Uploaded byV. Bonales, M.D.
Field Care Audit 10/2014
This document provides an overview of orthopedic anatomy and injuries of the skeletal system. It describes the basic anatomy and functions of bones and joints in the upper and lower extremities. Specific topics covered include bone structure, development and healing; anatomy of the hand, wrist, arm, shoulder, spine, pelvis and leg; common orthopedic injuries such as fractures and dislocations; and concepts such as compartment syndrome. The goal is to educate emergency physicians on orthopedic assessment and management.
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Field Care Audit 10/2014
- 1. Orthopedics 101 101 V. Bonales, M.D. Emergency Medicine Physician RMH PCMD
- 2. OObbjjeeccttiivveess • Physiologyof the skeletal system • Skeletal anatomy • Bone trauma • FCA (2 cases)
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- 4. DDiivviissiioonnss • 206bones –Axial Skeleton • Skull, vertebral column, thoracic cage –Appendicular Skeleton • Clavicle & scapula, upper limbs, pelvic girdle, lower limbs
- 5. SSkkeelleettaall SSyysstteemm •Functions –Support and protection –Body movement –Blood cell formation (hematopoiesis) –Storage of salts (CaPO4)
- 6. BBoonneess • Boneis a connective tissue –Made up of calcium phosphate & calcium carbonate –Cells are called “osteocytes”
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- 8. BBoonnee oorrggaanniizzaattiioonn •Osteocytes sit in lacunae – Communicate via canaliculi • Lacunae form concentric circles around central (Haversian) canals • Groupings form long cylinder groups called osteons (Haversian system)
- 10. BBoonnee oorrggaanniizzaattiioonn •Compact bone • Spongy bone
- 11. BBoonnee oorrggaanniizzaattiioonn •Periosteum • Compact bone • Spongy bone • Endosteum • Medullary cavity • Marrow • N/A/V
- 12. BBoonnee oorrggaanniizzaattiioonn •Perforating canals connect central canals –Connect to medullary cavity • Periosteum covers the entire bone
- 13. BBoonnee DDeevveellooppmmeenntt -- CCaarrttiillaaggee • Cells = chondrocytes • Covered by perichondrium –Provides blood & nutrients to avascular cartilage
- 14. FFiibbrrooccaarrttiillaaggee • Containscollagen –Very tough • Need vitamin C • Shock absorber • Cushions the vertebrae (discs) & knees
- 15. EEllaassttiicc CCaarrttiillaaggee •Contains elastic fibers • Flexible • Found in ears & larynx - epiglottis
- 16. Hyaline CCaarrttiillaaggee •Most common –Ends of bones –Tip of nose –Rings of the respiratory tract –Important in bone growth
- 17. BBoonnee DDeevveellooppmmeenntt •Two types – Intramembranous – flat bones – Endochondral – long bones
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- 20. Bone Strength •120 lbs of pressure to break the femur • 15 lbs of pressure to break the humerus • 7 lbs of pressure to break a collar bone or rib • 5 lbs of pressure to break a wrist
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- 22. WWoorrkkiinngg ddiissttaall ttoo pprrooxxiimmaall……
- 23. HHaanndd BBoonneess •Phalanges • Metacarpals • Carpals – Scaphoid – Lunate – Triquetrum – Pisiform – Trapezoid – Trapezium – Capitate – Hamate
- 24. CCaarrppaallss • Scaphoid –Anatomical snuff box –Most often broken with fall (FOOSH) –Needs to be cast even if no evidence of a fx • Fx will show up 10 days later
- 26. HHaanndd CCiirrccuullaattiioonn •Redundant circulation • Volar arch (deep & superficial) – Half from radial artery, half from ulnar artery
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- 28. FFoorreeaarrmm BBoonneess •Radius – Styloid process – Head of the radius • Ulna – Styloid process – Olecranon & coronoid processes – Trochlear notch • Olecranon process • Coronoid process • Trochlear notch
- 29. MMeeddiiaann NNeerrvvee •Crosses under flexor retinaculum & carpal ligament to get to hand • Irritation of tendons w/in this area leads to carpal tunnel syndrome
- 33. FFoorreeaarrmm CCiirrccuullaattiioonn •Radial Artery & Vein • Ulnar Artery & Vein • Cubital fossa
- 34. UUppppeerr AArrmm --BBoonnee • Humerus – Trochlea & capitulum – Lateral & medial epicondyles – Coronoid & olecranon fossas –Greater & lesser tubercles – Head
- 37. UUppppeerr AArrmm --CCiirrccuullaattiioonn
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- 39. BBrraacchhiiaall PPlleexxuuss •Musculocutaneous • Axillary • Radial – Extensors of forearm – Sensation to dorsum of arm • Ulnar – ½ Hand muscles – Sensation lateral 1/3 hand • Median – Flexors of forearm – ½ Hand muscles – Sensation medial 1/3 hand
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- 41. Spine Cervical Spine 7 vertebrae Axis Atlas Ligaments Anterior Posterior
- 42. Spine Trauma AxialLoad Injuries
- 43. Spine Trauma Hyperextensioninjuries Hyperflexion injuries
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- 47. Spine Trauma Hangman’sFracture - Bilateral pedicle Fx - Distraction C2-C3 - Due to complete disruption
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- 50. Spine Trauma Cspine precautions placed when: – Any neck discomfort or numbness in extremities – Not fully alert or AMS – Other painful injuries
- 51. Spine Trauma Rigidcollars, such as the Philadelphia and the extrication collars, reduce flexion and extension to about 30% normal and rotation and lateral movement to about 50%.
- 52. Spine Trauma bestimmobilization method – secure patient to a hard board – place sandbags at either side of head – rigid collar around the neck – decreases movement to about 5% of normal.
- 53. Spine Trauma ThoracicSpine 12 vertebrae Attached to rib cage Ligaments Anterior Posterior
- 54. Spine Trauma •Axial loading – Burst fracture – Nerve findings common
- 55. Spine Trauma •Hyperextension injuries – Very unstable fracture
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- 57. Spine Trauma •Lumbar Spine – 5 vertebrae – Fractures require significant mechanism
- 58. Spine Trauma Flexioninjuries Wedge compression fracture Requires a high energy process
- 59. Head and SpineInjuries Look for motor or sensory deficits Deficit will point to location of injury Remember dual innervation of cervical cape Log roll & keep spine in neutral position
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- 61. Chest Trauma SternalFracture Indicates worse mechanism of injury Not an indicator of cardiac injury
- 62. Chest Trauma RibFractures 9 - 11 watch for intra-abdominal injuries Flail Chest Three or more consecutive ribs Broken in 2 or more places Same side of chest Paradoxical Chest Movement
- 63. Chest Trauma Lungcontusions More common in children Serious cause of morbidity Elderly COPD
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- 65. Blunt Force Trauma Medial Malleolus
- 67. Iliac Artery &vein Femoral Artery & vein Popliteal Artery & vein Anterior & posterior Tibial Artery & Vein Dorsalis pedis artery
- 72. • Sciatic nerve • Knee flexion • Leads to • Common peroneal nerve • Ankle & toes dorsiflexion • “foot drop” • Tibial nerve • Ankle plantar flexion
- 73. • Femur •Head • Inserts into pelvic bone • Neck • Most common site of Fx • Greater trocanter • Lesser trocanter • Shaft • Medial epicondyle • Lateral epicondyle • Medial condyle • Lateral condyle
- 74. • Femoral nerve • Knee extension, hip flexion • Knee jerk response • Femoral triangle • Nerve • Artery • Vein • lYmph “The NAVY goes toward the water”
- 78. • Cartilage •Hyaline • Fibrocartilage • Meniscus • Medial & lateral • Ligaments • Medial collateral • Lateral collateral • Anterior cruciate • Posterior cruciate • Patellar
- 80. “Unhappy trio” •Medial meniscus & ligament attached • Anterior cruciate
- 81. • Tibia &fibula • Medial & lateral condyles • Head of fibula • Tibial tuberosity • Lateral malleolus • Medial malleolus L M
- 84. • Mortise joint • Medial & lateral ligaments • Lateral ligament & fibular fx
- 86. • Tarsals •Calcaneus • Talus • Metatarsals • Phalanges
- 91. Crush Injury occurswhen body part subjected to high degree of force or pressure
- 92. Blunt Force Trauma Bleeding Bruising Fracture Laceration Compartment Syndrome
- 94. Compartment Syndrome Notan acute occurrence Symptoms: Pain out of proportion/passive motion Parasthesias/Paralysis Pallor Pulselessness Poiklothermia
- 95. Blunt Force Trauma Compartment Pressures Normal about zero; usually less than 10 mm Hg Capillary blood flow compromised at >20 mm Hg Muscles/nerves at risk for ischemic necrosis >30 to 40 mm Hg. Nerve is most sensitive, followed by muscle tissue.
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Editor's Notes
- #46 Type I fracture A type I fracture (less than 5% of cases) is an oblique fracture through the upper part of the odontoid process. This type of fracture occasionally is associated with gross instability due to traction forces applied to, and subsequent injury of, the apical and/or alar ligaments. This is an avulsion injury to the tip of the odontoid and usually is stable. Type II fracture: A type II fracture (more than 60% of cases) is a fracture occurring at the base of the odontoid as it attaches to the body of C2 Type III fracture A type III fracture (30% of cases) occurs when the fracture line extends through the body of the axis. The fracture line can extend laterally into the superior articular facet for the atlas. Another type of odontoid process fracture is a vertical fracture through the odontoid process and body of the axis (less than 5% of cases).
- #48 traumatic spondylolisthesis for the more common injury pattern usually seen as a result of falls and MVAs. The injury pattern seen secondary to judicial hangings is a fracture-dislocation of C2. More precisely, it is a bilateral pedicle fracture of C2, along with distraction of C2 from C3 secondary to complete disruption of the disk and ligaments between C2 and C3.
- #56 T10 – T11 fracture dislocation secondary to logging accident
- #57 50% chance of associated intra-abdominal injury.
- #59 Wearing seatbelt with no shoulder belt
- #95 Although not an acute event, should be aware of if managing crush injuries