UNMC Orthopaedic Surgery

Welcome to your
M4 Clerkship and
Welcome to
Department of Orthopaedic Surgery
Omaha and Rehabilitation
 Introduction
• Welcome
• Expectations and goals
• General considerations for Orthopaedic history
and physical exam
• Introduction to reading x-rays
• Trauma/Open Fractures
• Compartment Syndrome
 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
 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
 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.
• 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
 Goals
• At the end of your rotation you should be
able to:
1. Read basic x-rays appropriately
2. Perform an orthopaedic history and physical
3. Recognize common fractures, their classification,
and know how to acutely manage them
4. Understand basic patient care for the
Orthopaedic patient
5. Be able to diagnose common musculoskeletal
problems
CALL
• 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.
We’d 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.
• 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.
CONFERENCES
 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.
 Conference Schedules
Mon Tues Wed Thurs Fri
600am 530am 600am 600am 600am
Textbook Medical Pediatric Trauma Hand
Conference Student Ortho Conference Conference
Lectures Conference
630am
Grand 630am
Rounds Gold Joint
Conference

Sorrell Center UNMC Ortho Children’s Creighton UNMC Ortho

Room 1005 Library Hospital Med Ctr Library
Glow Aud. Morrison Rm
3rd Floor Lobby Lvl
 Orthopaedic Basics
- History and Physical Exam -
- How to Read an X-Ray -
- Principles of Casting/Splinting –
- Fracture Fixation -

Department of Orthopaedic Surgery

and Rehabilitation
 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
 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
 Physical Exam Basics
• NVI What does this mean?
1. Neurologic exam- Always document the
neurologic status. Some fractures are
associated with nerve injuries and knowing
the status of the nerve is critical
2. Vascular exam- Always check for pulses
distal to the fracture sight. Missed vascular
injuries can be devastating
 Physical Exam
• NEVER trust someone else’s 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
Imaging
 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
 Reading X-rays
1. Say what it is- what anatomic structure are
you looking at and how many different views
are there
2. Condition of the soft tissue- Open vs Closed
3. Regional Location- Diaphysis (rule of 1/3),
Metaphysis, Epiphysis including intra and
extra-articular, and Physis (pedi)
4. Direction of the fracture line- Transverse,
Oblique, Spiral
 Reading X-rays
5. Condition of the bone- comminution (3 or
more parts), Segmental (middle fragment),
Butterfly segment, incomplete, avulsion,
stress, impacted
6. Deformity-Displacemtent (distal with respect
to proximal), angulation (varus, valgus),
rotation, shortening (in cm’s), distraction
 Fracture Pattern
• Transverse
• Produced by a
distracting or tensile
force
 Fracture Pattern
• Spiral
• Produced by a torsional
force
 Fracture Pattern
• Butterfly
• Produced by pure
bending force
 Fracture Pattern
• Comminuted
• Broken into many
pieces- high energy with
combined forces
 Displacement
• Characterized by % of bone
contact on either view
 Angulation
• Distal fragment relative to
proximal
– Varus, Valgus, Anterior, Posterior
• Apex of angle formed by
fragments
– E.g., Apex Anterior, Apex Medial,
Apex Ulnar
 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
 Location-Diaphysis
• Shaft portion of bone
 Location-Metaphysis
• The ends of the bone (if
the fracture goes into a
joint it is described as
intra- articular)
 Now All Together
• Transverse fracture of
the femur at the middle
third- distal third
junction with 100%
displacement and varus
(or apex lateral)
angulation
What do you see?
What do you see?
What do you see?
 Casting, Splinting, and
Definitive Fracture Fixaiton
 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
 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
 Definitive Fracture Fixation
Options
• Traction
– Useful in patients who
are too sick for surgery
– Useful to maintain
alignment until definitive
fixation
 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
Indications- Emergent
Stabilization
 Definitive Fracture Fixation
Options
• Open Reduction and
Internal fixation with
Plates and screws
– Used for many fractures
especially those
involving joints
 Definitive Fracture Fixation
Options
• Intramedullary Nails
– Treatment of choice for
most tibia and femur
fractures
– Used in selected
humerus and forearm
fractures
 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
Open Fractures
 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
 Evaluation of open fractures
• ABC’s
• 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
 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
 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
Orthopaedic Trauma
- General Principles -

Department of Orthopaedic Surgery

and Rehabilitation
 Orthopaedic Trauma
• Defined- The care of
fractures and soft tissue
injuries of the
extremities either in the
setting of multiple
trauma or isolated
injuries
 Orthopaedic Trauma
• Orthopaedic trauma surgeons care
for complex fractures,
periarticular fractures, fractures
involving the pelvis and
acetabulum, and fracture
nonunions, malunions and
infections.
 Trauma
• Field Triage
– Airway
– Breathing
– Circulation
– Extrication of Patient
– Shock Management
– Fracture Stabilization
– Transport
 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

 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
 ATLS
• A- establish an Airway
• B- Breathe for the pt. (if
they aren’t)
• C- assess and restore
Circulation
• D- assess neurologic
Disability
• E- Expose entire patient
 Primary Survey
• Rapid assessment of ABC’s and addressing life
threatening problems (ie establishing airway and
ventilation, placing chest tubes, control active
hemorrhage)
• Place large bore IV’s and begin fluid replacement for
patients in shock
• Obtain Xray of Chest, Pelvis, and Lateral C-Spine
 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
 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
 Urgent Skeletal Issues
• Irrigation and Debridement of open fractures
• Reduction of dislocations
• Splinting of fractures
• Fixation of femur fractures
• Addressing compartment syndromes
 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
 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)
Compartment Syndrome
 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)
 Etiology
• Burns
• High pressure injection
• Trauma
– fractures
– crush
• Medical (Iatrogenic)
– Tight dressings/casts
coagulation, dialysis,
traction
 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 > tissue pressure
• Hypotension decreases tolerance to compartmental
pressure increases
 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
 Compartment Syndrome
Diagnosis
• The 6 P’s
– Pressure – rigid compartment w/ shiny skin
– Pain - out of proportion (the most consistent finding in an
awake pt)
• Passive stretch pain
– Paresthesias
– Paralysis
– Pallor Late findings
– Poikilothermia

• Pulselessness – not a characteristic of C.S.

 Diagnosis: Pressure
Measurement
• Threshold number is
controversial
• Peak pressure zone 2cm
from fracture
 Treatment
• must decompress all compartments at risk
• skin, fat, fascia widely decompressed
• debridement of necrotic tissue
• do not close wounds
 Extremity Compartment
Syndromes
• Gluteal
• Thigh
• Calf
• Foot
• Hand
• Forearm
• Arm
Questions??