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Orthopaedic Injuries for General Practitioners - 2

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Daniel Robin

on 16 September 2014

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Transcript of Orthopaedic Injuries for General Practitioners - 2

Operative
Clavicle Fracture

Acromio Clavicular joint sprain / dislocation

Gleno-humeral dislocation

Surgical Neck of humerus Fracture
Shoulder Injuries - DDx
Complications:
avascular necrosis

up to 1 year post injury
non-union

Usually young adult with fall outstretched hand

tenderness and swelling in anatomical snuffbox - request "scaphoid series" films.

if x-ray normal but clinical suspicion
still treat as per presumed Scaphoid #
R/v in 10/7 – Remove POP – clinically re-Ax and Rpt X-ray
If still sore but normal
repeat
x-ray CT
vs B/S vs MRI

If displaced
, poor Px from non-op Rx
refer for ORIF
Scaphoid Fracture
Torus = buckle = "green stick"
Colles
Assessment:
dorsal angulation of 10 degrees
on Lateral view is maximum acceptable
Unless demented, elderly, low demand
impacted radius with shortening relative to ulnar needs reduction (lengthening)
Paeds - more dorsal angulation can be acceptable if extraphyseal - remodelling of 1* per month in v young, esp if close to joint.
refer intra-articular fractures.
Common Wrist Fractures
Phalanges and Metacarpals
Distal Radius
Scaphoid
Radial Head / Supracondylar
Surgical Neck of Humerus
Gleno-humeral Dislocation
Clavicle
Patellar Dislocation
Ankle
Metatarsals
Closed Treatment of Common Fractures and Dislocations
Tubigrip
to reduce swelling and limit direct contact with skin

Wrap Velband / Sofban with
½ thickness overlap
each turn

Avoid bunching/creasing in ANY flexure
(cubital/popliteal fossa) – skin/vascular compromise

Allow slightly more padding at either end of planned POP to allow it to be “turned back” and give a soft edge to POP
How to Apply a Plaster - Padding
Do Nothing = “Primum Non Nocere” – generally v. rarely!
Inappropriate for injury – rare – splintage usually
Inappropriate for patient – e.g. neonate with uncomplicated midshaft clavicle #
Inappropriate for GP - sometimes

Splint in situ – almost always (initially)

Closed Reduction and Splintage
Local Anaesthetic, Manipulation, Plaster (LAMP)
- e.g. Bier's Block/Haematoma Block/Digital Nerve Block
General Anaesthetic, Manipulation, Plaster (GAMP)
e.g. Morph/Midaz or Propofol "conscious sedation"

Treatment Options in the ED
Mainly useful in adults
if X-ray and CT inconclusive,
despite clinical suspicion of undisplaced fracture
AND MRI is contra-indicated/unavailable
B/S
If suspicious of “pathological” fracture
atypical patient
Known osteoporosis on bisphosponate, develops thigh pain with no trauma
History of malignancy, now in “remission”
atypical mechanism of injury
usually less force than would normally be expected – e.g. spiral fracture of humerus/femur after rolling out of bed
Premorbid pain around region prior to presentation
atypical appearance of bone in general
Moth-eaten

/ sclerotic / expanded on plain X-ray
atypical pattern of fracture
Peri-articular fracture with minimal trauma
If suspicious of significant ligamentous injury associated with fracture or dislocation
E.g. patellar / tibio-femoral (“knee”) / gleno-humeral dislocations
MRI
Always request
at LEAST two views in orthogonal planes
i.e. AP and lateral projections

Almost always should include
views including the joint above and below
suspected area of injury

Sometimes require
special views
E.g. “mortise” view of ankle, “axillary lateral” view of glenohumeral joint, “scaphoid series” if snuff-box tenderness
X-ray
Depends largely on Hx = context of injury
Patient
paediatric / adult / geriatric
Mechanism
low energy / high energy
Environment
clean, safe / contaminated, complex

Examination = Assessment and treatment of ABC and Primary and secondary survey, as per EMST protocols
Initial assessment
X-ray review – how to describe to an orthopaedic surgeon over the phone

Fractures and reductions

Dislocations

("?Septic Arthritis?")

Managing complications

Plastering techniques.
Topics to be Covered
Review of investigation modalities and treatment options for commonly seen orthopaedic injuries

Learn orthopaedic terminology and how to describe x-ray results (to an orthopaedic surgeon)

Improve awareness of potential complications and pitfalls associated with fractures and dislocations including the treatment options

Be aware of the pain management options
Objectives
BEWARE! The “Floating” Shoulder
Consider referring displaced segmental mid-shaft clavicle fractures
Posterior Dislocation X-rays
Antero-Inferior Dislocation X-ray
Anterior Dislocation X-ray
Clinically:
usually young male
gives good history recurrent dislocation
O/E
“Prominent” acromion
Palpate under acromion laterally
Humeral head impalpable “no-one home!”.
X-R
Mercedes Benz
Light Bulb Sign!
Always ask for axillary lateral X-ray
Gleno-Humeral Dislocation – Anterior vs Posterior
Older patient osteoporotic type fracture or younger with significant trauma.

If in acceptable position, minimal displacement of fragments
Non-operative =
collar and cuff sling
+ analgesia 2/52
Repeat XR's 2/52 - if no change commence Physio and repeat films 2/52'ly for 6/52.

If displaced/angulated, younger age, higher comminution, intra-articular split = refer to Ortho
Surgical Neck of Humerus (SNOH) Fracture
Orthopaedic Emergency!!!
ALWAYS refer
, even (especially?) at night
High incidence of neurovascular injury so...
Carefully check Radial pulse and hand reperfusion
Splint in Extension
or position where pulse maintained
Should NEVER attempt manipulation in ED!
Paediatric Supracondylar Humeral Fracture
Dorsal Angulation
Generally, use
cold water
– allows more time to mould POP

How to
Hold and dunk
a POP roll

Roll POP on
, overlapping by ½ thickness and avoid creasing

Areas which require
special reinforcement
Palm / over extensor surfaces of joints / plantar and heel surfaces
Use a backslab over the top of cylindrical POP

Avoid POP
ending

over
fibular neck
– common peroneal nerve
How to Apply a Plaster - Plaster
Ensure patient is sufficiently
“relaxed”
and has sufficient
analgesia

Make sure you
have everything you need within reach
and “ready to go”
Underpadding
(Velband/Sofban/Tubigrip)
Plaster
(/ Fibreglass)
Water
(Image Intensifier)

Exaggerate the Deformity
to de-tension surrounding (deforming) soft tissues

Very firm in-line traction with counter-traction
supplied by “assistant”

Reverse Deformity
/ Deforming Forces

Splintage (Plaster) with
3-point moulding
to maintain position
Management Principles for Closed Reduction of Displaced Fractures
IS VERY useful

in cases of:
suspected septic arthritis
- esp. U/S-guided aspiration
paediatric patients
- detection of undisplaced intra-articular fractures e.g. elbow – multiple physes



Almost NEVER useful

to an orthopaedic surgeon in detecting adult injuries (including meniscal tears!)

Rarely – as an
adjunct to X-ray if MRI is impossible
U/S
Almost always useful for investigation of
intra-articular fractures
, esp. if considering referral to orthopaedic surgeon

Worry/refer if, on CT, the injury involves
Large joint
(i.e. knee, shoulder, wrist, ankle, elbow, hip)
Incongruity of articular surface ≥ 2mm
– vertical step or horizontal gap

Useful in some cases of confirming clinical diagnosis when plain X-rays inconclusive (although consider MRI if available,
sometimes - undisplaced #'d NOF / Scaphoid
)
CT
Daniel Robin
MBBS (hons), MS, FRACS (Ortho)

Orthopaedic Injuries
for General Practitioners

Emergency

Do NOT leave skin looking “tented” over bones

Immediate closed reduction (after X-ray) and moulded POP/backslab

Re-X-ray to confirm reduction
Ankle Fracture - Dislocation
Only if the relationship between talus and tibia can be maintained
- only questionable in Type B fractures
Ensure ankle is not unstable by
using stress views
OR
Treat all as unstable
Weekly X-rays
for at least 3/52
watch for displacement
of talus relative to tibia
Ankle Fractures – Closed Treatment
BEWARE! The Lateral 1/3rd Clavicle Fracture
Midshaft
Must refer if
Skin
tented
/under threat
Open #
Associated
brachial plexus injury
“Floating shoulder”

Consider referral if
Displaced segmental fragments

Non-operative Rx
figure of 8 brace – usually cumbersome = fails
Broad arm sling – only until comfortable
, otherwise elbow stiffens
Can take 12/52 for union

Lateral 1/3
Usually best result with
operative Rx
Clavicle Fractures
External rotation method of Liedelmeyer (?Kocher?)
patient supine and with good analgesia = muscle relaxation
involved arm is slowly and gently adducted to the side
elbow is flexed to 90*
slow, gentle external rotation is applied until reduction felt – often with forearm to 90*
Then internal rotation to maintain reduced position
No traction
required

The forward elevation maneuver of Cooper and Milch
Drs hand is used to elevated pts arm 10-20* in forward flexion and slight abduction
Humeral head is held in dislocated position by Drs other hand
until…
Forward flexion and abudction is continued until the arm is directly overhead
Then hand that is bracing humeral head can thumb it over glenoid and reduce

Modified Hippocratic Method of Traction – counter-traction
Longitudinal traction on arm in abduction (with foot in axilla = Hippocratic counter-traction)
Towel/sheet wrapped around upper trunk as counter-traction
gentle int/ ext rotation

Stimson – 5kg wt fastened to arm – leave hanging for 20 min+
Commonly Used (“Safer”) Closed Reduction Techniques for Anterior Dislocations
Axillary Lateral X-ray
Non-operative
Exclude
elbow dislocation
and
Essex Lopresti
Injury
check wrist!

Rule of “3”
<3mm separation / step
<30% of head
<30* angulation

Check
ROM
Aspirate joint
Inject local anaestheic
Check pron/sup

If non-op then splint/sling for 2/52, then gentle ROM
Elbow Fractures in Adults – Radial Head Fracture
Elbow Fractures in Adults – Fat Pad Sign
Radial Height and Inclination
Joint related pain without history of trauma, +/- associated fever = ?septic arthritis

DISCUSS
WITH (LOCAL) ORTHOPAEDIC SURGEON

DO NOT GIVE ANTIBIOTICS
UNTIL EFFUSION CONFIRMED (U/S) AND
JOINT HAS BEEN ASPIRATED
(UNDER U/S)


?Septic Arthritis?
RICE + splintage (!)
Oral
Simple
Paracetamol
NSAIDs
Opiate / Opiate-like
Opiates (Codiene /
Oxycodone
)
Tramadol
Parenteral
Inhaled / Volatile
Penthrane
/ Nitrous Oxide
Intravenous
Paracetamol / Ketorolac / Tramadol / Morphine
Local Anaesthetic Injections
Lignocaine / Bupivacaine / Prilocaine /
Ropivacaine
Analgesia
X-ray
Computerised Tomography (CT)
Investigations
You know your EMST/ATLS protocols

You know nothing/very little else about orthopaedics

Infinite capacity for learning
Assumptions Made:
Stable vs Unstable Ankle Fractures
Weber Classification
Describes location of
fibular

fracture
in context of ankle fracture
Likelihood of syndesmotic ligament disruption between tibia and fibula (and therefore need to treat this operatively while internally fixing fracture)

Ankle Fractures
Essential

If poorly done will exacerbate deformity!

Common sense but
requires practise

3-point moulding
How to
Apply
a Plaster -
Moulding
Management Principles for Closed Reduction of Displaced Fractures
QUESTIONS?
Reduction and Plastering Technique for Ankle Fractures
Commonly Used (“Safer”) Closed Reduction Techniques for Anterior Dislocations
Nuclear Medical Bone Scan (B/S)
Ultrasound (U/S)
Magnetic Resonance Imaging (MRI)
MRI requires GA for most kids <10 yrs old
CT delivers radiation, best avoided in paeds
Takes at least
72/24 from time of injury
to become “hot” – may not detect most acute fractures
Pacemaker / claustrophobic / non-compliant / intra-occular foreign body
Undisplaced # NOF / scaphoid
Fracture
=
any
break in the cortex of a bone

Subluxation
= joint has lost normal articular relationship, but
still some (abnormal) contact between articulating surfaces

Dislocation
(“luxation”) = joint has lost normal articular relationship with
no contact between articulating surfaces
Terminology or “Orthospeak”
Diaphysis / shaft

Metaphysis (near joint line but not necessarily involving joint)

Physis / growth plate (in paeds)

Epiphysis (paeds) / Intra-articular
Which PART of the bone?
Which Bone?

Which PART of the bone?
Diaphysis / shaft
Metaphysis (near joint line but not necessarily involving joint)
Physis / growth plate (in paeds)
Epiphysis (paeds) / Intra-articular

What is the fracture pattern?
Transverse
Sprial/Oblique
Segmental
Comminuted
How to Describe a Fracture
Is it displaced or undisplaced?
Translated
Angulated
Shortened
Rotated

Are there any complications?
Dislocation of adjacent joint
Isolated Neurological or Vascular Impairment
Compartment Syndrome
Open Fracture
Open fractures
(GPs mostly see gd I, hopefully not III)
Any fracture/dislocation with
neurological or vascular compromise
(esp. if progressive!)
Compartment syndrome

midshaft tibial # most common, but beware of other presentations
Supracondylar Humerus # in children
, esp. if
pulseless
Pelvic
(usually not pubic ramus) /
Femoral Shaft
Fractures – potential for torrential
internal bleeding
#’d NOF
Ideally should have operative treatment within 24/24
Orthopaedic Emergencies
(or, “when should I be referring this on
urgently
…?”)
Any injury with any of the abovementioned
complications (or high potential for Cx’s
- esp. paed supracondylar humerus
, closed tibial fractures
)

Spinal Injuries
of any sort (not always urgent...)

Intra-articular / Physeal
injuries

Long bone
injuries with significant
Displacement
angulation
rotational
deformity

Dislocations of most large joints
, esp. if
Incompletely
/imperfectly reducible
in
children/young
adults

(high potential to become...)
Recurrent
“What should I be calling for an Orthopaedic Opinion?”
Assess
Analgesia
Decontaminate
– 3+ L N/Saline Lavage
Reduce deformity
(put bone back under skin)
Splintage + antiseptic dressing
(Bettadiene)
Antibiotics

– 2g Cephazolin + 3mg/kg Gentamicin IV (
+ 1.2g Penicillin if farmyard/anaerobes
) + Tet Tox / Booster
Definitive Rx
Grade 3 Open #
Skin wound:
< 1 cm
Soft tissue:
minimal
injury
Wound bed:

clean
Bone injury:
simple
w/ minimal comminution
Grade 1 Open #
Used to classify “open fractures”
Fracture site is open to the environment
Usually skin
pelvic fractures can be open to intestines/urogenital tract!
not described in Gustillo classification
Grade 1-3
quantifies the amount of soft tissue damage associated with the fracture
Open Fractures – Gustillo and Anderson Classification
Pressure within damaged muscle of limb compartment gradually exceeds perfusion pressure of feeding vessels
Recognising Complications
ALMOST NEVER
FOR THE GP

ONLY IF
YOU CANNOT GET A PATIENT TO ORTHOPAEDIC ATTENTION WITHIN (6 HOURS) OF INJURY AND
LIMB IS IN THREAT FROM VASCULAR COMPROMISE
(COMPARTMENT SYNDROME)
Managing Complications
Assess
Analgesia
Decontaminate

– 3+ L N/Saline Lavage
Reduce deformity
(put bone back under skin)
Splintage + antiseptic dressing

(Bettadiene)
Antibiotics
– 2g Cephazolin + 3mg/kg
Gentamicin
IV + Tet Tox / Booster
Definitive Rx
Grade 2 Open #
No Tourniquet
Permits visualisation of perfused tissue

Longitudinal incisions
overlying involved compartment(s)

Ensure
complete division of overlying muscle fasciae
to permit muscle expansion/decompression and restore blood flow to limb

May close skin (rarely), but
leave underlying fascia open,
if easily apposable without recreating tight compartment
Managing Complications
"Transverse, distal (metaphyseal) radial and ulnar fractures with 100% radial translation, 45 degrees apex-ulnar angulation and 2 cm of shortening."

"Off-ended, extra-physeal (metaphyseal) distal radius and ulnar fractures in skeletally immature patient"
Anatomic description – e.g. 2
"Transverse, mid-diaphyseal fractures of radius and ulnar with 30 degrees of apex-radial angulation. There is no apparent shortening or rotation"
Anatomic description – e.g. 1
Rotated
Is it displaced or undisplaced?
What is the fracture pattern?
How to do a four-compartment Fasciotomy (calf)
4) Compartment Syndrome
Are there any complications?
Translated
Angulated
Shortened
1) Dislocation of adjacent joint = Fracture-Dislocation
5) Isolated Neurological or Vascular Impairment
2) Open Fracture
3) Open Fracture-Dislocation (!)
CLINICAL DIAGNOSIS, SUPPORTED BY MEASURING COMPARTMENT PRESSURES IF UNCERTAIN, OR IN OBTUNDED PATIENT
The 6 "
P's
"
Initially venous congestion ->
neural ischaemia (
p
araesthesiae /
p
aralysis) ->
arterial ischaemia (
p
allor /
p
erishingly cold /
p
ulseless (LATE!)) ->
muscular infarction (
p
ain out of proportion to passive movement
->
pain at rest)
COMPARTMENT SYNDROME OF FOREARM / CALF
DECOMPRESSIVE FASCIOTOMY
Definition
Assess
Analgesia
Decontaminate
– 1-2 L N/Saline Lavage
Splintage + antiseptic dressing
(Bettadiene)
Antibiotics

– 2g Cephazolin IV + Tet Tox / Booster
Definitive Rx
Management
Definition
Skin wound:
>1cm, < 10cm
Soft tissue:
Moderate injury
Wound Bed:
Minimal contamination
Bone injury:
moderate
with possible comminution
Management
Definition
Skin wound:

>10cm
Soft tissue / Wound Bed:
A –
Severely contaminated
,
no flap
required
B –
Severely Contaminated
, tissue loss =
flap required
C – Above plus
neurovascular injury
Bone injury:
frequently
comminuted/segmental
Management
Only used for pediatric fractures that involve the open growth plate (physis)

Five types (I-V)

Potential consequences for later bone growth
Growth - Plate Involvement?
Salter-Harris Classification
I - S
lip
II - A
bove
III - L
ateral
IV - T
hrough
V - R
ammed
Common safe, effective, needs to be taught and supervised.
Prepare patient.
IV access in both limbs
Analgesia +/- Midazolam.
Monitoring
, consent, Plaster,
2 Doctors
,


Technique
Double cuff
to affected limb
extravasate by
elevation for 2-3 minutes
inflate to
100mmHg above systolic
then inject
0.5% Prilocaine, ½ ml/Kg
Wait 5 minutes,
then pull
Leave cuff up
for >30/60
Bier’s Block
Scaphoid Fracture
How to Describe a Fracture
By Smartphone / Internet
Dorsal Dislocation /#-dislocation of Proximal Phalanx
Simple dislocation - metacarpal block - then closed reduction using longitudinal traction.
If stable, buddy strap for 6/52.
If unstable then 3/52 in dorsally-based 20* extension-blocking splint
Fracture dislocation - Reduce closed as above and re-X-ray.
IF <30% of joint surface involved
and
stable in flexion, then 3/52 in 20* flexed dorsal blocking splint.
IF >30% or unstable, then refer to Ortho/Plastics
Metacarpal #'s
Metacarpal #'s
Closed reduction and cast in "position of safety"
Refer on if:
multiple
short >3mm
malrotated
angulated >10* in 2nd/3rd
angulated >20* in 4th/5th
Patello-Femoral Dislocation
Likelihood of fracture instability and therefore treatment
A = stable (usually) - weight-bearing below-knee plaster or cam boot 6-12/52
B = possibly unstable (usually) - if
undisplaced
then below knee plaster cylinder, non-weight-bearing 6/52, X-rays weekly for 3/52. If displaced then refer for ORIF
C = unstable - refer for ORIF
Full transcript