ORTHOPEDICS DR. WALID AL-MEKHLAFI 2023 ORTHOPEDICS DR. WALID AL-MEKHLAFI 2023 ANATOMY ANATOMY Cervical Vertebrae Clavicle Rib Radius Ulna Pelvis Femur Tibia Fibula Skull -Mandible -Scapula Sternum Humerus Thoracic Vertebrae Lumbar Vertebrae Sacrum -Patella Sacrum Cervical Thoracic Lumbar Coccyx Disc Lamina Spinous procss Pedicle Body Transverse process Lateral masses Greater trochantor Lateral epicondyle Fibula -Hip bone Femur Anterior view head -Neck ertochancteric Intertrochanteriç -Lesser trochanter Body (shaf) Adductor tubercle Medial crest epicondyle -Patella Medial condyle' Tibia Greater trochanter -Gluteal,. tuberosity Iinea asnera oicondvle Posterior view Condylar Lateral condyle Fibula Tibial tuberosity Fibula - Lateral condyle Anterior view Articular surf! of medial cordse Medial condyle -Anterior border Interosseou membranc Tibis Medial malleolus Articular surtace Posteriaor view icular surface of latersal oondyle Head of fibula Soleal line Fibula Lateral nalleolus EXAMINATION BASICS Determine the point of maximum tenderness Examine the joint above and below the site of injury Check for joint stability Check the neurovascular status of the extremity distal to the site of injury Neurovascular compromise requires emergent reduction of the fracture or dislocation Is the fracture open – high risk of osteomyelitis Signs of compartment syndrome – Five P’s EXAMINATION BASICS Determine the point of maximum tenderness Examine the joint above and below the site of injury Check for joint stability Check the neurovascular status of the extremity distal to the site of injury Neurovascular compromise requires emergent reduction of the fracture or dislocation ls the fracture open - high risk of osteomyelitis Signs of compartment syndrome - Five P's COMPARTMENT SYNDROME Ischemic injury to the muscles and nerves in a particular closed fascial compartment Caused by edema in a closed compartment This leads to: • Decreased venous return • Eventual decreased arterial flow Commonly seen with tibia or forearm fractures Most commonly seen in lower extremity compartments • Anterior> lateral > deep posterior> posterior • Upper extremities: deep flexor compartment COMPARTMENT SYNDROME Ischemic injury to the muscles and nerves in a particular closed fascial compartment Caused by edema in a closed compartment This leads to: Decreased venous return Eventual decreased arterial flow Commonly seen with tibia or forearm fractures Most commonly seen in lower extremity compartments Anterior> Ilateral > deep posterior> posterior Upper extremities: deep flexor compartment Clinical features: 1. Burning, poorly localized pain disproportionate to injury 2. Pain on active or passive stretch of muscles 3. Paresthesias in distribution of nerves 4. Pallor – late and ominous sign 5. Pulselessness – late and ominous sign 6. Skin color, temperature, cap refill, and distal pulses are important to document but are unreliable monitors for compartment syndrome because the pressure needed to produce compartment syndrome are well below arterial Clinical features: 1. Burning, poorly localized pain disproportionate to injury 2. Pain on active or passive stretch of muscles 3. Paresthesias in distribution of nerves 4. Pallor - late and ominous sign 5. Pulselessness - late and ominous sign 6. Skin color, temperature, cap refill, and distal pulses are important to document but are unreliable monitors for compartment syndrome because the pressure needed to produce compartment syndrome are well below arterial Diagnosis • handheld device for measuring compartment pressure • pressures > 30mmHg are abnormal Treatment • immediate fasciotomy Diagnosis handheld device for measuring compartment pressure pressures > 30mmHg are abnormal Treatment immediate fasciotomy Fig 1 Pane of the Cross sectios is viewed oking romateent Fascia encoses Compartments of the leg Tbia partmen compar mnatment Suprfkil comatmgt COMPARTMENT SYNDROME NECROSIs OF SORTTISsUES SWELLING AND A. TWO LONG INCISIONS ARE N THE LOWWER LEG TIBIA AND ONE MEDIAL B. THROUGH THE LATERAL INCISION, THE COMPARTMENTSRAL AND ANTERIOR C THROUGH THE MEDIAL INCiSION, THE POSTERIOR COMPARTHENTS IS INCISED ORTHO INJURY NERVE INJURY Shoulder dislocation Axillary nerve Humeral shaft fracture Radial nerve Elbow injury Median and ulnar nerves Hip dislocation Femoral nerve Knee dislocation Peroneal or tibial nerves ORTHO INJURY Shoulder dislocation Humeral shaft fracture Elbow injury Hip dislocation Knee dislocation NERVE INJURY Axillary nerve Radial nerve Median and ulnar nerves Femoral nerve Peroneal or tibial nerves X-RAY EVALUATION Rule of two o Minimal of 2 views perpendicular to each other when possible o Include 2 joints - the joint above and the joint below o Include 2 limb comparison views Is the fracture intraarticular? – increased risk of subsequent arthritis Are the fragments distracted? Is there a joint dislocation? Rule of two X-RAY EVALUATION o Minimal of 2 views perpendicular to each other when possible o Include 2 joints - the joint above and the joint below o Include 2 limb comparison views Is the fracture intraarticular? - increased risk of subsequent arthritis Are the fragments distracted? Is there a joint dislocation? Clevwe Greenstick Types of Bone Fractures Transverse Comminuted Spiral Compound Clinical Features: 1. Pain 2. Loss of function 3. Deformity 4. Swelling 5. Discoloration 6. Tenderness 7. Crepitus Clinical Features: 1. Pain 2. Loss of function 3. Deformity 4. Swelling 5. Discoloration 6. Tenderness 7. Crepitus TREATMENT PRINCIPLES The first priorities remain ABCs Hypovolemic shock possible secondary to fractures 1. Pelvic fracture 2. Secondary to multiple fractures 3. Worsened by third spacing loss of ECF as edema in injured soft tissue seen with crush injuries Possible blood loss secondary to specific fractures o Pelvic fracture → 2 Liters o Femur fracture → 1.5 Liters o Tibia or humerus fracture → 0.5 Liters TREATMENT PRINCIPLES The first priorities remain ABCs Hypovolemic shock possible secondary to fractures 1. Pelvic fracture 2. Secondary to multiple fractures 3. Worsened by third spacing loss of ECF as edema in injured soft tissue seen with crush injuries Possible blood loss secondary to specific fractures o Pelvic fracture →2 Liters o Femur fracture 1.5 Liters o Tibia or humerus fracture 0.5 Liters Immobilize the joint proximal and distal to the fracture Always reassess neurovascular status after immobilization or manipulation Plaster Splinting Circumferential casting rarely done in the ED for an acute fracture → evolving edema may lead to compartment syndrome Ice and elevate for 48 hours post injury Healing occurs over 4-10 weeks if properly immobilized Consider analgesia and/or sedatives prior to attempting reduction Immobilize the joint proximal and distal to the fracture Always reassess neurovascular status after immobilization or manipulation Plaster Splinting Circumferential casting rarely done in the ED for an acute fracture - evolving edema may lead to compartment syndrome lce and elevate for 48 hours post injury Healing occurs over 4-10 weeks if properly immobilized Consider analgesia and/or sedatives prior to attempting reduction CERVICAL CERVICAL