Orthopedic Surgery Quiz on Open Fractures

Introduction to Orthopedics

• Course presented by Adam Kreutzer, DO (Orthopedic Resident) and Wade Faerber, DO (Orthopedic Program Director)
• OMSII course
• No interests to disclose related to products presented in course
• A historical image of the Tree of Andry by Nicolas Andry (1741) is included

Outline

• Pediatric Orthopedics
• Avascular necrosis (osteonecrosis)
• Osteonecrosis
• Osteoarthritis
• Fracture fixation
• Orthopaedic Infections
• Orthopaedic emergencies
• Spine
• Sports Orthopedics

Pediatric Anatomy

• Physis (growth plate)
• Epiphysis
• Metaphysis
• Diaphysis

Physeal Injuries

• Growth plates (physis) are weaker than surrounding bone in pediatric patients
• Injuries can cause growth arrest, leading to limb length inequality and/or deformity
• It is crucial to differentiate injured from non-injured anatomy

Salter-Harris Fractures

• Salter-Harris fractures are categorized into types 1-5 depending on the extent of the fracture's involvement of the growth plate
• Illustrated by a diagram

Pediatric Elbow Fractures

• Ossification centers of the elbow and their associated ages are described
• CRITOE refers to the ossification centers • Capitellum (1) • Radial head (3) • Internal or Medial epicondyle (5) • Trochlea (7) • Olecranon (9) • External epicondyle (11)

Most Common Pediatric Elbow Injuries

• Supracondylar fractures are the most common type (41%), followed by Radial Head Subluxation (28%), Lateral condylar physeal fractures (11%), Medial epicondylar apophyseal fracture (8%), Radial Head and Neck fractures (5%), Elbow dislocations (5%), and Medial condylar physeal fractures (1%)
• Peak ages for these injuries are provided.
• Requires OR and rarity are described.

Elbow- Things to Look For

• Anterior humeral line
• Radio-capitellar line

More Things to Look For

• Lateral view must be well done
• Look for a fat pad sign

Supracondylar Humerus Fracture

• Radiograph examples are included

Lateral Condyle Fracture

• Radiograph examples are included

Medial Epicondyle Fracture

• Orthopedic consult is needed for treatment.
• Treatment depends on location of fracture (surgical treatment or cast/splint)
• Radiograph examples are included.

Slipped Capital Femoral Epiphysis (SCFE)

• Most common disorder affecting adolescent hips (prevalence of 1/10,000).
• Risk factors like obesity and male gender are more prevalent in African Americans, Pacific Islanders, and Latino populations.
• Common in periods of rapid growth (10-16 years).
• Associated with hypothyroidism, renal osteodystrophy, growth hormone deficiency, hypopituitarism, and Down Syndrome
• Presented by thigh, groin, or knee pain (if knee pain, consider hip x-rays)
• Limping and/or obligatory external rotation present
• Examination will show these findings

Monteggia

• Ulna shaft fracture with radial head subluxation is mentioned.
• Radial head must point to capitellum in all views.
• Radiograph examples are included.

Galleazzi fracture

• Associated with radius fracture and distal radioulnar joint injury
• Diagrams of volar and dorsal Galeazzi fractures are shown

Subcapital Fracture

• The femoral neck is broken into three locations
  • Subcapital: below the femoral head
  • Transcervical: across the middle of the femoral neck
  • Basicervical: across the base of the femoral neck (similar to intertrochanteric facture)
• Diagram of fractures are included

Avascular Necrosis

• Death of marrow and bone cells
• Poorly understood etiology
• Steroids and EtOH may alter lipid metabolism
• 75% have subtle coagulation defects
• Preferred term to use is osteonecrosis (death of a segment of bone in situ, vessels generally remain)
• Femoral head, humeral head, knee, talus, and small bones are frequently affected
• Etiology—Trauma is the most common cause (#1 known cause), congenital, idiopathic, infectious, iatrogenic (SCFE reduction), metabolic, autoimmune, and neoplastic
• Mechanical disruption, external pressure, arterial thrombosis, and venous outflow obstruction are mechanisms.
• Blood supply description is included.
• Percentage of undisplaced femoral neck fractures (10%), displaced fractures (15-30%), and hip dislocations (10-15%) are mentioned.

Osteonecrosis of Carpus

• Scaphoid and lunate wrist bones are commonly affected

Anatomy- Blood Supply

• Description of blood supply to the proximal pole of the wrist
• Retrograde flow is highlighted
• High rate of non-unions is described (14-40%)

Osteoarthritis

• Progressive loss of cartilage in joints
• Diagnosis is made by plain x-rays—looking for joint space narrowing
• Risk factors include prior trauma, high impact activities, surrounding muscle weakness, and female gender.
• Avascular necrosis is another risk factor
• Cartilage water content increases and becomes disorganized
• Synovium becomes inflamed and thickened
• Subchondral bone remodels creating cysts with sclerotic edges
• Physical exam—antalgic gait, painful decreased ROM, swelling and generalized tenderness to palpation, and crepitus with ROM
• Examples of x-rays are included.

Osteoarthritis Treatment

• Initial treatment is conservative, including activity modification, NSAIDs (Meloxicam and Diclofenac gel), weight loss/muscle strengthening, and corticosteroid injections.
• Corticosteroid injections may include a lidocaine derivative (ropivacaine and Kenalog)
• Risk of septic arthritis is discussed

Corticosteroid Injections

• Effects: diagnostic and therapeutic; causes local atrophy of tissues; cartilage softening, progression of arthritis.

Total Hip Arthroplasty

• Types of implants are included: Acetabular Cup, Polyethylene Insert, Metal Femoral Head, Femoral Stem, Acetabular Cup, Ceramic Insert, and Ceramic Femoral Head

Total Knee Arthroplasty

• Types of implants are described

Challenges of Arthroplasty

• Implant selection
• Balancing the knee
• Bone defect management

How do we fix fractures?

• Casts
• Splints
• Screws
• Plates
• Intramedullary nails
• External fixation devices

Casting and Splinting

• Used to stabilize fractures
• Casts cover the entire extremity, splints do not
• Braces are removable, prefabricated plastics

Screws

• Lag screws: compress fractures
• Cancellous screws: coarser threads for cancellous bone
• Cortical screws: finer threads for cortical bone
• Cannulated screws: hollow for temporary fixation via wire
• Locking screws: specific plates

Plates

• Compression plates: oval holes pull fracture parts together
• Neutralization plates: used with lag screws, protect from rotational, bending, and shearing forces

Intramedullary Nails

• Large metal rods placed in medullary canal
• Allows for early weight-bearing

External Fixation

• Pins screwed into bone and connected with rigid bars
• Used for fractures with significant swelling or comminution (partial fracture)
• Can be a temporary measure

Orthopedic Infections

• Focus on specific infections: -Osteomyelitis, Septic Arthritis, Pyogenic Flexor Tenosynovitis, Necrotizing Fasciitis

Osteomyelitis

• Infection of bone with progressive degradation of bone and deep tissues
• Most frequent pathogen is Staphylococcus aureus.
• Pseudomonas aeruginosa (from sharp trauma through rubber soled shoes) can also cause osteomyelitis
• Risk factors include: trauma/surgery, IV drug use, poor blood supply, uncontrolled diabetes/immunocompromised

Osteomyelitis (Presenting Symptoms)

• Pain, erythema, antalgic gait, skin breakdown, draining sinus tract
• Labs: Elevated ESR, CRP (most sensitive), +/- WBC, +/- blood culture (if suspected hematogenous spread).
• Classification: Medullary, Superficial, Localized, or Diffuse
• Imaging: Radiographs (areas of lucency, sclerosis, periosteal reaction, lysis around hardware if present), CT, MRI (most sensitive for detecting early osteomyelitis)
• Treatment: antibiotics vs surgery (I&D or amputation)

Septic Arthritis

• Typically due to trauma or surgery to the joint or hematogenous spread
• Risk factors: immunocompromised, IV drug use, increased risk of gram-negative infection, endocarditis, recent joint surgery
• Pathogens: commonly S. aureus, but also S. epidermidis, N. gonorrhoeae, or gram-negative bacilli
• Labs: elevated WBC, ESR, CRP
• Joint aspirate: purulent, ≥50,000 WBC per mL. Cell count, gram stain, culture (antibiotics), crystals (gout/pseudogout)
• Treatment: urgent surgical irrigation, debridement; intra-op cultures; serial monitoring of ESR and CRP q48 for infection clearance

Pyogenic Flexor Tenosynovitis

• Flexor tendons are encased in synovial sheaths—supporting glide
• Trauma leads to enclosed tendon sheath infection These enclosed spaces do not tolerate infection expansion
• Kanavel's signs are important to identify: fusiform "sausage" digit, digit held in passive flexion, pain with passive extension, pain along tendon sheaths
• Risk factors: diabetes/immunocompromised, IVDU
• Pathogens: S. aureus is most common
• Labs: Elevated WBC, CRP, ESR
• Imaging: CT with contrast helps localize infection areas in/around tendon sheaths
• Treatment: early antibiotics, surgical I&D, cultures for antibiotic tailoring, elevation of extremity

Necrotizing Fasciitis

• Life-threatening infection that spreads along soft tissue planes, sparing underlying muscle
• Rapid tissue destruction; associated systemic toxicity; mortality rate: 32%
• Presentation: rapidly progressing cellulitis, abscess, severe pain, swelling, bullae (fluid-filled blisters), discoloration, subcutaneous emphysema, high fever, chills, tachycardia (severe sepsis)
• Diagnosis: LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score (≥ 6 suggests 92% PPV), emergent frozen section taken in OR, for suspected early infection
• Microbiology: commonly polymicrobial (type one), immunocompromised patients (DM or CKD), monomicrobial (type two), examples include S. pyogenes, S. aureus, and Clostridium; increased gram-negative monomicrobial cause in recent years—higher mortality
• Treatment: early radical surgical debridement, intra-operative findings of fat and muscle necrosis, venous thrombosis, or "dishwater" pus; broad-spectrum antibiotics, and hyperbaric oxygen

Orthopedic Emergencies

• Open fractures
• Pediatric injuries (SCFE, fractures)
• Spine injuries (Cauda Equina)
• Orthopedic infections
• Septic arthritis
• Flexor tenosynovitis
• Compartment syndrome

Open Fractures

• "Compound" (no longer used)
• Defined by skin/soft tissue break that communicates with the fracture
• High rate of infection; devascularization and soft tissue compromise; high rate of non-union; complications of osteomyelitis
• Surgery timing varies with bone fractured, classification of open fracture, age of patient, patient stability

Open Fracture Management

• Early IV antibiotics and updated tetanus prophylaxis
• Studies show increased infection rates with antibiotic delays over 3 hours
• Aggressive I&D recommended
• Low pressure lavage more effective than high pressure lavage
• Saline most effective irrigating agent

Compartment Syndrome

• Increased pressure in closed anatomic space, threatening enclosed tissue viability
• Immediate threat to muscle, nerve tissue
• Causes: high energy injuries, crush injuries, burns, intense muscle use, reperfusion injury
• Signs: 5 Ps (pain with passive stretch, pallor, pulselessness, paresthesias, paralysis)
• Diagnosis: may not be obvious with open wounds; must monitor and decompress; polytrauma, head injury, chemical overdose, sensory nerve abnormalities can increase difficulty of diagnosis
• Treatment goals: decompress all compartments at risk; widely decompress skin, fat, and fascia; debride necrotic tissue

Anatomy of Forearm Compartment Syndrome

• Four osteofascial compartments
  • Superficial Volar
  • Deep Volar
  • Dorsal
  • Mobile wad

Volkmann's Contracture

• Final sequela of forearm compartment syndrome
• Contracture of forearm flexors; dead muscle replaced with fibrous tissue

Compartment Syndrome – Case Example

• 13-year-old male injured right knee during basketball game
• Loud pop; unable to walk afterward
• Firm compartments, significant pain with passive stretch indicates compartment syndrome
• Radiograph example included.

Spinal Cord Injury

• Physical Examination
  • Sensory assessment (detailed maps of sensory innervation from the spinal cord illustrated)
  • Motor assessment
    • Grading (0-5)
    • Myotomes (specific muscle groups innervated by specific spinal cord segments are illustrated)
    • Spinal shock (absence of motor/sensory function below injury zone; usually resolves within 24-48 hours; bulbocavernosus reflex should return - unless conus involved in injury)
  • ASIA impairment scale (A-E)
• Definitions:
  • Incomplete injury: partial sensory/motor function below neurological level
  • Complete injury: absence of sensory/motor function below neurological level
  • Paraplegia:
    • Thoracic, lumbar, or sacral segment impairment; arm function is spared.
  • Quadriplegia:
    • Cervical segment impairment
• Anatomy: Spinal cord cross-section includes ascending (sensory) and descending (motor) tracts
• Blood supply: includes radicular arteries (Arteria radicularis magna of Adamkiewicz) and anterior and posterior spinal arteries.
• Clinical cord syndromes (complete, central, Brown-Sequard, anterior, posterior, conus medullaris, and cauda equina)
• Acute Management—emphasized surgery, timing, realignment, decompression

Sports Orthopedics

• Addresses injuries common to athletes
• Minimally invasive procedures are common (arthroscopy—small portal incisions for camera and instruments insertion)
• Commonly performed on shoulders and knees
• Also performed on elbows, wrists, hips, ankles

Rotator Cuff

• Made of four muscles surrounding humeral head
  • Supraspinatus, Infraspinatus, Teres minor, Subscapularis (SITS muscles)
• Functions:
  • Abduction, internal, and external rotation of the humerus
  • Dynamic shoulder stability

Shoulder Differential Diagnosis

• Rotator cuff is not only cause of shoulder pain
• Other possible causes evaluated via imaging and physical exam
  • Long head of biceps tendon
  • Acromioclavicular joint
  • Subacromial bursa
  • Labrum
  • Cartilage

Arthroscopic View of Shoulder

• Structures seen arthroscopically

Knee Joint

• Knee pain can have several causes
  • ACL, PCL, medial/lateral collateral ligaments, meniscus, cartilage, and surrounding muscle strain(s)

ACL

• Originates from lateral femoral condyle in the femoral notch and inserts on the tibia between the intercondylar eminences
• Responsible for rotation stability of the knee and preventing anterior translation of the tibia on the femur.
• Made of two bundles: anterior (resists anterior tibia translation), posterior (rotational stability).

ACL Injury Presentation

• Common in female soccer players from non-contact injuries
• Sudden pop followed by pain, ambulation issues, rapid swelling
• Physical exam often includes positive tests (anterior drawer, Lachman, pivot shift)

Meniscus Injury

• Can occur as an isolated injury or with other knee injuries (ex: ACL rupture)
• Tear location dictates treatment choices (repair vs. meniscectomy)
• Peripheral blood supply supports only the outer parts of the meniscus, middle parts are avascular.

Meniscal Tear Patterns

• Diagrams of different tear patterns are shown

Arthroscopic View of Meniscus

• Structures, including horns, are shown via arthroscopic imaging.

Knee Injuries in the Setting of Arthritis

• MRI might not be immediately used if pre-existing arthritis and new knee injury
• MRI use to determine extent of knee injury if no pre-existing arthritis
• This information can help patients with pre-existing arthritis conditions

Questions

• Provide question route—discussion board, or via [email protected]

Thank You

• Course conclusion.

Test your knowledge on open fractures, their characteristics, and surgical interventions. This quiz covers the urgent surgical needs, potential complications, and specific surgical tools used in orthopedic procedures. Challenge yourself and enhance your understanding of orthopedic care.