Trauma

Fractures: Definition: a fracture is a structural break in continuity of bone Location in the bone: diaphysis, metaphysis, epiphysis, intra-articular Extent: complete or incomplete (hairline, buckle, greenstick fractures) Configuration: trans erse, obli!ue, spiral, butterfly "imple fractures ha e # fracture line and $ fragments% Comminuted fractures ha e more than # fracture line and more than $ fragments% &elationship of fracture fragments to each other: nondisplaced: fragments remain in anatomic alignment% 'ersus displaced fractures: nonanatomic alignment% translated angulated rotated distracted o erriding impacted &elationship of fracture fragments to the en ironment closed (not exposed to the en ironment) ersus open (exposed to the en ironment ia a break in the soft tissues) (ustillo Classification )ype * < # cm +ound )ype ** , # cm +ound +ith moderate soft-tissue damage )ype *** extensi e soft-tissue damage -: ade!uate co erage, +ithout periosteal stripping or ascular in.ury% /: bone exposed +ith periosteal stripping, plastics consulted needed for soft tissue co erage of defect C: +ith ascular or ner e in.ury, ascular surgery consulted needed for essel in.ury 0racture healing 1nion - complete and timely healing Delayed union 2 healing that takes longer than expected 3onunion 2 healing has not occurred +ithin # year (time is fracture site dependent) 4alunion 2 healing +ith residual angular deformity Closed 0racture - treatment Closed reduction (realignment of fracture fragments) +ith immobili5ation Closed reduction and percutaneous fixation 6pen reduction and internal fixation (6&*0) operati e realignment +ith rods, plates, and scre+s for fixation External fixation operati e realignment +ith external de ice to hold fixation% may be used for extensi e soft tissue in.ury, extensi e comminution or a grade *** open fracture 6pen 0racture - treatment Complete neuro ascular examination -lign and splint fracture, monitor neuro ascular status post manipulation Culturing the +ound is contro ersial (not performed routinely at 1CL-)% Co er +ound, consider pressure dressing if oo5ing blood, take emergently to the 6&% *f unable to control hemorrhage (arteriogram s% 'ascular surgery consult if pulses absent) /egin antibiotics in the E& - -"-7% )his is the only Le el # e idence +e ha e for open fractures% -ncef #g *' !8 h%, +hich is good for gram positi e organisms% -dd (entamicin *' #mg9kg !8 for gram negati e co erage for )ype *** and some )ype ** fractures depending on attending preference%
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)etanus prophylaxis: *f patient has not been immuni5ed for tetanus, then tetanus immune globulin #g $:; units *4 and tetanus toxoid ;%:cc *4 at separate sites% *f pt pre iously immuni5ed for tetanus, then tetanus toxoid ;%:cc *4% 3e er irrigate or debride in the E&% -l+ays irrigate and debride in the controlled en ironment of the operating room% *n the 6& remo e all foreign material, irrigate and debride +ound: <)he solution to pollution is dilution=% *n terms of fracture management, consider *4 nail for tibia9femur% "panning external fixator for contaminated fractures9intra-articular fractures9unstable patients

Orthopedic Emergencies 7rimary trauma assessment -/Cs -ir+ay, /reathing, Circulation, Disability, E aluation 6pen fracture: needs to be in the 6& +ithin > hours (contro ersial, also depends on type, contamination, etc)% "ome type * fractures can +ait o ernight if needed% Compartment syndromes need fasciotomy Clinical exam, pain out of proportion to physical exam% Compartment pressures +ithin ?; mm@g of the diastolic pressure% @erniated disc or spine fracture +ith impending neurological lossA Cauda E!uina "yndrome: needs admission, neurologic exam, 4&* or C) myelogram, and decompression of the neurologic structures Dislocated .oint% 0or example, dislocated knee: risk of popliteal artery rupture and danger of a compartment syndrome% @and infections% )enosyno itis of one finger may spread to palm and other fingers ia common tendon sheath, and therefore need emergent antibiotics and possible *BD% "eptic .oint: risk of cartilage destruction, post infectious arthritis, and e en total loss of the entire femoral head +ith subse!uent leg length discrepancy% 0at embolism follo+ing long bone fracture or reaming, rodding or manipulation of the medullary canal of a long bone% Orthopaedic complications A: Compartment Syndrome *mportant 7oints abnormal increase in pressure +ithin an anatomic compartment "nake /ite: rare cause of compartment syndrome, treat ia stabili5ation and anti enom% 7resentation C 7s 7ain out of proportion to in.ury, pain +ith passi e motion 7aresthesia 7aralysis 7ulselessness E aluation )his is a clinical exam, pain out of proportion and tense compartments signal a need for emergent fasciotomy 4easure intracompartmental pressures Compartment pressures greater +ithin ?; mm@g of diastolic blood pressure 3ormal pressures usually around C-8 mm@g in a compartment% )reatment Emergency fasciotomy Complications
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'olkmannDs Contracture due to untreated compartment syndrome of the forearm% -ssociated +ith a supracondylar fracture in a child% 4ay also occur in open fractures Compromise of the brachial artery leading to ischemia, muscle death, and necrosis of the flexor muscle groups in the forearm "e ere flexion contracture of the forearm, +rist and fingers

B: Pulmonary Emboli *mportant 7oints emboli occluding pulmonary artery, arteriesA clot usually originates in the deep eins of the thigh and pel is and not in the calf &isk 0actors: bedridden, hypercoagulable states (i%e% cancerA medications such as oral contracepti esA surgery 2 may present $-? +ks after surgery) 7resentation difficulty breathing, shortness of breath, tachypnea, sinus tachycardia, delirium (due to hypoxia), cough, hemoptysis, anxiety, <impending sense of doom,= coma, pleuritic chest pain - ischemic necrosis sets up inflammatory response bet+een the isceral and parietal pleura, may hear rub o er the area% E aluation Chest E-ray 2 Look for the +edge, area of lung infarct caused by emboli% -rterial blood gas 2 76$ F G;mm@gA decreased 6$ saturation% EH( 2 sinus tachycardiaA right heart strain ($6 to saddle emboli 2 right heart pumping against saddle embolus in pulmonary arteries, emergent) '-I scan 2 many false positi es and false negati es Doppler 2 looking for D')Ds, nonin asi e 'enogram 2 gold standard, best +ay to locate emboli in eins "piral C) 2 useful at diagnosing pulmonary embolism 7ulmonary angiography 2 high risk, infre!uently performed )reatment &educe hypoxia, stabili5e clot, pre ent more clots and emboli 6xygen 2 ia mask *ntubation- if mask not effecti e -dd 7EE7 to entilator settings -nticoagulants- stabili5e9dissol e clot% *n general if the diagnosis is phlebitis, anticoagulate for ? mos% *f the diagnosis is 7E, anticoagulate for > mos% @eparin 2 *' :,;;; 2 #;,;;; units (or 8; units9kg) bolus follo+ed by a continuous infusion (#8 units9kg9hour) titrated to a 7)) bet+een #%: 2$%: times normal for :-#; days% Coumadin 2 +hile gi ing heparin start coumadin titrated to an *3& of $-? times normal for > months or longer depending on patient and etiology% "treptokinase #%: million units *' o er >; min% -dminister directly into in ol ed ein to dissol e clot% (3ot performed routinely may be done by *&) *'C (reenfield filter 2 pre ent clots from entering right heart% *ndicated if there is risk or e idence of more emboli% C: Fat Embolism *mportant 7oints Diffuse pneumonitis in the lungs secondary to the emboli5ation of fat and marro+ debris% Can result from trauma, fracture, reaming a canal, impaction of a prosthesis, or pressuri5ation +ith cement% 7resentation Cardio ascular, respiratory, and neurologic symptoms due to occlusion and therefore hypoperfusion of tissues%
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*ncreased heart rate, increased respiratory rate, fe er% may see petechiae under eyes, in axillary folds, and in nail beds% 7rogressi e hypoxia may lead to a delirious patient% E aluation Lab Jork-1p 2 -/( 2 decreased 76$, 7ulse 6x 2 decreased "p6$, CE& 2 diffuse pneumonitis, ( s% pulmonary thromboemboli 2 local pneumonitis), +hited out lungs )reatment 6xygen% *ntubate if indicated +ith 7EE7 "teroid bolus +ith #;; mg solumedrol (contro ersial but appears to be effecti e) @eparin contraindicated

Pediatric Orthopaedics
Pediatric Diseases -% -rthrogryposis 2 4ultiple rigid .oints, no skin creases, teratologic hip dislocation, sensation is intact and these patients ha e normal intelligence /% DuchenneDs 4uscular Dystrophy 2 sex linked recessi e, ele ated C7H, absent dystrophin protein, most patients die at age $;A /eckerDs muscular dystrophy has an abnormal dystrophin gene and is not as morbid as DuchenneDs C% Cerebral 7alsy 2 3onprogressi e upper motor neuron diseaseA in.ury to the immature brain, onset before $ years of ageA constellation of symptoms include spasticity, toe +alking, crouched gait, scoliosisA types include spastic, athetoid, ataxic, mixed D% 4yelodysplasia 2 0ailure of neural tube to close, patientDs functional le el is lo+est functioning ner e root, risk factors include maternal hypothermia, maternal insulin-dependent diabetes, alproic acid, folate deficiencyA most patients ha e a latex allergy, clubfeet, ertical talus, hip dislocation E% -dolescent idiopathic scoliosis 2 right thoracic is the most common, cur e progression most closely associated +ith peak gro+th elocityA bracing contro ersial but most +ill brace abo e $: degrees, most +ill perform surgery abo e C; degrees The Limping Child The Fi e !a"or Causes -% /% C% D% E% )oxic transient syno itis "eptic arthritis De elopmental dysplasia of the hip (DD@) Legg-Cal es-7erthes disease (LC7D) "lipped capital femoral epiphysis ("C0E)

0% DonDt forget other causesK #% )rauma $% Child abuse ?% *nfection: osteomyelitis C% -rthritis: .u enile rheumatoid% :% )umor: &habdomyosarcoma: 4uscle (;-:years) E+ings "arcoma: &ound cell (:-#: years) 6steosarcoma: "pindle cell (:-8;years, #G yr% 4edian)

A: Septic Arthritis o# the $ip% &nee% Foot% 'rist% Elbo( and Shoulder )oint *mportant 7oints
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bacterial infection of a .oint hip of particular concern as a medical emergency 1ntreated may !uickly lead to destruction of .oint cartilage and a ascular necrosis of femoral head due to decreased blood supply Caused by hematogenous spread of infection, often no kno+n source 7resentation Child +ith high fe er, limp, pain +ith passi e motion of hip, may lie +ith hip externally rotated, slight hip flexion E aluation Labs: ele ated J/C, C-reacti e protein and E"&, blood cultures often negati e &adiology: /one scan: focal area of increased uptake E-ray : may sho+ .oint effusions diagnosis: 41") aspirate .oint, send fluid for cell count, gram stain, culture and sensiti ity (certain aspirations may need fluoro guidance) )reatment )o 6& for immediate irrigation and debridement, must take a sample of the syno ial lining as +ell 6pen +ashout is standard but in select cases may perform an arthroscopic +ashout follo+ed by *' antibiotics for $-8 +eeks (per organism and *D recommendations) Empiric treatment +ith -ncef #g *' !8 h (do 36) gi e any antibiotics until cultures are takenKKK) 4odify according to culture results and bacterial sensiti ity follo+ed by $-C months of oral antibiotic, in consultation +ith *D 6rganisms "taph aureus: most common organism% (onorrhea in pediatric and adult populations Cocci: in the "outh+est 1"B: To*ic Syno itis: *mportant 7oints 'iral inflammation of the hip 7resentation similar to septic arthritis of the hip Diagnosis of exclusion 7resentation Child +ith lo+ fe er, limp of in lo+er extremity, pain +ith acti e and passi e motion, increased +armth of .oint E aluation Labs: J/C and E"& often normal, blood cultures negati e &adiology: bone scan: may or may not sho+ focal area of increased uptake E-ray: may sho+ .oint effusion 41") aspirate .oint if high index of suspicion for septic arthritis of hip, send fluid for cell count, gram stain, culture and sensiti ity Diagnosis of exclusion: 41") rule out septic arthritis of the hip )reatment gradual return to acti ities as tolerated bed rest longitudinal traction in select cases C: De elopmental Dysplasia o# the $ip +DD$, *mportant 7oints progressi e condition +ith abnormal de elopment of hip structures
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indicates hips that are unstable, subluxated, dislocated and9or ha e malformed acetabula formerly congenital dysplasia of the hip but may not be e ident at birth ? characteristic components: abnormal slope of acetabulum excessi e hip .oint laxity abnormal rotation of upper end of femoral shaft ? stages head of femur located +ithin inade!uate acetabulum head of femur slightly subluxed and mo ed a+ay from medial aspect of acetabulum head of femur dislocated &isk factors for DD@: positi e family history for DD@, female sex, breech presentation, primaparity, oligohydraminiosis -ssociated +ith: congenital muscular torticollis, skull and facial abnormalities, congenital hyperextension of the knee, metatarsus adductus, clubfoot deformities Definitions dislocated hip: no contact bet+een femoral head and acetabulum in resting position Dislocatable hip: in reduced position at rest% Can be dislocated +ith stressed flexion and abduction "ubluxable: in reduced position at rest% Can be dislocated +ith stressed flexion and abduction hip can be subluxed (partial contact bet+een femoral head and acetabulum) Dysplastic - no signs of instability but femoral head and acetabulum are abnormally shaped% @ips may9may not become unstable +ith continued de elopment )eratologic dislocation of the hip 2 secondary to another disease process occurs early during intrauterine de elopment stiff , high-riding, irreducible +ith se ere dysplasia of .oint at birth usually associated +ith neuromuscular abnormalities arthrogryposis, myelodysplasia 7resentation (according to age at diagnosis): 3e+born: if unilateral: asymmetrical skin folds on proximal thigh (not sensiti e or specific) of affected side and L (alea55i if hip is already dislocated, - /arlo+, L9- 6rtolani (depending on +hether reducible) if hip is subluxable or dislocatable, L /arlo+, L 6rtolani > month +ith DD@ and dislocated hip often asymptomatic unilateral: positi e (alea55i, L leg length discrepancy, asymmetric skin folds on proximal femur, trochanter displaced up+ard, broadened perineum on affected side asymmetric abduction ,#;Mdiscrepency bilateral: negati e (alea55i, no leg length discrepancy, symmetric abduction but less than >;M each side $ year old child +ith DD@ and dislocated hip unilateral: limp +ith tendency to+ards )rendelenberg s+ay due to +eak hip abductors on affected side, unilateral toe +alking, examination may re eal shortening of thigh, multiple skin folds, broadened perineum, prominence of trochanter, decreased distance trochanter to iliac crest bilateral: +addling gait E aluation all tests must be performed on a completely undressed child supine on a flat examination table a childDs hips 41") be examined +ith each examination from birth until +alking +ith normal gait (usually $-? years of age)
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(alea55i test: assess apparent femur length @ips flexed to N; adducted to midline +ith knees in flexion, childDs knees do not line up suggesting femur length discrepancy (positi e test) indicati e of apparent femur shortening on affected side due to femoral head in abnormally cephalad position% often associated +ith asymmetric skin folds on affected proximal thigh dysplastic hip must be compared to normal 3ote: negati e (alea55i test in patient +ith bilateral DD@ 6rtolani test: assess passi e subluxation or dislocation )humb on medial side of thigh, middle and index fingers o er greater trochanter, knees flexed to N;, se!uentially, each hip is brought from midline in N; degree of flexion and abducted, gentle anteriorly directed force on greater trochanter% palpable clunk +hen femoral head is seated into acetabulum (positi e test) indicates a dislocated but reducible femoral head 3ote: irreducibly dislocated hip +ill ha e negati e 6rtolani test 3ote: hip clicks - audible high pitched sounds +ithout palpable clunk - on hip examination likely caused by iliotibial band mo ing o er greater trochanter or iliopsoas tendon sliding o er iliac crest% normal and usually disappears +ithin C-> months% /arlo+ test: stress test to assess potential for hip subluxation or dislocation )humb on medial side of thigh, middle and index fingers o er greater trochanter, knees flexed to N;, se!uentially, each hip is placed in N; flexion in neutral adduction +ith gentle force directed posteriorly% "ensation of displacement of femoral head posteriorly out of acetabulum is positi e test% 3ormal (negati e test), no instability% 0ound% degree of displacement (positi e test) indicates subluxable or dislocatable 3ote: +ill be negati e if the hip is already in a dislocated position &adiologic e aluation 1ltrasound: less than > months - ultrasound may help delineate configuration and position of femoral head and acetabulum - cartilaginous structures not seen on E&% "tatic or dynamic in con.unction +ith /arlo+ test% @igh degree of interobser er ariability% @as not been sho+n to be reliable as screening test (high false L at birth) E&: -7 +ith hip extended and lo+er extremities in neutral rotation and frog leg ie+s% 4ost reliable after age , C-> months +hen femoral head has begun to ossify% 3ormal femoral head: belo+ ilium pointing to+ards triradiate cartilage% *ntact "hentonDs line (cur e made by femoral neck and an anterior rami% normal acetabular angle) )reatment +depends on age of presentation, degree of DD@) 7a lik harness treatment of choice for child +ith dislocated, subluxable, dislocatable hip identified as ne+born to :-> months consist of suspenders +ith chest cerclage, anterior flexion straps, posterior abduction straps pro iding suspension for t+o stirrup boots maintains hip in N;-#;; flexion, and limits adduction thus helping childDs musculature to hold hip in reduced position and +hile allo+ing for some mo ement in a safe range of reduction stability to encourage normal hip de elopment continued for 8-#$ +eeks, follo+ed radiographically successful in N;-N:M cases bilateral dislocations, late diagnosis (beyond >-G +eeks) irreducible at presentation likely to fail Complications: femoral ner e palsy, secondary to hyperflexion, failure to recogni5e persistent dislocation of hip - posterior dislocation and malformation of posterior acetabulum, gro+th disturbance of proximal femur, osteonecrosis of femoral head &eduction and spica casting 2 performed in operating room )reatment for child diagnosed at > month, failed 7a lik harness treatment Closed reduction, then spica casting
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4ay re!uire period of traction to be able to place hip opposite acetabulum Examination under anesthesia, +ith possible arthrogram to confirm position Casting in <human= position +ith hips flexed N;-#;; and abducted to C:->; Confirm placement +ith post-reduction C) Cast +orn for as many months as child is old or > months, changed at C-> +eek inter als to account for gro+th 0or child older than #8-$C months of age, inability to achie e closed reduction, open reduction +ith iliopsoas and adductor tenotomies L9- femoral shortening procedure, capsulorrhaphy may be necessary follo+ed by spica casting 6steotomies 'arious osteotomies ha e been de eloped to reshape acetabulum and or femur to impro e femoral head co erage and .oint mo ement Complications 1ntreated unilateral DD@ leads to leg length discrepancy, )rendelenburg gait due to poor force direction across hip .oint and pain due to degenerati e arthritis /ilateral DD@: hyperlordotic and +addling gait, pain due to degenerati e arthritis 4ay be treated +ith total hips arthroplasty or hip fusion D: Legg-Cal e-Perthes +LCPD, *mportant 7oints *diopathic a ascular necrosis of the femoral head 4ale to female ration C:# -ssociated +ith abnormalities of thrombosis (protein " or C deficiency) -ge at onset predicts outcome: younger age at onset (age C->) O better prognosis #;M bilateral hip in ol ement C stages *nitial: femoral head is dense% intermittent syno itis +ith hip pain and limp +hich increase +ith acti ity, decrease +ith rest 0ragmentation: femoral head is soft and deforms% loss of range of motion, particularly decrease in internal rotation and abduction @ealing: ne+ bone gro+s into femoral head% gradually symptomatic impro ement &esidual: femoral head is healed +ith residual deformity% minimal symptoms 7resentation 1sually presents ages C-N C-::# male: female ratio Classic patient profile: small thin acti e male child Child +ith limp, occasional hip or knee pain for +eeks to months 4ild limp, decreased range of motion of hip +ith limited internal rotation E aluation -7 and lateral E& of pel is: increase in density of affected femoral head compared to normal% 4ay be negati e early in disease% during later stages progresses through fragmentation, healing and residual stages )reatment 6bser ation and restriction from sports +ith rest and 3"-*Ds, restricted +eight bearing if symptoms se ere -bduction casting, abduction bracing Complications 7atients generally do +ell +ith ery mild to no symptoms during adolescence and adulthood P patients de elop degenerati e arthritis by :th decade 6lder age at onset, more se ere disease may need femoral or pel ic osteotomy
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E: Slipped Capital Femoral Epiphysis +SCFE, *mportant 7oints "eparation of the proximal femoral gro+th plate +ith displacement of proximal femoral epiphysis on femoral neck% displacement generally posterior ?;M bilateral hip in ol ement Defined as acute or chronic ($ +eeks or more) Defined as stable or unstable% )his is more important% 1nstable, or painful hips +here the child cannot bear +eight due to discomfort, re!uire immediate surgery 7resentation 1sually presents ages 8-#>, males,females $ classic patient profiles: obese, adolescent male, ery tall thin adolescent male -dolescent +ith limp, pain in hip, groin, thigh, or knee &arely may be associated +ith trauma 7ain in hip, may be referred to knee, limp, external rotation of limb, limited internal rotation and abduction of hip E aluation -7 and lateral of pel is: <ice cream falling off of cone= femoral epiphysis displaced posteriorly% /e sure to e aluate both hips radiographically )reatment "tabili5ation of slippage ia in-situ percutaneous pinning 4ay re!uire realignment osteotomy for moderate to se erely displaced chronic slips Complications 7roblems +ith gait, sitting, or appearance due to abnormal relationship bet+een femoral head and neck 6steonecrosis due to disruption of ascular supply to femoral head leading to degenerati e osteoarthritis

$A.D
-% 0lexor tendon in.uries a% Qone *: Distal to 0D" insertion b% Qone **: 0D" insertion to distal aspect of -# pulley (most difficult repair) c% Qone ***, *', 'A no associated pulleys, easier to repair d% &epair should include a C core sutures and an epitendinous repair /% @and infections a% 0lexor tenosyno itis 2 emergency, needs to ha e * and D% Hana el signDs, affected finger held in flexion, pain +ith passi e extension, fusiform s+elling, tenderness to palpation along flexor tendon sheath C% Compression neuropathies a% Carpal tunnel syndrome 2 compression of the median ner e, paresthesias in the radial three digits and the radial aspect of the ring fingerA +eakness of the thenar muscles% 4ay respond to night splinting but surgery is the only disease modifying treatment b% 1lnar neuropathy 2 most common at the cubital tunnel, paresthesias in the ulnar t+o digits and +eakness of the hand intrinsics% -lso may respond to splinting in extension but release may be necessary although does not ha e as good results as carpal tunnel release D% 7erilunate fracture9dislocations a% 0re!uently missed diagnosis after a fall on an outstretched hand% 4ay see a disruption of alignment of the carpal bones along +ith carpal bone fracture9distal radius fracture% 4ust release carpal tunnel if acute carpal tunnel syndrome occurs% E% &eplantation a% 3eeds to be done before > hours of +arm ischemia time% 6rder is thumb, middle, ring, small, and index% 4ost al+ays replant thumb and almost anything in children% Expect #; mm of $ point discrimination and :;M decrease &64%
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SPO/TS !ED0C0.E
"houlder 2 Easiest to stratify based upon age -% Roung patients #:-?;s a% 4ost often instability issues b% )1/" 2 )raumatic unilateral bankart surgery i% Classic athlete +ith acute single direction dislocation L apprehension and relocation tests ii% -ge is most important, younger patients +ill most likely dislocate again iii% 4ost often perform surgery after $nd or ?rd dislocation #% "urgery is arthroscopic bankart repair (anterior inferior portion of the labrum is torn) c% -4/&* 2 -traumatic multidirectional bilateral rehab inferior capsule shift i% Classic picture is a s+immer +ith multidirectional instability ii% )reatment is rehab rehab and rehab iii% "urgery only rarely indicated (capsular shift) /% 4iddle age C;->;s a% 4ay ha e instability or arthritis depending on presentation butS b% 4ost often ha e impingement (ha+kinDs sign and neerDs sign) c% &ehab first d% 4ay need subacromial decompression C% 6lder patients ,>; a% &otator cuff tears, arthritis b% -rthritis (see belo+) but may e entually need total shoulder arthroplasty c% &otator cuff tears (be+are of an older patient dislocating, this +ill commonly ha e a component of cuff tear as +ell) i% 4ay do an open or arthroscopic repair ii% *f rotator cuff tear and arthritis 2 bad problem, may need re erse total shoulder arthroplasty but this is only for lo+ demand elderly patients -% Hnee in.uries a% -CL tear i% Common noncontact, t+isting in.ury% *n the young healthy patient it should be reconstructed +ith autograft (your choice hamstring s bone patellar bone) rehab importantA no return to sport for >8 months b% 7CL tear i% Can be sports related or posterior force directed to tibia +ith foot plantar flexed% 4ostly treated +ith rehab, if repaired tibial inlay is best c% 4CL9LCL in.ury i% Can be associated +ith other in.uries% 4ost often nonoperati e treatment for isolated in.uries% d% 7osterolateral corner i% &epair corner acutely +ith possible staged repair of -CL or 7CL depending on in.ury% L Dial test e% Hnee dislocation i% 6rtho emergency, check ascular status, reduce, then check ascular status again, may re!uire post reduction angiogram then knee immobili5er

FOOT A.D A.&LE

-% -nkle sprain a% 7rimary stabili5er is the deltoid ligament b% -nterior talofibular ligament pre ents anterior translation c% /egin +ith immobili5ation then gradual return to acti ity d% "urgery includes repair of affected ligaments or possible reconstruction /% -chilles tendon a% )endonitis or tendonosis 2 treatment +ith eccentric strengthening
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b% -chilles tendon tear 2 treated either plantar flexed cast or surgical repair C% 7lantar fasciitis a% )herapy includes stretching, in.ection, and rarely surgery% 3ormally a self-limited condition D% @allux 'algus a% 4aternal predisposition b% 3ormal 4)7 angle is F N degrees and abnormal if , #: c% -bnormal intermetatarsal angle is , N degrees d% "urgery may include distal or proximal osteotomy, soft tissue release, fusion or resection arthroplasty depending on patient and degree of hallux algus E% Diabetic foot a% Diabetic ulcers should al+ays be taken seriously to pre ent amputation b% )est -/* should be abo e ;%C: c% )ranscutaneous oxygen should be abo e ?; mm@g d% )oe pressures should be abo e C; mm@g e% "erum albumin should be ,?%: mg9dL f% )otal lymphocyte should be , #:;; 0% 0latfeet a% Jeakness or deficiency of the posterior tibial tendon b% )est by ha ing patient do a single heel lift on the affected side c% Cast9splint9orthosis if flexible, no deformity and only slight pain d% 0DL transfer, medial calcaneal displacement osteotomy +ith -chilles lengthening for flexible deformity e% )riple arthrodesis if fixed deformity

T1!O/S
-% /enign or malignant a% *n general benign processes do 36) ha e cortical destruction or a significant soft tissue component /% -l+ays perform a thorough @B7 as most bony tumors are metastasis a% 7ain at night, +eight loss, pre ious history or cancer are all +orrisome C% Labs include C/C, Comprehensi e metabolic profile including alkaline phosphatase, E"&, C&7, and CE-A may need protein electrophoresis if myeloma is suspected D% &adiographs are a must +ith C) and 4&* most al+ays needed as +ell E% /one scan and 7E) scan to detect metastasis 0% /iopsies should be longitudinal incisions +ith good hemostasis a% -l+ays send to pathology and culture if concern of infection b% &esection may be intralesional (through the tumor), marginal (through the reacti e 5one), +ide (en bloc remo al), radical (entire compartment remo ed)%

A/T$/0T0S
A: Osteoarthritis *mportant 7oints 3on-inflammatory disorder of .oints characteri5ed by deterioration of articular cartilage and ne+ bone formation at .oint surfaces and margins Degeneration and loss of articular cartilage surface on +eight-bearing areas, eburnation of bone, subchondral cyst formation, osteophyte formation -ssociated +ith obesity, hereditary, occupation, endocrine disorders N;M of all people ha e some degenerati e changes in +eight-bearing .oints by age C; 6steoarthritis is 36) the same as age related changes to the .oint 7resentation pain, increased +ith .oint motion relie ed by rest, limitation of .oint motion due to pain, early -4 stiffness, e entual loss of &64 due to contractures
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 locali5ed .oint tenderness E aluation Labs: E"&, C/C, &0, calcium, alkaline phosphatase usually +ithin normal limits "yno ial 0luid: noninflammatory +ith minimal increased J/Cs, normal iscosity and glucose, no crystals or bacteria &adiographically: loss of .oint space, subchondral cysts, osteophytes, loose bodies, deformity and malalignment )reatment &est, assisti e de ices (cane, crutch), 3"-*Ds, physical therapy, bracing, intra-articular steroid in.ections or in.ections of hyaluronic acid (syn isc9euflexa) -ll of these modalities do not change the natural history of 6-, they only tempori5e the patient before definiti e treatment +hich +ould be a total .oint arthroplasty )otal .oint arthroplasty: commonly performed to increase .oint mobility, decrease pain, increase stability -rthrodesis: uncommonly performed, impro es .oint stability +ith decreased motion &esection arthroplasty: uncommonly performed% pro ides good motion +ith decreased stability Complications 1ntreated 6-: subluxation, .oint deformity, bony fusion of .oint, intrarticular loose bodies, leg length discrepancy )otal .oint arthroplasty: *nfection, leg length discrepancy, damage to the ner es, arteries, blood essels, stiffness, need for re ision surgery, pulmonary embolus, and medical complications of undergoing surgery +ith ad anced age L9- comorbidities B: /heumatoid Arthritis *mportant 7oints "ymmetric inflammatory arthritis in ol ing small and large .oints of at least > +eeks duration 4ust ha e C9G criteria -4 stiffness -rthritis of at least ? areas , > +eeks -rthritis of hand .oints , > +eeks "ymmetrical arthritis , > +eeks &heumatoid arthritis "erum rheumatoid factor &adiographic changes 7resentation *nsidious slo+ onset +eek-months, may ha e fatigue, malaise, anorexia, arthralgias, myalgias, -4 stiffness E aluation &adiographically, bony erosions )reatment 3arcotic analgesics, 3"-*Ds, corticosteroids, disease-modifying agents (pla!uenil, methotrexate, parenteral gold), monoclonal antibodies (rituxan) ha e changed the &- disease processes pre enting many of the se ere deformations of & *ncomplete or complete syno ectomy )otal .oint arthroplasty: commonly performed to increase .oint mobility, decrease pain, decrease stability arthrodesis: uncommonly performed, impro es .oint stability +ith decreased motion &esection arthroplasty: uncommonly performed% pro ides good motion +ith decreased stability Complications 1ntreated &-: subluxation, .oint deformity, bony fusion of .oint, intrarticular loose bodies, leg length discrepancy )otal .oint arthroplasty: *nfection, leg length discrepancy, damage to the ner es, arteries, blood essels,
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stiffness, need for re ision surgery, pulmonary embolus, and medical complications of undergoing surgery +ith ad anced age L9- comorbidities C: Crystalline -rthopathies *mportant 7oints (out: monosodium urate arthropathy 7seudogout: calcium pyrophosphate deposition disease 7resentation -cute inflammatory arthritis or chronic erosi e tophaceous arthritis )ypically, acute onset of painful, s+ollen, +arm and tender .oints +ith systemic fe er E aluation Labs: may ha e ele ated J/Cs, E"& Toint aspirate: polari5ed crystals (negati e birefringence gout, positi e birefringence pseudogout, negati e cultures) J/C in an aspirate of a nati e .oint% J/C ?;,;;;-:;,;;; goutA infection normally present +ith greater than 8;,;;; J/C% )he cutoffs are debatable and the gram stain, percentage of neutrophils in the .oint, blood J/C, presence or absence of crystals should help dictate treatment% )reatment -nti-inflammatory therapy +ith colchicine, indomethacin, allopurinolA ne er gi e allopurinol acutely

Orthopaedic 0n#ection
OSTEO!2EL0T0S *mportant 7oints /acterial or fungal infection of the bone generally de elops hematogenously, but may occur after open fracture or orthopedic procedure Definitions: -cute ersus chronic /rodies abscess: small local infection of bone +alled off by the body +ith sclerotic tissue *n olcrum 2 dead bone +ith ne+ bone formation around it "e!uestrum 2 dead bone in the middle of sclerotic bone 4ost common causes of osteomyelitis 4ost common 2 S. aureus *' drug users 2 P. aeruginosa "ickle-cell disease 2 "% aureus and "almonella "exually acti e 2 (onorrhea (al+ays a 1"4LE, 6*)E, or board !uestion but * ha e yet to see thisK) /arnyard in.ury 2 Clostridia 0ungal 2 Coccidiomycoses Toints 2 )uberculosis 7resentation 7ain, fe er, erythema, s+elling, drainage through sinus tract E aluation -cute appears on E& as rarefaction of bone +ith permeati e destruction takes at least #; days of infection before the periosteal reaction is present on plain radiographs Chronic appears on E& as sclerotic bone, +ith increased thickening of cortices, increased lucency of bone )reatment *rrigation and debridement (repetiti e, radical debridement)% Drill cortical +indo+ in bone, curette out medullary bone, liberal saline la age% -ntibiotics 2 $ months of *' antibiotics, follo+ed by oral antibiotics for $-C mos%
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 7re ent9protect from bone fracture 7ossible bone graft 2 after $ mos% of *' antibiotics% Complications *nfection can spread from the bone into an ad.acent .oint and cause a septic .oint% *nfection can spread into the skin, draining outside, causing chronic draining sinus (+ith increased risk of s!uamous cell cancer of the draining tract after draining o er many years this is also kno+n as carcinoma in-situ (/o+enDs disease)

Appendi* Sedimentation /ate: Erythrocyte Sedimentation /ate ;-$; $; 2 C; ,C; 8;-#$; 3ormal consider a benign or malignant tumor consider infection consider rheumatologic conditions such as &-, Lupus etc% @ormone sens% L L L steroids &ads sens L *#?# L L Chemo sens L L9L9L Life Expectancy > - #$ mo% $-C yr% $-C yr% $ yr% $ yr% #; yr%

!ETASTAS0S TO BO.E Lytic9/lastic Lung /reast )hyroid &enal 7rostate 4yeloma L L9/ L L / L

4ost common metastatic disease to bone is myeloma% )he most common primary malignant bone tumor is myeloma%

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