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  1. 1. Orthopedics
  2. 2. Introduction A.) fractures : comminuted, stress, compression ,pathologic ,open B.) Shoulder injuries: ant&post dislocation, clavicular & scaphoid fracture C.)Colles , Monteggia and Gallezia fracture D.) Hip fracture: femoral neck, intertrochanteric, femoral shaft E.)Hip dislocate: posterior F.)Knee injuries: MCL/LCL,ACL/PCL,meniscal
  3. 3. G.)Tibial stress injuries H.) rupture of achilles tendon I.) Wrist injuries: carpal tunnel syndrome, Trigger finger, Duputyren contracture J.)Compartment syndrome K.) neurovascular injury : Radial n, popliteal n. L.)Back pain, disc herniation M.) Ankylosing spondylitis N.) foot pain plantar fasccitis O.) morton neuroma
  4. 4. General Rules about Fractures  When you suspect a fracture, order 2 views at 90° to one another and always include the joints above and below the broken bone.  Always x-ray other sites “in the line of force” (e.g., lumbar spine for someone who falls and lands on the feet, hips in a patient who has been in a motor vehicle accident with force of knees against the dashboard).
  5. 5.  Closed reduction is the answer for fractures that are not badly displaced or angulated.  Open reduction and internal fixation is the answer when the fracture is everely displaced or angulated or cannot be aligned.  Open fractures (the broken bone sticking out through a wound) require cleaning in the OR and reduction within 6 hours from the time of the injury.  Always perform cervical spine films in any patient with facial injuries.
  6. 6. Fractures are always diagnosed with an x- ray. In terms of therapy, general rules are: • Closed reduction: mild fractures without displacement • Open reduction and internal fixation: severe fractures with displacement or misalignment of bone pieces • Open fractures: skin must be closed and the bone must be set in the operating room with debridement
  7. 7. Fractures  There are 5 main types of fractures, all of which present with pain, swelling, and deformity. 1.Comminuted fractures 2. Stress fractures 3. Compression fractures 4. Pathologic fracture 5. Open fracture
  8. 8. 1. Comminuted fractures: a fracture in which the bone gets broken into multiple pieces • Most commonly caused by crush injuries 2. Stress fractures: a complete fracture from repetitive insults to the bone in Question • Most common stress fracture is of the metatarsals. • On the USMLE Step 2 CK, vignettes may describe an athlete with persistent pain. • X-ray does not show evidence, so a CT or MRI must be conducted in order for diagnosis. • Treatment is with rehabilitation, reduced physical activity, and casting. If persistent, surgery is indicated.
  9. 9. 3. Compression fractures: a specific fracture of the vertebra in the setting of osteoporosis • Approximately one-third of osteoporotic vertebral injuries are lumbar, one-third are thoracolumbar, and one-third are thoracic in origin.
  10. 10. 4. Pathologic fracture: a fracture that occurs from minimal trauma to bone that is weakened by disease • Metastatic carcinoma (e.g., breast or colon), multiple myeloma, and Paget disease are a few examples of diseases that cause brittle bones. • On the USMLE Step 2 CK, look for a vignette in which an older person fractures a rib from coughing. • Treatment is surgical realignment of the bone
  11. 11. 5. Open fracture: a fracture when injury causes a broken bone to pierce the skin • An open fracture is associated with high rates of bacterial infection to the surrounding tissue • Surgery is always the right answer
  12. 12.  Anterior dislocation: This is the most common shoulder dislocation. Look for an arm held close to the body but an externally rotated forearm and associated numbness over the deltoid muscle (axillary nerve is stretched). • Posterior dislocation: The arm is held close to the body, and the forearm is internally rotated.
  13. 13. Anterior shoulder dislocation
  14. 14. Posterior dislocation
  15. 15. Clavicular fracture
  16. 16. Scaphoid fracture
  17. 17. Fracture Management A 27-year-old woman with a known seizure disorder has a grand mal seizure. She complains of left shoulder pain. PA and lateral x- rays are obtained and fail to reveal fracture or dislocation. She is given ibuprofen for pain. She returns 3 days later with persistent pain with her arm held close to her side. She reports that she is unable to move the left arm. What is the next step in management? a. Axillary radiograph of the left shoulder b. Change analgesic to Percocet c. CT of the left shoulder d. MRI of the left shoulder e. Ultrasound of tendon insertion sites
  18. 18.  Answer: A. Although anterior shoulder dislocations are easily seen on erect posteroanterior (PA) and lateral films— look for adducted arm and externally rotated forearm with numbness over deltoid (axillary nerve is stretched)— posterior shoulder dislocations are commonly missed on these views. Posterior shoulder dislocations should be suspected in a patient with a recent seizure or electrical burn and shoulder injury or pain. Order axillary or scapular views of the affected shoulder.
  19. 19. Following are the best choices for the management of fractures:  Clavicular fractures: Figure-eight sling  Colles’ fracture: Closed reduction and casting (Presents often in an elderly woman who falls on an outstretched hand. Look for a painful wrist with a “dinner-fork” deformity.”)
  20. 20. Figure eight sling for clavicular fracture
  21. 21. Colles fracture
  22. 22.  Direct blow to the ulna (Monteggia fracture) or radius (Galeazzi fracture) results in a combination of diaphyseal fracture and displaced dislocation of the nearby joint. Open reduction and internal fixation is needed for the diaphyseal fracture, and closed reduction for the dislocated joint.  Fall on an outstretched hand with persistent pain in the anatomical snuffbox is a scaphoid fracture until proven otherwise (takes > 3 weeks to be seen on x-ray). Place thumb spica cast to help
  23. 23. Thumb spica cast for scaphoid fracture
  24. 24. Hip fracture  Consider the possibility of a hip fracture in any elderly patient who sustains a fall. Look for externally rotated and shortened leg.  Femoral neck fractures are at high risk of avascular necrosis (tenuous blood supply) and are best treated with femoral head replacement.  Intertrochanteric fractures are treated with open reduction and pinning.  Femoral shaft fractures are treated with intramedullary rod fixation. Be aware of a high risk for fat emboli.
  25. 25. Femoral head replacement – femoral neck fracture
  26. 26. Femoral shaft fracture- intramedullar y rod fixation
  27. 27. Posterior dislocation of the hip  (history of head-on car collision where the knees hit the dashboard) is an orthopedic emergency. Differentiate it from hip fracture by an internally rotated leg (the leg is also shortened).  Emergency reduction is needed to avoid avascular necrosis
  28. 28. Emergency reduction for posterior hip dislocation
  29. 29. Knee injuries:  Medial/lateral collateral ligament injury (caused by a direct blow to the opposite side of the joint): Casting if isolated ligament injury; surgical repair if multiple ligaments injured.  Anterior/posterior cruciate ligament injuries (swelling pain and anterior/ posterior drawer sign): Young athletes need arthroscopic repair. Older patients may be treated with immobilization and rehabilitation.  Meniscal injury (prolonged pain and swelling with “catching” and “locking”,during ambulation). Treat with arthroscopic repair.
  30. 30. A 19-year-old man takes a hard blow from the oncoming defense during his second college football game. He complains of severe progressive pain in his knee and has difficulty ambulating. He is seen by the team doctor, who tells him to ice the knee. A week later the pain and swelling are still present. His family doctor orders an MRI that shows a torn ACL. What is the best therapy? a. Total knee replacement b. Rehabilitation c. NSAIDs d. Arthroscopic repair e. Reassurance
  31. 31.  Answer: D. Arthroscopic repair is the most definitive therapy, followed by rehabilitation.  The risk factor that should be considered is that he had direct trauma to the front of his knee. The mechanism of injury can give some insight into the type of problem that may subsequently arise.
  32. 32.  (e.g., history of military or cadet marches): x-ray may be negative initially. Treat with cast, order the patient not to bear weight, and repeat films in 2 weeks. Tibial stress injury
  33. 33. Rupture of the Achilles tendon (middle-aged man “overdoes it” at tennis or basketball, or patient with history of fluoroquinolone use, complaining of sudden “popping” and limping): Treat with casting in equinus position or surgical repair.
  34. 34. MRI
  35. 35. XRAY
  36. 36. Wrist Injuries  Carpal tunnel syndrome (CTS) is entrapment of the median nerve that causes pain and paresthesias. The most common causes are idiopathic: rheumatoid arthritis, acromegaly, and hypothyroidism are conditions that predispose one to CTS.
  37. 37. Diagnostic Testing The best initial test is the history and physical. Phalen’s test causes symptoms by flexing the wrist gently and holding the position. Tinel’s sign causes symptoms by tapping the nerve over the flexor retinaculum and awaiting paresthesias. Tinel’s sign has greater specificity than Phalen’s sign.
  38. 38. Treatment  The best initial therapy is NSAIDs and splinting If this does not alleviate symptoms, local steroid injections have been shown to help in some cases.  Surgical release is recommended when splinting no longer controls the patient’s symptoms.
  39. 39. Trigger finger (woman who awakens at night with an acutely flexed finger that “snaps” when forcibly extended) and De Quervain tenosynovitis (young mother carrying baby with flexed wrist and extended thumb to stabilize the baby’s head): Steroid injection is the best initial therapy.
  40. 40. A 39-year-old woman awoke from a nap with severe pain in her index finger and found it to be flexed while all other fingers were extended. When she tried to pull it free she heard a loud popping sound and the pain subsided. The following day she comes to her doctor's office concerned about the sound and pain. What is the most appropriate next stop in the management of this patient? a. Amputate the finger b. Steroid injection c. Rehabilitation d. Admit to the hospital e. NSAID therapy
  41. 41. Answer: B. Trigger finger is an acutely flexed and painful finger. Steroid injections have been shown to decrease pain and recurrence of trigger finger. It is the most cost effective treatment, and studies have shown a trial of steroids should be attempted prior to surgery. Trigger finger is caused by a stenosis of the tendon sheath leading to the finger in question. If steroids fail, surgery to cut the sheath that is restricting the tendon is the definitive treatment.
  42. 42. Duputyren contracture  a condition in which there is fixed forward curvature of one or more fingers, caused by the development of a fibrous connection between the finger tendons and the skin of the palm.  palm with palmar fascial nodules  Surgery is the treatment if collagenase fails.
  43. 43. Do not confuse trigger finger with Dupuytren contracture, a condition more common In men over the age of 40. Dupuytren contracture is when the palmar fascia becomes constricted and the hand can no longer be properly extended open. Surgery is the only effective therapy.
  44. 44. A 19-year-old woman broke her femur 3 days ago during a college soccer try out. This morning her mother brought her to the ED because she was short of breath. Physical examination reveals a confused patient who is awake but not alert or oriented and a splotchy magenta rash around the base of the neck and back. ABG reveals a P02 under 60 mm Hg. What is the most likely diagnosis? a. Fat embolism b. Myocardial infarction c. Pancreatitis d. Rhabdomyolysis
  45. 45. Answer: A. Fat embolism syndrome is characterized by a combination of confusion, petechial rash, and dyspnea. It is caused by fracture of long bones. Myocardial infarction may have shortness of breath, but is unlikely in a 19-year-old woman. Pancreatitis would present with severe abdominal pain. Rhabdomyolysis has high CPK from muscle breakdown with a urine analysis and dipstick that shows positive blood with
  46. 46. Fat Embolism Fracture of the long bone allows for fat to escape as little vesicles and cause occlusion of vasculature throughout the body. The most common bone is the femur. Onset of symptoms is within 5 days of the fracture. The patient will present with: • Confusion • Petechial rash on the upper extremity and trunk • Shortness of breath and tachypnea with dyspnea
  47. 47. Diagnostic Tests • ABG will show P02 under 60 mm Hg. • Chest x-ray will show infiltrates. • Urine analysis may show fat droplets.
  48. 48. Treatment  Treatment for fat embolism requires oxygen to keep P02 over 95%. If the patient becomes severely hypoxic, intubation followed by mechanical ventilation is necessary.
  49. 49. Compartment Syndrome Compartment syndrome is due to the compression of nerves, blood vessels, and muscle inside a closed space. This can also be within a cast after setting a fracture. The 6 signs of compartment syndrome are: “6P”
  50. 50. Compartement syndrome 6P 1. Pain: most commonly the first symptom 2. Pallor: lack of blood flow causes pale skin 3. Paresthesia: "pins and needles" sensation 4. Paralysis: inability to move the limb 5. Pulselessness: lack of distal pulses 6. Poikilothermia: cold to the touch
  51. 51.  Compartment syndrome is a medical emergency and immediate fasciotomy must be completed in order to relieve pressure before necrosis occurs.
  52. 52.  When a patient complains of pain at the site of a cast, always remove the cast and examine for compartment syndrome.  Look for a history of prolonged ischemia followed by reperfusion, crushing injuries, or other types of trauma.
  53. 53. Answer : B
  54. 54. Neurovascular Injuries
  55. 55. Back Pain-Disc Herniation A 45-year-old man with a history of back pain for several months presents with sudden-onset severe back pain that came on when he was moving a television. He describes an “electrical shock” that shoots down his leg, which is worse when he coughs or strains and is partially relieved by flexing his legs. The pain has prevented him from ambulating. Straight leg raising gives excruciating pain. What is the next step in management? a. CT of the spine b. Dexamethasone c. Immediate surgery d. Ibuprofen and brief bed rest e. MRI of the spine
  56. 56. Answer: D. This is the classic presentation of lumbar disc herniation. It occurs almost exclusively at L4–L5 or L5–S1. Peak age is 43– 46. Anti-inflammatories and a brief period of bed rest is all that is needed at this stage. Immediate surgical compression is needed if the history suggests cauda equina syndrome (look for bowel/bladder incontinence, flaccid anal sphincter, and saddle anesthesia). MRI can confirm both disc herniation and cauda equina, but do not answer MRI in classic cases of disc herniation. Trial of antiinflammatories is also the first step in management.
  57. 57. A sluggish ankle jerk reflex is suggestive of pathology at S1/S2. A sluggish patellar reflex is suggestive of pathology at L4/L5.
  58. 58. Lumbar mri show herniated disc
  59. 59. A 41 -year-old man presents to the ED after acute onset of lower back pain that began after he tried to lift an engine block at his job. He says he feels like lightning bolts are shooting down his legs and he is unable to move. Physical exam reveals a positive straight leg raise test and positive anal wink. What is the most appropriate next diagnostic step? a. X-ray of the cervical spine b. MRI of the spine c. CBC d. ESR e. Lumbar puncture
  60. 60.  Answer: B.  A patient who presents with acute onset of back pain and is under the age of 50 should have an MRI to rule out spinal cord compression due to a slipped disc or lumbar disc herniation. If asked for the most appropriate next step in management, answer antiinflammatory agents. The most common sites of lumbar disc herniation are L4-L5 and L5-Sl. The other choices are applicable but the most appropriate next step is an MRI. Lumbar puncture, however, has no role in the treatment of slipped disc.
  61. 61. Ankylosing Spondylitis  This presents in men in their 30s or early 40s with chronic back pain and morning stiffness that improve with activity. X-rays eventually show a “bamboo spine.”  It is associated with the HLA B-27 antigen; screen for uveitis and inflammatory bowel disease, which are also associated with HLA-B27.  Management involves anti- inflammatory agents and physical therapy.
  62. 62.  In cases of ankylosing spondylitis, do not answer HLA-B27 antigen testing in first- degree relatives. Risk of developing ankylosing spondylitis based on HLA-B27 positivity is low, and it is not indicated for screening.
  63. 63. Metastatic Malignancy  Suspect metastatic malignancy in an elderly patient with progressive and constant back pain that is worse at night and unrelieved by rest. There will be a history of weight loss.  X-rays will show the lytic (also look for hypercalcemia and/or elevated alkaline phosphatase) or blastic lesions. Always include a workup for the most likely malignancy based on history and type of bone lesion.
  64. 64. Perform the following imaging:  First order plain radiographs (especially important in multiple myeloma).  Bone scan is most sensitive in early disease.  MRI shows the greatest amount of detail and is the diagnostic test of choice if there are any neurologic symptoms (to rule out cord compression).
  65. 65.  Bone scans will not be helpful in purely lytic lesions (e.g., multiple myeloma). Instead order plain radiographs or MRI.  Lytic lesions can be caused by multiple myeloma and kidney and thyroid metastasis, while blastic lesions are caused by metastatic prostate cancer
  66. 66. Pedicle sign- lytic lesion
  67. 67. Foot Pain-Plantar Fasciitis  Plantar fasciitis commonly presents in older, overweight patients with sharp heel pain every time their foot strikes the ground. Pain is worse in the mornings.  X-rays may show a bony spur matching the location of the pain, and there is exquisite tenderness to palpation over the spur.  However, surgical resection of the bony spur is not indicated, so x-ray makes no difference.  Give symptomatic treatment; resolution occurs spontaneously in 12–18 months.
  68. 68. The pain in plantar fasciitis feels like a tack in the bottom of the foot and resolves quickly after walking.
  69. 69. Morton Neuroma  Morton neuroma is inflammation of the common digital nerve at the 3rd interspace, between the 3rd and 4th toes, caused by wearing pointy-toed shoes. The neuroma is palpable, and there is very tender spot there.  Management is analgesics and appropriate footwear. If this does not work, follow with surgical excision.

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