unmc orthopaedic surgery welcome to your m4 clerkship and welcome to omaha department of orthopaedic...

UNMC Orthopaedic UNMC Orthopaedic Surgery Surgery

Welcome to Welcome to your M4 your M4

Clerkship and Clerkship and Welcome to Welcome to

OmahaOmaha

Department of Orthopaedic Surgeryand Rehabilitation

IntroductionIntroduction

• WelcomeWelcome• Expectations and goalsExpectations and goals• General considerations for General considerations for

Orthopaedic history and physical Orthopaedic history and physical examexam

• Introduction to reading x-raysIntroduction to reading x-rays• Trauma/Open FracturesTrauma/Open Fractures• Compartment SyndromeCompartment Syndrome

WELCOMEWELCOME

• Welcome to UNMC and your Orthopaedic Welcome to UNMC and your Orthopaedic clerkshipclerkship

• We are here to teach you the basic We are here to teach you the basic foundations of Orthopaedics. foundations of Orthopaedics.

• With that, you should be able to gain a With that, you should be able to gain a feel for what a career in Orthopaedics feel for what a career in Orthopaedics may be like.may be like.

• We are happy to have you as a part of our We are happy to have you as a part of our team for the next month and hope you team for the next month and hope you gain a lot of useful information while you gain a lot of useful information while you are hereare here

Expectations: GeneralExpectations: General

• Show up on time, be available, and work Show up on time, be available, and work hardhard

• Read before surgical cases (anatomy and Read before surgical cases (anatomy and surgical plan)surgical plan)

• Be helpful, be inquisitive, ask questionsBe helpful, be inquisitive, ask questions• Learn basic management of common Learn basic management of common

musculoskeletal problemsmusculoskeletal problems• Participate actively in rounds, clinics, Participate actively in rounds, clinics,

conference, and general discussions about conference, and general discussions about Orthopaedic problemsOrthopaedic problems

Expectations Cont.Expectations Cont.

– Be able to access knowledge about Be able to access knowledge about Orthopaedics from books, internet, Orthopaedics from books, internet, journals, etc..journals, etc..

– Be able to answer questions about Be able to answer questions about musculoskeletal anatomy, common musculoskeletal anatomy, common injuries, treaments, etc.. injuries, treaments, etc.. EspeciallyEspecially when asked to look it up when asked to look it up beforehandbeforehand. .

• Clinical functioning at the level of an Clinical functioning at the level of an internintern– Think about the patient care plan:Think about the patient care plan:

• Pre-op planningPre-op planning• Medical workup before surgeryMedical workup before surgery• AntibioticsAntibiotics• Pain controlPain control• DVT prophylaxisDVT prophylaxis• Therapy goals & restrictionsTherapy goals & restrictions• Dressing changes / drain outputDressing changes / drain output• Discharge planning & clinic follow-upDischarge planning & clinic follow-up• Read other consult service notes for their Read other consult service notes for their

planplan

GoalsGoals

• At the end of your rotation you should At the end of your rotation you should be able to:be able to:

1.1. Read basic x-rays appropriatelyRead basic x-rays appropriately2.2. Perform an orthopaedic history and physicalPerform an orthopaedic history and physical3.3. Recognize common fractures, their Recognize common fractures, their

classification, and know how to acutely classification, and know how to acutely manage themmanage them

4.4. Understand basic patient care for the Understand basic patient care for the Orthopaedic patientOrthopaedic patient

5.5. Be able to diagnose common Be able to diagnose common musculoskeletal problemsmusculoskeletal problems

CALLCALL

• Divide call on trauma nights between Divide call on trauma nights between the students such that you average no the students such that you average no more frequently than q4 during your more frequently than q4 during your month.month.

• Be sure to get at least one full Be sure to get at least one full weekend off. We’d like you to be able weekend off. We’d like you to be able to both have a life and also get to to both have a life and also get to know a little about our city.know a little about our city.

• The actual schedule is left up to the The actual schedule is left up to the students to arrange. Be fair to each students to arrange. Be fair to each other.other.

• Carry the on-call pager and notify Carry the on-call pager and notify the junior resident on-call that you the junior resident on-call that you will be taking call with them that will be taking call with them that eveningevening

• The best opportunity to learn how to The best opportunity to learn how to suture, splint, cast, and possibly do suture, splint, cast, and possibly do reductions as a medical student reductions as a medical student takes place on-call and in the takes place on-call and in the ER/trauma bay.ER/trauma bay.

CONFERENCESCONFERENCES

Conference SchedulesConference Schedules

• Three rulesThree rules– If there is an assigned reading for a If there is an assigned reading for a

conference, be sure to get a copy and conference, be sure to get a copy and read it.read it.

– No scrubs in conference, dress No scrubs in conference, dress appropriately.appropriately.

– Be on timeBe on time. Tardiness to . Tardiness to conference will be looked upon very conference will be looked upon very poorly.poorly.

Conference SchedulesConference SchedulesMonMon TuesTues WedWed ThursThurs FriFri

600am600am

TextbookTextbook

ConferencConferencee

630am630am

Grand Grand RoundsRounds

530am530am

Medical Medical

StudentStudent

LecturesLectures

630am630am

Gold JointGold Joint


600am600am

PediatricPediatric

OrthoOrtho


600am600am

TraumaTrauma


600am600am

HandHand


Sorrell Sorrell Center Center Room Room 10051005

UNMC UNMC OrthoOrtho

LibraryLibrary

Children’sChildren’s

HospitalHospital

Glow Aud.Glow Aud.

33rdrd Floor Floor

CreightonCreighton

Med CtrMed Ctr

Morrison Morrison RmRm

Lobby LvlLobby Lvl

UNMC UNMC OrthoOrtho

LibraryLibrary

Orthopaedic Orthopaedic BasicsBasics

- History and Physical Exam - History and Physical Exam --

- How to Read an X-Ray -- How to Read an X-Ray -- Principles of - Principles of

Casting/Splinting –Casting/Splinting –- Fracture Fixation - - Fracture Fixation -


Orthopaedic HistoryOrthopaedic History

• A good general orthopaedic history A good general orthopaedic history contains:contains:– Onset, Duration, and Location of a problemOnset, Duration, and Location of a problem– Limitations and debilitation attributed to the Limitations and debilitation attributed to the

problemproblem– Good surgical history, especially with regards Good surgical history, especially with regards

to orthopaedic surgeries and prior anesthesiato orthopaedic surgeries and prior anesthesia– Co-morbid conditions that contribute to the Co-morbid conditions that contribute to the

problem or will preclude healing in some problem or will preclude healing in some mannermanner

Physical Exam BasicsPhysical Exam Basics

• Inspect and Palpate everything- start Inspect and Palpate everything- start with normal structures and move to with normal structures and move to abnormalabnormal

• Range of motion in all planesRange of motion in all planes• StrengthStrength• SensationSensation• ReflexesReflexes• GaitGait• StabilityStability

Physical Exam BasicsPhysical Exam Basics

• NVI What does this mean?NVI What does this mean?

1.1. Neurologic exam- Always document the Neurologic exam- Always document the neurologic status. Some fractures are neurologic status. Some fractures are associated with nerve injuries and associated with nerve injuries and knowing the status of the nerve is knowing the status of the nerve is criticalcritical

2.2. Vascular exam- Always check for pulses Vascular exam- Always check for pulses distal to the fracture sight. Missed distal to the fracture sight. Missed vascular injuries can be devastatingvascular injuries can be devastating

Physical ExamPhysical Exam

• NEVER trust someone else’s exam. NEVER trust someone else’s exam. ALWAYS put your hands on the ALWAYS put your hands on the patient and see for yourselfpatient and see for yourself

• Always trust your exam- you WILL Always trust your exam- you WILL pick up something that someone else pick up something that someone else has missed at some pointhas missed at some point

ImagingImaging

Intro to Reading X-raysIntro to Reading X-rays

• Reading a radiograph is essentially Reading a radiograph is essentially describing the anatomy of a certain describing the anatomy of a certain structurestructure

• In order for it to be universal and In order for it to be universal and understandable for others, clarity understandable for others, clarity and precision are essentialand precision are essential

• A fracture is described based on the A fracture is described based on the findings of the physical exam and a findings of the physical exam and a review of radiographsreview of radiographs

Reading X-raysReading X-rays

1.1. Say what it is- what anatomic structure Say what it is- what anatomic structure are you looking at and how many are you looking at and how many different views are theredifferent views are there

2.2. Condition of the soft tissue- Open vs Condition of the soft tissue- Open vs ClosedClosed

3.3. Regional Location- Diaphysis (rule of Regional Location- Diaphysis (rule of 1/3), Metaphysis, Epiphysis including 1/3), Metaphysis, Epiphysis including intra and extra-articular, and Physis intra and extra-articular, and Physis (pedi)(pedi)

4.4. Direction of the fracture line- Direction of the fracture line- Transverse, Oblique, SpiralTransverse, Oblique, Spiral

Reading X-raysReading X-rays

5.5. Condition of the bone- comminution Condition of the bone- comminution (3 or more parts), Segmental (3 or more parts), Segmental (middle fragment), Butterfly (middle fragment), Butterfly segment, incomplete, avulsion, segment, incomplete, avulsion, stress, impactedstress, impacted

6.6. Deformity-Displacemtent (distal Deformity-Displacemtent (distal with respect to proximal), with respect to proximal), angulation (varus, valgus), rotation, angulation (varus, valgus), rotation, shortening (in cm’s), distractionshortening (in cm’s), distraction

Fracture PatternFracture Pattern

• TransverseTransverse• Produced by a Produced by a

distracting or distracting or tensile forcetensile force


• SpiralSpiral• PProduced by a roduced by a

torsional forcetorsional force


• ButterflyButterfly• Produced by pure Produced by pure

bending forcebending force


• ComminutedComminuted• Broken into many Broken into many

pieces- high pieces- high energy with energy with combined forcescombined forces

DisplacementDisplacement

• Characterized by % of Characterized by % of bone contact on bone contact on either vieweither view

AngulationAngulation• Distal fragment relative to Distal fragment relative to

proximalproximal– Varus, Valgus, Anterior, Varus, Valgus, Anterior,

PosteriorPosterior

• Apex of angle formed by Apex of angle formed by fragmentsfragments– E.g., Apex Anterior, Apex E.g., Apex Anterior, Apex

Medial, Apex UlnarMedial, Apex Ulnar

LocationLocation

• Commonly described in thirds of Commonly described in thirds of affected boneaffected bone– ie distal third of tibia ie distal third of tibia – ie junction of proximal and middle third ie junction of proximal and middle third

of femurof femur– If fractured at two levels describe as If fractured at two levels describe as

segmentalsegmental

Location-DiaphysisLocation-Diaphysis

• Shaft portion of Shaft portion of bonebone

Location-MetaphysisLocation-Metaphysis

• The ends of the The ends of the bone (if the bone (if the fracture goes into fracture goes into a joint it is a joint it is described as intra- described as intra- articular)articular)

Now All TogetherNow All Together

• Transverse Transverse fracture of the fracture of the femur at the femur at the middle third- distal middle third- distal third junction with third junction with 100% 100% displacement and displacement and varus (or apex varus (or apex lateral) angulationlateral) angulation

What do you see?What do you see?

Casting, Splinting, Casting, Splinting, and Definitive and Definitive

Fracture FixaitonFracture Fixaiton

Definitive Fracture Definitive Fracture Fixation OptionsFixation Options

• Casts and SplintsCasts and Splints– Appropriate for Appropriate for

many fractures many fractures especially hand and especially hand and foot fracturesfoot fractures

– Adults typically will Adults typically will get plaster splints get plaster splints initially initially transitioned to transitioned to fiberglass casts as fiberglass casts as swelling decreasesswelling decreases

– Kids typically will Kids typically will get fiberglass castsget fiberglass casts

Definitive Fracture Definitive Fracture FixationFixation

• Delayed until patient is Delayed until patient is stable (may be days or stable (may be days or weeks)weeks)

• Femur Fracture has Femur Fracture has priority as delay in priority as delay in fixation has negative fixation has negative impact on pulmonary impact on pulmonary status by shower of fat status by shower of fat emboli to the lungsemboli to the lungs

• Goals is to stabilize Goals is to stabilize skeleton to allow patient skeleton to allow patient to rapidly mobilize from to rapidly mobilize from bedbed


• TractionTraction– Useful in patients Useful in patients

who are too sick for who are too sick for surgerysurgery

– Useful to maintain Useful to maintain alignment until alignment until definitive fixationdefinitive fixation


• External FixationExternal Fixation– Used primarily in Used primarily in

the treatment of the treatment of open fractures and open fractures and pelvis fracturespelvis fractures

– Also useful as Also useful as temporary temporary stabilization prior stabilization prior to definitive fixationto definitive fixation

Indications- Emergent Indications- Emergent StabilizationStabilization


• Open Reduction Open Reduction and Internal and Internal fixation with Plates fixation with Plates and screwsand screws– Used for many Used for many

fractures especially fractures especially those involving those involving jointsjoints


• Intramedullary Intramedullary NailsNails– Treatment of Treatment of

choice for most choice for most tibia and femur tibia and femur fracturesfractures

– Used in selected Used in selected humerus and humerus and forearm fracturesforearm fractures

• Joint Joint ReplacementReplacement– Used in displaced Used in displaced

femoral neck femoral neck fractures in geriatric fractures in geriatric patientspatients

– Allows for early Allows for early ambulationambulation

– Occasionally used in Occasionally used in geriatric pts with geriatric pts with comminuted comminuted shoulder or elbow shoulder or elbow fracturesfractures


Open FracturesOpen Fractures

Open FracturesOpen Fractures

• Open fractures refer to osseous Open fractures refer to osseous disruption in which a break in the skin disruption in which a break in the skin soft tissue communicates directly with soft tissue communicates directly with a fracturea fracture

• Any wound occurring on the same limb Any wound occurring on the same limb as a fracture must be suspected to be as a fracture must be suspected to be an open fracture until proven otherwisean open fracture until proven otherwise

• A missed open fracture can have dire A missed open fracture can have dire consequencesconsequences

Evaluation of open Evaluation of open fracturesfractures

• ABC’s ABC’s • Identify the injured area Identify the injured area • Assess neurovascular status of the limb both Assess neurovascular status of the limb both

proximal and distal to the wound. Always use the proximal and distal to the wound. Always use the normal side as a controlnormal side as a control

• Assess skin and soft tissue damage. Exploration of Assess skin and soft tissue damage. Exploration of a wound is not usually indicated in a trauma or a wound is not usually indicated in a trauma or emergency setting. If you know its an open emergency setting. If you know its an open fracture, splint it and prepare to go to the ORfracture, splint it and prepare to go to the OR

• DO NOT remove bone no matter how small or DO NOT remove bone no matter how small or insignificant a piece it may seeminsignificant a piece it may seem

• Always consider vascular injuries and Always consider vascular injuries and compartment syndrome with open fracturescompartment syndrome with open fractures

Classification of open Classification of open fracturesfractures

• Gustillo ClassificationGustillo Classification– Grade I- Clean skin opening of less than 1 cm, Grade I- Clean skin opening of less than 1 cm,

usually inside to outusually inside to out– Grade II- Open between 1 and 10 cm, extensive Grade II- Open between 1 and 10 cm, extensive

soft tissue injury, minimal to moderate crushingsoft tissue injury, minimal to moderate crushing– Grade III- Open more than 10cm, extensive Grade III- Open more than 10cm, extensive

tissue including muscle damage, high energytissue including muscle damage, high energy• IIIA- Laceration with adequate bone coverage, IIIA- Laceration with adequate bone coverage,

segmental features, gunshot injuriessegmental features, gunshot injuries• IIIB- Soft tissue injury with periosteal stripping, IIIB- Soft tissue injury with periosteal stripping,

usually associated with massive contaminationusually associated with massive contamination• IIIC- Any of the above with an associated vascular IIIC- Any of the above with an associated vascular

injuryinjury

Acute Management of open Acute Management of open fracturesfractures

• Address hemorrhage with direct pressureAddress hemorrhage with direct pressure• Initiate antibioticsInitiate antibiotics

– Grade I and II- Ancef 1g-2g IVGrade I and II- Ancef 1g-2g IV– Grade III- Ancef plus Gentamicin 2mg/kg IVGrade III- Ancef plus Gentamicin 2mg/kg IV– Farm injuries or gross contamination- add Farm injuries or gross contamination- add

PenicillinPenicillin– Apply saline soaked gauze dressing to woundApply saline soaked gauze dressing to wound– Attempt reduction and apply splintAttempt reduction and apply splint– Operate- most surgeons use 8 hrs as the window Operate- most surgeons use 8 hrs as the window

for decreasing the incidence of infection and for decreasing the incidence of infection and other related complications of open fracturesother related complications of open fractures

Orthopaedic Orthopaedic TraumaTrauma

- General Principles -- General Principles -


Orthopaedic TraumaOrthopaedic Trauma

• Defined- The care Defined- The care of fractures and of fractures and soft tissue injuries soft tissue injuries of the extremities of the extremities either in the either in the setting of multiple setting of multiple trauma or isolated trauma or isolated injuriesinjuries

Orthopaedic TraumaOrthopaedic Trauma

• Orthopaedic trauma Orthopaedic trauma surgeons care for complex surgeons care for complex fractures, periarticular fractures, periarticular fractures, fractures fractures, fractures involving the pelvis and involving the pelvis and acetabulum, and fracture acetabulum, and fracture nonunions, malunions and nonunions, malunions and infections.infections.

TraumaTrauma

• Field TriageField Triage– AirwayAirway– BreathingBreathing– CirculationCirculation– Extrication of PatientExtrication of Patient– Shock ManagementShock Management– Fracture StabilizationFracture Stabilization– TransportTransport

TraumaTrauma

• Golden Hour of TraumaGolden Hour of Trauma– Rapid transport of a severely injured Rapid transport of a severely injured

patient to a trauma center for definitive patient to a trauma center for definitive care. Initial treatment has a care. Initial treatment has a significantly higher chance for survival significantly higher chance for survival during this period.during this period.

UNMC Trauma and Critical Care Surgery Team

Trauma EvaluationTrauma Evaluation

• ATLS- Advanced Trauma and Life ATLS- Advanced Trauma and Life SupportSupport– A standardized protocol for the A standardized protocol for the

evaluation and treatment of victims of evaluation and treatment of victims of traumatrauma

– Developed by a Nebraska orthopaedic Developed by a Nebraska orthopaedic surgeon who was involved in a trauma surgeon who was involved in a trauma and was not satisfied with the lack of a and was not satisfied with the lack of a protocol for such patientsprotocol for such patients

ATLSATLS

• A- establish an A- establish an AAirwayirway• B- B- BBreathe for the pt. reathe for the pt.

(if they aren’t)(if they aren’t)• C- assess and restore C- assess and restore

CCirculationirculation• D- assess neurologic D- assess neurologic

DDisabilityisability• E- E- EExpose entire xpose entire

patientpatient

Primary SurveyPrimary Survey

• Rapid assessment of ABC’s and Rapid assessment of ABC’s and addressing life threatening problems (ie addressing life threatening problems (ie establishing airway and ventilation, establishing airway and ventilation, placing chest tubes, control active placing chest tubes, control active hemorrhage)hemorrhage)

• Place large bore IV’s and begin fluid Place large bore IV’s and begin fluid replacement for patients in shockreplacement for patients in shock

• Obtain Xray of Chest, Pelvis, and Lateral Obtain Xray of Chest, Pelvis, and Lateral C-SpineC-Spine

Secondary SurveySecondary Survey• Assessing entire patient Assessing entire patient

for other non-life for other non-life threatening injuries.threatening injuries.

• Orthopaedist assesses Orthopaedist assesses skeleton and splints skeleton and splints fractures and reduces fractures and reduces dislocationsdislocations

• Also evaluate distal Also evaluate distal pulses and peripheral pulses and peripheral nerve functionnerve function

• Obtain Xray or CT of Obtain Xray or CT of affected areas when pt affected areas when pt is stableis stable

Emergent Skeletal IssuesEmergent Skeletal Issues

• Hemorrhage control from Pelvis Fractures Hemorrhage control from Pelvis Fractures in pt with labile blood pressure (shock)in pt with labile blood pressure (shock)– Close pelvic volumeClose pelvic volume

• Hemorrhage control from open fracturesHemorrhage control from open fractures– Direct pressureDirect pressure

• Restore pulses by realigning fractures and Restore pulses by realigning fractures and dislocationsdislocations

Urgent Skeletal IssuesUrgent Skeletal Issues

• Irrigation and Debridement of open Irrigation and Debridement of open fracturesfractures

• Reduction of dislocationsReduction of dislocations• Splinting of fracturesSplinting of fractures• Fixation of femur fracturesFixation of femur fractures• Addressing compartment syndromesAddressing compartment syndromes

Trauma AssessmentTrauma Assessment• History History Mechanism of Mechanism of

InjuryInjury• PalpationPalpation• Note swelling, LacerationsNote swelling, Lacerations• Painful ROMPainful ROM• Crepitus- that grating Crepitus- that grating

feeling when two bone ends feeling when two bone ends rub against each otherrub against each other

• Abnormal Motion- ie the Abnormal Motion- ie the tibia bends in the middletibia bends in the middle

• Check pulses, sensory exam, Check pulses, sensory exam, and motor testing if possibleand motor testing if possible

Diagnosis- The examDiagnosis- The exam• Assess for lacerations that Assess for lacerations that

communicate with the fracturecommunicate with the fracture– Closed Fracture= intact skin over Closed Fracture= intact skin over

fracturefracture– Open Fracture= laceration Open Fracture= laceration

communicating with fracture (often communicating with fracture (often referred to as a compound fracture referred to as a compound fracture by lay persons)by lay persons)

Compartment Compartment SyndromeSyndrome

Compartment SyndromeCompartment Syndrome

• An emergent condition characterized by An emergent condition characterized by increased pressure within a closed increased pressure within a closed anatomical compartment with the potential anatomical compartment with the potential to cause irreversible damage to the to cause irreversible damage to the contents of the compartment (ie muscle contents of the compartment (ie muscle and nerves)and nerves)

EtiologyEtiology

• BurnsBurns• High pressure injectionHigh pressure injection• TraumaTrauma

– fracturesfractures– crush crush

• Medical (Iatrogenic)Medical (Iatrogenic)– Tight dressings/casts Tight dressings/casts

coagulation, dialysis, coagulation, dialysis, traction traction

PathophysiologyPathophysiology

• Fixed volume ~ pressure in a closed spaceFixed volume ~ pressure in a closed space• Rigid fasciaRigid fascia• Increased tissue pressure exceeds venous Increased tissue pressure exceeds venous

and capillary opening pressure producing and capillary opening pressure producing local hypoxia and capillary leak leading to local hypoxia and capillary leak leading to even > tissue pressureeven > tissue pressure

• Hypotension decreases tolerance to Hypotension decreases tolerance to compartmental pressure increasescompartmental pressure increases

Diagnosis

• In an awake patient this is a clinical In an awake patient this is a clinical diagnosisdiagnosis

• In an obtunded (drunk, head injured, In an obtunded (drunk, head injured, sedated, intubated) patient the diagnosis sedated, intubated) patient the diagnosis is made with pressure measurementsis made with pressure measurements

Compartment Syndrome Compartment Syndrome DiagnosisDiagnosis

• The 6 P’sThe 6 P’s– Pressure – rigid compartment w/ shiny skinPressure – rigid compartment w/ shiny skin– Pain - out of proportion (the most consistent Pain - out of proportion (the most consistent

finding in an awake pt)finding in an awake pt)• Passive stretch painPassive stretch pain

– ParesthesiasParesthesias– ParalysisParalysis– PallorPallor– PoikilothermiaPoikilothermia

• Pulselessness – not a characteristic of C.S.Pulselessness – not a characteristic of C.S.

Late findings

Diagnosis: Pressure Diagnosis: Pressure MeasurementMeasurement

• Threshold number Threshold number is controversialis controversial

• Peak pressure Peak pressure zone 2cm from zone 2cm from fracturefracture

Treatment Treatment

• must decompress all compartments at riskmust decompress all compartments at risk

• skin, fat, fascia widely decompressedskin, fat, fascia widely decompressed

• debridement of necrotic tissuedebridement of necrotic tissue

• do not close woundsdo not close wounds

Extremity Compartment Extremity Compartment SyndromesSyndromes

• GlutealGluteal• ThighThigh• CalfCalf• FootFoot• HandHand

• ForearmForearm

• ArmArm

Questions??Questions??

unmc orthopaedic surgery welcome to your m4 clerkship and welcome to omaha department of orthopaedic...

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orthopaedic history

orthopaedic patient

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orthopaedic clerkshipwelcome

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basic xrays

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