UNMC Orthopaedic Surgery

1. Department of Orthopaedic Surgery and Rehabilitation UNMC Orthopaedic Surgery Welcome to your M4 Clerkship and Welcome to Omaha

2. Introduction • Welcome • Expectations and goals • General considerations for Orthopaedic history and physical exam • Introduction to reading x-rays • Trauma/Open Fractures • Compartment Syndrome

3. WELCOME • Welcome to UNMC and your Orthopaedic clerkship • We are here to teach you the basic foundations of Orthopaedics. • With that, you should be able to gain a feel for what a career in Orthopaedics may be like. • We are happy to have you as a part of our team for the next month and hope you gain a lot of useful information while you are here

4. Expectations: General • Show up on time, be available, and work hard • Read before surgical cases (anatomy and surgical plan) • Be helpful, be inquisitive, ask questions • Learn basic management of common musculoskeletal problems • Participate actively in rounds, clinics, conference, and general discussions about Orthopaedic problems

5. Expectations Cont. • Be able to access knowledge about Orthopaedics from books, internet, journals, etc.. • Be able to answer questions about musculoskeletal anatomy, common injuries, treaments, etc.. Especiallywhen asked to look it up beforehand.

6. Clinical functioning at the level of an intern • Think about the patient care plan: • Pre-op planning • Medical workup before surgery • Antibiotics • Pain control • DVT prophylaxis • Therapy goals & restrictions • Dressing changes / drain output • Discharge planning & clinic follow-up • Read other consult service notes for their plan

7. Goals • At the end of your rotation you should be able to: • Read basic x-rays appropriately • Perform an orthopaedic history and physical • Recognize common fractures, their classification, and know how to acutely manage them • Understand basic patient care for the Orthopaedic patient • Be able to diagnose common musculoskeletal problems

8. CALL

9. Divide call on trauma nights between the students such that you average no more frequently than q4 during your month. • Be sure to get at least one full weekend off. We’d like you to be able to both have a life and also get to know a little about our city. • The actual schedule is left up to the students to arrange. Be fair to each other.

10. Carry the on-call pager and notify the junior resident on-call that you will be taking call with them that evening • The best opportunity to learn how to suture, splint, cast, and possibly do reductions as a medical student takes place on-call and in the ER/trauma bay.

11. CONFERENCES

12. Conference Schedules • Three rules • If there is an assigned reading for a conference, be sure to get a copy and read it. • No scrubs in conference, dress appropriately. • Be on time. Tardiness to conference will be looked upon very poorly.

13. Conference Schedules

14. Department of Orthopaedic Surgery and Rehabilitation Orthopaedic Basics- History and Physical Exam -- How to Read an X-Ray -- Principles of Casting/Splinting –- Fracture Fixation -

15. Orthopaedic History • A good general orthopaedic history contains: • Onset, Duration, and Location of a problem • Limitations and debilitation attributed to the problem • Good surgical history, especially with regards to orthopaedic surgeries and prior anesthesia • Co-morbid conditions that contribute to the problem or will preclude healing in some manner

16. Physical Exam Basics • Inspect and Palpate everything- start with normal structures and move to abnormal • Range of motion in all planes • Strength • Sensation • Reflexes • Gait • Stability

17. Physical Exam Basics • NVI What does this mean? • Neurologic exam- Always document the neurologic status. Some fractures are associated with nerve injuries and knowing the status of the nerve is critical • Vascular exam- Always check for pulses distal to the fracture sight. Missed vascular injuries can be devastating

18. Physical Exam • NEVER trust someone else’s exam. ALWAYS put your hands on the patient and see for yourself • Always trust your exam- you WILL pick up something that someone else has missed at some point

19. Imaging

20. Intro to Reading X-rays • Reading a radiograph is essentially describing the anatomy of a certain structure • In order for it to be universal and understandable for others, clarity and precision are essential • A fracture is described based on the findings of the physical exam and a review of radiographs

21. Reading X-rays • Say what it is- what anatomic structure are you looking at and how many different views are there • Condition of the soft tissue- Open vs Closed • Regional Location- Diaphysis (rule of 1/3), Metaphysis, Epiphysis including intra and extra-articular, and Physis (pedi) • Direction of the fracture line- Transverse, Oblique, Spiral

22. Reading X-rays • Condition of the bone- comminution (3 or more parts), Segmental (middle fragment), Butterfly segment, incomplete, avulsion, stress, impacted • Deformity-Displacemtent (distal with respect to proximal), angulation (varus, valgus), rotation, shortening (in cm’s), distraction

23. Fracture Pattern • Transverse • Produced by a distracting or tensile force

24. Fracture Pattern • Spiral • Produced by a torsional force

25. Fracture Pattern • Butterfly • Produced by pure bending force

26. Fracture Pattern • Comminuted • Broken into many pieces- high energy with combined forces

27. Displacement • Characterized by % of bone contact on either view

28. Angulation • Distal fragment relative to proximal • Varus, Valgus, Anterior, Posterior • Apex of angle formed by fragments • E.g., Apex Anterior, Apex Medial, Apex Ulnar

29. Location • Commonly described in thirds of affected bone • ie distal third of tibia • ie junction of proximal and middle third of femur • If fractured at two levels describe as segmental

30. Location-Diaphysis • Shaft portion of bone

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

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

33. What do you see?

34. What do you see?

35. What do you see?

36. Casting, Splinting, and Definitive Fracture Fixaiton

37. Definitive Fracture Fixation Options • Casts and Splints • Appropriate for many fractures especially hand and foot fractures • Adults typically will get plaster splints initially transitioned to fiberglass casts as swelling decreases • Kids typically will get fiberglass casts

38. Definitive Fracture Fixation • Delayed until patient is stable (may be days or weeks) • Femur Fracture has priority as delay in fixation has negative impact on pulmonary status by shower of fat emboli to the lungs • Goals is to stabilize skeleton to allow patient to rapidly mobilize from bed

39. Definitive Fracture Fixation Options • Traction • Useful in patients who are too sick for surgery • Useful to maintain alignment until definitive fixation

40. Definitive Fracture Fixation Options • External Fixation • Used primarily in the treatment of open fractures and pelvis fractures • Also useful as temporary stabilization prior to definitive fixation

41. Indications- Emergent Stabilization

42. Definitive Fracture Fixation Options • Open Reduction and Internal fixation with Plates and screws • Used for many fractures especially those involving joints

43. Definitive Fracture Fixation Options • Intramedullary Nails • Treatment of choice for most tibia and femur fractures • Used in selected humerus and forearm fractures

44. Definitive Fracture Fixation Options • Joint Replacement • Used in displaced femoral neck fractures in geriatric patients • Allows for early ambulation • Occasionally used in geriatric pts with comminuted shoulder or elbow fractures

45. Open Fractures

46. Open Fractures • Open fractures refer to osseous disruption in which a break in the skin soft tissue communicates directly with a fracture • Any wound occurring on the same limb as a fracture must be suspected to be an open fracture until proven otherwise • A missed open fracture can have dire consequences

47. Evaluation of open fractures • ABC’s • Identify the injured area • Assess neurovascular status of the limb both proximal and distal to the wound. Always use the normal side as a control • Assess skin and soft tissue damage. Exploration of a wound is not usually indicated in a trauma or emergency setting. If you know its an open fracture, splint it and prepare to go to the OR • DO NOT remove bone no matter how small or insignificant a piece it may seem • Always consider vascular injuries and compartment syndrome with open fractures

48. Classification of open fractures • Gustillo Classification • Grade I- Clean skin opening of less than 1 cm, usually inside to out • Grade II- Open between 1 and 10 cm, extensive soft tissue injury, minimal to moderate crushing • Grade III- Open more than 10cm, extensive tissue including muscle damage, high energy • IIIA- Laceration with adequate bone coverage, segmental features, gunshot injuries • IIIB- Soft tissue injury with periosteal stripping, usually associated with massive contamination • IIIC- Any of the above with an associated vascular injury

49. Acute Management of open fractures • Address hemorrhage with direct pressure • Initiate antibiotics • Grade I and II- Ancef 1g-2g IV • Grade III- Ancef plus Gentamicin 2mg/kg IV • Farm injuries or gross contamination- add Penicillin • Apply saline soaked gauze dressing to wound • Attempt reduction and apply splint • Operate- most surgeons use 8 hrs as the window for decreasing the incidence of infection and other related complications of open fractures

50. Department of Orthopaedic Surgery and Rehabilitation Orthopaedic Trauma- General Principles -