice for nerve compression
• MRI is study of choice, to look for nerve compression.
tx of cauda equina (best if done within ___)
Emergent surgery to decompress nerve roots. Discectomy or laminectomy.
Best prognosis if done within 48hrs of onset.
RF for neck fasc
- Immune compromised- Diabetes, AIDS, cancer.
- IV Drug users or skin poppers.
- Trauma to skin.
- Obesity
mortality rate with nec fasc
- Mortality rate 32%!
exam findings in nec fasc
- Cellulitis progressing rapidly. (“started last night and now it feels like my leg is on fire”) really quickly will see within hours (day or two max)
- Severe pain out of proportion to exam.
- Absence of trauma.
- Skin erythema, ischemia, bullae, induration (late findings)
- Subcutaneous air on XR (CLASSIC FINDING)
treatment of nec fasc
- Emergent surgery to radically excise area of necrosis
- Treat with broad based IV Antibiotics
- Will need multiple trips to OR for debridement and eventual closure.
- May result in amputation.
ortho HPI
Date of injury
mechanism
complaint
last meal. (have to NPO for at least 8 hours)
PMH ortho
Important to note heart dz
DM and how well controlled
immune suppressant illness.
PSH ortho
Any prior ortho surgeries in area of current issue
Especially important if a revision case.
MEDs Hx need to note for ortho
Blood thinners**, immunosuppressant meds, Vit. D, Ca.
PAIN MEDS
social hx need to note for ortho injury
Tobacco use is the big one!
Also IV drug use, and alcoholism makes for high fall risk and poor compliance.
why does tobacco use really impedes bone-healing?
Nicotine is a vasoconstrictor even down to the capillaries (the capillaries that supply your bones and tendons are really small so if you constrict those, you impede blood flow even more)
important family hx for ortho
Bleeding disorders, bad reactions to anesthesia.
PE ortho
Vitals general chest heart abdomen, extremities (stick to the one involved) imaging labs diagnosis plan
important pre OP steps
NPO status
Antibiotics if given
Blood thinners
What imaging has been done. Any further imaging needed?
Medically cleared? Need any more consults i.e. cardiology, pulmonology, hospitalist.
Is the patient consented do they need DPOA (Durable power of attorney) to sign?
Has the rep been notified do you have the right equipment available?
Remember the side RIGHT or LEFT
post op management of pt in clinic
- Check on pain, wounds, suture removal, weight bearing status, Range of motion (ROM), Immobilization (cast/brace). XR results
- Plan: PT, return to work, follow-up appointment.
who get’s clavicle fxs and what xrays do you want
i. Young active adults
XR:
2vw clavicle
standing/upright AP and cephalic tilt
Bilateral standing view to see shortening
when do you operate on a clavicle fx
iii. <100% displaced –non-op
iv. 100% displacement, comminution, >2cm shortening, skin tenting. Surgical.
non-op mngmt of clavicle fx
- Sling for comfort, gentle ROM 2-4 weeks
* Begin strength training at 6-8 weeks or when callus seen on XR.
operative clavicle fx managment
- Clavicle ORIF
- Wound care for 2 weeks
- Same limitations and progression of activity.
- 30% of cases need hardware removal 6-12mos after surgery due to irritation.
proximal humerus fx- who gets these
Common low energy injury in elderly ground level fall.
seen as high energy injury in young adults
what do you need to check with proximal humerus fx
- Look for brachial plexus or axillary nerve injury.
2. Fracture dislocations
exam for proximal humerus
- Pain, swelling, ecchymosis shoulder, upper arm, and chest.
- Neurological exam
xray for proximal humerus fx
- XR: True AP, Scap Y, Axillary.
Humeral head position (valgus angulation is bad)
Greater tuberosity position
might need a CT scan for pro op planning
how many proximal humerus fx are non-op
-who get’s non op treatment
- 85% of cases
- Minimally displaced surgical neck fx (part1,2,3)
- Greater tuberocity fx <5mm displaced.
- Poor surgical candidates
- Ask about patients functional goals.
non operative management for proximal huemrus fx
Sling/shoulder immobilizer.
Sarmiento brace/Coaptation brace - plastic device which squeezes the shoulder down
Hanging Arm cast-– big, bulky cast (used as a weight – it pulls the arm down and holds it out to length)
what are you concerned about with a humeral shaft fx
the radial nerve
radial nerve injury sxs
cannot extend wrist or fingers, pronates and extends elbow.
Can’t extend at the MCP joints but can extend the PIP and DIP joints (move the thumb)
Holstein-Lewis Fx
Spiral, distal third humerus fx (Holstein-Lewis) most common radial nerve injury. 22%
good thing is that it usually returns in a couple of months unless it is totally distracted
85-95% return in 3 mos
conservative treatment with a humeral fx
d. Initial splint/sling 7-10 days then Sarmiento brace 6-8 weeks.
e. When stable begin shoulder PROM, elbow AROM.
Sugar tong splint* Coaptation splint,*
ORIF W/ humeral fx
ORIF with plate
i. Anterolateral
1. Proximal third to midshaft fx.
2. Identify the radial N.
ii. Posterior
1. Distal to middle third
Intramedullary Nail (IMN) for humeral fx pros and cons
i. Typically antegrade
ii. Higher incidence of shoulder pain.
iii. Some believe higher incidence of nonunion.
iv. Radial N. at risk with lateral to medial distal locking screw
v. Musculocutaneous N. with anterior to posterior
distal humerus fx (4 types)
very complex
- Supracondylar
- Single column (condyle)
- Bicolumn
- Coronal Shear
what ROM limitations to you see with a distal humerus fx
Most people only regain 75% ROM/strength.
Realistic ROM is 30-130°
—->getting them out to extension is very rare
distal humerus fx exam needs to include
- Gross deformity and instability often seen.
- If seen AVOID ROM test due to possible neurovascular compromise.
- Check radial, ulnar, and median nerve.
- Distal pulses
- Monitor for forearm compartment syndrome
imagining needed for distal humerus fx
what XRAY views
when would a CT be indicated
- AP/Lateral of humerus and forearm.
- Oblique views of elbow helpful.
- In complex fx CT scan with 3D recon good for surgical planning.
nondisplaced supracondylar fx MC seen in
- Most common seen in kids.
- Immobilize in supination for lateral condyle fx
- Immobilize in pronation for medial condyle fx.
supracondylar- later fx Immobilize in
Immobilize in supination for lateral condyle fx
supracondylar-medial fx Immobilize in
pronation
CRPP would be utilized for what type of fx
Closed Reduction and Percutaneous Pinning
- Extra-articular fx
- Non-fragmented
- Common technique with kids
when would a ORIF be used for supracondylar
- Displaced supracondylar fx
- Intra-articular fx
- Segmented displaced fx
- For intra-articular involvement often need to do olecranon osteotomy
F/U for supracondylar fx
- Immobilization for 48hrs. Then passive, and active
assisted ROM for 6 weeks. - Begin progressive strengthening at 6 weeks
- If osteotomy, no active elbow extension for 6 weeks.
passive because you don’t want to displace the olecranon by pulling on the tendon
Terrible Triad
what is it and what is the MOA
i. Elbow dislocation or LCL tear.
ii. Radial head or neck fx
iii. Coronoid fx
fall on extended arm
TERRIBLE TRIAD TX
- Reduce the elbow, splint.
- Consider CT scan
- ORIF or arthroplasty of radial head. Coronoid ORIF, LCL reconstruction.
- Prognosis is often poor due to stiffness and instability.
Monteggia Fx
- Proximal 1/3 ulna fx with radial head dislocation.
Most common in kids
Monteggia Fx TX
- Non-op: MC with kids, if ulna can be reduced and radial head hold position in cast.
- Cast in supination
- Operative: Almost always in adults. Open, comminuted, or unstable fx.
Galeazzie Fx
Distal 1/3 Radius fx with distal ulna dislocation
2. Associated with Distal Radio-Ulnar Joint (DRUJ) dislocation.
Galeazzie TX
Tx: Surgically fix the radius. Stabilize the ulna immobilized in supination for 6 weeks.
Both bone forearm fx
what is important consideration in reduction
- Very common in kids, monkey bars are usually the culprit.
- Kids - can attempt closed reduction under sedation.
- Need to maintain the bow of the bones.
if they fuse can’t pronate or supinate
tx of forearm fx in adults
- Adults almost always need ORIF.
usually will get a plate on both (at least the ulna)
MC distal radius fx
Colles Fx-
Dorsal offset, MC, FOOSH
what is a smith’s
fall with hand flexed
ventral or Volar tilt. Fall on a flexed hand.
distal radial fx need to assess
- 5-20° dorsal angulation
- Radial Inclination <5° change
- <5mm Shortening
- <2mm articular step off or split
volar tilt - naturally 10 degree volar tilt so if it is back or flat you have an issue
how would you do a closed reduction distal radius
a. Hematoma block or conscious sedation.
b. Hang in finger traps for traction.
c. Hyperextend the wrist and pull distal portion up and over. Often feel and hear a crack.
Splint with plaster or fiberglass, with 3 point fixation mold
need to basically recreate fx and then pull up and over
need someone holding counter traction
surgical tx with distal radiation
usually if you can’t get a closed reduction
Volar Plate is MC.
Some cases need dorsal plate or both.
Kids may need perc pins or flexible rods.
With kids watch growth plate over time if fuses could develop ulnar positive wrist.
acceptable angulation of 5th finger
5th (pinky) finger- 40°
i. Can tolerate 60 degree angulation
acceptable angulation of 4th finger
4th (ring) finger- 30°
acceptable angulation of 2nd and 3rd finger
c. 2nd/3rd (index/middle) fingers- 10-20°
tx of boxer’s fx
d. Attempt reduction. Can try hematoma block if you’re nice.
e. Hang in finger traps and push back into position.
hematoma block (done breaks and htere is blood if you get blood you are in the right spot)
10ccs of lidocaine
more effective in fresh fxs
easy in radius wiht step off
highest rate of mortality for hip fxs in this age group
- 20-30% in first year
2. Up to 50% in ppl >85yo
artery that we are worried about with hip fx
If medial circumflex A. is compromised can lead to AVN.
wraps around the neck
types of hip fx
- Femoral head fx – very rare
- Femoral neck fx
- Intertrochanteric hip fx
- Subtrochanteric hip fx
femoral neck fx managemnet
non-displaced–> screws
can still have risk of AVN
displaced at risk for AVN
—> Hemi-hip arthroplasty (partial hip replacement because you’re just replacing the head not the cup )
Intertrochanteric hip fx mangment
Sliding Hip Screw/ Dynamic hip screw
or if unstable
Intramedullary Nail/ Cephalomedullary Nail.
Intramedullary Nail for femur fx pros and cons
Antegrade IM Nail:
Enter superior trochanter.
Retrograde IM Nail:
better for obese
common mngmt of femur fxs in children
Flexible Rods
External Fixation -when would we use this for the tx of a femur fx
Good to delay surgery if other injuries exist, or poor surgical candidate.
important tibial fx managment pearl
- Non-op if completely nondisplaced, or poor sx candidate.
6. Always NWB x12 weeks.
associated injuries with tibial fx
- Associated injuries: meniscal, LCL, MCL, ACL tear, compartment syndrome.
- Think about compartment syndrome.
conservative and surgical treatment of tibial plateau lecture
Conservative tx:
Long leg cast followed by boot 4-8 weeks
Tibial ORIF
i. IM Nail ii. Percutaneous plating iii. Flexible rids (kids)
Medial Malleolus fx- when would it be NWB
- NWB if true med. Mal fxWBAT if tip avulsion and ligaments intact.
If tibiotalar joint space widening with lateral mal fx
a. Transmalleolar screw fixation or tension band fixation.
Isolated lateral malleolus fx with <3mm tx with
Isolated lateral malleolus fx with <3mm displacement treat with walking cast/boot.
a. NWB for 6-8 weeks
Maisonneuve Fracture
Medial malleolar fx, or syndesmosis disruption with associated proximal fibular fx.
how to rule out Maisonneuve Fracture
get a knee xray
