Orthopaedic Critical Concepts
What Every MD Should Know
LSU School of Medicine
2014-2015
Topics to Be Covered….
 The Language of Orthopaedics
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Xrays & Common Fractures/Dislocations
 Orthopaedic Trauma
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Pelvic fractures
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Open fractures
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Compartment syndrome
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Dislocations
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Amputations/replants
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Spine injuries
 Septic arthritis
 Pediatric ortho considerations
What is a Fracture?
• Complete or incomplete break in a bone
• Can be caused by single high-intensity event
• Repetitive low-intensity fatigue
– Stress fracture
– Insufficiency fracture
How to describe fractures
• Which bone?
• Closed or Open (Compound)
• Where on the bone?
– Intraarticular/extraarticular
– Proximal, midshaft, distal
How to describe fractures
• Description of fracture line/lines
– Transverse/Oblique/Spiral
– Comminuted/Segmental
• Displacement
– Angulation
– Translation
– Length
Joint Injuries
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Dislocations/Subluxations
Open/Closed
Direction of displacement
Fracture-dislocations
Imaging
• Xrays
– Out of splint
– Joint above & below injury
– Contralateral films if needed for comparison
• When to CT?
– Intraarticular injuries, bony injuries
• When to MRI?
– R/o occult fractures, ligamentous/soft tissue, infxn
H&P is essential
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Mechanism of injury
Timing of injury
DON’T FEED OPEN FXS, DISLOCATIONS, ETC.
Look for swelling, deformity, ecchymosis,
lacerations.
• Localize tenderness
• Painful range of motion/
torque/loading
XRAYS & COMMON INJURIES
Shoulder
Shoulder
Elbow
Clavicle Fracture
Proximal Humerus Fracture
Different from this!
Humeral Shaft Fracture
Radial Head Fracture
Olecranon Fracture
Monteggia Fracture
Galeazzi Fracture
Distal Radius Fracture
Different from this distal radius fracture
Gilula’s arcs
Scaphoid Fracture Thumb Spica splint
Boxer’s Fracture  Ulnar gutter splint
Femoral Neck Fracture
80y patient?
25y patient?
Femur Fracture 
Can lose 1 L of blood into thigh
Patella Fracture 
Knee Immobilizer
Tibial Plateau Fracture 
CT Scan
Maisonneuve Fracture  Need full tib/fib views
Tibial Shaft Fracture  Beware of Compartment Syndrome
Ankle Fracture
Vs.
Pilon Fracture
5th MT avulsion
fracture
Different treatments for
each zone of injury
because of varying
etiology of injury/
rates of healing
Ankle Fracture Dislocation 
Needs immediate reduction
Some commonly missed injuries
Scapholunate Injury
Lunate Dislocation
Perilunate Dislocation
Lisfranc Sprain / Fracture
Non-Wt Bearing AP
Wt Bearing AP
Hip dislocation
Orthopaedic Trauma Emergencies
Basic Principles
 A(c)BCs always first, DE
 Circulation- pulse & bleeding
 Control any obvious external hemorrhage
 Secondary Survey
 Trauma series xray vs. CT scan
 Extremities
 Alignment, crepitus, contusions, open wounds
 Pelvic sheet/binder
 Restore alignment/perfusion
 Wound care
 Immobilization: splints/traction
Pelvic Fractures
Epidemiology of Pelvic Fractures
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10% of blunt trauma patients have pelvic fx
Mortality 14-50%
Usual causes- intracranial, intraabdominal
One large series only 12% of death due
directly to pelvic hemorrhage (Mucha, et al 1984)
• Associated injuries very common
- Bladder, urethra
- Head injury
- Long bone fracture
- Chest injuries
- Liver/spleen/abd
These patterns bleed!
These don’t
Emergency Management
• ATLS, ABCDE
• Secondary Survey- focused H&P
– AMPLE (All, Meds, PMH, Last PO, Event)
– Wounds? Continuous bleeding?
• Open pelvic fxshigh mortality
• Vaginal & rectal exams
– Blood at meatus/introitus, high-riding prostate,
scrotal hematoma bladder/urethral injury
Open Pelvic Fx
Closed degloving injuries
• Known as Morel-Lavallee lesion
• Commonly over greater trochanter
Pelvis Fracture Physical Exam
• Stability of the pelvis in AP & Lateral compression
• ONE EXAM ONLY – Do not repeatedly disrupt clot!
• Neurologic Exam
– 10-15% neurologic injury in pelvic trauma
– 30-40% in posteriorly unstable fractures
Sample treatment algorithm
Pelvic Sheet
Sheet stabilization
Routt, JOT
Keep sheet low—around greater trochanters
Pelvic embolization/angio
- Obturator, pudendal arteries with LC injuries
- Superior Gluteal Artery with posterior injuries
Open Fractures
• A break in the skin and soft
tissues communicating
with a fracture or its
hematoma
• A wound near a fracture is
a presumed open fracture!
• Start antibiotics ASAP
• Tetanus status
• Needs I&D ASAP
Antibiotics for open fractures
• Grade I
– Poke hole, ≤ 1 cm
– Cephalosporin
• Grade II
– Moderate injury, sufficient soft
tissue, min comminution
– Cephalosporin + aminoglycoside
• Grade III
– These are the bad ones
– cephalosporin + aminoglycoside
+/- penicillin (farm, vascular inj)
Assessment
• History
– Mechanism: high vs low energy
– Time since injury
– PMH/comorbidities
• Physical
– ONE LOOK! (19% vs 4% infxn)
– Neurovascular status
– Compartments
Initial Management
• ATLS, stabilize the patient
• Imaging
– Xrays, 2 orthogonal views
– Joint above and below fracture
• One look exam
– Remove gross debris, irrigate 1-2L, sterile betadine
dressing
• Realign/splint
– ↓ soft tissue tension, ↓ further soft tissue
damage, ↓ dead space, improve circulation
Bacteriology of Open Fractures
Blunt Trauma, Low Energy GSW
Staph, Strep
Farm Wounds
Clostridia
Fresh Water
Pseudomonas, Aeromonas
Sea Water
Aeromonas, Vibrios
War Wounds, High Energy GSW
Gram Negative
Treatment
• Continue antibiotics
• Irrigation
– 6-10L saline
• Debridement
– Decrease contamination
– Remove devitalized tissues
• Stabilization of fracture
– Protect soft tissues
– Restoration of alignment
Compartment Syndrome
• Volkmann described in 1881
– Irreversible hand contractures 2/2 forearm
ischemia
– Constrictive dressings to injured limb
• Elevated tissue pressure within a closed
fascial space
• Reduced tissue perfusion  ischemia cell
death  necrosis
• True Orthopaedic Emergency
Compartment Syndrome Etiology
Compartment Size
• Tight dressing, bandage or cast
• Local external pressurelying on limb
• Closure of fascial defects
Compartment Content
• Bleeding: Fx, vascular inj, bleeding disorders
• ↑ Capillary Permeability
– Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection
/ IVF extravasation / injection injury
Diff Dx: arterial occlusion, nerve injury, muscle
rupture
Compartment Syndrome
Tissue Survival
• Muscle
– 3-4 hours - reversible changes
– 6 hours - variable damage
– 8 hours - irreversible changes
• Nerve
– 2 hours - loses nerve conduction
– 4 hours - neuropraxia
– 8 hours - irreversible changes
Compartment Syndrome
Diagnosis
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Pain out of proportion
Palpably tense compartment
Pain with passive stretch
Paresthesia/hypoesthesia
Paralysis
Pulselessness/pallor
Clinical Evaluation
• Beware of epidural analgesia
• Strecker JBJS 1986, Morrow J. Trauma 1994
• Beware long acting nerve blocks
• Hyder JBJS Br 1995
• Beware intravenous opiate analgesia
• Kids: increasing pain medication requirement
• ? Pressure measurements ?
Initial/emergent management
• Loosen and/or remove cast or dressing
• Place at level of heart
(DO NOT ELEVATE above to optimize perfusion)
• Alert OR and Anesthesia
• Bedside procedure in emergent situations
• Get to OR ASAP!
Surgical Treatment
• Fasciotomy- release of all involved compartments
• Reliable, safe, effective if done in time
• Stabilize fractures as needed
Compartment Syndrome Sites
• Can occur anywhere in the body
• Most common in lower leg
• Forearm
• Thigh
• Hand
• Foot
• Arm
• Buttock
• Abdominal - >Trauma surgeons
Dislocations
• Reduce ASAP
– Protect the soft tissue, improve neurovascular status
– Time dislocated may make reduction more difficult
• Irreducible joints
– May need better anesthesia/OR
• Fracture dislocations, Iatrogenic injuries
– Beware of displacing nondisplaced fractures
• Native Hip dislocations
– Orthopaedic emergency  osteonecrosis
Iatrogenic Fracture
Attempted shoulder reduction
Amputations/Replants
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Thumbs
Multi-digit
Child
Distal to FDS, proximal to DIP
Metacarpal, wrist, forearm
Gently clean part, wrap in gauze, place in
plastic bag, place bag on ice
• DO NOT PUT PART DIRECTLY ON ICE
Spine Trauma
Spine Trauma In the Field
• Mechanism with potential for cervical spine injury?
 C-collar, backboard w straps on scene
• Roll/transport using logroll precautions with control
of C-spine
• Athletes: Leave helmet/shoulder pads on, cut or
remove facemask
• Motorcyclist: Take helmet off
Spine Trauma
• No need for C-spine films in awake, alert, nonintoxicated patient without neck pain or midline
tenderness without distracting injury.
• Avoid SBPs <90 after SCI, maintain MAPs ~90 x 1 wk.
• More evidence for complications from
methylprednisolone admin than for clinical benefit
• ~60% of Cspine fx pts have other injuries: 34% head
& neck, 17% intrathoracic, 10% intraabd/pelvic, 30%
nonspine orthopaedic
• Up to 20% of spine fx pts have a noncontinugous
spine injury
Neurogenic versus Spinal Shock
• Hypotension & brady
• Can be fatal
• Loss of sympathetic
tonecirculatory
collapse
• Tx: careful fluid mgmt,
pressors PRN
• Temp loss of function &
reflexes below SCI
• Flaccid areflexive paralysis
• Hypotension & brady
• Absent bulbocavernosus
reflex
• Usually resolves w/in 48⁰
• After? Spasticity,
hyperreflexia, clonus
Bulbocavernosus Reflex
• Squeeze of glans penis or tug on foley
contraction of anal sphincter
• Absence implies spinal shock
• Return indicates end of spinal shock
• Conus or cauda injury can cause permanent
loss
Septic Arthritis
Etiology of Septic Arthritis
• Hematogenous seeding
• Distant infection, IVDA, surgery, dental work
• Direct inoculation
• Penetrating trauma, joint aspiration/injection
• Contiguous spread
• cellulitis, septic bursitis, tenosynovitis,
osteomyelitis
Risk Factors
• Remote focus
• URI, UTI, pneumonia, skin ulcers/skin infection
• Systemic illness
– RA, DM, SLE, malignancy
• Prior joint surgery
• Pre-existing joint disease
– DJD, RA, PTA, Gout, CPPD, osteonecrosis
• Immunosuppression
• steroids, chemotherapy, elderly age
Kaandorp CJ et al: Arthritis Rheum, 38:1819, 1993
Animal Models of Septic Arthritis
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Day 2:
Day 5:
Day 7:
Day 11:
Day 17:
Day 35:
clinical symptoms pronounced
GAG depletion
cartilage softening/fissuring
pannus overgrowth
joint capsule erosion
fibrosis/joint destruction
Anatomic Locations
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Knee
40-50%
Hip
20-25%
Shoulder
10-15%
Elbow
<10%
Wrist
<10%
Ankle
<10%
Sternoclavicular, SI, Manubriosternal
Micro-Organisms
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S. aureus >40%, MRSA, Staph. epi
Streptococci
Pseudomonas aeruginosa (IVDA)
Gonococcal
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Young adult
Polyarthralgia (70%), tenosynovitis (67%), dermatitis (67%)
Synovial gram stain 25% yield
Urethral, cervical, rectal, pharyngeal cxs
Rarely need surgery
Tx: PCN
• Atypical: fungal, AFB, salmonella (SSD), Lyme, syphillis,
yeast, viral
Examination
• Painful, restricted ROM
• Warmth, effusion, cellulitis
• Diff dx: septic bursitis,
trauma, osteomyelitis
• Inflammatory causes: Gout,
CPPD, spondyloarthropathies,
RA, Lyme, SLE, Reiters
• Fever in 40-90%
• Labs: CBC, ESR, CRP
Synovial Fluid Analysis
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Cell count
Crystals
Gram stain & culture
Glucose, mucin, protein
Prosthetic joint?
– Let the orthopaedist aspirate
– May be septic with WBCs as low as 1100
Synovial Fluid Analysis
Normal
Color
Clarity
Viscosity
Mucin Clot
Clear/pale
Transparent
High
Good
WBC
< 300
Neutrophils
< 25%
Gram’s stain
(-)
Serum/Glucose 0.8-1.0
Protein (g/dL)
<3
Non-Inflammatory
Effusion
Yellow
Transparent
High
Good/Fair
< 2000
< 25%
(-)
0.8-1.0
<3
Inflammatory
Effusion
Yellow-white
Translucent
Low
Fair/Poor
2000-50,000
25- 75 %
(-)
0.5-0.8
<8
Septic
Yellow-white
Opaque
Very Low
Poor
> 50,000
> 80 %
(+)
< 0.5
<8
Treatment
• Joint sterilization & decompression
– Serial aspiration
– Arthroscopy
– Arthrotomy
• Antibiotics
– Adjunct therapy
– Guided by culture data
– Route/duration controversial
Pediatric orthopaedic
considerations
Common/high risk issues
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Cervical spine injury and positioning
Child abuse fractures
Physeal fractures—esp high risk types
SCFE
Supracondylar fractures
Open fractures
Compartment syndrome
Large head, small body
• Birth to age 8: 87% Cspine
injuries at C3 and above
• Age 8 & above: adult
patterns
• Immobilize with cutout
board/raise body on
blankets to maintain
neutral (8 and under)
• When in doubt MRI
Child Abuse
• Mult stages of healing fxs:
posterior ribs, skull, corner
fx, spiral humerus/femur fx
• Fxs in non-walking age child
• Burns, bruises, withdrawn
affect
• Distinguish from OI--can
order genetic testing for
COL1A1 and COL1A2
mutation
Pediatric Injury patterns
• Ligaments stronger than
immature bone
• Weakest point: through
physeal cartilage
• Fractures can be
nondisplaced or
spontaneously reduce
• Swollen? Treat as injury.
Pediatric ankle ‘sprain’
• Physeal injury often
nondisplaced
• Ligaments stronger
than physis
• Palpate physis
versus ligaments
• Presumptive tx: 4
wks SLC
Growth Plate Injuries
Prognosis varies by grade and anatomic site
Displaced physeal injuries
• Requires urgent
reduction with adequate
sedation
• One attempt: minimize
iatrogenic trauma &
damage to the physis
• These should be done by
an orthopaedist
Case 1
• 9yM sp fall
off bike
Green’s Skeletal Trauma in Children 2003
SH fractures about the knee
• Presumed knee
dislocation!
• Detailed physical exam
• ABIs for diminished
pulses or any concern
• Watch compartments
carefully
• Radiographs
• MINIMAL APPEARING
FRACTURE HERE CAN BE
DEVASTATING
Proximal Tibia Physeal Fractures
• Popliteal trifurcation at level
of physis
• Anterior tibial artery
tethered by IO membrane,
soleus arch
• Minimal protection from
posterior bony spikes; tear
easily.
• Fractures often self-reduce
or ‘reduced’ in field
• Maintain high suspicion even
with benign xrays.
Green’s Skeletal Trauma in Children 2003
Case 2
• 14yM playing
basketball
• Jumped and
suddenly felt
pain in knee
• History of
Osgood Schlatter
disease
Green’s Skeletal Trauma in Children 2003
Adolescent Tibial Tuberosity Fracture
• High risk for vascular
injury, compartment
syndrome
• Tear of anterior
recurrent tibial artery
vascular leash with
retraction into
anterior
compartment
–Wall, JBJS 1979;
Pape, Clin Orthop 1993
Gray’s Anatomy 1918
Pediatric hip dislocation
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MVC , football
Usually posterior
Associated physeal fxs
Acetabular fxs rare
Reduction should be done
by orthopaedics under
fluoro
• Risk of femoral physis
displacement during
reduction
Case 3
• 13yM with 4 wks of persistent right knee
pain. Denies injury/trauma. No
fevers/chills. “Hurts when I run and
sometimes when I walk.”
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AFVSS, overweight, walking with limp
No swelling or point tenderness of knee
Right Knee films negative.
Labs normal.
What to do next?
Hip/Pelvis Xrays
Knee pain = referred from hip until proven otherwise
Slipped capital femoral epiphysis
• Patient dc’d from ER x 2 with negative knee
xrays while ambulatory
• Suddenly pt unable to bear weight-weakened growth plate became unstable
• Increased displacement/instability high
risk for AVN, late deformity, arthritis
• Obtain hip xrays & hip exam if knee
pathology is not obvious
– Limited internal rotation of hip
– Obligatory external rotation with flexion
Supracondylar humerus fractures
• Look for skin tenting, anterior
bruising, distal swelling
• Thorough neurovascular exam
• NV injuries can occur before and
after reduction
• Pulseless pink hand  Vessel in
spasm? Vessel injury with good
collateral circulation?
• Mgmt controversial
• Pulseless blue hand  High risk of
need for vascular repair,
compartment syndrome
Call ortho immediatelyavoid manipulation of
the arm
Another
supracondylar
humerus
fracture,
much less risk
Pediatric Elbow Injuries
• 65% of all pediatric trauma
• SCH fractures: 50-70%
• Most common fracture in children
requiring surgery
• Peak age 5-7 years
• Nondominant > dominant
Pediatric compartment syndrome
• Pain  Increasing analgesia
requirement.
• Dose meds by body weight
• Can still develop over 30 h
from injury/surgery
Pediatric compartment syndrome
• Higher risk injuries
• Distal femur and proximal tibia fxs – knee dislocation
equivalents
• Tibial shaft fxs
• Forearm fxs
• SCH fxs (vascular injury)
• Floating elbows up to 30% incidence
• Femur fxs – muscular thighs
• Reduce displaced fractures  swelling improves
fin