Tarascon Pocket Orthopaedica, Third Edition

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Author: Damian M. Rispoli

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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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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

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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) 90

Respiratory (/min) 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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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


Incision

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Emergency Procedures Dorsal incisions 2nd and 4th metacarpal

Damian Rispoli 2009

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.


11/17/2009 12:18:40 AM


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

General Orthopaedics—Ca++/Phosphate 68

11/17/2009 12:18:40 AM


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

69 General Orthopaedics—Metabolic Bone Disease

11/17/2009 12:18:40 AM

66016_CH02_PTR.indd 70 Coarse thick trabeculae, picture frame vertebrae, enlarged bone

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)

General Orthopaedics—Metabolic Bone Disease 70

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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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72

General Orthopaedics—Osteoporosis

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


11/17/2009 12:18:41 AM

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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General Orthopaedics—Perioperative Management

74

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.


11/17/2009 12:18:41 AM

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


11/17/2009 12:18:41 AM

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


11/17/2009 12:18:41 AM

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 (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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79

General Orthopaedics—Osteonecrosis

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


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)

11/17/2009 12:18:41 AM

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


11/17/2009 1:17:55 AM

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


Ofloxacin


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


11/17/2009 1:17:56 AM

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


11/17/2009 1:17:56 AM

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

89


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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


11/17/2009 1:17:57 AM

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


Normal

11/17/2009 1:17:57 AM


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

99 Pediatric Orthopaedics—Dysplastic Conditions

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66016_CH03_PTR.indd 100 Delayed walking

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)

Pediatric Orthopaedics—Dysplastic Conditions 100

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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

Damian Rispoli 2009

Salter-Harris Classification (JBJS 45A:587-622;1963)

101

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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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103

Pediatric Orthopaedics—Slipped Capital Femoral Epiphysis

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

Damian Rispoli 2009

MetaphysealDiaphyseal Angle

Drennan’s Angle (JBJS 64:1158 –1163,1982)

Damian Rispoli 2009

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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

↑

↑


Pyarthrosis

↑

↑

↑ or ↓**

Osteomyelitis

↑

↑

↑

Soft tissue abscess/ cellulitis

↑

↑

acute ↑

Acute rheumatic fever

↑

↑


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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105

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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107

Pediatric Orthopaedics—Limp

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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Pediatric Orthopaedics—Limp

108

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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Pediatric Orthopaedics—Scoliosis

110

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)

Damian Rispoli 2009


4

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112

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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Pediatric Orthopaedics—Child Abuse

116

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

118

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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)

119

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Physical Exam and Injections

120

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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121


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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124

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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125

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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128

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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129


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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132

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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133


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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135


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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136

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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137


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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138

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: 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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144

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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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: 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

156

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

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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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159

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Radiologic Views

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Radiologic Views

160

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

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

165

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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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167

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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169

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.

170

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171

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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173

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

11/17/2009 12:17:17 AM

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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175

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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177

Trauma—Adult

Hand Injury/Eponym


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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Trauma—Adult

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


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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179

Trauma—Adult

Hand Injury/Eponym


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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Trauma—Adult

180

Hand (Continued) Injury/Eponym


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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181

Trauma—Adult

Wrist Injury/Eponym


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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183

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


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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185

Trauma—Adult

Elbow Injury/Eponym


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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187

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

66016_CH05_PTR.indd 187

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

11/17/2009 12:17:21 AM

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


Injury/Eponym

Shoulder

Radial nerve exploration: Open fracture, penetrating trauma with radial nerve dysfunction, palsy following manipulation, > 3.5 months without recovery.


Injury/Eponym

Shoulder

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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


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


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


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


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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66016_CH05_PTR.indd 201 Grossly negative

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


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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203

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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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


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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205

Trauma—Adult

Hip Fractures Injury/Eponym


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


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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209

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


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


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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211

Trauma—Adult

Knee Dislocation/Soft Tissue Injury Injury/Eponym


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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213

Trauma—Adult

Leg/Ankle Fractures/Dislocations Injury/Eponym


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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Trauma—Adult

214

Leg/Ankle Fractures/Dislocations Injury/Eponym


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


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

Trauma—Adult 216

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217

Trauma—Adult

Foot Fractures and Dislocations (Continued) Injury/Eponym


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)


Injury/Eponym

Pediatric Trauma—Wrist and Hand Fractures

TRAUMA—PEDIATRIC

Trauma—Pediatric 218

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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


Injury/Eponym

Wrist and Hand Fractures

219 Trauma—Pediatric

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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 )


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)


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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


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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


11/17/2009 1:09:38 AM

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

11/17/2009 1:09:38 AM

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


11/17/2009 1:09:39 AM

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


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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


D—Sacrum/coccyx

B—Linear, non-displaced pelvic fracture


C—Iliac wing

Duverney→


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


11/17/2009 1:09:39 AM

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

66016_CH06_PTR.indd 234

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


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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


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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)

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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.

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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


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)


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


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


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


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


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

11/17/2009 12:18:44 AM

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


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

11/17/2009 12:18:44 AM

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


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

11/17/2009 12:18:44 AM

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


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

11/17/2009 12:18:44 AM

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