Ortho Flashcards
Connaître les noms communs des fractures les + fréquentes
Début chap.42
Détailler le grade de Fracture de Gustillo et traitement/atb associés
Grades
Grade I: Wound less than 1 cm long, punctured from below
Grade II: Laceration 5 cm long; no contamination or crush; no excessive soft tissue loss, flaps, or avulsion
Grade III: Large laceration, associated contamination or crush; frequently includes a segmental fracture
IIIA: Involves extensive soft tissue stripping of bone
IIIB: Periosteal stripping has occurred
IIC: Major vascular injury present
Management
1.
Control hemorrhage in field with sterile pressure dressing after carefully removing gross debris (eg, wood, clothing, leaves).
2.
Splint without reduction, unless vascular compromise is present.
3.
Irrigate with saline, cover with saline-soaked sponges after arrival in the emergency department.
4.
Begin IV antibiotic prophylaxis, usually a first-generation cephalosporin for grade I, with the addition of an aminoglycoside for grades II and III. Ajout ampi ou PNC si blessure dans ferme (clostridium)
5.
Administration of tetanus prophylaxis, including tetanus immune globulin, for large crush wounds
Associé la fracture au nerf lésé
Nommer 10 causes de compartiment
Increased Compartment Content
Bleeding: lésion vasculaire, tr coagulation, A/C
Reperfusion post ischémie: pontage, post coro, embolectomie, post choc
Trauma: fx, convulsion
Utilisation muscles prolongées: exercise, convulsion, eclampsie, tétanie
Brûlures: thermiques, électriques
Chx ortho
Morsure serpent
Obstruction veineuse
Decreased Compartment Volume
Closure of fascial defects
Excessive traction on fractured limbs
Miscellaneous
Infiltrated infusion
Pressure transfusion
Leaky dialysis cannula
Muscle hypertrophy
Popliteal cyst
External Pressure
Tight casts, dressings, or air splints
Lying on limb
Nommer 10 compartiments pouvant être touchés
Lower Extremity
Leg
Anterior compartment
Lateral compartment
Deep posterior compartment
Superficial posterior compartment
Thigh
Quadriceps compartment
Buttock
Gluteal compartment
Upper Extremity
Hand
Interosseous compartment
Forearm
Dorsal compartment
Volar compartment
Arm
Deltoid compartment
Biceps compartment
Nommer 5 complications des fractures et 5 complications reliées à l’immobilité
Fractures
Hemorrhage
Vascular injuries
Nerve injuries
Compartment syndrome
Volkmann’s ischemic contracture
Avascular necrosis
Reflex dystrophy
Fat embolism syndrome
Immobility
Pneumonia
Deep venous thrombosis
Pulmonary embolism
Urinary tract infection
Wound infection
Decubitus ulcers
Muscle atrophy
Stress ulcers
L,aponévrose palmaire de la main est l’extension de quelle structure?
Le tendon du long palmaire
Nommer les muscles intrinsèques de la main
Éminence thénar: opposant pouce, abd, add, fléchisseur
Hypothénar: fléchisseur du 5e doigt, abd, opposant
4 lumbricaux: flexion MCP et extension IPP
3 interrosseux palmaires: add
4 interrosseux dorsaux : abd
Nommer les tendons extenseurs et les compartiments du poignet
Indications de consultation en plastie pour retrait CE dans main
•
Large or multiple foreign bodies
•
Evidence of tendon or neurovascular injury
•
Penetration of deep space of the hand, including deep palmar, thenar, and hypothenar space
•
Suspected joint penetration
•
Presence of fracture or bone penetration
•
Highly contaminated wound
•
Immune compromised patient
•
Lead foreign body
•
Liquid foreign body (eg, paint)
Dfn Jersey Finger
Tx: SOP
dfn mallet finger et tx
Tx:immobilisation en extension 10 deg pour 6-8 sem, consultation ortho/plastie en 7 jours
Décrire Seymour fracture
Décrivez l’angulation des fractures de la phalange proximale et moyenne (base et distale)
Prise en charge fx métacarpes
consult ortho pour tous sauf fx boxer (col du 5e méta)
Réduction - immobilisation position intrinsèque plus (extension poignet 30deg, MCP 90 et extension ipp, ipd)
Diaphyse, cible de : moins de 10º angulation dorsale doigts 2-3 et moins de 20º doigts 4-5 et pas de déformation en rotation
( doigts 2 à 5 = 10,20,30,40 deg)
Col: moins de 15º angulation dorsale doigts 2-3 et moins de 35º doigts 4 et 45 doigt 5
bennett vs rolando
Prise en charge subluxation/luxation IPP/IPD
IPD : rare, réduire, référer
IPP:
Dorsal and lateral dislocations should be immobilized in 20 to 30 degrees of flexion or with an extension block splint—dorsal splint allowing flexion but restricting extension—for 2 to 3 weeks, followed by active movement. Reduced volar dislocations should be splinted in full extension. Open or irreducible dislocations, unstable reductions, dislocations with volar plate avulsion and intraarticular fractures involving more than 30% of the joint surface should receive hand service referral.
Comment réduire subluxation dorsale MCP?
Hyperextension and longitudinal traction should be avoided because the volar plate of the MCP joint may become entrapped in the joint space. Rather, simple subluxed MCP joints should be reduced with the wrist in flexion, relaxing the flexor tendons, and applying direct dorsal pressure on the proximal phalanx. To stabilize, the hand should be splinted with 90 degrees of MCP joint flexion (see Fig 43.28). Hand service referral should be requested for complex dorsal and volar dislocations because both may require operative reduction for stabilization
Expliquer la lésion de stener
Associé à la lésion du ligament collatéral ulnaire du 1er MCP
Si lésion partielle - immobilisation spica 3 sem
Si lésion complète ou stener - immobilisation - référence
Prise en charge les lésion des tendons extenseurs selon les zones
Zone 1: mallet finger, immobilisation extension 6-8 sem, réparation si lésion ouverte, en chronique - déformation col de cygne ( par déplacement des bandes latérales vers l’aspect dorsal)
Zone 2: The central band inserts on the middle phalanx and the lateral bands extend to the base of the distal phalanx. Rarely, lacerations transecting all the tendons will produce a mallet deformity. Treatment options are similar to those for zone I injuries
Zone 3: cf autre question
Zone 4: réparation avec suture 5.0, rarement rétraction
Zone 5: lésion clenched fist ad preuve du contraire, exploration en SOP. Clavulin ou clinda + doxy/cipro/bactrim
Zone 6: réparation si facilement visible
Zone 7-8: référence en ortho/plastie
décrire la lésion des extenseurs zone 3
The Elson test may identify a central slip rupture; with the patient’s PIP joint in 90 degrees of flexion over the edge of a counter, the patient is asked to extend the middle phalanx actively. Weak extension with rigid DIP joint extension is suggestive of a central slip injury (Fig. 43. 37). Closed PIP joint injuries should be immobilized in extension, leaving the DIP joint free, with referral to a hand specialist
Identifier les zones des fléchisseurs a/n main
Expliquer comment tester fléchisseur profond et superficiel des doigts
Tx
Traitement: référence en plastie pour déterminer réparation immédiate ou retardée
Nommer les indications et CI de réimplantation après amputations
Indications
•
Multiple digits
•
Thumb
•
Wrist and forearm
•
Sharp amputations with minimal to moderate avulsion proximal to the elbow
•
Single digits amputated between PIP joint and DIP joint (distal to flexor digitorum superficialis [FDS] insertion)
•
All pediatric amputations
Contraindications
•
Amputations in unstable patients secondary to other life-threatening injuries
•
Multiple-level amputations
•
Self-inflicted amputations
•
Single-digit amputations proximal to FDS insertion
Nommer les zones du fingertips
Nommer les os du carpe
Nommer les 3 surfaces articulaires du radius a/n poignet
The radius has three articular surfaces at the wrist—radiocarpal joint, DRUJ, and an interface with the triangular fibrocartilage complex (TFCC), also known as the articular disk.
Avoir une vue d’ensemble des ligaments du poignet
Examen clinique des nerfs médian, radial, ulnaire
Bordures de la snuffbox anatomique
Radial: court extenseur du pouce et abd du pouce
ulnaire: long extenseur du pouce
Expliquer la position du radius et ulna distal en temps normal
Nommez les angles scapholunaire et capitolunaires normaux
Nommer 3 vues radiologiques du poignet additionnelles
Lésions possibles associes à une fx du pisiforme
The pisiform is unique in the carpus because it is the only sesamoid-like bone and attaches to the FCU tendon, articulating on its dorsal surface with the triquetrum. Although pisiform injuries are rare, occurring in less than 1% of all carpal fractures, given the important role of forming the lateral wall of Guyon’s canal, ulnar arterial damage and neurapraxias may be associated.
Décrire la dissociation scapholunaire ( stade 1)
Signe de Terry Tomas (gap > 2-3 mm) et signet ring sign ( anneau créé par scaphoid)
Décrire la luxation périlunaire, stade 2
et stade 3
Semi-lunaire aligné avec le radius mais capitatum luxé dorsalement
A stage III injury appears identical to a stage II injury but includes a dislocation of the triquetrum that is seen best on the PA view, with overlap of the triquetrum on the lunate or hamate. This injury may be associated with a volar triquetral fracture.
Décrire luxation lunaire stade 4
PA: semi-lunaire apparait triangulaire, piece of pie sign
latéral: lunaire luxé en antérieur, spilled cuptea sign
Décrire la fracture de Hutchinson ou du chauffeur
tx
Hutchinson’s fracture, or chauffeur’s fracture, is an intraarticular fracture of the radial styloid.
Tx: sugar tong splint - possible fixation chirurgicale selon stabilité et si atteinte ligaments périlunaires
Lésions DRUJ
Acute dislocation of the DRUJ can occur as an isolated injury, which is rare, or in association with a fracture to the distal radius (Colles’ fracture), radial diaphysis (Galeazzi’s fracture), or radial head (Essex-Lopresti injury)
This forcible rotation of the wrist causes disruption of the TFCC, the major stabilizer of the DRUJ, and may result in an associated avulsion fracture of the ulnar styloid.
With a dorsal dislocation of the ulna, the ulnar styloid appears more prominent than on the unaffected side, and significant pain and limitation of movement are noted on supination of the wrist. With a volar dislocation of the ulna, there is loss of the normal ulnar styloid prominence, with pain and limitation of movement on pronation. These characteristic clinical findings should alert the emergency clinician to the possibility of DRUJ disruption and prompt the appropriate investigations to confirm the presence or absence of injury.
Tunnel carpien
Contient 9 tendons (4 FDS, 4 FDP, long fléchisseur pouce) + nerf médian
conditions systémiques: grossesse, ménopause, rheumatoid arthritis, hypothyroidism, diabetes mellitus, renal failure, congestive heart failure, acromegaly, and collagen vascular diseases.
Décrire le syndrome d’intersection
clinically manifests with pain on the radial side of the wrist, approximately 4 to 8 cm proximal to the site of de Quervain’s disease.
Pathophysiologically, intersection syndrome occurs secondary to inflammation where the muscle bellies of the APL and EPB cross over the muscle bellies of the extensor carpi radialis longus and brevis proximal to the retinaculum.
Mêmes tendons pour DeQuervain
Nommer et décrire le contenu des 3 compartiments de l’avant-bras
Tx fracture Monteggia et Galeazzi
SOP
Décrire la lésion d’Essex-Lopresti
The Essex-Lopresti lesion, or longitudinal radioulnar disassociation, refers to an unstable forearm as a result of a triad of injuries to the radial head, disruption of the interosseous membrane, and violation of the DRUJ.
Référence en ortho
Connaître l’anatomie du coude
Fx diaphyse humérale
Tx non conservateur dans plus de 80% des cas
Hanging cast ou sugar tong
Attention R/O atteinte nerf radial
Fx supracondylienne
Surtout 5-10a, extension (98%) ou flexion
In children with extension-type supracondylar fractures, the arm is held at the side and has a characteristic S-shaped configuration, whereas with flexion-type supracondylar fractures, the forearm is supported with the opposite hand with the elbow flexed to 90 degrees. There may be anterior angulation of the sharp distal end of the proximal fragment into the antecubital fossa, which could injure the brachial artery and median nerve
The anterior interosseous nerve is the most commonly injured, followed by the radial, median, and ulnar nerves. Most deficits seen at the time of injury are neurapraxias that resolve with conservative management.
Sauf si flexion: nerf ulnaire + fréquent
Gartland classification
Type I: Minimal or no displacement
Type II: Displacement of the fracture but with the posterior cortex intact
Type IIA: No rotational component
Type IIB: Some rotational component
Type III: Displaced, no cortical contact
Type IIIA: No rotation of the fracture
Type IIIB: Rotation present
En extension:
Type 1: immobilisation coude 80deg, mobilisation après 3 sem
type 2: conservateur vs fixation percut
En lfexion:
In type I fracture, the periosteum is minimally displaced. These injuries do not need to be immobilized in extension. The elbow can be comfortably flexed and should be immobilized in a splint as with extension injuries. Type II and III injuries should be referred to an orthopedist immediately. Type II injuries are manipulated into extension and then either in a long arm cast or with percutaneous pins. Type III injuries are treated with closed reduction and percutaneous pinning but will require open reduction if closed reduction fails
Décrire les 2 lignes à faire sur une RX du coude
Fx condyles du coude
Latéral + fréquent
Fixation SOP si déplacement sup 2 mm
condyle latéral: immobilisation coude extension, supination
condyle médial: coude extension, pronation, poignet flexion
Tx fracture épicondyle médiale
For epicondylar fractures, if the fracture fragment is minimally displaced (<5 mm), treatment with a posterior splint is appropriate. To minimize distraction of the fragment by the forearm flexors, the elbow and wrist are flexed with the forearm pronated.
Fx épicondyle latérale: très très rare
Prise en charge fx olécrâne
Attention nerf ulnaire
Si fx non déplacée, immobilisation 45-90 deg flexion 3 sem
Si déplacement de plus de 2mm ou déplacement en flexion - SOP
Fx tête radiale
Types
Tx
Radial head fractures are classified into four types: type I, undisplaced fractures; type II, marginal fractures (involving <30% of the articular surface) with more than 2 mm displacement, including impaction or angulation; type III, comminuted fractures of the entire radial head; and type IV, any of the previous types with elbow dislocation
Tx types 1-2, exercises mobilisation après 2-3 jours. Référence en spécialité si ROM diminuée
3-4: ortho
Prise en charge luxation du coude
Attention nerf médian et artère brachiale
Réduction luxation postérieure: supination, flexion 30deg, traction en ligne, si non réussi, appliquer pression inférieure avec traction
Immobilisation avec attelle postérieure - éval ortho - mobilisation précoce si pas d’instabilité
Rupture du biceps
Rupture proximale du long chef - flexion demeure ok, car court chef compense, svt âge moyen, sportifs
Rupture distale a/n insertion au radius, associé à tendinite/IRC/DB/ atteinte inflammatoire, faiblesse flexion et supination
Nommer les ligaments de l’articulation acromioclaviculaire
Connaître les ligaments de l’articulation glénohumérale
Nommer les 3 types de fractures du 1/3 latéral de la clavicule
Nommer les conditions de référence en ortho pour fx clavicule / types de fx à risque de SOP
- atteinte neurovasculaire, étirement de la peau, interposition tiss mous
- Consultation en 72 hrs pour fx latérale type 2
- Fx comminutives ou déplacées du tiers moyen (plus de 18 mm raccourcissement)
FR non union: tabac, femme, âge avancé
Connaître la classification de base des fractures de l’humérus proximal
(1 part, 2 part… et classification anatomique)
Luxation sternoclaviculaire
3 grades
A grade I injury is a mild sprain of the sternoclavicular and costoclavicular ligaments.(immobilisation avec attelle, mobilisation rapide) A grade II injury is associated with subluxation of the joint (anterior or posterior) secondary to disruption of the sternoclavicular ligament and capsule. ( immobilisation avec attelle, ortho, hab 4-6 sem) Complete rupture of the sternoclavicular and costoclavicular ligaments results in a grade III injury (dislocation) - ortho, réduction fermée vs ouverte
Luxation postérieure : urgence, réduction en SOP préférable
Expliquer la classification des luxations acromioclaviculaires et son nom
Traitement
Rockwood:
- entorse
- AC
- AC + CC
puis PSI (postérieur, supérieur, inférieur)
distance coracoclaviculaire normale 11 à 13 mm
Tx : type 1-2, immobilisation avec attelle, reprise mvt lorsque dlr diminuée 1,2 sem
The management of type III injuries is variable, although most favor initial nonoperative management.4 Selected patients who are young, are serious athletes, have severe displacement (more than 2 cm), and perform repetitive overhead activities may be candidates for surgical intervention. Treatment of type III injuries in the ED should consist of sling immobilization and sports medicine or orthopedic referral. Type IV, V, and VI injuries require early surgical treatment
Luxation postérieure
Signe à la RX
Réduction
Lightbulb au RX
Réduction avec rotation interne et traction latérale ou Stimson
Immobilisation en rotation interne ou externe si possible
Différencier Bankart et Hill Sach’s
Hill Sach: fx par impaction a/n aspect postéro-latéral tête humérale
Positions de luxation postérieure glénohumérale
- Sous acromiale
- Sous glénoidienne
- souspineux
Nommer et décrire 7 méthodes de réduction de luxation d’épaule
Stimson: position ventrale, accrocher poids 10-15 livres au bras luxé, réduction après 20-30 minutes
Traction-contre traction: traction / contretraction avec bras en abduction
Rotation externe: amener bras en adduction, flexion coude 90deg, puis rotation externe lente (pas de traction
Cunningham: Adduct the affected arm to the body and place elbow in full flexion resting against operator’s shoulder. Operator then provides traction by placing their wrist on patient’s forearm while asking the patient to shrug shoulders superiorly and posteriorly. The operator adds massage down through the trapezius, deltoid, and the biceps muscles. This technique is targeted to relax muscles causing a dynamic obstruction.
Milch: amener bras en rotation externe et abd, si pas de réduction à 90 deg abd et 90deg rotation externe, appliquer traction sur humérus avec pression latérale et supérieure sur tête humérale
FARES: A variation of the Milch technique called FARES (FAst, REliable, and Safe). Move the limb anteriorly and posteriorly in small oscillating movements while continuing to apply traction and start slowly abducting the limb. Once the limb is abducted to 90 degrees, externally rotate the limb at the shoulder, with ongoing traction and oscillating anterior/ posterior movements. Continue to slowly abduct the limb past this position. Clunk! Reduction is usually achieved once the limb is abducted to 120 degrees.
Manipulation scapula: Apply traction (manual or hanging weights), and then manipulate the scapula by rotating the inferior tip medially and stabilizing the superior and medial edges with the opposite hand.
Complications luxation glénohumérale
Fracture
Bankart - Hill Sach
Récidive luxation
Lésion nerf axillaire
Rupture coiffe rotateur
Instabilité épaule
Décrire la luxation glénohumérale inférieure
Luxatio Erecta
Bras bloqué en abd 110-160deg, au RX - humérus parallèle à l’épine de la scapula
Réduction par traction-contretraction
Complications Fx tubérosité, lésion labrale, lésion nerf axillaire, thrombose/lacération artère axillaire, déchirure coiffe rotateurs
Discuter de la dissociation scapulothoracique
Dissociation complète du MS
Au RX, déplacement latéral > 1 cm de la scapula p/r côté opposé
Associated osseous injuries include acromioclavicular separation, displaced fractures of the clavicle, and dislocations of the SCJ. Vascular lesions (subclavian, axillary, or brachial vessels) have been reported in 64% to 100% of patients and severe neurologic injuries in 94%.
Nommer un signe au RX de déchirure de la coiffe des rotateurs
The normal distance from the superior aspect of the humerus to the undersurface of the acromion ranges from 7 to 14 mm. A distance of less than 6 mm is highly suggestive of a complete tear.
Nommer 2 tests à l’examen physique pour dx tendinite bicipitale
Yergason et speed
Rupture tendon biceps proximal
The normal distance from the superior aspect of the humerus to the undersurface of the acromion ranges from 7 to 14 mm. A distance of less than 6 mm is highly suggestive of a complete tear.
Nommer 6 indications d’imagerie lors dlr lombaire
History of malignancy
Fever with localized back pain
Back pain with history of intravenous (IV) drug use, recent tattoo, or bacterial source
New neurologic deficit (especially loss of bowel or bladder function or saddle anesthesia)
Direct trauma
Worsening pain after spinal surgery
Sudden onset of back pain in patients on anticoagulants
Recent spinal procedure, such as epidural injection
Connaître les ligaments du bassin
Expliquer la classification de Tile pour les fx du bassin
Type A: Stable, posterior arch intact; includes avulsion fractures, isolated iliac wing fracture, pubic rami fractures, minimally displaced ring fracture, and transverse fractures of the sacrum or coccyx.
Type B: Partially stable, incomplete disruption of the posterior arch; includes anteroposterior injuries (“open-book” fracture) and lateral compression injuries; may be unilateral or bilateral; these injuries are rotationally unstable but vertically stable.
Type C: Unstable, complete disruption of the posterior arch; includes iliac, sacroiliac, and vertical sacral injuries that result from vertical shearing forces; may be unilateral or bilateral. These injuries are both rotationally and vertically unstable.
Expliquer classification Young-Burgess
Anteroposterior Compression
I.
Symphysis diastasis <2.5 cm
II.
Symphysis diastasis >2.5 cm, sacrospinous and anterior sacroiliac ligament disruption, results in rotational instability
III.
Symphysis diastasis >2.5 cm, with complete disruption of the anterior and posterior sacroiliac ligament, results in complete rotational and vertical instability
Lateral Compression
I.
Sacral crush injury on ipsilateral side
II.
Sacral crush injury with disruption of posterior sacroiliac ligaments; iliac wing fracture may be present (crescent fracture); rotationally unstable
III.
Severe internal rotation of ipsilateral hemipelvis with external rotation of contralateral side (“windswept” pelvis), rotationally unstable
Vertical Shear
Vertical displacement of symphysis and sacroiliac joints resulting in complete rotational and vertical instability
Combined Mechanisms
Any combination of the aforementioned mechanisms
Fx transverse du sacrum
Simple transverse fractures at or below S4 are treated conservatively. Above S4, neurologic injuries are common, necessitating careful clinical evaluation and surgery when neurologic compromise is present.
Nommer les sites d’avulsion a/n bassin avec les muscles associés
Nommer 5 indices au RX de fracture de l’arc postérieur ( svt vertical shearing injuries)
Avulsion of L5 transverse process*
Avulsion of ischial spine*
Avulsion of lower lateral lip of the sacrum (sacrotuberous ligament)*
Displacement at the site of a pubic ramus fracture
Asymmetry or lack of definition of bone cortex at superior aspect of the sacral foramina
Décrire les types de fx du sacrum et la principale complication associée
Fracture transverse: n’implique pas “ pelvic ring” mais fx verticale oui
Nommer les 3 types de fx de l’acetabulum
Nommer les 3 comopartiments de la cuisse et les structures contenues dans chacun
Nommer 5 causes non traumatiques de nécrose avasculaire de la hanche
chronic corticosteroid therapy, chronic alcoholism, hemoglobinopathy (eg, sickle cell anemia), dysbarism, and chronic pancreatitis. AVN is an emerging complication associated with human immunodeficiency virus (HIV) infection
Traitement fx stress col fémoral
Treatment of stress fractures of the femoral neck is based on involvement of the compressive or tensile aspect.
Compressive-side fractures (médial) involving less than half of the cortex are inherently stable and can be treated conservatively with partial weight bearing with crutches.
Tension-side fractures (latéral) and compressive-side fractures involving more than half the cortex are considered unstable and at risk for displacement. These fractures should be treated operatively with screw fixation.
3 signes au RX de luxation hanche
Ligne Shenton
Position du petit trochanter ( luxation post/rotation interne/troch non visible)
Grosseur de la tête fémorale (luxation postérieure, apparait plus petite, plus grosse si luxation antérieure)
Techniques de réduction luxation postérieure hanche
Allis (réduction postérieure et obturateur)
To perform the Allis technique for reduction of posterior hip dislocation:
- Place the patient in the supine position, with the pelvis stabilized by an assistant.
- With the knee flexed, apply steady traction in line with the deformity.
- Slowly bring the hip to 90 degrees of flexion while applying steady upward traction and gentle rotation.
- Ask the assistant to push the greater trochanter forward toward the acetabulum.
- Once reduction has been achieved, bring the hip to the extended position while maintaining traction.
Stimson:
To perform Stimson’s technique for reduction of posterior hip dislocation:
- Place the patient in a prone position, with the leg hanging over the edge of the bed. The hip and knee are flexed at 90 degrees.
- Ask an assistant to stabilize the pelvis.
- Apply steady downward traction in line with the femur.
- Gently rotate the femoral head while the assistant pushes the greater trochanter anteriorly toward the acetabulum.
- Once reduction has been achieved, bring the hip to the extended position while maintaining traction
Captain Morgan
- With the patient supine on the stretcher in its lowest position, secure the pelvis to the stretcher with a bed sheet or strap. Place the strap over the ischial wings and pubic symphysis. This prevents you from lifting the patient off the bed and is more effective than having an assistant try to secure the pelvis.
- Stand at the side of the bed and place one foot up on the bed (like Captain Morgan standing on a rum barrel). If you need additional height, consider using a stable cardiopulmonary resuscitation (CPR) stool.
- Place the patient’s ipsilateral leg over your leg so that your knee is resting in his or her popliteal fossa.
- While holding the ankle in position with slight downward pressure, lift up with both legs to apply traction on the femur and reduce the hip.
- If traction alone does not work, use your hands to internally and externally rotate the leg to achieve the reduction
Whistler
1.
Start with the patient lying supine on the bed, and secure the patient’s hips to the bed, as for the Captain Morgan technique.
- Bend the contralateral leg so that the patient’s knee is flexed 90 degrees and the foot is on the bed.
- Bend the ipsilateral leg to the same position.
- Place your arm under the ipsilateral knee and rest it on top of the contralateral knee.
- Now rotate your body so that you are perpendicular to the patient and looking at his or her feet. This should cause you to squat a little.
- While holding the patient’s ipsilateral ankle with your other hand, slowly lift up with your legs, while keeping your arm straight and strong. This puts traction on the femur and should reduce the dislocation.
- If reduction is not achieved with traction alone, use your hand that is on the ankle to internally or externally rotate the leg to achieve the reduction.
Traction-contre traction avec pt en décubitus dorsal ( 1 strap autour genou, 1 autour aine/crête iliaque)
Technique réduction luxation antérieure hanche
To perform the technique for reduction of pubic dislocation:
- Place the patient in the supine position.
- Apply longitudinal traction in line with the deformity.
- Hyperextend and internally rotate the hip while an assistant applies downward pressure on the femoral head.
Nommer les 3 muscles insérés à la patte d’oie
Sartorius
Semi-tendineux
Gracilis
Nommer des complications retardées de la luxation du genou
TVP
Thrombose artérielle
Pseudoanévrysme
Ossification hétérotopique
compartiment (généralement précoce)
Décrire la fx de Segond
The avulsion occurs at the site of attachment of the lateral capsular ligament.
Most Segond fractures are caused by sports injuries; the mechanism is almost always knee flexion with excessive internal rotation and varus stress.
Fx épines intercondyliennes
Fosse intercondylienne antérieure: attache LCA et parties antérieure ménisques
Fosse post: attache LCP et parties post ménisques
Donc rupture LCA avec fx antérieure épine intercondylienne
Ostéochondrite disséquante
The disorder is found mainly in adolescents and results in partial or total separation of a segment of articular cartilage and subchondral bone from the underlying bone.
Atteint souvent la partie latérale du condyle médial
Signe au Rx de rupture du tendon de la patella
Patella alta (haute) may be sought on the lateral radiograph with use of a ratio of patellar length to patellar tendon length (Insall-Salvati ratio). If this ratio is less than 0.8, patella alta is present.
Tendinite du poplité
The popliteus is a small flat muscle that originates on the lateral femoral condyle and inserts on the posteromedial tibia, capsule, and lateral meniscus. It passes beneath the lateral head of the gastrocnemius
Functionally, it prevents external rotation of the tibia and withdraws the lateral meniscus during flexion to prevent impingement between the femur and tibia. A third function, along with the quadriceps and PCL, is to stabilize the knee by preventing forward displacement of the femur on the tibia.
The Webb test is performed with the patient supine and knee flexed to 90 degrees. The leg is rotated internally, and the patient is asked to resist the examiner’s attempt to rotate the leg externally. Reproduction of symptoms suggests the diagnosis.
Décrire les 4 compartiments de la jambe et les structures contenues dans chacun
The anterior compartment contains the tibialis anterior, long toe extensor muscles, anterior tibial artery, and deep peroneal nerve, which supplies sensation to the first web space of the foot.
The lateral compartment contains two muscles that evert the foot, the peroneus longus and brevis, and the superficial peroneal nerve, which supplies sensation to the dorsum of the foot.
The superficial posterior compartment contains the gastrocnemius, plantaris, and soleus muscles and sural nerve, which supplies the lateral side of the foot and distal calf.
The deep posterior compartment contains the tibialis posterior muscle, long toe flexor muscles, posterior tibial and peroneal arteries, and tibial nerve, which supplies sensation to the plantar aspect of the foot.
Nommer les 3 types de fx tubérosité tibiale
Décrire la fracture de Maisonneuve
This injury involves a medial ankle disruption (deltoid ligament tear or medial malleolar fracture), with complete tearing of the syndesmotic ligament joining the tibia and fibula and fracture of the proximal fibula. Consequently, the fibula floats free relative to the tibia, resulting in an unstable ankle mortise, for which surgical fixation is required. The possibility of this injury indicates the need for examination of the proximal fibula in all medial ankle injuries.
Réduction luxation tibiofibulaire proximale
reduction of an anterolateral dislocation can be accomplished in the ED by flexing the knee to 90 degrees, everting the ankle, and applying direct pressure to the head of the fibula. Orthopedic referral and immobilization of the knee for a minimum of 3 to 6 weeks are necessary after reduction. If closed reduction fails, the patient may require open reduction, with repair of the torn capsule ligaments and pinning.
Rupture plantaire grêle
The plantaris is a small variable muscle that originates at the lateral condyle of the femur and passes beneath the soleus to insert on the Achilles tendon. It is a feeble flexor of the knee and plantar flexor of the ankle joint, with little functional significance.
Attelle si douleur sévère, canne si moins sévère
Nommer et détailler les 4 groupes de tendons a/n cheville
The flexor retinaculum tethers the tendons of the tibialis posterior, digitorum longus, and flexor hallucis muscles behind the medial malleolus.
The peroneal retinaculum and tendon sheath tether the peroneus longus and brevis tendons behind the lateral malleolus.
The extensor retinaculum tethers the tendons of the tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius over the anterior aspect of the ankle.
Posteriorly, in the midline, lie the Achilles and plantaris tendons
Anatomie cheville
Évaluation mortaise au RX
Syndesmose A = clear space
Syndesmose B = overlap
Expliquer classification de Danis Weber
Weber A fractures involve inversion-adduction forces. Weber B fractures involve abduction forces. Weber C fractures involve eversion-abduction forces
Indication de référence en ortho pour fx cheville
Unimalleolar fractures
Displaced medial malleolar fracture
Medial malleolar fracture with lateral collateral ligament rupture
Displaced lateral malleolar fracture
Lateral malleolar fracture with deltoid ligament rupture
Lateral malleolar fracture with widened medial clear space
Unimalleolar fracture with syndesmotic diastasis
Fibula fracture at or proximal to the tibiotalar joint line
Displaced posterior malleolar fracture
Posterior malleolar fracture involving >25% of articular surface
All intraarticular fractures with an articular surface step deformity
All bimalleolar fractures
All trimalleolar fractures
All intraarticular fractures with step deformity
All open fractures
All pilon fractures
PEC fx cheville
Danis Weber A isolé (pas dlr en médial) : immobilisation 6-8 sem, pas MEC 3 sem
Weber C: atteinte médiale et syndesmose fréquente - ortho pour SOP
Weber B: 50% atteinte syndesmose, évaluation par ortho
Fx isolée malléole interne: pas MEC 3 sem - total 6-8 sem
Malléole postérieure
Treatment usually consists of casting for 6 weeks for nondisplaced fractures in which no associated injury or ankle instability is present CT is generally used to ensure anatomic reduction prior to conservative management. Fractures involving more than 25% of the tibial surface usually require open reduction and internal fixation (ORIF); however, this is an area of controversy, and displaced posterior malleolar fractures require orthopedics consultation.
Fx trimalléolaires: ortho/SOP
Fx bimalléolaires: controverse, éval ortho
Décrire la lésion de Maisonneuve
Quels muscles permettent la flexion plantaire en cas de rupture complète du tendon d’Achille?
Even in cases of complete Achilles tendon rupture, weak plantar flexion may still be possible because of the actions of the tibialis posterior, toe flexors, and peroneal muscles
Os et articulations du pied
Éversion et inversion a/n subtalaire
Add/Abd a/n midtarse
Anatomie du talus
Décrire une fx mineure du talus
Fx majeure du talus
Head: Their mechanism is a compressive force applied on a plantar-flexed foot and transmitted up through the talonavicular joint
Neck: dorsiflexion forcée - c.f. classification hawkins
Décrire classification hawkins des fx du col du talus
PEC fx talus
Neck: Type 1 fractures, which are nondisplaced, are the only talar neck fractures amenable to nonoperative treatment, which initially consists of 6 weeks of nonweightbearing in a cast. Close outpatient orthopedic follow-up is essential.40 Hawkins types 2 to 4 fractures or talar neck fractures with any displacement are managed surgically
Head + body: controversé, consultation ortho
Lésions ostéochondrales de la cheville
An osteochondral lesion should be considered in any patient with acute ligamentous ankle injury accompanied by gross edema and an effusion visible on plain radiographs. However, most osteochondral lesions are not diagnosed at the time of injury but present as persistent pain and effusions
Dfn luxation sous-talaire
Rupture ligament talo-calcanéum et talo-naviculaire. Luxation médiale plus fréquente (p/r ant/post/lat)
Comment calculer l’angle de Boehler?
Types de Lisfranc
Signes au RX de lisfranc
Anteroposterior View
Loss of alignment of the medial border of the second metatarsal with the middle cuneiform
Presence of a fleck sign from avulsion of the Lisfranc ligament
Diastasis > 2 mm between base of the first and second metatarsals
Compared to the uninjured foot: difference > 1 mm between base of the first and second metatarsals
Oblique View
Loss of alignment between the medial border of the fourth metatarsal and medial border of the cuboid
Lateral View
Loss of alignment between the plantar aspect of the fifth metatarsal and the medial cuneiform
Loss of dorsal alignment of tarsals with their respective metatarsals
Tx fx métatarses
most undisplaced metatarsal shaft fractures of the second through fifth metatarsals are treated with a below-knee walking cast or boot for 2 to 4 weeks. Although not strictly necessary, pain may necessitate a period of nonweightbearing.
Nondisplaced first metatarsal fractures should be treated with casting for 4 to 6 weeks.61 The patient should be nonweightbearing for at least the first 3 weeks, if not the entire period
Reduction should be considered in any metatarsal shaft fracture with more than 3 mm of displacement or 10 degrees of angulation. Closed reduction, with toe traps and countertraction at the ankle, is often successful. Non–weight-bearing casting for 4 to 6 weeks should follow
The indications for open reduction are controversial but generally include the presence of compartment syndrome, unstable fractures, open fractures, fractures that have failed closed reduction, and multiple fractures (fx déplacées 4e et 5e méta svt chirurgicales)
Tête / Col: plus svt déplacées et instables - chx + fréquente, si non déplacées, immobilisation 4-6 sem
Base 1 à 4: rare, penser à Lisfranc. Si non déplacé - immobilisation, déplacé Fixation
Fx base 5e méta
Zone 1: fx par avulsion bande latérale de l’aponévrose plantaire. Tx non chirurgical, botte de marche 3 sem
Zone 2 (Jones) minimalement 15 mm de l’extrémité proximale. Immobilisation 3 mois vs chx selon ortho
Zone 3: svt secondaire fx stress, immobilisation prolongée vs chx selon ortho
Fx phalanges d’orteils
Luxation MTP
Luxation IP
Non déplacées : buddy taping
Déplacées: réduction et buddy taping
Si déplacement persistant/rotation : fixation SOP
Fx intraarticulaires 1er orteil - svt fixation
Luxation MTP: réduction puis immobilisation avec botte de marche ou buddy taping avec attelle d’aluminium pour 3 sem
Luxation IP: si 1er orteil - botte marche 3 sem, si autres oreils buddy taping seulement
Nommer fx stress (MI) à haut risque de non union, malunion…
High-risk stress fractures often occur in bones with a vulnerable vascular supply. In the lower extremity, high-risk stress fractures include the femoral neck, anterior tibia, medial malleolus, navicular, proximal fifth metatarsal, and sesamoid bones.
Immobilisation requise et parfois chirurgie
Éléments pertinents à l’histoire et E/P en cas de douleur dorsolombaire
Historical Information
Recent significant trauma
History of cancer
Anticoagulant use
Intravenous drug use
History of prolonged glucocorticoid use
History of osteoporosis
History of abdominal aortic aneurysm
Patient > 50 yr
Unrelenting night or rest pain
Unexplained weight loss
Recent bacterial infection
Immunocompromised status
Failure to improve after 6 wk of conservative therapy
Physical Examination
Abnormal vital signs—hypotension, hypertension, tachycardia, fever
Unequal blood pressure readings in the upper extremities
Murmur of aortic insufficiency
Pulse deficit or circulatory compromise of the lower extremities
Pulsatile abdominal mass
Urinary retention
Urinary or stool incontinence
Loss of rectal sphincter tone
Severe or progressive neurologic deficit
Focal lower extremity weakness
New ataxia or difficulty walking
Acronyme pour rappel signes de douleur lombaire non organique
DORST—distraction, overreaction, regional disturbances, simulation tests, tenderness)
hard/soft vasculaire du genou
hard: pied moite/froid, absence pouls, hématome expansif, hémorragie pulsatile
soft: paresthésie, asymétrie pouls
Ratio Insall-Salvati
R = A/B: A(tendon rotule) / B (rotule)
inf 0.8: patella basse
sup 1.2 patella haute
Maladie Freiberg
NAV tête 2-3-4e méta
Nécrose avasculaire naviculaire (nom propre)
Kohler
