chapter 29. Orthopedic Surgery

ORTHOPEDIC SURGERY Definitions ●Fracture: loss of continuity of a bone ●Subluxation: normally apposing surfaces are partly out of contact ●Dislocation: normally apposing surfaces are completely out of contact Fractures ●Type ○Open/closed. Depends on integrity of overlying skin or mucosa (i.e. bone in bowel lumen but not skin is still open) ○Stress: usually in unconditioned patient who participates in vigorous exercise. Won’t show up for 2 weeks on XR. ○Pathologic: underlying disease/malignancy. Most common: osteoporosis. ●Site: diaphysis (long part) heals more slowly because of less blood supply. Usually needs more protection. ●Pattern ○Stress & pathologic: transverse ○Spiral/oblique: tendency to shorten ○>2 fragments: comminuted/multifragmented. Implies greater forces ●Salter-Harris Classification: increasing number parallels severity and predicts worse prognosis. ○I: At physis (growth plate) ○II: Through physis, exits through metaphysis ○III: Through physis, exits epiphysis Operative ○IV: Obliquely through metaphysis and epiphysis. Operative ○V: Crush physis. Hard to diagnose with radiology. ●Management ○Splint all musculoskeletal injuries in the field ○All open fractures are considered contaminated, need to be cultured. Give cephalosporin & metronidazole. Irrigated with saline (6L), debrided, reduced, reexplore at 48-72 hrs for more debridement ○Reduction: minimize fracture deformity. Open repair indicated if closed fails or is intra-articular (ex. S-H III, IV) ○Indications for external fixation: Open, infected, severely comminuted, or if bone graft necessary ●Stages of healing ○Hematoma, inflammation ○Soft callus (2 days - 6 wks) Hard callus (10 days - 4months) Bone remodeling (2 - 24months) Common Adult Musculoskeletal Injuries ●Carpal scaphoid: tenderness in snuffbox, not evident immediately by x-ray, avascular necrosis, nonunion if displaced ●Distal radius: Colles if distal. Closed reduction, reasses at 10 days to see if maintained. Verify median nerve function ●Olecranon fracture: loss of elbow extension. Since it is a fragment, requires open reduction ●Pulled elbow: Pain from impingement of annular ligament. Flex elbow and supinate hand. Common in children ●Supracondylar humerus: Common in kids (FOOH). Neurovascular risk, compartment syndrome. Pin fixation in OR ●Shoulder dislocation: Anterior (90%): decreased sensation axillary n, caused by forced external rotation. Posterior: Need perpendicular XR. Arm held internally rotated. Consider in epileptic postictal ●Hip fractures: Femoral neck: reduced and surgically fixed due to attendant complications may be replaced artificially ●Femoral shaft: Strongest bone in the body, considerable blood loss. Closed, intermedullary nailing ●Hip dislocation: Occurs in MVA when knee strikes dashboard. Posterior - foot drop. Urgent reduction avoid avascular ●Tibia and fibula: 33% of tibia is subcutaneous - often requires open reduction ●Ankle injuries: 1mm of displacement can reduce joint surface contact by 40%. Open reduction with internal fixation Common Pediatric Musculoskeletal Injuries ●Developmental dysplasia: Associated with breech. Ortolani (click) sign of dislocation. Barlow dislocaiton if unstable. ●Legg-Calve-Perthes: Onsteonecrosis of femoral head. Knee pain (obturator n.) Self-limited ●Slipped capital femoral epiphysis: Obese or growth spurt. Limp. Femoral head fixed with pins ●Osgood-Schlatter: partial avulsion of patellar tendon at tibial tubercle. Self-limited. ●Congenital club foot: Causes patient to walk on lateral border, not sole. Muscles become atrophic, contracted. Cast. ●Scoliosis: Most commonly idiopathic. Painless progressive. Girls 9x boys. Also associated with myelomeningiocele, cerebral palsy, neurofibromatosis.