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Orthopedics

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					                           Orthopedics

Always document joint above and below,
neurovascular, skin and compartments

Salter Fractures
    Epiphyseal plate is weaker than the supporting ligaments
Slipped
Above
Lower
Through
Ram




Salter V the worse

Recurrent Median Nerve

Boutoninere Deformity
   Central extensor slip disruption results in PIP flexion and DIP
     extension




Felon
Paronychia




Fight Bite Injuries

Herpetic Whitlow

Collar Button Abscess

Sporotrichosis
   Fungal infection with skip lesions
   Rx: Itraconazole




Gamekeeper’s Thumb
   Ulnar Collateral Ligament Strain
   RX-thumb spica splint

Mallet Finger
   Extensor tendon disruption
     Forced flexion of DIP
     Avulsion Fx of dorsal palate of distal phalanx
     Splint in Extension

Metacarpal Fracture (Neck)
   Boxer’s Fracture 5ht MCP

Metacarpal shaft Fractures
Accepted angulation
    Index 10%
    Long 20%
    Ring 30%
    Small 40%
    Usually index and long requires operative repair

Bennett’s Fracture
   Fracute at base of thumb
   Usually require ORIF

Rolando Fracture
   Like bennett’s but fractured in 3 places
   Usually require ORIF




Flexor Tenosynovitis
    Kanavel’s sign
        o Diffuse fusiform swelling
        o Hand held in flexion
        o Tenderness along sheath
        o Pain with extension
    Treatment- I AND D
Fingertip Injuries
    If exposed bone - bone will have to be trimed back

PIP dislocation
   Relocatated by axial traction, slight hyperextension and
     repositioning


Intrinsic Plus Splinting




Colles’ Fracture
     RX-closed reduction

Smith’s Fracture


Triquetrum fracture
    Most common dorsal chip fx of wrist




Scapholunate Dislocation
   Terry Thomas sign Letterman
Perilunate Dislocation
   Displacement of the capitate

Lunate Dislocation

Look for the 4 Cs to line up

High Pressure Injection Injury

Carpal tunnel Syndrome
     Entrapment of Medial Nerve
     +Phalen’s sign
     +Tinel test
     Treatment-Splint

DeQuervain’s Tenosynovitis
    +Finkelsteins test
    Treatment Splint

Galeazzi Fracture
   Fracture of distal radius and Radioulnar dislocation
   Ulnar Nerve injury can occur


Monteggia Fracture
   Fracture of proximal ulnar and radial head dislocation
   Radial Nerve injury can occur
     Galeazzi                       Monteggia
     MUGR (mugger)
     Monteggia fracture-dislocation: Ulnar
     Galeazzi fracture-dislocation: Radius

Essex-Lopresti Injury
        Radial head fracture with dislocation of distal RU joint with
          interosseous membrane disruption
        Severe wrist pain after FOOSH Mechanism
        RX-ORIF

Ulnar Nightstick Fracture
   Nondisplaced Fracture of ulnar shaft
   Complications include Missed Monteggia Fx and Radial Nerve
     Injury
   Rx-Splint if nondisplaced ORIF if displaced


Combined Radial and Ulnar Shaft fracture
   Takes a lot of force
   Beware of compartment syndrome
   Requires ORIF

Volkman’s Contracture
   Inadequate circulation in forearm
   Seen with elbow and forearm fxs and and tight cast

Nursemaid elbow
   Tear of annular ligament
     Xrays uneccessary
     Supinate arm and flex elbow –traditional
     Hyperpronation may work better – hold elbow at 90 degrees and
      hyperpronate wrist
         o Bek D et al. Pronation versus supination maneuvers for the reduction
            of ‘pulled elbow’: a randomized clinical trial European Journal of
            Emergency Medicine. 2009, 16(3), 135-8.
Olecranon Bursitis
   Avoid I and D aspirate instead

Epicondylitis
   Lateral (tennis)
   Medial (little league)

Elbow dislocations
    Majority are posterior
    Look for associated fx (medial epicodyle), nerve injuries (ulnar)
     and vascular injuries (brachial)

Radial head fracture
   Posterior fat pad always abnormal
   Classification:
        o I- nondisplaced
        o II- marginal displacement
        o III- Comminuted
        o IV-any above + elbow dislocation
   Rx
        o I & II-Sling early ROM
        o III & IV – Surgical

Supracondylar Fracture
   Most common occult fx in children
   Look for median nerve injury
   Other Complications: Brachial Artery Injury, Volkmans
     Contraction
   Anterior humeral line test-always perform to pick up subtle
     fractures
Proximal Humeral Fracture
   Majority nondisplaced when displaced Axillary nerve involved in
     1/3 of cases
  
Humeral Shaft Fractures
   6-15 % associated with radial nerve injuries
   Brachial artery rare
Anterior Shoulder Dislocation
   Look for axillary nerve injury
   Hill-Sachs Deformity (notch on posterior humeral head)
   Bankart’s lesion- labral tear leads to joint laxity




           External Rotation (Hennepin)
           Scapular manipulation

Posterior Shoulder Dislocation
      Look for light bulb sign ( humerus is internally rotated)
      Often occurs after seizure or electrical injury
      Rx=Reduce with traction-counter traction
Luxatio Erecta
      Rarest of dislocations <1%(I’ve never seen one); forearm
        locked over forehead ; anterior inferior dislocation in full
        extension
      Technique for reduction:




Clavicle Fracture
    Don’t use figure of 8: use sling
    Distal 1/3 managed surgically

Sternoclavicular Dislocation
    Look for associated injuries to great vessels
    CT chest
    IF in extremis can use towel clips
Humeral Fracture
   Mid Shaft and Proximal
   Rx with Sling

Rotator Cuff Injuries
   Older than 40
   
     (Supraspinatus, infraspinatus, and teres minor all insert on
     greater tuberosity; Subscapularis on lesser turbcle)
   with full tears cannot hold shoulder in abduction (drop test)
   MRI diagnostic

Thoraciac Outlet Syndrome
   Compression of the brachial plexus or subclavian artery or vein
     in the thoraciac outlet
   May be associated with a cervical rib
   Three types:
         o Neurologic (95%)
         o Venous
         o Arterial




     Dx- Elevate Arm Stress Test (EAST)
        o Raise arms above head and open and close for 3 minutes –
            positive if unable to complete test
        o Adson’s test – palpate pulse while patient turns head from
          side to side – only test arterial syndrome

Pelvic Fractures
   Most commonly occur with MVC and falls
   Types
        o I Avulsion
        o II Single Ring
        o III Double Ring
        o IV Acetbulum fx




Hip                                                   Fracture

     Intertrochanteric- seen in “younger” pt
     Femoral neck – seen with older patient
      CT or MRI if xrays negative and hip pain and cannot bear weight

Posterior hip dislocation
   Reduce ASAP (less than 6 hours)
   Complication AVN Femoral head

Legg-Calves-Perthes Disease
   Boys 4-8 with Limp
   AVN of femoral head
   May be bilateral
   Initial xrays may be negative




Slipped Capital Femoral Epiphysis
    Obese males 10-16
    Etiology is unknown
    X ray –melting Ice cream cone

                                                   Kline’s Line




Septic Arthritis

Transient Toxic Synovitis

Femur Fracture
Traumatic Myositis Ossificans

Osgood-Schlatter Disease
   Tibial apophysitis

Osteochondritis Dissecans
    Subchodral fx
    Usually adolescents
    Medial femur most common (others: talar dome, capitellum)
Patellar Dislocation

Quadriceps Tendon Rupture

Posterior Knee Dislocation
   associated with injury to popliteal artery
   If missed high amputation rate
   Peroneal Nerve Injury common

Tibial Plateau Fracture
    If lateral look for associated deep peroneal nerve injury-check 1st
      web space




Compartment Syndrome
     Most common is anterior compartment 2nd to Tibial fracture




      5 Ps Pain, Pallor, paresthesias, paralysis, pulselessness
     Use Stryker kit to measure pressure
     Injury >30 mm Hg
     Irreversible damage 4-6 hrs
     Treatment-fasciotomy

Gastrocnemius Rupture

Achilles Tendon Rupture
   Thompson test positive (Squeeze test)

Ankle Dislocation

Ankle Sprain

Ottawa Ankle Rules

Maisonneuve Fracture
   External rotation causes rupture of medial ligament complex
     (deltoid)
   Associated with proximal fibula fracture
   Always consider this with medial ankle sprains
Calcaneal Fracture
    Fall from a height
    Measure Bohler’s Angle




Fitfh Metatarsal Fracture
Lisfranc’s Injury

Tarsal Tunnel Injury

Morton’s Neuroma

Metatarsalgia

Plantar fasciitis

Sever’s Disease
   Apophysitis of Achilles Tendon Insertion

Osteomyelitis
   Trauma common precipitating event
   Plain films not helpful early (must loss 25% of bone to be seen
     on x-ray)
   ESR usually up
   Early DX –BONE SCAN

Organisms in Bone and Joint Infections
    Remember plastic = pseudomonas
Neonates       Group B Strep
IVDA           Pseudomonas
SSC            Salmonella, gram negatives
Foot Puncture   Psuedomonas
Cat Bites       Pasturella
Fresh Water Wounds Aeromonas
Diabetic        Polymicrobial
Human Bites     Eikenella corrodens, Staph, Strep
Reptile Bites   Salmonella

				
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posted:1/4/2013
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