UNMC Orthopaedic Surgery

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UNMC Orthopaedic Surgery

• Welcome to your M4 Clerkship and Welcome to Omaha

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Introduction

• Welcome
• Expectations and goals
• General considerations for Orthopaedic history
  and physical exam
• Introduction to reading x-rays
• Trauma/Open Fractures
• Compartment Syndrome

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WELCOME

• Welcome to UNMC and your Orthopaedic clerkship
• We are here to teach you the basic foundations of
  Orthopaedics.
• With that, you should be able to gain a feel for
  what a career in Orthopaedics may be like.
• We are happy to have you as a part of our team
  for the next month and hope you gain a lot of
  useful information while you are here

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Expectations General

• Show up on time, be available, and work hard
• Read before surgical cases (anatomy and surgical
  plan)
• Be helpful, be inquisitive, ask questions
• Learn basic management of common musculoskeletal
  problems
• Participate actively in rounds, clinics,
  conference, and general discussions about
  Orthopaedic problems

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Expectations Cont.

• Be able to access knowledge about Orthopaedics
  from books, internet, journals, etc..
• Be able to answer questions about musculoskeletal
  anatomy, common injuries, treaments, etc..
  Especially when asked to look it up beforehand.

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• Clinical functioning at the level of an intern
• Think about the patient care plan
• Pre-op planning
• Medical workup before surgery
• Antibiotics
• Pain control
• DVT prophylaxis
• Therapy goals restrictions
• Dressing changes / drain output
• Discharge planning clinic follow-up
• Read other consult service notes for their plan

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Goals

• At the end of your rotation you should be able
  to
• Read basic x-rays appropriately
• Perform an orthopaedic history and physical
• Recognize common fractures, their classification,
  and know how to acutely manage them
• Understand basic patient care for the Orthopaedic
  patient
• Be able to diagnose common musculoskeletal
  problems

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• CALL

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• Divide call on trauma nights between the students
  such that you average no more frequently than q4
  during your month.
• Be sure to get at least one full weekend off.
  Wed like you to be able to both have a life and
  also get to know a little about our city.
• The actual schedule is left up to the students to
  arrange. Be fair to each other.

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• Carry the on-call pager and notify the junior
  resident on-call that you will be taking call
  with them that evening
• The best opportunity to learn how to suture,
  splint, cast, and possibly do reductions as a
  medical student takes place on-call and in the
  ER/trauma bay.

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• CONFERENCES

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Conference Schedules

• Three rules
• If there is an assigned reading for a conference,
  be sure to get a copy and read it.
• No scrubs in conference, dress appropriately.
• Be on time. Tardiness to conference will be
  looked upon very poorly.

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Conference Schedules
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Orthopaedic Basics- History and Physical Exam
-- How to Read an X-Ray -- Principles of
Casting/Splinting - Fracture Fixation -
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Orthopaedic History

• A good general orthopaedic history contains
• Onset, Duration, and Location of a problem
• Limitations and debilitation attributed to the
  problem
• Good surgical history, especially with regards to
  orthopaedic surgeries and prior anesthesia
• Co-morbid conditions that contribute to the
  problem or will preclude healing in some manner

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Physical Exam Basics

• Inspect and Palpate everything- start with normal
  structures and move to abnormal
• Range of motion in all planes
• Strength
• Sensation
• Reflexes
• Gait
• Stability

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Physical Exam Basics

• NVI What does this mean?
• Neurologic exam- Always document the neurologic
  status. Some fractures are associated with nerve
  injuries and knowing the status of the nerve is
  critical
• Vascular exam- Always check for pulses distal to
  the fracture sight. Missed vascular injuries can
  be devastating

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Physical Exam

• NEVER trust someone elses exam. ALWAYS put your
  hands on the patient and see for yourself
• Always trust your exam- you WILL pick up
  something that someone else has missed at some
  point

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Imaging
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Intro to Reading X-rays

• Reading a radiograph is essentially describing
  the anatomy of a certain structure
• In order for it to be universal and
  understandable for others, clarity and precision
  are essential
• A fracture is described based on the findings of
  the physical exam and a review of radiographs

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Reading X-rays

• Say what it is- what anatomic structure are you
  looking at and how many different views are there
• Condition of the soft tissue- Open vs Closed
• Regional Location- Diaphysis (rule of 1/3),
  Metaphysis, Epiphysis including intra and
  extra-articular, and Physis (pedi)
• Direction of the fracture line- Transverse,
  Oblique, Spiral

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Reading X-rays

• Condition of the bone- comminution (3 or more
  parts), Segmental (middle fragment), Butterfly
  segment, incomplete, avulsion, stress, impacted
• Deformity-Displacemtent (distal with respect to
  proximal), angulation (varus, valgus), rotation,
  shortening (in cms), distraction

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Fracture Pattern

• Transverse
• Produced by a distracting or tensile force

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Fracture Pattern

• Spiral
• Produced by a torsional force

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Fracture Pattern

• Butterfly
• Produced by pure bending force

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Fracture Pattern

• Comminuted
• Broken into many pieces- high energy with
  combined forces

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Displacement

• Characterized by of bone contact on either view

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Angulation

• Distal fragment relative to proximal
• Varus, Valgus, Anterior, Posterior
• Apex of angle formed by fragments
• E.g., Apex Anterior, Apex Medial, Apex Ulnar

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Location

• Commonly described in thirds of affected bone
• ie distal third of tibia
• ie junction of proximal and middle third of femur
• If fractured at two levels describe as segmental

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Location-Diaphysis

• Shaft portion of bone

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Location-Metaphysis

• The ends of the bone (if the fracture goes into a
  joint it is described as intra- articular)

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Now All Together

• Transverse fracture of the femur at the middle
  third- distal third junction with 100
  displacement and varus (or apex lateral)
  angulation

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What do you see?
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What do you see?
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What do you see?
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Casting, Splinting, and Definitive Fracture
Fixaiton
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Definitive Fracture Fixation Options

• Casts and Splints
• Appropriate for many fractures especially hand
  and foot fractures
• Adults typically will get plaster splints
  initially transitioned to fiberglass casts as
  swelling decreases
• Kids typically will get fiberglass casts

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Definitive Fracture Fixation

• Delayed until patient is stable (may be days or
  weeks)
• Femur Fracture has priority as delay in fixation
  has negative impact on pulmonary status by shower
  of fat emboli to the lungs
• Goals is to stabilize skeleton to allow patient
  to rapidly mobilize from bed

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Definitive Fracture Fixation Options

• Traction
• Useful in patients who are too sick for surgery
• Useful to maintain alignment until definitive
  fixation

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Definitive Fracture Fixation Options

• External Fixation
• Used primarily in the treatment of open fractures
  and pelvis fractures
• Also useful as temporary stabilization prior to
  definitive fixation

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Indications- Emergent Stabilization
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Definitive Fracture Fixation Options

• Open Reduction and Internal fixation with Plates
  and screws
• Used for many fractures especially those
  involving joints

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Definitive Fracture Fixation Options

• Intramedullary Nails
• Treatment of choice for most tibia and femur
  fractures
• Used in selected humerus and forearm fractures

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Definitive Fracture Fixation Options

• Joint Replacement
• Used in displaced femoral neck fractures in
  geriatric patients
• Allows for early ambulation
• Occasionally used in geriatric pts with
  comminuted shoulder or elbow fractures

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Open Fractures
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Open Fractures

• Open fractures refer to osseous disruption in
  which a break in the skin soft tissue
  communicates directly with a fracture
• Any wound occurring on the same limb as a
  fracture must be suspected to be an open fracture
  until proven otherwise
• A missed open fracture can have dire consequences

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Evaluation of open fractures

• ABCs
• Identify the injured area
• Assess neurovascular status of the limb both
  proximal and distal to the wound. Always use the
  normal side as a control
• Assess skin and soft tissue damage. Exploration
  of a wound is not usually indicated in a trauma
  or emergency setting. If you know its an open
  fracture, splint it and prepare to go to the OR
• DO NOT remove bone no matter how small or
  insignificant a piece it may seem
• Always consider vascular injuries and compartment
  syndrome with open fractures

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Classification of open fractures

• Gustillo Classification
• Grade I- Clean skin opening of less than 1 cm,
  usually inside to out
• Grade II- Open between 1 and 10 cm, extensive
  soft tissue injury, minimal to moderate crushing
• Grade III- Open more than 10cm, extensive tissue
  including muscle damage, high energy
• IIIA- Laceration with adequate bone coverage,
  segmental features, gunshot injuries
• IIIB- Soft tissue injury with periosteal
  stripping, usually associated with massive
  contamination
• IIIC- Any of the above with an associated
  vascular injury

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Acute Management of open fractures

• Address hemorrhage with direct pressure
• Initiate antibiotics
• Grade I and II- Ancef 1g-2g IV
• Grade III- Ancef plus Gentamicin 2mg/kg IV
• Farm injuries or gross contamination- add
  Penicillin
• Apply saline soaked gauze dressing to wound
• Attempt reduction and apply splint
• Operate- most surgeons use 8 hrs as the window
  for decreasing the incidence of infection and
  other related complications of open fractures

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Orthopaedic Trauma- General Principles -
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Orthopaedic Trauma

• Defined- The care of fractures and soft tissue
  injuries of the extremities either in the setting
  of multiple trauma or isolated injuries

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Orthopaedic Trauma

• Orthopaedic trauma surgeons care for complex
  fractures, periarticular fractures, fractures
  involving the pelvis and acetabulum, and fracture
  nonunions, malunions and infections.

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Trauma

• Field Triage
• Airway
• Breathing
• Circulation
• Extrication of Patient
• Shock Management
• Fracture Stabilization
• Transport

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Trauma

• Golden Hour of Trauma
• Rapid transport of a severely injured patient to
  a trauma center for definitive care. Initial
  treatment has a significantly higher chance for
  survival during this period.

UNMC Trauma and Critical Care Surgery Team
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Trauma Evaluation

• ATLS- Advanced Trauma and Life Support
• A standardized protocol for the evaluation and
  treatment of victims of trauma
• Developed by a Nebraska orthopaedic surgeon who
  was involved in a trauma and was not satisfied
  with the lack of a protocol for such patients

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ATLS

• A- establish an Airway
• B- Breathe for the pt. (if they arent)
• C- assess and restore Circulation
• D- assess neurologic Disability
• E- Expose entire patient

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Primary Survey

• Rapid assessment of ABCs and addressing life
  threatening problems (ie establishing airway and
  ventilation, placing chest tubes, control active
  hemorrhage)
• Place large bore IVs and begin fluid replacement
  for patients in shock
• Obtain Xray of Chest, Pelvis, and Lateral C-Spine

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Secondary Survey

• Assessing entire patient for other non-life
  threatening injuries.
• Orthopaedist assesses skeleton and splints
  fractures and reduces dislocations
• Also evaluate distal pulses and peripheral nerve
  function
• Obtain Xray or CT of affected areas when pt is
  stable

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Emergent Skeletal Issues

• Hemorrhage control from Pelvis Fractures in pt
  with labile blood pressure (shock)
• Close pelvic volume
• Hemorrhage control from open fractures
• Direct pressure
• Restore pulses by realigning fractures and
  dislocations

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Urgent Skeletal Issues

• Irrigation and Debridement of open fractures
• Reduction of dislocations
• Splinting of fractures
• Fixation of femur fractures
• Addressing compartment syndromes

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Trauma Assessment

• History ? Mechanism of Injury
• Palpation
• Note swelling, Lacerations
• Painful ROM
• Crepitus- that grating feeling when two bone ends
  rub against each other
• Abnormal Motion- ie the tibia bends in the middle
• Check pulses, sensory exam, and motor testing if
  possible

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Diagnosis- The exam

• Assess for lacerations that communicate with the
  fracture
• Closed Fracture intact skin over fracture
• Open Fracture laceration communicating with
  fracture (often referred to as a compound
  fracture by lay persons)

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Compartment Syndrome
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Compartment Syndrome

• An emergent condition characterized by increased
  pressure within a closed anatomical compartment
  with the potential to cause irreversible damage
  to the contents of the compartment (ie muscle and
  nerves)

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Etiology

• Burns
• High pressure injection
• Trauma
• fractures
• crush
• Medical (Iatrogenic)
• Tight dressings/casts coagulation, dialysis,
  traction

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Pathophysiology

• Fixed volume pressure in a closed space
• Rigid fascia
• Increased tissue pressure exceeds venous and
  capillary opening pressure producing local
  hypoxia and capillary leak leading to even gt
  tissue pressure
• Hypotension decreases tolerance to compartmental
  pressure increases

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Diagnosis

• In an awake patient this is a clinical diagnosis
• In an obtunded (drunk, head injured, sedated,
  intubated) patient the diagnosis is made with
  pressure measurements

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Compartment Syndrome Diagnosis

• The 6 Ps
• Pressure rigid compartment w/ shiny skin
• Pain - out of proportion (the most consistent
  finding in an awake pt)
• Passive stretch pain
• Paresthesias
• Paralysis
• Pallor
• Poikilothermia
• Pulselessness not a characteristic of C.S.

Late findings
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Diagnosis Pressure Measurement

• Threshold number is controversial
• Peak pressure zone 2cm from fracture

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Treatment

• must decompress all compartments at risk
• skin, fat, fascia widely decompressed
• debridement of necrotic tissue
• do not close wounds

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Extremity Compartment Syndromes

• Gluteal
• Thigh
• Calf
• Foot
• Hand
• Forearm
• Arm

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Questions??