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Skeletal System
Shannon Carroll, MD
Suresh Agarwal, MD
Skeletal System
• Common Skeletal System Pathology encountered in
Critical Care
• Complications of Skeletal Injury
Slide 3
Skull
www.pycomall.com/images/P/skull.jpg
Slide 4
Skull Fractures
4 Major Types
• Linear
• Depressed
• Diastatic
• Basilar
Slide 5
Linear Skull Fracture
• Most common type
• Over Lateral Convexities
• Over squamous area of
temporal bone
– Damage to middle
meningeal artery
– Epidural Hematoma
www.hawaii.edu/medicine/pediatrics/pe
mxray/v5c09h2.jpg
Slide 6
Depressed Skull Fracture
• Displaced bone fragments
pushed into the cranial vault
• From blunt force by object with
small surface area
• Often damages underlying
brain tissue
• Complex = dura mater torn
• Contamination/Infection
• Often require surgery
anatpat.unicamp.br/minDsc35446+.jpg
Slide 7
Diastatic Skull Fracture
• Fracture causes widening of
suture
• Most commonly seen in infants
and small children
• Seen in adults along the
lambdoid suture
Pirouzmand F, Muhajarine N. Craniofac Surg. 2008 Jan;19(1):27-36. Definition of
topographic organization of skull profile in normal population and its implications on the role
of sutures in skull morphology. img.medscape.com/pi/emed/ckb/radiology/336139-3437649928.jpg
Slide 8
Basilar Skull Fracture
• From blunt force to the
forehead or occiput
• Usually anterior
– Often involves cribriform
plate
– Disruption of olfactory
nerves
• Posterior
– Through petrous bone and
internal auditory canal
– Disruption of the
vestibulocochlear nerve
and facial nerves
• CSF otorrhea/rhinorrhea
t0.gstatic.com/images?q=tbn:TuEw6pvP4iIG5M:http://i
mg.medscape.com/pi/emed/ckb/neurosurgery/247017248108-4155.jpg
Slide 9
Basilar Skull Fracture
Battle’s Sign
Raccoon Eyes
image.absoluteastronomy.com/im
ages/encyclopediaimages/b/bl/bla
ckeye_pigmentation.jpg
www.itim.nsw.gov.au/images/Bat
tle_Sign_s.jpg
Slide 10
Vertebral Injuries
• Vertebral Column forms the Axial Skeleton
• Among All Trauma Patients
– 4.3% Cervical Spine Injury
– 6.3% Thoracolumbar Spine Injury
– 1.3% Spinal Cord Injury
www.eorthopod.com/images/ContentImages/spi
ne/spine_thoracic/anatomy/thoracic_spine_anat
omy01.jpg
Slide 11
Vertebral Injuries
7 Mechanisms of Injury
• Flexion – compression
• Axial compression
• Flexion – distraction
• Hyperextension
• Rotation
• Shear
• Avulsion
Slide 12
Cervical Spine Injuries
www.physiotherapytreatment.com/images/human-lateralcervical-spine.jpg
Slide 13
Cervical Spine Injuries
• 25% Occiput to C2
• 75% C3 to C7
• Occipto-cervical subluxation
– Rare
– Usually fatal
• Fractures of the Atlas
– Pain
– Decreased mobility
• Atlanto-axial dislocation
– High risk of neurologic
deficit
www.springerlink.com/content/26ghau7p5nmpcjle/
Slide 14
Fractures of the Odontoid
• Apical ligament avulsion fracture
• Stable
• Minimal if any external support
img.medscape.com/pi/emed/ckb/orthopedic
_surgery/1230552-1267150-1299.jpg
Slide 15
Fractures of the Odontoid
• Waist of the odontoid
• Unstable
• Requires reduction or translation
and angulation
• Requires stabilization
– Surgical
– Halo vest
img.medscape.com/pi/emed/ckb/orthope
dic_surgery/1230552-1267150-1299.jpg
Slide 16
Fractures of the Odontoid
• Extends below the waist into the body of C2
• Best treated with a halo vest
• 15% incidence of nonunion with other immobilization
img.medscape.com/pi/emed/ckb/orthopedic
_surgery/1230552-1267150-1299.jpg
Slide 17
Thoracolumbar Spine Injuries
• L1 fracture 16%
• Spondylolisthesis
– Subluxation or Slip of one
vertebral body on another
– Most common in lumbar spine
– Treatment
• Conservative management
www.webinique.com/images/lumb
ar_spondylolisthesis_grades.jpg
• Fusion
Slide 18
Spinal Instability
• Disruption of anatomic components, motion or
supportive elements
• Excessive or abnormal spinal
motion
• 3 Column Model
– In thoracolumbar spine
– Instability = Injury to 2 or
3 columns
www.pgblazer.com/wpcontent/uploads/2009/11/three-columnconcept-2.jpg
Slide 19
Spinal Instability
• 50% Loss of Vertebral Body Height
• Angulation > 20%
• Compression Fractures
• Burst Fractures
www.pgblazer.com/wpcontent/uploads/2009/11/three-columnconcept-2.jpg
Slide 20
Non-operative Management of Spinal
Injuries
• Stable injuries
• No neurologic deficits
• Immobilization
www.alsab.ca/images/collar2.jpg
Slide 21
Spinal Immobilization
• C– spine
– Head halter
– Tongs
– Halo
images.allegrocentral.com/9E/75/J-TongsTraction-Tongs-557879-PRODUCTMEDIUM_IMAGE.jpg
www.ossur.com/lisalib/getfile.aspx?ite
mid=15083&proc=3
Slide 22
Spinal Immobilization
• T– and L– spine
– Bedrest
– Log rolling
– Rigid brace
www.optecusa.com/sites/default/files/imagec
ache/product_list/products_01_B09.jpg
Slide 23
Operative Management of Spinal Injuries
• Spinal Fusion
– Pedicle screws
and rods
• Vertebroplasty
• Kyphoplasty
eldoradopainmanagement.net/mediac/450_
www.backpain0/media/Compression_Render_Final.jpg
guide.com/Chapter_Fig_folders/C
h15_Carpentry_Folder/Ch15_Imag
es/15_3_Pedicle_Screws.jpg
www.vancouverspinedoctor.com/imag
es/balloon_kyphoplasty.jpg
Slide 24
Cervical Spine Clearance
The NEXUS Clinical Criteria
1. Tenderness at the posterior midline of the cervical spine
2. Focal neurologic deficit
3. Decreased level of alertness
4. Evidence of intoxication
5. Clinically apparent pain that might distract the patient from the pain
of a cervical spine injury
– Any of the above -> increased risk for cervical spine injury ->
requires radiographic evaluation
– Sensitivity: 99.6%
Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of
clinical criteria to rule out injury to the cervical spine in patients
– NPV: 99.9%
with blunt trauma. National Emergency X-Radiography Utilization
– Specificity: 12.9%
Study Group. N Engl J Med. 2000;343:94 –99.
– PPV: 2.7%
Slide 25
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST
practice management guidelines for identifying
cervical spine injuries following trauma. 2009.
Slide 26
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying cervical
spine injuries following trauma. 2009.
Slide 27
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST
practice management guidelines for
identifying cervical
spine injuries following trauma. 2009.
Slide 28
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST
practice management guidelines for
identifying cervical
spine injuries following trauma. 2009.
Slide 29
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al.
EAST practice management guidelines
for identifying cervical
spine injuries following trauma. 2009.
Slide 30
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST
practice management guidelines for
identifying cervical
spine injuries following trauma. 2009.
Slide 31
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST
practice management guidelines for
identifying cervical
spine injuries following trauma. 2009.
Slide 32
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST
practice management guidelines for
identifying cervical
spine injuries following trauma. 2009.
Slide 33
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al.
EAST practice management guidelines
for identifying cervical
spine injuries following trauma. 2009.
Slide 34
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST
practice management guidelines for
identifying cervical
spine injuries following trauma. 2009.
Slide 35
Chest Wall
www.chelseagoodchild.com/images/portfolio/tra
ditional/Rib_cage.jpg
Slide 36
Rib Fractures
• Overall mortality = 12%
• High-Energy Injuries:
– 1st or 2nd rib fractures
– Multiple rib fractures
– Scapula Fracture
• Rib Fractures in the Elderly (>65)
– 2 – 5 x greater risk of morbidity/mortality
– 19% Increase in mortality per rib fx
– 27% Increase in pneumonia
Slide 37
image.wetpaint.com/image/1/XO
MgDfktBYZImgBWx3Xc2g17156
9/GW537H600
Rib Fractures
• Treatment = Analgesia
– PCA
– Rib Blocks
– Epidural
– Intercostal/ Intrapleural
Catheter
www.learningradiology.com/caseofweek/caseoftheweekpix20
09-340/cow353-1lg.jpg
Slide 38
Flail Chest
Paradoxical Motion
• 2 ribs fractured in 2 locations
• Significant morbidity from underlying
pulmonary contusions
• “Pendelluft”
• Treatment:
– Supplemental O2
– Analgesia
– Pulmonary Toilet
– ?Endotracheal Intubation
– ?Surgical Stabilization
upload.wikimedia.org/wikipedia/commons
/3/39/Flail_chest_mechaincs.jpg
Slide 39
Surgical Stabilization
• Studies suggest
– Quickly restores
normal chest wall
mechanics
– Less pain
– Decreased mortality
– Decreased mechanical
ventilation needs
Gasparri MG, Almassi GH, Haasler GB
(2003) Surgical management of multiple rib
fractures. Chest 124:295S
www.acuteinnovations.com/files/ri
bloc-overview1.200903161712.jpg
– Shorter hospital stays
– Decreased long term morbidity
Slide 40
Suggested Indication for Surgical
Treatment of Rib Fractures
• Flail chest
• Reduction of pain and
• disability
• Chest wall deformity/defect
• Symptomatic rib fracture
non-union
• Thoracotomy for other
indications
Raminder Nirula1, Jose J. Diaz Jr.2, Donald D.
Trunkey3 and John C. Mayberry3. Rib
Fracture Repair: Indications, Technical
Issues, and Future Directions. World Journal
of Surgery 2009; 33(1): 14-22
Slide 41
Sternal Fractures
• “Steering Wheel Syndrome”
• Possible Associated Injury =
Blunt Cardiac Injury
• Most Common Associated
Injuries:
– Rib fractures
– Long bone fractures
– Head injuries
• Treatment:
– Rest
radiographics.rsna.org/content/21/5/
1257/F42.medium.gif
– Analgesia
– Monitor for EKG changes
Slide 42
Scapula Fractures
• From high energy trauma
• Rarely occur as an isolated injury
• Management:
– Sling
– Pendulum exercises at 3 weeks
– Strengthening at 6 weeks
www.eorthopod.com/sites/default/files/images/
adult_shoulder_fx_type_scapular_blade.jpg
Slide 43
Indications for Surgical Repair of
Scapula Fractures
• If it is one of multiple
shoulder fractures
• Displaced fracture of the
glenoid neck
• Displaced fracture of the
glenoid fossa
• Significant disruption of superior
shoulder suspensory complex
www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi
?book=physmedrehab&part=A3412&blobname
=ch4f4-30.jpg
Slide 44
Clavicle Fracture
• Classification
– Proximal (rare)
– Central (80%)
– Distal
• Risk of Nonunion
(highest in distal fractures)
• Treatment:
– Sling
www.drdavidduckworth.com.au/css/ima
ges/clavicle-side.jpg
– Pendulum exercises at 2 to 3 weeks
– Avoidance of heavy activity x 8 weeks
Slide 45
Clavicle Fractures
•
Indications for surgical fixation:
– Distal clavicle
images.google.com/imgres?img
url=http://assets.sbnation.com/a
ssets/161691
– Middle clavicle with >2cm of
shortening
– Open
– Symptomatic Nonunions
– Associated neurovascular
injury
– Complex injuries of the
shoulder
•
Surgical Procedure
assets.sbnation.com/assets/1616
91/clavicle_fracture_surgery_pho
to.gif
– Screw and Plate Fixation
images.google.com/imgres?imgurl=http://
assets.sbnation.com/assets/161691
– Intramedullary implants
Slide 46
Pelvis
www.exchange3d.com/cubecart/images/uploads/
aff973/Pelvis///Pelvis_thumb01.jpg
Slide 47
Pelvic Fractures
• Most Common Etiologies
– Motorcycle collisions
• Concomitant Injuries in >90%
of patients with pelvic fractures
– Pedestrian v. Motor vehicle
•
Most deaths due to:
– Fall > 15 feet
– Head Injury
– Motor vehicle collision
– Non-pelvic hemorrhage
– Lung Injury
• Mortality
– 7-14%
– Thromboembolic Events
– 30% w/ severe or open
fractures
– MSOF
– Most deaths due to other
traumatic causes
Slide 48
Pelvic Fractures
• Mean transfusion requirement =
8 units of packed red blood cells
• Minimize blood loss from pelvic fractures
– Early re-approximation and stabilization
• Bed Sheet
• Splint
t3.gstatic.com/images?q=tbn:oc6jX5VKvtYoDM:http
://www.vygia.com.vn/image/C-Clamp_02.jpg
• Clamp
• External Fixation
– Angiography
• Pelvic arterial disruption is
source of hemorrhage 3 – 20%
Slide 49
publicsafety.com/article/photos/11297429117
46_13.jpg
Pelvic Compression Fracture Vectors
• Lateral Compression
• Anterior-Posterior Compression
• Vertical Shear
images.google.com/imgres?imgurl=http://www.aofo
undation.org/AOFileServerSurgery/MyPortalFiles%
3FFilePath%3D/Surgery/en/_img/surgery/01Diagnosis/61/62-A1-xrays-
Slide 50
Lateral Compression Fracture
• Impact to lateral side of
pelvic ring
• Shortens diameter across
pelvis/decreases volume
of pelvis
• Little risk of vascular or
ligamentous injury
www.eorthopod.com/content/adultpelvis-fractures-types
Slide 51
Anterior-Posterior Compression
Fractures
• “Open Book”
• Mechanisms:
– Direct Impact to the
Iliac Spines
– Transmitted through
the femurs
• Can have ligamentous injury
without fracture
• Increases diameter/volume of pelvis
• Significant risk of bleeding
www.eorthopod.com/sites/default/files/images/
adult_pelvis_fx_causes06.jpg
• Unstable
Slide 52
Vertical Shear Pelvic Fractures
• Mechanism: Fall/Jump landing on straight leg
• Disruption of ligaments:
– Symphyseal
– Sacrospinous
– Sacrotuberous
– SI
– Increases Diameter/Volume
of Pelvis
• Less bleeding than A-P fractures,
but still significant risk
Slide 53
www.eorthopod.com/content/adult
-pelvis-fractures-types
Upper Extremity
www.buyamag.com/graphics/arm_ue200.jpg
Slide 54
Shoulder Fractures/Dislocations
• Acromioclavicular dislocation
– “Shoulder Separation”
– Mechanism: fall onto acromion
– Involved ligaments:
• Acromioclavicular ligament
• Coracoclavicular ligament
– Complications:
• Risk of Brachial Plexus Injury
• Risk of Subclavian Vessel Injury
– Treatment: Sling
Slide 55
www.jurewitz.com/upload/shoulder
_acromioclavicular_separation_intr
o01.jpg
Shoulder Fractures/Dislocations
• Floating Shoulder
– Glenoid neck fracture +
Clavicle fracture
– Glenohumeral joint without
attachment to the rest of the
skeleton
– Usually requires surgical
fixation of one of the elements
(clavicle)
Low CK, Lam AWM. Results of fixation of clavicle alone in
managing floating shoulder. Singapore Med .
2000;4(19):452-453.
Slide 56
Shoulder dislocation
• Anterior (85-95%)
– Risk of axillary nerve injury
– Treatment: Closed Reduction
• Posterior
http://www.sports-injury-info.com/image-files/shoulderdislocation.jpg
– Mechanisms: Seizures, Electrocution
– Risk of axillary artery injury
– Treatment: Closed Reduction
www.eorthopod.com/images/ContentImages/shoulder/shoul
der_dislocation/shoulder_dislocation_anatomy12.jpg
Slide 57
Humerus Fractures
Proximal Humerus Fractures
• Concomitant injuries:
– Rotator cuff injuries
– Shoulder dislocation
• Risk of peripheral nerve injuries
• Risk of axillary artery injury
• Nondisplaced Fractures
– Sling for a short period
– Early Range Of Motion
• Displaced Fractures
www.shouldersurgeon.com/graphic
– With impaction of humeral head: Nonop
s/4_parts_prox_humerus.jpg
– Most 2 Part Fractures: Closed reduction w/ percutaneous fixation
– Most 3 Part Fractures: ORIF
Slide 58
Humerus Fractures
• Midshaft Humerus Fractures
– Radial Nerve Injury
•
•
•
•
•
12% of Humeral Shaft Fractures
with fractures of the distal 1/3 of the Humerus
Runs in the spiral groove
70% resolve w/ conservative management
Splint wrist and digits
www.eorthopod.com/sites/default/files/images
/adult_humeral_fx_brace.jpg
– Nondisplaced: Sling
– Displaced:
•
•
•
•
Reduction with long arm cast for gravity traction
Fracture Brace
Plate and Screw Fixation
Intramedullary Nailing
Slide 59
Humerus Fractures
Supracondylar Humerus Fractures
• Almost always require ORIF
• Volkmann’s Contracture
– Supracondylar Humerus Fracture
– Anterior interosseus artery is occluded
www.unboundedmedicine.c
om/wp-content/Volkman.jpg
– After reduction, perfussion is restored
– Reperfussion injury leads to Flexor Compartment
Syndrome
Slide 60
Elbow Fractures/Dislocations
• “Terrible Triad of the Elbow”
– Elbow dislocation + Radial Head Fx
+ Coranoid Process of the Ulna Fx
– Requires surgery with repair or
reconstruction
• Nursemaid’s Elbow
– Subluxation of Radius at Elbow
– Cause: Traction to an extended,
pronated arm
– Tx: Closed Reduction
Slide 61
s3.beckshome.com/20060625Nursemaids-Elbow.jpg
Forearm Fractures
• Monteggia Fracture
– Proximal Ulna Fracture +
Radial Head Dislocation
– Treatment ORIF
• Galezzi Fracture-Dislocation
www.wheelessonline.com/images/i1/m
ont1.jpg
– Complex disruption of the
distal radioulnar joint +
Unstable radius fracture
– Surgical repair is almost
always necessary
www.learningradiology.com/caseofweek
/caseoftheweekpix2/cow157lg.jpg
Slide 62
Forearm Fractures
• Night-stick Fracture
– Isolated Ulnar Shaft Fracture
– Nondisplaced: Long arm cast
for short period, then functional bracing www.wheelessonline.com/image4/i1/nght1.jpg
– Displaced: Compression Plating
• Colles Fracture
– Fall on outstretched, extended wrist
– Distal Radius Fracture
z.about.com/d/orthopedics/1/0/2/1/fxapcolles.jpg
– Treatment: Closed Reduction
• Greenstick fracture
– Partially through bone
www.medscape.com/content/2002/00/44/65/446548/art– Opposite side of bone bent
ar446548.fig10.jpg
Slide 63
Scaphoid Fracture
•
½ of all isolated carpal bone fractures
•
Fracture locations:
– Waist (75%)
– Proximal Pole (20%)
– Distal Pole (5%)
– Blood supply from the ligaments at
the distal pole
•
Snuff Box tenderness
•
Risk of Avascular Necrosis
•
Operative Repair
patientsites.com/media/img/1225/wrist_scaphoid
_fracture_intro01.jpg
– Open Screw Placement
– Percutaneous Screw Placement
•
Cast to elbow
Slide 64
Finger/Thumb Fractures
• Rolando fracture
– T- or Y-shaped
– Thumb metacarpal base
– Difficult to manage
• Phalangeal fractures
– Usual treatment: Buddy taping
or splint immobilization
– Intra-articular invovlement:
• Closed reduction
• Fixation with percutaneous screws
• Fixation with Kirschner wires
Slide 65
radiographics.rsnajnls.org/content/
vol20/issue3/images/large/g00mc2
0l25x.jpeg
Lower Extremity
files.turbosquid.com/Preview/Content
_2009_07_13__17_30_11/leg_bones.
jpgf1dbe04a-ce4d-4150-9fc10fb1043c8a87Large.jpg
Slide 66
Femur Fracture
• Present in about 15% of seriously injured trauma
patients
• 8-10% Bilateral
• Mortality
– Unilateral = 10-12%
• 20% in patients > 65 years old
– Bilateral = 26-33%
– 90% due to concomitant injuries
• Decreased complications with surgical fixation within 24
hours
Slide 67
Hip Fractures
• 50% over 85years
– 6 month mortality of 20%
• Preoperative Management of
Unstable Fxs
– Buck’s Traction
– Skeletal Traction
www.lancastergeneralcollege.edu/content/upload/AssetMg
mt/images/College/conferences/Ortho_Traction_in_Orthope
dicCare.pdf
Slide 68
Hip Fractures
Femoral Neck Fractures
• Intracapsular
– High risk of Avascular Necrosis and Nonunion
– Intracapsular hematoma also may compromise perfusion
– Surgical emergency in young people
– Treatments:
• Internal fixation
• Hip arthroplasty
• Extracapsular
– Dynamic Hip Screw (DHS)
www.orthomeditec.com/images/dynam
ichipscrew.jpg
– Early weight bearing/Rehab
Slide 69
Hip Fractures
• Trochanteric Fractures
– More stable than femoral neck fractures
– Require ORIF
• Early Ambulation/Rehab
• Subtrochanteric Fractures
– High risk of failure of surgical fixation
– Treatments:
• ORIF
• Closed Reduction and Intramedullary Nailing
• Indirect reduction with blade-plate /screw-plate fixation
Slide 70
Hip Dislocations
• Reduction within 6 to 8 hours is crucial
• Posterior (85-95%)
– Leg internally rotated and adducted
– Risk of sciatic nerve injury
– Treatment: Closed Reduction
chestofbooks.com/health/anatomy/Human-BodyConstruction/images/Fig-515-Posterior-luxation-ofthe-hip-produced-by-rotati.jpg
• Anterior
– Leg externally rotated and abducted
– Risk of femoral artery injury
– Treatment: Closed Reduction
Slide 71
i21.photobucket.com/albums/b286/flagady15/
Bones/hip-fig1.jpg
Femoral Shaft Fractures
• Blood loss up to 1500 – 2000cc
• Important to reduce fracture and maintain alignment
early
• Closed Reduction and Reamed,
Interlocking Intramedullary Nail
• Ex-fix with Intramedullary Nail
– Days 5 to 10
• Associated Complications:
– Fat Embolism Syndrome
– Acute Lung Injury/ARDS
Slide 72
nyic.stemlegal.com/wpcontent/uploads/2009/01/femur-nailing.jpg
Patella Fractures
• Mechanism: Direct blow to flexed knee
• Nondisplaced: Long leg cast
• Comminuted:
– Open reduction and internal fixation
www.aofoundation.org/AOFileServer
Surgery/MyPortalFiles?
• Lag screws
• Tension Banding
– Partial or total Patellectomy
www.cahnlitigation.com/toetheslab/images/Post
%20Images/fracture_of_patella_2.JPG
www.aofoundation.org/AOFileServerSurgery/MyPortalFiles?
FilePath=/Surgery/en/_img/surgery/05-RedFix/34/P90tension-band-wiring/33_P90_i480L_C11_patella.jpg
Slide 73
Knee Dislocation
• May involve:
– Patello-femoral joint
– Tibio-femoral joint
• Usually Lateral
– Hemarthrosis or Effusion develops
– May be recurrent
– Treatment:
• Closed Reduction
• Knee immobilization for 4 to 6 weeks
• Complete Knee Dislocation:
www.ajronline.org/content/vol186/issue3/images/
large/00_04_0756_04b_cmyk.jpeg
– Anterior or Posterior
– Need angiogram to assess for Popliteal Artery injury
Slide 74
Tibia-Fibula Fractures
• Proximal and Midshaft Tibia Fractures
– High risk for compartment syndrome
• Tibial Plateau Fractures
– Nondisplaced proximal
tibia fractures: hinged knee brace
– Displaced/Unstable patient:
External fixator
www.rad.washington.edu/academics/academicsections/msk/teaching-materials/sundry-mskcomputer-programs/sundry-images-forprograms/3DCTS1_3DAP.jpg/image
– Deformity/Instability: Surgical Repair
Slide 75
Calcaneus Fractures
• Require tremendous force to the heal
• Frequently occur w/ spine injuries
• Nondisplaced and extra-articular: nonoperative
• Displaced and intra-articular: ORIF 2-3 weeks after injury
www.fighttimes.com/magazine/images/8/l-medcellxray5.jpg
www.mccainortho.com/Calcaneus%20Post%20O
p%20A.jpg
Slide 76
Talus Fractures
•
Risk of Avascular Necrosis (AVN)
– Especially if fracture is at neck of talus
– Dislocation is a surgical emergency
•
Closed reduction for most
•
Severely displaced: Precise reduction and fixation with Interfragmentary
Screws
www.foothyperbook.com/images/hindfoo
tTrauma/FxTalusNeck.gif
www.orthosupersite.com/images/
content/obj/0802/salem_fig1b.jpg
Slide 77
Metatarsal Fractures
• Jones Fracture
– Mechanism: Inversion of Foot
– 5th Metatarsal
– At risk for nonunion
www.eorthopod.com/content/adult-footfractures-types
www.eorthopod.com/content/adult-footfractures-types
Slide 78
Complications of Extremity Fractures
• Infection
– Findings often appear 10-21 days after infection
– Most common organism = Staph. aureus
– Also common = Pseudomonas aeruginosa and
Enterobacteriaceae
• Diagnosis
– Physical findings
– Constitutional symptoms
– Radiography
•
•
•
•
CT
MRI
3-phase bone scan
Radiolabeled WBC scan
Slide 79
Complications of Extremity Fractures
• Gas Gangrene
• Necrotizing fasciitis
• Treatment:
– Early wide debridement
– Antibiotics (PCN)
• Tetanus
– Highest risk w/
farming accidents
www2.cedarcrest.edu/academic/
– Treatment:
•
•
•
•
Supportive
Debridement
Immunization
Antibiotics
bio/hale/bioT_EID/lectures/tetan
us-pathogen2.jpg
Slide 80
www.meddean.luc.edu/lum
en/MedEd/mech/cases/Gra
m_Positive/slide1.jpg
amog.com/wpcontent/uploads/2009
/03/fasciitis.jpg
Osteomyelitis
• Acute Osteomyelitis
– Hematogenous Spread
– Contiguous Spread
• Subacute Osteomyelitis
• Chronic Osteomyelitis
ssl.gstatic.com/health/33576cb3c325418b
82afc7245394d485/ref/graphics/9712.jpg
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Diagnosis of Osteomyelitis
• Requires 2 of the 4 following criteria:
• Purulent material on aspiration of
affected bone
• Bone tissue or blood culture positive
• Localized classic physical findings
of bony tenderness, with overlying
soft-tissue erythema or edema
• Positive radiological imaging study
www.medicallook.com/diseases_images/osteomyelitis.jpg
Slide 82
Osteomyelitis
Most Common Organisms
• Staphylococcus aureus
• Gram negative infections (vertebral
bodies)
• Pseudomonas (IVDA)
• Fungal osteomyelitis (chronically
ill/TPN)
• Salmonella osteomyelitis (Sickle
Cell Disease)
upload.wikimedia.org/wikipedia/commons/5/59/Os
termyelitis_Tibia.jpg
• Group B streptococcus (Infants 2-4 weeks old)
• Haemophilus influenzae (6 months to 4 years old)
Slide 83
Osteomyelitis
• Treatment:
• Surgical Debridement
• ? Limb Loss
• Antibiotics
– Broad Spectrum IV
– Tissue cultures to narrow
• Hyperbaric Oxygen for Refractory
Kindwall EP. Uses of hyperbaric oxygen therapy in the
Osteomyelitis
1990s. Cleve Clin J Med. Sep-Oct 1992;59(5):517-28
radiographics.rsna.org/.../g07nv10c18x.jpeg
Slide 84
Complications of Extremity Fractures
• Fat Embolism
– Approx. 5000 deaths per year
– Classic Triad:
• Respiratory Compromise
img.medscape.com/pi/emed/ckb/vascul
ar_surgery/459840-459841-4605241723668tn.jpg
• Change in Mental Status
• Petechiae
– Half of all cases present only
with respiratory failure
– Treatment: Supportive
www.futurehealth.rochester.edu/dlp2
/dlpdict/petechiae.jpg
Slide 85
Thromboembolism
• Virchow’s Triad:
• DVT Prophylaxis:
– Hypercoagulability
•
SCDs
– Endothelial Damage
•
Foot pumps
– Venous Stasis
• More than 60% of DVTs are
Asymptomatic
– Heparin
•
LMWH
•
Coumadin
• PEs are the 3rd most common
cause of death in trauma
patients who survive past the
first day
Slide 86
Complications of Extremity Fractures
Compartment Syndrome
• Diagnosis primarily clinical
• Critical Pressures:
– Pain
– Compartment Pressure >
30mmHg
– Parasthesias
– Diastolic BP –
Compartment Pressure <
30mmHg
– Piokylothermia
– Pulseless
– Pain with passive range of
motion
Slide 87
Complications of Extremity Fractures
• Rhabdomyolysis
– Treatment = aggressive IVF
• Avoid buildup of myoglobin in renal tubules
• Prevent hyperkalemia
Slide 88
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