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Tarascon Pocket Orthopaedica Table of Contents Trauma Protocols Tension Pneumothorax Chest Tube IV Maintenance Therapy Cardiac Tamponade Foley Catheter Anatomy Muscle Tables Approaches Cross Sections Arteries Ligaments Nerve Plexi Peripheral Nerves Peripheral Nerves/Dermatomes Antimicrobials Arthritis—Septic Antibiotics for Surgical Prophylaxis Emergency Procedures Measuring Techniques Fasciotomy Acute Stabilization of the Pelvis General Orthopaedics Metabolic Bone Disease Osteoporosis Perioperative Management VTE Blood Transfusion Osteonecrosis Pain Management
Joint Prophylaxis Tetanus Joint Fluid Analysis Nerves, EMG/NCV Wound Healing Pediatric Orthopaedics Medications Milestones and Angles Growth Centers Foot Brachial Plexus General Dysplastic Conditions Salter-Harris Classification Slipped Capital Femoral Epiphysis Limp Scoliosis Child Abuse Perthes DDH Physical Exam and Injections Radiologic Views Sedation and Analgesia Spinal Evaluation Traction Trauma—Adult Trauma—Pediatric Trauma Scores/Classifications Tumor Appendix A: Steroid Preparations Appendix B: Internet Resources
1 2 2 3 3 3 7 7 17 21 26 30 36 39 46 49 49 58 61 62 62 67 68 69 71 73 75 77 78 80
81 83 84 86 88 89 89 90 92 95 96 97 99 101 102 104 109 115 117 118 119 141 162 165 170 176 218 241 244 249 250
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Notices and Obligatory Disclaimer FOR TARASCON BOOKS/SOFTWARE, VISIT WWW.TARASCON.COM Tarascon Pocket Pharmacopoeia • Classic Shirt-Pocket Edition • Deluxe Lab coat Pocket Edition • PDA software for Palm OS or Pocket PC Other Tarascon Pocketbooks • Tarascon Internal Medicine & Critical Care Pocketbook • Tarascon Primary Care Pocketbook • Tarascon Adult Emergency Pocketbook • Tarascon Pediatric Emergency Pocketbook & Software • How to Be a Truly Excellent Junior Medical Student “It’s not how much you know, it’s how fast you can find the answer.” The information in the Tarascon Pocket Orthopaedica is compiled from sources believed to be reliable, and exhaustive efforts have been put forth to make this book as accurate as possible. However, the accuracy and completeness of this work cannot be guaranteed. Despite our best efforts this book may contain typographical errors and omissions. The Tarascon Pocket Orthopaedica is intended as a quick and convenient reminder of information you have already learned elsewhere. The contents are to be used as a guide only, and healthcare professionals should use sound clinical judgment and individualize patient care. This book is not meant to be a replacement for training, experience, continuing medical education, or studying the latest literature and drug information. This book is sold without warranties of any kind, express or implied, and the publisher and editors disclaim any liability, loss, or damage caused by the contents. If you do not wish to be bound by the foregoing cautions and conditions, you may return your undamaged and unexpired book to our office for a full refund.
Important Caution Please Read This!
Cover Image Credit: © National Library of Medicine
Tarascon Pocket Orthopaedica, 3rd Edition ISBN 1-882742-38-9. Copyright © 2002, 2005, 2008 Damian M. Rispoli, MD. Published by Tarascon Publishing, Lompoc, California. Printed in the USA. All rights reserved. No portion of this publication may be reproduced or stored in any form or by any means (including electronic, photocopying) without our prior written permission. Tarascon Publishing is a division of Tarascon Inc. Tarascon Pocket Orthopaedica, Pocket Orthopaedica, Tarascon Pocket Pharmacopoeia, Tarascon Publishing, and It’s not how much you know, it’s how fast you can find the answer are registered trademarks of Tarascon Inc.
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Author/Editorial Board
Tarascon Pocket Orthopaedica, 3rd Edition Damian M. Rispoli, MD Editorial Board*
Brandon Horne, MD
Dmitry Tuder, MD
Wright-Patterson, AFB
Hand, Wilford Hall Medical Center
Joel Jenne, MD
Judd Robins, MD
Spine, Wilford Hall Medical Center
Orthopaedics, Wright-Patterson AFB
Warren Kadrmas
Matthew Schmitz, MD
Sports, Wilford Hall Medical Center Hand, US Air Force Academy
Orthopaedics, Andrews AFB Kshamata Skeete, MD Hand, Wilford Hall Medical Center
Mark W. Richardson, MD
James Bales, MD
Trauma, Wilford Hall Medical Center
PG5, Wilford Hall Medical Center
Eric Ritchie, MD
Benjamin Robinson, MD
Pediatrics, Wilford Hall Medical Center
PG5, Wilford Hall Medical Center
Craig Ruder, MD
Rob McGill, MD
Sports, Wilford Hall Medical Center
PG4, Wilford Hall Medical Center
Joseph Stuart, MD
Kimberly Broughton, MD
Orthopaedics, Nellis AFB
PG3, Wilford Hall Medical Center
Ky Kobayashi, MD
*Affiliations are given for information purposes only, and no affiliation sponsorship is claimed. Damian M. Rispoli authored this book in his private capacity. The views expressed in the book do not necessarily represent the views of either the United States Air Force or the United States government.
A Note from the Author The Tarascon Pocket Orthopaedica is intended as a quick reference for orthopaedic practice. It represents a compilation of facts and data that at one time I have had the occasion to need. It represents the basic information that was passed on to me from many talented individuals. If you find an error or wish to make a suggestion, please let us know (e-mail:
[email protected]). A special thanks for the continued support of my spouse, Vicki; and my children, Josh, Zack, Beth, Ben, and Erika
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TRAUMA PROTOCOLS Initial Approach to Trauma Assessment and Management PRIMARY SURVEY • If poor or no air movement, perform jaw thrust or insert A oral or nasal airway. Assess Airway • Intubate if Glasgow Coma Scale ≤ 8, poor response (immobilize cervical to above, severe shock, flail chest, or need to spine) hyperventilate. • Cricothyroidotomy or laryngeal mask airway if needed • Examine neck and thorax to detect deviated trachea, flail chest, sucking chest wound, and breath sounds. • Administer O2, apply pulse oximeter, measure ETCO2. B • Needle chest for tension pneumothorax, apply occlusive Assess Breathing dressing to 3 sides of sucking chest wound, reposition ET tube, or insert chest tubes (36–38 Fr) if needed. • Apply pressure to external bleeding sites, establish two large peripheral IV lines, obtain blood for basic labs and type and crossmatch, and administer 2 L NS IV prn. C • Check pulses, listen for heart sounds, observe neck veins, Assess Circulation assess cardiac rhythm, and treat cardiac tamponade. • Apply cardiac monitor and obtain BP and HR (pulse quality). (Neurologic Status) Measure Glasgow Coma Scale or assess if: D • AVPU (Alert, or respond to Verbal stimuli, Painful, Assess Disability Unresponsive to pain) • Pupil assessment—size, and reactivity • Completely undress patient (but keep warm) and E Exposure examine all surfaces. RESUSCITATION (Perform simultaneously during primary survey) • Reassess ABCDEs if patient deteriorates. Address abnormality as identified; place chest tube if needed. • Emergent thoracotomy if > 1.2–1.5 L of blood from Reassess ABCDEs initial chest tube, > 100–200 ml/hr after 1st hr, or persistent ↓BP. • Administer 2nd 2 L NS bolus, then blood prn. • Place NG tube and Foley catheter (unless contraindicated). Used with Permission Tarascon Adult Emergency Pocketbook, 3rd ed. Tarascon Publishing, Lompoc, CA.
1
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Trauma Protocols History Physical Exam X-rays Address Injuries Disposition
2 SECONDARY SURVEY • Obtain AMPLE history (See page 6) • Perform head-to-toe examination (including rectal/ back). • Obtain cervical spine, chest, pelvic films, CT scans, etc. • Reduce/splint fractures, call consultants as soon as needed; administer analgesics, tetanus, and antibiotics prn. • Initiate transfer, admit, or ready OR. Document all findings, X-rays, labs, consultants, and talk to family.
Used with Permission Tarascon Adult Emergency Pocketbook, 3rd ed. Tarascon Publishing, Lompoc, CA; 2005.
TRAUMA RADIOGRAPHS • Chest, AP pelvis, lateral C-spine. • Chest and pelvis radiograph may aid in resuscitative effort. • Abnormal C-spine film can identify but not rule out pathology. Trauma History A Allergies M Medications currently using (legal, illicit, and herbal) P Past illness/pregnancy L Last meal E Events/environment related to the injury Chest and pelvis radiograph may aid in resuscitative effort, Abnormal C-spine film can identify pathology. Negative or inadequate films don’t rule out pathology.
TENSION PNEUMOTHORAX • Chest pain, air hunger, respiratory distress, tachycardia, hypotension, hyper-resonant percussion, tracheal deviation, unilateral absent breath sounds, jugular venous distention (JVD), and cyanosis. • Emergent treatment: Large bore needle into the 2nd intercostal space in the midclavicular line. Definitive treatment requires a chest tube. CHEST TUBE • Transverse incision 6th rib midaxillary line. Tunnel to 5th rib midaxillary line, place curved clamp into chest over the top of the fifth rib (protects neuro-vascular bundle on inferior surface). Spread with clamp, insert finger into chest to clear area. Insert chest tube, secure in place, attach to Pleur-evac or Heimlich valve.
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3
Trauma Protocols IMPORTANT TRAUMA NUMBERS
Blood Volume 70 kg man ~ 5 L Child 80–90 mL/kg Initial fluid management 1–2 L in adult; 20 mL/kg kids Normal Acid-Base Values pH Arterial 7.37–7.43 Venous 7.32–7.38
Estimation of Systolic BP BP ~ 60 mm Hg carotid pulse BP ~ 70 mm Hg femoral pulse BP ~ 80 mm Hg radial pulse Warm all IV fluids!
PCo2 37–43 42–50
1 unit of packed red blood cells should ↑hemoglobin by 1.0 g/dL or hematocrit by 3.0%
HCO3 22–26 23–27
IV MAINTENANCE THERAPY 0–10 kg = 4 cc/kg/hr 10–20 = 40 cc/hr + 2 cc/kg/hr > 20 kg = 60 cc/hr + 1 cc/kg/hr Shock = inadequate tissue perfusion CARDIAC TAMPONADE • Beck’s triad—Venous pressure elevation, decreased arterial pressure, muffled heart tones. Echocardiogram or ultrasound may aid in diagnosis. Monitor ECG during pericardiocentesis, 16–18 gauge 6-inch needle, enter left and 1 cm inferior to xiphoid process, 45 degrees to the skin, advance while aiming at left scapular tip, aspirate as you advance. FOLEY CATHETER • Assess prostate, scrotum, and perineum for signs of trauma. Consider retrograde urethrogram (RUG) with pelvic fracture. Mandatory with exam abnormality (blood at meatus, high riding prostate, severe pelvic trauma). AMERICAN COLLEGE OF SURGEONS ESTIMATED FLUID AND BLOOD LOSSES
Blood loss (mL) Blood loss (%) Pulse rate Blood pressure Pulse pressure
Class I ≤ 750 ≤ 15 < 100 Normal Normal or ↑
Class II 750–1500 15–30 > 100 Normal Decreased
Class III 1500–2000 30–40 >120 Decreased Decreased
Class IV > 2000 > 40 > 130 Decreased Decreased (Continues)
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Trauma Protocols
4
AMERICAN COLLEGE OF SURGEONS ESTIMATED FLUID AND BLOOD LOSSES (Continued) Respiratory rate Urine output (mL/hr) Mental status Fluid replacement (3:1 rule)
Class I 14–20 > 30 Slightly anxious
Class II 20–30 20–30 Mildly anxious
Crystalloid
Crystalloid
Class III 30–40 5–15 Anxious, confused Crystalloid, blood
Class IV > 35 Negligible Confused, lethargic Crystalloid, blood
Krantz BE, ed. Advanced Trauma Life Support for Doctors, Student Course Manual. 6th ed. Chicago, IL: American College of Surgeons; 1997.
SYSTEMIC RESPONSES TO BLOOD LOSS (MILD, MODERATE, AND SEVERE) System
< 30% Loss Weak and thready pulse, increased heart rate
Cardiac
30–40% Loss Marked ↑ heart rate, low normal pressure, ↓ pulse pressure, absent peripheral with weak and thready central pulses
> 45% Loss Hypotension, tachycardia then bradycardia
CNS
Anxious, irritable, confused
↓ Level of consciousness and pain response
Comatose
Skin
Cool, clammy, mottled skin, prolonged cap refill
Cyanosis, markedly prolonged cap refill
Pale, cold
Kidneys
Increased specific gravity, decreased urine output
Minimal urine output
No urine output
AMERICAN COLLEGE OF SURGEONS PEDIATRIC VITAL SIGNS Age (years)
Wt. (kg)
0–1 1–3 3–5 6–12 >12
0–10 10–14 14–18 18–36 36–70
Heart Rate (bpm) <160 <150 <140 <120 <100
Blood Pressure (mm Hg) >60 >70 >75 >80 >90
Respiratory (/min) <60 <40 <35 <30 <30
Urine Output (mL/kg/hr) 2.0 1.5 1.0 1.0 0.5
Krantz BE, ed. Advanced Trauma Life Support for Doctors, Student Course Manual. 7th ed. Chicago, IL: American College of Surgeons; 2004.
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5
Trauma Protocols PEDIATRIC VERBAL SCORE
V-Score 5 4 3 2 1
Verbal Response Appropriate words or social smile, fixes and follows Cries, consolable Persistently irritable Restless, agitated None
Krantz BE, ed. Advanced Trauma Life Support for Doctors, Student Course Manual. 6th ed. Chicago, IL: American College of Surgeons; 1997:304.
GLASGOW COMA SCALE Eye Opening 4. Spontaneous 3. To verbal command 2. To pain
Best Verbal 5. Oriented, converses 4. Disoriented, converses 3. Inappropriate words
1. None
2. Incomprehensible 1. None
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Best Motor 6. Obeys commands 5. Localizes pain 4. Flexion, withdrawal 3. Flexion (abnormal) decorticate 2. Extension, decerebrate 1. None
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9%
18%
1%
18%
18% Back
18% Front
9%
9%
Used with Permission Tarascon Adult Emergency Pocketbook, 3rd ed. Tarascon Publishing, Lompoc, CA; 2005.
Carvajal’s solution 5,000 mI/m2 of burn + maintenance 2000 mI/m2 in 1st 24h, with ½ over the 1st 8 hours and ½ over the subsequent 16 hours.
CARVAJAL’S FORMULA
Lactated ringers 4 ml/kg/%burn body surface area in 1st 24 hours + maintenance fluid, with ½ over 1st 8 hours, & ½ over next 16 hours. (Hours calculated from time of injury not time of arrival)
Parkland Formula
ESTIMATION OF TOTAL BODY SURFACE AREA BURNED FLUID RESUSCITATION IN BURN VICTIMS
Trauma Protocols 6
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Long thoracic
Axillary
Lower subscapular
Axillary Upper and lower subscapular Suprascapular Suprascapular
Serratus anterior
Deltoid
Teres major
Teres minor
Supraspinatus Infraspinatus
Subscapularis
Nerve to subclavius
Nerve Spinal accessory Thoracodorsal Dorsal scapular Dorsal scapular Dorsal scapular Lateral/medial pectoral Medial pectoral
Subclavius
Pectoralis minor
Pectoralis major
Muscle Trapezius Latissimus dorsi Rhomboid major Rhomboid minor Levator scapulae
Shoulder Girdle
Supraspinatus fossa Infraspinatus fossa
Ventral scapula
Scapula, dorsolateral
Scapula, inferolateral
Ribs 1–9 Lateral 1/3 clavicle, acromion, lateral 1/3 scapula
Rib 1
Ribs 3–5
Sternum, ribs, clavicle
Origin Spinous process C7–T12 Spinous process T6–S5, ilium Spinous process T2–5 Spinous process C7–T1 Transverse process C1–4
Humerus, greater tuberosity Humerus, greater tuberosity
Humerus, lesser tuberosity
Humerus, medial intertubercular groove Humerus, greater tuberosity
Humerus, deltoid tubercle
Scapula, ventral medial
Clavicle, inferior
Insertion Clavicle, scapular spine, acromion Humerus, intertubercular groove Scapula, medial border Scapula, medial spine Scapula, superior medial Humerus, lateral intertubercular groove Scapula, coracoid
C(4),5,6 (superior trunk) C(4),5,6 (superior trunk)
C5,6,7 (posterior cord)
C5,6 (posterior cord)
C5,6,7 (posterior cord)
C5,6 (posterior cord)
C5,6,7 (roots)
C5,6 (superior trunk)
Spinal Segment CNXI, C2,3,4 C6,7,8 (posterior division) C5 (root) C5 (root) C5 (root) C5,6,7,8 T1 (lateral/ medial cord) C7,8 T1 (medial cord)
ANATOMY—MUSCLE TABLES
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Musculocutaneous
Radial
Musculocutaneous— medial Radial—lateral
Biceps
Triceps
Brachialis
Median
Median
Median
Median
Ulnar
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor carpi ulnaris
Forearm Region—Superficial Flexors
Nerve
Musculocutaneous
Muscle
Coracobrachialis
Arm Region Origin
Humerus, medial epicondyle, anterior radius Humerus, medial epicondyle, dorsal ulnar border
Humerus, medial epicondyle
Humerus, medial epicondyle
Humerus, medial epicondyle,coronoid
Anterior humerus
Coracoid Coracoid—short head Supraglenoid tubercle—long head Long head—infraglenoid tubercle Lateral head and medial head— posterior humerus
Middle phalangeal bases Pisiform, hamate, 5th metacarpal base
Palmar aponeurosis
2nd–3rd metacarpal bases
Radius, mid lateral
Ulna, coronoid process
Ulna, olecranon
C7,8 (medial cord)
C6,7 (medial and lateral cords) C6,7,(8) (medial and lateral cords) C7,8 T1 (medial and lateral cords) C7,8 T1 (medial and lateral cords)
C5,6 (lateral posterior cord)
C6,7,8 (T1) (posterior cord)
C5,6 (lateral cord)
Radius (radial tuberosity)
Spinal Segment C6,7 (lateral cord)
Insertion Humerus, mid/medial
Anatomy—Muscle Tables 8
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Median (anterior interosseous)
Pronator quadratus
Radial
Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous)
Extensor digitorum communis Extensor digiti minimi Extensor carpi ulnaris
Radial
Radial
Radial
Anconeus
Extensor carpi radialis brevis Extensor carpi radialis longus
Brachioradialis
Forearm Region—Superficial Extensors
Median (anterior interosseous)
Nerve Median (anterior interosseous)—index/long, Ulnar—ring/small
Flexor pollicis longus
Flexor digitorum profundus
Muscle
Forearm Region—Deep Flexors
Humerus, lateral supracondylar ridge Humerus, lateral supracondylar ridge Humerus, lateral epicondyle Humerus, lateral epicondyle Humerus, lateral epicondyle Common extensor tendon Humerus, lateral epicondyle
Distal ulna
Spinal Segment
C6,7,8 (posterior cord) C6,7,8 (posterior cord) C6,7,8 (posterior cord)
Small finger extensor apparatus 5th metacarpal base
C7,8 (posterior cord)
C(5),6,7,(8) (posterior cord)
C(5),6,7,(8) (posterior cord)
C5,6 (posterior cord)
C8 T1 (medial and lateral cords) C7,8 T1 (medial and lateral cords)
C7,8 T1 (medial and lateral cords)
Extensor aponeurosis
Ulna, proximal dorsal
2nd metacarpal base
3rd metacarpal base
Radius, distal lateral
Volar distal radius
Thumb distal phalangeal base
Radius, anterior and lateral
Insertion Distal phalangeal bases
Origin Ulna, anterior and medial
9 Anatomy—Muscle Tables
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Ulnar
Median Ulnar
Adductor pollicis
Median
Opponens pollicis
Flexor pollicis brevis - Superficial head - Deep head
Median
Nerve Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous)
Abductor pollicis brevis
Hand/Wrist—Thenar Muscles
Extensor indicis proprius
Extensor pollicis longus
Extensor pollicis brevis
Abductor pollicis longus
Supinator
Muscle
Forearm Region—Deep Extensors
Flexor retinaculum, trapezium
Trapezium Capitate, 2nd–3rd metacarpal
Scaphoid, trapezoid
Ulna, dorsolateral
Ulna, dorsolateral
Radius, dorsal
Radius, dorsal ulna
Origin Humerus, lateral epicondyle, ulna
Proximal phalangeal base, ulnar
Proximal phalangeal base, radial Thumb metacarpal Proximal phalangeal base, ulnar
Thumb proximal phalangeal base Thumb dorsal phalangeal base Index finger extensor aponeurosis (ulnar)
1st metacarpal base
Radius, dorsolateral
Insertion
C8 T1 (medial and lateral cord) C8 T1 (medial cord)
C8 T1 (medial cord)
C8 T1 (medial and lateral cord)
C8 T1 (medial and lateral cord)
C6,7,8 (posterior cord)
C6,7,8 (posterior cord)
C6,7,8 (posterior cord)
C6,7,8 (posterior cord)
C5,6,7 (posterior cord)
Spinal Segment
Anatomy—Muscle Tables 10
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Ulnar
Ulnar
Ulnar
Ulnar
Ulnar
Ulnar
Dorsal interossei
Volar interossei
Hand/Wrist—Intrinsic Muscles Median (index and middle) Lumbrical Ulnar (ring and small)
Opponens digiti minimi
Abductor digiti minimi Flexor digiti minimi brevis
Palmaris brevis
Hand/Wrist —Hypothenar Muscles Muscle Nerve
Metacarpal shaft
Metacarpal shaft
Flexor digitorum profundus (radially)
Hamate, transverse carpal ligament Hamate, transverse carpal ligament
Pisiform
Origin Transverse carpal ligament, palmar aponeurosis
Proximal phalangeal base, extensor apparatus Proximal phalangeal base, extensor apparatus
Radial aspect of lateral bands
Small finger metacarpal
Proximal phalangeal base, ulnar
Proximal phalangeal base, ulnar
Ulnar palm (fascial)
Insertion
C8 T1 (medial cord)
C8 T1 (medial cord)
C7,8 T1 (medial & lateral cords) C8 T1 (medial cord)
C8 T1 (medial cord)
C8 T1 (medial cord)
C8 T1 (medial cord)
C8 T1 (medial cord)
Spinal Segment
11 Anatomy—Muscle Tables
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Femoral
Psoas
Rectus femoris (direct and indirect heads)
Inferior pubic rami
Obturator (anterior) Obturator (anterior)
Pubic rami, anterior Inferior symphysis pubic arch
Obturator (posterior)
Adductor brevis
Adductor longus Gracilis
Adductor magnus
Inferior pubic rami, ischial tuberosity
Transverse process L1–L5 Direct: Ilium, anterior inferior spine Indirect: acetabulum, superior rim Anterior superior iliac spine
Iliac fossa
Origin
Obturator (posterior) Sciatic (tibial) [predominant]
Hip Adductors
Femoral
Femoral
Iliacus
Sartorius
Nerve
Femoral
Muscle
Hip Flexors
Femur, linea aspera, and adductor tubercle Femur, linea aspera/pectineal line Femur, linea aspera Tibia, part of pes anserinus
Tibia, part of pes anserinus
Tibial tubercle (quadriceps mechanism)
Lesser trochanter
Lesser trochanter
Insertion
L2,3,4 (anterior) L2,3,4 (anterior)
L2,3,4 (anterior)
L2,3,4 (anterior) L4,5 (anterior)
L2,3,4 (posterior)
L2,3,4 (posterior)
L(1),2,3,4 (posterior)
L2,3,4 (posterior)
Spinal Segment
Anatomy—Muscle Tables 12
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Nerve to quadratus femoris
Quadratus femoris
Superior gluteal
Superior gluteal
Superior gluteal
Gluteus medius
Gluteus minimus
Tensor fascia lata
Hip Abductors
Nerve to quadratus femoris
Inferior gemellus
Nerve to obturator internus
Nerve to obturator internus
Obturator
Nerve to piriformis
Piriformis
Obturator externus Obturator internus Superior gemellus
Inferior gluteal
Gluteus maximus
Hip External Rotators Muscle Nerve
Ilium, anterior iliac crest
Ilium, between anterior and inferior gluteal lines
Ilium, between posterior and anterior gluteal lines
Ischial tuberosity
Ischial tuberosity
Outer ischial spine
Origin Ilium, posterior-to-posterior gluteal line Sacrum, anterior sciatic notch Ischiopubic rami, obturator membrane Ischiopubic rami, obturator membrane
Femur, anterior border of greater trochanter (base) Tibia, Gerdy’s tubercle via iliotibial band
Femur, greater trochanter
Femur, quadrate line
Femur, medial greater trochanter Femur, medial greater trochanter Femur, medial greater trochanter
Femur, trochlear fossa
Insertion Posterior femur (gluteal sling), iliotibial band Femur, proximal greater trochanter (piriformis fossa)
L4–S1 (posterior)
L4–S1 (posterior)
L4–S1 (posterior)
L4–S1 (anterior)
L4–S1 (anterior)
L5–S3 (anterior)
L5–S3 (anterior)
L2,3,4 (anterior)
S1,2 (posterior)
L5–S2 (posterior)
Spinal Segment
13 Anatomy—Muscle Tables
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66016_CH01_PTR.indd 14
Femoral
Femoral
Femoral
Sciatic (tibial)
Sciatic (peroneal)
Sciatic (tibial)
Peroneal
Vastus lateralis
Vastus medialis
Vastus intermedius
Posterior Thigh Biceps, long head
Biceps, short head
Semimembranosus
Semitendinosus
Deep peroneal
Deep peroneal
Extensor digitorum longus
Peroneus tertius
Leg Muscles—Anterior Compartment Tibialis anterior Deep peroneal Extensor hallucis Deep peroneal longus
Nerve
Anterior Thigh Muscle
Lesser toes, mid and distal phalanx 5th metatarsal
Fibula, extensor digitorum longus tendon
L4,5, S1 (posterior)
L4,5, S1 (posterior)
L4,5, S1 (posterior) L4,5, S1 (posterior)
Medial cuneiform, 1st metatarsal
L5, S1,2 (anterior)
L4,5, S1 (anterior)
L5, S1,2 (anterior)
L5, S1 (anterior)
L2,3,4 (posterior)
L2,3,4 (posterior)
L2,3,4 (posterior)
Spinal Segment
Great toe, distal phalanx
Tibia, anterior crest Oblique popliteal ligament, posterior capsule, posterior medial tibia, popliteus, medial meniscus
Tibia, lateral condyle
Fibular head, lateral tibia
Insertion Lateral patella (quadriceps mechanism) Medial patella (quadriceps mechanism) Patella (quadriceps mechanism)
Tibial condyle, fibula
Lateral tibia Mid fibula, interosseous membrane
Ischial tuberosity, proximal/lateral
Ischial tuberosity, medial Lateral linea aspera, lateral intramuscular septum Ischial tuberosity, distal–medial
Origin Iliotibial line, greater trochanter, lateral linea aspera Iliotibial line, medial linea aspera, supracondylar line Femur, anterior proximal shaft
Anatomy—Muscle Tables 14
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66016_CH01_PTR.indd 15 Origin Proximal fibula Distal fibula
Tibia Tibia/fibula, interosseous membrane
Tibial
Tibial
Superolateral calcaneus
Fibula
Femur, lateral femoral condyle fibula, head
Tibial
Tibial
Ankle/Foot Muscles—Dorsal Layer Extensor digitorum Deep peroneal brevis
Flexor hallucis longus Flexor digitorum longus Tibialis posterior
Popliteus
Leg Muscles—Deep Posterior Compartment
Leg Muscles—Superficial Posterior Compartment Distal femur, posterior medial and lateral Gastrocnemius Tibial femoral condyles Soleus Tibial Fibula, tibia Plantaris Tibial Femur, lateral femoral condyle
Leg Muscles—Lateral Compartment Muscle Nerve Peroneus longus Superficial peroneal Peroneus brevis Superficial peroneal
Lesser toes, proximal phalangeal base
Navicular, medial cuneiform
Lesser toes, distal phalanx
Great toe, distal phalanx
Proximal tibia
L4,5, S1 (posterior)
L5, S1 (anterior)
L5, S1 (anterior)
L5, S1 (anterior)
L5, S1 (anterior)
L5, S1,2 (anterior) L5, S1,2 (anterior) L5, S1 (anterior)
Calcaneus (Achilles tendon)
Spinal Segment L4,5, S1 (posterior) L4,5, S1 (posterior)
Calcaneus (Achilles tendon) Calcaneus
Insertion Medial cuneiform, 1st metatarsal 5th metatarsal tuberosity
15 Anatomy—Muscle Tables
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66016_CH01_PTR.indd 16 Origin Calcaneal tuberosity Calcaneal tuberosity Calcaneal tuberosity
Small toe, proximal phalanx
3–5 metatarsal shafts
(This layer also includes the tendons of the peroneus longus and tibialis posterior.)
Lateral plantar
Base of proximal phalanx
Base of 5th metatarsal head
Proximal phalanx medially
Lateral plantar
Flexor digitorum minimi brevis
Fibular sesamoid
Great toe—proximal phalanx
Plantar interossei
Lateral plantar
Adductor hallucis
Cuboid lateral cuneiform Oblique head—2nd–4th metatarsal base, transverse head—plantar metatarsophalangeal ligament; toes 2–4
Extensor digitorum longus tendon
Flexor digitorum longus tendon
Insertion Great toe—proximal phalangeal base Lesser toes, distal phalanx Base of 5th toe
Fourth Plantar Layer (Two Muscles and Two Tendons) Dorsal interossei Lateral plantar Metatarsal shafts
Medial plantar
Flexor hallucis brevis
Third Plantar Layer (Three Muscles)
(This layer also includes the tendons of the flexor digitorum longus and flexor hallucis longus.)
Second Plantar Layer (Two Muscles and Two Tendons) Quadratus plantae Lateral plantar Medial and lateral calcaneus Medial and lateral Flexor digitorum longus Lumbrical plantar tendon
First Plantar Layer (Three Muscles) Muscle Nerve Abductor hallucis Medial plantar Flexor digitorum brevis Medial plantar Abductor digiti minimi Lateral plantar
S1,2 (anterior)
S1,2 (anterior)
S1,2 (anterior)
L5, S1,2 (anterior)
L5, S1 (anterior)
S1,2 (anterior) L4,5, S1,2 (anterior)
Spinal Segment L4,5, S1 (anterior) L4,5, S1 (anterior) S1,2 (anterior)
Anatomy—Muscle Tables 16
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ANATOMY—APPROACHES Approach/ Eponym Interval—Muscle (nerve) Shoulder Deltopectoral— Henry Lateral Posterior
Deltoid (axillary) and pectoralis major (medial/lateral pectoral) Deltoid splitting no internervous plane (~ 5 cm limit) Infraspinatus (suprascapular) and teres minor (axillary)
Proximal Humerus Anterior Anterolateral Posterior Lateral Elbow Posterior Medial Anterolateral
Anterior Posterolateral— Kocher
Deltoid (axillary) and pectoralis major (medial/lateral pectoral) Medial brachialis (musculocutaneous) and lateral brachialis (radial) No true internervous interval Brachialis (radial) and brachioradialis (radial) No true internervous interval; long and lateral head of triceps superficial, medial head splitting deep (radial) No true internervous interval; Triceps (radial) and brachioradialis (radial)
No internervous plane Proximal—Brachialis (musculocutaneous) and triceps (radial) Distal—Brachialis (musculocutaneous) and pronator teres (median) Proximal—Brachialis (musculocutaneous) and brachioradialis (radial) Distal—Pronator teres (median) and brachioradialis (radial) Proximal—Brachialis (musculocutaneous) and brachioradialis (radial) Distal—Pronator teres (median) and brachioradialis (radial) Anconeus (radial) & extensor carpi ulnaris (posterior interosseous)
Forearm Anterior—Henry Dorsal— Thompson Ulnar
Proximal—Pronator teres (median) and brachioradialis (radial) Distal—Brachioradialis (radial) and flexor carpi radialis (median) Proximal—Extensor carpi radialis brevis (radial) and extensor digitorum communis (posterior interosseous) Distal—Extensor carpi radialis brevis (radial) and extensor pollicis longus (posterior interosseous) Extensor carpi ulnaris (posterior interosseous) and flexor carpi ulnaris (ulnar)
17
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Anatomy—Approaches Approach/ Eponym
18
Interval—Muscle (nerve)
Wrist Dorsal Scaphoid—volar Scaphoid— dorsolateral Pelvis Ilioinguinal Extended iliofemoral
No internervous plane; between 3rd and 4th dorsal compartments No internervous plane; between flexor carpi radialis (median) and radial artery No internervous plane; between extensor pollicis longus and extensor pollicis brevis (posterior interosseous)
No true internervous plane (along pelvic crest) Superficial—Sartorius (femoral) and tensor fascia lata (superior gluteal) Deep—Rectus femoris (femoral) and gluteus medius (superior gluteal)
Hip Anterior—SmithPeterson Anterolateral— Watson-Jones Lateral— Hardinge
Superficial—Sartorius (femoral) and tensor fascia lata (superior gluteal) Deep—Rectus femoris (femoral) and gluteus medius (superior gluteal) No true internervous plane; tensor fascia lata (superior gluteal) and gluteus medius (superior gluteal) No true internervous plane Deep—Splits gluteus medius proximally (superior gluteal) —Splits vastus lateralis distally (femoral)
Posterior— Southern/ Moore
No true internervous plane Splits gluteus maximus (inferior gluteal)
Medial—Ludloff
Superficial—No true internervous plane; adductor longus and gracilis (anterior division obturator) Deep—Adductor brevis (anterior division obturator) and adductor magnus (sciatic [tibial]) and posterior division of obturator)
Femur Lateral Anteromedial Posterolateral Posterior distal femur
66016_CH01_PTR.indd 18
No internervous plane; splits vastus lateralis (femoral) No true internervous plane Rectus femoris (femoral) and vastus medialis (femoral) Vastus lateralis (femoral) and hamstrings (sciatic) Biceps femoris (sciatic) and vastus lateralis (femoral)
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19 Approach/ Eponym
Anatomy—Approaches Interval—Muscle (nerve)
Knee Medial parapatellar Medial Lateral Posterior
No true internervous plane Vastus medialis (femoral) and rectus femoris (femoral) No true internervous plane Vastus medialis (femoral) and sartorius (femoral) Iliotibial band (superior gluteal) and biceps femoris (sciatic) Semimembranosus/medial gastrocnemius (tibial) and biceps femoris/lateral gastrocnemius (tibial)
Leg Anterior
Anterolateral
Posterolateral Fibula
No internervous plane; tibialis anterior (peroneal) and tibial periosteum Superficial—Peroneus brevis (superficial peroneal) and extensor digitorum longus (deep peroneal) Deep—Tibialis posterior (tibial) and extensor muscles (deep peroneal) Gastrocnemius, soleus, flexor hallucis longus (tibial) and peroneus brevis and longus (superficial peroneal) Peroneal muscles (superficial peroneal) and flexor muscles (tibial)
Ankle Anterior or Dorsal To Medial Malleolus To Lateral Malleolus Posteromedial Posterolateral
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No internervous plane; extensor hallucis longus (deep peroneal) and extensor digitorum longus (deep peroneal) No internervous plane; direct approach Peroneus tertius (deep peroneal) and peroneus brevis (superficial peroneal) No internervous plane; tibialis posterior or flexor digitorum longus (tibial) and flexor digitorum longus or flexor hallucis longus (tibial) Peroneus brevis (superficial peroneal) and flexor hallucis longus (tibial)
11/17/2009 12:18:20 AM
Anatomy—Approaches
20 POPSIQ Mnemonic Pudendal nerve and artery Nerve to obturator internus Posterior femoral cutaneous nerve Sciatic nerve Inferior gluteal nerve and artery Nerve to quadratus femoris
Contents of the Sciatic Notch (Greater Sciatic Notch) Above the Piriformis Superior gluteal nerve Superior gluteal artery Below the Piriformis Inferior gluteal nerve Inferior gluteal artery Pudendal nerve Internal Pudendal nerve Nerve to the Obturator internus Sciatic nerve Posterior femoral cutaneous nerve Nerve to Quadratus femoris
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Damian Rispoli 2009
Lesser Sciatic Notch
Greater Sciatic Notch
11/17/2009 12:18:20 AM
ANATOMY—CROSS SECTIONS Proximal Arm Cross Section Cephalic v.
Short head, biceps Coracobrachialis
Pectoralis major
Median antebrachial cutaneous n. Basilic v. Median n. Ulnar n. Brachial a. and v.’s
Long head, biceps Musculocutaneous n. Humerus Lateral head, triceps
Medial brachial cutaneous n. Radial n.
Deltoid Long head, triceps
Teres major
Latissimus dorsi tendon Damian Rispoli 2009
Mid Arm Cross Section Lateral antebrachial cutaneous n. Humerus Medial intermuscular septum
Cephalic v. Brachialis
Biceps brachii Median n.
Posterior antebrachial cutaneous n.
Medial antebrachial cutaneous n.
Radial collateral a. Lateral IM septum Radial n.
Medial brachial cutaneous n. Basilic v.
Middle collateral a. Brachial a. and v.’s
Lateral head, triceps
Ulnar n. Superior ulnor collateral a.
Medial head, triceps Long head, triceps
Damian Rispoli 2009
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Anatomy—Cross Sections
22
Distal Arm Cross Section Biceps
Brachial fascia
Cephalic v.
Brachialis
Lateral antebrachial cutaneous n.
Median n. Medial antebrachial cutaneous n.
Brachioradialis Radial n.
Brachial a. & v.
Extensor carpi radialis longus
Ulnar n. Medium IM septum
Posterior antebrachial cutaneous n.
Triceps Humerus
Lateral IM septum
Triceps tendon
Damian Rispoli 2009
Proximal Forearm Cross Section (volar=top, right=ulnar) Radius
Superficial branch radial n. Medial antebrachial v. Radial a.
Brachioradialis
Pronator teres Medial antebrachial cutaneous n. Palmaris longus Flexor carpi radialis Flexor digitorum superficialis
Cephalic v. Lateral antebrachial cutaneous n. Extensor carpi radialis longus
Ulnar n. Flexor carpi ulnaris
Extensor carpi radialis brevis
Flexor digitorum profundus
Radial n. Extensor digitorum communis Extensor digiti quinti minimi
Anconeus FP longus
Posterior antebrachial cutaneous n.
Supinator
Median n., Ulnar a. & Common Interosseous a. (volar to dorsal) Ulna
Extensor carpi ulnaris Damian Rispoli 2009
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23
Anatomy—Cross Sections Mid Forearm Cross Section (volar=top, right=ulnar) Flexor carpi radialis
Flexor pollicus longus
Brachioradialis
Palmaris longus
Radial a. Superficial branch radial n.
Flexor digitorum superficialis Median n.
Extensor carpi radialis longus
Ulnar a. & n.
Radius
Flexor carpi ulnaris
Extensor carpi radialis brevis
Flexor digitorum profundus
Abductor pollicis longus
Ulna Extensor carpi ulnaris Interosseous membrane
Extensor digitorum Posterior interosseous n. & a. Extensor digiti minimi
Anterior interossous n. & a.
Damian Rispoli 2009
Wrist Cross Section (volar=top, right=ulnar) Palmaris longus
**Median n. Superficialis tendons** Profundus tendons**
**Flexor pollicis longus
Ulnar a.
Flexor carpi radialis
Ulnar n. Flexor carpi ulnaris
Radial a.
Compartment 6 Extensor carpi ulnaris Compartment 1 Abductor pollicis brevis Extensor pollicis brevis Compartment 2 Extensor carpi radialis longus & brevis
Compartment 5 Extensor digiti minimi
Compartment 3 Extensor pollicis longus
**Contents of the Carpal Tunnel Damian Rispoli 2009
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Compartment 4 Extensor digitorum & indicis proprius (indep. extensor is ulnar to the common extensor)
The posterior interosseous nerve is on the radial aspect of the floor of the 4th dorsal compartment
11/17/2009 12:18:22 AM
Anatomy—Cross Sections
24
Proximal Thigh Cross Section (anterior=top, right=medial) Lateral femoral cutaneous n.
Sartorius
Femoral and Deep femoral a. & v. Femoral n. Adductor longus Saphenous n.
Rectus femoris Tensor fascia lata Vastus mediaIis
Pectineus Obturator n. (ant.) Adductor brevis Obturator n. (post.) Gracilis
Iliopsoas Vastus intermedius Femur
Adductor magnus Semimembranosus Semitendonosus
Vastus lateralis Gluteus maximus Sciatic n.
Biceps femoris
Posterior femoral cutaneous n.
Damian Rispoli 2009
Mid Thigh Cross Section (anterior=top, right=medial) Vastus medialis Femoral a. & v.
Rectus femoris
Saphenous n & n. to v. medius
Vastus intermedius
Sartorius Adductor longus Adductor brevis
Vastus lateralis
Gracilis
Femur Iliotibial tract Biceps femoris, short head Biceps femoris, long head Damian Rispoli 2009
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Great saphenous v. Adductor magnus Deep femoral a. & v. Sciatic n. Semimembranosus Semitendonosus
11/17/2009 12:18:22 AM
25
Anatomy—Cross Sections Distal Thigh Cross Section (anterior=top, right=medial) Q femoris tendon Vastus intermedius
Vastus medialis
Articularis genu
Femur Adductor magnus tendon
Iliotibial tract
Saphenous n. Descending genicular a.
Vastus lateralis Popliteal a.
Sartorius Tibial n. Great saphenous v.
Common peroneal n. Biceps femoris
Gracilis
Semitendonosus Popliteal v.
Semimembranosus
Damian Rispoli 2009
Mid Leg Cross Section (anterior = top, right = medial) (A)
Anterior tibial a. & v. Deep peroneal n.
(A) (A)
Extensor hallucis longus
Extensor digitorum longus
Tibialis anterior(A) Tibia Tibialis posterior(DP)
(L)
Superficial peroneal n. (L)
Peroneus longus
(L)
Peroneus brevis Fibula
(DP) Flexor hallucis longus Lateral sural cutaneous n. (SP)
Lateral gastrocnemius
Personeal communicating branch of lateral saphenous n.
Great saphenous v. Saphenous n. Flexor digitorum longus(DP) Posterior tibial a. & v. Tibial n.(DP) Soleus(SP) Plantaris(SP) Medial gastrocnemius(SP) Medial sural cutaneous n.(SP) Lessor saphenous v.
Compartments: Anterior(A), Lateral(L), Deep Posterior(DP), Superficial Posterior(SP) Damian Rispoli 2009
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Structures at the elbow (Radial to Ulnar) Tendon – Artery – Nerve
Axillary artery
Anterior humeral circumflex
Posterior humeral circumflex
Deltoacromial branch
Thoracoacromial trunk
Pectoralis minor Thoracodorsal artery
Lateral thoracic artery
Supreme thoracic artery
Transverse cervical artery Thyrocervical trunk
Damian Rispoli 2009
Circumflex scapular artery Subcapular artery
Supracapular artery
Arteries about the Shoulder
ANATOMY—ARTERIES
26
11/17/2009 12:18:23 AM
27
Anatomy—Arteries Arteries about the Elbow
Superior ulnar collateral a. Inferior ulnar collateral a.
Middle collateral a.
Anterior ulnar recurrent a.
Radial collateral a.
Posterior ulnar recurrent a.
Brachial a.
Ulnar recurrent a. Radial recurrent a. Radial a. Interosseous recurrent a.
Ulnar a. Common interosseous a. Anterior interosseous a. Posterior interosseous a. Damian Rispoli 2009
Shoulder Spaces and Intervals (posterior view of shoulder)
Teres minor
Supraspinatus Infraspinatus Axillary n.
Triangular space Circumflex scapular a. Teres major
Damian Rispoli 2009
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Posterior humeral circumflex a. Quadrangular space Triceps, lateral head Radial n. Profunda brachii a. Traingular interval Triceps, long head
11/17/2009 12:18:24 AM
Anatomy—Arteries
28
Arteries of the Forearm Brachial a. Anterior ulnar recurrent a. Posterior ulnar recurrent a. Common interosseous a. Ulnar a.
Anterior interosseous a.
Dorsal carpal branch Superficial palmar branch
Radial recurrent a. Interosseous recurrent a. Posterior interosseous a. (behind IO membrane)
Radial a. Palmar branch Anterior interosseous a. Palmar carpal branch Damian Rispoli 2009
Nerves Frame the Wrist (Radial to Ulnar) Superficial branch of the radial nerve–radial artery–median nerve–ulnar artery–ulnar nerve
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29
Anatomy—Arteries Pelvic Arteries Iliolumbar a. Aorta External iliac a.
Common iliac a. Lateral sacral a. & branches
Internal iliac a. (hypogastric a.)
Middle rectal a. Internal pudendal a.
Superior gluteal a.
Superior vesicular a.
Obturator a. Damian Rispoli 2009
Vasculature of the knee Descending genicular a.
Descending branch of deep femoral a.
Hunter’s Canal
Femoral a. Saphenous a.
Articular a.
Popliteal a. Medial superior genicular a. Lateral superior genicular a.
Lateral superior genicular a.
Middle genicular a.
Lateral inferior genicular a.
Lateral inferior genicular a.
Anterior tibial recurrent a. Anterior tibial a. Damian Rispoli 2009
Posterior tibial a.
Medial inferior genicular a. Peroneal a.
Behind the Knee - Medial to Lateral Artery -Vein-Nerve
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ANATOMY—LIGAMENTS Glenohumeral Ligaments (lateral disarticulated view) Coracoacromial ligament Superior glenhumeral ligament
Acromion
Coracoid
Biceps tendon (long head)
Subscapularis Middle glenohumeral ligament
Infraspinatus Axillary pouch Teres minor Damian Rispoli 2009
Anterior inferior glenohumeral ligament Posterior inferior glenohumeral ligament
Shoulder (posteriorly) Triangular space—Circumflex scapular artery Quadrangular space—Posterior humeral circumflex artery, axillary nerve Triangular interval—Profunda brachii artery, radial nerve Axillary artery (divided into three parts by the pectoralis minor muscle) 1. Supreme thoracic artery (before muscle, one branch) 2. Thoracoacromial and lateral thoracic arteries (under muscle, two branches) 3. Subscapular, anterior, and posterior humeral circumflex arteries (after muscle, three branches) MEDIAL LAYERS OF THE KNEE (JBJS 61A:56-62, 1979) I. Sartorius and fascia II. Superficial medial collateral ligament, posterior oblique ligament, semimembranosus III. Deep medial collateral ligament, capsule LATERAL LAYERS OF THE KNEE (JBJS 64A:536-541, 1982) I. Iliotibial tract, biceps (peroneal nerve deep to layer I) II. Patellar retinaculum, patellofemoral ligament, popliteofibular ligament III. Arcuate ligament, fabella-fibular ligament, capsule, lateral collateral ligament 30
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31
Anatomy—Ligaments
Volar Wrist Ligaments
Triquetrocapitate ligament
Deltoid ligament (V)
Space of “Poirier” Radial collateral ligament
Lunotriquetral ligament Ulnolunate ligament
Radioscaphocapitate ligament
Short radiolunate ligament
Radioscapholunate ligament Radiolunate ligament (long radiolunate)
Damian Rispoli 2009
Elbow Ligaments
Annular Ligament
Radial Collateral Ligament
Lateral
Lateral ulnar collateral Ligament
Anterior Bundle
Medial
Transverse Bundle
Most important to stability
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Posterior Bundle
Damian Rispoli 2009
11/17/2009 12:18:27 AM
Anatomy—Ligaments
32
Pelvic Ligaments Iliolumbar Ligaments Anterior Sacral Ligaments
Sacrum Sacrospinous Ligament Sacrotuberous Ligament Arcuate Line (Pelvic Brim)
Ischial Spine Pubic rami Damian Rispoli 2009
Knee Ligaments Meniscofemoral ligaments Humphreys Anterior to PCL Wrisberg Posterior to PCL
Anterior cruciate ligament
Patellar tendon Transverse (intermeniscal ligament) Lateral Meniscus Popliteus
Medial Meniscus
Semimembranosus tendon
Posterior cruciate ligament
Damian Rispoli 2009
Lateral Meniscus more mobile (1-1.5cm/3x > medial) Medial Meniscus tethered by medial collateral ligament
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33
Anatomy—Ligaments Posterior Knee Ligaments/Tendons (medial=right, lateral=left) Plantaris
Medial gastrocnemius
Lateral gastrocnemius Adductor tubercle
Lateral collateral ligament Popliteus tendon
Semimembranosus
Five Insertions of the Semimembranosus 1. Oblique Popliteal ligament 2. Posterior capsule 3. Posteromedial tibia (main) 4. Popliteus 5. Medial meniscus
Oblique popliteal ligament Fabellofibular ligament Arcuate ligament Popliteus
Damian Rispoli 2009
Ankle Ligaments Posterior
Anterior Posterior inferior tibiofibular ligament
Deltoid ligament Posterior talofibular ligament (PTFL)
Anterior talofibular ligament (ATFL) Calcaneofibular ligament (CFL) Ligaments of the syndesmosis Anterior inferior tibiofibular ligament Posterior inferior tibiofibular ligament Transverse tibiofibular ligament Interosseous ligament Interosseous membrane
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Anterior inferior tibiofibular ligament Superficial deltoid Deep deltoid (more horizontal)
Damian Rispoli 2009
11/17/2009 12:18:28 AM
Anatomy—Ligaments
34
Finger Extensor Apparatus
A A
H
B
I
C
D
D
K C
E F G
E L G F
A. Terminal tendon B. Triangular ligament C. Transverse retinacular ligament D. Conjoined lateral band E. Oblique & transverse fibers of the intrinsic apparatus F. Lumbrical muscle (originating on the radial side of the flexor digitorum profunds tendon) G. Interossei muscle H. Flexor digitorum profundus insertion I. Flexor digitorum profundus tendon J. Extensor digitorum communis tendon K. Flexor digitorum superficialis tendon L. Sagittal bands Damian Rispoli 2009
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35
Anatomy—Ligaments Finger Puller Systam C1
C2
A1
A3
A2 MC
C3
P1
A4 P2
P3
Damian Rispoli 2009
A2 & A4 most important (prevents tendon bowstringing) A1 released in surgical treatment of a trigger digit
Brachial Plexus Roots
Trunks Divisions Cords
Branches
Trunks = upper, middle, lower Divisions = anterior and posterior Cords = lateral, posterior, medial
Dorsal scapular n. N. to Subclavius Suprascapular n. Long thoracic n. Lateral pectoral n. Medial pectoral n. Upper subscapular n. Thoracodorsal n. Lower subscapular n.
Musculocutaneous n. Axillary n. Radial n. Median n. Ulnar n. Medial brachial & antebrachial cutaneous n.
Plexus Mnemonic - Robert Taylor Drinks Cold Beer Roots, Trunks, Divisions, Cords, Branches Posterior Branches Mnemonic - STAR (medial to lateral) Subscapular (upper and lower surround thoracodorsal n.) Thoracodorsal Axillary Radial Damian Rispoli 2009
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ANATOMY—NERVE PLEXI Lumbar Plexus
Anterior Divisions
T12
Subcostal n.
L1
Iliohypogastric n. Ilioinguinal n.
L2
Anterior & Posterior Divisions
L3 Posterior Divisions
Lateral femoral cutaneous n. (L2,3)
L4 L5
Femoral n. (L2,3,4) Lumbosacral trunk Accessory obturator n. (L3,4) Obturator n. (L2,3,4) Damian Rispoli 2009
Sacral Plexus (Posterior Division) L4 L5 S1 S2 Anterior Division S3
Perforating cutaneous n. Posterior femoral cutaneous n. (S1,2 & Anterior S2,3)
Superior gluteal n. (L4,5,S1) Inferior gluteal n. (L5,S1,2) N. to piriformis Common peroneal (L4,5,S1,2) Damian Rispoli 2009
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Anatomy—Nerve Plexi
Sacral Plexus (Anterior Division) L4 L5 S1 S2 S3 S4
Pudendal n. (S2,3,4)
Tibial n. (L4,5,S1,2,3)
Posterior femoral cutaneous n. (S2,3, & posterior S1,2) To obturator internus & superior gemellus
To quadratus femoris & inferior gemellus Damian Rispoli 2009
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Anatomy—Nerve Plexi
38
C2 C2 C3
C5 C 5T 1
C6 C7 C8
C4
T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 L1 T12 L2 L3
C8 C8
C6
C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T8 T7 T9 T10 T12 T11 L1 L2 L3 L4 L5 S1 S2
C7 C8 S2
S1 S2
L4
S1 L5
S1
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S2
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ANATOMY—PERIPHERAL NERVES
Axillary (C5,6) and Musculocutaneous (C(4),5,6,7)
Lateral cord Posterior cord Medial cord
Deltoid Lateral Brachial cutaneous n. Coracobrachialis Biceps, short head
Brachialis (medial 1/2)
Biceps, long head
Lateral antebrachial cutaneous n. anterior & posterior branches
Damian Rispoli 2009
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Anatomy—Peripheral Nerves
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Median (C(5),6,7,8,T1) Anterior Interosseous n. -Flexor pollicis longus -Flexor digitorum profundus (index/long) -Pronator quadratus
Median n.
Pronator teres Palmaris longus Flexor carpi radialis Flexor digitorum superficialis Flexor pollicis longus
Lateral cord Posterior cord Medial cord
Median innervated hand muscles LOAF Lumbricals Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis
Flexor digitorum profundus (to index/middle) Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis Lumbricals Pronator quadratus Damian Rispoli 2009
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Anatomy—Peripheral Nerves
Radial (C5,6,7,8,T1) Lateral cord Posterior cord Medial cord Triceps, lateral head Triceps, long head Triceps, medial head Brachioradialis Ext. carpi radialis longus Anconeus PIN* Extensor carpi radialis brevis Extensor digitorum communis Extensor digiti quinti minimi Extensor carpi ulnaris
Last muscle to be innervated and last to recover – Extensor indicis proprius
Posterior brachial cutaneous n. Brachialis (lateral 1/2) Lateral antebrachial cutaneous n. Supinator Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis proprius *PIN = Posterior interoseous n. Damian Rispoli 2009
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Anatomy—Peripheral Nerves
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Ulnar (C(7),8,T1) Lateral cord Posterior cord Medial cord Ulnar n. Dorsal cutaneous branch
Last muscle to be innervated – 1st Dorsal interossei (index finger abduction)
Palmar cutaneous branch Flexor carpi ulnaris Flexor digitorum profundus (to ring/small) Dorsal and volar Interossei
Palmaris brevis Abductor digiti minimi Opponens minimi Flexor digiti minimi
Lumbricals (ring/small) Damian Rispoli 2009
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Anatomy—Peripheral Nerves
Femoral (L2,3,4(posterior)) & Obturator (L2,3,4(anterior))
Psoas major Iliacus Rectus femoris Sartorius Vastus medialis Obturator externus
Vastus lateralis Vastus intermedius Articularis genu
Pectineus Adductor longus Damian Rispoli 2009
Adductor brevis Gracilis Adductor magnus
Superior gluteal n. (L4,5,S1) - Gluteus medius, Gluteus minimus, Tensor fascia lata Inferior gluteal n. (L5,S1,2) - Gluteus maximus
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Anatomy—Peripheral Nerves
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Sciatic - Tibial Division (L4,5,S1,2,3) L4 L5 S1 S2 S3 Biceps femoris, long head
Adductor magnus Semitendonosus Semimembranosus
Gastrocnemius Soleus Tibialis posterior Flexor hallucis longus Abductor digiti minimi Flexor digitorum brevis
Popliteus Gastrocnemius Flexor digitorum longus
Abductor Hallucis Lumbricals
Quadratus plantae Flexor digiti minimi brevis & interossei Lumbricals
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Medial plantar n. Flexor hallucis brevis Adductor hallucis
Lateral plantar n. Damian Rispoli 2009
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Anatomy—Peripheral Nerves
Sciatic - Common Peroneal (L4,5,S1,2) L4 L5 S1 S2
Biceps femoris, short head Tibialis anterior Extensor hallucis brevis
Extensor hallucis longus Peroneus longus Peroneus brevis Extensor digitorum longus Peroneus tertius Extensor digitorum brevis Damian Rispoli 2009
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ANATOMY—PERIPHERAL NERVES/DERMATOMES Upper Extremity Peripheral Nerve Sensory Innervation Anterior
Posterior Supraclavicular n.
Anterior pectoral n.
Axillary n. Radial n. Inferior lateral brachial cutaneous n.
Lateral cutaneous n. Medial antebrachial cutaneous n.
Lateral antebrachial cutaneous n.
Ulnar n.Palmar cutaneous br.
Superficial branch radial n. Median n. Palmar cutaneous br.
Ulnar n.
Median n.
Radial n. Posterior brachial cutaneous n. Radial n. Posterior antebrachial cutaneous n. Ulnar n. Damian Rispoli 2009
Upper Extremity Dermatome Anterior
Posterior C4 T1 C5 C6 C7 C8 Damian Rispoli 2009
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Anatomy—Peripheral Nerves/Dermatomes
Lower Extremity Peripheral Sensory Innervation Posterior
Anterior FemoralGenitofemoral n. Obturator n. Lateral femoral cutaneous n. Posterior femoral cutaneous n. Saphenous n.
Tibial n. Lateral sural cutaneous n. Sural n.
Lateral calcaneal n.
Superficial peroneal n.
Medial calcaneal n. Medial plantar n.
Deep peroneal n.
Lateral plantar n.
Damian Rispoli 2009
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Anatomy—Peripheral Nerves/Dermatomes
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Lower Extremity Dermatome Anterior L1
Posterior L2 L3
S3 S4
L4
S5 C1
L2
L5 S2 S1
L3
L1 L2
L4
L5
S1 L4
L5
Damian Rispoli 2009
REFERENCES FOR ANATOMY SECTION Hollingshead WH. Anatomy for Surgeons. Vol. 3. 2nd ed. New York, NY: Harper and Rowe; 1969. Hoppenfeld S, DeBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 3rd ed. Philadelphia, PA: JB Lippincott; 2004. Miller MD, ed. Review of Orthopaedics. 4th ed. Philadelphia, PA: WB Saunders; 2004. Netter FH. The CIBA Collection of Medical Illustrations. Vol. 8. Summit, NJ: CIBA–Geigy; 1991. Pansky B. Review of Gross Anatomy. 5th ed. New York, NY: Macmillan; 1984.
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S. aureus, Streptococcus, gram-negative bacilli
N. gonorrhea (more common and most commonly missed), S. aureus, Streptococcus, rare aerobic gram negative bacilli
15+ years (sexually active)
15+ years (not sexually active)
S. aureus 27%, S. pyogenes and S. pneumonia 14%, H. influenza 3%, gram negative bacilli 6%, other 14% (unknown 36%)
S. aureus, Enterobacter, Group B Streptococcus, N. gonorrhea (Blood cultures often positive)
3 months—14 years
Birth—3 months
Acute Single Joint Age/Condition Common Microbes
Treatment/Notes 1st: MRSA not likely, nafcillin or oxacillin and IV cephalosporin with antipseudomonal activity 2nd: MRSA possible, vancomycin and IV cephalosporin with antipseudomonal activity Note: Also consider contiguous osteomyelitis. Especially in femoral head, proximal humerus, and radial head (up to 60% have bony involvement) 1st: Vancomycin and IV cephalosporin with antipseudomonal activity until culture results available, then tailor Note: H. influenza decreased since widespread vaccination in use 1st: Gram stain negative; ceftriaxone 1 g IV qd or cefotaxime or ceftizoxime 1 g IV q8h 2nd: Gram-positive cocci in clusters; vancomycin 1 gm IV q12h Note: S. aureus accounts for 50–80%. Cultures usually blood negative, joint positive. N. gonorrhea may not require operative irrigation and debridement. 1st: Vancomycin 1 gm IV q12h IV and cephalosporin with antipseudomonal activity 2nd: Vancomycin 1 gm IV q12h and ciprofloxacin or levofloxacin Note: Consider CPPD and gout (see joint fluid analysis section).
Typically requires operative drainage and antibiotics. Empiric therapy is initiated following cultures (blood, synovial fluid and/ or biopsy). Duration 2 weeks (H. influenza, Streptococcus sp., N. gonorrhea) 3 weeks (Staphylococcus sp. and GNR) [Mader JT, JBJS. 2001;83A(12):1878–1890.]
ARTHRITIS—SEPTIC
ANTIMICROBIALS
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N. gonorrhea, B. burgdorferi, acute rheumatic fever, hepatitis B, Parvovirus B19, rubella vaccine
B. burgdorferi
Adult
Lyme arthritis
1st: Doxycycline 100 mg po bid or amoxicillin 500 mg po qid x 30–60 days 2nd: Ceftriaxone 2 gm IV qd or PCN G 20–24 mU/d IV x 14–28 days
1st: Ceftriaxone 1 g IV qd Gram stain not usually helpful! Remember to screen for sexually transmitted disease. Consider Lyme if indicated, polyarticular gout, autoimmune disease.
Treatment/Notes ≤ 4–6 weeks: Irrigate and débride, antibiotics, retain prosthesis, 20–30% success >4–6 weeks: Irrigate and débride, remove prosthesis, antibiotic spacer, IV antibiotics, reimplant 6–12 wks (low virulence), 1 yr (virulent), 90–95% success Note: Culture/obtain tissue before initiating therapy. Susceptibilities are key. See tissue frozen section parameters in joint fluid analysis section.) (See
Bites **No pharmacological treatment substitutes for an adequate irrigation and if indicated a debridement of devitalized tissue. 1st: Amoxicillin/clavulanate (po) 875/125 mg bid or 500/125 mg tid Dog P. multocida, S. aureus, EF-4, 2nd: Clindamycin 300 mg po qid and either fluoroquinolone (adults) or trimethoprim/ NEJM 340:85–92, Bacteroides, Fusobacterium, sulfamethoxazole (kids) 1999 Capnocytophaga canimorsus Note: 5% of dog bites get infected, consider rabies 1st: Amoxicillin/clavulanate (po) 875/125 mg bid or 500/125 mg tid 2nd: Cefuroxime 500 mg po q12h or doxycycline 100 mg po bid (No cephalexin) Cat P. multocida, S. aureus NEJM 340:138, 1999 Note: Soft tissue rest, consider surgical drainage; hand is a common site. Beware puncture of teeth into tendon sheaths/joints. 80% get infected.
S. aureus, epidermidis 20–30%; Streptococcus, gram negative 15–25%; anaerobic 5–10%
Total joint
Acute Multiple Joints Age/Condition Common Microbes
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Bites **No pharmacological treatment substitutes for an adequate irrigation and if indicated a debridement of devitalized tissue. Age/Condition Common Microbes Treatment/Notes 1st: Amoxicillin/clavulanate (po) 875/125 mg bid or 500/125 mg tid Catfish barb Toxins Note: Antibiotics for prophylaxis. Barbs may need to be excised. Beware tendon sheath and joint penetration. 1st: Antibiotics as necessary prophylaxis with ceftriaxone Pseudomonas, Enterobacter, Snake (pit viper) Note: Antivenom is treatment. Give till symptoms resolve. Rarely need fasciotomy. NEJM 347:347, S. epidermidis, Clostridium Think tetanus! Follow for compartment syndrome. 2002 species Crotalidae is responsible for 99% of snakebites in the United States. Antivenin rather than surgery is the treatment of choice in severe rattlesnake envenomation in kids (JBJS 84A(19)1624–1629). Adult snake bites 80% upper extremities. Children upper = lower extremities. 1st: Amoxicillin/clavulanate (po) 875/125 mg bid or 500/125 mg tid Streptococcus and Miscellaneous— 2nd: Doxycycline 100 mg po bid (pig), 3rd generation cephalosporin, ticarcillin/clavulanate, Staphylococcus, bat, raccoon, ampicillin/sulbactam, imipenem Streptobacillus moniliformis skunk, rat, pig Note: Consider rabies immune globulin and vaccine if animal not available for testing or (rat) tests positive. 1st: Prophylaxis: amoxicillin/clavulanate (po) 875/125 mg bid x 5d; Otherwise: ampicillin/ Viridans strep 100%, sulbactam 1.5 g IV q6h or cefoxitin 2 g IV q8h or ticarcillin/clavulanate 3.1 g IV q6h or staph epidermidis 53%, piperacillin/tazobactam 3.375 g IV q6h; PCN allergy: clindamycin and ciprofloxacin or Corynebacterium 41%, Human trimethoprim/sulfamethoxazole S. aureus 29%, E. corrodens Note: Fight bites: Unreliable history from intoxicated patient. Joint penetration = surgical 15%, Bacteroides 82%, drainage. Be sure to check location of wound in all degrees of joint range of motion. People Peptostreptococcus 26% punch with closed fists and sustain layered penetration!
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Candida species
Herpes simplex
Herpetic whitlow
Water immersion
S. aureus, MRSA possible
Polymicrobial
Aerobic gram positive cocci, S. aureus, Enterococci
Nail biting
Hand/Paronychia
Chronic, recurrent limb threatening
Diabetic Foot Previously treated, limited, no osteomyelitis
Bursitis (May need wound debridement) Age/Condition Common Microbes S. aureus > 80%, rare Adult Mycobacterium tuberculum and marinum
1st: Irrigation/débride, obtain cultures 2nd: Trimethoprim/sulfamethoxazole 160/800 mg po bid pending culture results 1st: Acyclovir 400 mg po tid x 10 days 2nd: Famciclovir or valacyclovir Notes: Gram stain and culture negative. May be confused for a felon! 1st: Topical clotrimazole Note: Avoid hand immersion
1st: Not limb threatening. No sepsis: amoxicillin/sulbactam, piperacillin/tazobactam, ticarcillin/clavulanate, clindamycin and ceftriaxone/cefotaxime, ciprofloxacin, levofloxacin, or aztreonam 2nd: Septic/severe: Imipenem or meropenem or ertapenem and vancomycin Note: Superficial ulcer cultures unreliable. Surgical debridement essential. High index of suspicion for necrotizing fasciitis or osteomyelitis.
1st: Clindamycin 300 mg po qid or 1st-generation cephalosporin, amoxicillin/clavulanate (po) Note: Clindamycin 300 mg po qid or cephalexin 500 mg po qid x14d 90% cure
Treatment/Notes 1st: MSSA; nafcillin, oxacillin, or dicloxacillin 2nd: MRSA; vancomycin or linezolid Note: Splint/soft tissue rest. 2–3 weeks of antibiotics. Bursectomy uncommon.
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Osteomyelitis: A specific microbe diagnosis essential via blood and tissue cultures. The following represents the initial empiric treatment. Age/Condition Common Microbes Treatment/Notes S. aureus, gram-negative 1st: MRSA possible—Vancomycin and ceftazidime or cefepime 0–4 months bacilli, group A and B (3%) 2nd: MRSA not likely—Nafcillin or oxacillin and ceftazidime or cefepime Streptococcus Note: Look for local signs/symptoms. Blood culture often positive (> 67%). 1st: MRSA possible—Vancomycin Children > S. aureus, group A 2nd: MRSA not likely—Nafcillin or oxacillin add ceftazidime or cefepime if gram stain 4 months Streptococcus, rare bacilli positive for gram-negative bacilli Note: H. influenza in unimmunized. Vancomycin for PCN allergic. S. aureus most common 1st: MRSA possible—Vancomycin Adult > Cultures (blood/bone) critical 2nd: MRSA not likely—Nafcillin or oxacillin 21 years for treatment Note: Tailor to culture results. Sickle cell S. aureus most common, 1st: Ciprofloxacin anemia consider Salmonella 2nd: Levofloxacin 1st: Penicillinase-resistant PCN and ciprofloxacin Intravenous S. aureus, Pseudomonas 2nd: Vancomycin and ciprofloxacin drug user Note: Sternoclavicular joints, ribs, spine, and long bones. 1st: Penicillinase-resistant PCN and ciprofloxacin Dialysis S. aureus, Pseudomonas 2nd: Vancomycin and ciprofloxacin After open 1st: Vancomycin 1 g q12h IV and reduction S. aureus, gram negative bacilli, 2nd: Linezolid 600 mg IV/po bid (not FDA approved) and ceftazidime 2 g q8h IV or cefepime internal Pseudomonas aeruginosa 2 g q12h IV fixation Note: Think of in delayed unions and nonunions. (ORIF)
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Recommended Antibiotic Choices for Pediatric Osteomyelitis (JAAOS 9(3):166–175, 2001) IV Antibiotics Nafcillin 150–200 mg/kg/day and Neonate Gentamicin 5–7.5 mg/kg/day or Cefotaxime 150 mg/kg/day Nafcillin 150 mg/kg/day and < 3 years (Not Hib immunized) Cefotaxime 150 mg/kg/day or Single therapy with cefuroxime 150–200 mg/kg/day Cefazolin 100–150 mg/kg/day or > 3 years (Hib Immunized) Nafcillin 150–200 mg/kg/day or Clindamycin 30–40 mg/kg/day
PO Antibiotics (Divided qid) Dicloxacillin 75–100 mg/kg/day or Cephalexin 100–150 mg/kg/day or Clindamycin 30 mg/kg/day Dicloxacillin 75–100 mg/kg/day or Cephalexin 100–150 mg/kg/day or Clindamycin 30 mg/kg/day Dicloxacillin 75–100 mg/kg/day or Cephalexin 100–150 mg/kg/day or Clindamycin 30 mg/kg/day
Osteomyelitis: A specific microbe diagnosis essential via blood and tissue cultures. The following represents the initial empiric treatment. (Continued) Age/Condition Common Microbes Treatment/Notes 1st: Ciprofloxacin 750 mg po bid or levofloxacin 750 mg po qd Sneaker Pseudomonas aeruginosa 2nd: Ceftazidime 2 g q8h IV or cefepime 2 g q12h IV puncture Note: Look for foreign body, and débride if necessary (1–2% in kids) Vascular Base treatment on bone biopsy results; no acute treatment unless systemic illness Polymicrobial insufficiency Note: Surgery for exposed bone or osteomyelitis Chronic S. aureus, Pseudomonas, Based on results of deep culture osteomyelitis Enterobacter
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Anatomic Type Stage 1 Stage 2 Stage 3 Stage 4 Physiologic Class A Host B Host Bs Bl Bls C Host
Systemic compromise Local compromise Systemic and local compromise Treatment worse than the disease
Normal
Medullary osteomyelitis Superficial osteomyelitis Localized osteomyelitis Diffuse osteomyelitis
Description
Cierny-Mader Staging System (Contemp Orthop 10:17–37,1985)
Systemic (Bs) Malnutrition Renal, hepatic failure Diabetes mellitus Chronic hypoxia Immune disease Malignancy Extremes of age Immunosuppression/deficiency Asplenic HIV/AIDS Ethanol/tobacco abuse
Local Bl Chronic lymphedema Venous stasis Major vessel compromise Arteritis Extensive scarring Radiation fibrosis Small vessel disease Neuropathy
Systemic or Local Factors (Affecting Immune Surveillance, Metabolism, Vascularity)
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S. aureus, Group A , B, C, or G Streptococcus
Post-op infection Mild
Post-op infection Severe
S. aureus, Streptococcus, gramnegative rods
S. aureus, Group A , B, C, or G Streptococcus
Infection—wound, severe
Flexor tenosynovitis
Polymicrobial: S. aureus (MSSA, MRSA), group A and anaerobic Streptococcus, Enterobacter, C. perfringens and tetani, Pseudomonas, Aeromonas (water exposure), Acinetobacter
Cellulitis, severe
Common Microbes Group A Streptococcus, occasional Group B/C/G, S. aureus (MRSA)
Group A Streptococcus, S. aureus
Cellulitis, mild
Skin Infections Age/Condition
1st: Trimethoprim/sulfamethoxazole 160/800 mg po bid 2nd: Clindamycin 300–450 mg po tid Note: Early irrigation and debridement as indicated 1st: Vancomycin 1 gm IV q12h IV 2nd: Daptomycin 6 mg/kg IV qd, or ceftobiprole 500 mg IV qd Note: Early irrigation and debridement as indicated 1st: Cefazolin 1 g IV q8h 2nd: Nafcillin 1–2 g IV q4–6h, vancomycin 1 g IV q12h and gentamicin or imipenem 0.5–1 g IV q6h Note: IV antibiotics and observation if caught early (< 24 hr); maintain a low threshold for irrigation and debridement.
1st: Amoxicillin/clavulanate, ticarcillin/clavulanate, piperacillin/tazobactam, meropenem, doripenem (non FDA), or ertapenem and vancomycin 2nd: Vancomycin, daptomycin, or ceftobiprole and ciprofloxacin or levofloxacin Note: Surgical debridement if needed; splint for soft tissue rest. Tailor antibiotic to cultured bug.
1st: Nafcillin or oxacillin 2 g q4h IV, PCN G 1–2 mU IV q6h 2nd: Erythromycin, cefazolin, ampicillin/sulbactam, azithromycin, clarithromycin, tigecycline, daptomycin, or ceftobiprole Note: Irrigation and debridement of abscess if present; consider soft tissue splint. Workup to include ruling out abscess.
1st: Dicloxacillin 500 mg q6h po or cefazolin 1 g q8h IV Note: Splint/soft tissue rest
Treatment/Notes
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Splint and Elevation
66016_CH02_PTR.indd 57 Initial therapy: Clindamycin and imipenem, meropenem, amp/sulbactam, or piperacillin/tazobactam Definitive therapy based on intraoperative gram stain and culture Gram-positive cocci (clusters): Clindamycin and vancomycin, or linezolid Gram-positive cocci (chains/pairs): Clindamycin and piperacillin/tazobactam, amp/ sulbactam, or high-dose PCN
Polymicrobial with gram-positive cocci and gram-negative bacilli: Clindamycin and imipenem, meropenem, amp/sulbactam, or piperacillin/tazobactam Note: Wide immediate surgical debridement! Surgical delay > 24 hours increases mortality rate. Remove all necrotic fascia and fat. Skin excision back to healthy bleeding tissue. 2nd look at 24–48 hours, then as needed.
Rare 500–1500 cases/year (US) Involves fascia, subcutaneous tissue, and thrombosis of microcirculation Soft tissue crepitans (gas in the SQ tissue) may be the only early sign.
Treatment/Notes
3 types: I. Polymicrobial (80–90%) II. Group A ß-hemolytic strep III. Marine vibrios New group: MRSA recently reported
Common Microbes
Infection Imitators:
Gout/pseudogout (polarized light microscopy), calcific tendonitis (normal labs, intratendinous mineralization), pyoderma gangrenosum, or childhood leukemia masquerading as a septic joint
Necrotizing fasciitis: Presents with exquisite pain, swelling, and fever (rapidly progressive!) Hard signs (late): Hemorrhagic bullae, skin necrosis, fluctuance, crepitans, gas (inconsistent sign ~ 17% in one series) Types I. Immunocompromised host (most common)—Polymicrobial, synergistic, non-group A strep, aerobes/anaerobes II. Competent host—S. pyogenes alone or with Staphylococcus
JBJS 84A:1454–1459, 2003 JAAOS 17(3): 174–182, 2009
Surgical Emergency!
Necrotizing fasciitis
Skin Infections Age/Condition
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Antimicrobials
58
Key Atypical Infections Organism Sporothrix schenckii M. marinum M. tuberculosis M. avium
Systemic Therapy Ketoconazole, supersaturated solution of potassium iodide, amphotericin, surgical debridement Rifampin, tetracycline, minocycline, amikacin Isoniazid, rifampin, ethambutol, pyrazinamide Azithromycin, clarithromycin, ethambutol, rifabutin
Common Antibiotics—Mechanisms of Action Inhibits Antibiotics Carbenicillin, cephalosporin, methicillin, nafcillin, Cell wall synthesis oxacillin, penicillin, piperacillin, ticarcillin Cell membrane function Amphotericin, nystatin, polymyxin Aminoglycosides, chloramphenicol, clindamycin, Protein synthesis erythromycin, tetracycline Nucleic acid synthesis Sulfonamides DNA gyrase Quinolones Bacterial RNA synthesis Rifampin
ANTIBIOTICS FOR SURGICAL PROPHYLAXIS (JAAOS 16:283–293, 2008) TIMING • Begin within 60 minutes of incision (cephalosporin, clindamycin) 120 minutes (vancomycin) • Complete infusion > 10 minutes prior to tourniquet inflation DOSING • Single preoperative dose recommended • Redose during a prolonged procedure and increased blood loss • Discontinue antibiotics 24 hours after surgery • Dosage: • Cefazolin 1–2 gm (2 gm > 86 kg) • Cefuroxime 1.5 gm • Vancomycin and clindamycin based on patient weight • Pediatric dosage based on weight ANTIBIOTIC CHOICE • 1st choice: Cephalosporin (cefazolin, cefuroxime) • ß-lactam allergic: Clindamycin, vancomycin • History of MRSA (infection or colonization): Vancomycin
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Antimicrobials
ANTIBIOTIC REFERENCES Rottenberg EB. Harriet Lane Handbook. 16th ed. St. Louis, MO: Mosby Year Book; 2002. Browner BD, Levine AM, Jupiter BJ, Trafton PG, Krettek C. Skeletal Trauma. Philadelphia, PA: WB Saunders; 2002. Gilbert DN, Moellering RC, Sande MA. The Sanford Guide to Antimicrobial Therapy. Sperryville, VA: Antimicrobial Therapy; 2003. Miller MD. Review of Orthopaedics. 4th ed. Philadelphia, PA: WB Saunders; 2004. Abrams RA, Botte MJ. Hand infections: Treatment recommendations for specific types. JAAOS. 1996;4(4):219–230. Common Oral Antimicrobial Doses and Mixtures Antimicrobial Formulations Amoxicillin (Amoxil) Amoxicillin/clavulanate (Augmentin) [ES] Ampicillin (Polycillin) Azithromycin (Zithromax) Cefaclor (Ceclor) 2nd generation Cefadroxil (Duricef) 1st generation Cefdinir (Omnicef) 3rd generation Cefixime (Suprax) 3rd generation Cefpodoxime (Vantin) 3rd generation Cefprozil (Cefzil) 3rd generation Ceftibuten (Cedax) 3rd generation Cefuroxime (Ceftin) 2nd generation Cephalexin (Keflex) 1st generation Clarithromycin (Biaxin)
Susp: 125, 250 mg/5 mL Caps: 125, 250 mg Susp: 200, 400, [600] mg/5 mL Tabs: 125, 250, 500 mg Susp: 125, 250 mg/5 mL Caps: 250, 500 mg Susp: 100, 200, 1000 mg/5 mL Caps: 250 mg (max 500 mg) Susp: 125, 250 mg/5 mL Caps: 250, 500 mg Susp: 125, 250, 500 mg/5 mL Cap: 500, Tab: 1000 mg Susp: 125 mg/5 mL Cap: 300 mg Syrup: 100 mg/5 mL Tabs: 200, 400 mg Susp: 50, 100 mg/5 mL Tabs: 100, 200 mg Susp: 125, 250 mg/5 mL Tabs: 250 mg/5 mL Susp: 90, 180 mg/5 mL Caps: 400 mg Susp: 125 mg/5 mL Tabs: 125, 250, 500 mg Susp: 125, 250 mg/5 mL Caps: 250, 500 mg Susp: 125, 250 mg/5 mL Tabs: 250, 500 mg
Dose (Frequency)1 30–50 mg/kg/day (bid–tid) Max dose 500 mg 45 mg/kg/day (bid) Max dose 500 mg 50–100 mg/kg/day (qid) Max dose 500 mg 10 mg/kg qd 1st day, then 5 mg/kg qd x 4d 20–40 mg/kg/day (tid) Max dose 500 mg 30 mg/kg/day (bid) Max dose 1000 mg 14 mg/kg/day (qd–bid) Max daily dose 600 mg 8 mg/kg/day (qd/bid) Max dose 400 mg 10 mg/kg/day (bid) Max dose 400 mg 15 mg/kg/day (bid) Max dose 500 mg 9 mg/kg/day (qd) Max dose 400 mg 15–30 mg/kg/day (bid) Max dose 500 mg 25–50 mg/kg/day (qid) Max dose 500 mg 15 mg/kg/day (bid) Max dose 500 mg (Continues)
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Common Oral Antimicrobial Doses and Mixtures (Continued) Antimicrobial Formulations Dose (Frequency)1 10–30 mg/kg/day Solution: 75 mg/5 mL Clindamycin (Cleocin) (tid/bid) Cap: 75, 150 mg (max 600 mg) (30–40 mg/kg/d if DRSP)2 Susp: 62.5 mg/5 mL 25–100 mg/kg/day (qid) Dicloxacillin (Dynapen) Caps: 125, 250, 500 Max dose 500 mg Doxycycline (> 8 years) Tab/Cap: 50,100 mg Susp: 25 2–4 mg/kg/day (bid) (Vibramycin) mg/5 mL, Syrup: 50 mg/5 mL, Max dose 200 mg/day Erythromycin (ERYC, Susp: 200, 400 mg/5 mL 20–50 mg/kg/day (qid) EES, E-mycin) Tab: 200 (chew), 250, 400, 500 Max dose 500 mg Erythromycin/ 50 mg EM/kg/day (qid) sulfisoxazole Susp: 200 mg and 600 mg /5 mL Max EM dose 500 mg (Pediazole) Susp: 125, 250 per 5 mL 25–50 mg/kg/day (qid) Penicillin (Pen-Vee K) Tab: 125, 250, 500 mg Max dose 500 mg Trimethoprim/ Susp: 40 mg and 200 mg /5 mL 6–12 mg /kg/day TMP bid sulfamethoxazole Tabs: 80/400, 160/800 Max dose 160 TMP (Bactrim, Septra) 40 mg/kg/d X 7 d Vancomycin (Vancocin) Caps: 125, 250 Max dose 2000 mg/d 1 Max dose = maximum individual oral dose, 2DRSP = drug-resistant S. pneumoniae Modified with permission: Tarascon Pediatric Emergency Pocketbook. 5th ed. Lompoc, CA: Tarascon; 2007.
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EMERGENCY PROCEDURES Compartment Syndrome (JAAOS 4:209–218, 1996) Increased pressure within a confined space interferes with proper tissue perfusion within the space. Pressure increase may be intrinsic —Bleeding, edema, fluid Or extrinsic —Pneumatic antishock trousers, cast, tight dressing, overdistraction (external fixator) Findings —Pain out of proportion to physical findings (pain is the most reliable and earliest symptom), pain with passive ROM (cardinal sign), pain on palpation of the swollen compartment, tensely swollen compartment, tight shiny skin, hypesthesia, paraesthesia, anesthesia (late finding), weakness, paresis (late finding). Late findings occur after irreversible damage has occurred! Compartment Pressure Values (JBJS 78B:99–104, 1996, JBJS 62A:286–291, 1980) Within 30 mm Hg of diastolic pressure OR Above 45 mm Hg—absolute pressure
Compartment syndrome is felt to be present if compartment pressures are:
Needle manometer measurements are generally allowed to be slightly higher. Most surgeons prefer to use the measurement of compartment pressure relative to diastolic pressure. A “zone of peak pressure” occurs within several centimeters of the fracture site; values can vary significantly at greater distances causing an underestimation of the compartment pressure. Traditional Compartment Measurement Set-Up Three-way stopcock - open, saline meniscus in proximal tube, insert needle, increase pressure in syringe until meniscus moves, read pressure
Meniscus Mercury Manometer Manometer and limb must be at the same level Damian Rispoli 2009
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MEASURING TECHNIQUES (MULTIPLE) Needle manometer (Clin Orthop 113:43, 1975), wick catheter (JBJS 58A:1016, 1976), slit catheter (J Trauma 21:446–449, 1981), STIC catheter The simplest technique utilizes the STIC catheter. It is a handheld device that is easy to use and usually readily available at larger institutions. Another simple technique is to use an arterial line setup. This can be connected to a standard pressure monitor at the bedside or in the OR. Additionally, the arterial line setup comes in a sterile package and can then be used intraoperatively with the help of the OR nurse or anesthetist. Ensure the setup is “zeroed” at the level of the limb being tested. COMPARTMENT RELEASE (FASCIOTOMY) TECHNIQUES FINGER Usually done on the ulnar side of the index, long, and ring fingers and the radial side of the thumb and small finger. Special attention and alteration of this should be based on the patient’s vocation and avocation. The incision is a standard mid axial incision as shown. The line for the mid axial incision is drawn off points that correspond to the dorsal extent of the flexion creases in maximal flexion. The volar neurovascular bundles are left volar, and the line of dissection is between them and the flexor tendon sheath (Green DP, ed. Operative Hand Surgery. New York, NY: Churchill Livingstone; 1993).
Figer/Hand Compartment Release
Finger release incision
Volar/carpal tunnel release incision
Extensor hood over phalanx Volar neurovascular bundle
Hypothenar release incision
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Incision
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Incision for release of thenar compartment
HAND The volar incision lies in the crease between the thenar and hypothenar eminences. From it one can release the carpal tunnel and Guyon’s canal. The incision is curved over the wrist flexion crease to prevent contractures. The dorsal incisions are made in line with the second and fourth metacarpals as shown. The incisions split the dorsal interossei fascia and then course around the muscle to release the palmar interossei. The thenar and hypothenar compartments are released through incisions over the respective metacarpals.
FOREARM (CLIN ORTHOP, 134:225–229, 1978; 161:252–261, 1981) Two incisions, one dorsal and one volar, are used to decompress the forearm. The volar incision includes the carpal tunnel release. Taking the incision ulnar after the carpal tunnel release leaves tissue to cover the median nerve as it exits from under the flexor digitorum superficialis. The dorsal incision should be used to decompress the dorsal and mobile wad compartments. Intraoperative pressure measurements can aid in making the decision to proceed with the dorsal release. Often the volar release is sufficient to lower the pressure dorsally to subcritical levels.
ARM The volar incision can be carried up past the elbow and into an anterior lateral approach to the arm to release brachial compartments if necessary. Anterior and posterior compartments may then be released through the anterolateral incision.
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Forearm Fasciotomy Incisions Volar
Dorsal
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Thigh Fasciotomy (JBJS 68A:1439,1986) Anterior
Lateral
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THIGH (JBJS 68A:1439, 1986) Thigh compartment syndromes are being more commonly reported. The incisions are anterolateral and if needed straight medial. The hamstring compartment is released via the anterolateral incision. Always consider extension to the gluteal compartment as clinically indicated. LEG (JBJS 59A:184–187, 1977) Three common techniques for fasciotomy of the leg exist: fibulectomy, perifibular fasciotomy, and the double-incision technique. The most commonly advocated is the double-incision technique. The two vertical incisions must be separated by at least an 8-cm skin bridge. Both incisions span from knee to ankle. The medial incision is at least 2 cm posterior to the posteromedial border of the tibia (avoids bone exposure and damage to the saphenous nerve and vein). The fascia overlying the gastrocnemius is split to release the superficial compartment. The deep compartment fascia is split over the flexor digitorum longus, and proximally the soleal attachment to the tibia is released to access the proximal portion of the deep posterior compartment (tibialis posterior). The lateral incision is made midway between the posterolateral tibial border and the anterolateral border of the fibula. The fascia is split 1 cm anterior and 1 cm posterior to the intramuscular septum. The superficial peroneal nerve must be protected. Leg Fasciotomy (JBJS 59A:184–187, 1977) Anterior
Medial
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ANKLE (JBJS Br 84B(1):11–14, 2002) Consider extensor retinaculum syndrome (severe pain and swelling of the ankle, hypoesthesia or anaesthesia in the web space of the great toe, weakness of extensor hallucis longus and extensor digitorum communis, and pain on passive flexion of the toes, especially the great toe). Prompt recognition and decompression can potentially avoid negative long-term sequelae (JBJS Br 84B(1):11–14, 2002). FOOT (J. Orthop. Trauma, 223–228, 1992; Orthopedics 13:711–717, 1990) A foot compartment syndrome is difficult to detect. Clinical suspicion and pressure measurement are necessary to identify those requiring release. Two techniques are shown. The main compartments are medial, central, lateral, interosseous, and calcaneal. All involved compartments should be released if indicated. Important to note! (J Trauma 40(3):342–344, 1996) There is universal agreement that acute compartment syndromes should be treated surgically. However, the treatment of compartment syndromes presenting late with evidence of compartment damage is less clear. The damage done in a compartment is a function of many variables including compartment pressure magnitude, time of pressure elevation, diastolic pressure, concomitant crush injury, and time since onset, among others. It has been shown that late release of compartments is associated with an unacceptable complication rate. Hard and fast rules regarding the treatment of Foot Fasciotomy (J Orthop. Trauma 223-228, 1992; Orthopedics 13:711-717, 1990)
Dorsal Incision
Medial Incision
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compartment syndromes do not exist. The guidelines given along with heightened clinical suspicion and an educated response are most appropriate. Ensure you check serum CKs and place a Foley catheter to monitor urine color. If positive for myoglobinuria, treat with aggressive hydration and alkalinization with sodium bicarbonate. NOTE: A urine dipstick positive for blood in the absence of RBCs on microscopic analysis is indicative of myoglobinuria. ACUTE STABILIZATION OF THE PELVIS Hemodynamic instability in the presence of a grossly negative DPL (or other negative abdominal imaging study) and an unstable pelvis is an indication for acute pelvic stabilization. Methods Sheet wrapped around the pelvis and clamped snuggly Centered on greater trochanters Internal rotation of the legs and wrapping both together Skeletal traction Pelvic binder Specialized pelvic clamps Anterior external fixation frame
PELVIC EXTERNAL FIXATION Use 5-mm pins with the threads placed in the anterior half of the iliac crest. Pins must be at least 1 cm apart. Use 2–3 pins per side. Incisions, 2–3 cm, are made along the crest and angled towards the umbilicus. The crest is identified, and the walls may be palpated and/or the proper angle of the crest identified with a guide wire. The crest is perforated with a drill; the pin is then inserted and allowed to find its way between the inner and outer table. The pins should be directed towards the strong bone in the supra-acetabular region. All threads should be buried in the crest bone. Anterior inferior iliac spine (AIIS) pins may also be placed into the strong pillar of bone from this structure posteriorly. The incision is made below the anterior superior iliac spine over the sartorius muscle and the direct head of the rectus femoris. The AIIS is identified, and the pins are placed between the AIIS and the anterior superior iliac spine (ASIS), spaced by about 1 cm. The lateral femoral cutaneous nerve is the structure at greatest risk. A stronger biomechanical construct can be made utilizing supra-acetabular pins. Placement of these pins is usually made with fluoroscopic guidance and may not be well suited for an emergent situation (CORR 411(1):269–273, 2003, Inj 24(9):581–584, 1993). Any pin placement is confirmed after reduction and prior to leaving the OR. Frame construction should take into consideration possible need for abdominal exploration, interventional venous thrombosis, and concomitant injuries (including potential need for acetabular/pelvic fixation). Double frame can be helpful to allow access to belly without loss of fixation.
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Kidney
Intestine
Bone
End-Organ Effects
Parathyroid Hormone ↑ Osteoclastic activity ↑ Osteoclast precursors Acts indirectly on gut by ↑ 1,25-(OH)2 in kidney ↑ 25-(OH) D to 1,25-(OH)2 D in proximal tubules ↑ Resorption of filtered calcium ↑ Urinary loss of phosphorus
↓ Osteoclastic activity
↑↑↑ Intestinal uptake of calcium and phosphorous
Calcitonin
1,25-(OH)2 Vitamin D
Transient ↓ serum calcium
↑ Serum calcium ↑ Serum phosphorus
↑ Serum calcium ↓ Serum phosphorus
Effect on Serum Calcium and Phosphorous
↑↑↑ Osteoclastic activity
Regulation of Calcium and Phosphate Metabolism (JBJS 77A:459–469, 1995) Stimulus for Decreased Stimulus for Increased Excretion Excretion Parathyroid hormone (PTH) ↑ Serum calcium ↓ Serum calcium (parathyroid chief cells) ↑ 1,25-(OH)2 D ↑ PTH ↓ PTH 1,25-(OH)2 vitamin D ↓ Serum calcium ↑ Serum calcium (kidney proximal tubules) ↓ Serum phosphorus ↑ Serum phosphorus Calcitonin ↑ Serum calcium ↓ Serum calcium (thyroid parafollicular cells)
GENERAL ORTHOPAEDICS—Ca++/PHOSPHATE
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CRF— phosphate excretion
Diet vitamin D, malabsorption
I enzyme defect, II receptor defect
Renal osteodystrophy Rickets (osteomalacia)
Vit. D deficient
Vit. D dependent (Types I and II) Vit. D resistant (hypophosphatemic) Hypophosphatasia
Alkaline phosphatase
Phosphate resorption (tubular)
PTH receptor dysfunction
PHP/Albright’s
Clinical and Radiologic Overview of Metabolic Bone Disease Disease Etiology Hypercalcemia Hyperparathyroidism ↑ PTH—adenoma Familial syndromes PTH—MEN/Renal Hypocalcemia Hypoparathyroidism PTH—idiopathic
Calcified basal ganglia
Neuromuscular irritability Short metacarpal/tarsal Obesity Renal abnormalities Osteomalacia, hypotonia, muscle weakness, tetany Similar but (I) to (II) severity to vitamin D dependent, alopecia Hypophosphatemia, lower limb deformities, stunted growth Osteomalacia, early tooth loss
Osteopenia, focal lytic areas Osteopenia
Kidney stones, hyperreflexia Endocrine/renal dysfunction
Poor mineralization
Poor mineralization
Poor mineralization
(Continues)
Rachitic rosary, bowed long bones, growth plates
“Rugger jersey” spine
Brachydactyly, exostosis
Radiographic Finding
Clinical Findings
GENERAL ORTHOPAEDICS—METABOLIC BONE DISEASE
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Deformity, pain, congestive heart failure, fractures
Bone within bone
Insufficiency fractures Thin cortices, corner sign
Kyphosis, fracture Fatigue, bleeding, effusions
Hepatosplenomegaly, anemia
Radiographic Finding
Clinical Findings
MEN = multiple endocrine neoplasia; PTH = parathyroid hormone; CRF = chronic renal failure; PHP = pseudo hypoparathyroidism. Adapted from Miller MD, ed. Review of Orthopaedics. 3rd ed. Philadelphia, PA: WB.Saunders; 2000:25.
Disease Etiology Osteopenia Osteoporosis ↓ Estrogen—↓ bone mass Scurvy ↓ Diet Vitamin C Osteosclerosis or Increased Osseous Density Defunct osteoclasts, disordered Paget’s (5th decade) bone turnover Osteo/chondroclastic activity Osteopetrosis (thymus)
Clinical and Radiologic Overview of Metabolic Bone Disease (Continued)
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GENERAL ORTHOPAEDICS—OSTEOPOROSIS OSTEOPOROSIS (JBJS 90:1362–1374, 2008; JAAOS 12(2):67–71, 2004; JAAOS 7:19–31, 1999; JBJS 82A:1063–1070, 2000) DEXA (Osteoporosis criteria) Type I (postmenopausal) Type II Age related (> 75 years old) Based on 25-year-old control Affects 45% of women > 50 years old T-score Lifetime risk of 40% for fractures –2.0 SD without risk factors Treatment may reduce risk by 50% –1.5 SD with risk factors DEXA study is the most accurate. DEXA has the least radiation. Plain films reveal osteopenia > 30% Calcium Recommendations Age Range Infants Birth–3 months 6–12 months Children 1–5 years 5–10 years Adolescents/adult 11–24 years Female athletes Euestrogenic Hypoestrogenic Adults Men (25–65) Women (25–55) Pregnant/ nursing Postmenopausal With HRT* Without HRT* > 65 men/women
RDA (mg/day)
Suggested Dietary Intake (mg/day)
400 600
400 600
800 800
800 800–1200
1200
1200–1500
Not specified Not specified
1000 1500
800 800
1000 1500
1200
1200–1500
Not specified Not specified 800
1000 1200 1200**
Osteoporosis Risk Factors Sedentary Thin Caucasian N. European Smoker Alcohol Phenytoin Low calcium Low vitamin D Breast feeding Any adult fracture Bone density has the strongest relation with fracture, but fracture may occur even with normal bone density.
*HRT = hormone replacement therapy; ** Include 800 IU of vitamin D Adapted from Subcommittee on the Tenth Edition of the Recommended Dietary Allowance, National Research Council. Recommended Daily Allowances. 10th ed. Washington, DC. National Academies Press; 1989. Table adapted from Lane JM, Nydick M. Osteoporosis: Current modes of prevention and treatment. JAAOS. 1999;Jan/Feb:23.
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Vitamin D 200 IU daily < 50 years; 400 IU 51–70 years; 600 IU >71 years Vitamin D3 the preferred form TREATMENT PROTOCOLS MEN AND PREMENOPAUSAL WOMEN: Physiologic calcium, vitamin D (400–800 U/day), adequate nutrition, fall prevention, balance and exercise programs POSTMENOPAUSAL WOMEN* AND OSTEOPOROSIS: *Earlier intervention if the bone loss rate is increased and/or there are independent risk factors
Antiresorptive agents • Estrogens (consider progestin if uterus intact) • Concerns regarding increased malignancy risk and lack of cardiovascular and fracture reduction benefit have limited its use. • Alendronate (Fosamax), 10 mg/day or 70 mg/week • Risedronate (Actonel), 5 mg/day or 35 mg/week • Calcitonin (Miacalcin), 200 IU/day via nasal spray for mild bone loss, new fractures, or bone pain • Ibandronate (Boniva) 2.5 mg/day or 150 mg/month oral, 3mg/3 month IV • Zoledronic acid (Reclast) 5 mg IV yearly • Pamidronate (Aredia; intravenous infusion), approved for Paget’s disease and osteolysis associated with malignancy • Raloxifene (Evista), 60 mg/day, a selective estrogen-receptor modifier • Etidronate (Didronel), cycle of 400 mg/day for 2 weeks, rest 11 weeks; approved for Paget’s disease only • Tamoxifen (Nolvadex; antiestrogen agent), 70% as effective as estrogen; Used in the treatment of breast cancer Formative agents • Parathyroid hormone, 20 μgm/day (may combine with antiresorptive agents) intermittent use has a profound anabolic effect • Use > 2 years not tested, use < 2 years • No use in cases of increased risk for osteosarcoma including Paget’s disease, unexplained alkaline phosphatase and open physes, or prior history of XRT • No use in setting of bony metastasis, skeletal malignancy, or metabolic bone disease other than osteoporosis Formative agents (experimental) • Monofluorophosphate (Monocal; fluoride and calcium supplement), 24 mg of elemental fluoride per day, used as a nutritional additive • Slow-release sodium fluoride, under study
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GENERAL ORTHOPAEDICS—PERIOPERATIVE MANAGEMENT Perioperative Management in the Patient with Rheumatologic Disorders Medication NSAIDs
Corticosteroids
Methotrexate
Important Drug Interactions Antihypertensive medications Warfarin Increased risk of tendon rupture if used with fluoroquinolones Antifungal; clarithromycin may potentiate steroid effects Possible neutropenia if used with PCN IV
Leflunomide
May elevate levels of warfarin or rifampin
Sulfasalazine
May potentiate warfarin’s effects
Hydroxychloroquine Tumor necrosis factor antagonists
Avoid live vaccines
Perioperative Management Stop 5 half-lives before surgery Aspirin 7–10 days prior
Minor procedures—continue Moderate or major procedures consider holding 1–2 doses in uncontrolled diabetes, elderly, liver, lung, or kidney disease Minor procedures—continue Moderate or major procedures consider holding 1–2 days before, restart 1–2 after surgery
Minor procedures—continue Moderate or major procedures consider holding etanercept 1 week, plan surgery at the end of the dosing interval for adalimumab and infliximab. Restart 10–14 days. Minor procedures—continue Moderate or major procedures consider holding 1–2 days before, restart 10 days after surgery
Interleukin antagonists
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Nonsteroidal Anti-Inflammatory Drug Half-Life Half-Life Drug (hours) Celecoxib 11 Diclofenac 2 Etodolac 6–7 Ibuprofen 1.6–1.9 Indomethacin 4.5 Nabumetone 24 – 29 Naproxen sodium 12–15 Piroxicam 30
Supplemental Hydrocortisone for Surgical Stress Surgical Stress Procedure Recommended Supplemental Dose Minor Hand or foot surgery 25 mg hydrocortisone (5 mg prednisone) Arthroscopy day of surgery Moderate Joint replacement 50–75 mg hydrocortisone (prednisone arthroplasty 10–15 mg) day of procedure tapering Ligament over 1–2 days to preoperative dose reconstruction Major Poly trauma 100–150 mg hydrocortisone (prednisone Bilateral or revision 20–30 mg) day of procedure tapering arthroplasty over 1–2 days to preoperative dose Multilevel spine fusion Modified from Howe CR, Gardner GC, Kadel NJ. Perioperative medication management for the patient with rheumatoid arthritis. JAAOS. 2006;14:544–551.
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GENERAL ORTHOPAEDICS—VTE VENOUS THROMBOEMBOLIC DISEASE Patient factors that increase DVT/PE risk: • Hypercoagulable states • Previous documented PE Patient factors that increase the risk for major bleeding • History of bleeding disorder • History of recent GI bleed • History of recent hemorrhagic stroke Due to improvements in operative and anaesthetic technique that affords accelerated rehabilitation, the pulmonary embolism rate (including the rate for fatal pulmonary embolism) for total hip and knee arthroplasty has decreased independent of routine thromboembolic prophylaxis. A North American consensus to prophylax postoperatively exists for both total hip and knee arthroplasty. Most thrombosis in elective surgery occurs in the 1st postoperative week with the peak occurring at 4 days. Decreases Thromboembolic Risk: • Epidural and spinal anaesthetic, hypotensive anaesthesia, autologous transfusions, decreased blood loss (JBJS 82A:252–270; 2000) Efficacy and Safety: • Warfarin (lowest risk for proximal deep venous thrombosis and symptomatic pulmonary embolism) • Sequential compression devices (lowest risk for postoperative bleeding complication) • Low molecular weight heparins (lowest total deep venous thrombosis risk; increased risk of postoperative bleeding) • Low-dose heparin (increased risk of major and minor postoperative bleeding complications)
Warfarin, sequential compression devices, and low molecular weight heparin all individually decreased the risk of pulmonary embolism. No difference in the rate of fatal pulmonary embolism among the agents You would need a cohort of 100,000 patients to see a change in the incidence of fatal pulmonary embolism rate. Deep venous thrombosis may not lead to fatal pulmonary embolism in a predictable manner. 75
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General Orthopaedics—VTE JBJS 82A(7):929–938,2000. JBJS 81A(3):339–346,1999. JBJS 81A(5):690–696,1999.
76 Low molecular weight heparin (reports cite enoxaparin) with indwelling catheters contraindicated due to increased bleeding risk (occurrence of epidural hematomas with concomitant use)
Low molecular weight heparins—enoxaparin, fondaparinux, ximelagatran Treatment Regimen (JAAOS 17(3):183–196, 2009) Current accepted treatment regimen for patients of standard risk of PE only • Aspirin 325 mg BID starting the day of surgery for 6 weeks (may decrease to 81 mg QD in the setting of GI symptoms) Current accepted treatment regimen for patients of standard or elevated risk of PE: • Low molecular weight heparin dosed per package insert starting 12–24h postsurgery for 7–12 days • Synthetic pentasaccharides dosed per package insert starting 12–24h postsurgery for 7–12 days • Warfarin with an INR goal of ≤ 2.0 starting either the night before or after surgery and for 2–6 weeks Current accepted treatment regimen for patients of standard risk of PE and an elevated risk of major bleeding: • Aspirin 325 mg bid starting the day of surgery for 6 weeks (may decrease to 81 mg qd in the setting of GI symptoms) • Warfarin with an INR goal of ≤ 2.0 starting either the night before or after surgery and for 2–6 weeks • None Current accepted treatment regimen for patients of an elevated risk of major bleeding and PE: • Aspirin 325 mg bid starting the day of surgery for 6 weeks (may decrease to 81 mg qd in the setting of GI symptoms) • Warfarin with an INR goal of ≤ 2.0 starting either the night before or after surgery and for 2–6 weeks • None NOTE: Differences exist between the AAOS and Chest guidelines (Chest 132(2):513–520,2009) Chest Guidelines for Duration of Therapy (Chest 126(3):361, 2004) Total knee arthroplasty 10 days Total hip arthroplasty 28 days Hip fracture 28 days
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GENERAL ORTHOPAEDICS—BLOOD TRANSFUSION Estimated Risk of Allogeneic Blood Transfusion Viral HIV Hepatitis B virus Hepatitis C virus Human T-cell lymphotrophic virus Cytomegalovirus Bacterial contamination Systemic Reactions Fatal hemolytic Nonfatal hemolytic Fever Urticaria Allergic Graft vs. host disease Alloimmunization
⎬
1:1 million 1:100,000 1:500–5000 1:2 million Varies ~ 1:2500 Varies ~ 1:2500 Less than 1:6 million 1:6000 1:100 Rare Common
Keating AM, Meding JB. Perioperative blood management practices in elective orthopaedic surgery. JAAOS. 2002;10(6):393–400.
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GENERAL ORTHOPAEDICS—OSTEONECROSIS Alcoholism Dysbaric disorders Gaucher’s disease Hemoglobinopathies (HbS) Hypercoagulable states Irradiation Viral etiologies (hepatitis, HIV, CMV, rubella, rubeola, varicella Malignancy (metastatic carcinoma, acute promyelocytic and lymphoid leukemia)
Etiologies Antiphospholipid antibody syndrome Endotoxic reactions/systemic bacterial infections Hyperlipidemia (types II and IV) Inflammatory (lupus, inflammatory bowel disease) Trauma (dislocation, neck fracture) Pregnancy Hypersensitivity states (anaphylaxis, allograft rejection) Hypercortisolism (endogenous [Cushing’s] and exogenous)
MRI—Single best study to detect osteonecrosis; 98% specificity Natural History • Necrotic sector small (<15%)—May resolve, prognosis usually good • Necrotic sector large (>50%)—Collapse and arthrosis 85%, usually needs a total hip replacement Treatment Options (among others): • Observation (crutches, unload joint) • Core decompression with curettage and grafting • Vascularized fibular strut grafting • Rotational osteotomy • Hip arthrodesis • Hip arthroplasty Stages are graded on the quantity of the femoral head involvement. Involvement is calculated by finding the product of the % involvement of the coronal AP and the % involvement of the sagittal lateral.
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Staging System for Osteonecrosis of the Hip Steinberg Modification of the Ficat/Arlet Classification (JBJS 77B:34, 1995) Stage O I II III IV V VI Stage II
III
IV
V
Criteria Normal radiographs, bone scan, and MRI Normal radiographs, positive bone scan, and/or MRI Abnormal radiographs—cystic or sclerotic changes in femoral head Abnormal radiographs—subchondral collapse/crescent sign Abnormal radiographs—femoral head flattening Abnormal radiographs—loss of joint space +/– acetabular changes Abnormal radiographs—degenerative changes (advanced) Grading A B C A B C A B C A B C
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Criteria < 20% head involvement on radiographs or MRI 20–40% > 40% Crescent (subchondral collapse) < 15%, no flattening 15–30% crescent, no flattening > 30% crescent, no flattening < 15% collapse and < 2-mm depression 15–30% or 2–4 mm > 30% or > 4 mm Mild (IV and includes estimate of acetabular involvement) Moderate (IV and includes estimate of acetabular involvement) Severe (IV and includes estimate of acetabular involvement)
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GENERAL ORTHOPAEDICS—PAIN MANAGEMENT DEGENERATIVE ARTHRITIS PAIN MANAGEMENT: 1ST LINE OF TREATMENT Tylenol • Safest medication, no gastrointestinal irritation; however, has no antiinflammatory properties • Maximum dose 4000 mg/day • Must be cautious of concomitant liver disease especially with alcohol abuse 2ND LINE OF TREATMENT NSAIDs (aspirin and cyclo-oxygenase 1 inhibitors) • Decreased platelet function, renal toxicity, hepatic toxicity (rare), gastrointestinal irritation • Absolute risk of gastrointestinal irritation constant over time; cumulative risk increases with time • 100,000 hospitalizations annually for gastrointestinal side effects • 16,500 deaths annually • 2.5–5.5 times more likely to be hospitalized than without NSAIDs • Utilization with misoprostol, omeprazole, lansoprazole decreases gastrointestinal risk Cyclo-oxygenase 2 inhibitors • No platelet inhibition • Lower gastrointestinal risk • Possible increased cardiovascular risk • Some studies suggest an opioid-sparing effect postoperatively • Cyclo-oxygenase 2 has been shown to be important in bone healing, but early studies don’t show a clinical effect (rabbit model) JBJS 84A(10):1763–1768,2002. Several prostaglandins, notably E2, are implicated in new bone formation. Don’t use celecoxib in sulfonamide allergic patients.
NSAIDs: Decrease the antihypertensive properties of the thiazide diuretics and angiotensin-converting enzyme inhibitors Increase circulating warfarin levels Increase circulating lithium levels
JAAOS 12(3):139–143, 2004
NSAIDs are the most common pharmacologic agent used to treat osteoarthrosis. 80
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GENERAL ORTHOPAEDICS—JOINT PROPHYLAXIS Joint Arthroplasty Antibiotic Prophylaxis Dental and Urologic Procedure Recommendations Potentially Increased Risk Immunocompromised/Suppressed Inflammatory arthropathies (rheumatoid arthritis, systemic lupus erythematosus) Disease-induced immunosuppression Drug-induced immunosuppression XRT-induced immunosuppression
Patients with Comorbidities Previous prosthetic joint infection 1st 2 years postarthroplasty Hemophilia Insulin-dependent diabetes Malnourishment Malignancy HIV infection
Consider Prophylaxis for: (higher incidence of bacteremia) Dental Procedures Cleaning (expectation of bleeding) Dental implants/replants Extractions Periodontal procedures Endodontic (root canal) procedures Placement of orthodontic bands Intraligamentary anesthetic injection Urologic Procedures Stone manipulation (including lithotripsy) Transmural incisions (except percutaneous drainage procedure or simple ligation with excision) Any upper tract endoscopic procedure Any procedure with bowel involvement Transrectal prostate biopsy Procedures with entry into urinary tract in patients with higher risk of bacterial colonization Indwelling catheter, intermittent catheterization Indwelling urethral stent Urinary retention Recent or recurrent urinary tract infection or prostatitis Urinary diversion American Academy of Orthopaedic Surgeons. Antibiotic Prophylaxis for Urologic Patients with Total Joint Replacements. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002. Document 1023. American Academy of Orthopaedic Surgeons. Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002. Document 1014. JADA 1997;128(7):1004–1008.
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General Orthopaedics—Joint Prophylaxis
82
Suggested Antibiotic Prophylaxis if Dental Criteria Are Met PCN tolerant
Amoxicillin, cephalexin, cephradine—2 gm po 1 hour prior
PCN allergic
Clindamycin—600 mg po 1 hour prior
Can’t take po, PCN tolerant
Ampicillin—2 gm IV/IM 1 hour prior or cefazolin— 1 gm IV/IM 1 hour prior
Can’t take po, PCN allergic
Clindamycin—600 mg IV/IM 1 hour prior
Suggested Antibiotic Prophylaxis if Urologic Criteria Are Met PCN Tolerant (choice of quinolone or amp/gent)
Preprocedure Dosing
Ciprofloxacin
500 mg po 1–2 hours prior
Levofloxacin
500 mg po 1–2 hours prior
Ofloxacin
400 mg po 1–2 hours prior
Ampicillin and gentamicin
2 gm IV and 1.5 mg/kg IV 30–60 minutes prior
PCN Allergic
Preprocedure Dosing
Vancomycin and gentamicin
1 gm IV over 1–2 hours and 1.5 mg/kg IV 30–60 minutes prior
Suggested Antibiotic Prophylaxis for GI Procedures PCN Tolerant
Preprocedure
Ampicillin and gentamicin
2 gm IV and 1.5 mg/kg (80 mg) IV 30 minutes prior
Amoxicillin
Postprocedure
1.5 gm po 6 hours post
PCN Allergic
Preprocedure
Postprocedure
Vancomycin and gentamicin
1 gm IV and 1.5 mg/kg IV (~80) 1 hour prior
Repeat 8 hours post
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GENERAL ORTHOPAEDICS—TETANUS Wound Classification for Tetanus Prophylaxis Clinical Features
Tetanus Prone
Age of wound
> 6 hours
≤ 6 hours
Configuration
Stellate, avulsion
Linear
Depth
> 1 cm
≤ 1 cm
Mechanism
Missile, crush, burn, frostbite
Sharp surface (glass, knife)
Devitalized Tissue
Present
Absent
Present
Absent
Contaminants (dirt, saliva)
Nontetanus Prone
a
Tetanus Immunization Schedule
Tetanus Prone Tetanus Product
Tdb
TIG
Unknown, < 3 doses
Yes
3 or more doses
Noc
Nontetanus Prone Td
TIG
Yes
Yes
No
No
Nod
No
a Data from Morbidity and Mortality Weekly Report. 1990;39:37. b Yes, if wound > 24 hours old. For children < 7 yr., DPT (DT if pertussis vaccine contraindicated). For persons ≥ 7 yr, Td preferred to tetanus toxoid alone. c Yes, if > 5 yr since last booster. d Yes, if > 10 yr since last booster.
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LABORATORY JOINT FLUID ANALYSIS (JAMA 264:1009–1014, 1990) Types
I—Noninflammatory
II—Inflammatory
III—Septic
IV—Hemorrhagic
GROSS EXAMINATION Blood (hemarthrosis), fat (violation of subchondral bone/fracture) The more inflammatory the joint fluid is the more opaque it becomes. Total WBC count < 2000 mm3—Noninflammatory May be seen in systemic lupus erythematosus, systemic sclerosis, and crystalline arthropathy. Osteoarthrosis typically has a WBC count < 1000 mm3. 2000–100,000 mm3—Intermediate range Some joint sepsis can be in the 50K–100K range, especially Gonococcus, TB, immunecompromised host, and partially treated infection. Likewise crystalline arthropathies, rheumatoid arthritis, and Reiter’s can also be in the 50K–100K range. > 100,000 mm3—Septic joint until proven otherwise The presence of crystals does not rule out infection with this presentation.
DIFFERENTIAL (% NEUTROPHILS) < 50% Noninflammatory < 90% RA > 95% Infectious
Gram Stain 50–75% sensitive (Do it yourself if necessary) Culture > 90% sensitive
CULTURE Cultures are indispensable in directing antibiotic therapy. Sterile prep and handling are imperative! Blood culture vials could increase sensitivity. POLARIZED MICROSCOPY Monosodium urate crystals (gout): Needle-shaped or long with blunt ends, strongly negative birefringent (brilliantly bright against a dark background) Calcium pyrophosphate crystals (CPPD or pseudogout): Rod shaped/rhomboidal, weak positive birefringent
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85
Laboratory NOTE: INTRA-ARTICULAR BETAMETHASONE CAN MIMIC GOUT CRYSTALS. Using polarized light microscopy Gout—yellow when parallel, blue when perpendicular; CPPD—opposite
GLUCOSE (? SIGNIFICANCE) Low glucose can be found in any joint with increased cellular activity within the joint. Thus it can be low in sepsis, RA, or crystalline arthropathies. To be useful it must also be compared to serum glucose. Glucose is limited in its ability to aid in the differentiation of infectious versus noninfectious etiologies. STRING TEST (QUANTITATIVE TESTS OF VISCOSITY DON’T SUPPORT THIS TEST) Inflammatory (↓ viscosity) short string, noninflammatory (↑ viscosity) long string. Of historical interest only. TESTS FOR INFECTION Gram Stain 1. Heat fix slide until dry 2. Grams violet x 1 minute, rinse 3. Grams iodine x 1 minute, rinse
4. Decolorizer 30 seconds 5. Safranin x 1 minute, rinse 6. Air dry
Tissue Frozen Section (Tissue biopsy the most inflammatory looking tissue) 0 Polymorphonuclear cells/high-power field is evidence of the lack of infection 5–10 Polymorphonuclear cells/high-power field is evidence of a probable infection (Clin. Orthop. 1982;170:175–183) > 10 Polymorphonuclear cells/high-power field increases specificity to 99% (JBJS 78A:1553–1558, 1996)
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GENERAL ORTHOPAEDICS—NERVES, EMG/NCV EMG Findings/Meaning Finding
Significance
Silence at rest, bi- and triphasic potentials
Normal
Fibrillation potential at rest, positive sharp waves
Partial denervation
Polyphasic motor units
Chronic denervation
New motor units
Nerve regeneration
No action potential
Complete lesion
EMG/NCV Normal Values Nerve
Distal Latency (m sec.)
Amplitude (mv)
Median (motor/sensory)
2.4–4.4/2.5–3.7
4–18/> 0.02
Ulnar (motor/sensory)
1.8–3.5/2.5–3.7
6–16/> 0.02
2.4–2.7
> 0.012
Radial (sensory)
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+ (chronic)
+ (chronic)
+/– (severe)
Adapted from Robinson LR. Role of neurophysiologic evaluation in diagnosis. J Am Acad Orthop Surg. 2000;8:195.
Large polyphasic MUAPs
Normal
Normal + (acute)
+/– (severe)
↓ (focal)
Normal
+ (acute)
Conduction velocity
Normal
Fibrillations
↓ (diffuse)
+/– ↓ ↑ (focal)
Normal
Normal
↓ (focal)
Normal
Distal latency
+/– +/–
+
↑ (diffuse)
↑ (diffuse)
+/– ↓
+/– ↓
Demyelinating Polyneuropathy
+
↓ (diffuse)
Sensory nerve amplitude
Axonal Polyneuropathy
+/– ↓
↓ (focal)
+/– ↓
Focal Entrapment
Plexus Lesion
Root Lesion
Finding
Motor nerve amplitude
Electrodiagnostic Findings in Various Peripheral Nerve Disorders
87 General Orthopaedics—Nerves, EMG/NCV
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General Orthopaedics—Wound Healing
88
Nerve Injury Classification Seddon
Sunderland
Pathologic Findings
Neurapraxia
1
Localized myelin damage (compression)
Axonotmesis
2
Loss of axonal continuity; endo-, peri-, and epineurium intact
3
Axonal and endoneurial continuity lost
4
Axonal, endoneurial, perineurial continuity lost
5
Complete nerve lesion
Neurotmesis
Sunderland S. Nerve Injuries and Their Repair: A Critical Appraisal. New York, NY: Churchill Livingstone; 1991. Seddon HJ. Surgical Disorders of the Peripheral Nerves. Baltimore, MD: Williams and Wilkins; 1972:68–88.
GENERAL ORTHOPAEDICS—WOUND HEALING Normal Wound Healing Indices
Malnutrition/Poor Wound Healing
Serum albumin > 3.5 g/dl Absolute lymphocyte count > 1500/mm3 Absolute Doppler pressure 70 mm Hg Differential pressure index (ABI) > 0.5 TCPO2 30 mm Hg
Total lymphocyte count < 1500/mm3 Serum albumin < 3.5 gm/dL Serum transferrin level < 226 mg/dL
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PEDIATRIC ORTHOPAEDICS—MEDICATIONS Analgesics (All doses mg/kg unless otherwise noted) Medication
Product
Dosage
Route
Maximum
Acetaminophen drops
80 mg/0.8 mL
10–15 mg/kg q4–6h
po
5 dose/day
Acetaminophen elixir
160 mg/5 mL
10–15 mg/kg q4–6h
po
5 dose/day
Acetaminophen chew
80 mg
10–15 mg/kg q4–6h
po
5 dose/day
Acetaminophen tabs
325 mg
10–15 mg/kg q4–6h
po
5 dose/day
Aspirin
81 mg
10–15 mg/kg q4–6h
po
100 mg/5 mL
5–10 mg/kg q6–8h
po
40 mg/kg/d
120 mg Acet/12 mg, codeine/5 mL
3–6 yr: 5 mL 7–12: 10 mL q4–6h
po
60 mg/dose Codeine
Diazepam
0.12–.08 mg/kg/d divided tid–qid 0.04–0.2 q2–4h
po/pr
0.6 / 8 hr
Meperidine
1–1.8 mg/kg
IV/SC/po slow IV
Morphine
0.1–0.2 mg/kg 0.1–0.2 mg/kg
IV/IM/ SC po
15 mg q4h
Codeine
0.5–1.2 mg/kg q4h
po
≥ 1 year
Ibuprofen Acetaminophen elixir/codeine
IV/IM
Antihistamines Hydroxyzine
10 mg/5 mL
0.5 qid
Diphenhydramine
12.5 mg/5mL 25, 50 mg
5 mg/kg/d Divided qid
po po/IV/IM 300 mg/day
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PEDIATRIC ORTHOPAEDICS—MILESTONES AND ANGLES Gait Sitting—6 months Cruises—12 months (variable) Independent walking—15 months Runs—18 months
Mature gait kinematics—3–7 years Time/distance parameters (step length and velocity) continue to increase until growth complete
Rotational Profile Foot progression angle: 5°–20° external rotation
Maximum varus ~ Birth Genu rectus ~ 18 months Maximum valgus ~ 3 years
Hip Internal rotation: 30°–60° (< 20° femoral anteversion) Femoral Anteversion; 1 years—31° Hip External rotation: 20°–60° (> 70° femoral 8 years—24° anteversion) 15 years—15° (Improves 15° up to Thigh foot angle: 0°–20° external rotation 15 years old) (< negative 10° tibial torsion) Development of Cervical Spine Age
Feature
< 6 mo
C1 body invisible and all synchondroses are open, vertebrate are normally wedged anteriorly, and there is often no lordosis to the noninjured spine.
1 yr
Body of C1 becomes visible radiographically.
3 yr
Posteriorly located spinous process synchondroses fuse. Dens becomes ossified (visible radiographically).
3–6 yr
Neurocentral (body) and C2-odontoid synchondroses fuse. Summit ossification center appears at the apex (top) of the odontoid. Anterior wedging of the vertebral bodies resolve (and is not normal if seen).
8 yr
Pseudosubluxation and predental widening resolve; lordosis is normal now.
12–14 yr
Secondary ossification centers appear at spinous process tips; summit ossification center of odontoid fuses (if it does not os odontoideum occurs); superior/inferior epiphyseal rings appear on body.
25 yr
Secondary ossification centers at tips of spinous processes fuse. Superior/inferior epiphyseal rings fuse to vertebral body.
Used with permission Tarascon Pediatric Emergency Pocketbook. 5th ed. Lompoc, CA: Tarascon; 2007.
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Pediatric Orthopaedics—Milestones and Angles
91
Reflexes Reflex
Disappears
Hand grasping
2–4 months
Plantar grasping
1 year
Moro
4–6 months
Stepping
1–2 months
Crossed extension
1 month
Withdrawal
Should always be present
Positive support response
4 months
Extensor thrust
2 months
Symmetrical tonic neck
Present by 6 months, no absolute time for disappearance
Parachute
Present by 6 months, persists through life
Characteristics of Myelodysplasia Levels Level Hip
Feet
Orthosis
Ambulation
L1
External rotation/ — flexion
Knee
Equinovarus
HKAFO
Non
L2*
Adduction/ flexion
Flexed
Equinovarus
HKAFO
Non
L3*
Adduction/ flexion
Recurvatum
Equinovarus
KAFO
Household
L4*
Adduction/ flexion
Extension
Cavovarus
AFO
Household +
L5
flexion
Limited flexion
Calcaneovalgus
S1
AFO
Community
Shoes
Near normal
*Increased risk of hip dislocation in these groups. HKAFO: Hip knee ankle foot orthosis KAFO: Knee ankle foot orthosis AFO: ankle foot orthosis
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PEDIATRIC ORTHOPAEDICS—GROWTH CENTERS Growth Plates (Range in parenthesis/age in years except as noted) Growth Plate
Appearance
Clavicular body
6th fetal week
Medial clavicle
Closure
17
18–24
Acromion
15–18
18–19
Coracoid
1
18–21
1st fetal week
20–21
18
19
Scapular body Glenoid Humeral body
6–8th fetal week
“
Humeral head (80% of humeral growth)
: 6 mo–2 yr : 3 mo–18 mo
Head/tuberosities 4–6 Fuse with shaft : 19–21, : 18–20
Greater tuberosity
: 1/2–1, : 1/4–1.5
“
Lesser tuberosity Lateral epicondyle Trochlea Capitellum Medial epicondyle Olecranon Radius body Radial head Radial tuberosity Distal radius
3–5 : 12, : 11 5 mo, 4 mo : 5 mo, : 4 mo (6 wk–8 mo)
“ : 17, : 14” “ “
: 5–7, : 3–6 (3–7)
: 18, : 15
: 10, : 8
: 15–17, : 14–15
6–12th fetal week : 5, : 4 (3–6) 10–12 3 mo–1.5 (3 mo–1.5)
: 15–17, : 14–15 14–18 : 19, : 17
LEG GROWTH Femur 15% proximal & 38% distal Tibia 27% proximal & 15% distal 92
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Pediatric Orthopaedics—Growth Centers
93
Growth Plates Growth Plate Ulna body Distal ulna
Appearance
Closure
6th–8th fetal week : 6, : 5 (4–9)
: 19, : 17
: 5.5, : 4.5 (2.5–9)
Variable
Lunate
4 (6 mo–9.5)
Variable
Triquetrum
: 2.25, :1.75 (1/2–4)
Variable
Pisiform
: 11, : 9
Variable
Trapezium
: 5, : 4 (1.5–10)
Variable
Trapezoid
: 6, : 4 (2.5–9)
Variable
Hamate
6 mo (0–1.5)
Variable
Capitate
6 mo (0–1)
Variable
Thumb metacarpal
: 2.5, : 1.66 (1–3.5)
14–21
Proximal thumb P1
5 mo–2.5
14–21
Proximal thumb P2
: 1.5, : 1
14–21
Scaphoid
Distal I/M/R/S metacarpal Phalanges PI, II, and III
1–1.5
14–21
5 mo–2.5
14–21
Iliac crest
Puberty
16–18
Iliac tubercle ischial spine
13–15
Fuse at puberty
Pubic tubercle
18–20
Fuse at puberty
Acetabulum
10–13
Fuse at puberty
Ischial spine
13–15
Fuse at puberty (Continues)
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94
Pediatric Orthopaedics—Growth Centers
Growth Plates (Continued) Growth Plate
Appearance
Femoral body
6th–12th fetal week
Femoral head
4 mo
Greater trochanter Lesser trochanter Distal femur Patella Proximal tibia
3 : 12, : 11 36th fetal week : 4–5, : 3 40th fetal week
Closure
: 17–18, : 16–17 16–17 16–17 : 18–19, : 17 Fuse at puberty : 18–19, : 16–17
Tibial tuberosity
7–15
Proximal fibula
: 4, : 3
: 18–20, : 16–18
Distal tibia
6 mo
17–18 (med. mal. 16–18)
Distal fibula Calcaneus Calcaneal apophysis Talus Cuboid
: 1, : 9 mo
19
17–18
24–26 fetal week
12–22
5–12
12–22
26–28 fetal week
Variable
40 fetal week
Variable
Navicular
: 3, : 2
Variable
Cuneiforms
3 mo–2
Variable
Metatarsal
8–12th fetal weeks
18
Phalanges
6 mo–4 yr
11–22
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PEDIATRIC ORTHOPAEDICS—FOOT
Angles and Characteristics Metatarsus Adductus
Talipes Equinovarus
Talo-calcaneal angle
20°–40°
< 20°
Characteristics
Adducted forefoot
Talus and calcaneus parallel
Normal Talo-Calcaneal Angle Is 20°–40°
Angles and Characteristics Calcaneovalgus
Metatarsus varus
+ Dorsiflexion
Yes
Yes
Clubfoot No
Shape of sole
Deviates laterally “Banana”
Deviates medially “Kidney”
Deviates medially “Kidney”
Heel position
Valgus
Valgus
Varus
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Pediatric Orthopaedics—Foot
96
CLUBFOOT TREATMENT—PONSETI TECHNIQUE (JBJS 74A(3): 448–454, 1992) • Long leg cast changed weekly • Usually requires Achilles tenotomy at 6 weeks to correct equines • Dennis-Brown bar and boots full-time for 3 months; nap and nighttime until 3 years • Correct in this order: Cavus Adductus Varus Equinus
PEDIATRICS—BRACHIAL PLEXUS Brachial Plexus Birth Injuries Name
Roots
Loss
Prognosis
Erb-Duchenne
C5/6
Deltoid, elbow flexors, dorsiflexion at hand/ wrist, “waiter’s tip deformity”
Best
Klumpke Total plexus
C8/T1 C5–T1
Hand intrinsics, wrist flexors Flaccid arm, sensory and motor loss
Poor Worst
2:1000 births, clavicle and proximal humerus fractures may mimic with pseudo-paralysis. Treat by maintaining passive ROM. Return may be up to 18 months. No biceps function at 3 months is an ominous sign.
OSTEOCHONDROSES Osteochondroses (Osteonecrosis at Apophysis/physis) Location
Eponym
Elbow (capitellum)
Panner’s
Phalanges (hand)
Thiemann’s
Spine
Scheuermann’s
Ischiopubic synchondrosis
Van Neck’s
Femoral head
Legg-Calve-Perthes
Inferior patella
Sinding-Larsen-Johansson
Proximal tibial epiphysis
Blount’s
Tibial tuberosity
Osgood-Schlatter’s
Calcaneus
Sever’s
Tarsal navicular
Köhler’s
Metatarsal head
Freiberg’s
Scaphoid
Preiser’s
Lunate
Kienböck’s
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PEDIATRIC ORTHOPAEDICS—GENERAL Osteochondritis Dissecans Knee and elbow most common Elbow (Panner’s disease) - Capitellum, common in throwers Knee-Lateral aspect of medial femoral condyle Activity related pain, tenderness, effusion
Trauma, ischemia Abnormal ossification 10–15 years May be polyarticular
Arthroscopic Classification of Osteochondritis Dissecans (Guhl) Classification
Stage
Intact
Treatment
I
Drilling (K-wire retrograde)
Early-separated lesion
II
In-situ pinning
Partially detached lesion
III
Débride base, reduce, pinning
Salvageable loose body
IV
Unsalvageable loose body
Débride base, reduce, pinning Removal and debridement
NOTE: Attempt casting if physis is open in stages I & II.
Night Pains (Awakens Child at Night, Less or Potentially Gone During the Daytime) Localized pain (short differential) Leukemia Acute osteomyelitis
Osteoid osteoma
Generalized pain (long differential) Spinal dysraphism or tether Skeletal tumor Fibrous dysplasia Muscle—hemangioma Subacute osteomyelitis
Knee—osteochondritis Feet—deformity Perthes disease of the hips Joints—arthritis Köhler’s disease
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Pediatric Orthopaedics—General
98
Back Pain in Children: Diagnostic Workup According to Symptom Severity Clinical Situation
Recommended work-up
No systemic signs (fever) Negative physical exam Pain < 3 months
Often none Close follow-up +/– radiographs
No systemic signs (fever) Pain > 3 months
Radiographs
Negative exam Normal X-rays
CBC, ESR Bone scan with SPECT*
Positive bone scan Negative X-rays
Add CT (rule out bony tumor, spondylolysis)
Positive ESR
Add antinuclear antibodies and HLA-B27
Positive neurologic findings Symptoms worsened at follow-up
MRI
* SPECT = single-photon emission computed tomography Bhatia NN, Chow G, Timon SJ, Watts HG. Diagnostic modalities for the evaluation of pediatric back pain. JPO. 2008;28(2):230–233.
Mucopolysaccharidosis Syndrome
Inheritance
Intelligence
Cornea
Urinary Excretion
I. Hurler’s (Worst)
Autosomal recessive
Mental retardation
Cloudy
Dermatan/heparan sulphate
II. Hunter’s
X-linked recessive
Mental retardation
Clear
Dermatan/heparan sulphate
III. Sanfilippo’s
Autosomal recessive
Mental retardation
Clear
Heparan sulphate
IV. Morquio’s (most common)
Autosomal recessive
Cloudy
Keratan sulphate
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PTH-related peptide receptor
Schmid metaphyseal chondrodysplasia
Jansen metaphyseal chondrodysplasia
AD
Type II collagen
Type X collagen
Kniest syndrome
AD
AD
AD AR (fatal)
Chondrodysplasia punctata
AD/SM XR
Type II collagen
SED (tarda)
SED (congenita)
Cartilage oligomeric AD protein (COMP)
Pseudoachondroplasia
AD/SM
Mode
Fibroblast growth factor receptor-3
Error
Achondroplasia (most common form)
Dysplasia
Disproportionate Dwarfism
M
M
P
P
E
E
E
E
Zone
Stippled epiphysis
Platyspondyly, dysplastic dens
Platyspondyly, delayed epiphysis
Metaphyseal flaring, delayed epiphyseal ossification, hypoplastic dens
Lumbar stenosis, bow legs. At risk for atlantoaxial instability and spinal stenosis
Radiologic Features
Severe limb shortening, prominent forehead, micrognathia
Coxa vara, wide eyes, bow legs, waddling gait
(Continues)
Flared metaphysis, wide irregular physes Bowed legs
Flared metaphysis, wide irregular physes Bowed legs
Detached retina, scoliosis, cleft palate Dumbbell femurs, osteopenia/hypoplasia
Flat facies
Kyphosis, hip pain
Flattened facies
Normal facies, short limbed, ligamentous laxity, atlantoaxial instability, scoliosis, early OA
Abnormal facies and spine inhibition of endochondral ossification
Clinical Findings
PEDIATRIC ORTHOPAEDICS—DYSPLASTIC CONDITIONS
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Bow legs
Mild dwarfing Delayed ambulation— waddling gait
AD
M
P
P
Kyphoscoliosis, odontoid hypoplasia
Thick bone, bullet-shaped metacarpals
Radiologic Features
Absent clavicles, wide cranial sutures Delayed physeal closure
Short limbs and stature Kyphoscoliosis Cleft palate, cauliflower ears, hitchhiker thumb, rigid clubfoot
Corneal changes, urinary sugars, atlantoaxial instability
Symmetrical cortical thickening
Hemienlarged epiphysis
Irregular epiphyseal ossification
Radiologic Features
NOTES: AD = autosomal dominant, SM = spontaneous mutation, AR = autosomal recessive, XR = X-linked recessive, SED = spondyloepiphyseal dysplasia, OA = osteoarthrosis. Zones: E = epiphyseal, M = metaphyseal, D = diaphyseal, P = physeal. Dietz FR, Matthews KD. Update of the genetic basis of disorders with orthopaedic manifestations. JBJS.1996;78A(10):1583–1598.
Cleidocranial dysplasia
AR
Diastrophic dysplasia
Sulfate transporter
D
M
E
Zone Clinical Findings
Inheritance Zone Clinical Findings AR/XR
Error
Mucopolysaccharidosis
Dysplasia
Proportionate Dwarfism
AD
Progressive diaphyseal dysplasia
AD —
I- COMP II-type IX collagen
Multiple epiphyseal dysplasia
Mode
Dysplasia epiphysealis hemimelica (Trevor’s)
Error
Dysplasia
Disproportionate Dwarfism (Continued)
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PEDIATRIC ORTHOPAEDICS—SALTER-HARRIS CLASSIFICATION Salter-Harris Classification of Physeal Injuries (JBJS 45A:587–622, 1963) Type
Description
Characteristics
I
Transverse through growth plate
Younger age
II
Same as I with a metaphyseal fragment (Thurston-Holland fragment)
Older age (> 10)
III
Through growth plate with extension through epiphysis into joint
Intra-articular
IV
Through epiphysis and metaphysis
Growth arrest
V
Crush injury to the growth plate
Late growth arrest
VI
Damage to the perichondral ring of Lacroix
Physeal bridge/asymmetric growth irregularity (angular deformity)
I
II ThurstonHolland Fragment
III
IV
V
VI
S - Sliding A - Above L - Lower T - Through E - Everything R - Periosteal Ring
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PEDIATRIC ORTHOPAEDICS—SLIPPED CAPITAL FEMORAL EPIPHYSIS Slipped Capital Femoral Epiphysis (JBJS 82A:1185, 2000) Prevalence 0.2/100,000 (Japan) to 10.08/100,000 (Northeastern US) 60% male Mean age = 13.5 in boys, 12 in girls
50% > 95th percentile for weight Bilaterality as high as 63%
Classification Preslip
Acute (10–15%)
Chronic (85%)
Acute on chronic
Stable–Walk without crutches (nearly 0% avascular necrosis) Unstable–Can’t walk without crutches (up to 50% avascular necrosis) RADIOGRAPHIC EVALUATION Radiographs show a superior and anterior slip of the proximal femoral metaphysis with respect to the capital femoral epiphysis. In a gradual slip you may see superior and anterior remodeling on the femoral metaphysis and periosteal new bone formation. Ultrasound to look for effusion and periosteal bone formation (unstable). MRI and bone scans may also be used. PHYSICAL EXAM Flexed and externally rotated position may mimic fracture in pain and presentation. (Represents a Salter-Harris I of the proximal femoral physis.) GRADING Slips < 30° mild, 30–50° moderate, > 50° severe (AVN risk increases with severity) Good results with in-situ pinning with mild and moderate slips. TREATMENT In-situ pinning favored—single pin under fluoroscopic guidance (still controversies especially with respect to traction, reduction) Treatments ranging from hip spica casting to osteotomies have been proposed. Prophylactic pinning of the contralateral side is controversial: • Incidence of bilateral slip ~20% • Should be strongly considered for age < 10 yr, endocrinopathy, renal failure, patients with predicted unreliable follow-up (J Bone Joint Surg Am. 2004 Dec;86-A(12):2658–2665.)
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Femoral Head below Kline’s line Blurring
Femoral Head above Kline’s line No Blurring
Metaphyseal Kline’s line should No Slip Blanch intersect a part of the lateral aspect of the femoral capital epiphysis Kline’s Line and Metaphyseal Blurring
Slip
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MetaphysealDiaphyseal Angle
Drennan’s Angle (JBJS 64:1158 –1163,1982)
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PEDIATRIC ORTHOPAEDICS—LIMP Ranges of Values for the Differential Diagnoses of the Child with a Limp Condition
Complete Blood Count
Erythrocyte Tc99 Bone scan Sedimentation Rate Increased vascularity (Following trend useful) = Increased uptake
Transient synovitis
↔, mild ↑
↔, mild ↑
↑
Slipped capital femoral epiphysis
↔, mild ↑
↔, mild ↑
acute ↑ chronic with osteonecrosis ↓
Herniated nucleus pulposus
↔, mild ↑
↔, mild ↑
↔
Spondylolisthesis, spondylolysis
↔, mild ↑
↔, mild ↑
↑
Pauciarticular juvenile rheumatoid arthritis (JRA)
↔, mild ↑
mild to moderate ↑
↑ at involved joints
Lyme disease
↑
↑
↑ at involved joints
Pyarthrosis
↑
↑
↑ or ↓**
Osteomyelitis
↑
↑
↑
Soft tissue abscess/ cellulitis
↑
↑
acute ↑
Acute rheumatic fever
↑
↑
↑ at involved joints
Polyarticular/systemic JRA
↑
↑
↑
Discitis
↑
↑
↑
Trauma
↔ or ↑
mild ↑
↔ (subacute) ↑ (stress fracture)
NOTE: Look for left shift with pyogenic process; platelets may elevate as an acute phase reactant. **NOTE: Fluid collection in joint may obscure uptake giving a false negative. Gallium localizes WBC collections better.
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Pediatric Orthopaedics—Limp C-REACTIVE PROTEIN MORE USEFUL THAN ESR TO FOLLOW TREND, AND RETURNS MORE QUICKLY TO NORMAL.
Radiographs Obtain spine, pelvis, and extremity Periosteal reaction ~ 2 weeks Medial joint space increased > 2 mm in hip is significant Endosteal erosion, disc space mineralization in discitis
ULTRASOUND Less invasive, easy to get, operator dependent MRI Good for soft tissue and differential between dead and living bone Early Perthes: evaluate spinal cord and disc Transient Synovitis vs. Septic Arthritis Diagnosis
Sequelae
Transient synovitis
Self-limited
Septic arthritis
Osteonecrosis Growth arrest Sepsis Joint destruction
Differential diagnosis: Slipped capital femoral epiphysis Fracture Legg-Calves-Perthes disease Rheumatoid arthritis Osteomyelitis Psoas abscess Pyogenic sacroiliitis Lyme disease
Five Predictors of Septic Hip Arthritis ESR > 40 C-reactive protein > 2.0 mg/dL WBC > 12,000 Nonweight bearing Temperature > 38.5˚ or 101.5˚ (Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP. JBJS 88A:1251-1257, 2006)
C-reactive protein and fever strongest independent risk factor
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Pediatric Orthopaedics—Limp Number of Predictors Present No predictors 1 predictors 2 predictors 3 predictors 4 predictors 5 predictors
106 Percent Chance of a Septic Arthritis 16.9% 36.7% 62.4% 82.6% 93.1% 97.5%
Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. JBJS. 2006;88A:1251–1257.
~10–16% of septic arthritis from contiguous bacterial osteomyelitis (hip, shoulder, ankle). Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. JAAOS. 2001;9(3):166–175. Osteomyelitis in Children See antibiotic section for choice of antibiotics and common pathogens. Usually via a blood-borne route. Rarely crosses the physis (subacute osteomyelitis can) and usually resides in the metaphysis or epiphysis due to vascular anatomy. Physical exam may show pain, loss of function, erythema, warmth, and occasionally abscess.
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Osteomyelitis Algorithm Possible Osteomyelitis
Radiographs
Negative
Positive
Bone scan
Negative
MRI, CT, US
Consider Aspiration
Positive Antibiotics
Antibiotics
Negative
No clinical improvement for 48 hours Positive
Biopsy and surgical debridement Antibiotics
Positive
Negative
Antibiotics
MRI, CT, US, reassess diagnosis
Biopsy and surgical debridement
Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. JAAOS. 2001;9(3):166–175.
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Limp—Differential Diagnosis Toddlers
4–10 years
11–16 years
Developmental hip dysplasia Mild cerebral palsy Toddlers fracture Juvenile RA Discitis
Perthes Osteomyelitis Septic hip/joint Leg length difference > 1–2 inch
Slipped capital femoral epiphysis Toxic synovitis DDH (untreated) Tumor Tarsal coalition Toxic synovitis
A hip radiograph is invaluable for any child with a limp and without an obvious etiology. Vertebral Infection > 5 years: Low-grade fever, nonweight bearing, flexed spinal posture, +/– abdominal pain < 5 years: Usually toxic appearing Discitis Refusal to walk or sit, decreased ROM of spine, MRI is diagnostic early Radiographs may show late disc space narrowing Treat: Bed rest (no traction), immobilization, +/– antibiotics Genu Varum Disorder of the posterior medial physis Blount’s disease = Drennan’s angle > 11° Metaphyseal beaking African-American, obese common Treatment Based on Age and Langenskiöld Stages Age
Stage
Treatment
< 18 months 18–24 months 2–3 years 3–8 years
I–II I–II I–II III–V VI (bony bridge)
None Night bracing Daytime brace Osteotomy Resection of bony bridge
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PEDIATRIC ORTHOPAEDICS—SCOLIOSIS SCOLIOSIS NEUROMUSCULAR SCOLIOSIS Common in neuromuscular conditions, may progress rapidly, may progress after maturation, often associated with pelvic obliquity, bony deformities, and involvement of the cervical spine Infantile Idiopathic Scoliosis 2 months–3 years Left-sided thoracic Male predominance Skull flattening
Other associated defects Most common in United Kingdom Curve < 20°, rib vertebral angle difference < 20° resolve MRI severe curves
Juvenile Idiopathic Scoliosis 3–10 years High risk for progression
70% need treatment 50% surgery 50% bracing
ADOLESCENT IDIOPATHIC SCOLIOSIS Progression vs. Magnitude/Skeletal Maturity (expressed in percentage of progression) Risser Sign
5–19°
20–29°
1–2
22%
68%
2–4
1.6%
23%
(Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. JBJS. 1984;66:1067)
Scoliometer threshold = 7°, progression = increased Cobb angle > 5° (curve apex < T8 use Boston bucket >, T7 use Boston + Milwaukee) Hard or difficult to brace hypokyphosis/thoracic lordosis in a brace
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Treatment Guidelines Curve
Progression
Risser stage
— 5–10° — — —
0–4 0–1 0–1 0–4 5
0–25° 25–30° 30–40° > 45° > 50°
*Posterior spinal fusion; add anterior spinal fusion for > 75°,
Therapy Serial observation Brace (halt or slow progression) Brace (halt or slow progression) Surgery * Surgery (young adults) < 10,
< 13
Progression Risk Factors (Curve > 20°, < 12 years, Risser 0–1 at presentation) MR Imaging Criteria/Rapid Progression (Tumor, Tethered Cord, Syringomyelia) Structural abnormality in plain films Excessive kyphosis Juvenile onset (< 11) Abnormal neurologic exam
Pain Left thoracic curve and focal neuro finding Radiographic abnormality Associated syndromes
King Curves (Patterns of Idiopathic Scoliosis) (JBJS 83A:1302–1313, 1983) Type
Definition
Flexibility
I
S-shaped thoracolumbar curve, crosses midline
Lumbar > thoracic
II
S-shaped thoracolumbar curve, crosses midline
Lumbar < thoracic
III
Right thoracic curve, T4 does not tilt into the curve
Lumbar vertebrae highly flexible
IV
Long thoracic curve, T4 tilts into the curve
L4 tilts to thoracic curve
V
Double thoracic curve
T1 tilts to upper curve
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3 2 1
Risser Stages (5 = Fusion of Iliac Apophysis)
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4
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Congenital Spinal Deformities Associated with genitourinary abnormalities (25%), cardiac (10%), and dysraphism (25%– commonly diastematomyelia) Risk of Progression
Curve progression
Unilateral unsegmented bar and contralateral hemivertebrae
Rapid and relentless
Unilateral unsegmented bar
Rapid
Fully segmented hemivertebrae
Steady
Partially segmented hemivertebrae
Less rapid, < 40° at maturity
Incarcerated hemivertebrae
None or slow
Nonsegmented hemivertebrae
Little
NOTE: Top three usually need surgery. Bottom three can be observed—partially segmented hemivertebrae will sometimes need excision.
Lenke Classification of Adolescent Idiopathic Scoliosis (JBJS 83A(8):1169–1181, 2001) Type Curve Type
Proximal Thoracic
Main Thoracic
Thoracolumbar/ Lumbar
1
Main thoracic (MT)
Nonstructural
Structural (Major)
Non-Structural
2
Double thoracic (DT) Structural
Structural (Major)
Non-Structural
3
Double major (DM)
Nonstructural
Structural (Major)
Structural
4
Triple major (TM)
Structural
Structural (Major)
Structural
5
Thoracolumbar/ lumbar (TL/L)
Nonstructural
Non-Structural
Structural(Major*)
6
Thoracolumbar/ lumbar-main thoracic (TL/L-MT)
Nonstructural
Structural
Structural(Major*)
Note: Major = Largest Cobb measurement, always structural. Minor = all other curves with structural criteria.
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May have a thoracic, thoracolumbar, and/or lumbar apex
CSVL does not touch the apical vertebral body or bodies immediately above or below the apical disc
Lumbar Modifier C
Apical body
CSVL - Central Sacral Vertical Line Lenke LG, Betz RR, Harms J. JBJS 83A:1169-1181, 2001
If in doubt choose Type B
Must have a thoracic apex
Lumbar Modifier B CSVL touches apical vertebral body/bodies or pedicles, minimal to moderate L-spine rotation
Lumbar Modifier A
CSVL between pedicles up to stable vertebrae, no or minimal scoliosis and rotation of L-spine
Apical disc
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66016_CH03_PTR.indd 114 Apex T2–T11-12 Disc T12–L1 L1–2 disc, L4
Thoracic Thoracolumbar Lumbar
Location of Apex (Scoliosis Research Society definition) Curve
Thoracic Sagittal Modifier
Modifiers (See Lumbar Modifiers)
Side-bending Cobb ≥ 25° T2–T5 Kyphosis ≥ +20° Side-bending Cobb ≥ 25° T10–L2 Kyphosis ≥ +20° Side-bending Cobb ≥ 25° T10–L2 Kyphosis ≥ +20°
> 40°
N [Normal] + [Positive] hyperkyphotic
Classification Notation Curve type (1–6) + lumbar spine modifier (A, B, or C) + thoracic sagittal modifier (–, N, or +)
< 10° 10°–40°
– [Negative] hypokyphotic
Thoracic Sagittal Profile T5–T12
Thoracolumbar/lumbar
Main thoracic
Proximal thoracic
Structural Criteria (Minor Curves)
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Scheuermann’s Kyphosis (Thoracic) (Lowe TG. Scheuermann disease. JBJS 72A:940–945, 1990) Kyphosis > 45°, 5° or more anterior wedging at three consecutive vertebrae Other radiographic findings = disc narrowing, end-plate changes, spondylolysis (30–50%), scoliosis (33%), and Schmorl’s nodes more common, adolescents with poor posture and occasionally aching pain Hyperkyphosis that does not improve with hyperextension (if hyperkyphosis improves with hyperextension diagnosis = postural kyphosis, tight hamstrings Brace progressive curves (Risser 1–3), > 1 year, may improve curve Risser 5, > 75°, consider fusion Lumbar Scheuermann’s—Athletes/manual laborers, less common, end-plate changes, Schmorl’s nodes, ↓ disc height, lacks wedging, mechanical back pain Usually self-limited
PEDIATRIC ORTHOPAEDICS—CHILD ABUSE SKELETAL SURVEY IN CHILD ABUSE AP bilateral hands, forearms, arms, thighs, legs, and feet AP/lateral axial skeleton and trunk AP/lateral skull Differential Diagnosis in Child Abuse Diagnosis
Factors and/or characteristics
Accident
Age, mechanism of injury, assoc. injuries, no delay in seeking care
Birth trauma
Obstetric history, callus within 2 weeks of birth, humeral or clavicle fracture, distal humeral physeal separation
Osteogenesis imperfecta
Family history, osteopenia, blue sclera, dental abnormalities, wormian bones, skin-test abnormalities
Caffey’s disease
Family history, diffuse periosteal elevation, mandibular involvement, irritability, inflammation, swelling, stiffness (Continues)
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Differential Diagnosis in Child Abuse (Continued) Diagnosis
Factors and/or characteristics
Rickets
Physeal widening, metabolic abnormalities, deformity, osteopenia, Looser’s lines, laboratory abnormalities
Congenital syphilis
Metaphyseal erosions, periosteal bone formation, positive serological tests, pseudoparalysis
Congenital insensitivity to pain, Riley-Day syndrome
Infection, joint destruction, neurologic abnormalities, family history
Coagulation disorders
Bruising, coagulopathy, laboratory abnormalities
Leukemia
Metaphyseal lucencies, systemic symptoms, hematologic abnormalities, + bone marrow biopsy
Normal radiographic variants
Angulation of ossifying metaphysis, cortical irregularities, spurring, juxtaphyseal variants
Adapted from Kocher MS, Kasser JR. Orthopedic aspects of child abuse. J Am Acad Orthop Surg. 2000;8:10–20.
Specificity of Musculoskeletal Findings in Child Abuse High specificity
Metaphyseal corner lesions, posterior rib, scapular, spinous process, or sternal fractures
Moderate specificity
Multiple fractures, fractures of different ages, epiphyseal separations, vertebral body, digital, or complex skull fractures
Low specificity (but common in child abuse)
Clavicular, long-bone shaft, or linear skull fractures
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PEDIATRIC ORTHOPAEDICS—PERTHES LEGG-CALVES-PERTHES DISEASE Osteonecrosis of the proximal femoral epiphysis Boys 4 to 8 years old, Delayed skeletal maturation Legg-Calves-Perthes Stages Stage Characteristics Initial Physeal irregularity, metaphyseal blurring, radiolucencies Fragmentation Radiolucencies and radiodensities Reossification Normal density returns Healed Residual deformity
Herring Classification (JPO 12:143–150, 1992): A ⴝ normal pillar height, B ⴝ > 50% height, C ⴝ < 50% Herring’s Modified Lateral Pillar Classification and Surgical Indications (JBJS 86A:2121–2134, 2004) Chronological Skeletal Herring Group Surgical Treatment Age Age A, B, B/C No benefit from surgical treatment ≤8 ≤6 border (tend to do well) Innominate osteotomy >8 >6 B, B/C border or varus femoral osteotomy No benefit from surgical treatment Any Any C (tend to do well)
Risks— Positive family history, low birth weight, abnormal birth presentation Physical signs— Trendelenburg gait, hip or knee pain, decreased range of motion (especially abduction and internal rotation) Key to prognosis— Age > 6 years ⫽ worse Bilateral 12–15% 117
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PEDIATRIC ORTHOPAEDICS—DDH DEVELOPMENTAL DYSPLASIA OF THE HIP Developmental dysplasia of the hip (DDH) (Risk = 1:1000) Associated conditions: metatarsus adductus, clubfoot, calcaneovalgus, torticollis Increased in Native Americans and Laplanders Rare in individuals of African descent Risk with History 6% risk with normal parents and 1 affected sibling 12% risk with 1 affected parent 36% risk with 1 affected parent and sibling Distribution 80% Female Left 60%, right 20%, both 20% Increased risk with breech or first born Twice as common in subsequent siblings
Radiographs may be confirmatory, but do not rule out the diagnosis of DDH. If subluxation suspected, dynamic ultrasound may be helpful. ALGORITHM FOR EVALUATION AND TREATMENT OF DDH (JAAOS 8:232–242, 1999) Abnormal hip at birth Subluxated
Dislocated or dislocatable
Observe at three weeks
Nonreducible
Stable
Subluxation
No treatment
Pavlik harness
Stable/no dysplasia Wean from harness
Reducible
Neuromuscular examination Operative treatment
Subluxation Neuromuscular examination
The surgeon places Pavlik initially Weekly follow-ups till full ROM If not reduced/stable by 3 weeks,consider other treatment options 2-week follow-ups till clinically and radiographically stable AP pelvis out of brace; wean out of brace If residual acetabular dysplasia persists, the harness may be worn 12 hours/day until radiographs show no dysplasia
Pavlik harness*
Reduced
Full-time wean No dysplasia
Not reduced at 2 weeks Reevaluate
Dysplasia
End harness
Closed or open reduction
Abduction brace *6 weeks plus 2 times the age (weeks) at application
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PHYSICAL EXAM AND INJECTIONS Physical Exam: Hand Test Allen’s (J Trauma 21: 471–479,1981)
Carpal tunnel compression Crossed finger test (JHS 5:560–565,1980)
Elbow flexion Elson test (JBJS(Br) 68: 229–231,1986)
Finkelstein Flexor digitorum profundus Flexor digitorum superficialis
Froment’s
Passive test of continuity Phalen’s (JBJS 48:211–228, 1966)
Description Compress radial and ulnar arteries at wrist, make fist, relax fist, release arteries one at a time, shows ulnar and radial artery patency (Can be performed on fingers) Direct pressure over the carpal tunnel just distal to distal wrist flexion crease, 30–60 sec. Cross long and index finger (tests 1st volar and 2nd dorsal interosseous muscle) Hyperflexion elbow ~ 30–60 seconds, reproduces ulnar nerve symptoms Flex finger at proximal interphalangeal joint over table edge, have patient extend the joint against resistance. Distal joint should remain supple. Thumb in palm, ulnar flex wrist, clenching fist can give a false positive result. Reproduces pain in 1st dorsal compartment Hyperextend MCPJ, lock PIPJ in extension, have patient flex DIPJ Isolate finger by extending all others, have patient flex finger. Flex finger with metacarpophalangeal joint extended; otherwise, hand intrinsics contribute. Have patient pinch a piece of paper. Weak pinch and flexion of DIPJ of thumb signifies ulnar neuropathy (weak adductor pollicis and flexor pollicis brevis) Flex wrist, grasp forearm just proximal to wrist flexion crease, squeezing here will flex fingers
Positive Findings
Volar flex wrist ~ 30–60s (reproduces median nerve findings)
Median nerve compression
Arterial patency in the hand Reproduces median nerve symptoms Intact ulnar nerve Ulnar nerve compression Central slip intact
DeQuervain’s tenosynovitis Tendon continuity
Tendon continuity
Ulnar neuropathy
Tendon continuity
(Continues)
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Physical Exam: Hand (Continued) Test Description The four flexor digitorum profundus tendons share a common muscle belly. Shortening of one tendon Quadriga effect causes the muscle tendon units of the remaining three tendons to functionally lengthen. Shucking ulnar wrist while stabilizing Regan test the lunate Axial load skull with the neck in extension and deviation to the Spurling’s symptomatic side— worsens nerve root compression Flex wrist—fingers extend. Extend Tenodesis effect wrist— fingers flex (resting tone— intact tendons). Tap directly over peripheral nerve, Tinel’s symptoms in distribution of nerve Thumb over volar distal pole of scaphoid, radial deviation of Watson test wrist flexes scaphoid, with torn (JHS 13: scapholunate ligament the proximal 657–660,1980) pole of the scaphoid slips over the dorsal lip of the radius
Flexor Digitorum Profundus Damian Rispoli 2009
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Positive Findings Limits full flexion of uninvolved digits Lunotriquetral ligament Nerve root compression, radicular pain Tendon continuity Nerve irritation, neuroma Scapholunate interosseous ligament tear
Flexor Digitorum Superficialis (You must isolate and test each finger separately)
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Physical Exam and Injections
Quick Neurologic Assessment of the Hand
Anterior Interosseous Nerve
Ulnar Nerve
Posterior Interosseous Nerve
-Tests the flexor digitorum profundus (index) and flexor pollicis longus
-Active finger abduction -See crossed finger test
-Tests the extensor indicis proprius and digiti quinti minimi Damian Rispoli 2009
Flexor and Extensor Tendon Zones Flexor Zones
I
I
I
I
II TI III
IV
TII TIII
V Damian Rispoli 2009
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I. Distal to flexor digitorum superficialis insertion II. Within finger flexor retinaculum (“No man’s Land”) III. The palm IV. Carpal tunnel V. Wrist and Forearm TI. Distal to flexor pollicis longus insertion TII. Thumb flexor retinaculum TIII. Thenar eminence Extensor zones I. Distal interphalangeal joint II. Middle phalanx (PII) III. Proximal interphalangeal joint IV. Proximal phalanx (PI) V. Metacarpal VI. Dorsal wrist VII. Distal forearm VIII. Mid/proximal forearm
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Flexor Sheaths, Radial, and Ulnar Bursa
Tendon Sheaths
Ulnar Bursa
Radial Bursa
Flexor Tendons Damian Rispoli 2009
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Tenodesis Effect
Manual compression proximal to wrist causes passive finger flexion
Damian Rispoli 2009
Mallet Finger
Loss of continuity of the terminal tendon of the extensor apparatus Patient lacks the ability to actively extend terminal phalanx Damian Rispoli 2009
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Swan Neck Deformity
Lax or disrupted volar plate Dorsal subluxation of the sagittal bands Flexion of the distal phalanx Hyperextension of the proximal interphalangeal joint Damian Rispoli 2009
Judgement of the Rotational Alignment in the Fingers and Hand
Rotational alignment of the fingers is estimated by the fact that as the fingers are flexed into a first they will point to the tubercle of the scaphoid. Additionally, at resting flexion the nail beds of the fingers will be roughly parallel. Damian Rispoli 2009
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Physical Exam and Injections Finger Block - Flexor Tendon Sheath Block
Direct volar injection midline and down to bone over the A2 pulley. Slowly withdraw while injecting. Inject when you feel a loss of resistance to avoid injecting the substance of the tendons. You can feel the fluid flow into the flexor sheath.
Damian Rispoli 2009
Digital nerve block may also be performed by blocking the volar and dorsal sensory branches at the level of the metacarpophalangeal joint. Hematoma Block
Damian Rispoli 2009
Palpate the fracture site. Inject indirectly on the bone moving towards the fracture site until the anaesthetic flows freely. Alternately inject then asprate at the fracture site (‘‘barbotage’’). Used commonly for adult distal radius fractures and pediatric upper extremity fractures.
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126 WRIST INJECTION
• Inject dorsally through the fourth dorsal compartment 1 cm distal to Lister’s tubercle aiming for the capito-lunate interval. Palpate/visualize the fluid entering the wrist joint.
WRIST BLOCK • Ulnar nerve—Inject radial and dorsal to the flexor carpi ulnaris (FCU) at the proximal wrist flexion crease. Beware the ulnar artery just radial to the nerve. Raise a wheal ulnar to the FCU tendon to get the dorsal branch. • Median nerve—Inject ulnar to the palmaris longus tendon at the distal wrist flexion crease. Angle needle 30° to the skin, aiming distally. Stop needle or injection for any median nerve symptoms. • Radial nerve—Inject radial to the radial artery at the level of the radial styloid. Raise a wheal around dorsally and radially to get all the branches at this level.
Wrist Block Sensory Branch of the Radial nerve
Ulnar Nerve
Median Nerve
Damian Rispoli 2009
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127 Physical Exam: Elbow Test
Lateral pivot shift
Milking maneuver
PIN compression
Tennis elbow
Valgus instability
Posterolateral rotatory drawer (JBJS 73:440–446,1991)
Physical Exam and Injections Description Patient supine, elbow flexed; hold wrist in supination and apply valgus load; other hand hold forearm and adds an axial load Grasp thumb of supinated hand and pull lateral while applying counterforce to lateral elbow. Pain and instability occur in midrange from flexion to extension. Resisted supination with the elbow flexed reproduces pain over PIN at the proximal volar forearm Pain just distal to the lateral epicondyle with resisted wrist extension (elbow extended) Valgus load applied to the extended elbow with the wrist in supination Stabilize the humerus, elbow extended; grasp the proximal forearm with the thumb under the radial head, supinate the forearm, slowly flex the elbow; subluxation reaches maximum at 40˚ flexion
Moving valgus stress (AJSM 33(2): 231–239,2005)
Constant moderate valgus force is applied to the fully flexed elbow; quickly extend the elbow
Radiocapitellar plica (Arthroscopy 17(5): 491–495,2001)
Full extension of the elbow in supination Full flexion of the elbow in pronation
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Positive Findings Apprehension ⫽ lateral collateral ligament insufficiency
Medial collateral ligament laxity
Posterior interosseous nerve compression Lateral epicondylitis Medial collateral ligament insufficiency
Posterolateral rotatory instability
Medial elbow pain at 120°-70˚, medial collateral ligament tear (total/partial) Click at terminal flexion or ext. reproduces pain with a symptomatic plica
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Posterolateral Rotatory Drawer
Damian Rispoli 2009
Patient supine Shoulder flexed to 90° and stable Posterior and lateral force on the proximal radius External rotation force ~40° of flexion
Moving Valgus Stress Test (AJSM 33(2):231–9, 2005)
Support Elbow Quickly Extend Valgus Stress
Pain = MCL injury (usually 120−170)
Damian Rispoli 2009
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Lateral Pivot Shift Test
Valgus Force Axial Compression Maximal Supination Damian Rispoli 2009
From Flexion to Extension (radiocapitellar joint subluxed to reduced)
Elbow Joint Injection/Aspiration
Damian Rispoli 2009
Inject in the center of a triangle formed by the radial head, lateral epicondyle, and the olecranon. Alternately you can inject directly into the olecranon fossa from the posterolateral edge of the olecranon.
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130 Carrying Angle
The angle formed by the arm and the forearm. Important to observe when treating elbow fractures.
Normally a variable valgus angulation
Damian Rispoli 2009
Physical Exam: Shoulder Test Apprehension (JBJS 66B:551–556, 1984) Belly press (JBJS 78A:1015–1023, 1996) Cross arm
Drop arm Drop sign (JSES 5:307–313, 1996)
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Description 90° of abduction and external rotation; apprehension of dislocation Hands flat on stomach, have patient actively keep elbows anterior to frontal plane of body Bring arm from 90˚ forward flexion to across the chest, causing pain at acromioclavicular joint Slowly lower arm from 90° abduction to the side; drop arm is positive 90˚elevation, near full external rotation, elbow flexed to 90˚; support elbow, release wrist
Positive Findings Anterior capsular instability Intact subscapularis Acromioclavicular arthrosis Rotator cuff tear Drop wrist ⫽ infraspinatus tear
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131 Physical Exam: Shoulder Test External rotation lag sign (JSES 5:307–313, 1996) Hawkins test (AJSM 8: 151–158,1980) Horn blower’s Jobe test (Clin Orthop 173:117– 124, 1983 and Clin Sp Med 2:281–289, 1983) Lag sign(JBJS 78A: 1015–1023, 1996) Liftoff (JBJS 73B:389–394, 1991)
Load shift
Neer impingement sign
Neer impingement test (Clin Orthop 173: 70–77,1983) O’Brien (AJSM 26(5):610–614, 1998)
Physical Exam and Injections Description Elbow passive flexed @ 90˚, 20˚ elevation, near max external rotation Impingement with internal rotation at 90° forward flexion (labral and AC* joint pathology → false ⫹) Lifts arm up to 90° external rotation and 90° abduction, weak ⫽ abnormal
Pain ⫽ impingement
Shoulder at 90˚ abduction, 30˚ forward flexion, internal rotation (thumbpointed down)
Weakness ⫽ supraspinatus tear
Maximum internal rotation at shoulder. Unable to maintain liftoff position is ⫹ Patient lifts flat hand off back, ability to liftoff ⫽ intact subscapularis Axially applied force to humerus while bringing the arm from straight lateral abduction to 90° of forward flexion Causes apprehension or posterior shift No pain with test after subacromial injection Passive forward flexion > 90 degrees, scapula stabilized by examiner (arthrosis, stiffness, Ca⫹⫹ tendonitis, and bony lesions → false ⫹) 1. Shoulder 90° forward flexion, 30° adduction, resisted forward flexion with thumb pointed to ground 2. Rotate to full supination, andresisted forward flexion again
*SLAP ⫽ superior labrum anterior posterior, AC ⫽ acromioclavicular joint
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Positive Findings Can’t hold position ⫽ superior or posterior cuff tear
Posterior rotator cuff tear
Subscapularis pathology Intact subscapularis
Posterior capsular instability
Pain relief ⫽ impingement
Pain ⫽ impingement 1. Pain/click suggest SLAP* lesion 2. Ant/superior pain suggest AC* pathology (Continues)
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Physical Exam: Shoulder (Continued) Test Description Patient supine, posterior Posterior drawer directed force with shoulder at (JBJS 66B:557–560, 80°–120˚abduction and 30˚ 1966) forward flexion Supine apprehension; apprehension Relocation resolves with a posterior directed force on humerus Flex shoulder against resistance, Speed’s elbow extended, forearm (JBJS 48:1496–1502, supinated. Pain in the bicipital 1966) groove ⫽ ⫹ Downward axial load to humerus Sulcus sign subluxates humeral head inferiorly Resisted supination, elbow at 90°. Yergason forearm in pronation
Positive Findings Posterior subluxation ⫽ posterior instability Anterior capsular instability Pain ⫽ bicipital tendonitis, SLAP* Ligamentous laxity Pain ⫽ bicipital tendonitis
*SLAP ⫽ superior labrum anterior posterior, AC ⫽ acromioclavicular joint
Acromioclavicular Joint Injection/Aspiration
Palpate the AC joint inject at a 45° angle to the skin lateral to medial, joint should accept 0.5 – 1.5 cc of fluid. Damian Rispoli 2009
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Subacromial Injection
Damian Rispoli 2009
Palpate the acromial arch, inject under the arch from anterior to posterior
Glenohumeral Joint Aspiration/Injection
Injection Point
Palpate the glenohumeral joint line from posterior about 2 cm inferior and 1 cm medial to the posterolateral acromion. Aim the needle towards the coracoid anateriorly. Damian Rispoli 2009
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Physical Exam and Injections Physical Exam: Spine Test Adson’s test (AnnSurg 85:839–857, 1927)
Babinski
Bowstring Crossed straight leg raise
Femoral nerve traction test
Description Patient seated, arm dependent, neck toward side being tested and extended, deep breath. ↓ pulse is positive Stroking the bottom of the foot causes reflex toe extension Hip flexed to 90°, knee flexed to reduce radicular symptoms, pressure placed on tibial nerve in popliteal area Passive lifting of contralateral straight leg, flex hip with straight knee Place the patient laterally on the unaffected side, examiner passively extends the hip and flexes the knee of the affected side
Clonus
Forced dorsiflexion of the foot
Hoffmann’s
Flicking DIPJ of middle finger causes involuntary flexion of DIPJ of index and IPJ of thumb
Lhermitte’s
Forward flexion of neck causes lancinating pain down spinal cord to arms/legs
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134 Positive Findings ↓ pulse ⫽ thoracic outlet syndrome Upper motor neuron lesion Myelopathic sign (myelopathy, stroke, multiple sclerosis) Reproduces radicular pain 98% specific for HNP (lower lumbar radiculopathy) Reproduces radicular pain (upper lumbar radiculopathy) Reflex rhythmic plantar flexion response > 4 beats Upper motor neuron lesion Myelopathic sign (myelopathy, stroke, multiple sclerosis) Upper motor neuron lesion Myelopathic sign (myelopathy, stroke, multiple sclerosis) Stenotic sign causing myelopathy
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Physical Exam: Spine Test
Nonorganic signs (Waddele’s signs) (Spine 5: 117–125, 1980)
Straight leg raise
Description 1. Pain (out of proportion) to superficial touch (superficial tenderness) 2. Pain with axial rotation of the pelvis and with axial loading on the top of the skull (simulation) 3. Sitting straight leg raise < lying SLR (distraction) 4. Nonanatomic weakness or sensory changes 5. Overreaction
Passive lifting of straight leg, flex hip with straight knee, ± dorsiflexion of foot (Lasègue maneuver)
Positive Findings
May indicate heavy psychosocial overlay (three or more of five signs present)
Reproduces radicular symptoms; dorsiflexion should reproduce symptoms at less hip flexion (lower lumbar radiculopathy)
Femoroacetabular disease patterns No Impingement
Pincer Impingement
Cam Normal Clearance Impingement
Combined Impingement Reduced Femoral Head and Neck Offset
Over-coverage of femoral Head by the acetabulum
Combination of Cam and Pincer Redrawn from Lavigne M. Parvizi J. Beck M. Siebenrock KA. Ganz R. Leunig M. Anteriorfemoroacetabular Impingement Part I. Clin Orthop Rel Res 2004, 18:61–66.
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Developmental Hip Dysplasia
Hold thigh gently (like holding a tomato), don’t press too hard on the thigh
Barlow
Relaxation (the baby) is imperative, sleeping is perfect.
Damian Rispoli 2009
OrtolanI (Out to In)
Physical Exam: Hip Test Anteroposterior impingement Barlow FABER
Galeazzi
Ober
Ortolani
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Description Patient supine with the hip in 90° of flexion. Internal rotation and adduction recreates the symptoms Infant relaxed, hips flexed; gently adduct, hip may sublux or dislocate Flexion, abduction, and external rotation may cause pain in sacroiliac joint, hip joint, or iliopsoas insertion. Infant relaxed and supine, feet flat, knees flexed. Asymmetric knee height ⫽ DDH Lateral position, contralateral side down, hip and knee at 90°. Examiner abducts and extends hip (ipsilateral knee at 90°); adduct hip towards the contralateral leg Infant relaxed hips flexed; gently abduct, hip should relocate
Positive Findings Pain is indicative of femoroacetabular impingement Subluxable or dislocatable DDH Sacroiliac joint, hip joint, tendonitis DDH, dislocated hip Contracture in the iliotibial band or tensor fascia lata prevents adduction past midline Developmental hip dysplasia (DDH)
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Physical Exam: Hip (Continued) Test Description Supine position, patient slides Posteroinferior buttocks to the end of the table and impingement extends the hip, externally rotate the hip Active straight leg raise against Resisted straight resistance reproduces groin or low leg raise posterior buttock pain (also known as the Stinchfield test) Physical Exam: Knee Test Anterior drawer
Asymmetric external rotation
Dial test (CORR 1991; 264:235–238)
External rotation recurvatum Lachman’s
Description Pull tibia forward with knee at 90° Patient prone, knees flexed at 90°, externally rotate both feet at 30° and 90°. Asymmetric external rotation > 10°–15° ⫽ posterolateral corner injury, if asymmetric at both 30° and 90° then PLC and PCL. Supine with hip flexed to 90° or prone with the hip at 0°. Test with knee at 30° and 90°. Grasp both feet and maximally externally rotate. Compare sides. Pick up leg by great toe, knee goes into varus and recurvatum and tibial external rotation. Posterolateral tibial subluxation. Pull tibia forward with respect to femur with knee flexed to 30°
McMurray’s (JBJS Br 29:407– 414,1942)
Supine, knee and hip flexed to 90°. Valgus load and tibial internal and external rotation.
Patellar apprehension
Laterally push patella with the knee in 20°–30° of flexion
Pivot shift
Take extended and internally rotated knee and flex with a valgus force, relocation ⫽ ACL injury
Positive Findings Pain is indicative of femoroacetabular impingement Hip irritability or arthrosis
Positive Findings Laxity ⫽ ACL injury (test symmetry)
PLC or PLC/PCL injury
Asymmetry at: 30° ⫽ posterolateral corner 90° ⫽ posterior cruciate ligament Combined posterior lateral and ACL or PCL injury Laxity ⫽ ACL injury (test symmetry) Pain at medial joint line and click ⫽ medial meniscal tear Apprehension ⫽ patellar dislocation or subluxation ACL injury (test symmetry) (Continues)
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Physical Exam: Knee (Continued) Test Description Knee flexed at 90°, foot flat and fixed, posterior force on tibia. Posterior drawer Subluxation of condyles towards or anterior to the anterior tibial margin ⫽ PCL laxity/deficiency Varus/valgus Flex knee 0° off exam table edge, at 0° stress varus and valgus Varus/valgus Flex knee 30° off exam table edge, at 30° stress varus and valgus
Positive Findings PCL injury or insufficiency MCL/LCL and PCL or ACL Valgus laxity ⫽ MCL Varus laxity ⫽ LCL
Knee Injection/Aspiration Reliability of Intra-articular delivery: Lateral mid patellar 93%, Anteromedial 75%, Anterolateral 71% (JBJS 84A 1522-1527, 2003.)
Tilt patella away from needle. Insert needle under the patella and into the knee joint. May go either medial or lateral. This can also be done with the knee flexed at 90° using standard inferior arthroscopy portal landmarks.
Damian Rispoli 2009
Physical Exam: Ankle/Foot Test Description Ankle squeeze test
Ant. drawer
Coleman block test
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Squeeze calf above syndesmosis, pain at syndesmosis or below ⫽ injury Knee flexed, quad relaxed, cup heel, stabilize tibia, pull forward on heel. Asymmetric anterior excursion ⫽ ankle instability (anterior tibiofibular ligament injury) Place a block under the lateral hindfoot, supple hindfoot deformities accommodate for the block, fixed do not accommodate
Positive Findings High ankle sprain, syndesmosis injury Asymmetric excursion ⫽ ankle instability Fixed hindfoot deformity
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Physical Exam and Injections
Physical Exam: Ankle/Foot (Continued) Test Description
Silfverskiöld
Test dorsiflexion of the ankle with the knee extended and then flexed at 90°
Single leg heel raise
Patient standing, lift one foot off ground, raise heel of contralateral side. Lack of ability to perform or weakness with lack of hindfoot inversion is positive.
Talar tilt (JAAOS 6:368– 377, 1998)
Inversion at ankle causes tilting and lifting of the talus from the mortise
Thompson’s
Patient prone, knee flexed, squeezing calf should cause ankle plantar flexion
Too many toes sign
Patient standing, examine from behind looking for number of toes laterally. Asymmetric examine is positive.
Positive Findings Dorsiflexion > with knee flexion ⫽ Isolated gastrosoleus contracture Posterior tibial tendon dysfunction Asymmetry ⫽ ankle instability ⬎ 5˚ comparison, ⬎ 10˚ absolute Absence of plantar flexion ⫽ Achilles rupture Too many toes ⫽ posterior tibial tendon dysfunction
Ankle Joint Aspiration/Injection Palpate the joint line, direct the needle at the medial or lateral corner and under the tibial plafond. Avoid saphenous vein medially, the superficial peroneal nerve laterally, and the dorsalis pedis artery centrally. Damian Rispoli 2009
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Ankle Block Posterior View (medial left, lateral right)
Saphenous n. Tibial n. Deep peroneal n.
Sural n. Achilles tendon
Superficial peroneal n.
Extensor retinaculum
Damian Rispoli 2009
Anterior View (lateral left, medial right)
Tibial nerve block—Inject behind the medial malleolus, halfway between the malleolus and the calcaneus. Deep peroneal nerve block—Inject lateral to the extensor hallucis longus and anterior tibial artery level with the inferior extensor retinaculum. Superficial peroneal nerve block—Inject subcutaneously anterior to the extensor tendons. Saphenous nerve—Inject subcutaneously anterior to the medial malleolus. Sural nerve—Inject midway between the posterior border of the lateral malleolus and the calcaneus.
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RADIOLOGIC VIEWS Radiologic Views: Spine Line/Angle Normal
Description
Significance In trauma: 3–5 mm: rupture of 3 mm— Atlanto Dens transverse ligament adults interval (ADI) 5–10 mm: alar 4 mm—kids ligament stretched 10–12 mm: rupture of all ligaments ADI increased with atlantoaxial instability (Down’s, Morquio’s, Larsen’s, achondroplasia, SED, rheumatoid arthritis, trauma) Cobb method is the method chosen by the Scoliosis Research Society for measuring and Cobb angle 0° following scoliotic curves. Can also be used to measure kyphosis and lordosis Straight line from the Intrusion of odontoid posterior edge of the into foramen Odontoid tip foramen magnum to magnum Basilar Chamberlain’s ⬍ 3 mm the upper corner of invagination. Seen line above this the most posterior in rheumatoid line aspect of the hard arthritis, congenital palate conditions. (Continues) Distance from the anterior odontoid to posterior border of the anterior arch of C1
Cervical Radiographic Lines Anterior Skull Base
Wackenheim’s
Posterior Skull Base
McCrae’s
Chamberlain’s
McGregor’s C1
Hard Palate
C2
ADI
SAC
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Radiologic Views: Spine (Continued) Line/Angle Normal Description The distance between a line drawn from tip of dens to basion and ⫺4 mm to Harris line second line drawn 12 mm parallel to the posterior border of the dens
McCrae’s line
Odontoid tip should be below this line
McGregor’s line
Odontoid tip not ⬎ 4.5 mm above this line
Pavlov’s ratio
⬎ 0.8
Power’s ratio
⬍ 0.9 normal
Lateral C-spine: Diameter line drawn in the plane of the foramen magnum opening Upper corner of the most posterior aspect of the hard palate to the lowest border of the occipital skull Distance from the posterior margin of the vertebral body to the anterior margin of the spinous process divided by the distance from the anterior to the posterior margin of the vertebral body
Occipitocervical injury
Any existing compression will likely be asymptomatic if the tip is below this line Landmarks identifiable in all age groups
⬍ 0.8 is consistent with cervical stenosis
Ratio of lines drawn from basion to C1 posterior arch and opisthion to C1 anterior arch
⬍ 1 Anterior atlanto-occipital dissociation. Does not identify posterior dislocation or distraction injuries. Risk for progression of slip Defect in the pars interarticularis (spondylolysis)
Sacral inclination
Normal ⬍ 30°
Angle formed by a line drawn parallel to the posterior sacrum at S1 and one perpendicular to the floor
Scotty dog
No collar
Oblique view of the lumbar spine
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Significance
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Radiologic Views
Radiologic Views: Spine Line/Angle Normal
Space available for the cord (SAC)
13–14 mm at craniocervical junction; 12 mm below C2
Slip angle
⬍ 10 °
Description Distance from posterior aspect of odontoid (craniocervical junction) or vertebral body (below C2) to the nearest posterior structure Angle formed by a line perpendicular to the sacrum at S1 and the inferior end plate of L5
Significance
Smaller distances indicative of cord compression/ stenosis
Risk for progression of slip if > 10°
Cobb Angle Choose the “end vertebra,” the most tilted from the horizontal above the apex and below the apex of the curve. Draw a horizontal line across the upper end plate of the upper vertebrae and the lower end plate of the lower vertebrae. Draw lines perpendicular to these tangents until they intersect each other. The angle of the intersection is the Cobb angle.
Damian Rispoli 2009
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Lumbar Oblique Radiographs Spondylolysis 80% seen on lateral view, additional 15% seen on oblique view. Collar
Damian Rispoli 2009
Measurements in Spondylolisthesis Slip Angle Sacral Inclination
Listhesis is also graded on the percentage of displacement of the superior vertebrae on the inferior vertebrae.
Damian Rispoli 2009
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I. 0–25% II. 25–25% III. 50–25% IV. > 75%
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Radiologic Views
Power’s Ratio - AB/CD, Normal < 1.0 Skull Base
Anterior C1
Damian Rispoli 2009
Anterior C2
Damian Rispoli 2009
Scapholunate Angle
Capitolunate Angle
Normal 30–60 degrees
Normal < 30 degrees
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Radiologic Views
146
Anterior and Posterior Fat Pad Sign
Damian Rispoli 2009
Hemarthrosis lifts the capsule and pericapsular fat out of the coronoid and olecranon fossae. Posterior sign is highly significant; anterior may be present without injury/trauma.
Both lines should bisect the central 1/3 of the capitellum
Radiocapitellar Line Anterior Humeral Line Damian Rispoli 2009
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Radiologic Views
Radiologic Views: Upper Extremity Line/angle
Normal
Description
Significance
Anterior humeral line
Line passes through mid third of the lateral condylar ossific nucleus
Line carried straight down from the anterior cortex of the humeral diaphysis
Asymmetric, anterior, or posterior to the middle third of the capitellum indicative of fracture
Capitolunate angle
0°–15°
Carrying angle
10°–15° 15°–20° 15° in kids
Radial inclination
22° (24° ± 2.5°)
Radiocapitellar line
Line passes thru mid 1/3 of capitellum
Line drawn down the longitudinal axis of the radius
Radiolunate angle (lunate tilt)
0°
Longitudinal axis of the radius with the axis of the lunate
Intersection of the capitate axis and lunate axis on the lateral wrist view Angle formed by the longitudinal axis of the humerus and the longitudinal axis of the ulna measured in the frontal plane with the elbow in extension. The angle formed by the intersection of a line between the most distal points on the lateral and ulnar edges of the distal radius with a line perpendicular to the longitudinal axis of the radius on a PA view of the wrist
> 20° suggests carpal instability
Carrying angle is usually symmetric and can be used as an indicator of malalignment
Useful in estimating the degree of deformity of distal radius fractures
Dislocation/ subluxation of radial head (Monteggia fracture) ⬎ 15° flexion ⫽ VISI ⬎ 10° extension ⫽ DISI (Continues)
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Radiologic Views: Upper Extremity (Continued) Line/angle Normal Description On lateral view, angle formed by line drawn between the most distal volar 11° volar and dorsal tips of Radial volar tilt (11° ± 2°) the distal radius and a line drawn perpendicular to the longitudinal axis of the radius Scapholunate 30°–60° Angle formed by the angle scaphoid axis and the lunate axis
Significance In fractures: > 5 mm of radial shortening on the PA or > 20° of dorsal angulation on the lateral is associated with a poor outcome. ⬎ 70° ⫽ DISI. ⬍ 30° ⫽ VISI. ORIF scaphoid if ⬎ 60° and displaced ⬎ 1 mm
Scapholunate interval
⬍ 3° mm
Gap between scaphoid and lunate on PA clenched fist view (consider comparison view or dynamic study)
Gap ⬎ 3 mm suggests scapholunate ligament tear
Ulnar variance
0° mm
On PA of wrist, draw one line perpendicular to the longitudinal axis of the radius and tangential to the articular pole of the distal ulna and one line perpendicular to the longitudinal axis of the radius and tangential to the lunate fossa of the distal radius. Measure the distance between the lines. Ulnar tangent distal to the radial tangent ⫽ positive ulnar variance.
0 mm ⫽ ulnar neutral, stress distribution 80% thru proximal radius and 20% thru proximal ulna. ⫹ 4 mm ulnar positive variance. The ratio is 40% radius, 60% ulna. With negative ulnar variance, stress is 96% radius, 4% ulna.
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Radiologic Views
Radiologic Views: Upper Extremity Line/angle Normal Wrist arcs Collinear
Description On lateral wrist, in neutral position, radial, lunate, and capitate axes are colinear. Seen on the PA radiograph of the wrist.
Significance Asynchronous angulation indicative of carpal instability
NOTE: VISI = Volar intercalated segmental instability, DISI = Dorsal intercalated segmental instability
Damian Rispoli 2009
Volar Tilt ~ 11 Degrees
Osteoarthrosis vs. Rheumatoid Osteophytes None Sclerosis Osteopenia Asymmetric Symmetric Subchondral cysts Periarticular erosions Burnt-out rheumatoid arthritis may look like or mimic osteoarthrosis. MRI Signal Characteristics Bright on T1—Fat, gadolinium, methemoglobin, proteinaceous fluid, melanin Bright on T2—Fluid Bright with gadolinium—Vascular tissue STIR (poor resolution)—Fluid (profoundly suppresses fat signal) Gradient echo—Cartilage, “blooming” artifact in ferrous laden tissue (pigmented villonodular synovitis)
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Radiologic Views
150 Metacarpals
Thumb Metacarpal
Hook of Hamate Hamate Trapezium
Triquetrum
Trapezoid
Pisiform
Capitate Ulna
Scaphoid Lunate Sigmoid Notch
Radius
Damian Rispoli 2009
Wrist Radiographic Lines
Damian Rispoli 2009
Radial Inclination ~ 21 Degrees
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Radiologic Views Metacarpals Thumb Metacarpal
Capitate
Trapezoid
Lunate
Scaphoid
Trapezium
Radius
Ulna Damian Rispoli 2009
Lateral Wrist Radiograph
DDH Lines and Radiographic Assessment DDH side
Normal side
HiIgenreiner’s Line
Acetabular Index
Shenton’s Lines Perkin’s Lines
Damian Rispoli 2009
Note: Break in Shenton’s line and absence of ossific nucleus on DDH side (ossific nucleus normally presents at 4–6 months is delayed and small in DDH)
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Radiologic Views
152
Acetabular roof llioischial line lschial spine
Posterior acetabular lip
lliopectineal line Teardrop
Anterior acetabular lip
Damian Rispoli 2009
Pelvic Radiographic Lines Radiologic Views: Hip/Pelvis Line/Angle Normal Acetabular index
Anterior center edge angle
Birth < 30° 1 yr < 25° 3 yr < 20° 6 yr < 15° 10 yr < 10° Normal ⱖ 17°
Epiphyseal angle
⬍ 25°
Hilgenreiner’s line
Ossific nucleus inferior to this line
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Description
Significance
Angle formed a line drawn along the roof of the acetabulum and Hilgenreiner’s line
Indicates degree of acetabular dysplasia
On a false profile view the angle between a line drawn from the center of the femoral head and one from the center of the hip to the foremost aspect of the acetabulum Angle formed by a line tangent to proximal femoral epiphysis and Hilgenreiner’s line A horizontal reference line drawn through the triradiate cartilage
40°–70° ⫽ coxa vara
In a dislocated hip, the femoral head is in the upper outer quadrant.
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153
Radiologic Views
Radiologic Views: Hip/Pelvis Line/Angle
Normal
Description
Significance
Ilioischial line
No cortical disruption
Cortical disruption indicates a fracture of the posterior column. Teardrop may be V or U shaped in the presence of acetabular dysplasia.
Iliopectineal line
No cortical disruption
AP view of pelvis: The serpiginous line that runs from the most distal juncture of the sacrum to the ischium, along the border of the ischium to the ischial tuberosity, and down to the distal juncture of the medial border of the posterior column of the acetabulum. AP view: The most medial border of the pelvic ring. Oblique (obturator) view: the pelvic brim line, the anteromedial border of the anterior column.
Klein’s line
Symmetric left–right
Line drawn tangent to the superior femoral neck on the AP pelvis
Neck shaft angle
124° ⫾ 7°
Angle formed by a line drawn through the femoral neck and a line drawn through the femoral shaft
Perkins vertical line
Ossific nucleus medial to this line
A reference line that runs vertically through the lateral aspect of the bony acetabulum and is perpendicular to Hilgenreiner’s line
Can be suggestive of a SCFE (warning— bilateral slips!) ⬍ 110° ⫽ significant coxa vara. Coxa valga significance is variable, depends on acetabular coverage. Usually ↑ the valgus ↓ the coverage. Four quadrants are created by the intersection of Hilgenreiner’s and Perkins lines. In a subluxated hip, the femoral head will be in the lower, outer quadrant. (Continues)
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Cortical disruption indicates a fracture of the anterior column
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Radiologic Views
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Radiologic Views: Hip/Pelvis (Continued) Line/Angle Normal Description Shenton’s line (curve)
Smooth curve without a break
Teardrop
Teardrop shape; 5–8 mm medial to head ⬎ 5–8 mm suggests lateral displacement 20–35° Abnormal ⫽ ⬍ 20°
Wiberg center edge angle (CE angle)
Significance
Traces the arc between top of obturator foramen and medial femoral neck AP hip/pelvis, teardropshaped line medial to the head of the femur (quadrilateral plate)
Smooth curve broken in hip dysplasia, some fractures, and hip dislocation Disruption suggests fracture or penetration through the acetabulum into the pelvis
Angle formed by a line drawn from center of the femoral head to the lateral edge of the acetabular roof and line through the center of the femoral head and perpendicular to Hilgenreiner’s line
Decreased in dysplasia of the acetabulum as seen in hip dysplasia
Anterior Center Edge Angle (Lequesne Rev Rheum 28:643-52, 1961)
Line from the center of the femoral head to the lateral aspect of the acctabulm
Vertical line through the center of the femoral head
False-profile radiograph (65 degree oblique with the foot rotated parallel to the x-ray cassette) Damian Rispoli 2009
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Radiologic Views
Blumensaat’s line (roof of the intercondylar notch)
Notch in lateral condyle Tibial Spines Medial Plateau (concave) Damian Rispoli 2009
Knee Radiographic Lines
Discoid Meniscus (squaring, widening, cupping)
Pelligrini-Steida Lesion (Chronic MCL)
Lateral Capsular Sign (Segond fracture – associate with anterior cruciate ligament tear)
Fairbank’s Changes -post menisectomy(squaring, ridging, narrowing) [sclerosis is often added, but not stated in the original article] Damian Rispoli 2009
AP Knee Radiograph
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Radiologic Views
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Radiologic Views: Lower Extremity Line /Angle
Normal
Description
Significance
Blumensaat’s line
NA
A line drawn along the superior aspect of the intercondylar notch on a lateral knee view
The lower pole of the patella should reach this line. In patella alta, the lower pole is above this line. Increased in patients with recurrent patella dislocations
Congruence angle
: ⫺6° : ⫺10°
Insall ratio
1:1 ratio (0.8–1.2)
Lateral patellofemoral angle (Laurin)
Opens laterally
Proximal tibial metaphysealdiaphyseal angle
⬍ 11°
Q angle
⬍ 15°
Sulcus angle
126°–150° (average 138°)
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Angle formed by a line from apex of sulcus angle through lowest point of articular ridge of patella and line bisecting sulcus angle Measure on the lateral knee view flexed to 30°, ratio of patella length to length of patellar tendon Angle formed by a line drawn parallel to the lateral surface of the patella and a line drawn from the medial to lateral femoral condyles Angle formed by a line perpendicular to axis of the tibia and a line going through the medial and lateral lips of the proximal tibial metaphysis Not a radiographic angle. Measured clinically from the angle derived by a line from the ASIS to the center of the patella, with a line from the center of the patella down the tibial spine. Angle formed by a line drawn from the lowest point of intercondylar sulcus to highest points on the medial and lateral femoral condyles (knee flexed 45°, X-ray beam angled 30° from horizontal)
20% variation represents patella alta or patella baja Lines may be parallel or open medially in patients with recurrent patella subluxation In varus, an angle ⬎ 11° suggests Blount’s disease. Many feel ⬎ 14° ⫽ Blount’s. Increased Q angle associated with laterally subluxated patella (from the increased lateral force of the quadriceps) Larger angles are associated with subluxation or dislocation of the patella
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Radiologic Views
Radiologic Views: Foot/Ankle Line/Angle Normal
Description
Significance
Anteroposterior talocalcaneal angle (Kite’s angle)
25°–45°
An angle formed by the longitudinal axis of the calcaneus and the longitudinal axis of the talus
In club foot and hindfoot varus the angle is decreased. Approaches “parallelism.”
Bohler’s angle
25°–40°
Measures the posterior facet height; shows degree of deformity and compression in calcaneal fractures
Angle may be increased, decreased, or reversed depending on the severity of the calcaneal fracture.
Fleck at the base of the 2nd metatarsal seen on AP or 30˚oblique weight-bearing or stress view
Avulsion of the Lisfranc ligament of the base of the 2nd metatarsal
Fleck sign
First metatarsophalangeal angle
< 15°
Angle formed by a line through the longitudinal axis of the 1st metatarsal with that drawn through the longitudinal axis of the proximal phalanx
Increased in hallux valgus (bunions)
Gissane angle
120°–145°
Angle that runs from the calcaneo-cuboid joint to the posterior margin of the posterior facet
May be altered in calcaneal fracture. It indicates the anterior, middle, and posterior facet relationships. (Continues)
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Radiologic Views: Foot/Ankle (Continued) Line/Angle Normal Description
Significance
Intermetatarsal angle
< 9°
Angle formed by lines through the longitudinal axis of the 1st and 2nd metatarsals
An angle of >15° merits consideration of a proximal osteotomy to correct deformity
Lateral talocalcaneal angle
35°–50°
Angle formed by a line drawn through the longitudinal axis of the talus and a line drawn along the plantar surface of the calcaneus
Decreased in club foot (talipes equinovarus)
Meary’s angle
0°
Lateral foot X-ray: An angle formed by the longitudinal axis of the talus and the longitudinal axis of the first metatarsal
> 0° indicates cavus deformity due to forefoot cavus as opposed to hindfoot cavus
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Radiologic Views
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Radiologic Views
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Bohler’s Angle Normal 25–40 degrees
Gissane’s Angle Normal 120–145 degrees
Damian Rispoli 2009
Bunion Angles
Hallux Valgus Angle (Normal < 15 degrees)
Intermetatarsal Angle (Normal < 9 degrees)
Damian Rispoli 2009
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Radiologic Views
Radiographic Assessment of Tarso-Metatarsal Joint Injuries Obtain Weight Bearing AP, Lateral, and 30° Oblique views If weight bearing is not possible take stress views (forefoot abduction stess) 1st/2nd Metatarsal base distance ≤ 3mm (any doubt obtain comparison views) Medial border of the 2nd metatarsal is in line with the medial border of the middle cuneiform. 1st metatarsal aligns with the medial/lateral borders of the medial cuneiform 1st/2nd interspace continuous with the medial/middle cuneiform interspace 30° Oblique – Medial border of the 4th metatarsal is in line with the medial border of the medial border of the cuboid The lateral border of the 3rd metatarsal is in mile with the lateral border of the lateral cuneiform 3rd/4th interspace continuous with lateral cuneiform/cuboid
AP View–
Damian Rispoli 2009
30 Degree Oblique
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AP View
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SEDATION AND ANALGESIA OVERVIEW Local anesthesia and blocks do not always provide the degree of analgesia optimal for performing many orthopaedic procedures. Associated anxiety and motion control can also be significant, especially in children. The goal of procedural sedation is to permit safe and effective control of pain, anxiety, and motion to enable a necessary procedure while providing an appropriate degree of amnesia or decreased awareness. Hospitals are required by The Joint Commission on Accreditation of Healthcare Organizations (The Joint Commission) to adhere to fairly strict requirements for any occurrence of procedural sedation in any location. SEDATION PRINCIPLES • Sedation exists as a continuum from mild sedation/analgesia to general anesthesia (except for the dissociative agent ketamine). • To best achieve a specified response on the sedation continuum, carefully titrate IV sedatives at spaced intervals (except for the dissociative agent ketamine). • Patients are at highest risk for developing complications during the 5–10 minutes following IV sedative administration and during the immediate postprocedure period when external stimuli are discontinued. • Moderate sedation (formerly “conscious sedation”) is sedation to the point at which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. • Deep sedation is more advanced than moderate sedation in that patients cannot be easily aroused, but still respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired, and there is a higher risk of adverse events than with moderate sedation. SEDATION ENVIRONMENT REQUIREMENTS • Resuscitation equipment: Oxygen, suction, age-appropriate bag-valve mask, and intubation equipment. Reversal agents naloxone and flumazenil if opioids or benzodiazepines are being used, respectively. • Monitoring equipment: Continuous pulse oximetry, ECG monitoring, periodic vital signs as appropriate for sedation depth. Capnography if available. 162
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Sedation and Analgesia
• Personnel: A minimum of two individuals experienced at procedural sedation: Either two physicians, or one physician and one assistant (e.g., nurse, respiratory therapist). They must understand the pharmacology of their sedatives and be proficient at maintaining airway patency and assisting ventilation if needed. One individual must be available to continuously observe and monitor the patient for potential complications, although they may perform minor, interruptible assistant tasks. For deep or dissociative (i.e., ketamine) sedation one individual must have training in advanced life support interventions (e.g., airway management, resuscitation) and experience with this level of sedation. • Presedation evaluation: Sedation must be preceded by a directed history and physical examination, with the following elements assessed and documented (Joint Commission requirement): underlying medical problems (e.g., ASA physical status class), medications, allergies, previous adverse reaction. • Experience with sedation or general anesthesia, time and nature of last oral intake, heart and lung exam. The airway must be evaluated for abnormalities that might impair resuscitation. • Fasting: For elective procedures, the American Society of Anesthesiologists recommends an age-stratified fasting guideline of 2 to 3 hours for clear liquids and 4 to 8 hours for solids and nonclear liquids. In nonfasting situations a risk-benefit analysis must be performed balancing the potential for vomiting and aspiration with the timing and urgency of the procedure and the required depth of sedation. • Discharge: Patients should be monitored until alert and oriented (or returned to age-appropriate baseline), and vital signs should be stable and at baseline.
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Sedation, motion control, anxiolysis. No analgesia. Reversible with flumazenil.
IV: Initial 1 mg, then titrated to max 5 mg. IM: 5 mg or 0.07 mg/kg IM
IV (0.5–5 yr): Initial 0.05–0.1 mg/kg, then titrated to max 0.6 mg/kg. IV (6–12 yr): Initial 0.025–0.05 mg/kg, then titrated to max 0.4 mg/kg. IM: 0.1–0.15 mg/kg.
IV: 2–3 IM: 10–20
IV: 45–60 IM: 60–120
Reduce dose when used in combination with opioids. May produce paradoxical excitement.
Clinical effects
Adult dose
Peds dose
Onset (min)
Duration (min)
Comments
Fentanyl
Reduce dosing when combined with midazolam
IV: 30–60
IV: 3–5
IV: 1.0 mcg/ kg/dose, repeat q3 min prn, titrate to effect
IV: 50 mcg, may repeat q3min, titrate
Analgesia. Reversible w/ naloxone.
Ketamine
Multiple contraindications, administer concurrent atropine to prevent hypersalivation. 0.01 mg/kg, min. 0.1 mg, max. 0.5 mg
IV: Dissociation 15; recovery 60. IM: diss 15–30; rec 90–150
IV: 1 IM: 3–5
IV: 1–1.5 mg/kg slowly over 1–2 min, may repeat ½ dose q10min prn. IM: 4–5 mg/kg, may repeat after 10 min
Not recommended; risk of unpleasant recovery reactions.
Analgesia, dissociation, amnesia, motion control.
Nitrous Oxide
Requires gas scavenging and special equip. Several contraindications.
< 5 minutes following discontinuation
<5
Preset mix with minimum 40% O 2 self-administered by demand valve mask (requires cooperative patient)
Mild anxiolysis, analgesia, sedation, amnesia
*Alterations in dosing may be indicated based upon the clinical situation and the practitioner’s experience with these agents. Doses may vary when used in combination with other agents, especially when benzodiazepines are combined with opioids. Use lower doses in geriatric patients and those with significant cardiopulmonary disease. References: McCarty EC. Ketamine sedation for the reduction of children’s fractures in the ED. JBJS. 2000;7:912–918. Krauss. Sedation and analgesia for procedures in children. N Engl J Med. 2000;342:938–945. The Joint Commission. http://www.jointcommission.org. ASA. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 1996;84:459–471.
Midazolam (Versed)
Drug
Sedation Drug Dosing (NEJM 342:938–945, 2000)*
Sedation and Analgesia 164
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SPINAL EVALUATION Concussions in Athletes (Observe and Evaluate for at least 15 minutes) (AJSM 27:5 676–685, 1999) Grade Symptoms Duration Recommended return 1 Confusion, no amnesia Minutes When symptoms resolve 2 Retrograde amnesia Hours to days 1 week* 3 Amnesia after impact Days 1 month* *Second episode—out for the entire season. Any athlete that is symptomatic after a concussion requires serial evaluation. If at any point exam reveals deterioration in mental status or loss of consciousness after a concussion immediate transportation to an emergency facility is indicated.
Return-to-Play Criteria Same Day Not the Same Day Signs and symptoms cleared in 15 minutes Signs and symptoms last > 15 minutes Normal neurologic examination Signs and symptoms return No documented loss of consciousness Documented loss of consciousness Any new headache within 48–72 hours—No play, full medical evaluation Beware unilateral headache in the younger athlete
SIGNIFICANT SIGNS AND SYMPTOMS Dizziness, slowness to respond, difficulty concentrating, physical sluggishness, memory loss (especially retrograde) POSTCONCUSSION SYNDROME (OCCURS WITH GRADE 2/3) Persistent headaches, irritability, confusion, difficulty concentrating CLASSIC CONCUSSION Includes an unconscious period (> 5 minutes obtain CT) DIFFUSE AXONAL INJURY Defined by LOC > 6 hr—consider avoidance of all future contact sports Steroids in Emergent Cord Injury (NEJM 277:1597, 1997) Contraindications: Age < 13 (controversial), nerve root or cauda equina, gunshot wounds (or other penetrating injury) , pregnancy, already on steroids, other life threatening injury Therapy (Methylprednisone) initiated within 3 hours after injury: From 3–8 hours after injury: 30 mg/kg IV for the first hour 30 mg/kg IV for the first hour 5.4 mg/kg/hr IV for the next 23 hours 5.4 mg/kg/hr IV for the next 47 hours Remember to protect gastric mucosa with H2 blocker
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Spinal Evaluation
166
AUTONOMIC DYSREFLEXIA Catastrophic hypertensive event caused by impacted feces or an obstructed urinary catheter and occurs with complete spinal cord injury above T8–T10. Spondylolysis and Spondylolisthesis Class I II III IV V VI
Type Congenital Isthmic Degenerative Traumatic Pathologic Postsurgical
Listhesis Grades I 0–25% II 25–50% III 50–75% IV 75–100% V > 100%
Age Child 5–50 Older Young Any Adult
Spondylolysis Defect in the pars interarticularis Most common cause of low back pain in children Fatigue fracture (gymnastics, football linemen) 80% visible on plain films, 15% on obliques (scottie dog) Treatment is symptomatic, avoid extension Casting for more severe or symptomatic cases
Muscle Strength Testing Score Exam 0 No movement 1 Visible contraction 2 Movement without gravity 3 Movement with gravity 4 Less than full strength 5 Full strength
Frankel Grade Grade A B C D E
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Pathology/Other Dysplastic S1 superior facet Elongation/fracture of L5 S1 pars Subluxation due to facet (L4,L5) arthrosis Acute fracture (not pars) Bony elements destroyed/incompetent Over resected arches/facets
Reflexes Root Level C5 C6 C7 L4 S1
Reflex Biceps Brachioradialis Triceps Knee jerk Ankle jerk
Function Complete paralysis Sensory function only below level of injury Incomplete motor function (grade 1–2/5) below injury level Fair to good motor function (grade 3– 4/5) below injury level Normal function (5/5)
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Spinal Evaluation
Upper vs. Lower Motor Lesions Findings
UMN
LMN
Strength
↓
↓
Tone
↑
↓
Deep tendon reflex
↑
↓
Superficial tendon reflex
↓
↓
Babinski
+
⫺
Clonus
⫹
⫺
Fasciculations
⫺
⫹
Atrophy
⫺
⫹
Simon SR. Orthopedic Basic Science. 2nd ed. Rosemont, IL: AAOS; 1994:354.
Lumbar Spinal Stenosis: Canal ⱕ 12 mm, Stenosis ⱕ 10 mm AP diameter, Lateral recess stenosis ⬍ 2 mm
Spinal Cross Section Dorsal Columns (Sensory – deep touch, proprioception, vibratory)
Arm/Leg/Trunk (Medial to Lateral) Damian Rispoli 2009
Ventral Corticospinal Tract (Motor – voluntary)
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Lateral Corticospinal Tract (Motor)
Lateral Spinothalamic Tracts (Sensory – pain/temperature) Ventral Spinothalamic Tracts (Sensory – light touch)
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Spinal Evaluation
168
Low Back Pain Red Flags Trauma
Demonstrable muscle weakness
> 50 years old
Bowel or bladder dysfunction/incontinence
Fever
Saddle anesthesia
History of cancer
Decreased sphincter tone
Metabolic disorder
Night pain Unexplained weight loss
LOW BACK PAIN TREATMENT Acute LBP (≤ 6 weeks) 70% better in 2 wks, 90% better in 4–6 weeks - NSAIDS or acetaminophen (opiates/muscle relaxants of no additional benefit) - Minimize bed rest < 48 hours (encourage modified light activity) - Radiographs or MRI in the presence of red flags Chronic LBP (> 6 weeks), worsening radiculopathy -Rule out cauda equina syndrome—surgical emergency -Radiographs, MRI as indicated -Enlist the aid of pain clinic, mental health, etc. **Workman’s compensation and pending litigation have worse long-term prognosis. Spinal Cord Injury Syndromes
BrownSequard
Mechanism of Injury/ Pathology Penetrating trauma
Characteristics
Prognosis
Loss of ipsilateral motor, contralateral pain and temperature
Best
Root
Foraminal compression/ herniated disc
Based on level
Good
Central
Age > 50, extension injury, possible vascular etiology
Upper > lower extremities, motor and sensory loss
Fair
Anterior
Flexion-compression
Incomplete motor, some sensory loss
Poor
Complete
Burst fracture, canal compromise
No function below level of injury
Poor
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Spinal Evaluation
Spinal Cord Injury Treatment by Functional Level Level Working Not Working < C4 — Diaphragm, upper extremities C4 Diaphragm/trapezius Upper extremities C5 Elbow flexors Below elbow
Wheelchair chin/puff Electric wheelchair, ratchet Wheelchair, flexor hinge Wheelchair, independent Wheelchair, independent
C6 C7 T1
Wrist extensors Elbow extensors Intrinsics
T2–12
Upper extremities, abdominals
L1
Lower extremities
L2
Upper extremities, abdominals, quads Iliopsoas
L3 L4
Quadriceps Tibialis anterior
L5
Extensor hallucis and digitorum longus Gastrocnemius, soleus
Ankle Toe dorsi flexion, plantar flexors Plantar flexors
Wheelchair, HKAFO (nonfunctional ambulation) KAFO, minimal ambulation KAFO, household ambulation AFO, community amb. AFO, community ambulation AFO, independent
Bowel/bladder
⫾ metatarsal bar
S1
Elbow extensors Grasp Abdominals, lower extremities Lower extremities
Treatment/Mobility Respirator dependent
Knee/ankle
NOTE: Level ⫽ functional level (functional level is the most distal intact motor level (fair motor grade). HKAFO ⫽ hip knee ankle foot orthosis, KAFO ⫽ knee ankle foot orthosis, AFO ⫽ ankle foot orthosis. Adapted from Miller MD, ed. Review of Orthopaedics. 3rd ed. Philadelphia, PA: WB Saunders; 2000:458.
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TRACTION TRACTION SETUPS (Zimmer Traction Handbook: A Complete Reference Guide to the Basics of Traction. Warsaw, Ind.: Zimmer; 1992.) GENERAL PRINCIPLES • Skin traction should not be used over an open wound. • Skin traction should not be used when it would impede or affect the neurovascular status of the limb. • Ensure no history of allergies to skin adhesives. • Do not reuse traction cord. • Pad all bony prominences. • All weights must hang free and must not lie above the patient. • Knots must be free from pulleys, especially in dynamic traction. • Likewise, the moving parts of the traction setup should be free from interference from bed, bed sheets, etc. • You must communicate and explain the basic principles and dangers to the support staff. • Patient transport should be done under physician supervision, or the traction setup rechecked upon arrival at any new location. • Skin care and neurovascular status need to be monitored regularly. TRACTION PIN PLACEMENT CALCANEAL TRACTION PIN The pin is placed on the bone via an incision through the skin and blunt dissection down to the calcaneus. It is placed from medial to lateral. The pin is positioned at a point 2.5 cm inferior and 2.5 cm posterior to the tip of the lateral malleolus on the medial aspect of the calcaneus. The pin is then drilled through the calcaneus and delivered via a stab incision laterally. Care is taken to protect the medial neurovascular structures and the subtalar joint.
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Traction Lower Extremity Traction Pin Placement
Distal Femoral Traction Pin
Proximal Tibial Traction Pin
Damian Rispoli 2009
DISTAL FEMORAL PIN • With knee flexed at 90⬚ if planning 90–90 position to prevent iliotibial band interference with traction • Parallel to the joint surface • 90° to the shaft • 5/64 or 3/32-threaded Steinmann pin; when the pin tents the lateral skin an incision is used to deliver it through the skin. • Pin level is 1 fingerbreadth above patella with the knee extended or just above the distal femoral flare. • If intramedullary fixation is planned, the pin must be placed anterior or posterior to the center to allow for rod passage. • Pin is passed medial to lateral to protect neurovascular structures through Hunters canal (adductor hiatus). PROXIMAL TIBIAL TRACTION PIN • At the level of the tibial tubercle • 1–2 cm posterior to anterior tibial crest • Passed lateral to medial to protect common peroneal nerve • Not favored in children due to potential interference with growth plates • Consider knee stability prior to placement
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Traction
172 TRACTION IS NOT BENIGN! TRACTION TYPES
PEDIATRIC TRACTION • In general, skeletal traction is not recommended as a method of treatment for children over 12 years old (increased incidence of shortening and angulation). • Indications include unstable femur fracture < 6 years old, > 3 cm shortening. • Fracture < 6 years old, unstable in hip spica; associated other injuries in a child able to cooperate with bed rest. • Skin complications can occur with > 5 pounds skin traction. BRYANT’S TRACTION (RARELY USED, NV COMPLICATIONS) • Hips at 90°, knees at 0°, chest restraint, Bradford frame, weight adjusted to just lift the sacrum off the Bradford frame. • (Do not use in > 2 years, > 25 lb., beware of serious neurovascular compromise.) MODIFIED BRYANT’S TRACTION • Decreases incidence of neurovascular compromise. • May use in older patients with contraindications to a femoral traction pin. RUSSELL SKIN TRACTION/SPLIT RUSSELL’S TRACTION (adults and children) • Peroneal nerve neurapraxia possible. • Posterior bowing at fracture site possible. BUCKS TRACTION • Elevate the foot of the bed; closely monitor skin!
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Traction Application of Skin Traction
Damian Rispoli 2009
Benzoin to lateral and medial leg Horseshoe of adhesive backed felt Wrap loosely with an ace wrap Include metal traction bar in felt loop
90–90 Skeletal Traction Hip and knee at 90 degrees Beware of over distraction
**The distal femoral traction pin is placed with the knee flexed so the iliotibial band does not drag over the pin.
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Damian Rispoli 2009
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Traction
174 Russell’s Skin Traction
Skin traction to leg Pillow or traction setup supporting femur Sling may also be placed on leg with pillow supporting the thigh
Damian Rispoli 2009
Balanced Suspension (with or without skeletal traction) –Elevate foot of bed
Damian Rispoli 2009
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Traction
HALO PLACEMENT • Halo is placed just below the area of greatest circumference, just above the eyebrows, ⬃ 1 cm above ear tips, and below the skull equator. • Pins placed with local anesthetic; positions as shown. • Eyes closed tightly. Areas shaved. • Pins subsequently tightened circumferentially in a diagonal, opposite manner. 2 lb.-in, 4 lb.-in., and finally 6–8 lb.-in (adults) 4–6 lb.-in. (child < 5 yr), 2 lb.-in. or finger tight in infants/toddlers. • Children need multiple pins (up to 8). • Retighten at 24–48 hr. Supraorbital nerve Frontal Sinu
Supratrochlear nerve Frontal Sinus
SA
AV
SA
SA = Safe Areas, AV = Avoid Area
SA
SA
Damian Rispoli 2009
Halo Placement
GARDENER-WELLS TONGS
Damian Rispoli 2009
-Pins positioned below the temporal ridges, 2cm above the external auditory canal and temporalis muscle -Tongs are secure when pressure pin extrudes 1mm
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TRAUMA—ADULT Hand Injury/Eponym
Classification/Limits
Treatment
Distal phalanx fracture
Longitudinal, transverse, comminuted
Splint 3–4 weeks (PIPJ free), Nail broken/avulsed—fix nailed Nail intact—trephination alone (JHS 24A: 1166, 1999)
Extensor digitorum avulsion (terminal tendon) Mallet finger
Stretched Torn Bony avulsion
Splint distal interphalangeal joint in extension Full time for 6 weeks Then only at night for 6 weeks
Flexor digitorum profundus tendon avulsion
Leddy/Packer (JHS
Fix within 7–10 days
Rugger jersey finger
Metacarpal and phalangeal fracture
2:66–69,1979)
I—Tendon retracts to palm II—Tendon retracts to PIPJ
Fix within 2 weeks (may repair late up to 3 months)
III—Bony fragment retracts to A4 pulley
ORIF (early)
IIIA (IV)—Bony fragment and avulsed tendon
ORIF and reattach tendon (early)
Indications for operative treatment: -Malrotation (spiral, oblique) -Intraarticular, open fracture (relative) -Subcapital phalangeal fracture -Bone loss, polytrauma, and hand fracture -Multiple hand/wrist fractures -Fracture with soft tissue injury -Reconstruction, shortening (< 1 cm)
Goal – Full and rapid restoration of function! Dealers (surgeons) choice (avoid > 4 weeks immobilization): -ORIF (associated with stiffness) -Open reduction, percutaneous pinning -Closed reduction, percutaneous pinning -Traction (used uncommonly – PIPJ fracture/dislocations) -ORIF (composite wiring, intramedullary fixation, external fixation)
176
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Trauma—Adult
Hand Injury/Eponym
Classification/Limits
Treatment
Central slip disruption Boutonniere
Soft tissue Bony fragment
Acute (< 1 month)—extension splint x 6 weeks Chronic—Regain passive range of motion, then Fowler tenotomy or central slip reconstruction
Extensor tendon laceration
< 50% laceration > 50% laceration
Primary closure, rehabilitation Repair tendon, rehabilitation
Boutonniere Deformity
Damian Rispoli 2009
Note: Central slip disruption, volar subluxation of lateral bands, characteristic deformity. Tenderness over the PIPJ may be the only obvious acute clinical finding.
Thumb Metacarpal Fractures
Bennett’s
Rolando’s
Transverse
Oblique
Salter-Harris II Damian Rispoli 2009
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178
Acceptable limits on phalangeal fractures: < 10˚ rotation (some argue no rotational deformity) < 1–2 mm of articular step off (goal is anatomic reduction of the joint) 5˚ in the sagittal/10˚coronal plane (shaft) 20˚ in the sagittal plane (metaphyseal) < 25°–30˚ apex volar (↑ risk of pseudoclawing) Small Joint Fusion (from Green’s Hand Surgery): Fingers MCPJ: Index 25° and add 5° each additional digit PIPJ: Index 40° and add 5° each additional digit DIPJ: 0° ± 5°–10° of supination Thumb IPJ 0°–15° MCPJ 5°–15° with 10° pronation CMCJ 40° palmar abduction, 20° radial adduction (aim for pulp-to-pulp contact with fingers) Green DP, Hotchkiss RN, Pederson WC, Wolfe SW. Green's Operative Hand Surgery, 5th ed. Philadelphia: Elsevier; 2005.
Acceptable limits on metacarpal fractures: Minimal to no rotational deformity 1–2 mm of step off (goal is anatomic reduction) < 10˚ in the coronal plane Sagittal deformity < 10˚ index/long, < 20˚ ring, < 30˚ small No pseudoclawing (limit apex volar malreduction) Hand Injury/Eponym
Classification/Limits
Flexor tendon laceration
Zone specific classification (See p. 90) 90
Treatment > 60% repair (JBJS 84A(9): 1684–1706)
Tendon repair may delay up to 2–3 weeks, atraumatic technique, strict supervised rehabilitation postoperatively
4th/5th metacarpal neck Boxers fracture
20°–45° angulation acceptable Check rotation!
Closed reduction cast/splint x 3–4 weeks
2nd/3rd metacarpal neck
15° is acceptable
Percutaneous pinning to adjacent metacarpal or ORIF
Transverse metacarpal
Accept 30° 5th, 20° 4th, 10° 2nd and 3rd
Closed reduction/cast versus percutaneous pinning or ORIF
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Trauma—Adult
Hand Injury/Eponym
Classification/Limits
Treatment
Oblique metacarpal
< 5 mm short
Closed reduction or open reduction, percutaneous pinning
> 5 mm or malrotation
Percutaneous pinning or ORIF
Intra-articular volar lip
Closed reduction, percutaneous pinning, ORIF if necessary
Intra-articular Y
ORIF (if noncomminuted) External fixation/traction (if comminuted)
Transverse
Closed reduction spica cast x 4 week
Oblique
Closed reduction spica cast x 4 week
5th metacarpal base Baby Bennett
Intra-articular base fracture
Most stable (if not) Closed reduction, percutaneous pinning
DIPJ dislocation
Dorsal
Closed reduction, splint x 2 weeks
With collateral sprain
Buddy tape 3–6 weeks
With collateral tear
Fix radial collateral ligament (index, ring, and middle) Fix ulnar collateral ligament (small finger, dominant hand)
Volar PIPJ dislocation
Volar (central slip torn) Rotatory
ORIF irreducible or incongruous Attempted closed reduction, open if fails closed reduction
Dorsal PIPJ dislocation
Dorsal (volar plate torn)
Closed reduction (open if not reducible) then:
I—Hyper extension
Buddy tape or extension block splint
II—Major ligament injury
Extension block splint
III—Proximal dislocation
Extension splint x 4–6 wk, consider OR for > 4 mm residual displacement
Located Subluxated (V sign dorsally—Light )
Extension block Volar plate arthroplasty, ORIF, traction splint, force couple pinning
Thumb metacarpal Bennett’s→ Rolando’s→
Dorsal PIPJ fracturedislocation
(Continues)
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180
Hand (Continued) Injury/Eponym
Classification/Limits
Treatment
MCPJ dislocation
Collateral ligament injury
Splint MCP 50° x 3 weeks, ORIF > 2–3 mm or > 20% joint surface Closed reduction (translation without traction), splint x 7–10 days Open reduction
Dorsal, Simple
Dorsal, Complex (volar plate interposition) Volar
CMCJ dislocation
Thumb MCPJ ulnar collateral ligament injury Gamekeeper
Thumb MCPJ radial collateral ligament Thumb MCPJ dorsal dislocation
Small finger CMCJ dislocation Multiple CMCJ dislocation Sprain (< 35° on stress views) Tear (> 35° or 15°> than noninjured) Test in full extension and 30°of flexion
Sprain/tear Simple Complex
Thumb CMCJ dislocation Hamate metacarpal fracture/ dislocation
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Cain IA—ligament injury IB—dorsal hamate fracture II—comminuted dorsal hamate fracture III—coronal hamate fracture
Open reduction (sesamoid in ↑ joint space, palmar skin puckered, less deformity seen) Closed reduction, percutaneous pinning Open reduction, percutaneous pinning Thumb spica cast x 6 weeks Open repair (Stener lesion = adductor aponeurosis interposition between torn ends of ulnar collateral ligament) Splint x 4 weeks followed by removable splint x 4 weeks Reduce, cast x 3 weeks Single reduction attempt (Volar plate ± Flexor pollicis longus interposition) Hyperpronation and percutaneous pinning Cast 6–10 weeks Reduce/stable-cast, reduce/ unstable-percutaneous pinning Reduce/stable-cast, reduce/ unstable-ORIF ORIF-restore dorsal buttress ORIF-restore joint surface (GOAL: < 2 mm step off, < 5 mm short)
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Trauma—Adult
Wrist Injury/Eponym
Classification/Limits
Treatment
Distal radius Colle’s (dorsal) Smith’s (volar)
AO A—Extra-articular B—Intra-articular with part of metaphysis intact C—complex intraarticular (See box on pg. 184 for limits)
Closed reduction/cast or closed reduction/pinning/cast or ORIF Closed reduction/pinning/cast versus external fixation, open reduction Closed reduction/pinning/cast versus external fixation, open reduction
Distal radius dorsal rim Dorsal Barton’s
Reduce, pronation ORIF if necessary
Radial styloid Chauffeur’s
Reduce, percutaneous pinning or cannulated screw, cast in ulnar deviation
Volar rim Volar Barton’s
ORIF
Late osteoarthrosis increases following distal radius fractures with residual dorsal tilt > 10˚ or > 1 mm articular step off.
Damian Rispoli 2009
Dorsal Barton’s Fracture
Damian Rispoli 2009 Damian Rispoli 2009
Radial Styloid Fracture Volar Barton’s Fracture
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Trauma—Adult
182
Wrist Injury/Eponym
Classification
Treatment
Distal radioulnar joint dislocation
Dorsal
Reduce, long arm cast in supination x 6 weeks Reduce, long arm cast in pronation x 6 weeks Open reduction ± internal fixation or percutaneous pinning if irreducible
Volar
Scaphoid (78% of all carpal fractures) [blood supply dorsal and distal]
Can be classified based on time or anatomic configuration Evaluate scapholunate interval with clenched fist views or intraoperative stress view Consider splint x 1–3 weeks and repeat X-rays if not radiographically apparent fracture MRI if acutely or if pain persists
Stable/nondisplaced—long arm cast up to 3+ months or CR vs. OR and IF Displaced [I mm, scapholunate > 60°, lunatocapitate > 15°]—ORIF
Dorsal chip
Commonly triquetrum
Short arm cast x 6 weeks
Hook of Hamate
CT to evaluate
Acute—Short arm cast x 6 weeks Chronic—Excise for persistent pain
Perilunate dislocation ± scaphoid fracture
Mayfield (stage II = I + II, III = II + III, etc.) I—Scapholunate dissociation II—Lunocapitate dissociation III—Lunotriquetral disruption IV—Lunate dislocation
Early (6–8 weeks) Open reduction, ligament repair, percutaneous pinning, ORIF scaphoid fracture if present
Radius and ulna—Both bone
Nondisplaced or displaced
ORIF (selective nonoperative in nondisplaced)
Ulna fracture Nightstick
Nondisplaced
Long arm cast or fracture brace (accept 10° and 50% displacement) ORIF—Beware wrist/elbow injury
Radius/Ulnar Shaft
Displaced
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Trauma—Adult
Radius/Ulnar Shaft Injury/Eponym
Classification
Treatment
Proximal ulna fracture/ radial head dislocation Monteggia
Bado (ClinOrthop 50:71–86,1967) I—Radial head anterior II—Head posterior III—Head lateral IV—Head anterior and both bone fracture
ORIF, closed reduction of radial head (open if nonreducible) (PIN most commonly injured nerve)
Proximal Radius
Non-displaced
Long arm cast in supination, close follow-up
Displaced
ORIF
Eponyms: Galeazzi, Piedmont, reverse Monteggia, fracture of necessity, etc.
ORIF
Supracondylar
Extension—Nondisplaced
Long arm cast
Malgaigne
Displaced
ORIF (double plating)
Transcondylar Kocher Posadas
(very uncommon fracture) Intra articular—posterior fragment Intra articular—anterior fragment
Reduce (closed treatment difficult, ankylosis common), percutaneous pinning, ORIF if necessary (no consensus in the literature)
Condylar Milch (lateral > medial)
I—Lateral trochlear ridge intact (Salter-Harris IV) II—Fracture through lateral trochlear ridge (SalterHarris II)
Nondisplaced—Long arm cast in supination (lateral), long arm cast in pronation (medial), some need ORIF ORIF
Distal radius fracture and radioulnar dissociation Elbow
MONTEGGIA FRACTURE
Proximal Ulna Fracture Dislocation of the Radial Head
Damian Rispoli 2009
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Trauma—Adult
184
Distal Radius Fracture Limitations (Consider open reduction) ≥ 2 mm loss of radial height Change in radial inclination ≥ 10˚ Loss of volar tilt ≥10˚ Loss of reduction of the distal radioulnar joint > 1–2 mm step off
Disrupted DRUJ
Radius Fracture
External Fixation Note: > 2 mm capitolunate gap = potential over distraction (stiffness) Distal radioulnar joint disrupted in distal radius fractures if dorsal tilt > 25–30⬚ and ulnar styloid > 3 mm displaced Damian Rispoli 2009
Galeazzi Fracture
Elbow Injury/Eponym
Classification/Limits
Treatment
Bicolumnar
AO (see illustration) A: Extra-articular B: Partial articular C: Complete articular
Generally these fractures are treated operatively. Restoration of the joint surface is paramount. Rigid fixation with early motion (immobilize < 2 weeks) helps to avoid fibrosis/ ankylosis that occurs with prolonged immobilization. Total elbow replacement may be considered in the elderly with osteoporotic bone where fixation may be difficult or impossible to attain.
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Trauma—Adult
Elbow Injury/Eponym
Classification/Limits
Treatment
Olecranon
Colton (Inj 5:121–9,1973) I—Nondisplaced
Cast/splint, 3 weeks or less
II—Displaced A—Avulsion
ORIF (tension band/lag screw)
Coronoid
B—Oblique/ transverse
Oblique—screw Transverse—tension band
C—Comminuted
Attempt reduction and fixation if not possible to excise (coronoid and anterior structures must be intact for stability, advance/ reattach triceps to bone)
D—Fracture/dislocation
ORIF (no excision)
Regan/Morrey (JBJS
Early motion
71A:1348–1354,1989)
I—Tip avulsion II—< 50%
Early motion
III—> 50%
ORIF
Capitellar Hahn-Steinthall
I—Large trochlear piece
Nondisplaced splint, displacedORIF
Kocher-Lorenz
II—Minimal subchondral bone (Kocher-Lorenz)
Nondisplaced splint Displaced-ORIF vs. excise
III—Comminuted (rare)
ORIF vs. excision
Trochlea Laugier
Very rare
Nondisplaced—splint Displaced—ORIF
Epicondylar
Medial (Granger) more common than lateral
Manipulation/reduction, posterior splint with the elbow and wrist flexed x 10–14 days, then active motion is begun, symptomatic fragments can be excised late (Continues)
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Trauma—Adult
186
Coronal Shear Fractures
HahnSteinthall
KocherLorenz Damian Rispoli 2009
AO Classification of Distal Humerus Fractures
A1
A2
A3
B1
B2
B3
C1
C2
C3 Damian Rispoli 2009
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Trauma—Adult
Elbow (Continued) Injury/Eponym Classification/Limits
Treatment
Radial Head
Mason I—Nondisplaced
Early motion, ± aspiration
II—Moderate displacement
Treat like type I for no mechanical block, ORIF for mechanical block, or consider ORIF if >1/3 of joint, > 30° angulation, > 3mm step off
II—Comminuted
ORIF versus excision + replacement for instability (elbow or DRUJ)
Elbow dislocation
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IV—With dislocation
Reduce dislocation, ORIF
Hotchkiss (JAAOS 5:1–10,1997) I—Non/minimal displaced, no mechanical block, < 2 mm displaced or marginal lip
Early motion, ± aspiration
II—Displaced head > 2 mm or angulated neck, ± block or incongruity, without severe comminution (reconstructible)
ORIF
III—Severe comminution, not reconstructible (radiographic or intraoperative determination)
Excision with replacement for instability of elbow or DRUJ
General principles
Stable—Closed reduction, < 7days immobilize, Unstable— open repair.
Types—Posterior (commonest 90%)
Humeral countertraction, distal forearm traction, correct medial/lateral first, then distal traction and flexion
Anterior
Reversal of posterior technique
Medial/lateral
Humeral countertraction, distal forearm traction, medial/ lateral slide
Divergent
Reduce ulna first, radius second
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Trauma—Adult
188 Essex-Lopresti
Radial Head Fracture
Disrupted Interosseous Membrane
Disrupted Distal Radio-Ulnar Joint Damian Rispoli 2009
Proximal Humerus Anatomic Neck Greater Tuberosity Lesser Tuberosity
Head
Surgical Neck
Damian Rispoli 2009
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Location/pattern [spiral fracture and radial nerve injury = HolsteinLewis]
Humeral shaft
Treatment Coaptation splint, cast brace, or hanging arm cast. ORIF—Floating elbow, segmental, pathologic, obesity, ipsilateral chest wall injury, polytrauma, bilateral fractures, spinal cord injury, need to weight bear, brachial artery or plexus injury, unacceptable alignment in splint (> 15° varus/valgus, > 20° anterior/posterior, > 3 cm short, > 15˚ malrotation) or radial nerve palsy postreduction.
(A part is defined as > 1 cm displaced or > 45° angulated)
4 part
3 part
2 part
1 part
Prosthesis vs. osteotomy
Neer
(> 50%)
Proximal humerus
Transfer lesser tuberosity to defect
Unstable (20–50%)
Hill-Sachs
(Continues)
Valgus affected most amenable to nonoperative treatment ORIF vs. closed reduction percutaneous pinning/screw fixation Hemiarthroplasty for completely displaced humeral head segments with high likelihood of avascular necrosis (Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427–433.)
Early motion with nonoperative treatment
Closed treatment
Stable (< 20%)
Impression
Treatment
Classification/Limits
Injury/Eponym
Shoulder
Radial nerve exploration: Open fracture, penetrating trauma with radial nerve dysfunction, palsy following manipulation, > 3.5 months without recovery.
Classification/Limits
Injury/Eponym
Shoulder
189 Trauma—Adult
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Trauma—Adult
190
Group II Distal Clavicle Fracture Type I Type IIA Type IIB
Type III
Type V
**Type IV is a periosteal sleeve fracture Damian Rispoli 2009
AO Classification of Proximal Humeral Fractures
A: Unifocal Extra-articular 2-part fracture Intact Blood Supply
B: Bifocal Extra-articular Possible injury to blood supply
C: Articular fracture involving the anatomic neck High likelihood of necrosis Damian Rispoli 2009
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Group I: Middle 1/3 (85%) 190) Group II: (see page 190 Distal 1/3 (Neer) (10%) I—Minimal displacement II—Medial to coraco-clavicular ligament A—Ligaments intact and with distal fragment B—Conoid torn, trapezoid with intact distal fragment III—Involving acromioclavicular joint IV—Periosteal sleeve V—Comminuted Group III: Medial 1/3 (5%)
Clavicle
Absolute: ≥ 2 cm short (controversial), open fracture, displaced with skin compromise, vascular injuries needing repair, pathologic fracture + trapezius paralysis, scapulothoracic dissociation Relative: > 2 cm displaced, floating shoulder, neurologic disorder, bilateral injuries, multiple trauma, ipsilateral upper extremity fracture, prolonged need for recumbency, intolerance to immobilization
Consider ORIF for Group I and III:
Group I: Majority will heal with nonoperative treatment Completely displaced fractures best treated with ORIF (JBJS 89A(1):1–10,2007) Group II: I and IV—Conservative IIA and IIB and V—selective ORIF in patients with high demands III—Closed, late acromioclavicular excision for arthrosis Group III: Nonoperative
Prosthesis, selective ORIF in young patient with reconstructible fracture (controversial)
Closed reduction, ORIF if three part
May need CT to appreciate
Posterior (lesser tuberosity displaced)
Head splitting fracture
Anterior (greater tuberosity displaced)
Proximal humerus fracture/ dislocation
Treatment 5 mm displacement after reduction—ORIF
Classification/Limits
Injury/ Eponym
Shoulder (Continued)
CLASSIFICATION
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II. Combined
I.
III.
IIA. Anterior
IV.
IIB. Posterior
Normal extension of the articular surface under biceps anchor < or = 5mm
Damian Rispoli 2009
I. Fraying of the biceps anchor II. Tear of the biceps anchor/labrum anterior & posterior to midline A. Tear anterior to midline B. Tear posterior to midline Ill. Bucket handle type tear with an intact biceps tendon IV. Tear extends from biceps anchor/labrum up into biceps tendon (Arthroscopy 6:274–279,1990) V. Anterior-inferior Bankart lesion extends into biceps anchor VI. Unstable labral flap tear with a tear of the biceps anchor VII. Tear of the biceps anchor extends inferior to the middle glenohumeral ligament (AJSM 23(1:93-98,1995)
Superior Labrum Anterior Posterior (SLAP) Lesions
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Seizure, electrical shock
Subcoracoid > subglenoid
Anterior dislocation
Posterior dislocation
Internal forequarter amputation AP CXR—medial scapular border > 1.5 x other side
Scapulothoracic dissociation
Lateral upper arm traction, distal lower arm traction, and gentle rotation (Continues)
Reduce: Stimson—Prone, arm hanging with weight at wrist Milch—External rotation, abduction, posteriorly directed force on the anterior of the shoulder Traction/countertraction—Stabilize chest, distal/abduction traction on forearm, add gentle rotation Confirm reduction (X-rays), immobilize (classically comfortable adduction/internal rotation)
Closed reduction, massive internal trauma, massive vascular and brachial plexus injuries
ORIF if > 25% glenoid involved or greater than 5 mm of step off and humeral head subluxated Up to 20% of the glenoid can be excised with the labrum repaired back to the rim.
Selective ORIF large displaced fragment
Ideberg I—Anterior avulsion II—Transverse/oblique fracture inferior glenoid free III—Upper 1/3 glenoid and coracoid IV—Horizontal glenoid thru body V—Combination II–IV
III—Neck and tubercle
Glenoid
Closed treatment Selective ORIF large displaced fragment (associated injury common)
Treatment
II—Coracoid and acromion
Scapula
Zdravkovich and Damholt (ActaOrthop 45:60–5,1974) I—Body
Classification/Limits
Injury/Eponym
Shoulder Girdle
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66016_CH05_PTR.indd 194 Sling/range of motion
Selective ORIF (not in contact sports) Reduce/repair Reduce/repair Reduce/repair
I—Acromioclavicular ligament (AC) sprain [0%]
II—AC tear, coracoclavicular (CC) sprain [0–25%]
III—AC, CC [25–100%]
IV—Clavicular subluxated posterior into trapezius
V—Type III with large displacement [100–300%]
VI—Clavicle subcoracoid
Acromioclavicular injury (percent displaced in [ ])
Biceps Tendon
Sternoclavicular injury
Sling/range of motion
Partial Complete
Rotator cuff tear
Distal Proximal
Surgical repair Rehabilitation versus repair in young or active
Nonoperative
Closed reduction with towel clip, open reduction if closed reduction fails (beware great vessels, have thoracic surgeon readily available or present)
Posterior
Atraumatic
Closed reduction with traction
Anterior
Rehabilitation, débride if fails conservative Rehabilitation, surgical repair in athletes, failed conservative treatment
Reduce/immobilize
Luxatio erecta
Inferior dislocation
Treatment
Classification/Limits
Injury/Eponym
Shoulder Girdle (Continued)
Trauma—Adult 194
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66016_CH05_PTR.indd 195 Halo vs. screw vs. C1–2 fusion Risk for nonunion: Fracture pattern, displaced > 5 mm, posterior displacement, quality of reduction, smoking, age > 65 Halo immobilization vs. cervical orthosis
II—Base fracture (high nonunion rate ~ 36%)
III—Fracture into body
(Continues)
Anderson/ D’Alonzo (JBJS 56A(8):1663–1674, 1974) I—Oblique apical/avulsion
Odontoid fracture
Cervical orthosis (beware associated injury)
Stable fractures (posterior arch or nondisplaced fractures) treated with cervical orthosis Asymmetric lateral mass fracture or Jefferson “burst” fractures require halo immobilization Transverse ligament rupture without a bony avulsion requires fusion
Levine/Edwards (JBJS 73A(5):680–691,1991) A. Transverse process B. Posterior arch C. Anterior arch D. Comminuted or lateral mass E. Burst
C1 Fracture (Jefferson = axial load)
May require halo immobilization Halo and occiput/C1 or C2 fusion
Anterior or posterior (usually fatal)
Hard collar
III—Avulsion
Occiput—C1 Dislocation
Hard collar
II—Plus skull fracture
Treatment
Classification/Limits
Anderson/Montesano (Spine 13(7):731–736,1988) I—Impaction
Injury/Eponym
Occipital condyle fracture
Cervical Spine
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Clay shovelers
C3–7 spinous process fracture C3–7 teardrop fracture
Flexion + axial load with anterior column injury and often posteriorly displaced vertebral body
Canal compression
Unilateral (< 25% displacement of vertebral body) Bilateral (25–50% displacement of vertebral body) Translation Angular displacement
IIa—C2—Three disc torn, anterior longitudinal ligament intact, slight or no translation but severe angulation III—Fracture/dislocation
II—Significant angulation and translation
Classification/Limits Levine I—Nondisplaced (No angulation, < 3 mm)
C3-C7 burst
C3-C7 fracture
C3-C7 facet dislocation
Injury/Eponym Traumatic spondylolisthesis of C2 Hangman’s
Cervical Spine (Continued) Treatment
Neuro deficit: Corpectomy, fusion, +/– posterior instrumentation Neuro intact: Treat based on instability, collar vs. halo vs. anterior fusion
Symptomatic
< 25% compression with intact posterior wall = nonoperative; stable = halo immobilization; unstable = fusion
> 3.5 mm—fusion > 11°—fusion
Attempt reduction (< 4 mm translation, < 10° angulation) halo (failure—rule out disc rupture, ± fusion) Traction (10 lb + 5 lb/level), open reduction/posterior fusion failed closed reduction, consider MRI rule out disc herniation
Reduction/halo with some extension Careful not to overdistract Reduction/halo
Cervical orthosis
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197
Trauma—Adult
Thoracic and Lumbar Spine Injury/Eponym Burst fracture
Classification/Limits A—Axial load B—Axial and flexion C—Axial and flexion D—Axial and rotation E—Axial and lateral flexion
Flexion/ distraction Chance
Beware of intra abdominal/ seatbelt injuries
Fracture— dislocation
Flexion—rotation Shear
Treatment Stable = hyperextension cast/brace Unstable (height < 50%, angulation > 20°, canal compromise > 50%, scoliosis > 10°, neurologic injury) = early operative stabilization Bony = hyperextension cast/brace Soft tissue = ORIF ORIF—Early mobilization
CLINICAL INSTABILITY IN THE LOWER CERVICAL SPINE (Spine1:15, 1976) 2 points each—Anterior elements destroyed or functionless, posterior elements destroyed or functionless, sagittal plane translation > 3.5 mm, relative sagittal plane rotation > 11°, positive stretch test, spinal cord damage 1 point each—Nerve root damage, abnormal disc narrowing, dangerous loading anticipated > 5 is unstable Sacral Spine Injury/Eponym Sacral fracture
Classification Zone I—Sacral ala (neurologic injury rare) II—Sacral foramina (28% neural injury) III—Medial to foramina (> 50% neural injury)
Treatment Observation—Stable/impacted, < 1 cm displacement Iliosacral fixation (ORIF vs. percutaneous) Unstable
Fracture Types and Columnar involvement (Spine: 8, 1983) Type Compression
Anterior Compression
Middle None
Posterior None or distraction
Burst Seat belt Fracture/ dislocation
Compression None or compression Compression ± rotation/shear
Compression Distraction Distraction ± rotation/shear
None or distraction Distraction Distraction ± rotation/shear
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198
Stable Spine Fracture Criteria: -No transient or persistent neurological injury -Acceptable alignment -At least one column intact -No significant ligamentous disruption
Gun Shot Wounds to the Spine (remove bullet/ fragment—decompress): -Progressive neurologic deficit due to neural compression (bullet, fragment, hematoma) -Persistent cerebrospinous fluid leak -Spinal instability -Consider decompression for cauda equina level injuries
Define projectile path for broad spectrum IV antibiotic coverage Posterior entrance: 48–72 hours AP wound (transabdominal, no colon injury): minimum 5–7 days AP wound (transcolonic): 7–14 days—HIGH RATE OF INFECTION
Stress Fractures Low Risk: Upper extremity, ribs, pars interarticularis, pelvis (sacrum, pubic rami), femoral shaft, tibial shaft, fibula, calcaneus, and metatarsal shaft High Risk: Femoral neck, patella, anterior cortex of the tibia, medial malleolus, talus, tarsal navicular, 5th metatarsal, 2nd metatarsal base, and great toe sesamoids
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199
Trauma—Adult
Pelvis Fractures (See Algorithm page 201 201) Injury/Eponym Classification/Limits Pelvis (see page Young and Burgess (SkelRad 15:103–109, 1986) 200) Lateral compression (LC) LC = lateral I—Sacral compression, compression transverse anterior ring injury (fracture vs. symphysis injury) LC II—Sacral/Iliac wing fracture, anterior ring fracture (sacrospinous (SS) and sacrotuberous (ST) ligament intact) LC III—LCII + SS and ST ligament torn and contralateral sacroiliac (SI) disruption APC = anterior Anterior posterior posterior compression (APC) I— compression < 2.5 cm symphysis pubis, ± sacroiliac (SI) joint widening APC II—Disrupted symphysis or anterior ring, SS and ST torn
VS = vertical shear
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APC III—APC II and postSI ligament (internal hemipelvectomy) Vertical shear—APC III and vertical displacement CMI—Combination mechanism injury
Treatment Weight-bearing status depends on stability of pelvic ring component, selected stabilization for unstable complete sacral fractures
External fixation. ORIF vs. closed reduction percutaneous fixation
External fixation vs. ORIF vs. closed reduction percutaneous fixation Symptomatic treatment
Anterior external fixation versus ORIF vs. closed reduction percutaneous fixation Selective nonoperative if poor surgical candidate Same as APC II
Same as APC II
Same as APC II
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Damian Rispoli 2009
Anterior Posterior Compression
Lateral Compression
I
Vertical Shear
II
Young and Burgess Classification of Pelvic Fractures III
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Emergent angiography (emergent embolization for pelvic arterial bleeding)
Hemodynamics unstable
Stabilize pelvic fracture - external fixator, ORIF, traction
Definitive fixation (Formalize external fixation, ORIF [immediate versus delayed], Percutaneous options)
Hemodynamics stable
Exploratory Laparotomy
Grossly positive
Supraumbilical DPL, CT scan, or ultrasound
Sheet or pelvic binder application
Hemodynamically unstable with unstable pelvic fracture
PELVIC FRACTURES WITH HEMODYNAMIC INSTABILITY
Selective exploration and packing (rarely done)
Large and expanding
Assess retroperitoneal hematoma
Many centers now forego emergent anterior external fixation, preferring a binder or equivalent and awaiting definitive fixation
Angiography on call
201 Trauma—Adult
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Trauma—Adult
202
Pelvis Fractures Injury/Eponym
Classification/Limits
Treatment
Acetabular fracture 159) (see page 159
Letournel Five simple fracture patterns Posterior wall Posterior column Anterior wall Anterior column Simple transverse Five complex/associated fracture patterns T-shaped Posterior wall and column Transverse and posterior wall Anterior with posterior hemitransverse Associated both columns
Nonoperative: Roof arc angle > 45° as measured off the AP, iliac oblique, and obturator oblique < 50% posterior wall with stable reduction* < 2–3 mm displacement Severe osteoporosis Medical contraindication Relative nonoperative indications: Secondary congruence of the acetabulum with a associated both column fracture ORIF—Unstable joint, incongruous joint Note: Consider fluoroscopic exam under anaesthesia to aid in decision to ORIF posterior wall fractures. Note: Temporary skeletal traction
Damian Rispoli 2009
Proximal Femoral Neck Shaft Angle 124 +/– 7 degrees
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Trauma—Adult
Head Neck InterTrochanteric
SubTrochanteric
Damian Rispoli 2009
Hip Fractures
Letournel Classification of Acetabular Fractures (JBJS 46A:1615-1647, 1964) Simple Acetabular Fractures (5 types) Posterior Wall
Posterior Column
Anterior Wall
Anterior Column
Transverse
Complex/ Associated Acetabular Fractures (5 types)
Damian Rispoli 2009
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T-shaped Posterior Transverse Anterior Both Column & Posterior with Posterior Columns & Wall Wall Hemitransverse
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Trauma—Adult
204
Periprosthetic Femur Fracture Classification and Treatment Type
Fracture Location
I
Trochanteric region
Recommended Treatment Nonoperative
II
Proximal metaphysis/ diaphysis not involving stem tip
Nonoperative or cerclage fixation
IIIA
Diaphyseal fracture at stem tip Disruption of prosthetic interface (< 5%)
Long-stem ingrowth revision or ORIF: plate with screws ± cerclage ORIF: cortical struts with cerclage cables
IIIB
Diaphyseal fracture at stem tip Disruption of prosthetic interface (> 25%)
Cemented stem: long-stem ingrowth revision Ingrowth stem: long-stem ingrowth revision or ORIF: plate with screws ± cerclage ORIF: cortical struts with cerclage cables
IIIC
Supracondylar fracture at tip of a long stem prosthesis
Nonoperative if stable or ORIF: plate with screws ± cerclage ORIF: custom intramedullary rod extension to prosthesis
IV
Supracondylar fracture distant to the stem tip
Nonoperative if stable or ORIF: plate with screws (must extend proximal to stem tip) ORIF: supracondylar intramedullary nail Long-stem ingrowth revision
Adapted from Miller MD, ed. Review of Orthopaedics. 3rd ed. Philadelphia, PA: WB Saunders; 2000:252.
Hip Fractures Injury/Eponym
Classification/Limits
Treatment
Femoral neck
Garden (JBJS 53B:183–196,1971) I—Incomplete, valgus impacted II—Complete, nondisplaced III—Complete, partial displaced IV—Complete fracture and displacement
Closed reduction internal fixation (three screws) vs. hip screw ± derotational screw Hemiarthroplasty—Elderly, sick, pathologic fracture, rheumatoid arthritis, patient with a seizure disorder, Parkinson’s disease, Garden types III and IV, total hip arthroplasty for patient with preexisting osteoarthrosis
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Trauma—Adult
Hip Fractures Injury/Eponym
Classification/Limits
Treatment
Femoral neck (Continued)
Blickenstaff/Morris (stress fractures) I—Callus II—Nondisplaced III—Displaced
Advance weight bearing as tolerated Tension side—Closed reduction internal fixation Compression—Like type I Closed reduction internal fixation (acute), ORIF (subacute/chronic)
Femoral neck avascular necrosis: Nondisplaced—8–18%; displaced—15–33%. Nonunion: Nondisplaced < 5%; displaced 10–30%
Intertrochanteric
Evans (JBJS 31B:190– 203,1949) I—Nondisplaced II—Displaced III—Reverse obliquity IV—Subtrochanteric spike Stable/unstable
Closed reduction internal fixation with sliding compression screw vs. cephalomedullary nail with trochanteric entry point Unstable = type III or posteromedial comminution No sliding hip screw with type III (reverse obliquity-fixed angle device) Osteopenia/pathologic fracture— Consider calcar replacing hemiarthroplasty Nonoperative treatment is always an option; higher morbidity and mortality
Greater trochanter
Nondisplaced Displaced
Activity modification > 1 cm ORIF
Lesser trochanter
Nondisplaced Displaced (Beware pathologic fracture)
Activity modification > 2 cm ORIF
Subtrochanteric
Seinsheimer (JBJS
Intramedullary nail-locked (cephalomedullary nail trochanteric entry)
60A:300–306,1978)
I—Non/minimally displaced
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II—2 part
Intramedullary nail-locked
III—3 part
Reconstruction nail or condylar plate/screw
IV—Comminuted
Reconstruction nail or condylar plate/screw
V—Subtrochanteric— intertrochanteric
Sliding compression screw + long side plate (older), condylar blade (young)
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206
Hip Dislocations Injury/Eponym Anterior
Classification/Limits Epstein I—Superior A—No fracture B—Head fracture C—Acetabular fracture II—Inferior A—No fracture B—Head fracture C—Acetabular fracture
Treatment Emergent closed reduction, open if irreducible ORIF if irreducible unstable, or intra articular bodies Methods: Stimson—Prone, leg hanging off table, immobilize pelvis, knee/ ankle at 90°, distal traction, and gentle rotation Allis—Supine, stabilize pelvis, lateral traction to inner thigh, long traction to femur, slight hip flexion, and rotation Reverse Bigelow—Supine, hip partial flexion and abduction, distal jerk, no reduction, then add internal rotation and extend
Posterior
Thompson/Epstein I—No or minimal fracture II—Posterior acetabular rim III—Comminuted rim IV—Acetabular floor V—Femoral head (JBJS 73A:746–778,1951)
Emergent closed reduction, open if necessary ORIF if irreducible unstable, or intraarticular bodies Methods: Stimson—Prone, leg hanging off table, immobilize pelvis, knee/hip at 90°, distal traction, and gentle rotation Allis—Supine, stabilize pelvis, traction inline with deformity, hip flexion to 90°, and rotation Bigelow—Supine, stabilize pelvis, hand holds ankle; forearm behind knee to apply long traction, hip flexed to 90°or more, abduction, external rotation, extension to lever head into acetabulum (Continues)
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Trauma—Adult Pipkin Classification (JBJS 39A:1027-1042, 1957)
I
II
III
IV Damian Rispoli 2009
Shatzker Classification (ClinOrthop 138:94-104, 1979)
I
II
III
IV
V
VI
Damian Rispoli 2009
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208
Hip Dislocations (Continued) Injury/Eponym
Classification/Limits
Treatment
Posterior with femoral head (type V ThomasEpstein)
Pipkin (see page 207) I—Head caudad
All—Emergent closed reduction Excise loose fragment if blocks motion or displaced; ORIF if large fragment
II—Head cephalad
ORIF if large fragment or part of weight-bearing dome
III—Femoral head and neck
ORIF (young), selective arthroplasty (older)
IV—Associated acetabular fracture
ORIF (young), selective arthroplasty (older)
Femoral Shaft Fractures Femur (2 cm from lesser trochanter to 8 cm above joint)
Winquist (OCNA 11:633– 647,1980) I—Transverse, < 25% butterfly II—Transverse, 25–50% butterfly III— > 50% butterfly, no comminution IV—Comminuted, no cortical contact V—Segmental Limits: < 15˚ malrotation, < 1–1.5 cm shortening
Femoral neck and shaft
Femoral shaft/ tibial shaft
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Locked intramedullary nail (external fixator, ORIF, traction)
Closed reduction percutaneous pinning vs. ORIF of neck (first). Intramedullary rod or plate for shaft vs. cephalomedullary nail “Floating knee”
Intramedullary rod femur and tibia; consider external fixator for tibia or femur (based on extent of soft tissue injury) Can use external fixator for a temporary solution
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Trauma—Adult Knee Dislocation Algorithm Multiple ligament injured knee History/exam/radiographs Dislocated
Emergent closed reduction
Located
Vascular/neurologic status
+
Dislocated
Pulses? Doppler?
− Vascular consult arteriogram
Surgical reduction Located Consider external fixation to maintain reduction
+/- Vascular repair +/- External fixation Ankle—brachial index If > 0.9 low likelihood of significant arterial injury Consider arteriogram Beware of intimal tears presenting with late vascular
Observation period Neurovascular status Skin—MRI Ligament surgery
Knee Fractures Injury/Eponym
Classification/Limits
Treatment
Supracondylar
AO
> 6–8 cm proximal—intramedullary nail anterograde < 6–8 cm condylar blade plate/screw, retrograde nail, distal femoral locking plate (required ORIF of displaced articular fragments)
Patella
Nondisplaced, transverse, lower pole, upper pole, comminuted, vertical
Nondisplaced = cylinder cast, knee immobilizer if extensor mechanism intact ORIF (tension band)—no active extension, < 2 mm separation, incongruent joint, consider excising comminuted fragment and reattaching tendon (Continues)
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210
Knee Fractures (Continued) Injury/Eponym
Classification/Limits
Treatment
Tibial plateau (treatment based on joint stability, displacement and articular congruity)
Shatzker (see page 163) I—Split lateral plateau
Closed treatment if nondisplaced; closed reduction percutaneous fixation if no incarcerated meniscus by scope or MRI; ORIF if incarcerated meniscus
II—Split/ depression lateral plateau
Closed treatment if nondisplaced; ORIF with elevation of the depressed joint surface for > 3 mm displacement (some accept as much as 4–10 mm) or instability
III—Isolated depression
Closed treatment, ORIF (similar criteria as type II)
IV—Medial split/ depression
Closed treatment (only for selected nondisplaced), otherwise ORIF
V—Bicondylar
ORIF versus external fixation
VI—Type V and metaphyseal extension
ORIF versus external fixation
Meyer/McKeever (JBJS 41A:209– 222,1959) I—Anterior elevation
Long leg cast 15–20° of flexion x 4–6 weeks
II—Anterior 1/3–1/2 elevated
Long leg cast 15–20° of flexion x 4–6 weeks, unstable = MRI and treat like III
IIIA—Displaced
MRI, arthroscopic fixation versus ORIF
IIIB—Displaced and rotated
MRI, arthroscopic fixation versus ORIF
Tibial spine
Tibial tubercle
ORIF
Knee Dislocation/Soft Tissue Injury Quadriceps rupture
Surgical repair
Patellar tendon rupture
Surgical repair
Patellar dislocation
Conservative treatment. Rule out osteochondral injury Evaluate medial patella-femoral ligament, consider repair
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Trauma—Adult
Knee Dislocation/Soft Tissue Injury Injury/Eponym
Classification/Limits
Treatment
Proximal tibia-fibula dislocation
Ogden - Subluxation - Posteromedial - Anterolateral - Superior
Treat subluxation conservatively Dislocations—Closed reduction (knee 90°) ± anesthesia, Limited immobilization Selective ORIF for unstable injuries
Knee dislocation
Descriptive of tibia in relation to femur
See algorithm page 209
Tibia/Fibular Fractures Tibia
Johner/Wruhs A—Simple 1—Spiral 2—Oblique 3—Transverse B—Butterfly 1—By torsion 2—One (bend) 3—Multiple (bend) C—Comminuted 1—Torsion 2—Segmental 3—Crush
Closed reduction and cast = low energy, minimal displaced, isolated All others—intramedullary nail, external fixator, plate **Maintain a high index of suspicion for compartment syndrome Acceptable reduction limits 5° varus and valgus, 10° anterior and posterior, 10° rotation, and 1 cm shortening (Rockwood CR, Green DP. Fractures in Adults. 4th ed. Baltimore, MD: Lippincott-Raven; 1996:2139)
Maissenouve Fracture Proximal Fibula Fracture
Injury to IO Membrane
Distal Syndesmosis Injury
Weber Classification
C: Above the Joint Line B: At the Joint Line A: Below the Joint Line Damian Rispoli 2009
Damian Rispoli 2009
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Trauma—Adult
212 Lauge-Hansen Classification (ArchSurg 60:957-985, 1950)
II
II
I
III I
Supination-Adduction
IV
Supination-External Rotation
III III
IV
IV I
II
II
Pronation-Abduction
I
Pronation-External Rotation Damian Rispoli 2009
Classification of Acute Lateral Ankle Sprains Grade Description I
ATFL stretching without complete tear
II
Partial to complete ATFL tear with a partial tear of the CFL
III
ATFL and CFL tear, Possible capsular disruption and PTFL tear
ATFL—anterior talofibular ligament CFL—calcaneofibular ligament PTFL—posterior talofibular ligament (JAAOS 16:608–615, 2008)
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Trauma—Adult
Leg/Ankle Fractures/Dislocations Injury/Eponym
Classification/Limits
Treatment
Ankle fractures AITFL = anterior inferior talofibular ligament PITFL = posterior inferior talofibular ligament
Lauge-Hansen (ArchSurg
Bimalleolar fracture or equivalent ORIF Selected nonoperative treatment for nondisplaced fractures without syndesmotic injury Syndesmotic screw for widened mortise
60:957–985,1950)
Supination-Adduction 1—Lateral malleolus or lateral collateral ligament 2—Medial malleolus— shear Supination-External rotation 1—AITFL 2—Lateral malleolus (spiral) 3—Posterior malleolus or PITFL 4—Medial malleolus or deltoid ligament Pronation-Abduction 1—Medial malleolus or deltoid 2—AITFL /PITFL or posterior malleolus 3—Lateral malleolus Pronation-External rotation 1—Medial malleolus or deltoid 2—AITFL or bony avulsion 3—High fibular 4—Posterior malleolus or PITFL Danis/Weber A—Fibular fracture below the syndesmosis B—At the syndesmosis C—Above the syndesmosis
Syndesmotic fixation: Tibia-fibular diastasis > 1 mm > 2 mm lateral talar shift Tibia/fibula clear space > 6 mm Medial clear space > 4 mm or 2.5 mm ↑ on external rotation stress radiograph < 10 mm tibia/fibula overlap on anteroposterior radiograph < 1 mm tibia/fibula overlap on mortise radiograph In general A = Closed B and C = ORIF ± syndesmotic screw
Tibial stress fracture
Activity modification
Fibular shaft
Cast for pain control (continues)
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214
Leg/Ankle Fractures/Dislocations Injury/Eponym
Classification/Limits
Treatment
Tibial plafond
Ruedi/Allgower I—Minimally displaced II—Incongruous III—Comminuted
Nonoperative stable/nondisplaced fractures II and III—ORIF vs. external fixation if displaced (min. invasive). Soft tissues are the key. You can always bridge and wait.
Achilles tendon rupture
Casting (higher rerupture) vs. surgical repair (skin necrosis)
Foot Fractures and Dislocations Stress fracture, March
2nd metatarsal, calcaneus
Activity modification and short leg cast
Posterior talar process Shepard’s
Short leg cast or excision of fragments
Lateral talar process
Short leg cast, excision of fragments, or ORIF
Talar head
Nondisplaced
Nonoperative
Displaced
ORIF or fragment excision
Talar body
ORIF for displaced fractures
Talar neck
Hawkins/Canale I—Nondisplaced (< 1 mm), vertical
Short leg nonwalking cast
Aviators Astralgus
II—Displaced + subtalar subluxation dislocation
ORIF— Anatomic reduction
III—Displaced and talar body dislocation
ORIF— Anatomic reduction
IV—With talar head dislocation
ORIF (lateral screw first to prevent varus)—Anatomic reduction
Calcaneus—Medial (85%) Calcaneus—Lateral (15%)
Closed reduction/cast, open reduction if irreducible Blocks to reduction: Lateral—posterior tibial tendon, flexor digitorum longus Medial—extensor digitorum brevis, talonavicular joint
Subtalar dislocation Basketball foot
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Hawkins sign – Relative osteoporosis of the talar dome at 6–8 weeks signifies an intact vascular supply (JBJS 52A:991–1002, 1970)
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215
Trauma—Adult
Foot Fractures and Dislocations Injury/Eponym
Classification/Limits
Treatment
Calcaneal fractures
A: Avulsion, process, tuberosity B: Nonarticular C: Articular involving the posterior facet
Midtarsal injury
Medial stress Longitudinal stress Lateral stress Plantar stress Crush Cortical avulsion Tuberosity fracture Body fracture Stress fracture
Short leg nonwalking cast vs. ORIF CT scan beneficial, selective ORIF for articular displacement and calcaneal body widening The overall goal is to restore congruous joint surface and the overall morphology of the calcaneus. Closed reduction percutaneous fixation vs. ORIF/percutaneous fixation The goal is restoration of the anatomic relationships Reduce/pin large fragment ORIF (screw/washer) ORIF displaced Short leg nonwalking cast ORIF and bone graft or external fixator (restore lateral column)
Navicular (Be vigilant for midtarsal injury) Cuboid, Nutcracker Tarso-metatarsal fracture/dislocation
Homolateral isolated divergent
Closed reduction percutaneous fixation vs. ORIF (usual—reliably reduces joints) Lisfranc ligament—Base of the 2nd metatarsal to the medial cuneiform Can consider primary fusion for predominantly ligamentous injuries (JBJS 88A(3):514–520,2006)
Shaft
Closed reduction/selective fixation displaced 1st metatarsal 2nd through 4th nonoperative unless it alters weight-bearing dynamics
Head
Closed reduction ± cast/pinning
5th metatarsal (OCNA 26:353– 361,1995) Zone I (tuberosity avulsion)
Symptomatic care in Ace wrap, hard sole shoe, or short leg walking cast
Lisfranc
Metatarsal
Pseudo-Jones→
(Continues)
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Tuberosity
Non-Comminuted Comminuted
Medial Sustentaculum
Anterior Process
Comminuted
Nondisplaced
2-Part
3-Part
Damian Rispoli 2009
4 or More Parts
Group C: Articular Fractures Involving Posterior Facet
Non-Comminuted
Group B: Nonarticular Body
Calcaneus Fractures OTA
Group A: Avulsion, Process, or Tuberosity
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Trauma—Adult
Foot Fractures and Dislocations (Continued) Injury/Eponym
Classification/Limits
Treatment
Jones →
Zone II
Short leg non-weight-bearing cast x 6 weeks, ORIF (late or athlete)
JBJS 84A:209– 214,2002→
Zone III (diaphyseal stress fracture) Type I (acute) Type II (delayed) Type III (nonunion)
Short leg non-weight-bearing cast x 6+ weeks Prolonged short leg non-weightbearing cast (sedentary); otherwise ORIF with/without bone grafting ORIF if symptomatic or high performance athlete, may consider pulsed electromagnetic field (JAAOS 8(5):332–8,2000)
Metatarsophalangeal joint dislocation
Reduce/buddy tape ± pinning (unstable)
Phalanges
Buddy tape ± cast or cast shoe Selective ORIF versus percutaneous pinning intraarticular displaced fracture
5th Metatarsal Fractures Peroneus Tertius Peroneus Brevis
Lateral Band of Plantar Fascia (Implicated in Zone I Fractures)
Zone III Zone II
Damian Rispoli 2009
Zone I
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Proximal and middle phalanx
Jersey or reverse mallet (physeal E)
Closed reduction/splint, percutaneous pinning (often), ORIF if needed ORIF (usually necessary) if displaced or incongruous
D—Articular/condylar
Closed reduction ± percutaneous pinning (angulation > 20° age < 10 years, 10°–15° age > 10 years), ORIF if needed
B—Shaft
C—Phalangeal neck
Closed reduction/splint, percutaneous pinning if unstable, ORIF joint incongruity (> 25% of joint surface, displacement > 1.5 mm)
Extension splinting x 6 weeks (rarely operative) Type B with large dorsal fragment > 50% or significant volar sag may need operative intervention Type C and D need operative intervention to restore joint surface and extensor continuity Type E requires tendon repair, retraction proximal to the A4 pulley likely means disruption of the vincular system—repair acutely (< 1 week)
Closed reduction/splinting—stable Pinning—unstable
Treatment
A—Physeal -extra-articular Salter-Harris II -intra-articular III/IV
Physeal (Mallet finger) A—Salter-Harris I or II B—Salter-Harris III or IV C—A and dislocation D—Avulsed extensor and SalterHarris fracture E—Volar
Extraphyseal A—Transverse B—Longitudinal split C—Comminuted
Distal phalanx fractures
Seymour fracture (any distal phalanx fracture with a nail bed injury)
Classification/Limits
Injury/Eponym
Pediatric Trauma—Wrist and Hand Fractures
TRAUMA—PEDIATRIC
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Finger metacarpal dislocation
Closed reduction percutaneous pinning, ORIF if irreducible
(Continues)
Closed, unstable = percutaneous pinning, ORIF rare
D—Metacarpal base fracture
Closed reduction usually unsuccessful; operative reduction as needed
Closed, unstable = percutaneous pinning
C—Shaft fracture
Dorsal (index finger most common)
Closed, unstable = percutaneous pinning, displaced head splitting need ORIF
B—Neck fracture
Irrigation and debridement, reduction then treat as closed
Open injuries
A—Epiphyseal and physeal
Reduction under local anesthesia Without collateral or volar plate instability—buddy tape x 3 weeks Collateral instability—immobilize @ 20°–30° flexion x 3 weeks, then buddy tape Volar plate laxity–dorsal splint at 45° or extension block splinting x 3 weeks
Dislocation
Metacarpal fractures
Buddy tape
Jammed finger
Proximal interphalangeal joint dislocation (PIPJ)
Treatment
Classification/Limits
Injury/Eponym
Wrist and Hand Fractures
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Complete complex
Extremely rare
A—Distal pole 1—Extra-articular, 2—Intra-articular B—Midwaist C—Proximal pole
Scaphoid
Cast immobilization (long arm thumb spica cast) Significantly displaced (considered based on skeletal age and angulation >10° and > 1 mm displacement) or additional carpal injury consider open reduction percutaneous pinning vs. internal fixation
Closed reduction percutaneous pinning
Closed reduction, ± percutaneous pinning for instability Displaced type D fracture = ORIF, external fixation (severe open fractures), traction (complex injuries) Displaced Salter-Harris fractures need ORIF
Metacarpal base A—Distal to physis B—Salter-Harris II, fragment ulnar C—Salter-Harris II, fragment radial D—Salter-Harris III or IV
CMCJ dislocation
Accept angulation < 20° (treat like finger metacarpal fractures)
Shaft
Closed reduction (treat like finger metacarpal fractures)
(Collaterals torn and volar plate torn and interposed in joint)
Complete simple
Thumb metacarpal fractures Head
(Collaterals torn and volar plate torn and not in joint)
Farabeuf Incomplete dislocation
Thumb metacarpal dislocation
Treatment All—Closed reduction vs. open reduction for failed closed, cast x 3 weeks (collaterals intact )
Classification/Limits
Injury/Eponym
Wrist and Hand Fractures (Continued)
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Greenstick Compression Complete
(Continues)
(Rockwood CA, Wilkins KE, Beaty JH. Fractures in Children. 4th ed. Philadelphia, PA: Lippincott-Williams and Wilkins, 1997, 524 and Green NE, Swointkowski MF. Skeletal Trauma in Children. Vol. 3. Philadelphia, PA: W.B. Saunders;1998:203)
Majority closed reduction /cast Closed reduction percutaneous intramedullary pinning indications: Severe swelling, ipsilateral fracture, re-reduction (external fixation, open reduction uncommon) Limits of Acceptable Alignment— < 8 years: 15° angulation, 45° malrotation, 100% displacement, complete loss of radial bow : 9–14 years or : 9–16 years: 10° angulation, 30° malrotation, 100% displacement, partial loss of radial bow
Acceptable angulation distal metaphysis (volar-dorsal plane)—30° with 5 yr growth remaining; subtract 5° for each year less Acceptable angulation distal metaphyseal (radial-ulnar plane)—20° with 5 yr growth remaining Reduction goals—80% apposition, 100% correction
Radius and ulna Both bone Acceptable angulation (see definitions that follow)
Closed reduction/cast Open reduction for failed closed reduction
A—Transphyseal
B—Intraphyseal (styloid)
Distal ulna
Closed reduction/cast Operative indications: Soft tissue injury, associated proximal ipsilateral fracture, failed closed reduction, open, comminuted intraphyseal, carpal tunnel symptoms, compartment syndrome
Salter-Harris classification
Distal radius
Treatment
Classification
Injury/Eponym
Radius/Ulnar Shaft (Fracture/Dislocation)
221 Trauma—Pediatric
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66016_CH06_PTR.indd 222 Reduce (supination), ± ORIF
IV—Anterior dislocation of the radial head, fracture of the middle 1/3 of the radius, and an ulna fracture at the same or more proximal level
Reduce ± ORIF
Minimally displaced head Displaced head
Galeazzi
Ulnar fracture/radial neck fracture
Radius fracture/distal radioulnar joint dislocation
Reduce (traction/supination), long arm cast 90° flexion/ supination Closed reduction percutaneous pinning if reduction unstable > 12 year old and failed closed reduction = ORIF
Reduce (supination/pressure), long arm cast—100° flexion, supination
Radial head dislocation
Radial head subluxation
Flexion, supination, pressure over radial head
Reduce (extension/pressure), long arm cast, 90° flexion/supination
III—Lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis
Nursemaid’s (see page 227)
Reduce (traction/extension), long arm cast, some extension
II—Posterior dislocation of the radial head with an ulnar diaphyseal or metaphyseal fracture with posterior angulation
Monteggia
Bado I—Anterior dislocation of the radial head with a fracture of the ulnar diaphysis
Ulnar fracture/radial head dislocation
Treatment Reduce (traction/flexion), long arm cast—flexion/ supination [most common ~ 70%]
Classification
Injury/Eponym
Radius/Ulnar Shaft (Fracture/Dislocation) (Continued)
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Distal humeral physeal separation
Closed reduction percutaneous pinning Closed reduction percutaneous pinning
B—1 yr–3 yr, Salter-Harris I
C—3–12 yr, Salter-Harris II
(Continues)
Closed vs. open reduction percutaneous pinning Be careful of neurovascular status with casting in flexion > 90°. Closed reduction and cast
Closed reduction, long arm cast vs. percutaneous pinning
III—No contact
DeLee A—< 12 mo, Salter-Harris I
Long arm cast vs. posterior splint
II—Displaced and contact
Closed reduction percutaneous pinning (Two lateral pins favored by some over medial/lateral configuration)
III—No cortical contact (posterior medial and posterior lateral)
I—Nondisplaced
Closed reduction, long arm cast > 90° vs. percutaneous pinning
II—Displaced, posterior cortex intact
Supracondylar Flexion
Long arm cast—90° flexion, forearm neutral
I—Nondisplaced
Supracondylar Extension
Treatment
Classification
Injury/Eponym
Elbow
223 Trauma—Pediatric
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Jakob I—Intact articular surface II—Articular surface disrupted III—Rotated fragment
Lateral condyle fractures
III—Displaced
Little Leaguer elbow
Nonoperative = non/minimally displaced, displaced low demand Operative indications (absolute) = irreducible incarcerated Operative indications (relative) = ulnar nerve dysfunction, high-demand function
Closed or open reduction/percutaneous pinning vs. internal fixation
II—Complete, nondisplaced
Acute injuries Non/minimally displaced Displaced Incarcerated (without dislocation) (with dislocation) Chronic tension
Closed reduction/cast vs. percutaneous pinning
Kilfoyle I—Fracture to physis
Medial condyle fracture
Medial epicondylar apophysis
Splint vs. cast
Hahn-Steinthall Kocher-Lorenz
Closed reduction/cast vs. ORIF Excise vs. ORIF
< 2 mm displaced—Closed reduction/cast and close F/U > 2 mm—Closed reduction percutaneous pinning Grossly unstable = open reduction percutaneous pinning
Treatment
Capitellum fracture
Milch I—Salter-Harris IV, fracture through capitella-trochlear groove II—Salter-Harris II, fracture through trochlea
Classification
Injury/Eponym
Elbow (Continued)
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66016_CH06_PTR.indd 225 (Continues)
Nondisplaced = splint/cast in extension Displaced = ORIF vs. percutaneous pinning
Olecranon apophysis
I—Apophysitis II—Incomplete stress III—Complete fracture A—Pure apophyseal B—Apophysis and metaphysis
Immobilization, incarceration operative intervention
Young = sedation, closed reduction Older > 9 years old = general anesthesia, closed reduction Aftercare = active elbow flexion at 5 days, sling at 10 days
Limited open reduction and traction
Proximal radio-ulnar joint intact A—Posterior (posterior-medial and posterior-lateral) B—Anterior C—Medial D—Lateral Proximal radioulnar joint dislocation A—Divergent (anterior-posterior and medial-lateral B—Radioulnar translocation
III—Metaphyseal comminution
Lateral epicondylar apophysis
Elbow dislocation
Closed reduction percutaneous pinning vs. traction ORIF
Treatment
II—Displaced, no metaphyseal comminution
T-Condylar
Toniolo/Wilkins I—Nondisplaced
Classification
Injury/Eponym
Elbow
225 Trauma—Pediatric
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Classification
A—Flexion B—Extension (1-Valgus, 2-Varus) C—Shear
Group I—Head 1—Valgus fracture A—Salter-Harris I/II B—Salter-Harris IV C—Metaphyseal fracture 2—With elbow dislocation D—Reduction injury E—Dislocation injury Group II—Neck 1—Angular 2—Torsional Group III—Stress 1—Osteochondritis dissicans 2—Physeal injury + neck angulation
Injury/Eponym
Olecranon metaphysis
Radial head and neck
Elbow (Continued) Treatment
66016_CH06_PTR.indd 226 Fixed 40° angulation, < 60° pronation/supination, 3 mm translation, head completely displaced = wire reduction, open reduction ± internal fixation
> 45° = closed reduction (general anesthesia) using flexion-pronation, Ace wrap, or percutaneous pins, then long arm cast x 10–14 days
> 30° = closed reduction (general anesthesia) using flexion-pronation, long arm cast x 10–14 days
< 30°, no angulation = long arm cast vs. posterior splint, and early range of motion
Nondisplaced = cast in extension Significantly displaced = ORIF
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227
Trauma—Pediatric
Milch Fracture Calssification
Milch I (Salter-Harris IV)
Milch II (Salter-Harris II) Damian Rispoli 2009
Nursemaid’s Elbow Nursemaid’s Elbow -Refusal to move arm -Pain at elbow -May give characteristic history (longitudinal pull) Treatment -Supinate forearm -Flex elbow with pressure over radial head -Radial head should relocate -Success is walking away to return later and see the child using the arm
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2. Flex Elbow
3. Gentle pressure on radial head 1. Supinate Forearm
Damian Rispoli 2009
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66016_CH06_PTR.indd 228 Figure-of-8, sling
Sternoclavicular joint
Sling Closed vs. open reduction
Posterior
Sling
Anterior
Salter-Harris I and II
> 2 years old
Medial clavicle
Supportive
0–2 years old
(Baxter MP, Wiley JJ. Fractures of the proximal humeral epiphysis. Their influence on growth. JBJS(Br)86;68:570–573 and Beringer DC, Weiner DS, Noble JS, Bell RH. Severely displaced proximal humeral epiphyseal fractures. A follow-up study. JPO 98;18:31–37)
Midshaft clavicle
Sugar tong splint
> 12 years
Minimally displaced = splint vs. hanging arm cast Unstable ± percutaneous pinning Soft tissue interposition or open fracture—ORIF Two studies support nonoperative treatment even in the face of severe displacement or angulation
Velpeau
3–12 years
Salter-Harris Neer-Horowitz I—≤ 5 mm displaced II—≤ 1/3 shaft III—≤ 2/3 shaft IV—Complete shaft
Collar and cuff
0–3 years
Proximal humerus
Splint
Birth injury
Humeral shaft
Treatment
Classification
Injury/Eponym
Shoulder
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Classification
Treatment
66016_CH06_PTR.indd 229 Closed reduction vs. open reduction/repair Open reduction, repair, reconstruction Closed reduction vs. open reduction
IV—Posterior displacement
V—Significant superior displaced (> 100% contralateral side)
VI—Inferior displaced (subcoracoid rare)
Scapulothoracic dissociation
I–III = Closed treatment
I—Sprain II—Partial tear dorsal periosteum III—Large tear dorsal periosteum
Acromioclavicular joint
ABCs, reconstruction/repair
Sling, figure-of-8, consider ORIF for certain type IIs
Similar to adults
Anatomic
I—Nondisplaced, intact ligaments IIA—Fracture medial to coraco-clavicular ligaments IIB—Conoid ligament tear III—Fracture into acromioclavicular joint
Lateral clavicle
Closed reduction, rehabilitation, ± reconstruction/repair
Scapular fracture
Traumatic Anterior and posterior
Glenohumeral dislocation
Medial clavicular physis is the last to close (~ 25 years old). Sternoclavicular dislocations usually represent Salter-Harris type II fractures.
Injury/Eponym
Shoulder
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66016_CH06_PTR.indd 230 High index of suspicion, CT and MRI
Usually nonoperative Unstable = fuse
Posterior ligament injuries Wedge/compression fracture Distraction/shear fracture Fracture—dislocation Facet dislocation/listhesis
Flexion With compression Without compression Distraction Shear
C2–C7 fracture
Thoracic and lumbar fractures
Usually nonoperative Operative fixation—Unstable, open wound, progressive neurological deficit, slipped vertebral apophysis
Minerva cast vs. HALO immobilization
C2 fracture Hangman’s
< 1 week—Soft collar, NSAIDS < 1 month—Relax, traction, collar/brace 4–6 weeks 1–3 month—HALO > 3 month—C1–C2 fusion
C1–C2 fusion
Occiput—C3 fusion Minerva vs. HALO vest
Ligament disruption Rotatory subluxation I—No anterior shift II—Anterior < 5 mm III—Anterior > 5 mm IV—Posterior shift
High mortality
Occiput—C1 dislocation
Treatment
C1–C2 injuries
Spinal Cord Injury Without Radiographic Abnormality
SCIWORA
C1—Atlas fracture
Classification
Injury/Eponym
Spine Fractures
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Hip dislocation
Anterior Posterior
Closed reduction, open reduction (irreducible), CT scan (intra-articular bodies)
Nonweight bearing
Traction then casting vs. closed reduction and compression screw
IV—Intertrochanteric
Percutaneous pinning
Abduction spica cast, close F/U, ORIF indicated for displacement in cast
Nondisplaced
Compression
Closed reduction vs. open reduction percutaneous pinning/ compression screw
III—Cervicotrochanteric Displaced
Devas Tension
Closed reduction vs. open reduction percutaneous pinning (AVN increases with displacement)
II—Transcervical (45–50%)
Stress fracture
Closed reduction and spica cast vs. open reduction percutaneous pinning (open treatment more common with head dislocation)
Delbet I—Transepiphyseal (with and without dislocation)
Hip fracture
Treatment
Classification
Injury/Eponym
Hip Fracture and Dislocations
231 Trauma—Pediatric
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66016_CH06_PTR.indd 232 Bedrest x 6 wk, advance partial weight bearing as tolerated Bedrest, traction, ORIF > 3 cm Treat as pelvic fracture
B—2 vertical fracture/dislocation
C—Severe multiple fractures
IV—Acetabular fracture A—Small fragment, + dislocation
Straddle→
Malgaigne→
ORIF
Bedrest x 6 wk, advance partial weight bearing as tolerated
III—Double break A—2 anterior fracture/dislocation
ORIF
Short bedrest, advance weight bearing as tolerated
C—Fracture/subluxation sacroiliac joint
D—Due to central fracture/dislocation
Short bedrest, advance weight bearing as tolerated
B—Fracture/subluxation symphysis
Restore congruity
Short bedrest, advance partial weight bearing as tolerated
II—Single break A—2 ipsilateral rami
C—Linear, unstable joint
Short bedrest, advance partial weight bearing as tolerated
D—Sacrum/coccyx
B—Linear, non-displaced pelvic fracture
Short bedrest, advance partial weight bearing as tolerated
C—Iliac wing
Duverney→
Short bedrest, advance partial weight bearing as tolerated
B—Pubis/ischium
Restore joint congruity and hip stability Short period of rest, relax muscles associated with spine/ tuberosity, advance partial weight bearing as tolerated
Key and Conwell I—No ring break A—Avulsion fracture (ASIS, AIIS, Ischial tuberosity)
Pelvic fracture
Treatment
Classification
Injury/Eponym
Pelvic and Acetabulum Fractures
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Subtrochanteric/ Supracondylar
Anatomic/descriptive
Femur fracture
Subtrochanteric Supracondylar
(JBJS 84A(12):2288–2300,2002)
2–10 years old—Overgrowth averages 0.9 cm
Treatment is very variable between centers!
Classification
Injury/Eponym
Femoral Shaft Fractures
Traction and cast vs. cast brace Stable—Cast Unstable—Closed vs. open reduction internal fixation/percutaneous pinning
0–2 years: 30° varus/valgus, 30° anterior/posterior, 15 mm short 2–5 years: 15° varus/valgus, 20° anterior/posterior, 20 mm short 6–10 years: 10° varus/valgus, 15° anterior/posterior, 15 mm short > 11 years: 5° varus/valgus, 10° anterior/posterior, 10 mm short
Philadelphia, PA: Lippincott-Williams and Wilkins; 1997:1201.
0–6 mo Stable—Pavlik Unstable—Immediate spica or traction and delayed spica 6 mo–5 yr < 3 cm shortening—Immediate spica > 3 cm initial, > 2 cm in spica traction—Delayed spica Polytrauma—External fixator, flexible intramedullary nails 6–11yr Stable—Immediate spica Unstable—Traction, delayed spica, external fixator, flexible intramedullary nail 12—Adult Flexible/rigid intramedullary nail based on maturity and fracture Configuration Limits of Acceptable Angulation: Rockwood CA, Wilkins KE, Beaty JH. Fractures in Children. 4th ed.
Treatment
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Nondisplaced—Long leg cast, 30° flexion Displaced—Closed reduction percutaneous pinning Nondisplaced, minimally displaced with active extension to 0°—Long leg cast Displaced—ORIF
Salter-Harris
Salter-Harris
Ogden (JBJS 62A:205–215,1980) I—Distal, secondary ossification center II—Junction 1° and 2° ossification centers III—Into knee joint
Myers/McKeever (JBJS 52A:1677–1684,1970) I—Incomplete, nondisplaced II—Hinged (posterior) III—Supinated/rotated
Distal femoral physeal fracture
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Proximal tibial physeal fracture
Tibial tubercle avulsion
Intercondylar eminence fracture
Attempt closed reduction, long leg cast in extension (neutral—10°) ORIF if irreducible
I,II—Closed reduction, long leg cast III,IV—Closed reduction percutaneous pinning
Fix one, usually the tibia Fix femur if: Severe head trauma with posturing, skeletal maturity, severe soft tissue injury, irreducible closed
Letts/Vincent A—Diaphyseal/closed B—Metaphyseal/diaphyseal closed C—Epiphyseal/diaphyseal D—One fracture open E—Both open
Floating knee
Treatment
Classification
Injury/Eponym
Knee Fractures and Dislocations
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66016_CH06_PTR.indd 235 Closed reduction, rest vs. cast
Tibiofibular joint dislocation
Subluxation Anterior/lateral Posterior/medial Superior
Closed reduction, cylinder cast Intra-articular osteochondral fracture may need excision vs. ORIF
Similar to adults except kids may be primarily repaired; isolated ligament injuries may be treated nonoperatively
Patellar dislocation
Anatomic
ORIF (tension band) ORIF ± tension band
Periosteal sleeve (usually 8–12 yr)
Knee dislocation
Long leg cast
Nondisplaced
Displaced (2–3 mm step off or 3 mm)
Patella fracture
Treatment
Osteochondral fractures (knee)
Initially treat with ↓ activity ± immobilization unless unstable or detached Operative treatment for failure on nonoperative x 3–6 mo (arthroscopy) < 1 cm excise and drill; ≥ 1 cm consider open curettage, reduction, and fixation
Classification
33% bilateral, < , 5–15 yr
Injury/Eponym
Knee Fractures and Dislocations
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***GOAL < 1 cm short < 10° angulation (varus, valgus, or recurvatum)
I—Proximal tibial metaphyseal fracture
Tibia and fibular fracture
IV—Special Toddler’s Bicycle spoke Pathologic
III—Diaphyseal fracture isolated tibial, isolated fibular, both
II—Distal tibial metaphyseal fracture
Classification
Injury/Eponym
Tibia and Fibula Fracture
Long leg cast Soft tissue reconstruction/stabilization Based on pathologic condition and fracture ** Be sure to counsel for overgrowth and correction based on age Valgus deformity—Spontaneous correction to 3 years postinjury
Nondisplaced—Long leg cast 10° flexion Displaced—Closed vs. open reduction, long leg cast Nondisplaced—Long leg cast Displaced—Closed reduction, long leg cast Nondisplaced—Long leg cast Displaced—Closed vs. open reduction, long leg cast, internal or external fixation (plate/screws, flexible nails)
Treatment
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Ankle fracture
Treatment
Triplane and Tillaux—Based on CT scan > 2 mm displacement and > 2 mm step off—ORIF; otherwise, treat in long leg cast
**Restore ankle mortise/joint surface
Closed vs. open reduction, cast ± percutaneous pinning or screw fixation
CT scan SH I and II postreduction due to higher incidence of malreduction (JPedOrthop 23:733-739, 2003)
Acceptable ≥ 2 years growth < 15° plantar flex < 10 valgus No varus < 2 years growth < 5° all planes
Classification
Supination-inversion -Transverse fibula, shear medial malleolus Pronation/Eversion External rotation -High fibula, medial malleolar transverse physeal Supination-plantar flexion -Transphyseal posterior Supination-external rotation -Oblique fibular, oblique tibial Axial compression (Salter-Harris V) Juvenile Tillaux (Salter-Harris III lateral tibial physis) Triplane (Salter-Harris III tibia anterior lateral, Salter-Harris IV posterior medial)
Injury/Eponym
Ankle Fracture
237 Trauma—Pediatric
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Trauma—Pediatric
238
Anterior Lateral Axial Section
Damian Rispoli 2009
Juvenile Tillaux
Tri-Plane Fracture
AP Damian Rispoli 2009
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Lateral
Radiographic Representation
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66016_CH06_PTR.indd 239 Nonoperative Unstable—Closed reduction percutaneous pinning Short leg nonwalking cast, ORIF ± graft Short leg cast vs. postoperative shoe
Jones
Pseudo-Jones
Base 5th metatarsal
(Continues)
Nondisplaced—Cast Displaced—Closed reduction percutaneous pinning vs. open reduction percutaneous pinning vs. internal fixation
Nonoperative
Metatarsals
Anatomic
Hardcastle A—Complete incongruity B—Partial instability C—Divergent or total instability
Arthroscopy—Excision, microfracture, bone graft Arthroscopy—Excision, microfracture, bone graft
IV—Displaced
Tarsometatarsal injuries
6 wk non-weight-bearing
III—Complete, nondisplaced
Lesser tarsal fracture
6 wk non-weight-bearing
Closed reduction percutaneous pinning
III—Displaced
II—Incomplete separation
Cast vs. closed reduction percutaneous pinning
II—Minimally displaced
Berndt/Harty I—Subchondral trabecular injury
Cast
Neck I—Nondisplaced
Talus fracture
Osteochondral fracture
Treatment
Classification
Injury/Eponym
Foot Fractures
239 Trauma—Pediatric
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66016_CH06_PTR.indd 240 Historically treated nonoperatively
Older age and joint incongruity may need closed reduction percutaneous pinning vs. ORIF
(JPedOrthop 27(8):856–862, 2007)
Good results with operative treatment
Nonoperative
Calcaneus
Essex-Lopresti Type 1 A—Tuberosity/apophysis B—Sustentaculum tali C—Anterior process D—Anterior inferior lateral process E—Body avulsion Type 2 Tuberosity posteriorly ± superior involvement Type 3 Body, no subtalar involvement Type 4 Subtalar involvement, Nondisplaced Type 5 Subtalar involvement, displaced A—Tongue B—Joint depression Type 6 Nonclassifiable
Activity modification
Treatment
Phalangeal fracture
Classification
Stress fracture
Injury/Eponym
Foot Fractures (Continued)
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TRAUMA SCORES/CLASSIFICATIONS Gustillo Classification (J Trauma 24:742–746, 1984) Grade
Description
Antibiotic Choice
I*
I
Wound usually < 1 cm, clean, minimal muscle contusion, low energy fracture (usually inside-out type wound)
1st-generation cephalosporin such as cefazolin (Ancef) 1 gm IV q8h for 3 days (postwound closure)
3L
II
Wound usually > 1 cm, significant 1st-generation cephalosporin such soft tissue injury (flaps, avulsed as cefazolin (Ancef) 1 gm IV q8h for skin, nerve injury extensive 3 days (postwound closure) muscle contusions), minimal to moderate crush component, moderate energy fractures, minimal comminution
6L
III**
Wound usually > 10 cm, extensive Cefazolin for 5 days plus gentamicin soft tissue damage, high energy 2 mg/kg and adjusted for serum fractures, crush/shear injuries levels or tobramycin, add 4 million units IV PCN G q6h for farmyard, highly contaminated, vascular injuries, or extensive crush injuries
9L
IIIA
Soft tissue adequate for local coverage, gunshot wound (GSW), segmental fracture
“
IIIB
Periosteal stripping, exposed Consider antibiotic bead pouch*** bone, extensive soft tissue injury, contamination, requires soft tissue reconstructive surgery
“
IIIC
Type III with vascular injury requiring repair for limb survival
“
Consider antibiotic bead pouch***
Chapman MW, Olson SA. Open fractures. In Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults. 4th ed. Philadelphia: Lippincott-Raven Publishers; 1996: 305–352. Anglen JA, Wound Irrigation in Musculoskeletal Injury, JAAOS. 2001 9(4):219–226. *Irrigation—Additives (antiseptics, antibiotics, and surfactants) not universally recommended **Automatic type IIIs—Segmental fractures, farmyard injuries, fractures occurring in highly contaminated environments, shotgun wounds, high-velocity gunshot wounds ***Antibiotic beads—Tobramycin, gentamicin, vancomycin, or cephalosporin (0.5–1 g per 40 g cement) Topical antibiotics in the irrigant are controversial but favored by some. Consider culture. (ClinOrthop., 212:227, 1986)
241
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Trauma Scores/Classifications
242
THOROUGH AND ADEQUATE DEBRIDEMENT AND IRRIGATION IS IMPERATIVE AND THE KEYSTONE IN THE TREATMENT OF ALL OPEN INJURIES. OPEN HAND INJURIES 1. The patient as a whole 2. Other injuries; resuscitation 3. History 4. Physical exam 5. Restoration of blood flow 6. Debridement (repeat debridement) 7. Skeletal stability 8. Repair of damaged structures 9. Appropriate timing of closure and coverage (when in doubt don’t close) 10. Proper dressings and elevation 11. Tetanus prophylaxis and antibiotics (antibiotics as useful “adjuncts.” Antibiotics never substitute for adequate debridement. Cover severe wounds with oxacillin, or 1st-generation cephalosporin.) 12. Secondary reconstruction 13. Rehabilitation (as early as possible) 14. Tetanus prophylaxis (Brown PW. Open Injuries of the Hand In Green’s Operative Hand Surgery. 3rd ed. Philadelphia, PA: Churchill Livingstone; 1993:1607–1630.)
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243
Trauma Scores/Classifications
Mangled Extremity Severity Scale (J Trauma 30:568–573, 1990) Component
Points
A. Skeletal and soft tissue injury Low energy (stab, simple fracture, low-velocity [civilian] GSW)
1
Medium energy (open fracture, multiple fracture)
2
High energy (close-range shotgun blast, high-velocity GSW [military or assault weapon], crush injury)
3
Very high energy (same as high energy but add grossly contaminated or devitalized tissue)
4
B. Limb ischemia (double score time > 6 hr) Pulse decreased or gone with normal perfusion
1
Pulseless, paraesthetic, decreased capillary refill
2
Cool, paralyzed, insensate, anesthetic
3
C. Shock Transient hypotension (systolic < 90)
1
Persistent hypotension (systolic < 90)
2
D. Age (years) 30–50
1
> 50
2
MSS score > 7 predicts the need for initial or eventual amputation, ≤ 6 predicts a viable limb
ABBREVIATED INJURY SCALE (AIS)/INJURY SEVERITY SCORE (ISS) The AIS rates and compares injuries. Injuries are cataloged to nine body sections and assigned a numeric value (1–6) to each injury based on severity. The ISS summarizes the AIS data. It is the sum of the squares of the scores from the three most severely injured body regions. The six body regions used in the ISS are head/neck, face, chest, abdominal or pelvic contents, extremities or pelvic girdle, and external. ISS scores range from 1–75. A score of 6 in any region makes the ISS 75, regardless of other involved areas. ISS ≥ 18 defines a multiple trauma patient. ISS < 30 usually indicates a favorable prognosis, whereas > 60 is usually fatal.
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TUMOR Age Distribution of Various Common Bone Lesions Age
Malignant
Benign
Birth to 5 yr
Leukemia
Osteomyelitis
10–25 yr
Metastatic neuroblastoma
Osteofibrous dysplasia
Metastatic rhabdomyosarcoma
Osteochondroma (after 5 yr)
Wilm’s tumor
Chondroblastoma (after 5 yr)
Osteosarcoma
Eosinophilic granuloma
Ewing’s sarcoma
Osteomyelitis
Leukemia
Enchondroma
Adamantinoma
Fibrous dysplasia Aneurysmal bone cyst Giant cell tumor Simple bone cyst
40–80 yr
Metastatic bone disease
Hyperparathyroidism
Myeloma
Paget’s disease
Lymphoma
Mastocytosis
Paget’s sarcoma Postradiation sarcoma Malignant fibrous histiocytoma Staging System for Musculoskeletal Lesions (Enneking) Stage
GTM
Description
IA
G1T1M0
Low grade, intracompartmental, no metastasis
IB
G1T2M0
Low grade, extracompartmental, no metastasis
IIA
G2T1M0
High grade, intracompartmental, no metastasis
IIB
G2T2M0
High grade extracompartmental, no metastasis
IIIA
G1 or 2 T1M1
Any grade, intracompartmental, metastasis
IIIB
G1 or 2T2M1
Any grade, extracompartmental, metastasis
Grade: G1 = low-grade, less common, metastasis < 25%, G2 = high-grade, metastasis > 25% Tumor site: T1 intracompartmental, T2 extracompartmental. Metastasis: M0 = no metastasis (regional or systemic), M1 = metastasis (regional or systemic) Skip lesions places the patient into a stage III category.
244
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245
Tumor
General Guidelines for Prophylactic Fixation in Metastatic Disease Pattern of bone destruction
Purely lytic—High risk Purely blastic—Lower risk
Size
< 25–35% cortical destruction—Low risk > 50–75% cortical destruction—High risk
Location
High-risk regions—Femur neck, subtrochanteric, diaphysis
Pain
Risk increased with activity related pain (mechanical pain)
Postirradiation
Fixation to improve pain and increase mechanical strength (Beware of wound healing complications postradiation.)
Prognosis
Survival < 4 weeks—Nonoperative treatment
Reproduced from Frassica FJ, Frassica DA, McCarthy EF, Riley LH. Metastatic bone disease: Evaluation, clinicopathologic features, biopsy, fracture risk, nonsurgical treatment, and supportive management. AAOS Instructional Course Lectures. 2000;49:453–459.
Scoring System to Predict Pathological Fracture Parameter
Score 1
2 Moderate
3
Pain
None
Activity related
Location
Upper extremity
Lower extremity
Peritrochanteric
Bone destruction
Blastic
Mixed
Lytic
Size
< 1/3
1/3–2/3
> 2/3
Fracture group: median 10, range 7–12; nonfracture group: median 7, range 4–9 Scores 9 or higher fixation recommended Reproduced from Mirels H. Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. ClinOrthop. 1989;249:256–264.
Osteoblastic Metastasis—“LBP”—Lung/breast/prostate 30–60–90% of respective lesions are blastic on radiographic evaluation. SKELETAL FIXATION OF METASTATIC CARCINOMA • Goal is to maximize function and minimize pain. • The goal is not to affect a cure in metastatic disease. • Skeletal fixation or radiation therapy can meet goals (should generally radiate following skeletal fixation).
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Tumor
246
Laboratory Studies in Evaluation of a New Tumor Patient 5–40 years
40–80 years
Complete blood count with differential
Complete blood count with differential
Erythrocyte sedimentation rate
Erythrocyte sedimentation rate
Peripheral blood smear
Chemistry group, calcium and phosphate Serum or urine electrophoresis Urinalysis PSA
Laboratory Studies in Evaluation of a New Tumor Patient (Continued)
CBC—Myeloma, infection, any marrow packing disorder ESR—Infection Peripheral blood smear—Lymphoma, leukemia, infection Chemistry, calcium, phosphate—Metabolic disease, diabetes, metastasis, osteosarcoma Serum or urine electrophoresis—Myeloma Urinalysis—Renal cell Round Cell Lesions by Age Lesion
Age
Neuroblastoma
2–3
Eosinophilic granuloma
4–20
Ewing’s sarcoma
10–25
Lymphoma
30–60
Myeloma
50 +
Metastasis
50 +
Infection
Any
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Subchondral bone lesions Giant cell tumor Chondroblastoma Clear cell chondrosarcoma
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247
Tumor
Five Lesions that Can Look Like Anything (Radiographically)
Lodwick’s Classification (Radiographs of Bone Lesions)
Fibrous dysplasia
IA. Well circumscribed, sclerotic
Metastatic lesions
IB. Circumscribed, minimally sclerotic
Chondroid lesions
IC. Poorly circumscribed
Infection
II. Moth eaten (geographic)
Eosinophilic granuloma
III. Permeative (diffuse)
Malignant Bone Lesions
Malignant Soft Tissue Lesions
Osteosarcoma1
Soft tissue sarcoma
Chondrosarcoma2
Fibrosarcoma
Ewing’s sarcoma3
Liposarcoma4
Metastatic lesions
Leiomyosarcoma
Lymphoma
Malignant spindle cell sarcoma NOS
Myeloma
Malignant schwannoma/neurofibrosarcoma
Chordoma
Rhabdomyosarcoma5
Adamantinoma
Synovial sarcoma6
1,2,3
1st, 2nd, and 3rd most common primary bone sarcomas. 4 Most common soft tissue sarcoma in adults. 5 Most common soft tissue sarcoma < 15 years old. 6 Most common soft tissue sarcoma of the lower extremities.
Intra-Articular Tumors Synovial chondromatosis Synovial cell sarcoma (rare) Synovial chondrosarcoma Lipoma arborescens Pigmented villonodular synovitis (nodular or diffuse) Musculoskeletal Tumor Society (MSTS) Stages of Disease Benign Disease
Malignant Disease
1 Benign, inactive (latent)
I Low grade
2 Benign, active
II High grade
3 Benign, aggressive
III With regional or distant metastasis
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Chondroblastoma
Osteosarcoma
Enchondroma Chondrosarcoma
Simple Bone Cyst Osteoblastoma
Chondromyxoid Fibroma
Osteoid Osteoma
Fibrous Cortical Defect Adamantinoma Fibrous Dysplasia
Redrawn from Madewell JE, Ragsdale BD, Sweet DE. Radiologic and Pathologic analysis of solitary bone lesions, Part I. Internal Margins. Radiol Clin North Am 1981;19(4):784-814
M e t a p h y s i s
D i a p h y s i s
Damian Rispoli 2009
Giant-Cell Tumor (adult extends to Epiphysis end of bone)
Giant-Cell TumorChild
Osteochondroma
Non-ossyfying fibroma
Fibrosarcoma
Round Cell Lesions -Ewings Sarcoma (equally as common in the metaphysis) -Reticulum Cell Sarcoma -Myeloma
Tumor 248
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APPENDIX A: STEROID PREPARATIONS
Steroid Preparations
Solubility
Generic Name
Trade Name
Equivalent Dose (mg)*
Most soluble
Betamethasone sodium phosphate
Celestone
0.6
Soluble
Dexamethasone sodium phosphate Prednisolone sodium phosphate
Decadron Hydeltrasol
0.75 5
Slightly soluble
Prednisolone tebutate Triamcinolone triacetate Methylprednisone acetate
Prednisol TBA Aristospan Forte Depo-Medrol
Relatively insoluble
Dexamethasone acetate Hydrocortisone acetate Prednisolone acetate Triamcinolone acetonide
Decadron-LA Hydro-acetone Predalone Kenalog
0.75 20 5 4
Combination
Triamcinolone hexacetonide Betamethasone sodium phosphate Betamethasone acetate1
Aristospan Celestone Soluspan
4 0.6
5 4 4
*For example, 0.6 mg of betamethasone sodium phosphate is equivalent to 0.75 mg of dexamethasone sodium phosphate, which is equivalent to 5 mg of prednisolone. 1
Betamethasone acetate is slightly soluble
Fadale PD, Wiggins ME. Corticosteroid injections: Their use and abuse. JAAOS. 1994;2(3):133–139.
Three Main Concerns Postinjection flare
Long-term joint damage
Serious infection
Local cutaneous atrophy
Steroid arthropathy
Other Concerns Crystal-induced synovitis
Intra-articular steroid injections have been shown to be: Good for short-term pain relief in osteoarthrosis flares Good short-term relief ~1–3 weeks (placebo-controlled studies) Recommended no more than four injections per year in a single joint (AAOS IMCA Osteoarthritis of the Knee, 2002)
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APPENDIX B: INTERNET RESOURCES JOURNALS American Journal of Sports Medicine—www.ajsm.org Arthroscopy—www.arthroscopyjournal.org Clinical Orthopaedic and Related Research—http://www.clinorthop.org Journal of Bone and Joint Surgery—www.jbjs.org Journal of Foot and Ankle Surgery—www.jfas.org Journal of Hand Surgery—http://www.sciencedirect.com/science/journal/03635023 Journal of the American Academy of Orthopaedic Surgeons—www.jaaos.org Journal of Trauma—www.jtrauma.com Orthopedics Today—www.orthopedicstoday.com Physician and Sports Medicine—www.physsportsmed.com Seminars in Musculoskeletal Radiology—www.thieme.com Spine—www.spinejournal.com COMPANIES Biomet—www.biomet.com DePuy/ACE—www.depuy.com Howmedica—www.howmedica.com Industry Link (various companies)—http://www.slackinc.com/idirectories/orthonet-x. htm Johnson & Johnson—www.johnsonandjohnson.com Lippincott—www.lww.com Orthofix—www.orthofix.com Smith & Nephew—http://global.smith-nephew.com/master/6600.htm Tarascon Publishing—www.tarascon.com WB Saunders—www.harcourt-international.com Wright—www.WMT.com Zimmer—www.zimmer.com ORTHOPEDIC WEB SITES American Academy of Orthopedic Surgery—www.aaos.org Orthopedic Medicine—www.orthopedics.about.com SLACK Orthopedic Internet Directory—www.orthopedicstoday.com Orthopaedic Database—www.ORTHOGUIDE.com Wheeless Online—www.wheelessonline.com Bone tumor information site—www.bonetumor.org GENERAL WEB SITES U.S. Centers for Disease Control and Prevention—www.cdc.gov U.S. National Library of Medicine—www.nlm.nih.gov National Inst. of Health—www.nih.gov NIH Library—www.ncrr.nih.gov 250
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INDEX Note: A p indicates that the entry is a pediatric reference A Acetabular fractures, 202, 203 Acetabular index (DDH), 151, 152 Acid-base values, 3 Acromioclavicular joint injection/aspiration, 132 Adolescent idiopathic scoliosis, 109–112 Adson’s test, 134 Adult trauma ankle, 211–214 elbow, 183–187 femur, 208 foot, 214–217 forearm, 182–183 hand, 176–180 hip, 204–208 knee, 209–211 leg, 211–214 pelvis, 199–202 periprosthetic, 204 shoulder, 189–194 spine, 195–198 wrist, 181–182 AIS/ISS, 243 Allen’s test, 119 Allogenic blood transfusion risk, 77 Analgesia and sedation, 162–164 Analgesics, 89p Angles, 89p Ankle block, 140 fasciotomy, 66 joint injection/ aspiration, 139 muscles, 15–16
radiographic views, 157–158 tests, 138–139 trauma (fracture), 211–214, 237p Anterior drawer ankle, 138 knee, 137 Anterior humeral line, 147 Anterior interosseous nerve quick neurologic test, 121 schematic, 40 Anteroposterior talocalcaneal angle (Kite), 157 Antibiotic doses, 59–60p Antibiotic mechanisms, 58 Antihistamines, 89p Antimicrobial antivenin, 51 bites, 50–51 bursitis, 52 diabetic foot, 52 flexor tenosynovitis, 56 hand, 52 necrotizing fasciitis, 57 osteomyelitis, 53–55, 106p septic arthritis, 49–50 skin infections, 56–57 Apprehension test (shoulder), 130 Approaches, 17–20 Arm cross section, 21–22 fasciotomy, 63–64 muscles, 8 trauma (fracture), 182–183 Arteries axillary, 30 elbow, 26–27
forearm, 28 knee, 29 pelvis, 29 shoulder, 26 Asymmetric external rotation test, 137 Atlanto Dens interval, 141 Atypical infections, 58 Autonomic dysreflexia, 166 Axillary n. schematic, 39
B Babinski sign (spine), 134 Baby Bennett’s fracture, 179 Back pain in children, 98p Bado classification, 183, 222p Balanced suspension, 174 Barlow (DDH), 136p Barton’s fracture, 181 Basketball foot, 214 Belly press, 130 Bennett’s fracture, 177, 179 Berndt/Harty classification, 239p Bites (traumatic), 51 Blanch sign (SCFE), 103p Blickenstaff/Morris class (femoral neck), 205 Blood estimated loss, 3–4 pressure estimation, 3 systemic response, 4 transfusion risk, 77 volume, 3 Blount’s disease, 96, 108 Blumensaat’s line, 155, 156 Bohler’s angle, 157, 160
251
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Index Both bone fracture, 182, 221p Boutonniere, 177 Bowstring (spine), 134 Boxer’s fracture, 178 Brachial plexus, 35 Brachial plexus injuries, 96p Brown-Sequard syndrome, 168 Bryant’s traction, 172 Buck’s traction, 172 Burns, 6 Bursitis, 52
C Ca++ & PO4 metabolism, 68 Ca++ pyrophosphate, 84 Ca++ recommendation, 71 Cain classification, 180 Calcaneal traction pin, 170 Calcaneovalgus, 95p Capitolunate angle, 147 Cardiac tamponade, 3 Carpal bone angular alignment (x-ray), 147, 149 Carpal tunnel tests, 119 Carrying angle (elbow), 147 Carvajal’s formula for fluid resuscitation in burns, 6 Cat bite, 50 Catfish barb, 51 Central cord syndrome, 168 Cervical spine development, 90p Cervical spine radiographic lines Atlanto Dens interval, 141 Chamberlain’s line, 141 McCrae’s line, 142 McGregor’s line, 142 Pavlov’s ratio, 142 Power’s ratio, 142, 145 space available for the cord (SAC), 143
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252 Cervical spine trauma, 195–197 Chamberlain’s line, 141 Chance fracture, 197 Chauffeur’s fracture, 181 Chest tube, 2 Child abuse, 115–116p Chondrocalcinosis, 84 Cierny-Mader staging system, 55 Clonus (spine), 134 Clubfoot, 96p Cobb angle, 141, 143 Coleman block test, 138 Colle’s fracture, 181 Colton classification, 185 Common peroneal nerve, 45 Compartment syndrome, 61–62 Complete cord syndrome, 168 Concussion, 165 Congenital spine, 112p Congruence angle, 156 Coxa vara epiphyseal angle, 152 neck shaft angle, 153, 202 Cross arm test, 130 Cross section arm, 21–22 forearm, 22–23 leg, 25 spinal cord, 167 thigh, 24–25 wrist, 23 Crossed finger test, 119 Crossed straight leg raise, 134
D Danis/Weber classification, 213 DDH lines/angles, 152–154 Deep peroneal n. block, 140 Delbet class, 231p DeLee class, 223p Dermatomes, 38 peripheral, 46, 47
Developmental dysplasia of the hip (DDH), 118 DEXA osteoporosis criteria, 71 Diabetic foot infection, 52 Diffuse axonal injury, 165 Discitis, 108p Discoid meniscus, 155 Dislocation carpus/perilunate, 182 elbow, 187, 225p facet, 196 hand, 179–180, 218–220p hip, 206–208, 231p knee, 210–211, 235p patella, 210, 235p radial head, 222p scapulothoracic, 193, 229p shoulder, 193, 228–229p tibia-fibula, 211, 236p Distal clavicle fracture, 190 Dog bite, 50 Drennan’s angle, 103 Drop arm test, 130 Duverney fracture, 232p Dysplastic conditions, 99–100p
E Elbow fat pad (x-ray), 146 flexion test, 119 Injection, 129 ligaments, 31 radiographic views, 130, 147–149 tests, 127–130 trauma (fracture), 183–187, 223–227p Elson test, 119 EMG, 86–88 Epiphyseal angle, 152 Epstein classification, 206 Erb-Duchenne palsy, 96p
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253 Essex/Lopresti classification, 240p Extensor tendon zones, 121 External rotation lag, 131 External rotation recurvatum (knee), 137
Foot deformities, 95–96p fasciotomy, 66 muscles, 15–16 radiographic views, 157–161 trauma (fracture), F 214–217, 239–240p FABER test, 136 Foot radiology, 89p Fairbank’s changes, 155 Forearm Fasciotomy arteries, 28 ankle, 66 cross section, 22–23 arm, 63–64 fasciotomy, 63–64 finger, 62 muscles, 8–10 foot, 66 trauma (fracture), forearm, 63–64 182–183, 221–222p hand, 62–63 Fractures leg, 65 acetabular, 202, 203 thigh, 64–65 ankle, 212–214, 237p Femoral nerve arm, 182–183, schematic, 43 221–222p traction test, 134 carpal bones, 182, 219p Femoral traction pin, 171 elbow, 183–187, Femur trauma (fracture), 223–227p 208, 233p femur, 208, 233p Finger foot, 214–217, fasciotomy, 62 239–240p mallet finger, 123 forearm, 182–183, Finger block, 125 221–222p Finger extensor apparatus, 34 hand, 176–180, Finger fasciotomy, 62 218–220p Finger puller system, 35 hip, 204–205, 231p Finklestein’s test, 119 knee, 209–210, First metatarsophalangeal 234–235p angle (bunion), 157 pelvic, 199–202, 232p Fleck sign, 157 periprosthetic, 204 Flexor tendon Salter-Harris, 101p block, 125 shoulder, 189–194, laceration, 178 228–229p sheaths, 122 spine, 101p, 195–198, test for continuity, 119 197, 230p zones, 121 tibia, 210, 236p Flexor tenosynovitis, 56 wrist, 181–182, Floating knee, 208, 234p 218–220p Fluid loss estimate, 3–4 Frankel grading, 166 Fluid management, 3 Froment’s sign, 119 Foley catheter, 3 Frozen section, 85
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Index G Galeazzi fracture, 183, 184, 222p Galeazzi test, 136 Gamekeeper’s thumb, 180 Garden classification, 204 Gardener-Wells tongs, 175 Genu varum, 108p Gissane’s angle, 157, 160 Glasgow coma scale, 5 Glenohumeral injection, 133 Glenohumeral ligaments, 30 Gout crystals, 85 Gram stain, 85 Growth centers, 92–94p Guhl classification of Osteochondritis dessicans, 97p Gun shot wounds (spine), 198 Gustillo classification, 241
H Hahn-Steinthall class, 185, 186, 224p Halo placement, 175 Hand fasciotomy, 62–63 infections, 52 injuries, 242 muscles, 10–11 rotational alignment, 124 tests, 119–120, 119–125 trauma (fracture), 176–180, 218–220p Hangman’s fracture, 196 Hardcastle classification, 239p Hardinge approach, 18 Hawkins sign, 214 Hawkins test, 131 Hawkins/Canale classification, 214 Hematoma block, 125 Henry’s approach, 17 Herpetic whitlow, 52 Herring classification, 117p
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Index Hilgenreiner’s line, 151, 152 Hill-Sachs lesion, 189 Hip muscles, 12–13 radiographic lines, 152–154 trauma (fracture), 204–208, 231p Hip tests, 136–137 Hoffman’s sign (spine), 134 Holstein-Lewis fracture, 189 Horn blower’s test, 131 Hotchkiss classification, 187 Human bite, 51 Hunter’s syndrome, 98p Hurler’s syndrome, 98p Hydrocortisone, supplemental, 74
I Ideberg classification, 193 Ilioischial line, 152, 153 Iliopectineal line, 152, 153 Impingement sign, 131 Impingement test, 131 Infantile idiopathic scoliosis, 109p Infection imitators, 57 Inferior gluteal n., 43 Insall ratio (patella), 156 Intermetatarsal angle, 158, 160 IV, initial fluid, 3 IV maintenance, 3
J Jakob classification, 224p Jefferson fracture, 195 Jersey fracture, 218p Johner/Wruhs classification, 211 Joint fluid analysis, 84 Jones fracture, 84, 239p Juvenile idiopathic scoliosis, 109p
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254 K Key/Conwell class, 232p Kilfoyle classification, 224p King curves, 110p Kite’s angle, 157 Klein’s line, 153 Kline’s line, 103p Knee arteries, 29 diaphyseal angle, 103p injection/aspiration, 138 lateral and medial layers, 30 radiographic lines, 155–156 tests, 137–138 trauma (fracture), 209–211, 234–235p Kocher-Lorenz fracture, 185, 186, 224p Kocher’s approach, 17 Kocher’s fracture, 183 Kyphosis, 115
L Lachman’s test, 137 Lag sign, 131 Lateral capsular sign, 155 Lateral patellofemoral angle (Laurin), 156 Lateral pivot shift test, 127 Lateral talocalcaneal angle, 158 Lauge-Hansen, 213 Laugier fracture, 185 Laurin angle (patella), 156 Leg cross section, 25 fasciotomy, 65 muscles, 14–15 trauma (fracture), 211–214, 235–236p Legg-Calves-Perthes, 117p Lenke classification, scoliosis, 112 Letournel class, 202, 203 Letts/Vincent class, 234p
Lhermitte’s sign (spine), 134 Liftoff test, 131 Ligament of Humphrey, 32 Ligament of Wrisburg, 32 Ligaments ankle, 33 elbow, 31 knee, 32–33 pelvic, 32 shoulder, 30 syndesmotic, 33 wrist, 31 Limp in children, 104–108p Lisfranc injury, 215 Little leaguer elbow, 224p Load shift test, 131 Low back pain, 168 Lower v. upper motor neuron lesions, 167 Ludloff approach, 18 Lumbar oblique x-ray, 144 plexus, 36 stenosis, 167 trauma (fracture), 197 Lunate tilt, 147 Lyme arthritis, 50
M Malgaigne fracture, 183, 232p Mallet finger, 123, 176, 218p Malnutrition indices, 88 March fracture, 214 Mason classification, 187 Mayfield’s stages, 182 McCrae’s line, 141, 142 McGregor’s line, 141, 142 Meary’s angle, 158 Median nerve innervated hand muscles (loaf), 40 quick neurologic test, 121 schematic, 40 Meniscal mobility, 32
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255 MESS (mangled extremity severity scale), 243 Metabolic bone disease, 69–70 Metacarpal fracture, 176 Metaphyseal blanch sign, 103p Metaphyseal-diaphyseal angle, 103p, 156p Metatarsus varus, 95p Meyer/McKeever classification, 210 Milch classification, 224p, 227p Milch fracture, 183 Milestones, 89p Milking maneuver, 127 Modified Bryant’s traction, 172 Monteggia fracture, 183, 222p Moore approach, 18 Morquio’s syndrome, 98p Motor innervation axillary/MC, 39 common peroneal, 45 femoral/obturator, 43 inferior gluteal, 43 median, 40 obturator, 43 radial, 41 sciatic, 44 superior gluteal, 43 tibial, 44 ulnar, 42 MRI signal characteristics, 149 Mucopolysaccharidosis, 98p Muscle strength testing, 166 Muscles arm, 8 foot/ankle, 15–16 forearm, 8–10 hand/wrist, 10–11 hip, 12–13 leg, 14–15
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Index shoulder, 7 thigh, 14 Musculocutaneous nerve, 39 Myelodysplasia levels, 91 Myers/McKeever classification, 234p
N 90-90 traction, 173 Neck-shaft angle, 153, 202 Necrotizing fasciitis, 57 Needle manometer, 61 Neer classification, 189 Neer impingement test/ sign, 131 Nerve injury classification, 88 Nerves, EMG/NCV, 86–88 Night pains in children, 97p Nightstick fracture, 182 NSAIDs, 73, 74 Nursemaid’s elbow, 222p, 227p Nutcracker fracture, 215
O O’Brien’s test, 131 Obturator nerve, 43 Ogden classification, 211, 234p Open hand injuries, 242 Oral antibiotic doses, 59–60p Orthopaedic oncology. See Tumor Ortolani test, 136p Osteoarthrosis (radiographic arthritis), 149 Osteochondral fracture, 239p Osteochondritis dessicans, Guhl classification, 97p Osteochondroses, 96 Osteomyelitis, 53–55b, 106p Osteomyelitis algorithm, 107p Osteonecrosis, 78–79 Osteoporosis, 71–72
P Pain management OA, 80 Parkland formula for fluid resuscitation in burns, 6 Passive test of continuity, 119 Patellar apprehension, 137 Pavlov’s ratio, 142 Pediatric child abuse, 115–116p foot deformities, 95–96p genu varum, 108p growth plates/centers, 92–94p limp, 104–108p medications, 89p milestones and angles, 89p myelo levels, 91p night pains, 97p osteomyelitis, 53–54 reflexes, 91p rotational profile, 90p septic arthritis, 49, 105 verbal score, 5p vital signs, 4p Pediatric trauma ankle, 237p elbow, 223–227p femur, 233p foot, 239–240p forearm, 221–222p hand/wrist, 218–220p hip, 231p knee, 234–235p leg, 235–236p pelvis, 232p shoulder, 228–229p spine, 230p Pelligrini-Steida lesion, 155 Pelvic external fixation, 67 Pelvic radiograph arteries, 29 ligaments, 32 Pelvic stabilization, acute, 67
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Index Pelvis radiographic lines, 152–154 trauma (fracture), 199–202, 232p Perioperative management, 73–74 Peripheral dermatomes lower extremity, 47 upper extremity, 46 Peripheral nerve disorders, EMG findings, 87 Peripheral sensory innervation, 45 Periprosthetic fractures, 204 Perkins vertical line, 151, 153 Phalangeal fracture, 176, 178 Phalen’s test, 119 Phosphate metabolism, 68 Physical exam/injections elbow, 127–130 foot/ankle, 138–139 hand, 119–125 hip, 136–137 knee, 137–138 shoulder, 130–133 spine, 134–135 wrist, 126 Piedmont fracture, 183 Pipkin classification, 207, 208 Pivot shift (knee), 137 Plexus brachial, 35 lumbar, 36 sacral (anterior), 36 sacral (posterior), 37 Pneumothorax (tension), 2 Posadas fracture, 183 Post menisectomy radiographic changes, 155 Posterior drawer knee, 138 shoulder, 132
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256 Posterior interosseous nerve schematic, 41 PIN compression, 127 quick neurologic test, 121 Posterolateral rotatory instability (elbow), 127 Power’s ratio, 142, 145 Primary survey, 1 Prophylaxis, tetanus, 83 Prophylaxis in total joints dental, 81–82 GI, 82 Proximal metaphysealdiaphyseal angle, 103p, 156p Pseudogout, 84 Pseudo-Jones fracture, 215, 239, 239p
Q Q angle (knee), 156 Quadrangular space, 30 Quadrigia effect, 120
R Radial bursa, 122 Radial head dislocation, 222p Radial inclination, 147 Radial nerve quick neurologic test, 121 schematic, 41 Radial nerve post criteria, 189 Radial volar tilt, 148 Radio-capitellar line, 147 Radiologic views foot/ankle, 157–161 hip/pelvis, 152–154 lower extremity, 155–156 spine, 141–145 upper extremity, 147–149 Radiolunate angle, 147 Reflexes, 91p, 166 Regan/Morrey classification, 185 Regan’s test, 120
Relocation sign, 132 Resisted straight leg raise, 137 Return to play criteria, 165 Reverse mallet finger, 218p Reverse Monteggia fracture, 183 Rheumatoid arthritis (Osteoarthrosis), 149 Rheumatologic disorders, perioperative management, 73–74 Risser stages, 110p, 111p Rolando’s fracture, 177, 179 Rotational profile, 90p Ruedi/Allgower classification, 214 Rugger jersey finger, 176 Rule of nines (BSA), 6 Russell’s traction, 172
S Sacral inclination, 142 Sacral plexus, 36–37 Sacral spine trauma, 197 Salter-Harris classification, 101p, 234p San Filippo’s syndrome, 98p Saphenous nerve block, 140 Scapholunate angle, 145, 148 interval, 148 Scapulothoracic dislocation, 193, 229p Scheuermann’s kyphosis, 115 Sciatic nerve, 44, 45 Sciatic notch, contents, 20 Scoliometer, 109p Scoliosis, 109p Cobb angle, 141, 143 King curves, 110p Risser stages, 110p, 111p Scotty dog, 142 Secondary survey, 2 Sedation and analgesia, 162–164
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257 Seddon classification, 88 Segond fracture, 155 Seinsheimer classification, 205 Semimembranosus five insertions, 33 Septic arthritis, 49–50, 105 Seymour fracture, 218p Shatzker classification, 207, 210 Shenton’s line, 151, 154 Shoulder arteries, 26 ligaments, 30 muscles, 7 spaces, 27, 30 tests, 130–133 trauma (fracture), 189–194, 228–229p Skeletal survey (abuse), 116p Skin infections, 56–57 Skin traction, 174 SLAP lesions, 192 Slip angle (spondylolisthesis), 143 Slipped capital femoral epiphysis, 102–103p Klein’s line, 153 Small joint fusion, 178 Smith-Peterson approach, 18 Smith’s fracture, 181 Snake bite, 51 Southern approach, 18 Space available for the cord (SAC), 143 Speed’s test, 132 Spinal cord injury, 165–169 deformities, 109p dermatomes, 38 Spine gun shot wounds, 198 radiology, 141–145 stable fracture criteria, 198 stenosis criteria, 167 tests, 134–135
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Index trauma (fracture), 195–198, 230p Split Russell’s traction, 172, 174 Spondylolisthesis, 144, 166 sacral inclination, 142 slip angle, 143 Spondylolysis, 166 Scotty dog, 142 Spurling’s test, 120 Steroids in cord injury, 165 Straddle fracture, 232p Straight leg raise, 135 Stress fracture risk, 198 Subacromial injection, 133 Sulcus angle (patella), 156 Sulcus sign, 132 Sunderland classification, 88 Superficial peroneal nerve block (ankle), 140 Superior gluteal nerve, 43 Sural nerve block, 140 Swan neck deformity, 124 Systemic responses to blood loss, 4 Systolic blood pressure, estimated, 3
Thigh fasciotomy, 64–65 Thompson approach, 17 Thompson/Epstein class, 206 Thompson’s test, 139 Thoracic spine trauma, 197 Thurston-Holland fragment, 101p Tibial nerve block, 140 schematic, 44 Tibial traction pin, 171 Tillaux fracture, 238p Tinel’s test, 120 Tissue frozen section, 85 Toniolo/Wilkins class, 225p Too many toes sign, 139 Total joint prophylaxis, 81–82 Traction, 170–175 Traction pins, 170 Trauma. See Adult trauma; Pediatric trauma Trauma radiographs, 2 Triangular interval, 30 Triangular space, 30 Triplane fracture, 238p Tumor, 244–248
U T Talar tilt, 139 Talipes equinovarus, 95p Talo-calcaneal angle, 95p Tamponade (cardiac), 3 Tarso-metatarsal injuries (x-ray), 161 Teardrop, 152, 154 Tendon laceration, 178 Tennis elbow test, 127 Tension pneumothorax, 2 Tetanus immunization, 83 wound classification, 83 Thigh cross section, 24–25 muscles, 14 trauma (fracture), 208
Ulnar bursa, 122 Ulnar nerve quick neurologic test, 121 schematic, 42 Ulnar variance, 138 Upper versus lower motor nerve lesions, 167
V Valgus elbow test, 127 Varus/valgus (knee), 138 Vasculature elbow, 26–27 forearm, 28 knee, 29 pelvis, 29 shoulder, 26
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Index Venous thromboembolic disease (VTE), 75–76 Verbal score, 5p Vertebral infection, 108p Vital signs, 4p V-sign of Light, 179
W Waddell’s signs, 135 Watson-Jones approach, 18 Watson’s test, 120
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258 Weber classification, 211 Wiberg center edge angle, 154 Winquist classification, 208 Wound healing indices, 88 Wrist cross section, 23 ligaments, 31 muscles, 10–11 trauma (fracture), 181–182, 218–220p
Wrist block, 126 Wrist injection, 126 Wrist radiographic angles, 147–148 capitolunate, 145 scapholunate angle, 145
Y Yergason’s, 132 Young/Burgess class, 199, 200
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