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  • Anteriorly dislocated tend to be externally rotated and abducted. Greater risk of femoral artery/vein injury when ant disloc.
  • Compartment syndrome is a dreaded complication of tib-fib fractures. This cross-section is about mid-calf.You put your hand on the sole of the patient’s foot to check their plantarfexion. Deep peroneal is in the anterior compartment, it allows you to pull your toe to the front of your shin. Loss of dorsiflexion = foot drop
  • This image uncopyrighted from a personal injury lawyer’s website.
  • Address the use of femoral nerve block for pain control
  • Another example of unstable from Gary Larson’s Far Side “How nature says ‘don’t touch.’”Intertroch fractures that are on a fracture line perpendicular to this (from trochanter to trochanter) can be stable, but are still non-weightbearing.
  • Traction may compromise blood flow to the femoral head.
  • Arch drawn long inferior edge of obdurator foramen and medial edge of femoral neck should be smoothDiscuss value of femoral nerve block in these fractures
  • Ask about how you detect fibular nerve injuryDiscussion of hard signs on next page
  • Black diamond slopes are hard….Pulseless, pallor, poikiothermia, paresthesia, paralysis
  • The Lachman is more difficult to do when the patient has large legs. It is necessary to stabilize the femur with the nondominant hand while trying to displace the tibia anteriorly with the dominant hand.Sensitivity is not as good in the setting of acute trauma.Management: x-ray, RICE, knee immobilizer (bcs you can’t really tell if more than one ligament is involved), ortho f/u
  • Tibial plateau and femoral condyle fractures are non-weightbearing and operative. CT is indicated and ortho consult is mandatory.Medial plateau fractures are associated with PCL and LCL injuries.
  • Some knee extension may be intact with complete tendon rupture if retinaculum is still intact.Immobilize and ortho consult in ED. Operative repair after one week if extensor function is impaired.
  • Nothing obvious here.
  • Ankle is everted in stress view. Check out the gap between the fibula and tibia and the gap between the medial malleolus and talus
  • Can also be caused by forced dorsiflexion
  • This is what you need to know about the ankle in a nutshell. The deltoid is a very tough complex of 3 ligaments
  • Ask whichnerve is needed to plantarflex - tibial
  • Needs posterior short leg splint and ortho f/u in 2-3days.Ever prescribe cipro or Levaquin? Ever give corticosteroids to an asthmatic?
  • Goal is to recognize that this view doesn’t help much
  • This lady slipped on a bar of soap in the tub, fell back, and kicked the faucet on her way down.
  • The talus is displaced in this AP view
  • Foot stays planted while the rest of the person topples. Involves disruption of talonavicular and talocalcaneal joints.
  • Transcript

    • 1. Orthopedics Board Reviewpart 2: downstairs
    • 2. MS/PGY1sName that dislocation anddescribe how it happened.
    • 3. Posterior Hip Dislocation Accounts for 90% of hip dislocations Posteriorly directed force applied to flexed kneePGY2s:How quickly should you reduce this dislocation afteridentifying it? Why?
    • 4. Complications of Posterior Hip Dislocation Reduce within 6 hours Risk of femoral head avascular necrosis (AVN) increases as delay to reduction increases >6hrs Up to 50% have associated acetabulum or femur fracture Sciatic nerve injury, Dr. Gagandeep Singh* occurs in about 10%PGY3s:Name the radiographic view that helps you assess theacetabulum.How can you clinically assess for sciatic nerve injury?
    • 5. The Judet view (45° oblique) is the best plain film method for visualizing the acetabulum.Posterior rim fractures commonly result from posterior dislocations – can result in instability and accelerated osteoarthritis.
    • 6. The sciatic nerve branches into the common peroneal and the tibial nerves• Motor: dorsiflexors • Motor: plantarflexors• Sensory: web space of • Sensory: sole of the the great toe (this is foot the deep peroneal branch) Blech… anatomy. Thanks, Dr. tmi.
    • 7. Turns out this stuff is also good to know if you are considering compartment syndrome after a tib-fib fracture • Motor: dorsiflexors • Motor: plantarflexors • Sensory: web space of • Sensory: sole of the foot the great toe (this is the deep fibular branch) tibiaDeep peronealn. within theanterior Tibial n. withincompartment the deep posterior compartment Cross section of leg
    • 8. Grandma has fallen and she can’t get up. (Really, you knew this had to be coming.) For the next few slides: MS/PGY1: Name the fracture type. PGY2: Traction or no traction? PGY3: You’ll get your question when we get there.
    • 9. 1s: Name it.2s: Traction?3s: Low-energy fractures of this type are associated withchronic use of which class of drugs?
    • 10. Subtrochanteric femur fracturesTraction is recommendedThe atypical step-like fracturepattern in this x-ray should makeyou think of bisphosphonate-associated fractureIf the mechanism doesn’t makesense, also think of primary ormetastatic malignancyMay be complicated by 1-2 literblood loss from deep femoralartery injury Andrews, NA
    • 11. Sadowski, et. al.3s: What is the 6-month mortality associated with thisinjury?
    • 12. Reverse obliqueintertrochanteric femur fracture Traction is recommended Hip fractures have a 10-30% 6-month mortality, mostly from infection or pulmonary embolism Can also be complicated by life- threatening hemorrhage The reverse intertroch fracture is always unstable, and you should manage it as cautiously as you would this guy…
    • 13.*3s: Give a major complication of this type of fracture.
    • 14. Femoral neck fractureTraction is contraindicatedAVN is a major complicationPatients with nondisplacedfemoral neck fractures maybe ambulatoryCT or MRI may be required ifclinical suspicion is high andradiographs are negativeThe Shenton line is used toassess AP films for thisfracture…
    • 15. Shenton line
    • 16. MS/PGY1s:Name the soft tissuestructures that are damagedhere.PGY2s: What vascular injuryis associated with thisdislocation?PGY3s: What nerve injury isassociated with thisdislocation?
    • 17. Tibiofemoral (knee) dislocation Anticipate damage to ACL, PCL, MCL, LCL, medial and lateral menisci, and synovial capsule Because this injury is grossly unstable, spontaneous reduction occurs in up to 50% of cases Popliteal artery injury in up to 1/3 of cases If undetected may result in ischemia and amputation If no hard signs of vascular injury, consider admission for serial exams Common peroneal nerve injury is also common
    • 18. The“hard signs” The Hard Signs Hemorrhage Expanding hematoma Thrill Bruit Ischemia (5 P’s)
    • 19. MS/PGY1s: This 28yo patient came out from the bottom of ascrum pile with this swollen, painful knee. He’s worried thathe “tore his other ACL.” How will you assess for ACL injury?
    • 20. About that ACL Anterior Drawer test Lachman test Knee is flexed to 90° Knee is flexed to 30° Most sensitive ( 84%)• Mechanism of injury is typically deceleration or hyperextension from a blow to the anterior knee• Patients often report feeling a “pop” which is followed by rapid and impressive swelling 70% of patients with acute, traumatic hemarthrosis have an ACL injury
    • 21. Aside from the effusion, the x-ray is negative for this patient.You decide to perform arthrocentesis to improve mobility andreduce pain. When you empty the bloody aspirate into abasin, round, shiny globs coalesce on the surface. PGY2s: What is that stuff? What caused it?
    • 22. Lipohemarthrosis indicates occult fractureFat globules escape to the synovial space from fracturedboneIn order of likelihood, suspect Tibial plateau fracture Lateral plateau fractures often associated with ACL and MCL injuries Mechanism: blow to lateral knee Tibial spine avulsion Anterior attachment point for ACL More common in peds who have tougher ligaments than bones Femoral condyle fracture Uncommon, but associated with popliteal artery and fibular nerve injury
    • 23. Sometimes you can see lipohemarthrosis on plain film • fat *
    • 24. Swollen knee – can’t walkSuppose on your initial history, the patient tells you he hasbeen unable to walk since the injury occurred. He is unableto extend his knee on your exam. PGY3s: Now what is your differential diagnosis? How can exam/work-up help you differentiate these injuries?
    • 25. Knee extensor injuries Patellar tendon rupture Hip flexion intact, knee extension absent or very weak May see patella alta on x-ray Patients usually younger than 40yo Quadriceps tendon rupture Both hip flexion and knee extension disrupted Patients usually older than 40yo Patella fracture Transverse fractures may disrupt extensor functionMechanism is the same for all injuries: forceful quadricepscontraction or a direct blow to the flexed knee
    • 26. What would the Canadians do?Your patient presents after anunfortunate mishap involving acute new pair of heels. Hehas not been able to walksince the mishap because ofpain. He is swollen andtender over both malleolli onexam.MS/PGY1s: Review theOttawa ankle rules and tell meif he should get an x-ray.
    • 27. Ottawa Ankle RuleGet the x-ray if the patient is 18-55yo, has any malleolarpain, and any one of these:1. Bony tenderness at tip or distal 6cm of posterior edge of the medial malleolus2. Bony tenderness at tip or distal 6cm of posterior edge of the lateral malleolus3. Inability to bear weight for 4 steps immediately and in the EDThis decision rule is 97-100% sensitive for radiographicallydetectable ankle injuries.
    • 28. PGY2s: Interpret, please.Identify the talus and medial, lateral, and posterior malleoli.
    • 29. This guy seemed to have an unusual amount of painwhen you squeezed his calf, so you get stress views. Now what do you see?
    • 30. Syndesmotic disruptionWhen caused by eversionmechanism, indicates medialstructural disruption. Thismeans medial malleolusfracture or deltoid ligamenttear.PGY3s: What x-ray view will Normal values (mortise view):you order now? What is the Tibiofibular clear space < 10mmeponym of the fracture you are Tibiofibular overlap > 5mmtrying to exclude?
    • 31. Maisonneuve fracture oblique proximal fibula fracture AND medial malleolus fracture OR deltoid ligament tear Long leg splint, non- weightbearing, and timely ortho f/u
    • 32. The tibiofibular syndesmosis is Inversion is limited by: important for lateral malleolus rotational stability. tibia and anteior talofibular ligament (ATFL) and Eversion is limited by: calaneofibular ligament medial malleolus (CFL) and talus deltoid ligament(s) calcaneus Most commonly injured ankle ligament: ATFL The plafond is the articular surface of the distal tibia.A pilon fracture is a high-energy comminuted distal tib/fib fracture caused by axial force to the plafond.
    • 33. Your next Flex patient…Amidst a post-olympics fervor, a middle-aged accountantwas skoolin’ some punks in b-ball at the Y when he injuredhis heel. He was coming down off a jump shot when hethinks someone kicked the back of his heel. He felt a popback there.On your exam, he is tender on the back of his heel andseems weak with plantar flexion.MS/PGY1: What has he injured?PGY2: Name and describe the clinical exam maneuver you’lldo to verify your diagnosis.PGY3s: Name two classes of medications that increase riskfor this type of injury.
    • 34. Achilles tendon rupture  Thompson test attempts to induce plantar flexion by squeezing the gastrocnemius Negative (Achilles intact) Positive (complete Achilles rupture) Corticosteroids and fluoroquinolones may cause tendinopathies
    • 35. True story…22yo F ~20 weeks by LMP, intoxicated and high, is broughtto the ED by JSO after she reportedly jumped from a secondstory window. Swelling and ecchymoses of the feet promptthis x-ray. MS/PGY1: Where’s the fracture? PGY2: What associated injuries must you consider? PGY3: Name the angle you can measure on x-ray to look for subtle fractures of this type and how to measure it.
    • 36. Calcaneus fracture Most commonly caused by fall/jump from height and landing on feet 10% have lumbar spine fractures *Boehler’s angle is normally 20-40° <20° indicatesfracture
    • 37. How to read a lateral foot x-ray Navicular – most commonly fractured bone of midfoot If this doesn’t look like the profile for a bunny slope, think Lisfranc and look at other views better remember BoehlerToe stuff 5th metatarsal head – (pseudo)Jones fracture?
    • 38. What to do with the AP viewMost common If the line between thesite of stress 1st and 2nd metatarsalsfractures in the and cuboids is widefoot: 2nd and 3rd or you see a fracturemetatarsals at the base of the 2nd metatarsal, think Lisfranc dislocation Jones fracture? navicular Intact and snug talus with the talus?
    • 39. The oblique view If the line between the 2nd and 3rd metatarsals and cuboids is disrupted or wide, think Lisfranc dislocation taluscalcaneus
    • 40. Let’s practice. MS/PGY1s: Where’s the injury? (Dr. Frank Gailliard)*
    • 41. PGY2s: Give at least one eponym for this fracture. (Dr. Frank Gailliard)PGY3s: Which tendon is responsible for this injury?
    • 42. Pseudo-Jones or Dancer fractureAvulsion of base of 5thmetatarsalAttachment point ofperoneus brevisInversion mechanismHard-soled shoe, WBAT
    • 43. Jones fractureTransverse metaphyseal-diaphyseal junctionfracture of 5th metatarsalInversion mechanismHigh incidence of nonunionNWB, ortho f/u for castingor surgery within 48 hours (Dr. Frank Gailliard)
    • 44. MS/PGY1s: Anything seem amiss here?
    • 45. Here’s the AP from the same patient…
    • 46. Lisfranc fracture-dislocation PGY2s: How much displacement is allowed between the 1st and 2nd metatarsal base? PGY3s: Discuss management for these injuries.
    • 47. Lisfranc dislocation1mm or greater gap between the 1st and 2nd metatarsalbases indicates unstable injuryRequire ortho consult for immediate reduction ofdislocationMechanism: direct trauma or hyperdorsiflexionSuspect when exam demonstrates pain with torsion ofmidfoot or plantar ecchymosisBilateral weightbearing AP views or CT aid diagnosisMisdiagnosis rate of 20%Complicated acutely by compartment syndrome
    • 48. Final challenge (Dr. Frank Gailliard)MS/PGY1s: Anything look weird here?
    • 49. There’s something wonkyabout the navicular bone… PGY2s and 3s: What is this injury called? What’s your management plan? (Dr. Frank Gailliard)
    • 50. Subtalar dislocationMechanism: significant torsional forceUsually presents with deformity, but dramatic swelling canconceal the dislocationAlways unstableRequires immediate reduction and rapid ortho f/u
    • 51. Tintinalli, 7th editionHarwood-Nuss, 4th editionKoval & Zuckerman, Handbook of Fractures, 3rd editionWheless’ Textbook of Orthopedics, whelessonline.comAndrews, NA. Atypical subtrochanteric and femoral shaft fractures in bisphosphonateusers: Five years and counting, yet still too many unanswered questions. IBMSBoneKEy (2010) 7, 296–303 (2010)Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment ofReverse Oblique and Transverse Intertrochanteric Fractures with Use of anIntramedullary Nail or a 95° Screw-Plate : A Prospective, Randomized Study. J BoneJoint Surg Am, 2002 Mar 01;84(3):372-381Christos SC, Chiampas G, Offman R, and Rifenburg R. Ultrasound-Guided Three-In-One Nerve Block for Femur Fractures. West J Emerg Med. 2010 September; 11(4):310–313.Good sources for radiographs used in this*Images used with permission under Creative Commons licensingUnlabeled radiographs from our ED