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Key Points
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Definitive tx in open fractures may be delayed until the wound is sufficiently cleaned and
healthy tissue is available
Fractures of the scapula generally result from significant MOI: look for additional injuries to
the head, lungs, ribs, and spine
Shoulder one of MC dislocated joints: MC anterior; posterior associated with seizures or
electric shock
Humeral shaft fracture: direct trauma or FOOSH (esp. elderly); look for radial nerve
damage
Osteoarthritis
o 22% of US population, expected to be 25% by 2030
o Wt loss of 11 pounds decrease risk of knee osteoarthritis in women by 50%
o Regular physical activity lowers incidence as well
Smaller incisions, better cosmesis BUT there is decreased visualization intra-op (increased
risk of malposition, fracture, nerve, vascular injuries)
Orthopedic Trauma
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Utilized when patients are severely injured or when soft tissue damage or
swelling where it is unsafe to make incisions or undergo surgery
Involves placement of pins proximal and distal to fracture through healthy
tissues
Pins are connected by rods placed on the outside of the extremity
Open Fractures
o Occur when the bone breaks through the skin
o Typically result from high energy injuries and associated with significant damage to
the surrounding soft tissues and contamination of the wound
o Require immediate irrigation and debridement in OR and antibiotics to prevent
wound infections and osteomyelitis
o Look for surrounding neurovascular injuries
o Definitive treatment generally delayed until the wound is sufficiently cleaned and
healthy tissue is available to cover the fracture
Compartment Syndrome
o ORTHOPEDIC EMERGENCY!
o Significant swelling within a compartment of an injured extremity that jeopardizes
blood flow to the limb
o Increased pressure compromises perfusion to muscles resulting in ischemia or
necrosis
o S+S
Pain, numbness, passive stretch to muscles of compartment causes severe
pain
o Dx
Based on clinical exam
Can be measured by placing needles in compartment (necessary for
unconscious patients)
o TX EMERGENT FASCIOTOMY! Overlying tight fascia is released through long incisions
ASAP to prevent irreversible necrosis and contractures of nerves and muscles,
which can result in loss of function
Scapula Fractures
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Significant MOI, look for associated head, lung, rib, and spine injuries
Most tx non-op with exception of glenoid fractures
Intraarticular fractures (displacement of glenoid articulating surface) indicates need for
open reduction and internal fixation
Shoulder Dislocations
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Elbow Dislocations
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Common
Typically occur posteriorly after FOOSH
Results in injury to joint capsule and rupture of LCL +/- MCL involvement +/- fractures of
the radial head, coronoid, or humeral epicondyles
Simples
o Urgently reduced under sedation
o Brief treatment long arm splint (7-10 days)
o Too long of splinting w/o early ROM results in stiffness
Associated with fractures
o Surgically if instability
o Terrible Triad
Elbow dislocation
Most can be treated non-op with sling 1-2 days followed by ROM
Displaced or blocks sup/pron of forearm Surgery
o Well reduced 1-2 screws
o Multiple pieces radial head replacement with metallic implant
o Elderly excision of radial head (may contribute to elbow instability or wrist
symptoms over time)
Olecranon Fractures
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Forearm Fractures
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Pelvic Fractures
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High energy trauma associated with head, chest, abdominal, and urogenital injuries
Acetabular Fractures
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Occurs when femoral head driven into hip socket in high energy trauma
CT important to visualize pattern
Generally require surgery to restore congruent, stable, acetabulum
o Prevent early degenerative changes and osteoarthritis
o Should utilized experienced surgeons
Hip Dislocations
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Hip Fractures
Knee Dislocations
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Ankle Dislocations
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Ankle Fractures
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Twisting injuries
Depends on:
o Direction of force
o Position of foot and ankle at time of injury
Initial treatment
o Closed reduction and placement of well-padded splint
o Swelling often significant therefore elevate the foot
Surgery
o Delayed 1-2 weeks until swelling decreases to limit the risk of wound healing
problems
Malleolar Fractures
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Lateral
o Isolated require anatomic reduction
o Talus may sublux
1mm of talar shift decreased surface contact between talus and tibia by 40%
Increased risk or arthritis
o Closed reduction and casting may be successful
o If cannot be reduced, open reduction internal fixation
Medial
o Isolated usually avulsion injury
o Minimally displaced tx with cast or walking boot
o Displaced fixed with screws
Bimalleolar
o Generally require surgery
o More unstable
Talux will sublux or completely dislocate laterally
o Surgery
Reduction and fixation of both
o Trimalleolar
Posterior articular surface of distal tibia (posterior malleolus) can be fractured
as well
Fixed if involving >25% of surface
Syndesmosis Injuries
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Widening of space between distal tibia and fibula post-reduction indicative of injury
o Place screws laterally
o Keep non wt bearing for several weeks
o Screws generally removed after 12 weeks, but can be left in place (often
asymptomatic)
Calcaneal Fractures
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Talus Fractures
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Nondisplaced
o Cast
o 15% risk osteonecrosis
Displaced
o Surgical with screw fixation
o 30-100% risk osteonecrosis
o High risk arthritis
Foot Fractures
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SHOULDER
Rotator Cuff
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Among the most common reasons for visit to orthopedic sports specialist
Forceful or repeated overhead pulling movements
Provides shoulder movement and glenohumeral joint stability
Injuries lead to pain, weakness, and restricted movement of the arm
Arthroscopic techniques considered equal or superior to open techniques for most
indications
Rehab post-op important in restoring strength, motion, and function
Three stages of rehab
o First 4-6 weeks
Immobilization sling
Passive exercise therapist
o After 4-6 weeks
Active exercise
o At 8-12 weeks
Muscle strength and improvement of control increase by starting
strengthening exercise program
Shoulder Instability
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Labrum helps to deepen socket and stabilize GH joint. Also serves as attachment point for
many shoulder ligaments and one biceps tendon
Superior labrum AP (SLAP)
o Lesion anterior and posterior to attachment of biceps tendon +/- biceps tendon
involvement
o Trauma or repetitive shoulder motion
Xray looks for concomitant injuries or osteoarthritic changes
MRI to visualize labrum and other soft tissue
May do gadolinium arthrogram (more sensitive for labral injury detection)
Conservative
o NSAIDs
o PT
Surgery
o If no improvement with conservative
o SLAP injuries with biceps tendon involvement may require tenotomy or tenodesis
Post-op
o Shoulder immobilization in sling 4 weeks
o PT improves ROM and prevents scar tissue/stiffness from developing
o Strengthening exercise about 4-6 weeks post-op
o Return to action 3-4 months after surgery (early interval throwing)
Impingement Syndromes
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Acromioclavicular Joint
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KNEE
Knee
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Largest joint
Pivotal hinge joint (flexion, extension, medial + lateral rotation)
Bears axial load, torsion, and shear forces
Vulnerable to acute injury and osteoarthritis
Menisci
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Crescent-shaped fibrocartilage
o Joint stability
o Shock absorption
o Load distribution
o Proprioception
Sudden tears during sports (contact) or while squatting and twisting the knee
S+S
o Pain, stiffness, swelling
o Catching or locking of the knee, buckling or giving way
o Impaired ROM
Xray for concomitant injury, alignment, and osteoarthritis
MRI to visualize menisci and soft tissue
Partial (subtotal) meniscectomy MC surgical procedure
o Important to preserve load-distributing function to prevent osteoarthritis
o Orthobiologics
Most common tears: radial and longitudinal
Less common
o Root can be devastating, alter knee contact forces
Meniscus transplantation in young patients
Post-op
o Immobilized with brace
o Wt bearing protected to allow meniscus to heal
o Healing complete, ROM and strength to be regained
o PT integral part of healing
o Return to play 4-6 months post-op
Collateral Ligaments
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o
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Cruciate Ligaments
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