Orthopedics Toronto Notes Abridged for the PDA To be used only in consultation with the printed Toronto Notes

An Approach to Orthopedics
Harsha Malempati, Andrew Van Houwelingen and Aaron Van Vliet, chapter editors Cagla Eskicioglu and Nadra Ginting, associate editors Maja Segedi, EBM editor Dr. Herbert von Schroeder, staff editor History Physical Examination Investigations Fracture Description Management of Fractures Fracture Healing Fracture Complications Avascular Necrosis (AVN) Orthopedic Emergencies Multiple Long Bone Fractures and Unstable Pelvic Fractures Open Fractures Septic Joint Osteomyelitis Compartment Syndrome Cauda Equina Syndrome Hip Dislocation

History
identifying data chief complaint history of present illness mechanism of injury description of pain: OPQRST (Onset, Provoking/Palliative factors, Quality/Quantity, Radiation, Site, Timing) acute vs. chronic symptoms inflammatory symptoms morning stiffness, tenderness, swelling, warmth, redness degenerative symptoms increased with activity, decreased with rest mechanical symptoms locking, giving way (knee) constitutional symptoms: fever, chills, night sweats, fatigue, anorexia, weight loss lifestyle effects/ADLs referred symptoms: shoulder pain from heart or diaphragm, arm pain from neck, leg pain from back, back pain from kidney, aortic aneurysm, duodenal ulcer, pancreatitis review of systems past medical history orthopedic history: injuries, fractures, investigations (x-ray, CT, MRI), surgery cancer history other: medical illnesses, surgeries medication + allergies time of last meal and beverage (only if surgery is likely within next 24 hours)

Physical Examination
look: general observation of movement, SEADS feel: palpate soft tissue, bone and joint line for tenderness, temperature, deformity, effusion and joint laxity move: active then passive range of movement (ROM) for affected joint(s) and joints above and below, palpate for crepitus neurovascular tests pulse (palpate, Doppler) sensation (fine touch, pinprick in dermatomal distribution) reflexes (grade 0 ^ 4) power (0 ^ 5) special tests: refer to each subsection

Investigations
plain x-ray: anteroposterior (AP), lateral, oblique(s) CT: for bony anatomy not well visualized with x-ray MRI: soft tissue evaluation (meniscus, ligaments, tendons, intervertebral discs) arthrography: injection of radio-opaque dye into joint followed by x-ray, CT or MRI (e.g. rotator cuff tear) nuclear medicine scan: nonspecific test to show areas of increased bony production (tumour, fracture, infection) technetium (bone scan): osteoblastic activity and increased blood flow gallium: chronic inflammation and infection fluoroscopy: real-time static or dynamic visualization (e.g. intraoperative fracture management) ultrasound: helps to identify cysts, rotator cuff tears, ligament injuries (requires skilled operator) myelography: injection of radio-opaque dye into epidural space to outline spinal cord and roots aspiration: aspirate fluid from joint for analysis nerve studies electromyelography (EMG): intramuscular needle electrodes to evaluate muscle units nerve conduction studies (NCS): latency suggests nerve abnormalities

Fractures General Principles

Fracture Description
open versus closed (refer to Orthopedic Emergencies, OR5) neurovascular status location along the length of the bone diaphysis (proximal 1/3, middle 1/3, distal 1/3) metaphysis epiphysis (extra-articular, intra-articular) pattern of fracture transverse high energy, direct force oblique angular and rotational force spiral rotational force comminuted (? 3 fragments) fracture undisplaced versus displaced undisplaced no change in alignment or relationship of the bone on either side of the fracture displaced angulated described by apex; varus/valgus; or distal fragment translated described by percent of bone width and direction rotated by clinical exam only shortened due to overlap or impaction

Management of Fractures
airway, breathing, and circulation (ABCs), primary survey and secondary survey (ATLS protocol) establish that the patient is stable rule out other fractures/injuries range of all joints is determined, ligaments are stressed and neurovascular evaluations are performed rule out open fracture take an AMPLE history allergies, medications, past medical history, last meal, events surrounding injury analgesia splint fracture to prevent further soft tissue injuries imaging reduction closed reduction apply traction in the long axis of the limb reverse the mechanism that produced the fracture indications for open reduction NO CAST (see side bar) other indications include failed closed reduction cannot cast or apply traction due to site (hip fracture) pathologic fractures potential for improved function with open reduction with internal fixation (ORIF) potential complications infection non union implant failure new fracture re-check neurovascular status after reduction stabilization external stabilization splints; casts; traction, external fixator internal stabilization percutaneous pinning; extramedullary fixation (screws, plates, wires); intramedullary fixation (rods) post reduction imaging DVT prophylaxis (for pelvic and hip fractures) rehabilitation: to avoid joint stiffness isometric exercises to avoid muscle atrophy ROM for adjacent joints continuous passive movement (CPM) following rigid fixation of fracture allows joint motion to prevent stiffness for intra-articular fractures once cast/splint removed and fracture healed ^ resistive muscle strengthening follow-up: evaluate bone healing

Fracture Healing
Normal Healing weeks 0-3 weeks 3-6 weeks 6-12 months 6-12 years 1-2 hematoma, macrophages surround fracture site osteoclasts remove sharp edges, callus forms within hematoma bone forms within the callus, bridging fragments cortical gap is bridged by bone normal architecture is achieved through remodelling

Figure 1. Stages of Bone Healing

Evaluation of Healing: Tests of Union

clinical: no longer tender to palpation or angulation stress x-ray: trabeculae cross fracture site, visible callus bridging site

Fracture Complications
Table 1. Fracture Complications
Early compartment syndrome* neurological injury vascular injury infection implant failure fracture blisters sepsis deep vein thrombosis (DVT) pulmonary embolus (PE) actue respiratory distress syndrome (ARDS) hemorrhagic shock Late mal/nonunion avascular necrosis (AVN) osteomyelitis heterotopic ossification (HO) post-traumatic arthritis reflex sympathetic dystrophy (RSD) (vitamin C 500 mg QD may incidence)

Local

Systemic

* see Orthopedic Emergencies, OR7

Avascular Necrosis (AVN; Osteonecrosis)

Definition
disruption of blood supply to bone resulting in ischemia occurs in bones extensively covered in cartilage which rely on intra-osseous blood supply (femoral head) or in bones with a distal proximal blood supply (proximal pole of scaphoid, body of talus, femoral head)

Risk Factors
steroid use chronic alcohol use post-traumatic fracture/dislocation septic arthritis sickle cell disease storage disease (e.g. Gauchers disease) dysbarism (Caissons disease the bends) idiopathic (Chandlers disease)

Orthopedic Emergencies
Multiple Long Bone Fractures and Unstable Pelvic Fracture
Etiology
high energy trauma generally multiple lower extremity and/or pelvic fractures may be associated with spinal injuries or life threatening injuries

Clinical Presentation
local swelling, tenderness, deformity of the hips and instability of the pelvis with palpation

Investigations
routine views of pelvis: AP, inlet, outlet and Judet (Iliac oblique and obturator oblique) views, push-pull views to assess rotational and vertical instability (see Table 14 for classification of pelvic fractures) x-ray AP and lateral of all long bones suspected to be injured

Management
ABCs assess genitourinary injury (rectal exam/vaginal exam mandatory) external or internal fixation of all fractures

Complications
hemorrhage life threatening acute respiratory distress syndrome (ARDS) fat embolism syndrome pulmonary embolism bladder/bowel injury neurological damage obstetrical difficulties persistent sacro-iliac joint pain post-traumatic arthritis of the hip with acetabular fractures

Open Fracutre (Gustilo Classification)

Definition
fracture with communication with the external environment

Management
if neurovascular status is impaired, reduce ASAP obtain culture and cover with sterile dressing tetanus inoculation IV antibiotics (Table 2) splint fracture (alleviates pain, prevents further tissue, nerve or vessel damage) NPO and prepare for OR operative irrigation and debridement within 6 hours to decrease risk of infection open reduction and stabilization of the fracture wound usually left open to drain

 re-examine, with possible repeat I&D in 48 hours and closure if appropriate

Complications
osteomyelitis soft tissue damage neurovascular injury blood loss nonunion

Septic Joint
Etiology
most commonly caused by S. aureus consider Neisseria gonorrhoreae in sexually active patients most common route of infection is hematogenous

Clinical Presentation
localized joint pain, erythema, warmth, swelling with pain on active and passive ROM, inability to bear weight, fever

Investigations
x-ray (to r/o osteomyelitis), ESR, WBC, blood cultures joint aspirate (WBC > 80,000 with > 90% neutrophils, protein level > 4.4 mg/dL; glucose level << blood glucose level; no crystals; positive gram stain results)

Managment
hip joint is emergently decompressed and drained surgically; other joints may be serially aspirated IV antibiotics

Osteomyelitis
Etiology
most common organism is S. aureus consider Salmonella typhi in patients with sickle cell disease neonates and immunocompromised patients are susceptible to gram-negative organisms

Clinical Presentation
localized extremity pain, fever, 1 to 2 weeks after respiratory infection or infection at another non-bony site

Investigations
x-ray shows lytic, eccentrically located serpiginous lesion involving the cortex blood culture, aspirate cultures, ESR, CBC (leukocytosis), bone scan (increased uptake)

Managment
IV antibiotics surgical decortication and drainage, local antibiotics (i.e. antibiotic beads) if patient does not improve after 36 hours on IV antibiotics

Compartment Syndrome
Definition
increased interstitial pressure in an anatomical compartment (forearm, calf) where muscle and tissue are bounded by fascia and bone (fibro-osseous compartment) with little room for expansion interstitial pressure exceeds capillary perfusion pressure leading to muscle necrosis (in 4-6h) and eventually nerve necrosis

Etiology
intracompartmental: fracture (particularly tibial fractures, pediatric supracondylar fractures, and forearm fractures), crush injury, revascularization extracompartmental: constrictive dressing (circumferential cast), circumferential burn

Physical Examination
5 Ps (see side bar)

Investigation
compartment pressure monitoring (normal = 0 mmHg; urgent ? 30 mmHg or within 30 mmHg of diastolic BP)

Treatment
remove constrictive dressings (casts, splints) elevate limb definitive treatment: fasciotomy to release compartments

Complications
rhabdomyolysis, renal failure, Volkmanns ischemic contracture

Cauda Equina Syndrome

Etiology
most frequent cause is large central disc herniation

Clinical Presentation
progressive neurological deficit presenting with saddle anesthesia decreased anal tone and reflex fecal incontinence urinary retention

Managment
emergency decompression will cause permanent urinary/bowel incontinence if untreated

Hip Dislocation
reduce hip dislocations ASAP (ideally within 6 hours) to risk of AVN of the femoral head

1. ANTERIOR HIP DISLOCATION (rare) Etiology

blow to knee with hip widely abducted

Clinical Features
shortened, abducted, externally rotated limb

Treatment
closed reduction under GA (Allis reduction maneuver) post-reduction CT to assess joint congruity

2. POSTERIOR HIP DISLOCATION Mechanism

severe force to knee with hip flexed and adducted (e.g. knee into dashboard in MVC)

Clinical Features
shortened, adducted and internally rotated limb

Treatment
closed reduction under GA (Bigelow maneuver) ORIF if unstable, intra-articular fragments or posterior wall fracture post-reduction CT to assess joint congruity and fractures traction x 6 weeks

3. CENTRAL HIP DISLOCATION Etiology

traumatic injury where femoral head is pushed through acetabulum toward pelvic cavity

COMPLICATIONS FOR ALL HIP DISLOCATIONS

post-traumatic arthritis AVN fracture of femoral shaft or neck sciatic nerve palsy in 25% (10% permanent) heterotopic ossification (HO) damage to femoral head