KSU Ortho Team Final PDF

Ortho team From slides Doctor's Notes Team's Note 430 team note Important Team leader: Sulaiman Mohammed Alsakran (Principles of fractures, Common spine disorders) Team members: 1. Abdulkhaliq Saad Alghamdi (Common Hip Disorders, MSK tumours) 2. Abdullah Abed Alhallaly (Metabolic bone d...

Ortho team From slides Doctor's Notes Team's Note 430 team note Important Team leader: Sulaiman Mohammed Alsakran (Principles of fractures, Common spine disorders) Team members: 1. Abdulkhaliq Saad Alghamdi (Common Hip Disorders, MSK tumours) 2. Abdullah Abed Alhallaly (Metabolic bone disorders, Open fracture) 3. Abdulrahman Waleed Aldahmash (Spinal Injuries, Peripheral nerve injuries) 4. Abdulrahman Suliaman Alqadeeb (Common pediatric fractures) 5. Ahmed Hussain Saleem (revision: Principles of fractures, Common pediatric fractures, Compartment syndrome) 6. Khalid Mohammed Bedawi (revision: Common Lower Limb Disorder, Peripheral nerve injuries) 7. Majid Jamaan Ajarem (Common adult fractures, Common Lower Limb Disorder) 8. Nawaf Mohammed Abohamra (Compartment syndrome, chronic shoulder disorder, Sport & soft tissue injuries) 9. Othman Mohammed Almazyad (revision: Peripheral nerve injuries, chronic shoulder disorder, , Sport & soft tissue injuries, Metabolic bone disorders ) 10. Salman Ayed Alsolami (Bone & joint infection, Degenerative joint disorder) 11. Abdullah Fowzan Alfowzan (revision: Common spine disorders) 12. Firas Abdulstar Ghomraoui (revision: Common Hip Disorders) 13. Saud Hussain Alhilal (revision: Open fracture, Common adult fractures) 14. Abdullah Ali Baqays (revision: Spinal Injuries) 1 Contents 1-Principles of fractures................................................................................................................................ 3 2-Common adult fracture........................................................................................................................... 12 3-Common pediatric fractures.................................................................................................................... 33 4- Open fracture (emergencies/ red flags)................................................................................................. 47 5- Bone & joint infection (emergencies/ red flags)..................................................................................... 66 6- Compartment syndrome and acute joints dislocation............................................................................. 80 7- Common spine disorders........................................................................................................................ 90 8- Spinal Injuries....................................................................................................................................... 103 9- Common Pediatric Hip Disorders......................................................................................................... 116 10- Common Pediatric Lower Limb Disorder.......................................................................................... 134 11- Degenerative joint disorder................................................................................................................. 147 12- Peripheral nerve injuries..................................................................................................................... 156 13- Chronic shoulder disorder................................................................................................................... 163 14- MSK tumours..................................................................................................................................... 175 15- Sport & soft tissue injuries................................................................................................................. 191 16- Metabolic bone disorders.................................................................................................................... 204 2  1- Principles of fractures OBJECTIVES: Introduction. Basic science of fracture healing. Principles of evaluating patients with fractures. Principles of management. Common fractures in adults Introduction: Fracture means literally broken bone. This can be described in different ways: 1. Extent  Complete: fracture extends 360° of bone circumference (all around). Almost all adult fracture are complete fracture.  Incomplete: seen almost only in children: e.g. Greensick, and Buckle fracture. Complete Greensick Buckle fracture 2. Location  Name of bone.  Side.  Diaphysis, metaphysis or epiphysis.  Long bones (diaphysis): divide them in thirds (proximal, middle or distal third).  Metaphysis: intra-articular v.s extra-articular. 3 3. Morphology  Transverse: loading mode resulting in fracture is tension. Due to high energy mechanism.  Oblique: loading mode is compression. (high energy mechanism, the fracture is on one plate).  Spiral: loading mode is torsion. (low energy mechanism, the fracture is on tow plate).  Fracture with Butterfly fragment: loading mode is bending and compression. It also called a wedge fracture.  Comminuted fracture: 3 or more fragments.  Segmental fracture (the bone is broken above and below). Transverse Oblique Spiral 4. Mechanism  High energy vs. low energy. (in high energy fracture there is more tissue damage than other types e.g. RTA) (low energy e.g. fall from height).  Multiple injuries vs. isolated injury.  Pathological fracture: normal load in presences of weakened bone (tumor, osteoporosis, infection).  Stress fracture: normal bone subjected to repeated load (military recruits). 4  5. Associated soft tissue injuries  Close fracture: skin integrity is maintained.  Open fracture: fracture is exposed to external environment. Any skin breach in proximity of a fracture is an open fracture until proven otherwise. Fracture healing Indirect bone healing (endochondral ossification) occurs in nature with untreated fracture. It is called indirect because of formation of cartilage at intermediate stage. It runs in 4 stages: 1.Hematoma formation 2.Soft callus formation 3.Hard Callus formation 4.Remodeling  Direct bone healing happens after surgery. It is called direct because there will be no cartilage formation. When we put plate and screws there will be no movement so it will heal in indirect way. Principles of evaluation: 1. History:  Patients complain of pain and inability to use the limb (if they are conscious and able to communicate)  What information can help you make the diagnosis?  Onset: o When and how did the symptoms begin? o Specific traumatic incident vs. gradual onset?  If there was a specific trauma, the details of the event are essential information:  Mechanism of injury? o Circumstances of the event? Work-related? o Severity of symptoms at the time of injury and progression after? 5  o Always ask about the mechanism if the patient have fallen down (low energy mechanism) you have to ask about height (floor level, who many steps), why, when, and how did he fall. o In RTA (high energy mechanism) ask about speed, driver or the passenger, back or the front seat, seat belted or not, ejected on not, deployed air bag, death at the seen. o Suspect pathological fracture, ask about pain before the event o Suspect a stress fracture, ask about the patient career(e.g. military, recently joined a gym). 2. Physical exam:  Inspection o Swelling. o Ecchymosis. o Deformity. o If fracture is open: Bleeding, Protruding bone.  Palpation o Bony tenderness. o Don’t do range of motion, because it is painful.  If a fracture is suspected what should we rule out? o Neurovascular injury (N/V exam). To examine the vascular status do examination of the pulses, capillary refill, color, and temperature. o Compartment syndrome. o Associated MSK injuries (examine joint above and below at minimum). 3. Imaging:  X-rays are 2D: get minimum two orthogonal views!  Include joint above and below injury.  NB: Fractures hurt, immobilization helps.  Immobilizing a patient in a backslab is the most effective way to relieve pain from a fracture and may be done BEFORE getting x-rays.  Fractures may be obvious on x-ray  Undisplaced or stress fractures are sometimes not immediately apparent  If the fracture could extend to the joint order CT (we need CT if the fracture in distal third) 6   If you suspect a fracture and can't see it on x-ray, order MRI  Secondary signs of fracture on x-ray: we only use the signs if we didn't see clear fracture and its rarely used in adult fracture because almost always fracture can be seen ( this signs mostly used for pediatric fractures) Soft tissue swelling Fat pad signs (arrow) Periosteal reaction Joint effusion cortical buckle How to describe a fracture: 1. Clinical parameters  Open vs. closed. (ANY break in the skin in proximity to the fracture site is OPEN until proven otherwise)  Neurovascular status  Presence of clinical deformity 2. Radiographic parameters  Location: o Which bone? o Which part of the bone? (Epiphysis or Metaphysis or Diaphysis) Epiphysis -intraarticular? Metaphysis Diaphysis -divide into 1/3s 7  Use anatomic landmarks when possible. e.g. medial malleolus, ulnar styloid, etc  Pattern: o Simple vs. comminuted o Complete vs. incomplete o Orientation of fracture line (Transverse , Oblique, Spiral)  Displacement: o Displacement is the opposite of apposition o Position of distal fragment relative to proximal o Expressed as a percentage Displaced (translated) posteriorly  Angulation: o Deviation from normal alignment o Direction of angulation defined by apex of o Expressed in degrees Treatment Principles: 1. Reduction if necessary:  IF fracture is displaced.  Meant to re-align fracture fragments.  Reduction is done to relive pain minimize soft tissue injury.  Can be consider definitive if fragments’ position is accepted.  Should be followed by immobilization.  Reduction (alignment) is done with traction and countertraction.  Patient must receive analgesia prior to reduction (most commonly used method is conscious sedation in ER)  NV assessment is done before and after reduction.  If the patient has undisplaced fracture do you need to reduce it? no 2. Immobilization (temporary):  To hold reduction in position.  To provide support to broken limb  To prevent further damage.  Control the Pain  In most fracture immobilization we immobilize the joint above and joint below 8  backslab (below knee) humeral brace sling I complete cast (below elbow) skin traction skeletal traction 3. Definitive treatment:  If satisfactory reduction cannot be achieved or held at initial stage.  Reduction can be attempted close or open (surgery)  Immobilization can be achieved with: Plate and screws, IM nail, EX-fix  Open reduction: it is done if you expose the bone fracture itself not just opening the skin ( you have to reach the bone)  When you do open reduction you will do fixation. Screws plat and Screws IM nail 9  4. Rehabilitation:  Motion as early as possible without jeopardizing maintenance of reduction.  Wt bearing restriction for short period. (couple weeks)  Move unaffected areas immediately Multiple Trauma: 1. Multi-disciplinary approach. 2. Run by Trauma Team Leader (TTL) at ER. Orthopedic is part of the team. 3. Follow trauma Protocol as per your institution. 4. Treatment is prioritized toward life threatening conditions then to limb threatening conditions. Complication of fractures: 1. Fracture extend inside the joint → osteoarthritis, stiffness 2. Fracture does not heal → nonunion 3. Long time to heal → delayed union 4. Healed in wrong position → malunion 5. Avascular necrosis in the head 6. Infection 7. DVT, PE 8. Hardware failure 10 Summary:  Fracture means literally broken bone.  This can be described in different ways: 1. Extent: complete, incomplete: 2. Location: Name of bone, Side, and in Diaphysis, metaphysis, or epiphysis 3. Morphology: Transverse, Oblique, Spiral, Butterfly fragment, Comminuted, Segmental. 4. Mechanism: High energy, low energy, Multiple injuries, isolated injury, Pathological fracture, Stress fracture. 5. Associated soft tissue injuries: Close or Open fracture.  Natural Bone Healing: Indirect bone healing (endochondral ossification), direct healing.  Principles of evaluation: 1. History: pain and inability to use the limb. 2. Physical exam: Swelling, Ecchymosis, Deformity, Bony tenderness. 3. Imaging: X-rays (two orthogonal views) (Include joint above and below) Immobilizition is done BEFORE getting x-rays  How to describe a fracture: 1. Clinical parameters: Open vs. Closed, Neurovascular status, Clinical deformity 2. Radiographic parameters: Location, Pattern, Displacement, Angulation, Shortening  Treatment: 1. Reduce (if necessary): to maximize healing potential and to insure good function after healing 2. Immobilize: to relieve pain, and to prevent motion that may interfere with union, and to prevent displacement or angulation of fracture 3. Rehabilitate: to insure return to function 11  2- Common adult fracture OBJECTIVES: CLAVICAL FRACTURE HUMERUS (PROXIMAL & SHAFT) BOTH BONE FOREARM FRACTURS DISTAL RADIUS'FRACTURE HIP FRACTURE FEMUR SHAFT FRACTURE TIBIAL SHAFT FRACTURE ANKLE FRACTURE CLAVICAL FRACTURE:  Clavicle is 'S' shape bone  It is anchored to scapula via ACJ  It is anchored to trunk via SCJ  Most of fracture occurs as result from fall onto shoulder Fracture is classified into proximal, middle and lateral third fractures. 12  Most of fractures are of middle third. Why we classify fractures? 1. Easy communication with each others. 2. Treatment 3. Research preps Clinical findings:  Check the skin Injury to brachial plexus and subclavian artery/vein may be present Rarely, Pneumothorax can occur. X-rays: AP chest Clavicle special view. (You don’t need to know it in details) Fracture in middle third of Clavicle which butterfly fragment Treatment: In clavicle fractures, we do not reduce it, because you can’t immobilize it then after (imp) – Most of clavicle fractures are treated with a sling. (If it is not displaced). – Few fractures should be treated surgically with open reduction and internal fixation, as if: Skin is tented Severe 13  displacement: – 100% displacement – >2 cm overlap open reduction and internal fixation Sling PROXIMAL HUMERUS ANATOMY: Proximal humerus has four anatomic parts: – Head – Greater tubrosity – Lesser tubrosity – Shaft Anatomic neck v.s surgical neck. PROXIMAL HUMERUS FRACTURE: In younger patients: violent trauma. ( car accident ) In older patients: minor trauma. ( fall in kitchen or bathroom) Most fractures are minimally displaced. Complete fracture in surgical neck of humerus with minimally displaced 14 PHYSICAL EXAM: Expose the shoulder very well. lateral skin patch Look for fracture signs (swelling, ecchymosis and deformity) Check the skin. Peripheral N/V exam. A Axillary nerve: lateral skin patch (deltoid atrophy) Examine joint above and below i.e. cervical spine and elbow. X-rays: Axillary views, to see if there any dislocation AP, lateral and axillary views. mr b You should do all views then do others like CT n If i ask you in exam and I give you AP view what the next step ? r n Do other views. Fracture is defined by the fragments displaced. Displacement: more than 1 cm. me not displaced (less than 1cm) fracture of greater tuborsity of humerus in normal 15  The findings are: the surgical neck is broken, the greater tuberosity is broken, the head and greater tubrosity are also displaced. Thus, it is a displaced proximal humerus fracture. Displaced fracture If fracture is not displaced: NWB: non-weight bearing – Treatment with sling and NWB of UE for 6-8 weeks. UE: upper extremity. – Early ROM exercises after 2-4 weeks. (if you miss ROM >> stiffness) ROM: range of motion. – Normal function can be resumed after 3-4 months. If the fracture is displaced: – Surgery is indicated. – ORIF(open reduction and internal fixation): is indicated (plate and screws). – Shoulder hemi-arthroplasty is indicated in some cases. HUMERUS SHAFT FRACTURE: It can be classified based on location of fracture. (proximal, middle and distal) Fracture symptoms. On exam: – Skin – N/V – Compartment 16 Spiral fracture in meddle third of the humerus.  Watch for radial nerve palsy. Treatment: Almost all humerus shaft fracture can be treated non-surgically. – Close reduction – Functional brace x 4-6 weeks + NWB – Early ROM of elbow and shoulder. Surgery is indicated for specific conditions like: – Segmental fracture – Open fracture – Obese patient – Bilateral fracture (both humerus) – Floating elbow ( forearm and humerus) Surgery: ORIF with plate and screws. BOTH BONES FOREARM FRACTURE: Forearm is complex with two mobile parallel bones. Radius and ulna articulate proximally and distally. It very unlikely to fracture only one bone without disruption of their articulation: – Both bone fracture – Monteggia fracture – Galeazzi fracture. Fractures are often from fall or direct blow. Both bones fracture: – Means radius and ulna are broken. Monteggia fracture: 17  – Means proximal or middle third ulna shaft fracture with dislocation of radius proximally (at elbow) Galeazzi fracture: Means distal third shaft radius fracture with disruption of DRUJ. CLINICAL: Symptoms and signs of fracture Check the skin Check the compartments of forearm Check Ulnar, median and radial nerve (PIN,AIN) Check vascularity: color, temperature, capillary refill and pulse. 18 Investigations: 2 orthogonal views CT scan if fracture extends into joint. (If the fracture extends to the joint > there’s a risk of osteoarthritis.) Treatment: Both bone fracture: – Reduce and splint at ER/clinic (temporary to relief pain) – Are treated almost always with ORIF: (plate and screws) Monteggia fracture: – ORIF ulna and close reduction of radial head Galeazzi fracture: – ORIF radius and close reduction of DRUJ. DISTAL RADIUS FRACTURE: Most common fracture of upper extremity. Most frequently are seen in older women. Young adults fractures are most commonly secondary to high energy trauma. Mechanism of injury: outstretching the Wrist. Extra-articular fracture: – Colles’ Fracture: dorsal angulation, shortening and radial deviation. Determination of type of angulation is Done in regard to the distal fragment. If the distal fragment is going dorsally >> Dorsal angulation, and vice versa. Displaced posterior / dorsal. 19  – Smith’s fracture: shortening and volar angulation. (reverse Colles’) displaced anterior / volar Intra-articular fracture : – Barton’s fracture: volar or dorsal – Others Lateral view of Barton’s fracture Clinical: Smith’s Colles’ X-rays: 20 CT scan if fracture extends into joint. Treatment: Smith’s Extra-articular Colles’ fractures: – Close reduction and cast application. – Immobilization for 6-8 weeks. – ROM exercises after cast removal. – Surgery: if reduction is not accepted Intra-articular fracture: – a step more than 2 mm is an indication for surgery. – ORIF with plate and screws. cast ORIF 21 Lower extremity: HIP FRACTURE (old patients >60): It is the most common fracture of LL. It is associated with osteoporosis. Most common mechanism is a fall from standing height. Other causes of fall (stroke, MI) should be rolled out during clinical evaluation. (imp) It is a life changing event. Mortality rate around 20%-25% after one year. Fractures can be classified – Intra-capsular – Extra-capsular – Displaced vs not displaced Intra-capsular: – Subcapital – Trans-cervical Extra-capsular: – Basicervical – Intertrochanteric AVN (avascular necrosis) risk is higher with intra-capsular fracture. AVN is necrosis of head of femur because blood supply comes through the neck. Clinical: Full detailed history of mechanism of injury. R/O syncope, chest pain, weakness etc. 22  A detailed systemic review. Deformity: Abduction, External rotation and shortening. Assess distal N/V status Avoid ROM if fracture is expected. Common associated injuries: 1. Distal radius fracture Roll Out: – Acute coronary 2. Proximal humerus fracture syndrome – Stroke 3. Subdural hematoma X-rays 3 views are needed: – AP pelvis (shows both hips) – AP hip – Lateral hip MRI is sensitive for occult fracture (if you can’t decide whether a fracture is present or not) Basicervical fracture Trans-cervical fracture 23 fr Treatment: No close reduction is needed. No traction is needed. Patient needs surgery ideally within 48 hrs. The goal is to ambulate patient as soon as possible. Be sure that DVT prophylaxis is started. Be sure that patient will be evaluated for osteoporosis after discharge. If fracture is intra-capsular: – Displaced: hemiarthroplasty – Not displaced: percutaneous in situ Screws fixation. percutaneous in situ Screws fixation. Hemiarthroplasty If fracture is Extra-capsular: – Stable: Close reduction and DHS (direct hip screw). – Unstable: Intra-medullary devise (IM). DHS and IM nail are used for fixation (internal/external rotation) in this case: internal rotation  Fracture instabilities signs: (you can read it at home I will not cover it here) 1. Large LT fragment 2. Extension to subtrochantric region 24  3. 4 parts fracture. DHS IM nail Complications:  Nonunion – 2% (IT fractures) – 5% (non displaced neck fracture) – 30% (displaced neck fracture) AVN (femoral neck fracture) – 10% (non displaced) – 30% (displaced) Death: early 4%. At 1 year: 20%40'% VTE Femoral Neck FRACTURE (Young Patients): It is a completely different entity from similar fractures in elders (>60 years). High energy mechanism. ATLS protocol. 2.5%: associated femoral shaft fracture. (long femur X-ray) Patient should be taken to operative room for ORIF within 6 hours. Nonunion: 30% (most common complication) High energy > highly displaced > difficult to reduce (Needs open reduction) AVN: 25%-30% 25 Femur Shaft Fracture: Most common: – high energy mechanisms – Young patients (male 4 mm lateral translation Stable – weber B Medial joint line widen = lateral translation of talus = unstable fracture of ankle MANAGEMENT:  Intact medial malleolus: o Weber A: – Splint + NWB X 6 weeks. – Early ROM. o Weber B/C: – If medial joint line widen (unstable): ORIF – If not: Call Orthopedic for stress film x-rays.  If both malleoli are broken: o ORIF 32  3-Common pediatric fractures The different between adult and pediatric bones:  Pediatric bone has a higher water content and lower mineral content per unit volume than adult bone so less brittle than adult bone.  The physis (growth plate) is a unique cartilaginous structure is frequently weaker than bone in torsion, shear, and bending, predisposing the child to injury through it.  The physis is traditionally divided into four zones that the injury through it can cause shortening, angular deformities.  The periosteum in a child is a thick fibrous structure than adult bone so there is high remodeling rate (because of periodteum, the bone will remodel very well)  Ligaments in children are functionally stronger than bone Therefore, a higher proportion of injuries that produce sprains in adults result in fractures in children. Common Pediatric Fractures:  Upper limb a. Clavicle b. Supracondylar Fracture c. Distal Radius.  Lower limbs a. Femur fractures A. CLAVICLE FRACTURES:  8% to 15% of all pediatric fractures  0.5% of normal deliveries and in 1.6% of breech deliveries  90% of obstetric fractures (due to small birth canal)  80% of clavicle fractures occur in the shaft  The periosteal sleeve always remains in the anatomic position. Therefore, remodeling is ensured. Mechanism of Injury:  Indirect: Fall onto an outstretched hand  Direct: This is the most common mechanism, it carries the highest incidence of injury to the underlying neurovascular and pulmonary structures  Birth injury: patients will present with pseudo-paralysis of the limbs 33 Clinical Evaluation: -  Birth fractures: asymmetric shoulders, palpable mass overlying the fractured clavicle.  Typically present with a painful (acute), palpable mass along the clavicle, Tenderness, Decrease rage of motion there may be tenting of the skin, crepitus, and ecchymosis.  Neurovascular, the brachial plexus and upper extremity vasculature may injured.  Pulmonary status must be assessed. Why? May penetrate the lung and cause pneumothorax Radiographic Evaluation: a. AP view (the most important) b. cephalic tilt view c. apical oblique view Classification (Descriptive):  Location (middle, lateral, medial)  Open versus closed  Displacement  Angulation  Fracture type: segmental, comminuted, greenstick Allman classification: - Type 1: Middle third (most common) Type 2: Distal to the coracoclavicular ligaments (lateral third) Type 3: Proximal (medial) third 34 Treatment: 80% are treated conservative:  Newborn to Age 2 Years o Clavicle fracture in a newborn will unite in approximately 1 week. o Infants may be treated symptomatically with a simple sling or figure-of-eight bandage applied for 2 to 3 weeks.  Age 2 to 12 Years o A figure-of-eight bandage or sling is indicated for 2 to 4 week Indication of operative treatment:  Open fractures.  Neurovascular compromise.  Floating Elbow due to fracture in humerus and clavicle Complications (rare): -  Neurovascular compromise  Malunion  Nonunion  Pulmonary injury B. SUPRACONDYLAR FRACTURE:  Most common pediatric fracture. Due to ligamentous laxity, its site in the metaphysis, and because the distal part of the humerus is very thin.  55% to 75% of all elbow fractures.  The male-to-female ratio is 3:2.  The peak incidence is from 5 to 8 years  The left, or none dominant side, is most frequently injured 35 MECHANISM OF INJURY:  Indirect: most commonly a result of a fall onto an outstretched upper extremity. (Extension type >95%)  Direct: a fall onto a flexed elbow or from an object striking the elbow (e.g., baseball bat, automobile)---(Flexion type < 3%) Clinical Evaluation:  A swollen, tender elbow with painful range of motion.  S-shaped angulation at the elbow  Pucker sign (dimpling of the skin anteriorly)  Neurovascular examination: the median, radial, and ulnar nerves as well as their terminal branches. Capillary refill and distal pulses should be documented. The commonest never to be injured is anterior interosseous never which is branch from the median nerve and it is associated more with extension. The way to assess: ask the patient to do (ok) sign. Gartland classification: 36 Proper X-ray: - AP and lateral - joint above & joint below - other limb (compare) - Two occasions - special view Type 1 Type 2 Lateral elbow x-ray AP view 37  Type 3 Flexion type Treatment 38  Type 1 Extension Flexion Immobilization in a long arm cast Immobilization in a long arm cast in or splint at 60 to 90 degrees of near extension is indicated for 2 to 3 flexion is indicated for 2 to 3 weeks. weeks Type 2 Extension flexion reduce by closed methods followed by casting; Closed reduction is followed by it may require pinning if unstable ,sever percutaneous pinning swelling ,tilting 39  Type 3 extension flexion Open reduction and internal Attempt fixation may be necessary for closed Reduction is often difficult; most rotationally unstable fractures, reduction and require open reduction and open fractures, and those with pinning internal fixation with crossed neurovascular injury pins Complications:  Neurologic injury (7% to 10%) o Most are neurapraxias requiring no treatment Median nerve/anterior interosseous nerve (most common)  Vascular injury (0.5%) brachial artery  Direct injury to the brachial artery, or secondary to swelling.  Loss of motion  Myositis ossificans: soft bone formation in the muscle, during manipulation, which will cause decrease ROM  Angular deformity (varus more frequently than valgus) (10% to 20)  Compartment syndrome ( girls  Bimodal distribution of incidence 2 to 4 years of age, mid-adolescence.  In children younger than walking age, 80% of these injuries are caused by child abuse; this decreases to 30% in toddlers.  In adolescence, >90% due to RTA (most common) MECHANISM OF INJURY:  Direct trauma: Motor vehicle accident, pedestrian injury, fall, and child abuse  Indirect trauma: Rotational injury  Pathologic fractures: osteogenesis imperfecta, nonossifying fibroma, bone cysts, and tumors  How to know if it’s direct or indirect from x-ray? Transverse and comminuted fractures are direct, the spiral is indirect. 43 CLINICAL EVALUATION:  An inability to ambulate, with extreme pain, variable swelling, and variable gross deformity  A careful neurovascular examination is essential  a careful examination of the overlying soft tissues to rule out the possibility of an open fracture RADIOGRAPHIC EVALUATION: a. Anteroposterior and lateral views b. x-ray most include hip ,knee joints CLASSIFICATION:  Descriptive o Open versus closed o Level of fracture: proximal, middle, distal third o Fracture pattern: transverse, spiral, oblique, butterfly fragment o Comminution o Displacement o Angulation  Anatomic o Subtrochanteric Shaft o Supracondylar TREATMENT: Age 95%). b. Unstable: Skeletal traction followed by spica casting if there is difficulty to maintain length and acceptable alignment. Ages 6 to 12 Years a. Flexible intramedullary nails b. Bridge plating c. External fixation: when?  Multiple injuries, open fracture, comminuted and unstable patient Ages 12 to Maturity Intramedullary fixation with either flexible or interlocked nails (age>16y) is the treatment of choice. 45 Operative Indications  Multiple trauma, including head trauma  Open fracture  Vascular injury  Pathologic fracture  Uncooperative patient COMPLICATIONS: Malunion Remodeling will not correct rotational deformities Nonunion –rare Muscle weakness Leg length discrepancy Secondary to shortening or overgrowth Overgrowth of 1.5 to 2.0 cm is common in the 2- to 10-year age Osteonecrosis with antegrade IM nail>> decreased O2 transfusion and nutrient>>> ischemia and lack of immune response). - Raised compartment pressure. ( due to swelling) - Ischemia and lack of immune response. - As a result of all the above the patient at higher risk to develop an infection. - Infection in the presence of a fracture : - Difficult to eradicate - Prolonged antibiotics - Multiple surgeries - Significant morbidity - Significant costs - The fracture will not heal thus you will be obliged to cast him for long time > muscles wasting and joint stiffness. An open fracture is a usually a “red flag” warning of significant trauma ➡ Detailed assessment of the patient is necessary An open fracture is associated with significant morbidity. Must act quickly the sooner you treat the less chance the patient gets into complications. 48  A delay in management is proven to increase the likelihood of complications Give urgent priority while triaging (e.g. open fracture is code 1 ,while closed is 3), provide initial management and consult urgently Diagnosis: - Sometimes obvious! - Other times, settle,,, be observant ( the wound is very small, needs high suspension from the doctor) - So how to know if this is an open fracture or a skin cut ? - You have to keep in mind that any wound close to a fracture is potentially an open fracture until proven otherwise!!! - Whenever a fracture is diagnosed, go back and check the skin. - If you are unsure consider the fracture as open. Over treatment is better than under treatment in this case. - How do you know if the break in the skin is considered an opening between the outside environment and goes all the way deep down to the bone? - A small wound continuously oozing blood (even after applying pressure with a gauze it keeps bleeding), especially if you see fat droplets within the blood (like oil within the blood and it is diagnostic), is an open fracture! (it came from the bone marrow) - Not always close to the fracture. (e.g. a deep bone as femur get fractured, it has to travel a distance because it is covered in soft tissue such as muscle and breaks through the skin away from the site of fracture). ( the deeper the bone the more coverage of soft tissue around the bone the far the opening) - Don’t probe!! - If in doubt, use good light, if there is a break in the dermis or fat is seen, call it an open fracture. - Better to overcall than miss it! 49 Algorithm: Assess and stabilize the patient, ATLS principles. Assess the condition of the soft tissue and bone to help grade the open fracture Manage the wound locally. (try straighten the alignment) Stabilize the fracture. IV antibiotics Tetanus status Assessment: If polytrauma, apply ATLS principles. If isolated injury: Mechanism and circumstances of injury. Time since injury. (the management differ between an open fracture since 1 hour than an open fracture since 12 hours) Past Medical H/Past Surgical H/Allergy/Drugs/Smoking/when was his last meal.(smoking delays the healing and increase the chance of developing an infection) Tetanus vaccination status Ask when was the last meal, if he ate soon before the fracture doctors will apply a different type of intubation. Examine the affected region for: 1- Soft tissue: o Degree of contamination (clean cut with scissors VS leg crashed under a bulldozer in a farm) o Necrotic and devitalized tissue o Size of wound o Coverage loss (the presence of a skin loss that might needs a graft ) 50  o Compartment syndrome( if some compartments are opened some still closed. i.e. the leg has four compartment if two are cut and opened with the accident there still other two who could get swollen and increases in their pressure) 2- Bone: o Comminution (simple VS fragmented) o Stripping of bone periosteum (periosteum important for bone healing and growth) ( if a bone exposed and stripped from everything it is worse than a bone still attached to a soft tissue and to periosteum) o Away from injury to joint above and below. o X-rays to joint above and below 3- neurovascular status distally : o On arrival and post reduction and splinting later. o Document everything to avoid any medico legal issue. Open fracture grade: (take full Hx to grade correctly ) 1- Grade 1 : all these conditions have to apply to consider it as grade 1 - Less or equal to 1 cm, clean (no dirt, the patient is not swimming at time of injury) non segmental nor severely comminuted fracture, less than 6 hours since injury 2- Grade 2 : - >1cm wound, not extensive soft tissue injury or contamination, non segmental nor severely comminuted fracture, no bone stripping and with adequate soft tissue coverage. (could be 20 cm but clean cut and no extensive soft tissue loss) Same as Grade 1 but the wound is > 1 cm 51  3- Grade 3 : anything that does not apply to grade 1 or 2 - 3A: Any size with extensive soft tissue contamination or injury but not requiring soft tissue coverage procedure, or with a segmental or severely comminuted fracture, or late presentation more than 6 hours - 3B: Any open fracture that requires soft tissue coverage procedure. - 3C: Any open fracture that requires vascular repair.( patient came with pulselessness or deformed limp such as wrist drop ) - If combined conditions always take the worse which is 3C( e.g. patient came with an open fracture that needs both soft tissue coverage in addition to vascular repair so we consider it as 3C ). it requires soft tissue coverage. Differ depending on the It is more than 1 cm and it So it is either grade 3B or 3C. scenario: requires soft tissue how to know ? if there is a coverage. So it is either If the injury occurred 6h pulse then it is 3C. ago, it is 3A If there is a vascular injury , it is 3C - You can’t decide based on the picture alone. 52 Management: First you have to do what we said before from stabilizing, to grading. 1- locally : - Take a picture! ( you don’t want to reopen the wound every time another doctor wants to examine it ( intern, registrar, consultant, ortho team). - If dirty, irrigate with normal saline to remove gross contamination.do not use water even if it was sterile.( because osmolarity of the water is more so the tissue will loss fluid due to the concentration gradient. Just irrigate, if there is a big piece you can remove it by sterile equipment). - If bone sticking out try to reduce gently then immobilize and re-check neurovascular status. - Cover with sterile wet gauze. Wet because a dry gauze will stick to the wound and cause more injury when removing it. - If bleeding apply direct pressure on wound. Never use a tourniquet, it will comprise the blood supply. - No culture swabs in ER. Some studies said it is useless Grade 1 > one antibiotic. Grade 2 > two antibiotics 2- Antibiotics: Grade 3 > three antibiotics - First generation Cephalosporin for gram positives (Ex: Cefazolin) in all open fractures. - Aminoglycoside to cover gram negatives ( Ex: Gentamicin) sometimes not required in grade 1 but in general it is safer to give in all grades. Gram + is most common but you can’t guarantee it is only gram +. So If grade 1 and you said I will only cover gram+ or you said I will cover both positive and negative , both answers are correct. - In reality we give both antibiotics to cover both gram positive and negative in grade 1 and 2. - Add penicillin or ampicillin or clindamycin( for anaerobes) for clostridium in grade 3 open fractures and all farm and soaked wounds. 53 3- Tetanus prevention: Wound types: a- Clean wounds: ➡ realignment of limb > if persistant > ➡ vascular intervention  Hard signs > realignment of limb > improved > ➡ Close observation  Why we do realignment? because Realignment can result in unkincking of vessels, lowering compartment pressure, relaxation of arterial spasm ABI (the ankle brachial index) is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. Normal range 1.0-1.2.we do it because the presence of a pulse alone does not exclude vascular injury. < 0.9 associated with vascular pathology Rarely can give false negative result (Ex. Profunda femoris) Always used in high risk fractures (knee) If positive > Urgent vascular intervention 57  What they will ask for to assess if it became abnormal (i.e. ABI 6 hours you have to do Prophylactic fasciotomy. (due to reperfusion reaction i.e. after repairing the vessel the reperfusion will cause edema in the muscle leading to increased pressure>>> compartment syndrome)  Grade 3C open fractures have the worst outcome 58   Amputation may be necessary in severe cases Nerve injuries: Cause of medico-legal concern Accurate assessment and documentation at presentation, post reduction, post-surgery is essential Remember to examine for motor and sensation prior to sedation. Closed fractures with nerve injuries usually does not require surgery : why? ➡ Usually good outcome >80% ➡ Usually managed conservatively in the early stages ➡ Recovery may take more than 6 months ( most of the time it will recover spontaneously) 59  Intact nerve before reduction, absent after reduction: o Controversial management o Usually observe it is acceptable if you say I will redisplce the fracture after you discovered that after the reduction there were absence of nerve intact. But is has been proven that it Radial nerve run in is not always useful. Just observe. the spiral groove  Closed Fracture requiring surgery with nerve injury : (what dictate the need of surgery is the fracture not the nerve injury) o Limited exploration(do not perform another incision specially for fixing the nerve itself, we do surgery for fixation of bone only if the nerve is in our way we fixed if not we don’t do another incision). Open fracture with nerve injury: o Explore, tag nerve ends for later repair.(we do suture like a tube between the two ends of the nerve ends) Follow up: Clinically: o Electrodiagnostic assessment start at 6 weeks then serially every 6 weeks( 6 weeks because if done before 6 weeks it is useless and it cannot be read) o If no improvement:  Nerve exploration: neurolysis / repair / grafting  Tendon transfers to preserve function. ( done when the nerve grafting is not expected to succeed or already failed. E.g. we take one of the plantar flexor tendons in case of foot drop )  In other words some Tendons are transferred in order to restore more normal movement to a foot and ankle that has lost function.  Common sites of nerve injury : o Shoulder fracture / dislocation > Axillary nerve o Distal humeral shaft fracture > Radial nerve o Elbow fracture / dislocation > Median>>radial>>ulnar o Hip fracture / dislocation > Sciatic nerve o Knee fracture / dislocation > Peroneal nerve 60  Pelvic trauma In the poly trauma patient:  Pelvis anatomy :  Pathology : how the patient may cause instability fracture to his pelvis ?  We have three mechanism : o 1- fall on one leg causing vertical sheers pelvic fracture( figure G).extremely unstable o 2- lateral compression , e.g. car accident (figure D,E,F) o 3- Anterior force causing open book. (A,B,C)  More survival with open book then lateral compression and least is the vertical. Figure A : Anterior force causing a little opening in the sacro-illiac joint. Figure B: Anterior force causing a little opening in the sacro-illiac joint and instability. Figure C :more force caused open book pelvis. In this kind of injuery, the left and right halves of the pelvis are separated at front and rear, the front opening more than the rear, i.e. like opening a book Figure D,E,F : lateral compression 61 Figure G : vertical shears pelvic fracture.  Pelvic fractures / instability may cause life threatening bleeding. The bleeding will be from the internal iliac artery and it will be retroperitoneal that’s why it cannot be seen in US(FAST). So a patient comes after a high energy trauma we give him blood his blood pressure will increase then after a while it will go down, so what to do? Give him fluid again the patient will response then the pressure will go down again this will tell you it is a matter of volume not cardiogenic or anything else. so where is the fluid we are giving is going??? You have to suspect an internal bleeding. Diagnosing pelvic instability can save lives Diagnosis: History: High vs. Low eneregy trauma Mechanism of injury: Anterior vs. Lateral vs. Axial force Pelvic skin contusion, bruising Short extremity (in vertical shears) Careful neurologic assessment. Primary survey : part of “C” circulation o Assess stability by gentle compression on the ASIS o Traction on the leg and assess pelvic instability (traction on leg while your hand at the iliac crest if it moves then it is a vertical shear fracture).  If unstable or painful: Apply sheet around hips and close the pelvis gently (around the trochanter used in case of compression fracture) This results in decreased intra-pelvic volume leading to tamponading the bleeding(by increasing the pressure around the vessel the blood pressure will rise). Traction on the leg to stabilize vertical instability. This minimizes ongoing vasculature injury and bleeding 62  Rectal exam: o Bone fragments ( a pelvic bone fragment got inside the rectum and it could be sharp so be careful) o High riding prostate ( a sign of pelvic fracture) o bleeding Blood at the meatus Labial or scrotal echymosis Vaginal exam All these are hints of pelvic fracture along with the Hx of high energy trauma and bruising on the side. Management: Stabilize pelvis with binder If vertically unstable apply traction IV resuscitation Look for other injuries Check response If partial response, may require angiography for embolization of bleeders May require external fixator and/or pelvic clamp( the patient going to OR for other issue like abdominal laparotomy or something we do external fixation) Early diagnosis Aggressive resuscitation Coordinated team effort In the right picture, the binder is too Save lives tight that it may block the external iliac artery. The binder should be around the level of the femoral head. 63 Summary :  Open fracture A fracture that at some point communicated with the environment.  The bone could be visible within the opening wound at time of presentation or not.  that any wound close to a fracture is potentially an open fracture until proven otherwise!!!  If a small wound continuously oozing blood+ you see fat droplet within the blood, it is an open fracture.  If poly trauma apply ATLS  If isolated take full Hx( time since injury, PSM , PSS, allergy, drugs, smoking, when was the last meal)  Asses the affected limp for : (soft tissue , bone , neurovascular status)  Remember to check neurovascular status on arrival, post reduction, and after splinting, before OR, and after OR. Document everything.  Open fracture grade: o Grade 1 : less than or equal to 1 cm , < 6 h since injury, clean wound, non- segmental nor severely comminuted. o Grade 2 : same as grade 1 except > 1 cm o Grade 3 : anything that does not apply on 1 or 2 :  3A: any size, > 6 h, no need for soft tissue coverage, extensive contamination of soft tissue.  3B: any open fracture needs soft tissue coverage  3C; any open fracture needs vascular repair  To know wither it is 3B or 3C check for pulse.  Grade 1 give 1st generation cephalosporin ( gram +) Ex: cefazolin  Grade 2 cover both gram – and +  Grade 3 add penicillin to cover for anaerobes such as clostridium  In real life we try to cover for both gram – and + in grade 1.  Tetanus vaccination :  clean wound : if booster less than 10 years do nothing, if more than 10 years or patient does not know or unconscious give 0.5 ml Td  Other wounds: if booster less than 5 year do nothing, more than 5 years give 0.5 ml Td. If not known or patient unconscious give 0.5 ml Td + TIG 250U (immunoglobulin)  In OR : irrigate with normal saline, debride necrotic tissue.  Remove bone fragments without soft tissue attachment except those with articular surface.  Do not close wound on first look. Recheck again after 48-72 hours.  Avoid internal fixator, we use external fixator.  In vascular injury : 64  Hard sign >>> do realignment>>>improved>>> close observation.  Hard sign>>> do realignment >>> persistent >>> vascular intervention.  Orthopedic surgeon go first do quick fixation then vascular surgeon to do repair.  Nerve injury :  Close fracture that does not needs surgery for fixation but with nerve injury>>observe  Intact before reduction , absent after reduction: usually observe  Close fracture require open reduction and internal fixation but there is nerve injury >>>limited exploration  Open fracture with nerve injury >>> explore, tag nerve ends for later repair.  Pelvic fracture :  fall on one leg causing vertical sheers pelvic fracture.extremely unstable  lateral compression , e.g. car accident  Anterior force causing open book.  More survival with open book then lateral compression and least is the vertical. 65  5- Bone & joint infection (emergencies/ red flags) (This is 430 team work, we coped it because it’s identical to our lecture) Introduction: Bone infections are considered one of the red flags because if you ignore them, they may affect patient's life (he may die). Also, they are easily preventable just by giving the right treatment at the right time & they are very obvious (clear to identify)  Initial treatment  based on presumed infection type  clinical findings and symptoms.  Definitive treatment  based on final culture  Glycocalyx : [It's a polysaccharide formed by the bacteria around metal implants (e.g. prosthetic knee) to protect themselves against the immunity, usually the treatment is not completed unless the metal is removed. - exopolysaccharide coating - envelops bacteria - enhances bacterial adherence to biologic implants Bone Infection: 1. Osteomyelitis. [oste= bone, myel= bone marrow , itis= inflammation] 2. Septic arthritis. -Mostly OM is treated medically by Abx unless there is pus. 3. Infected Total Joint Arthoplasty. -While waiting for the culture results (take 3-5 days) always 1] Osteomyelitis: start with broad spectrum empirical Abx depending on the infection of bone and bone marrow most common organism in this area. Route of infection – direct inoculation  Open fractures, , e.g. inserting the bacteria while you are giving an injection to a patient with tendonitis.[ from the environment ] – blood-borne organisms  hematogenous [most common] 66  Determination of the offending organism – NOT a clinical diagnosis – DEEP CULTURE is essential Classification A. Acute hemotagenous OM B. Acute OM C. Subacute OM D. Chronic OM A. Acute Hematogenous OM: [No Hx of trauma , open wound or injections (nothing from outside) before 2 weeks ] Case: child, Hx of sore throat 2 weeks ago. He was ok but 5 days ago he started to limp then unable to walk. He is febrile & look sick [acute presentation]  Clinical features caused by blood-borne organisms b/c they are More common in children rich blood – Boys > girls supplied areas. – most common in long bone metaphysis or epiphysis – Lower extremity >> upper extremity Pain [localized] Loss of function of the involved extremity (e.g. if it's in the upper extremity he will not be able to shake hands, eat,wave &move…) Soft tissue abscess.[ Redness/swelling][ localized to the site of infection especially at the beginning ]. Fever. 67  Radiographic Changes:[ x-ray is not a diagnostic tool] soft tissue swelling (early) [ the only sign you’re going to see in acute presentation bone demineralization (10-14 days) sequestra  dead bone with surrounding granulation tissue. which looks in the X- ray as a white area within a black area. The black area is the infection while the white area is the necrotic bone  late sign.[It has to be removed in the OR b/c mostly it won’t resolve by itself otherwise they will become a source of infection] involucrum  periosteal new bone [which looks in the X-ray as if the cortex of the bone is doubled with a black space, separates the 2 layers]  late sign Taking a sample from the throat to know the organism doesn’t help b/c it is usually different organism. Also, the culture will take 5 days either you take it from the bone or throat. So, there is no benefit.  Diagnosis elevated WBC count elevated ESR: [ takes almost 3 weeks to peak up] blood cultures  may be positive C-reactive protein: [ very important for diagnosis & follow up of treatment, it takes 5 days to peak up]  most sensitive monitor of infection course in children  short half-life  dissipates in about 1 week after effective treatment Case about CRP: If you have a young patient with a history of frequent travelling abroad (these people have tendency to have multiple organisms) & you gave him a broad spectrum first generation cephalosporin, in 5 days the patient still spiking fever & he doesn't look well (this mean that you don't treat the right organism with the right Abx) & the clinical examination suggesting that he isn't responding , what you are going to do?? -Request CRP & it will peak up within 5 days & if the patient isn't responding to Abx , you have to change it otherwise he will go into septic shock & die. 68  Nuclear medicine studies  may help when not sure. [there will be high uptake(reactive area)but it is not specific (it just give a clue) b/c it could be soft tissue, bone infection or pathology other than infection like tumor] MRI: [the best diagnostic/sensitive tool but it takes time to arrange, children need to be anesthetized][MRI is the most sensitive for infection] - shows changes in bone and bone marrow before plain films - decreased T1-weighted bone marrow signal intensity - increased postgadolinium fat-suppressed T1-weighted signal intensity - increased T2-weighted signal relative to normal fat There is increase signal intensity of the proximal tibia which indicates OM of proximal tibia  Treatment Outline: [Mostly with broad spectrum Abx at first then change to specific Abx after the culture except in some indications. So, it's treated medically most of the time not surgery].  Take samples for culture  Start empirical broad-spectrum Abx  Observe improvement with clinical parameters (Temp, pain) and blood tests (ESR,CRP).  Review culture results within 3-5 days, if you find discrepancy between what you thought is the organism & the culture result then you have to think either you need to adjust your Abx or not and proceed accordingly. 69  Case: Pt is suspected to have OM and you admit him & started to give him empirical Abx because you thought that it is S.aureus as it's the most common organism. However the culture showed that the organism is not covered by your Abx>> what should you do? If the pt is improving clinically(symptoms) + Lab test ( CRP going down) to your Abx don’t change it even if the sensitivity test shows that the organism isn't sensitive to the ABx. If there is not improvement change it.  Decide on duration of Abx (IV vs oral) [Duration mostly complete 6 weeks, sometimes start with IV for few weeks and then orally and sometime all the 6 weeks IV depends on the severity  ,immunocompromised pt,…ect] e.g.: young ,no medical problems barely acute presentation 3 weeks is enough. While if he is old with HTN,DM and renal failure max (6weeks).  Empirical Treatment  Before definitive cultures become available  based on patient’s age and other circumstances -The most common organism in all age groups is S.aureus. So, what you need to think about is the second organism in each age. 70  Organism Empirical Tx Notes Newborn - Staphylococcus aureus(most Broad - Immunity is not fully common) Spectrum Abx Developed so they may be [0-4 months] - Gram-negative bacilli. Afebrile(don't have fever) - Group B streptococcus. ,Cry.[difficult to dx] - 70% positive blood Culture before Abx, not aspiration from bone or deep tissue..[other age groups are less] - You may find some swelling. - can't localize the pain, wherever you touch the baby, he will cry. Children - S. aureus (most common). Broad - Haemophilus influenza - Coliforms  (uncommon  Spectrum Abx [ >4 months] Vaccnine) Boneinfections almost Completely eliminated  due to Vaccination. Adults - S. aureus(most common). Broad - Wide variety of other organisms Spectrum Abx [≥21 years old have been isolated. [especially in people who have abnormal life style.] Sickle cell - Salmonella is a characteristic( Broad Anaemia most specific) organism – but Spectrum Abx not the most common - S.aureus is still the most common Empirical – S. aureus Broad They are treated aggressively Treatment Spectrum Abx (combining 2-3 Abx or one but – S. epidermidis (b/c come from Very tough Abx)b/c they are Hemodialysis skin) considered as and IV drug immunocimpramised patients. abuser – Pseudomonas aeruginosa 71  Operative Treatment: Indications for operative intervention:  Drainage of an abscess  Débridement of infected and necrotic tissues  sequestrum prevent further destruction.  Refractory cases that show no improvement or the patient is getting worse after non- operative treatment. B. Acute OM: After open fracture or open reduction with internal fixation.[injections]  Clinical findings  similar to acute hematogenous OM.[same presentation the only difference is the treatment]  Treatment:  Radical I&D [Irrigation & Debridement], remove anything looks like dirty or died tissue SURGERY.[ b/c infection after open fractures tends to be chronic also you want to prevent the infection before its happening that why you start aggressively by surgery].  Removal of orthopaedic hardware if necessary.  Soft tissue coverage for open wounds  if needed. [The bone must be covered to prevent infection and if it’s infected it will get worse].  Most common offending organisms are:  S. aureus.  P.aeruginosa.  Coliforms.  Empirical therapy Broad-spectrum Abx. 72 C. Subacute OM:  Diagnosis [Usually]: - Painful limp.[mild] - No systemic and often no local signs or symptoms. - Signs and symptoms on plain radiograph.  May occur in: - Partially treated acute osteomyelitis. - Occasionally in fracture hematoma.  Frequently normal tests: [usually results appear normal] – WBC count. – Blood cultures.  Usually useful tests:  ESR.  Bone cultures.  Radiographs  Brodie’s abscess (the arrow)  localized radiolucency seen in long bone [femoral,tibia] metaphyses  difficult to differentiate from Ewing’s sarcoma.  Treatment:  Most commonly involves femur and tibia.  It can cross the physis even in older children.  Metaphyseal Brodie’s abscess  surgical curettage. D. Chronic OM: Can arise from: - Inappropriately treated acute osteomyelitis - Trauma - Soft tissue Anatomical classification  check fig.[not imp] Population at risk:  Elderly.  Immunosuppressed patients. (e.g. rheumatoid arthritis)  Diabetic patients.  IV drug abusers.  Hemodialysis patient. 73  Most common organisms: - S. aureus. - Enterobacteriaceae. - P. aeruginosa.  Clinical Features:[ not acute presentation & mostly no fever/some pain/some loss of function] Skin and soft tissues involvement.[pus discharge] Sinus tract  may occasionally develop squamous cell carcinoma.[b/c of the chronic irritation] Periods of quiescence  followed by acute exacerbations.[means they don’t present the same for the whole period, they recover and then relapse …so on] Sonogram: It is a special X-ray procedure that is done with contrast dye to visualize any abnormal opening (sinus) in the body. If the dye reaches the bone that means it is chronic OM.  Diagnosis: Nuclear medicine  activity of the disease Best test to identify the organisms Operative sampling of deep specimens from multiple foci.  Treatment: [Should Be Based on the Culture] - Empirical Therapy  is not indicated. MCQ [wait for the culture unless it is acute in-top if chronic] IV antibiotics  must be based on deep cultures. 74 Surgical Debridement: [ imp to remove the implant] Complete removal of compromised bone and soft tissue Hardware: - Most important factor. - Almost impossible to eliminate infection without removing implant. [If you can't remove the implant e.g. patient with fractured ankle. You wait until the fractured heal & then take it out & then do your aggressive treatment & Abx. If you can't &the patient stared to develop septicemia or septic shock, you need to transform your implant by removing it & put external fixture but don't leave the fracture loose & mobile]. – Organisms grow in a glycocalyx (biofilm) shields them from antibodies and antibiotics. Bone grafting and soft tissue coverage is often required. Amputations are still required in certain cases. -Treatment is to open & clean the abscess & if you can take culture. 2] Septic Arthritis: [mostly treated surgically b/c the cartilage is very sensitive to infection, So if it was leaved for a few hours to a day the cartilage will be gone forevertake the patient to the OR and wash it out]  Route of infection: – Hematogenous spread. – Extension of metaphyseal osteomyelitis in children. – Complication of a diagnostic or therapeutic joint procedure.  Most commonly in infants (hip) and children.  Metaphyseal osteomyelitis can lead to septic arthritis in: [ areas where it’s near the cartilage (within the joint capsule].  Proximal femur[e.g. greater trochanter]  most common in this category.  Proximal humerus.[suspect the shoulder is also affected].  Radial neck.  Distal fibula. (ankle). 75  Adults at risk for septic arthritis are those with:  RA  Due to joint effusion, Synovium is always inflamed & the immunity is compromised. – Tuberculosis  most characteristic Case: Pt has septic artharitis in the elbow – S. aureus most common  Suspect RA  IV drug abuse  Pseudomonas most characteristic, but not the most common.  Treatment Outline: 1st OR (surgery]: open or orthoscopic & take sample for culture) 2nd  Empirical Abx & after 3-4 days you will get the result & adjust according to it. o Empirical therapy: [After the surgery][if the patient has OM and SA is suspected take him to the OR, SA has the priority} Prior to the availability of definitive cultures. Based on the patient's age and/or special circumstances. a. Newborn (up to 3 months of age): o Most common organisms:  S. aureus.  Group B streptococcus. o Less common organisms:  Enterobacteriaceae.  Neisseria gonorrhoeae. – 70% with adjacent bony involvement. – Blood cultures are commonly positive. – Initial abx after sugical wash out  broad-spectrum Abx. b. Children (3 months to 14 years of age) o Most common organisms:  S. aureus.  Streptococcus pyogenes.  S. pneumonia.  H. influenzae  markedly decreased with vaccination.  Gram-negative bacilli. – Initial treatment  broad-spectrum Abx. 76  Acute monarticular septic arthritis in adults: [severity depends on how many joint is involved, if monarticular = less serious while if polyarticular = more serious]. o Most common organisms:  S. aureus  Streptococci  gram-negative bacilli – Antibiotic treatment  broad-spectrum Abx  Chronic monarticular septic arthritis o Most common organisms:  Brucella  Nocardia  Mycobacteria  fungi  Polyarticular septic arthritis: o Most common organisms:  Gonococci  B.urgdorferi  acute rheumatic fever  viruses  Surgical Treatment: Mainstay of treatment. – Surgical drainage  open or arthroscopic.[Orthoscopic is used more b/c it is less invasive, can reach difficult places, same results as open] when you are asked what is better? Say the results are comparable and you can do either. – Daily aspiration [not recommended]. o Tuberculosis infections  pannus  similar to that of inflammatory arthritis.[not imp] o Late sequelae of septic arthritis soft tissue contractures It's a problem even after cleaning the joint may require soft tissue procedures (such as a quadricepsplasty to be able to bend the knee).[not imp]. Just remember that the treatment of choice for SA is surgery (either open or arthroscopic) & give empirical Abx after the surgery. 77 3] Infected Total Joint Arthoplasty [TJA]: [always when there is a metal you are afraid of infection, most common knee then hip & shoulder].  Prevention:[measures to avoid infection][the best Treatment is prevention]. Perioperative intravenous antibiotics  most effective method for decreasing its incidence Good operative technique Laminar flow  avoiding obstruction between the air source and the operative wound Special “space suits” Most patients with TJA do not need prophylactic antibiotics for dental procedures Before TKA revision  knee aspiration is important to rule out infection.[so if there is any sign of infection e.g scratch don’t start TKA procedure] Laminar flow Special “space suits”  Most common pathogen:  S. epidermidis most common with any foreign body.[b/c the problem comes from the skin].  S. aureus.  Group B streptococcus.  Diagnosis:  ESR  most sensitive but not specific.  Culture of the hip aspirate sensitive and specific.  CRP may be helpful.  Most accurate test tissue culture.  Preoperative skin ulcerations   risk. 78   Treatment Outline:  Acute infections [within 2-3 weeks of arthroplasty]: [Just wash it out & take the insert out & replace it]. – Prosthesis salvage  stable prosthesis. – Exchange polyethylene [a plastic material] components – Synovectomy beneficial.  chronic TJA infections [>3 weeks of arthroplasty]: – Implant and cement remova.[to replace the metal , take it out & put a new one]. – Staged exchange arthroplasty. – Glycocalyx:  Formed by polymicrobial organisms.  Difficult infection control without removing prosthesis and vigorous debridement. – Helpful steps:  Use of antibiotic-impregnated cement.  Antibiotic spacers/beads. 1- Take out all the implant. 2- Put a. Polyethylene (to prevent soft tissue contraction)and b. Cement is mixed with Abx and placed in the joint. 3- After infection is over. 4- Place a new implant. The doctor mentioned these scenarios at the end of the lecture: 1- You have a patient who is 30 years old , drug abuser came to the ER because of limping , inability to walk, fever & pain. What you are going to do? - Hx. - Physical EX. BP=80/40. The doctor mention that he is in septic shock. So, he will start very aggressive Abx & IV fluid & take the patient to the OR ASAP. Let us assume that the patient was taken to the OR , it was septic arthritis with distal femur OM , you washed it out & you debris the joint. Everything was good & the patient stabilized a little bet & you took him back to his room. What you are going to do now?? -continue on Abx & monitor his response by clinical exam , vital signs , WBC, ESR, CRP. - The second day you find the patient looks better than before but the vital sign is still spiking fever & CRP is still high. So, you give broad spectrum ABx or add another Abx to the one you already gave. 79 6- Compartment syndrome and acute joints dislocation Objectives of Compartment Syndrome: 1. To explain the pathophysiology of CS 2. To Identify patients at risk of developing CS 3. To be able to diagnose and initially manage patients with CS 4. To be able to describe the possible complications of CS Objectives of Acute Joints Dislocations: 1. To describe mechanisms of joint stability 2. To be able diagnose patients with a possible acute joint dislocation 3. to be able to describe general principles of managing a patient with a dislocated joint 4. to describe possible complications of joint dislocations in general and in major joints such as the shoulder, hip and knee Compartment Syndrome What is a compartment? It is a Group of muscles in a limb that is surrounded by fascia, This fascia keeps each compartment separate from each other and it can expand for some degree but not too much. What is the tissue pressure normally? 80  Let’s assume that its 3-5 mmHg, how does it affect the compartment? So let’s for an example take the tibial artery, it normally has a high pressure and it has branches and branches re-branch and re-branch till we reach ARTERIOLES. Arterioles becomes capillaries and capillaries becomes venioles. So at this point the thickness of the vessel’s walls becomes very thin and that’s where the exchange of oxygen and materials occur “This place is called Capillary Fill”. And exchange occurs by DIFFUSION. So for this process to occur, the pressure of capillaries must be HIGHER than the pressure of the atmosphere around it. So what happens in compartment syndrome is that the pressure of the compartment becomes VERY HIGH so that the process of exchange becomes affected. So when the blood reaches the capillary and tries to expel wastes, the high pressure of the compartment prevents it. So the blood will continue its flow and goes to the venule side and the venous blood becomes oxygenated rather than de-oxygenated. The blood will not stop from moving unless the pressure of compartment reaches the diastolic pressure or more (80 or above) (So Compartment pressure > Capillaries pressure. = a problem in exchange.) The difference between acute leg ischemia and compartment syndrome is that Acute leg ischemia have a complete block of blood supply from the artery while in compartment syndrome we rarely see complete block. (So you will rarely see “Pulseless” as a sign of Compartment Syndrome) Risk Factors:  Trauma: Open or Closed fracture so a person got his leg crushed by an accident, what will happen? There will be cell damage > Leakage of cell fluid > Edema > Compression > Blood supply and oxygenation becomes compromised > some cell may die > dead cells leak their fluid > more edema > more pressure. And so on! How it happens in open fracture: may be the bone is out and the compartment is intact or maybe there is a small opening in the fascia but surrounded by dead cells and edema so it will also cause pressure. * When you look at this picture you will see that the skin is damaged but the fascia is intact, thus the muscle can’t expand = Compartment Syndrome. 81   If there is Fascitis. The fascia may be necrotized and melted, Thus there will be no pressure on the muscles and they can expand but when they reach the skin there may be a pressure because the skin will prevent this expand.  Also in burns, the pressure comes outside of the compartment “Edema” but the edema itself may apply an outside pressure on the compartment, thus we don’t do Fasciotomy in burns, we do Escharotomy..  Injection injections may mistakenly go inside the compartments thus increasing pressure.  Bleeding  Prolonged vascular occlusion (reperfusion injury) Tissue Damage caused by return of blood flow after a period of ischemia. So it’s a big mistake to put a tourniquet above the wound instead of direct pressure because there will be muscle damage, also when you remove the tourniquet after several hours the blood will flow back but it will find that the tissue has already gone and it will spill and cause more pressure and will even damage the survived tissue. Also it might cause acute renal failure because of myoglobin release by muscles.  Venomous bite  Intra-osseous fluid replacement  IV fluid extravasation  Tight bandage  Post-surgery: The most important symptom of CS is PAIN. So a patient after surgery will not feel pain because of anesthesia thus we have to check him for compartment syndrome repeatedly. Threshold pressure:  30 mm Hg (rigid). The Compartment’s pressure itself = 30 or above.  Less than 30 mm Hg difference between compartment pressure and diastolic pressure (clinically relevant). For example: A patient with a diastolic pressure of 90 and a compartment pressure of 70, the difference between them = 90 – 70 = 20 which is less than 30 , so we consider it a Compartment syndrome. Another example, a patient with a fracture in the ulna has a diastolic pressure of 80 and a compartment pressure of 25. 80 – 25 = 55 which is more than 30 so its not a Compartment Syndrome. 82 Diagnosis:  Early: - Most important sign is PAIN. It increases while stretching the involved compartment. For example if you want to check the posterior compartment of the leg you will do dorsiflexion. The pain will be increased when there is Compartment syndrome. - Presence of Risk Factors: patient with ankle spray mostly will not have a CS because ankle doesn’t have much muscles and have ligaments and tendons. But in tibia fracture we consider it as a risk factor. - Measurement of compartment pressure is high - High index of suspicion  Late: - 4 Ps: Paralysis, Paresthesia, Pallor and Pulslessness. - Pulslessness usually not common, Compartment pressure usually very high. - Tight, woody compartment - Tender compartment - Measurements Rarely necessary, must be done at area of highest expected pressure and may give false low result  Time window for CS is 6 Hours. But it differs from person to person.  Skin will not be affected because skin perfusion is extra compartment. So after a very long time of CS “1 day” the skin will still be normal! Management:  Initial (undeveloped CS): - Maintain normal blood pressure - Remove any constricting bandage Ex: Watch, Bandage, Cast - Keep limb at heart level We don’t want to make it above heart level because we don’t want to decrease capillary fill and we don’t want to make it below heart level because it will decrease venous return. - Regular close monitoring (15-30 minute intervals) - Avoid nerve blocks, sedation and strong analgesia to obtain patients feed back  Fully developed CS: - Maintain normal blood pressure 83  - Remove any constricting bandage - Keep limb at heart level - Diuresis to avoid kidney tubular injury if late - We do the same above + Check heart and kidney function and we plan for an emergent surgery “Fasciotomy”  Fasciotomy: - Releasing the compartment fascia - Allows swollen muscles to expand in volume - Results in decreased compartment pressure - Avoids further damage - Does not reverse already occurred damage - Ideally should be done as soon as diagnosis is made - Should be done as long as there is still viable tissue - Should not be done if there is no expected viable tissue, Otherwise infection is likely. - Debridement of all necrotic tissue is necessary - Second and third look surgeries are often required - Closure of skin is usually achieved after swelling has subsided - Skin grafting is often required  Indications of fasciotomy: - 6 hours of total ischemia time (ex: arterial embolism) - Significant tissue injury - Worsening initial clinical picture - Delayed presentation with a picture of developed CS - Absolute Compartment pressure >30 mmHg or myoglobenemia>myoglobinuria> kidney tubular damage  Loss of function of the involved compartment: - Flexion contracture - Paralysis - Loss of sensation - Leg:  Anterior compartment: Drop foot we give him splint to protect his toes while walking 84   Deep posterior compartment: Clowed toes Loss of sensation in the sole  Forearm: Volar compartment > Volkman contracture Images below Acute Joint Dislocation Joint stability: Why some joints are more prone to dislocation than others?  Bony stability - Shape of the joint (ball and socket vs round on flat)  Soft Tissue : - Dynamic stabilizer: Tendons/Muscles so you can move your patella laterally but when you contract your quadriceps it comes back to its place. - Static stabilizer: Ligaments ± meniscus/labrum when you move your leg to valgus or varus it holds its place because of tendons and ligaments mostly. Also in shoulder, what keeps humerus stable in its place is the capsule and the labrum.  Complex synergy leading to a FUNCTIONAL and STABLE joint Joint Dislocations:  Dislocation is a Total loss of contact between the articular surfaces of the joint while Sublaxation is a partial loss of contact between the articular surfaces of the joint  There is Acute joint dislocation and Chronic joint dislocation  It takes higher energy to dislocate a joint with bony stability than a joint with mainly soft tissue stability 85   Connective tissue disorders may lead to increased joint instability due to abnormal soft tissue stabilizers.  Dislocation of a major joint should lead to considering other injuries. Major joints: Anything in spine, Shoulder, Elbow, Wrist, Hip