Orthopedics

Question 1

compartment syndrome

Answer 1

• Can occur in any extremity
  
  • Lower leg most common.
• Etiology is typically trauma related.
  
  • Crush injury
  • Fracture
  • External compression i.e. casts, splints, dressings.
  • Bleeding/hematoma
  • Burns
  • Positional – overdose found down.
• Pain out of proportion to injury
  
  • Be aware of the sedated or unconscious patient.
• 5 P’s:
  
  • Pain to passive stretch – BEST INDICATOR
  • Paresthesia
  • Pain
  • Peripheral pulses absent
  • Paralysis
• Compartment Pressure Measurement
  
  • To be done if inconclusive PE findings.
• If fracture present perform within 5cm of fx site.
• Anterior compartment: 1cm lateral to anterior tibia.
• Deep Posterior compartment: Posterior to medial portion of tibia point needle towards fibula.
• Lateral border: lateral entry to fibula
• Superficial Posterior: Middle of calf
• If pressures within 30mmHg of diastolic BP it is positive for compartment syndrome.
• Operate immediately
  
  • Call attending get scheduled for OR now
  • Diastolic BP 88, Intracompartment pressure 68.
    
    • 88 – 68 = 20mm Hg Compartment syndrome.
    • Emergency Fasciotomy of all 4 compartments
    • Take intraoperative pressures to confirm release.

Question 2

fasciotomy

Answer 2

• Technique:
• Dual medial and lateral incision 15-18cm in length
• Removal of necrotic tissue/muscle.
• Pack open with gauze
• F/U wound care is essential to prevent infection. Usually need wound vac and can do a delayed primary closure or skin graft.

Question 3

open fractures

Answer 3

• 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
• Apply external traction if needed.
• Start antibiotics per facility protocol. We use IV Tobramycin and Ancef.
• Give Tetanus if needed.
• Make pt. NPO, ask last meal.
• Call your attending.
• Don’t forget the XR

Question 4

neuro status

Answer 4

• Upper extremity
  
  • Know sensory and motor intervention.
  • Motor:
    
    • Radial Nerve- Extend elbow, supinate, and extend wrist and fingers.(wrist drop)
    • Ulnar Nerve- Flexion of 4^th &5^th fingers, and adductors. (Claw hand)
    • Medial Nerve- Pronation, flexes & abducts 1^st, 2^nd, 3^rd fingers. (Carpal Tunnel)
• Lower Extremity:
  
  • Motor:
    
    • Femoral Nerve- Extends knee, some hip flexion.
    • Superior Gluteal Nerve- Hip extension.
    • Sciatic/Tibial N. – Flexes knee, foot, & toes. (Must find during THA)
    • Deep Peroneal N.- Plantar flxion. (Foot Drop)
    • Superficial Peroneal N- eversion of foot .
  • Can you dorsiflex and plantarflex the big toe

Question 5

vascular compromise

Answer 5

• Check skin, pulses, capillary refill.
• Upper Ext- Radial and brachial if needed.
• Lower Ext.- Dorsalis Pedis and posterior tibial. Use Doppler if needed.
• Get CT angio of knee if posterior knee dislocation.

Question 6

dislocations

Answer 6

• Get them reduced then no longer an emergency.
• Typically need sedation or nerve block.
• If no n/v compromise get a XR first.
• ALWAYS get post reduction films.
• Check n/v post reduction

Question 7

septic joint

Answer 7

• Septic joint can happen in any joint. Most common in knee >50% of cases.
• Risk factors include elderly, immune compromised, RA, hx of joint replacement, IV Drug users.
• Can Cause significant cartilage damage within 8hrs, can lead to sepsis and death.
• Most common cause Staph Aureus.
• Don’t forget Neisseria Gonorrhea!
• Exam Findings
  
  • Pain in absence of trauma
  • Red, Hot, Swollen Joint.
  • Fevers, malaise, may appear toxic.
  • Inability to bear weight or tolerate passive ROM.
• Diagnostics
  
  • Labs:
    
    • WBC often elevated
    • ESR
    • CRP – Most helpful as it will rise within hours of infection.
  • Joint aspiration is study of choice.
    
    • Order Cell count w/ diff, gram stain, culture, crystals.
    • Concerning if joint fluid is cloudy and/or purulent.
    • WBC >40K, gram +, absence of crystals, +Cult confirms.
    • Whenever aspirating a joint use sterile technique.
• Treatment Septic Joint
  
  • IV Antibiotics immediately.
    
    • 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.
  • Needs to go to surgery ASAP.
    
    • Operative irrigation and drainage.
    • In presence of hardware be prepared to do revision surgery or staged procedure if necessary.

Question 8

cauda equina syndrome

Answer 8

• Caused by compression to nerve roots at the lumbosacral region.
• Causes: Disc herniation (most common), trauma/fx, tumor, epidural abscess or hematoma.
• Symptoms: Saddle numbness, bowel and bladder incontinence, impotence, bilateral leg pain, lower extremity weakness.
• Exam:
  
  • Muscle atrophy
  • Lower ext. weakness
  • Absence of pin prick sensation at perianal region.
  • Lack of rectal tone or voluntary contracture.
  • Lack of anal wink ;)
  • MRI is study of choice, to look for nerve compression.
• Treatment:
  
  • Emergent surgery to decompress nerve roots. Discectomy or laminectomy.
  • Best prognosis if done within 48hrs of onset.

Question 9

necrotizing fasciitis

Answer 9

• rapidly progressing cellulitis cases (hrs)
  
  • Risk Factors:
    
    • Immune compromised- Diabetes, AIDS, cancer.
    • IV Drug users or skin poppers.
    • Trauma to skin.
    • Obesity
    • Mortality rate 32%!
• Exam Findings:
  
  • Cellulitis progressing rapidly.
  • Severe pain out of proportion to exam.
  • Absence of trauma.
  • Skin erythema, ischemia, bullae, induration.
  • Subcutaneous air
• Treatment:
  
  • 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.

Question 10

ortho consult

Answer 10

• HPI: Date of injury, mechanism, complaint, last meal.
• PMH: Important to note heart dz, DM and how well controlled, immune suppressant illness.
• PSH: Any prior ortho surgeries in area of current issue. Especially important if a revision case.
• Meds: Blood thinners, immunosuppressant meds, Vit. D, Ca.
• Allergies:
• Social Hx: Tobacco use is the big one!, Also IV drug use, and alcoholism makes for high fall risk and poor compliance.
• Family Hx: Bleeding disorders, bad reactions to anesthesia.
• Exam
  
  • Vitals:
  • General:
  • Chest
  • Heart
  • Abdomen
  • Extremities: Stick to the one involved.
  • Imaging:
  • Labs :
  • Diagnosis:
  • Plan:
• Keys for Pre-op pt.
  
  • 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 to sign?
  • Has the rep been notified do you have the right equipment available?
  • Remember the side RIGHT or LEFT

Question 11

clavicle fx

Answer 11

• Young active adults
• XR: 2vw clavicle, standing/upright AP and cephalic tilt. Bilateral standing view to see shortening.
• <100% displaced –non-op
• 100% displacement, comminution, >2cm shortening, skin tenting. Surgical.
• Tx:
  
  • Non-op:
    
    • Sling for comfort, gentle ROM 2-4 weeks
    • Begin strength training at 6-8 weeks or when callus seen on XR.
  • Operative:
    
    • 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.

Question 12

proximal humerus fx

Answer 12

• Common low energy injury in elderly ground level fall.
• High energy injury for young adults.
  
  • Look for brachial plexus or axillary nerve injury.
  • Fracture dislocations
• Exam
  
  • Pain, swelling, ecchymosis shoulder, upper arm, and chest.
  • Neurological exam
  • XR: True AP, Scap Y, Axillary.
    
    • Humeral head position (valgus angulation is bad)
    • Greater tuberosity position.
  • CT scan for pre-op planning, intraarticular involvement, position uncertain.
• Treatment
  
  • Non-op:
    
    • 85% of cases
    • Minimally displaced surgical neck fx (part1,2,3)
    • Greater tuberocity fx <5mm displaced.
    • Poor surgical candidates
    • Ask about patients functional goals.
    • Sling/shoulder immobilizer.
  • Sarmiento brace/Coaptation brace
  • Hanging Arm cast
  • Early ROM- Pendulum swings within 2 weeks.
  • Greater tuberocity fxs no active abduction for 6 weeks
  • Dislocations no abduction/external rotation x8-12 weks
  • Increase AROM and WB at 6 weeks or when callus seen on XR.
  • PT very important to regain good functional outcome.

Question 13

humeral shaft fx

Answer 13

• Think about the RADIAL NERVE
• Describe fx: Spiral, oblique, transverse, comminuted.
• Proximal, Middle, or Distal third.

Question 14

holstein-lewis fx

Answer 14

• Spiral, distal third fx (Holstein-Lewis) most common radial nerve injury. 22%
• Radial Nerve Palsy: cannot extend wrist or fingers, pronates and extends elbow.
• Incidence 8-15% of cases.
• 85-90% return in 3 mos.
• Conservative Treatment – don’t need to know the numbers
  
  • <20° Anterior angulation
  • <30° Varus/valgus
  • <3cm Shortening
  • Initial splint/sling 7-10 days then Sarmiento brace 6-8 weeks.
  • When stable begin shoulder PROM, elbow AROM.
• Surgical Treatment
  
  • ORIF with plate
    
    • Anterolateral
      
      • Proximal third to midshaft fx.
      • Identify the radial N.
    • Posterior
      
      • Distal to middle third
• Surgical Treatment
  
  • Intramedullary Nail (IMN)
    
    • Typically antegrade
    • Higher incidence of shoulder pain.
    • Some believe higher incidence of nonunion.
    • Radial N. at risk with lateral to medial distal locking screw
    • Musculocutaneous N. with anterior to posterior

Question 15

distal humerus fx

Answer 15

• These can be complex
• Basic patterns:
  
  • Supracondylar
  • Single column (condyle)
  • Bicolumn
  • Coronal Shear
  • Prognosis isn’t great.
  • Most people only regain 75% ROM/strength.
  • Realistic ROM is 30-130°
• Exam
  
  • 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
  • Imaging:
    
    • AP/Lateral of humerus and forearm.
    • Oblique views of elbow helpful.
    • In complex fx CT scan with 3D recon good for surgical planning.
• Non-op reserved for nondisplaced fx
  
  • Most common seen in kids.
  • Immobilize in supination for lateral condyle fx
  • Immobilize in pronation for medial condyle fx.
• CRPP
  
  • Extra-articular fx
  • Non-fragmented
  • Common technique with kids
• ORIF
  
  • Displaced supracondylar fx
  • Intra-articular fx
  • Segmented displaced fx
  • For intra-articular involvement often need to do olecranon osteotomy
• Follow-up care
  
  • 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.

Question 16

terrible triad

Answer 16

• Elbow dislocation or LCL tear.
• Radial head or neck fx
• Coronoid fx
• Mechanism- fall on extended arm
• Treatment
  
  • 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.

Question 17

Monteggia fx

Answer 17

• Monteggia Fx
  
  • Proximal 1/3 ulna fx with radial head dislocation.
  • Most common in kids
  • Annular ligament tear associated with radial head dislocation.
• 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.

Question 18

Galeazzie fx

Answer 18

• Distal 1/3 Radius fx with distal ulna dislocation
• Associated with Distal Radio-Ulnar Joint (DRUJ) dislocation.
• Tx: Surgically fix the radius. Stabilize the ulna immobilized in supination for 6 weeks.

Question 19

both bone forearm fx

Answer 19

• 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 .
• Adults almost always need ORIF.
• Relatively high rate of non-union in adults.

Question 20

distal radius fx

Answer 20

• Collies Fx- Dorsal offset, MC, FOOSH
• Smith’s Fx- Volar tilt. Fall on a flexed hand.
• Treatment
  
  • No easy answer, lots of opinions out there.
  • General Guidelines for acceptable margins:
    
    • 5-20° dorsal angulation
    • Radial Inclination <5° change
    • <5mm Shortening
    • <2mm articular step off or split
  • Treat the patient not the fracture!
  • Attempt closed reduction unless severely comminuted, or intraarticular.
  • Fun procedure that is often successful.
• Closed Reduction Distal Radius
  
  • Hematoma block or conscious sedation.
  • Hang in finger traps for traction.
  • 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.
• Surgical treatment
  
  • 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.

Question 21

boxers fx

Answer 21

• Classic is 5^th or 4^th metacarpal fx.
• Usually caused by punching something you shouldn’t…which is everything in my opinion.
• Very common among Chico State students.

Question 22

metacarpal fx

Answer 22

• Acceptable angulation:
  
  • 5^th (pinky) finger- 40°
  • 4^th (ring) finger- 30°
  • 2^nd/3^rd (index/middle) fingers- 10-20°
  • Attempt reduction. Can try hematoma block if your nice.
  • Hang in finger traps and push back into position.
• Most are treated conservatively. Those that are operated on often have stiffness post-op.

Question 23

hip replacement

Answer 23

• Pathology:
  
  • Osteoarthritis (OA)
  • Fracture
  • Avascular Necrosis
  • Rheumatoid Arthritis (RA)

Question 24

total hip replacement (THA)

Answer 24

• Typically worked up over several years by joint specialist.
• Symptoms: progressive pain, “get up and go pain”, stiffness. Pain felt in groin and buttock.
• Fails conservative treatment:
  
  • NSAIDS, PT, Cortisone injections.
• This is an ELECTIVE surgery. Let the patient decide when they’re ready.
• Get medical clearance if comorbidities exist.
• Pt. should be as healthy as possible prior to surgery.
• Posterior approach :
  
  • Traditional, better for obese pts for wound healing.
  • Elderly with comorbidities d/t shorter surgery.
• Anterior approach:
  
  • Better for thin, active pts.
  • Less risk of dislocation post-op.
• Post-op Care
  
  • In hospital 1-3 nights.
  • WBAT day of surgery.
  • Drain in place 24-48hrs.
  • Blood thinners x3-12wks
  • F/U 2-3 weeks for wound check, staple removal.
  • PT/OT can start right away.
  • Posterior hip precautions:
    
    • No hip flexion >90° with internal rotation beyond midline x3 months
  • Anterior hip precautions:
    
    • No hyperextension of hip x 3 months.
    • Antibiotics recommended prior to dental procedures for life by AAOS.

Question 25

hip fractures

Answer 25

• High rate of mortality:
  
  • 20-30% in first year
  • Up to 50% in ppl >85yo
  • If medial circumflex A. is compromised can lead to AVN.
    
    • Think of this when seeing a traumatic hip dislocation as well.
    • Ruined Bo Jackson’s career.

Question 26

femoral neck fx ORIF

Answer 26

• Sliding Hip Screw/Dynamic hip screw (DHS)
• Similar criteria to cannulated screws, can also use for ND intertroch.
• Hemi-hip arthroplasty
  
  • Can consider in most elderly pts regardless of fx position.
  • Should be reserved for Garden III, IV in pts <85yo, or if AVN occurs after screw fixation fails.

Question 27

intertrochanteric fx

Answer 27

• Intermedullary Nail (IM)/ Cephalomedullary Nail.
  
  • MC now
• Plating- less common with the advancement in nails.

Question 28

femoral shaft fx

Answer 28

• High Energy fx.
  
  • Very painful
  • Muscles contract shortening the bone.
  • Can loose a lot of blood.1000-1500mL
  • Patterns: Transverse, oblique, spiral, comminuted.
• treament
  
  • Non-op: Rare for those with severe comorbidities who would not survive surgery.
    
    • Long leg cast NWB.
  • IM Nail
  • Flexible rods
  • Ex-Fix
  • Plate fixation
  • Intramedullary Nail
    
    • Antegrade IM Nail:
      
      • Enter superior trochanter.
    • Retrograde IM Nail:
      
      • Enter below the patella.
      • Better for bilateral fxs can do in supine.
      • Obese pts.
      • Distal component.
  • Flexible Rods
    
    • Only used for young children who’s growth plates have not fused.
    • Usually remove in 4-6 months.
    • Protected weight bearing with long leg cast.
  • External Fixation
    
    • Good to delay surgery if other injuries exist, or poor surgical candidate.
    • Will need ORIF in 2-3 weeks.
    • Place 2 pins above and below the fx site.
    • Check pin sites, risk for infection.
  • Femoral Plate
    
    • Used for severely comminuted fractures with multiple displaced fragments.
    • Peri-prosthetic fxs.
    • Large lateral incision or percutaneous.

Question 29

total knee arthroplasty (TKA)

Answer 29

• Pathology:
  
  • Osteoarthritis, post-traumatic arthritis, RA.
  • Knee weight bearing AP, Lat, posterior and sunrise XR.
  • Fail conservative management: NSAIDs, PT, bracing, cortisone injections, and viscous supplementation.
  • Knee Joint made up of 3 compartments: Medial, lateral, and patellofemoral.
• Types of knee replacements:
  
  • Total knee replacement MC
  • Unicompartmental knee replacement.
  • Patellofemoral knee replacement.
• Post-op
  
  • Inpatient 1-3 days
  • WBAT day of surgery
  • PT/OT to work on ROM right away.
  • Blood thinners 3-12wks
  • Expect a lot of pain and swelling for 1-3 weeks.
  • ROM goal +/- 20 degrees of pre-op motion.

Question 30

tibial plateau fx

Answer 30

• These can get ugly.
• Associated injuries: meniscal, LCL, MCL, ACL tear, compartment syndrome.
• XR: 4 vw knee.
• Often CT scan for surgery
• Non-op if completely nondisplaced, or poor sx candidate.
• Always NWB x12 weeks.

Question 31

tibial shaft fx

Answer 31

• Most common long bone fx.
• Common open fx
• Think about compartment syndrome.
• XR: AP/lat full length tib/fib views.
• Conservative tx:
  
  • Long leg cast followed by boot 4-8 weeks
  • Acceptable position:
  • <5° varus/valgus
  • <10° anterior/posterior
  • 50% Cortical apposition
  • <1cm shortening
  • <10° rotations malalignment.
• Tibial ORIF
  
  • IM Nail
  • Percutaneous plating
  • Flexible rids (kids)

Question 32

ankle fx

Answer 32

• Lateral Malleolus fx
• Medial Malleolus fx
• Bimalleolar fx
• Posterior Malleolus
• Syndesmosis injury
• XR: 4 view ankle, AP, Lat, Mortise and stress view.
  
  • Manual external rotation, with plantar flexion is ideal.
  • Hanging stress is what we do.
  • Evaluates congruency of syndesmosis and deltoid ligament.
  • Medial clear space should be no more than 4mm.
• Isolated lateral malleolus fx with <3mm displacement treat with walking cast/boot.
• If tibiotalar joint space widening must fix.
  
  • Transmalleolar screw fixation or tension band fixation.

Question 33

medial malleolus fx

Answer 33

• Non-op if nondisplaced or tip avulsion.
• WBAT if tip avulsion and ligaments intact.
• NWB if true med. Mal fx
• Check for swelling/blisters prior to surgery.
• ORIF
  
  • Lag screw fixation
  • Antiglide plate with screw fixation
  • NWB 6-8 weeks
    
    • Newer studies recommending early WB as soon as 2 weeks.
  • Early ROM advised

Question 34

Maisonneuve fx

Answer 34

• Medial malleolar fx, or syndesmosis disruption with associated proximal fibular fx.