Western U FOM 6 Orthopedics Lecture PDF

Introduction to Orthopedics OMSII Adam Kreutzer, DO – Orthopedic Resident Wade Faerber, DO - Orthopedic Program Director We have no interests to disclose related to products presented In this course. Tree of Andry: Nicolas Andry...

Introduction to Orthopedics OMSII Adam Kreutzer, DO – Orthopedic Resident Wade Faerber, DO - Orthopedic Program Director We have no interests to disclose related to products presented In this course. Tree of Andry: Nicolas Andry (1741) Outline Pediatric Orthopedics Avascular necrosis (osteonecrosis) Osteonecrosis Osteoarthritis Fracture fixation Orthopaedic Infections Orthopaedic emergencies Spine Sports Orthopedics Pediatric anatomy Physeal injuries Growth plates(physis) in the pediatric patient is a site of weakness compared to the surrounding bone. Injury may lead to growth arrest causing limb length inequality and/or deformity Important to recognize injured vs non-injured anatomy Physeal fractures  Pediatric elbow fractures Ossification centers of the elbow and age it starts to ossify. CRITOE Capitellum (1) Radial head (3) Internal or Medial epicondyle (5) Trochlea (7) Olecranon (9) External epicondyle (11) Most common pediatric elbow injuries Elbow- things to look for More things to look for Lateral must be a good lateral Look for a fat pad sign Lateral condyle fracture Pay close attention! Slipped Capital Femoral Epiphysis (SCFE) Most common disorder affecting adolescent hips with a prevalence of 1/10,000 Risk factors Obesity, males More common in African Americans, Pacific islanders, and Latino population. Occurs more common in periods of rapid growth (10-16 years). Should be assessed for hypothyroidism, renal osteodystromy, growth hormone deficiency, hypopituitarism, and Down Syndrome. SCFE continued Presentation Thigh, groin, or knee pain If knee pain in this age group, should consider hip x-rays since 15-50% of hip pain in adolescents may come from hip pathology Exam May limp Obligate external rotation Monteggia (ulna shaft fracture with radial head subluxation) Very important to make sure that the radial head points to the capitellum in all views Galleazzi fracture If you have a radius fracture, may also have an injury to the distal radioulnar joint Read this: This is an AP and cross table lateral view of the left hip in a skeletally mature individual demonstrating a sub-capital femoral neck fracture with varus angulation and displacement. What does sub-capital mean? The femoral neck is broken up into three fracture locations: − Subcapital: below the femoral head itself. − Transcervical: across the middle of the femoral neck. − Basicervical: across the base of the femoral neck (very similar to an intertrochanteric facture.) Avascular Necrosis Death of marrow and bone cells Often poorly understood etiology − Steroids & EtOH may alter lipid metabolism − 75% may have subtle coagulation defects Osteonecrosis − in situ death of a segment of bone − preferred term; vessels generally remain Avascular Necrosis Femoral head most common other common (15% with hip AVN) − humeral head − knee − talus − small bone of hands & feet Etiology Trauma Steroids 80% bilateral − #1 known cause Congenital EtOH Idiopathic Radiation Infectious SLE Iatrogenic (SCFE reduction). Medications Metabolic − HIV; Chemo; Autoimmune Transplants Neoplastic Mechanism Mechanical disruption External pressure or damage to vessel wall Arterial Thrombosis Venous Outflow obstruction Blood Supply Ascending cervical branch of medial femoral circumflex Trauma 10% undisplaced femoral neck fractures 15-30% displaced fractures 10-15% hip dislocations Osteonecrosis of Carpus Scaphoid and lunate are the common wrist bones affected.  Anatomy-Blood Supply Superficial branch of radial artery − Distal − Volar Dorsal carpal branch of radial artery (main blood supply, 80% of the proximal pole supply) − Dorsal − Retrograde flow Poor supply to proximal pole Leads to high rate of non- unions & AVN of proximal pole fractures (14-40%) Osteoarthritis Arthritis is the progressive loss of cartilage in joints. Diagnose with plain x-rays of the affected joint and look for joint space narrowing. Risk factors include previous trauma, high impact activities, surrounding muscular weakness, and female gender. − Avascular necrosis is another risk factor for arthritis development. Osteoarthritis continued Changes occur in the effected joint. − Cartilage water content increases and collagen becomes increasingly disorganized. − Synovium becomes inflamed and thickened. − Subchondral bone remodels creating cysts with sclerotic edges. Osteoarthritis Physical examination: − May ambulate with antalgic gait − Painful, decreased range of motion. − May have swelling and generalized tenderness to palpation. − Crepitus with range of motion. Osteoarthritis x-rays. Osteoarthrits x-rays Osteoarthritis Treatment Initial treatment should be conservative with activity modification, NSAIDs (Meloxicam and Diclofenac gel), weight loss/strengthening of surrounding muscles, and finally corticosteroid injections. Corticosteroid injections are often a combination of of a lidocaine derivative with the corticosteroid (we use ropivacaine and Kenalog). Corticosteroid injections Diagnostic and therapeutic. Can cause local atrophy of tissues, cartilage softening, and speed up the progression of arthritis BUT this doesn’t matter given the treatment. Very small amount of the medication leaves the joint but still only give the injections once every 3-4 months. Increased risk of septic arthritis (will talk about this later). Total Hip Arthroplasty Total Knee Arthroplasty Challenges of arthroplasty Implant selection. Balancing the knee. Bone defect management. Challenges of arthroplasty How do we fix fractures? Casts Splints Screws Plates Intramedullary nails External fixation devices. Casting and Splinting Used to stabilize fractures. Cast wraps all the way around the extremity while a splint does not. Brace is usually a removable prefabricated plastic. Can be the final treatment or a temporizing measure depending on the situation. Screws Lag screws: These screws are used to compress a fracture. The screw is placed perpendicular to the fracture. Cancellous screws: coarser threads designed to anchor in medullary bone. Cortical screws: finer threads designed to anchor in cortical bone. Cannulated screws: hollow in the middle. Designed to screw over a wire that has been drilled into the bone for temporary fixation. Locking screws: having threads on the heads so they can lock into special plates. Plates: Compression plate: have oval holes designed to allow the plate to pull the fracture parts together. Neutralization plates: often used in conjunction with lag screws. Designed to protect lag screw from rotational, bending, and shearing forces. Intramedullary nails A large metal rod placed down the medullary canal Allows for early weightbearing. External fixation The use of pins screwed directly into the bone connected by a rigid series of bars for fracture stabilization. Use for fractures with significant swelling or comminution. Often used as a temporizing measure. Orthopedic Infections Osteomyelitis Infection of bone with progressive degradation of bone and deep tissues. Most common pathogen is Staphylococcus aureus Classic boards question: Pseudomonas aeruginosa from sharp trauma through rubber soled shoe. Risk Factors: Trauma/surgery IV drug use Poor blood supply Uncontrolled diabetes/immunocompromised Osteomyelitis Presenting symptoms Pain, erythema, antalgic gait, skin break down, draining sinus tract Labs ˄ ESR, ˄ CRP (most sensitive), +/- ˄WBC, +/- blood culture (if suspected hematogenous spread) Classification 1)Medullary, 2)Superficial, 3)Localized, 4)Diffuse Cierny and Mader Classification Osteomyelitis Imaging Radiographs Areas of lucency, sclerosis, periosteal reaction, and lysis around hardware if present Computed Tomography Magnetic Resonance Imaging Most sensitive for detecting early osteomyelitis Biopsy and bone culture is gold standard for diagnosis Treatment Antibiotics vs Surgery (I&D or amputation) Septic Arthritis Infection enclosed within the joint capsule Proliferation of bacteria in the synovial membrane results in accumulation of polymorphonuclear (PMN) leukocytes and the inflammatory effects leading to permanent joint damage. Sepsis can develop from joint infection and can become life threatening Septic Arthritis Presentation Febrile, tachycardic Warm, erythematous, swollen joint Short arc range of motion Patient will only tolerate minimal passive motion of the affected joint due to increased intra-articular pressure and pain Will often refuse to weight bear through affected joint Septic Arthritis Typically due to trauma or surgery to the joint, but can occur due to hematogenous or contiguous spread Risk Factors Immunocompromised IV drug use At increased risk of gram-negative infection Endocarditis Recent joint surgery Pathogens S. aureus (by far most common) S. epidermidis N. gonnorhea (sexually active patients) Gram negative bacilli Septic Arthritis Labs Elevated WBC, ESR, CRP Joint Aspirate: Purulent, >50,000 WBC per mL When performing joint aspirate order cell count, gram stain, culture (antibiotics), crystals (r/o gout/pseudogout) Treatment Urgent Surgical Irrigation and debridement Acquire intra-op cultures to tailor antibiotic therapy Serial monitoring of ESR and CRP q48 for infection clearance Pyogenic Flexor Tenosynovitis Flexor tendons of the hand are encased in synovial sheaths to help the tendons glide Trauma can lead to enclosed infection of these tendon sheaths These enclosed spaces do not tolerate expansion from infection Pyogenic Flexor Tenosynovitis Kanavel’s signs 1. Fusiform “sausage” digit 2. Digit held in passive flexion 3. Pain with passive extension 4. Pain along tendon sheaths Flexor Tenosynovitis Risk Factors Diabetes/Immunocompromised IVDU Pathogens S. aureus is the most common pathogen Pasturella- animal bites Eikenella- human bites (also seen in “fight bites”) Labs Elevated WBC, CRP, ESR Imaging CT with contrast helps localize areas of infection, may detect infection within tendon sheaths. Not always needed. Can be diagnosed clinically. Treatment Antibiotics alone if caught very early Surgical I&D Cultures taken to tailor antibiotic treatment Elevation of affected extremity  Necrotizing Fasciitis Necrotizing fasciitis is a life threatening infection that spreads along soft tissue planes often sparing the underlying muscle Characterized by rapid destruction of tissue with associated systemic toxicity Prognosis life threatening infection mortality rate of 32% Necrotizing Fasciitis Presentation Rapidly progressing cellulitis +/- abscess à severe pain, swelling, bullae, discoloration, subcutaneous emphysema. High fever, chills, tachycardia (severe sepsis) Necrotizing Fasciitis Diagnosis LRINEC score 92% PPV when score is > 6 For suspected early infection, emergent frozen section taken in OR Necrotizing Fasciitis Microbiology- Most common polymicrobial Type one polymicrobial Immunocompromised (DM or CKD) Type two monomicrobial Examples include S pyogenes, S Aureus or Clostridium Recent years demonstrate increased gram negative monomicrobial cause – and have higher mortality rates (Klebsiella pneumonia, Escherichia coli)  Necrotizing Fasciitis Treatment Early Radical Surgical Debridement Intra-op findings: fat and muscle necrosis, venous thrombosis, “dishwater” pus Broad-Spectrum Antibiotics +/- Hyperbaric Oxygen Necrotizing Fasciitis Orthopedic Emergencies  Orthopedic Emergencies ▪ Open Fractures ▪ Orthopedic infections ▪ Septic arthritis ▪ Pediatric Injury ▪ Flexor tenosynovitis ▪ Slipped Capital Femoral Epiphysis ▪ Compartment (SCFE) syndrome ▪ Fractures ▪ Spine Injuries ▪ Cauda Equina Open Fractures  Open Fractures ▪ “Compound” (term no longer used) ▪ Defined by a break of the skin & soft tissue that creates a wound communicating w/ the fracture.  OPEN FRACTURES Danger: ▪ High rate of infection ▪ Devascularization and soft tissue compromise ▪ High rate of non-union ▪ Complication of osteomyelitis ▪ Timing to surgery varies with bone fractured, classification of open fracture, age of patient, stability of patient. Open Fracture Management Initiate early IV antibiotics and update tetanus prophylaxis − Studies have shown increased infection rate when antibiotics are delayed greater than three hours Aggressive I&D − Low pressure lavage has been shown to be more effective in reducing bacteria than high pressure lavage (Flow Investigators, JOT Sept 2011) − Saline shown to be most effective irrigating agent Infection risk factors include the amount of energy producing the injury, degree of soft tissue damage, and amount of wound contamination 69 Compartment syndrome  COMPARTMENT SYNDROME ▪ Condition in which increased pressure within a closed anatomic space threatens the viability of enclosed tissues. ▪ Immediate threat is to the viability of muscle and nerve tissue within the involved compartment. ▪ Causes: High energy injuries, crush injuries, burns, intense muscle use, Reperfusion injury, etc) Diagnosis May not be obvious Open wounds do not exclude compartment syndrome If considering the diagnosis must monitor and decompress Polytrauma, head injury, chemical overdose, abnormalities in sensory nerves can increase the difficulty of diagnosis COMPARTMENT SYNDROME ▪ Signs of acute disruption of arterial flow = 5 Ps ▪ Pain with passive stretch ▪ Pallor ▪ Pulselessness ▪ Paresthesias ▪ Paralysis Treatment Goals Must decompress all compartments at risk Skin, fat, fascia widely decompressed Debridement of 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 the forearm flexors with replacement of the dead muscle with fibrous tissue. Ozer K. Nerve Lesions in Volkmann Ischemic Contracture. J Hand Surg Am. 2020 Aug;45(8):746-757. doi: 10.1016/j.jhsa.2020.03.027. Epub 2020 Jun 26. PMID: 32600789.  COMPARTMENT SYNDROME 13 year old male injured his right knee while jumping in basketball game. Hear a loud pop and was unable to walk after. Presented with firm compartments, significant pain with passive stretch. Based on clinical exam had compartment syndrome. https://www.orthobullets.com/trauma/1001/leg-compartment-syndrome Ballistic trauma Prevalence Over the past century over 223 million guns have been introduced in the united states. Department of Justice press release indicated in 2011 11,101 fatal and 467,300 nonfatal firearm victimizations occurred. All cause (accidental, intentional, and self inflicted) ballistic trauma is the second leading cause of death in young men. Homicide rate of young men is 20 times higher than any other country in the world. Ballistic Basics There are two basic classifications under which bullets are categorized: − Low velocity ▪ less than 1000 feet per second ▪ Includes most handguns, except for magnums − High velocity ▪ Greater than 2000 feet per second ▪ Most rifles Ballistic Physics Kinetic energy (velocity biggest contributor to energy) − KE = 1/2mv2 Some important points to consider, from the above equation with regards to energy dissipation: 1. Striking energy 2. Exit energy 3. Trajectory 4. Bullet type (caliber, construction, configuration) 5. Tissue drag 6. Yaw 83 Kinetic Energy Dissipation Deforming forces in the body include both mechanical and thermal injury. − As bullet contacts bone, fragmentation may occur which increases permanent cavity size (Maiden 2009) Degree of injury depends on specific gravity of traversed tissue (compressibility) − Liver and muscle are associated with increased trauma due to shockwave dissipation with significant momentary cavities 84  Bullet Contamination Old myth that bullet velocity creates enough heat to sterilize bullet is incorrect. − In 1978, Wolf et al coated bullets with S. Aureus and shot them into sterile ballistics gel. − Positive cultures grew from gel. One study showed that retained bullets and bullet fragments did not increase the risk of infection even after penetrating the GI organs (Watters, JOT March 2011) 85 Indications for Foreign Body Extraction Loss of function Superficial location Association with wound infection Intraarticular Subarachnoid retention 86 Spinal Cord Injury Physical Examination Sensory Spinal Cord Injury Physical Examination Motor − Grading ▪ 0 total paralysis ▪ 1 palpable/visible contractions ▪ 2 active full ROM without gravity ▪ 3 active full ROM against gravity ▪ 4 active full ROM against moderate resistance ▪ 5 active full ROM at full strength Spinal Cord Injury Physical Examination Motor − Myotomes ▪ C4 diaphragm ▪ C5 deltoid, biceps ▪ C6 wrist extensors, elbow flexors ▪ C7 elbow extensors, wrist flexors ▪ C8 finger flexors ▪ T1 small finger abductor Spinal Cord Injury Physical Examination Motor − Myotomes ▪ L2 hip flexors ▪ L3 knee extensors ▪ L4 ankle dorsiflexors ▪ L5 Extensor hallucis longus ▪ S1 ankle plantar flexors ▪ S2-S4 external anal sphincter Spinal Cord Injury Physical Examination Spinal shock ▪ Absence of motor/sensory function with the absence of physiologic reflexes below zone of injury − Usually resolves within 24 to 48 hours − Return of bulbocavernosus reflex (unless conus involved in zone of injury) − Cannot grade spinal injury until shock resolves. Spinal Cord Injury Physical Examination ASIA impairment scale − A Complete paralysis − B Sensory function only below injured level − C Incomplete motor (gr 1-2) below level − D Fair-good motor (gr 3-4) below level − E Normal motor function (gr 5)  Spinal Cord Injury Definitions Incomplete injury ▪ partial preservation of sensory/motor function below the neurological level Complete injury ▪ absence of sensory and motor function below neurological level Paraplegia ▪ impairment of motor/sensory function in thoracic, lumbar, or sacral segments (arm function is spared) Quadriplegia ▪ impairment of cervical segments Spinal Cord Injury Anatomy Spinal cord − Cross section Spinal Cord Injury Anatomy Blood supply − Radicular arteries − Arteria radicularis magna (of Adamkiewicz) ▪ from intersegmental branch of descending aorta in lower left thoracic region (T8-L1) − Anterior and posterior spinal arteries Spinal Cord Injury Clinical Cord Syndromes Complete cord ▪ No sensory/motor sparing below level of injury ▪ Poor prognosis Spinal Cord Injury Clinical Cord Syndromes Central cord ▪ Extension injury in patients > 50 y/o ▪ Usually cervical, with upper extremities weaker ▪ Ambulates, but has difficulty holding walker Spinal Cord Injury Clinical Cord Syndromes Brown-Sequard ▪ Penetrating trauma ▪ Ipsilateral motor and proprioceptive loss ▪ Contralateral pain and temperature loss ▪ 90% chance of ambulation with intact bowel/bladder control ▪ Proximal extensors recover before distal flexors ▪ Pain/temperature recovery precedes motor ▪ Sometimes above to ambulate with brace on one side Spinal Cord Injury Clinical Cord Syndromes Anterior cord ▪ Flexion-compression injury ▪ Variable motor/pain/temperature involvement ▪ Proprioception spared ▪ Poor prognosis Spinal Cord Injury Clinical Cord Syndromes Posterior cord ▪ Loss of proprioception ▪ Motor/pain/temperature preserved ▪ Difficulty in ambulation due to proprioceptive loss Spinal Cord Injury Clinical Cord Syndromes Conus medullaris and cauda equina ▪ Injury to sacral cord segments or lumbosacral nerve roots ▪ Areflexic bladder with bowel and lower extremity involvement ▪ Symmetrical vs asymmetrical distribution Spinal Cord Injury Acute Management Surgery − Timing controversial − Spinal column realignment − Decompression ▪ Neurologic improvement inversely proportional to duration and magnitude of compression − Stabilization Sports Orthopedics A subspecialty that addresses injuries common to athletes and focuses on minimally invasive ways to address these issues. Often able to address injuries with arthroscopic procedures where small incisions called portals are made in the skin allowing for a camera to be introduced into the joint through one and instruments to be introduced through another. Commonly performed on shoulders and knees but can also be done for elbows, wrists, hips, and ankles. Rotator cuff Made of 4 muscles that surround the humeral head. − Supraspinatus, Infraspinatus, Teres minor, Subscapularis (SITS muscles). Two functions. − Responsible for abduction, internal, and external rotation of the humerus. − Also responsible for dynamic stability of the shoulder with movement. Rotator Cuff Shoulder differential diagnosis Besides the rotator cuff, there are other pain generators in the shoulder that need to be evaluated through imaging and physical exam. Long head of the biceps tendon. Acromioclavicular joint. Subacromial bursa. Labrum Cartilage (arthritis) Arthroscopic View of Shoulder Knee joint Knee pain can also have a number of different causes. − ACL − PCL − Medial/lateral collateral ligaments − Menisci − Cartilage (arthritis) − Surrounding muscle strain. 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 the anterior translation of the tibia) and posterior (provides the rotations stability). ACL Injury Presentation More often female soccer players who have noncontact injuries from pivoting or landing from jumping where they feel a pop, have pain preventing ambulation, and swelling that happens quickly. When the patient is seen in clinic, often they can have decreased range of motion of the knee, some residual swelling from the injury, and will have a positive anterior drawer test, positive Lachman test, and positive pivot shift test. But wait! Theres more! ACL injuries are frequently encountered in conjunction with meniscus injuries that can come from the initial injury (lateral meniscus) or can come from the instability of living with an ACL deficient knee (medial meniscus). Meniscus Injury Can occur as an isolated injury or in conjunction with other injuries around the knee (ACL rupture). Important to know the location and patter of the tear which dictates treatment options including repair versus meniscectomy. The blood supply for the meniscus comes from the periphery and goes approximately 1/3 of the way in. The middle 2/3 of the meniscus are avascular and thus will not heal. Meniscal tear patterns Arthroscopic view of meniscus Knee injuries in the setting of arthritis With many injuries in the knee, an MRI can be a useful tool in diagnosis and surgical planning. When a patient has pre-existing arthritis in the setting of a new knee injury, MRI should not be performed. It will not change treatment of the issue. This can be hard for patients to understand, but it is made harder when the referring doctor tells them that an MRI will likely be ordered. Questions? Please make sure to send all questions regarding material presented to day to the discussion board or feel free to reach out via email to; [email protected] Thank You