UNMC Orthopaedic Surgery
Welcome to your
M4 Clerkship and
Welcome to
Omaha
Department of Orthopaedic Surgery
and Rehabilitation
Introduction
• Welcome
• Expectations and goals
• General considerations for Orthopaedic history
and physical exam
• Introduction to reading x-rays
• Trauma/Open Fractures
• Compartment Syndrome
WELCOME
• Welcome to UNMC and your Orthopaedic
clerkship
• We are here to teach you the basic foundations
of Orthopaedics.
• With that, you should be able to gain a feel for
what a career in Orthopaedics may be like.
• We are happy to have you as a part of our team
for the next month and hope you gain a lot of
useful information while you are here
Expectations: General
• Show up on time, be available, and work hard
• Read before surgical cases (anatomy and surgical
plan)
• Be helpful, be inquisitive, ask questions
• Learn basic management of common musculoskeletal
problems
• Participate actively in rounds, clinics, conference, and
general discussions about Orthopaedic problems
Expectations Cont.
– Be able to access knowledge about Orthopaedics
from books, internet, journals, etc..
– Be able to answer questions about musculoskeletal
anatomy, common injuries, treaments, etc..
Especially when asked to look it up beforehand.
• Clinical functioning at the level of an intern
– Think about the patient care plan:
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Pre-op planning
Medical workup before surgery
Antibiotics
Pain control
DVT prophylaxis
Therapy goals & restrictions
Dressing changes / drain output
Discharge planning & clinic follow-up
Read other consult service notes for their plan
Goals
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At the end of your rotation you should be able
to:
1. Read basic x-rays appropriately
2. Perform an orthopaedic history and physical
3. Recognize common fractures, their classification,
and know how to acutely manage them
4. Understand basic patient care for the Orthopaedic
patient
5. Be able to diagnose common musculoskeletal
problems
CALL
• Divide call on trauma nights between the
students such that you average no more
frequently than q4 during your month.
• Be sure to get at least one full weekend off.
We’d like you to be able to both have a life and
also get to know a little about our city.
• The actual schedule is left up to the students to
arrange. Be fair to each other.
• Carry the on-call pager and notify the junior
resident on-call that you will be taking call with
them that evening
• The best opportunity to learn how to suture,
splint, cast, and possibly do reductions as a
medical student takes place on-call and in the
ER/trauma bay.
CONFERENCES
Conference Schedules
• Three rules
– If there is an assigned reading for a conference,
be sure to get a copy and read it.
– No scrubs in conference, dress appropriately.
– Be on time. Tardiness to conference will be
looked upon very poorly.
Conference Schedules
Mon
600am
Textbook
Conference
630am
Grand
Rounds
Tues
530am
Medical
Student
Lectures
Wed
Thurs
Fri
600am
Pediatric
Ortho
Conference
600am
Trauma
Conference
600am
Hand
Conference
Children’s
Hospital
Glow Aud.
3rd Floor
Creighton
Med Ctr
Morrison Rm
Lobby Lvl
UNMC
Ortho
Library
630am
Gold Joint
Conference
Sorrell Center UNMC
Room 1005
Ortho
Library
Orthopaedic Basics
- History and Physical Exam - How to Read an X-Ray - Principles of Casting/Splinting –
- Fracture Fixation -
Department of Orthopaedic Surgery
and Rehabilitation
Orthopaedic History
• A good general orthopaedic history contains:
– Onset, Duration, and Location of a problem
– Limitations and debilitation attributed to the
problem
– Good surgical history, especially with regards to
orthopaedic surgeries and prior anesthesia
– Co-morbid conditions that contribute to the
problem or will preclude healing in some manner
Physical Exam Basics
• Inspect and Palpate everything- start with
normal structures and move to abnormal
• Range of motion in all planes
• Strength
• Sensation
• Reflexes
• Gait
• Stability
Physical Exam Basics
• NVI What does this mean?
1. Neurologic exam- Always document the
neurologic status. Some fractures are
associated with nerve injuries and knowing the
status of the nerve is critical
2. Vascular exam- Always check for pulses distal
to the fracture sight. Missed vascular injuries
can be devastating
Physical Exam
• NEVER trust someone else’s exam. ALWAYS
put your hands on the patient and see for
yourself
• Always trust your exam- you WILL pick up
something that someone else has missed at some
point
Imaging
Intro to Reading X-rays
• Reading a radiograph is essentially describing the
anatomy of a certain structure
• In order for it to be universal and
understandable for others, clarity and precision
are essential
• A fracture is described based on the findings of
the physical exam and a review of radiographs
Reading X-rays
1. Say what it is- what anatomic structure are you
looking at and how many different views are
there
2. Condition of the soft tissue- Open vs Closed
3. Regional Location- Diaphysis (rule of 1/3),
Metaphysis, Epiphysis including intra and
extra-articular, and Physis (pedi)
4. Direction of the fracture line- Transverse,
Oblique, Spiral
Reading X-rays
5. Condition of the bone- comminution (3 or
more parts), Segmental (middle fragment),
Butterfly segment, incomplete, avulsion, stress,
impacted
6. Deformity-Displacemtent (distal with respect
to proximal), angulation (varus, valgus),
rotation, shortening (in cm’s), distraction
Fracture Pattern
• Transverse
• Produced by a distracting
or tensile force
Fracture Pattern
• Spiral
• Produced by a torsional
force
Fracture Pattern
• Butterfly
• Produced by pure
bending force
Fracture Pattern
• Comminuted
• Broken into many
pieces- high energy with
combined forces
Displacement
• Characterized by % of bone
contact on either view
Angulation
• Distal fragment relative to
proximal
– Varus, Valgus, Anterior, Posterior
• Apex of angle formed by
fragments
– E.g., Apex Anterior, Apex Medial,
Apex Ulnar
Location
• Commonly described in thirds of affected bone
– ie distal third of tibia
– ie junction of proximal and middle third of femur
– If fractured at two levels describe as segmental
Location-Diaphysis
• Shaft portion of bone
Location-Metaphysis
• The ends of the bone (if
the fracture goes into a
joint it is described as
intra- articular)
Now All Together
• Transverse fracture of
the femur at the middle
third- distal third
junction with 100%
displacement and varus
(or apex lateral)
angulation
What do you see?
What do you see?
What do you see?
Casting, Splinting, and
Definitive Fracture Fixaiton
Definitive Fracture Fixation
Options
• Casts and Splints
– Appropriate for many
fractures especially hand
and foot fractures
– Adults typically will get
plaster splints initially
transitioned to fiberglass
casts as swelling decreases
– Kids typically will get
fiberglass casts
Definitive Fracture Fixation
• Delayed until patient is stable
(may be days or weeks)
• Femur Fracture has priority as
delay in fixation has negative
impact on pulmonary status by
shower of fat emboli to the lungs
• Goals is to stabilize skeleton to
allow patient to rapidly mobilize
from bed
Definitive Fracture Fixation
Options
• Traction
– Useful in patients who are
too sick for surgery
– Useful to maintain
alignment until definitive
fixation
Definitive Fracture Fixation
Options
• External Fixation
– Used primarily in the
treatment of open
fractures and pelvis
fractures
– Also useful as temporary
stabilization prior to
definitive fixation
Indications- Emergent
Stabilization
Definitive Fracture Fixation
Options
• Open Reduction and
Internal fixation with
Plates and screws
– Used for many fractures
especially those involving
joints
Definitive Fracture Fixation
Options
• Intramedullary Nails
– Treatment of choice for
most tibia and femur
fractures
– Used in selected humerus
and forearm fractures
Definitive Fracture Fixation
Options
• Joint Replacement
– Used in displaced femoral
neck fractures in geriatric
patients
– Allows for early
ambulation
– Occasionally used in
geriatric pts with
comminuted shoulder or
elbow fractures
Open Fractures
Open Fractures
• Open fractures refer to osseous disruption in
which a break in the skin soft tissue
communicates directly with a fracture
• Any wound occurring on the same limb as a
fracture must be suspected to be an open
fracture until proven otherwise
• A missed open fracture can have dire
consequences
Evaluation of open fractures
• ABC’s
• Identify the injured area
• Assess neurovascular status of the limb both proximal and distal
to the wound. Always use the normal side as a control
• Assess skin and soft tissue damage. Exploration of a wound is
not usually indicated in a trauma or emergency setting. If you
know its an open fracture, splint it and prepare to go to the OR
• DO NOT remove bone no matter how small or insignificant a
piece it may seem
• Always consider vascular injuries and compartment syndrome
with open fractures
Classification of open fractures
• Gustillo Classification
– Grade I- Clean skin opening of less than 1 cm, usually inside
to out
– Grade II- Open between 1 and 10 cm, extensive soft tissue
injury, minimal to moderate crushing
– Grade III- Open more than 10cm, extensive tissue including
muscle damage, high energy
• IIIA- Laceration with adequate bone coverage, segmental features,
gunshot injuries
• IIIB- Soft tissue injury with periosteal stripping, usually associated
with massive contamination
• IIIC- Any of the above with an associated vascular injury
Acute Management of open fractures
• Address hemorrhage with direct pressure
• Initiate antibiotics
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Grade I and II- Ancef 1g-2g IV
Grade III- Ancef plus Gentamicin 2mg/kg IV
Farm injuries or gross contamination- add Penicillin
Apply saline soaked gauze dressing to wound
Attempt reduction and apply splint
Operate- most surgeons use 8 hrs as the window for
decreasing the incidence of infection and other related
complications of open fractures
Orthopaedic Trauma
- General Principles -
Department of Orthopaedic Surgery
and Rehabilitation
Orthopaedic Trauma
• Defined- The care of
fractures and soft tissue
injuries of the extremities
either in the setting of
multiple trauma or
isolated injuries
Orthopaedic Trauma
• Orthopaedic trauma surgeons care
for complex fractures, periarticular
fractures, fractures involving the
pelvis and acetabulum, and fracture
nonunions, malunions and
infections.
Trauma
• Field Triage
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Airway
Breathing
Circulation
Extrication of Patient
Shock Management
Fracture Stabilization
Transport
Trauma
• Golden Hour of Trauma
– Rapid transport of a severely injured patient to a
trauma center for definitive care. Initial treatment
has a significantly higher chance for survival during
this period.
UNMC Trauma and Critical Care Surgery Team
Trauma Evaluation
• ATLS- Advanced Trauma and Life Support
– A standardized protocol for the evaluation and
treatment of victims of trauma
– Developed by a Nebraska orthopaedic surgeon who
was involved in a trauma and was not satisfied with
the lack of a protocol for such patients
ATLS
• A- establish an Airway
• B- Breathe for the pt. (if they
aren’t)
• C- assess and restore
Circulation
• D- assess neurologic
Disability
• E- Expose entire patient
Primary Survey
• Rapid assessment of ABC’s and addressing life
threatening problems (ie establishing airway and
ventilation, placing chest tubes, control active
hemorrhage)
• Place large bore IV’s and begin fluid replacement for
patients in shock
• Obtain Xray of Chest, Pelvis, and Lateral C-Spine
Secondary Survey
• Assessing entire patient for
other non-life threatening
injuries.
• Orthopaedist assesses
skeleton and splints fractures
and reduces dislocations
• Also evaluate distal pulses
and peripheral nerve function
• Obtain Xray or CT of
affected areas when pt is
stable
Emergent Skeletal Issues
• Hemorrhage control from Pelvis Fractures in pt with
labile blood pressure (shock)
– Close pelvic volume
• Hemorrhage control from open fractures
– Direct pressure
• Restore pulses by realigning fractures and dislocations
Urgent Skeletal Issues
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Irrigation and Debridement of open fractures
Reduction of dislocations
Splinting of fractures
Fixation of femur fractures
Addressing compartment syndromes
Trauma Assessment
History  Mechanism of Injury
Palpation
Note swelling, Lacerations
Painful ROM
Crepitus- that grating feeling when
two bone ends rub against each
other
• Abnormal Motion- ie the tibia
bends in the middle
• Check pulses, sensory exam, and
motor testing if possible
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Diagnosis- The exam
• Assess for lacerations that communicate with
the fracture
– Closed Fracture= intact skin over fracture
– Open Fracture= laceration communicating with
fracture (often referred to as a compound
fracture by lay persons)
Compartment Syndrome
Compartment Syndrome
• An emergent condition characterized by
increased pressure within a closed
anatomical compartment with the potential
to cause irreversible damage to the
contents of the compartment (ie muscle
and nerves)
Etiology
• Burns
• High pressure injection
• Trauma
– fractures
– crush
• Medical (Iatrogenic)
– Tight dressings/casts
coagulation, dialysis,
traction
Pathophysiology
• Fixed volume ~ pressure in a closed space
• Rigid fascia
• Increased tissue pressure exceeds venous and capillary
opening pressure producing local hypoxia and capillary
leak leading to even > tissue pressure
• Hypotension decreases tolerance to compartmental
pressure increases
Diagnosis
• In an awake patient this is a clinical diagnosis
• In an obtunded (drunk, head injured, sedated,
intubated) patient the diagnosis is made with pressure
measurements
Compartment Syndrome
Diagnosis
• The 6 P’s
– Pressure – rigid compartment w/ shiny skin
– Pain - out of proportion (the most consistent finding in an
awake pt)
• Passive stretch pain
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Paresthesias
Paralysis
Pallor
Poikilothermia
Late findings
• Pulselessness – not a characteristic of C.S.
Diagnosis: Pressure
Measurement
• Threshold number is
controversial
• Peak pressure zone 2cm
from fracture
Treatment
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must decompress all compartments at risk
skin, fat, fascia widely decompressed
debridement of necrotic tissue
do not close wounds
Extremity Compartment
Syndromes
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Gluteal
Thigh
Calf
Foot
Hand
Forearm
Arm
Questions??