ORTHOPEDICS

L-NU – College of Medicine

Lecturer: Dr. Jess Belocura

INTRODUCTION TO ORTHOPEDICS injuries and knowing the status of the

General Considerations of Bone and Joint nerve is critical
Affectation  Vascular exam
o Always check for pulses distal to the
ORTHO = Straight, Upright, Correct fracture sight. Missed vascular injuries
PAIOS = Child can be devastating
 First used by Nicolas Andry, a French doctor
(1841) in a book titled Orthopedia: The art to  NEVER trust someone else’s exam. ALWAYS put your
correct and prevent deformities in children 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
ORTHOPEDIC SPECIALTY
 is the branch of medicine which manage trauma
and disease of Musculoskeletal system RED FLAGS
 It includes: bones, muscles, tendons, ligaments,  Red Flags = warning Symptom or sign
joints, peripheral nerves, vertebral column and  Red flags should always be looked for and
spinal cord and its nerves. remembered
 Trauma and Orthopedic Surgery  Presence of a red flag means the necessity for
 Sub-specialties in orthopedics include : Pediatric urgent or different action/intervention
Orthopedic, Sport and reconstructive Orthopedics, Examples of Red Flags
Orthopedic Trauma, Arthroplasty, Spinal surgery,  Open fractures
Hand, and foot and Ankle surgery • more serious and very high possibility of
infection and complications
Sub-Specialties in orthopedic include:  Complicated Fractures
 General • fracture with injury to major blood vessel,
 Pediatric Orthopedic nerve or nearby structure
 Sport and Reconstructive Orthopedic  Compartment Syndrome
 Orthopedic Trauma • increase in intra-compartment pressure
 Arthroplasty (Joint Replacement) which endangers the blood circulation of
 Spinal Surgery the limb and may affect nerve supply
 Foot and Ankle surgery  Cauda Equina Syndrome:
 Oncology • Compression of the nerve roots of the
 Hand Surgery cauda Equina at the spinal canal which
 Upper Limb affect motor and nerve supply to the lower
limbs and bowel and bladder sphincter
ORTHOPEDIC HISTORY control (also saddle or peri-anal area)
A good general orthopedic history contains:  Infection of bone, joint and soft tissue
 Onset, Duration, and Location of a problem • Osteomyelitis:
 Limitations and debilitation attributed to the • Infection of the bone
problem • Septic Arthritis:
 Good surgical history, especially with regards to • Infection of the joint
orthopaedic surgeries and prior anesthesia • Cellulitis:
 Co-morbid conditions that contribute to the • Spreading Infection of the soft
problem or will preclude healing in some manner tissue. May cause septicemia or
irreversible damage
Physical Exam Basics  Multiple trauma or Pelvic Injury:
 Inspect and Palpate everything- start with normal • more than one fracture or injuries
structures and move to abnormal sustained at the same time, consider
 Range of motion in all planes massive blood loss and associated injuries
 Strength  Acute joint Dislocations:
 Sensation • requires urgent reduction or may cause
 Reflexes serious complications
 Gait
 Stability

NVI – What does this mean?

 Neurologic exam
o Always document the neurologic status.
Some fractures are associated with nerve

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 ORTHOPEDICS
L-NU – College of Medicine
Lecturer: Dr. Jess Belocura

Cubitus Varus  Metabolic

 Tumor

Traumatic Injuries
 Fractures
 Dislocations
 Soft tissues injuries: ligaments, tendons
 Nerve injuries
 Epiphyseal injuries

Orthopaedic Trauma
 The care of fractures and soft tissue injuries of the
extremities either in the setting of multiple trauma
Cubitus Valgus or isolated injuries
 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
INTRO TO READING X-RAYS  Fracture Stabilization
 Reading a radiograph is essentially describing the  Transport
anatomy of a certain structure Golden Hour of Trauma
 In order for it to be universal and understandable  Rapid transport of a severely injured patient to a
for others, clarity and precision are essential trauma center for definitive care. Initial treatment
 A fracture is described based on the findings of the has a significantly higher chance for survival during
physical exam and a review of radiographs this period.

Reading X-rays Trauma Evaluation

1. Say what it is- what anatomic structure are you ATLS- Advanced Trauma and Life Support
looking at and how many different views are there  A standardized protocol for the evaluation and
2. Condition of the soft tissue- Open vs Closed treatment of victims of trauma
3. Regional Location- Diaphysis (rule of 1/3),  Developed by a Nebraska orthopaedic surgeon
Metaphysis, Epiphysis including intra and extra- who was involved in a trauma and was not
articular, and Physis (pedi) satisfied with the lack of a protocol for such
4. Direction of the fracture line- Transverse, Oblique, patients
Spiral  A- establish an Airway
5. Condition of the bone- comminution (3 or more  B- Breathe for the pt. (if they aren’t)
parts), Segmental (middle fragment), Butterfly  C- assess and restore Circulation
segment, incomplete, avulsion, stress, impacted  D- assess neurologic Disability
6. Deformity-Displacemtent (distal with respect to  E- Expose entire patient
proximal), angulation (varus, valgus), rotation,
shortening (in cm’s), distraction Primary Survey
 Rapid assessment of ABC’s and addressing life
Acquired or Congenital threatening problems (ie establishing airway and
Acquired conditions include: ventilation, placing chest tubes, control active
 Trauma hemorrhage)
 Developmental  Place large bore IV’s and begin fluid replacement
 Inflammation for patients in shock
 Infection  Obtain Xray of Chest, Pelvis, and Lateral C-Spine
 Neuromuscular
 Degenerative

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 ORTHOPEDICS
L-NU – College of Medicine
Lecturer: Dr. Jess Belocura

Secondary Survey Etiology

 Assessing entire patient for other non-life  Burns
threatening injuries.  High pressure injection
 Orthopaedist assesses skeleton and splints  Trauma
fractures and reduces dislocations • fractures
 Also evaluate distal pulses and peripheral nerve • crush
function  Medical (Iatrogenic)
 Obtain Xray or CT of affected areas when pt is • Tight dressings/casts coagulation, dialysis,
stable traction

Emergent Skeletal Issues Pathophysiology

 Hemorrhage control from Pelvis Fractures in pt  Fixed volume ~ pressure in a closed space
with labile blood pressure (shock)  Rigid fascia
• Close pelvic volume  Increased tissue pressure exceeds venous and
 Hemorrhage control from open fractures capillary opening pressure producing local hypoxia
• Direct pressure and capillary leak leading to even > tissue pressure
 Restore pulses by realigning fractures and  Hypotension decreases tolerance to compartmental
dislocations pressure increases

Urgent Skeletal Issues

 Irrigation and Debridement of open fractures Diagnosis
 Reduction of dislocations  In an awake patient this is a clinical diagnosis
 Splinting of fractures  In an obtunded (drunk, head injured, sedated,
 Fixation of femur fractures intubated) patient the diagnosis is made with
 Addressing compartment syndromes pressure measurements

Trauma Assessment Compartment Syndrome Diagnosis

 History � Mechanism of Injury  The 6 P’s
 Palpation  Pressure
 Note swelling, Lacerations • rigid compartment w/ shiny skin
 Painful ROM  Pain
 Crepitus- that grating feeling when two bone ends • out of proportion (the most
rub against each other consistent finding in an awake pt)
 Abnormal Motion- ie the tibia bends in the middle • Passive stretch pain
 Check pulses, sensory exam, and motor testing if  Paresthesias
possible  Paralysis
 Pallor
Diagnosis- The exam  Poikilothermia
 Assess for lacerations that communicate with the  Pulselessness – not a characteristic of C.S.
fracture
• Closed Fracture Diagnosis: Pressure Measurement
• intact skin over fracture  Threshold number is controversial
• Open Fracture  Peak pressure zone 2cm from fracture
• laceration communicating with
fracture (often referred to as a
compound fracture by lay
persons)

COMPARTMENT SYNDROME
 An emergent condition
characterized by increased
pressure within a closed Treatment
anatomical compartment with  must decompress all compartments at risk
the potential to cause  skin, fat, fascia widely decompressed
irreversible damage to the  debridement of necrotic tissue
contents of the compartment (ie  do not close wounds
muscle and nerves)

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 ORTHOPEDICS
L-NU – College of Medicine
Lecturer: Dr. Jess Belocura

Extremity Compartment Syndromes Avulsion Fracture

 Gluteal Force due to Resisted Muscle Action:
 Thigh
 Calf
 Foot
 Hand
 Forearm
 Arm

Fractures: Break in the continuity of bone

“Avulsion” Transverse pattern

Dislocations
 Complete separation of the articular surface
 Distal to proximal fragment
o Anterior, Posterior, Inferior, Superior

Intra-articular Fractures
 If displaced
• should always be
treated by ORIF
• Open Reduction
and Internal
Fixation
 failure to reduce and fix such
Fracture Dislocation fracture results in loss of
 Dislocation with fracture of the bone function, deformity and early
degenerative changes

Soft tissue injuries of the knee

 Always X-Ray Joint

o Above and Below

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 ORTHOPEDICS
L-NU – College of Medicine
Lecturer: Dr. Jess Belocura

Anterior Cruciate Ligament injury: MRI

 The anterior
cruciate ligament
(ACL) is one of
the key ligaments
that help stabilize
your knee joint.
The ACL connects
your thighbone
(femur) to your
shinbone (tibia).
It's most
commonly torn
during sports that
involve sudden
stops and
changes in direction — such as basketball, soccer, Developmental Foot deformity: Hallux Valgus
tennis and volleyball.  Hallux valgus is the
most common foot
Congenital Anomaly : Talipes Equino Varus TEV deformity. It is a
 Clubfoot, also progressive foot
known as talipes deformity in which the
equinovarus first
(TEV), is a metatarsophalangeal
common foot (MTP) joint is affected
abnormality, in and is often
which the foot accompanied by
points significant functional
downward and disability and foot
inward. The condition is present at birth, and pain. This joint is
involves the foot and lower leg. gradually subluxed
(lateral deviation of
(Developmental Dislocation of Hip) DDH the MTP joint)
 Developmental resulting in abduction of the first metatarsal while
dysplasia of the the phalanges adduct. This often leads to the
hip (DDH) is a development of soft tissue and bony prominence
condition where on the medial side of what is called a bunion
the "ball and (exostosis on the dorsomedial aspect of the first
socket" joint of metatarsal head).
the hip does not  In this foot deformity, the medial eminence
properly form in becomes prominent as the distal end of the first
babies and metatarsal drifts medially and the proximal phalanx
young children. deviates laterally. The first MTP becomes subluxed,
It's sometimes leading to a lateral deviation of the hallux, medial
called displacement of the distal end of the first
congenital hip metatarsal and bony enlargement of the first
dislocation or hip dysplasia. The hip joint attaches metatarsal head
the thigh bone (femur) to the pelvis.
Spinal Deformities: Kyphosis or Hyperlordosis
Developmental: SCFE (Slipped Capital Femoral  Kyphosis is a spinal disorder in which an
Epiphysis) excessive outward curve of the spine results in an
 Slipped capital femoral epiphysis (SCFE) is a hip abnormal rounding of the upper back. The
condition that occurs in teens and pre-teens who condition is sometimes known as "roundback" or—
are still growing. For reasons that are not well in the case of a severe curve—as "hunchback."
understood, the ball at the head of the femur Kyphosis can occur at any age, but is common
(thighbone) slips off the neck of the bone in a during adolescence.
backwards direction.  Hyperlordosis is a condition in which there is an
excessive spine curvature in the lower back.

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 ORTHOPEDICS
L-NU – College of Medicine
Lecturer: Dr. Jess Belocura

Hyperlordosis creates type of arthritis that occurs most often in people

a characteristic C- 50 years of age and older, but may occur in
shaped curve in the younger people, too. In osteoarthritis, the cartilage
lower back, or in the knee joint gradually wears away.
lumbar region, where
the spine curves Metabolic Disorders (Rickets): Bow Legs
inward just above  Rickets is a condition
the buttocks. It often that results in weak or
occurs as a result of soft bones in children.
poor posture or a Symptoms include
lack of exercise bowed legs, stunted
growth, bone pain, large
Spinal Deformity: Scoliosis forehead, and trouble
 Scoliosis is a sleeping. Complications
sideways curvature may include bone
of the spine. fractures, muscle
Scoliosis is a spasms, an abnormally
sideways curvature curved spine, or
of the spine that intellectual disability.
occurs most often
during the growth Osteoporosis: Hip Fracture
spurt just before  Hip fractures from
puberty. While osteoporosis are usually
scoliosis can be the result of a fall and
caused by most commonly occur in
conditions such as people in their late 70s or
cerebral palsy and muscular dystrophy, the cause 80s. A broken hip will
of most scoliosis is unknown require hospitalization and
will often require an
operation to repair the
Degenerative Disorders break. Most hospitals have
 Occur at any joint a plan for rehabilitation
 Knee & hip most common sites that follows hip surgery.
 Can be primary or secondary
 Can lead to pain and/or deformity and/or loss of Osteoporosis: Colles fracture
function  Colles Fracture is
known to be connected
Osteoarthritis of Hip to decreased bone
 A hip damaged mineral density (BMD).
by osteoarthritis. Thus, it can be an
In osteoarthritis, early sign of
the cartilage in osteoporosis and
the hip joint therefore an increased
gradually wears risk of new fractures.
away over time.
As the cartilage Bone Tumor
wears away, it  Bone tumors develop when cells within a bone
becomes frayed divide uncontrollably, forming a lump or mass of
and rough, and the protective joint space between abnormal tissue. Most bone tumors are benign (not
the bones decreases. This can result in bone cancerous). Benign tumors are usually not life-
rubbing on bone. threatening and, in most cases, will not spread to
other parts of the body.
Osteoarthritis of Knee
 Osteoarthritis is the most
common form of arthritis in the
knee. It is a degenerative,
"wear-and-tear"

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 ORTHOPEDICS
L-NU – College of Medicine
Lecturer: Dr. Jess Belocura

Neurological Evaluation: Sensory & Motor Clinical Skills: Knee Aspiration

Nerve Injury: Muscle wasting

 Muscle wasting is a loss of muscle mass due to the
muscles weakening and shrinking. There are
several possible causes of muscle wasting,
including certain medical conditions, such as
amyotrophic lateral sclerosis

Spinal Cord Injury

 Often results from fracture dislocation of spine
 When injury is at cervical spine it may result in
Tetraplegia
 Injury at dorsal spine may result in Paraplegia

Physiotherapy for Orthopaedic Patients

 Physiotherapy is an important part of recovery
 It is used for : pain relief, prevention of stiffness,
muscle strengthening, mobilization of stiff joint or
spine, training non-weight bearing or partial weight
bearing
 Physiotherapy modalities include: heat, cold,
exercise, ultrasound, traction, electrical stimulation

Clinical Skill: Cast application