as given by Dr. Gilligan

1. ME BONE DOCTOR.
BONE BROKE.
ME FIX BONE.
BONE BETTER.
NOW TIME FOR LIFT WEIGHTS.

5. Salter Harris

7. Common Ortho neurovascular injuries
• Anterior shoulder dislocation- axillary nerve (weak deltoid and numbness
around lateral upper arm
• Proximal humerus fx
– Located at surgical neck
– Treat with closed reduction and immobilization
– Above the tuberosities (anatomic neck) risks avascular necrosis
• Supracondylar fx of humerus- in kids, Volkmann’s ischemic contracture
(compartment syndrome), median nerve- anterior interosseous branch (and
artery), weak thenar muscles, wrist flexion and decreased sensation radial
palm and 3.5 fingers; brachial artery
• Midshaft humerus fx : radial nerve (20% injury rate with fx), closed fx, 90%
return of nerve function, open fx, nerve should be explored
• Posterior knee dislocation: popliteal artery injury- hard signs of vascular injury
require intervention, otherwise ABI. If >.9, rules out injury
• Distal radius fx: median nerve injury
• Fibular neck fx: common peroneal nerve- foot drop

8. Compartment syndrome
• Pain out of proportion to physical exam is the hallmark of extremity compartment syndrome
• Most commonly anterior compartment of the leg (foot drop)
– Pain on passive movement
– Pallor
– Pulselessness (LATE FINDING!)
– Paralysis
– Paresthesia
• Compartment pressure
– >30 mm Hg (lower if hypotensive)
• Ultimately a clinical diagnosis, compartment release if high index of suspicion
• Chronic exertional compartment syndrome
– Heavy , repetitive use
– Consistent history (similar to claudication)
– Compartment release successful in lower extremity

11. Treatment of open fx’s
• Irrigation and debridement
• Culture, then start antibiotics (orthocillin)
• Tetanus prophylaxis
• Stabilize fx
• Biggest risk of nonunion is smoking

14. Hydrofluoric acid burn
• Immediately severely painful
• Tissue penetration with necrosis of soft tissue and
bone erosion (binds Ca and Mg)
• Application of calcium gluconate gel binds F
• When severe, hypocalcemia common

15. Frostbite
• Essentially a burn, initial presentation for all depths is similar
• Classified by depth of damage to the skin (known after thawing)
– 1st degree- central whitish area surround by erythema
– 2nd degree- present with blisters within 24 hours
– 3rd degree- blisters progressing to eschar
– 4th degree- tissue necrosis
• Treatment
– Only rewarm when there is no risk of refreezing
– Rapid rewarming by submersion in warm (104-107.6 F) water for 15-30 min
– Tetanus prophylaxis and analgesia
– Pad and splint injured extremities
– Monitor for compartment syndrome
– IV or intra-arterial tPA within 24 hrs may reduce tissue loss
– Demarcation over 1-3 months with conservative debridement

16. Peripheral nerve injuries
• Neuropraxia
– Physiologic interruption of nerve conduction
– Stretch injury
– Good prognosis, recovery based on nerve length
• Axonotmesis
– Axonal and myelin loss with intact Schwann cell sheath
– Axon undergoes Wallerian degeneration
– Sensory loss with axonal regeneration 1 mm/day (1 inch/month)
– Fair prognosis
• Neurotmesis
– Complete division of nerve
– Spontaneous recovery impossible
– Repaired by precise apposition of nerve ends

18. Spinal cord injury
(SCI)
• IV steroid protocol for blunt SCI only
– Based on time since injury
– <3 hrs, 3-8 hours, >8 hours
– for <3 hours- 30 mg bolus of methylprednisolone
(over 15 minutes) followed by 5.4 mg/kg/hr
infusion over 23 hours
– For 3-8 hours- 30 mg bolus, followed by 5.4
mg/kg/hr over 47 hours
– For >8 hours- no steroids

19. The controversy
Following the NASCIS trials, the use of high-dose methylprednisolone
in nonpenetrating acute SCI had become the standard of care in North
America. Nesathurai and Shanker revisited these studies and
questioned the validity of the results.[45] These authors cited concerns
about the statistical analysis, randomization, and clinical endpoints
used in the study. In addition, the investigators noted that even if the
benefits of steroid therapy were valid, the clinical gains were
questionable. Other reports have also cited flaws in the study designs,
trial conduct, and final presentation of the data.
The risks of steroid therapy are not inconsequential. An increased
incidence of infection and avascular necrosis has been documented.

20. Revised recommendations
The Congress of Neurological Surgeons (CNS) has stated that steroid therapy "should only
be undertaken with the knowledge that the evidence suggesting harmful side effects is
more consistent than any suggestion of clinical benefit.“ The American College of Surgeons
(ACS) has modified their advanced trauma life support (ACLS) guidelines to state that
methylprednisolone is "a recommended treatment" rather than "the recommended
treatment." The Canadian Association of Emergency Physicians (CAEP) is no longer
recommending high-dose methylprednisolone as the standard of care.
In a survey conducted by Eck and colleagues, 90.5% of spine surgeons surveyed used
steroids in SCI, but only 24% believed that they were of any clinical benefit.[49] Note that
the investigators not only discovered that approximately 7% of spine surgeons do not
recommend or use steroids at all in acute SCI, but that most centers were following the
NASCIS II trial protocol.
Updated guidelines issued in 2013 by the CNS and the American Association of Neurological
Surgeons (AANS) recommend against the use of steroids early after an acute SCI. The
guidelines recommend that methylprednisolone not be used for the treatment of acute SCI
within the first 24-48 hours following injury. The previous standard was revised because of a
lack of medical evidence supporting the benefits of steroids in clinical settings and evidence
that high-dose steroids are associated with harmful adverse effects.

21. Summary
• Overall, the benefit from steroids is considered modest at best, but for
patients with complete or incomplete quadriplegia, a small improvement
in motor strength in one or more muscles can provide important
functional gains.
• The administration of steroids remains an institutional and physician
preference in spinal cord injury. Nevertheless, the administration of high-
dose steroids within 8 hours of injury for all patients with acute spinal cord
injury is practiced by most physicians.
• The current recommendation is to treat all patients with spinal cord injury
according to the local/regional protocol. If steroids are recommended,
they should be initiated within 8 hours of injury with the following steroid
protocol: methylprednisolone 30 mg/kg bolus over 15 minutes and an
infusion of methylprednisolone at 5.4 mg/kg/h for 23 hours beginning 45
minutes after the bolus.

22. Ortho tumors
• Multiple myeloma (malignant)
– Most common primary bone tumor- (neg bone scan)
• Osteoid Osteoma (benign)
– Teenagers (2nd decade)
– Presents at night (often back pain) relieved with salicylates
– Common in posterior elements of the spine
• Osteosarcoma (malignant)
– 2nd decade of life, distal femur most common location (then prox tibia)
– “Codman triangle” cortical destruction (“sunburst”)
– Hematogenous spread (mets to lung most common)
– Neoadjuvant chemo then en bloc resection (reconstruction vs amputation)
– Can arise from Paget bone disease in the elderly
• Enchondroma (benign)
– Benign neoplasm arising from cartilage (“popcorn” calcification)
– May be multiple (Ollier disease), with soft tissue hemangiomas (Maffucci syndrome)
• Chondroblastoma (benign)
– First and second decade (before epiphyseal closure) at the epiphysis
– Treat with curettage and bone grafting
• Chondrosarcoma (malignant)
– Malignant adult bone lesion (shoulder, pelvic girdle, knee, spine)
– Pain and/or mass present (“popcorn” calcifications)
– Wide resection
• Giant cell tumor (benign but locally aggressive)
– Xray shows eccentric lytic lesions in epiphysis
– Knee and distal radius most common
– Treat with curettage
– Can metastasize to the lungs (4%) but rarely fatal
• Unicameral bone cyst (benign)
– proximal humerus most common site (proximal femur, distal tibia)
– Occurs during rapid bone growth
– Treat with methyl prednisolone acetate injection

23. Osteosarcoma

24. Chondrosarcoma

25. Giant cell tumor

26. Ortho tumors (cont)
• Aneurysmal Bone cyst (benign)
– Osteolytic metaphyseal lesion
– Blood-filled cavernous spaces within fibrous tissue, no endothelial lining
– Curettage and bone grafting
• Ewing tumor (malignant)
– Arises from diaphyseal marrow of long bones
– Patients < 20 years old
– “Onion skinning” appearance on Xray
– Lymphatic and hematogenous spread (mets to lung)
• Chordoma (malignant)
– Back pain with loss of rectal tone
– Midline destructive lesion of sacrum with soft tissue mass (may be palpable)
– Arises of embryonic remnants of notochord
– Surgical excision
• Rhabdomysosarcoma (malignant)
– Patients < 20 years old
– Arises from striated muscle
– Hematogenous spread
– Chemo with WLE
• Most common cancers that metastasize to bone
– #1) Breast
– #2) Prostate
– Thyroid
– Lung
– Kidney
• Bone scan is the most sensitive test for metastatic disease in the bone

28. Random ortho facts
• Superior gluteal artery ligated with posterior iliac crest bone graft
• Most common organism in hand infections- staph aureus
• Organisms in septic arthritis
– Staph aureus
– Hemolytic strep
– Diagnosis after joint aspiration and gram stain
• Gonococcal arthritis
– Most common in females
– Migrating polyarthralgia
– Commonly involves knee, elbow, wrist
– Treat with 2 weeks of PCN and joint immobilization
• Spinal TB
– Pott disease (thoracic spine, anterior vertebral body)
– Insidious onset, worst pain at night
– Treat with antibiotics, rest, bracing
– Surgery for instability, neuro deficit, progressive kyphosis
• Gout
– Most common first metatarsal phalangeal (MTP) joint (great toe)
– Negative birefringence of rod-shaped urate crystals under polarized light (diagnostic)
– Treat with rest, NSAID’s
– Colchicine and allopurinol take time to work and are used as maintenance therapy
– Congenital Pyrophospate Disorder (pseudogout) similar except
• Short, blunt rhomboid crystals that are weakly birefringent
• Most common joint is the knee

29. Random ortho facts (cont)
• Rheumatoid arthritis
– Ulnar “drift”
– 4th and 5th decade
– Autoimmune, treat with steroids or immune modulators
• Osteoarthritis
– Joint pain, Bouchard (PIP) and Heberden (DIP) nodes
– Decreased joint mobility due to articular cartilage destruction, loss of joint space
– Treat with NSAID’s, joint replacement
• Slipped capital femoral epiphysis
– Most common in adolescent males (11-15 yo), 25% bilateral, risk of avascular necrosis
– External rotation due to medial and posterior displacement of capital epiphysis
– Pain referred to the knee (and sometimes groin, with hip pathology this is common)
– X-ray: widening and irregularity of epiphyseal plate
– Pinning in situ
• Leg-Calve-Perthes disease
– Males 4-8 yo, limping
– Avascular necrosis of femoral head; 10% bilateral
– X-ray: flattening of femoral head
– Treat with maintenance of motion, femoral head will remodel with time
• Osgood-Schlatter Disease
– Males 13-15 yo, tibial tubercle pain (knee pain)
– Traction apophysitis; traction injury caused by quadriceps
– X-ray: Irregular shape or fragmenting of tibial tubercle
– Mild symptoms: limit activity; Severe symptoms: cast for 6 weeks
• Charcot Joint
– Joint destruction caused by inability to sense required wt distribution
– Neuro disorders, diabetes most common cause

30. Ortho facts (cont)
• Rotator cuff muscles
• S upraspinatus
• I nfraspinatus
• T eres minor
• S ubscapularis
• Ligaments in acromioclavicular (AC) separation
• Coracoclavicular
• Acromioclavicular
• Clavicular fx
• Most common site is middle third
• Treat with sling and gentle ROM
• Main risk of fx is vascular impingement
• If >2cm shortening or open, ORIF
• Tennis elbow- lateral epicondylitis of the extensor carpi radialis brevis
• Scaphoid fx- fall on outstretched hand
• Pain in the anatomic snuff box
• May not be detected on immediate Xray (repeat Xray in three weeks or MRI/bone scan for dx)
• Treat with long arm thumb “spica” cast
• High incidence of avascular necrosis
• Nursemaid’s Elbow
• Usually traction injury from pulling up on a toddler’s hand
• Dislocation of the radial head (at the elbow)
• Reduced by flexing arm 90 degrees, supinating the arm, applying posterior force and extending the arm
• Audible “clunk” (sometimes)

31. Ortho facts (cont)
• Chance fx – associated with seatbelt (flexion) fx of lumbar spine
• Must rule out intraabdominal injury (specifically small bowel)
• Colles Fracture- distal radius fx from fall on outstretched hand
• Treat with closed reduction
• Monteggia fx- proximal ulna with radial head dislocation
• Also an outstretched hand
• Treat with ORIF
• Carpal tunnel
• Entrapment of medial nerve at the wrist
• Thenar atrophy
• Positive Tinel sign and Phalen maneuver
• Intial RX with splinting , NSAID’s, then surgery for carpal tunnel release
• Ganglion cyst- most common site is dorsal wrist
• Game keeper thumb (skiers)- disruption of ulnar collateral ligament of the
MCP of thumb
• Boutonniere Deformity- disruption of central extensor tendon, lateral
bands displace toward the palm causing PIP flexion and DIP extension
• Mallet deformity- DIP extensor tendon rupture
• Median, Ulnar, and Radial Nerve innervation

36. Ortho facts (cont)
• Type I collagen- bone (skin, tendon, dentin, primary collagen of wound healing
• Mutations result in osteogenesis imperfecta
• Type II collagen- articular cartwolage (vitreous humor)
• Type III collagen- skin, muscles and blood vessels
• Type IV collagen- basement membrane
• Type V collagen- cornea

37. Hip dislocations/fx
•Anterior hip dislocations may present in 2 different ways.
– Superiorly displaced dislocations present with the affected hip
extended and externally rotated
– The inferior type of anterior dislocations presents with the
affected hip flexed, abducted, and externally rotated.
•Posterior hip dislocation most commonly appears
shortened, internally rotated, and adducted.
• Femoral neck fx
– Alignment and length of the extremity is usually normal;
however, the classic presentation of patients with displaced
fractures is a shortened and externally rotated extremity.
– High risk for avascular necrosis of the femoral head