Section 10

ORTHOPAEDIC SURGERY STUDY GUIDE

FOR

MEDICAL STUDENTS, R1s and R2s

July 5, 2011

Jeffrey J. Eckardt M.D.–Professor and Chair,Orthopaedic Surgery

Joshua G. Bales M.D. - Resident

Trauma

Fractures:

  • Definition: a fracture is a structural break in continuity of bone
  • Location in the bone: diaphysis, metaphysis, epiphysis, intra-articular
  • Extent: complete or incomplete (hairline, buckle, greenstick fractures)
  • Configuration: transverse, oblique, spiral, butterfly
  • Simple fractures have 1 fracture line and 2 fragments. Comminuted fractures have more than 1 fracture line and more than 2 fragments.
  • Relationship of fracture fragments to each other: nondisplaced: fragments remain in anatomic alignment. Versus displaced fractures: nonanatomic alignment.
  • translated
  • angulated
  • rotated
  • distracted
  • overriding
  • impacted
  • Relationship of fracture fragments to the environment closed (not exposed to the environment) versus open (exposed to the environment via a break in the soft tissues)
  • Gustillo Classification
  • Type I 1 cm wound
  • Type II > 1 cm wound with moderate soft-tissue damage
  • Type III extensive soft-tissue damage

A: adequate coverage, without periosteal stripping or vascular injury.

B: bone exposed with periosteal stripping, plastics consulted needed for soft tissue coverage of defect

C: with vascular or nerve injury, vascular surgery consulted needed for vessel injury

  • Fracture healing
  • Union - complete and timely healing
  • Delayed union – healing that takes longer than expected
  • Nonunion – healing has not occurred within 1 year (time is fracture site dependent)
  • Malunion – healing with residual angular deformity
  • Closed Fracture - treatment
  • Closed reduction (realignment of fracture fragments) with immobilization
  • Closed reduction and percutaneous fixation
  • Open reduction and internal fixation (ORIF) operative realignment with rods, plates, and screws for fixation
  • External fixation operative realignment with external device to hold fixation. may be used for extensive soft tissue injury, extensive comminution or a grade III open fracture
  • Open Fracture - treatment
  • Complete neurovascular examination
  • Align and splint fracture, monitor neurovascular status post manipulation
  • Culturing the wound is controversial (not performed routinely at UCLA).
  • Cover wound, consider pressure dressing if oozing blood, take emergently to the OR. If unable to control hemorrhage (arteriogram vs. Vascular surgery consult if pulses absent)
  • Begin antibiotics in the ER - ASAP. This is the only Level 1 evidence we have for open fractures. Ancef 1g IV q8 h., which is good for gram positive organisms. Add Gentamicin IV 1mg/kg q8 for gram negative coverage for Type III and some Type II fractures depending on attending preference.
  • Tetanus prophylaxis: If patient has not been immunized for tetanus, then tetanus immune globulin 1g 250 units IM and tetanus toxoid 0.5cc IM at separate sites. If pt previously immunized for tetanus, then tetanus toxoid 0.5cc IM.
  • Never irrigate or debride in the ER. Always irrigate and debride in the controlled environment of the operating room.
  • In the OR remove all foreign material, irrigate and debride wound: “The solution to pollution is dilution”.
  • In terms of fracture management, consider IM nail for tibia/femur. Spanning external fixator for contaminated fractures/intra-articular fractures/unstable patients

Orthopedic Emergencies

  • Primary trauma assessment ABCs
  • Airway, Breathing, Circulation, Disability, Evaluation
  • Open fracture: needs to be in the OR within 6 hours (controversial, also depends on type, contamination, etc). Some type I fractures can wait overnight if needed.
  • Compartment syndromes need fasciotomy
  • Clinical exam, pain out of proportion to physical exam. Compartment pressures within 30 mmHg of the diastolic pressure.
  • Herniated disc or spine fracture with impending neurological loss; Cauda Equina Syndrome: needs admission, neurologic exam, MRI or CT myelogram, and decompression of the neurologic structures
  • Dislocated joint. For example, dislocated knee: risk of popliteal artery rupture and danger of a compartment syndrome.
  • Hand infections. Tenosynovitis of one finger may spread to palm and other fingers via common tendon sheath, and therefore need emergent antibiotics and possible I&D.
  • Septic joint: risk of cartilage destruction, post infectious arthritis, and even total loss of the entire femoral head with subsequent leg length discrepancy.
  • Fat embolism following long bone fracture or reaming, rodding or manipulation of the medullary canal of a long bone.

Orthopaedic complications

A: Compartment Syndrome

Important Points

  • abnormal increase in pressure within an anatomic compartment
  • Snake Bite: rare cause of compartment syndrome, treat via stabilization and antivenom.

Presentation

  • 4 Ps
  • Pain out of proportion to injury, pain with passive motion
  • Paresthesia
  • Paralysis
  • Pulselessness

Evaluation

  • This is a clinical exam, pain out of proportion and tense compartments signal a need for emergent fasciotomy
  • Measure intracompartmental pressures
  • Compartment pressures greater within 30 mmHg of diastolic blood pressure
  • Normal pressures usually around 4-8 mmHg in a compartment.

Treatment

  • Emergency fasciotomy

Complications

  • Volkmann’s Contracture due to untreated compartment syndrome of the forearm.
  • Associated with a supracondylar fracture in a child.
  • May also occur in open fractures
  • Compromise of the brachial artery leading to ischemia, muscle death, and necrosis of the flexor muscle groups in the forearm
  • Severe flexion contracture of the forearm, wrist and fingers

B: Pulmonary Emboli

Important Points

  • emboli occluding pulmonary artery, arteries; clot usually originates in the deep veins of the thigh and pelvis and not in the calf
  • Risk Factors: bedridden, hypercoagulable states (i.e. cancer; medications such as oral contraceptives; surgery – may present 2-3 wks after surgery)

Presentation

  • difficulty breathing, shortness of breath, tachypnea, sinus tachycardia, delirium (due to hypoxia), cough, hemoptysis, anxiety, “impending sense of doom,” coma, pleuritic chest pain - ischemic necrosis sets up inflammatory response between the visceral and parietal pleura, may hear rub over the area.

Evaluation

  • Chest X-ray – Look for the wedge, area of lung infarct caused by emboli.
  • Arterial blood gas – PO2 < 70mmHg; decreased O2 saturation.
  • EKG – sinus tachycardia; right heart strain (2O to saddle emboli – right heart pumping against saddle embolus in pulmonary arteries, emergent)
  • V-Q scan – many false positives and false negatives
  • Doppler – looking for DVT’s, noninvasive
  • Venogram – gold standard, best way to locate emboli in veins
  • SpiralCT – useful at diagnosing pulmonary embolism
  • Pulmonary angiography – high risk, infrequently performed

Treatment

  • Reduce hypoxia, stabilize clot, prevent more clots and emboli
  • Oxygen – via mask
  • Intubation- if mask not effective
  • Add PEEP to ventilator settings
  • Anticoagulants- stabilize/dissolve clot. In general if the diagnosis is phlebitis, anticoagulate for 3 mos. If the diagnosis is PE, anticoagulate for 6 mos.
  • Heparin – IV 5,000 – 10,000 units (or 80 units/kg) bolus followed by a continuous infusion (18 units/kg/hour) titrated to a PTT between 1.5 –2.5 times normal for 5-10 days.
  • Coumadin – while giving heparin start coumadin titrated to an INR of 2-3 times normal for 6 months or longer depending on patient and etiology.
  • Streptokinase 1.5 million units IV over 60 min. Administer directly into involved vein to dissolve clot. (Not performed routinely may be done by IR)
  • IVC Greenfield filter – prevent clots from entering right heart. Indicated if there is risk or evidence of more emboli.

C: Fat Embolism

Important Points

  • Diffuse pneumonitis in the lungs secondary to the embolization of fat and marrow debris.
  • Can result from trauma, fracture, reaming a canal, impaction of a prosthesis, or pressurization with cement.

Presentation

  • Cardiovascular, respiratory, and neurologic symptoms due to occlusion and therefore hypoperfusion of tissues. Increased heart rate, increased respiratory rate, fever. may see petechiae under eyes, in axillary folds, and in nail beds. Progressive hypoxia may lead to a delirious patient.

Evaluation

  • Lab Work-Up – ABG – decreased PO2, Pulse Ox – decreased SpO2,
  • CXR – diffuse pneumonitis, (vs. pulmonary thromboemboli – local pneumonitis), whited out lungs

Treatment

  • Oxygen. Intubate if indicated with PEEP
  • Steroid bolus with 100 mg solumedrol (controversial but appears to be effective)
  • Heparin contraindicated

Pediatric Orthopaedics

Pediatric Diseases

  1. Arthrogryposis – Multiple rigid joints, no skin creases, teratologic hip dislocation, sensation is intact and these patients have normal intelligence
  2. Duchenne’s Muscular Dystrophy – sex linked recessive, elevated CPK, absent dystrophin protein, most patients die at age 20; Becker’s muscular dystrophy has an abnormal dystrophin gene and is not as morbid as Duchenne’s
  3. Cerebral Palsy – Nonprogressive upper motor neuron disease; injury to the immature brain, onset before 2 years of age; constellation of symptoms include spasticity, toe walking, crouched gait, scoliosis; types include spastic, athetoid, ataxic, mixed
  4. Myelodysplasia – Failure of neural tube to close, patient’s functional level is lowest functioning nerve root, risk factors include maternal hypothermia, maternal insulin-dependent diabetes, valproic acid, folate deficiency; most patients have a latex allergy, clubfeet, vertical talus, hip dislocation
  5. Adolescent idiopathic scoliosis – right thoracic is the most common, curve progression most closely associated with peak growth velocity; bracing controversial but most will brace above 25 degrees, most will perform surgery above 40 degrees

The Limping Child The Five Major Causes

A. Toxic transient synovitis

B. Septic arthritis

C. Developmental dysplasia of the hip (DDH)

D. Legg-Calves-Perthes disease (LCPD)

E. Slipped capital femoral epiphysis (SCFE)

F. Don’t forget other causes!

1. Trauma

2. Child abuse

3. Infection: osteomyelitis

4. Arthritis: juvenile rheumatoid.

  1. Tumor:

Rhabdomyosarcoma: Muscle (0-5years)

Ewings Sarcoma: Round cell (5-15 years)

Osteosarcoma: Spindle cell (5-80years, 17 yr. Median)

A: Septic Arthritis of the Hip, Knee, Foot, Wrist, Elbow and Shoulder Joint

Important Points

  • bacterial infection of a joint hip of particular concern as a medical emergency
  • Untreated may quickly lead to destruction of joint cartilage and avascular necrosis of femoral head due to decreased blood supply
  • Caused by hematogenous spread of infection, often no known source

Presentation

  • Child with high fever, limp, pain with passive motion of hip, may lie with hip externally rotated, slight hip flexion

Evaluation

  • Labs: elevated WBC, C-reactive protein and ESR, blood cultures often negative
  • Radiology:
  • Bone scan: focal area of increased uptake
  • X-ray : may show joint effusions
  • diagnosis: MUST aspirate joint, send fluid for cell count, gram stain, culture and sensitivity (certain aspirations may need fluoro guidance)

Treatment

  • To OR for immediate irrigation and debridement, must take a sample of the synovial lining as well
  • Open washout is standard but in select cases may perform an arthroscopic washout
  • followed by IV antibiotics for 2-8 weeks (per organism and ID recommendations)
  • Empiric treatment with Ancef 1g IV q8 h (do NOT give any antibiotics until cultures are taken!!!)
  • Modify according to culture results and bacterial sensitivity
  • followed by 2-4 months of oral antibiotic, in consultation with ID

Organisms

  • Staph aureus: most common organism.
  • Gonorrhea in pediatric and adult populations
  • Cocci: in the Southwest USA

B: Toxic Synovitis: Important Points

  • Viral inflammation of the hip
  • Presentation similar to septic arthritis of the hip
  • Diagnosis of exclusion

Presentation

  • Child with low fever, limp of in lower extremity, pain with active and passive motion, increased warmth of joint

Evaluation

  • Labs: WBC and ESR often normal, blood cultures negative
  • Radiology:
  • bone scan: may or may not show focal area of increased uptake
  • X-ray: may show joint effusion
  • MUST aspirate joint if high index of suspicion for septic arthritis of hip, send fluid for cell count, gram stain, culture and sensitivity
  • Diagnosis of exclusion: MUST rule out septic arthritis of the hip

Treatment

  • gradual return to activities as tolerated
  • bed rest  longitudinal traction in select cases

C: Developmental Dysplasia of the Hip (DDH)

Important Points

  • progressive condition with abnormal development of hip structures
  • indicates hips that are unstable, subluxated, dislocated and/or have malformed acetabula
  • formerly congenital dysplasia of the hip but may not be evident at birth
  • 3 characteristic components:
  • abnormal slope of acetabulum
  • excessive hip joint laxity
  • abnormal rotation of upper end of femoral shaft
  • 3 stages
  • head of femur located within inadequate acetabulum
  • head of femur slightly subluxed and moved away from medial aspect of acetabulum
  • head of femur dislocated
  • Risk factors for DDH:
  • positive family history for DDH, female sex, breech presentation, primaparity, oligohydraminiosis
  • Associated with:
  • congenital muscular torticollis, skull and facial abnormalities, congenital hyperextension of the knee, metatarsus adductus, clubfoot deformities
  • Definitions
  • dislocated hip: no contact between femoral head and acetabulum in resting position
  • Dislocatable hip: in reduced position at rest. Can be dislocated with stressed flexion and abduction
  • Subluxable: in reduced position at rest. Can be dislocated with stressed flexion and abduction hip can be subluxed (partial contact between femoral head and acetabulum)
  • Dysplastic - no signs of instability but femoral head and acetabulum are abnormally shaped. Hips may/may not become unstable with continued development
  • Teratologic dislocation of the hip – secondary to another disease process
  • occurs early during intrauterine development
  • stiff , high-riding, irreducible with severe dysplasia of joint at birth
  • usually associated with neuromuscular abnormalities arthrogryposis, myelodysplasia

Presentation (according to age at diagnosis):

  • Newborn:
  • if unilateral: asymmetrical skin folds on proximal thigh (not sensitive or specific) of affected side and + Galeazzi
  • if hip is already dislocated, - Barlow, +/- Ortolani (depending on whether reducible)
  • if hip is subluxable or dislocatable, + Barlow, + Ortolani
  • 6 month with DDH and dislocated hip
  • often asymptomatic
  • unilateral: positive Galeazzi, + leg length discrepancy, asymmetric skin folds on proximal femur, trochanter displaced upward, broadened perineum on affected side asymmetric abduction >10%discrepency
  • bilateral: negative Galeazzi, no leg length discrepancy, symmetric abduction but less than 60% each side
  • 2 year old child with DDH and dislocated hip
  • unilateral: limp with tendency towards Trendelenberg sway due to weak hip abductors on affected side, unilateral toe walking, examination may reveal shortening of thigh, multiple skin folds, broadened perineum, prominence of trochanter, decreased distance trochanter to iliac crest
  • bilateral: waddling gait

Evaluation

  • all tests must be performed on a completely undressed child supine on a flat examination table
  • a child’s hips MUST be examined with each examination from birth until walking with normal gait (usually 2-3 years of age)
  • Galeazzi test: assess apparent femur length
  • Hips flexed to 90 adducted to midline with knees in flexion, child’s knees do not line up suggesting femur length discrepancy (positive test) indicative of apparent femur shortening on affected side due to femoral head in abnormally cephalad position.
  • often associated with asymmetric skin folds on affected proximal thigh
  • dysplastic hip must be compared to normal
  • Note: negative Galeazzi test in patient with bilateral DDH
  • Ortolani test: assess passive subluxation or dislocation
  • Thumb on medial side of thigh, middle and index fingers over greater trochanter, knees flexed to 90, sequentially, each hip is brought from midline in 90 degree of flexion and abducted, gentle anteriorly directed force on greater trochanter. palpable clunk when femoral head is seated into acetabulum (positive test) indicates a dislocated but reducible femoral head
  • Note: irreducibly dislocated hip will have negative Ortolani test
  • Note: hip clicks - audible high pitched sounds without palpable clunk - on hip examination likely caused by iliotibial band moving over greater trochanter or iliopsoas tendon sliding over iliac crest. normal and usually disappears within 4-6 months.
  • Barlow test: stress test to assess potential for hip subluxation or dislocation
  • Thumb on medial side of thigh, middle and index fingers over greater trochanter, knees flexed to 90, sequentially, each hip is placed in 90 flexion in neutral adduction with gentle force directed posteriorly. Sensation of displacement of femoral head posteriorly out of acetabulum is positive test. Normal (negative test), no instability. Found. degree of displacement (positive test) indicates subluxable or dislocatable
  • Note: will be negative if the hip is already in a dislocated position

Radiologic evaluation

  • Ultrasound: less than 6 months - ultrasound may help delineate configuration and position of femoral head and acetabulum - cartilaginous structures not seen on XR. Static or dynamic in conjunction with Barlow test. High degree of interobserver variability. Has not been shown to be reliable as screening test (high false + at birth)
  • XR: AP with hip extended and lower extremities in neutral rotation and frog leg views. Most reliable after age > 4-6 months when femoral head has begun to ossify. Normal femoral head: below ilium pointing towards triradiate cartilage. Intact Shenton’s line (curve made by femoral neck and an anterior rami. normal acetabular angle)

Treatment (depends on age of presentation, degree of DDH)

  • Pavlik harness
  • treatment of choice for child with dislocated, subluxable, dislocatable hip identified as newborn to 5-6 months
  • consist of suspenders with chest cerclage, anterior flexion straps, posterior abduction straps providing suspension for two stirrup boots
  • maintains hip in 90-100 flexion, and limits adduction thus helping child’s musculature to hold hip in reduced position and while allowing for some movement in a safe range of reduction stability to encourage normal hip development
  • continued for 8-12 weeks, followed radiographically
  • successful in 90-95% cases
  • bilateral dislocations, late diagnosis (beyond 6-7 weeks) irreducible at presentation likely to fail
  • Complications: femoral nerve palsy, secondary to hyperflexion, failure to recognize persistent dislocation of hip - posterior dislocation and malformation of posterior acetabulum, growth disturbance of proximal femur, osteonecrosis of femoral head
  • Reduction and spica casting – performed in operating room
  • Treatment for child diagnosed at 6 month, failed Pavlik harness treatment
  • Closed reduction, then spica casting
  • May require period of traction to be able to place hip opposite acetabulum
  • Examination under anesthesia, with possible arthrogram to confirm position
  • Casting in “human” position with hips flexed 90-100 and abducted to 45-60
  • Confirm placement with post-reduction CT
  • Cast worn for as many months as child is old or 6 months, changed at 4-6 week intervals to account for growth
  • For child older than 18-24 months of age, inability to achieve closed reduction, open reduction with iliopsoas and adductor tenotomies +/- femoral shortening procedure, capsulorrhaphy may be necessary followed by spica casting
  • Osteotomies
  • Various osteotomies have been developed to reshape acetabulum and or femur to improve femoral head coverage and joint movement

Complications