34 Orthopedic Injuries - Bài viết - Bệnh Học
Đọc và ngẫm: "Rượu nhạt uống lắm cũng say. Người khôn nói lắm dẫu hay cũng nhàm. [Ngạn ngữ Việt nam ] "
Chú ý: Các nội dung sai QUY ĐỊNHLuật chính tả sẽ bị XÓA
Nếu bạn đang gởi bài, hãy đọc qua bài này!


34 Orthopedic Injuries

Cho điểm
Orthopedic Injuries
Jason Robison
William M. Ricci
Treatment of Orthopedic Injuries
I. Initial Assessment
A. Priorities of management
Assessment and management of ABCs (airway, breathing, and circulation) take precedence over extremity injuries. Multisystem-injured patients benefit from early aggressive treatment of extremity and pelvic trauma.
B. History
In addition to standard medical history, the mechanism of injury, especially the relative energy associated with the injury (e.g., low energy fall vs. high-energy motor vehicle crash), is important to elucidate and helps to direct assessment, management, and prognosis of patients with musculoskeletal injuries. An orthopaedic history should also include preinjury functional level.
C. Examination

  • An orthopedic examination includes inspection, palpation, range-of-motion, strength, stability, and body region–specific tests. A systematic approach includes comparison to the unaffected side in isolated injuries and a complete skeletal evaluation in the multiply injured patient. Inspect the extremities for bruising, swelling, lacerations, abrasions, deformity, and asymmetry. Systematically palpate all extremities, noting tenderness, crepitus, and deformity of the underlying bone. Assess joint range of motion, stressing the joint in nonmotion planes to determine stability. Special tests are indicated for the further evaluation of specific injuries and can be found in comprehensive texts. In suspected cervical spine injury, maintain immobilization in a cervical collar until cervical spine injury is ruled out radiographically and/or clinically. Logroll the patient to examine and palpate the spine.
  • Assess extremity vascular status by checking pulses, capillary refill, temperature, and color and comparing to the opposite side.
  • Sensorimotor evaluation. Muscle strength evaluation in the setting of acute spinal cord injury or peripheral nerve injury is critical, and serial exams are often required. A sensory examination includes light touch in dermatomal and peripheral nerve distributions. In upper-extremity or cervical spine trauma, two-point discrimination of the fingers should be assessed.
  • Associated injuries. Severe or multiple injuries can mask other injuries. Especially important in this setting is a complete primary evaluation and then a secondary survey.

II. Radiologic Examination
All trauma and unconscious patients should have screening chest, pelvis, and cervical spine radiographs. Lateral cervical spine radiographs must visualize all cervical vertebrae to the C7-T1 junction. Assessment of extremity fractures and dislocations should include a minimum of two views 90 degrees to each other [usually anteroposterior (AP) and lateral views] of the affected area and should include both the joint above and the joint below the injury. Dislocations should be reduced as soon as possible, without the benefit of radiographs if necessary, because they are often associated with neurovascular and soft-tissue compromise.
III. Fractures and Dislocations
A. Terminology and classification

  • Accurate descriptions of fractures and dislocations begin with the bone or joint involved. For fractures, the anatomic region refers usually to the proximal, middle, or distal portion of the bone. Epiphyseal, metaphyseal, and diaphyseal (also head, base, and shaft) are acceptable descriptive terms of the fracture location. The quality of the fracture is described based on its orientation and the number of fracture fragments. A fracture is transverse if it runs relatively perpendicular to the long axis of the bone and oblique if it is angled. Spiral fractures propagate around and along a long bone and are caused by a twisting injury. Comminuted fractures have, by definition, more than two fragments. Intra-articular fractures involve the joint surface.
  • Alignment always references the distal fragment relative to the proximal fragment. Key components are angulation, translation, rotation, and shortening. Angulation is angular deformity in the coronal or sagittal plane, rotation is deformity about the long axis of the bone, translation is nonangular coronal or sagittal displacement with decreased bony apposition, and shortening is loss of bone length though the fracture.
  • Stable fractures and dislocations are not likely to displace after reduction (the “setting” of a fracture or dislocation) and appropriate immobilization, whereas unstable fractures are either unable to be reduced or are likely to lose reduction despite adequate immobilization.
  • Soft-tissue injury. Open or “compound” (an outdated term) fractures are those with a disruption of the overlying skin and tissue such that the fracture communicates with the external environment. Closed fractures are those that do not communicate with the external environment. Abrasions or lacerations that do not communicate with the fracture site are considered closed. Fractures complicated by associated neurovascular, ligamentous, or muscular injury require prompt recognition and injury-specific treatment.
  • Joint subluxation refers to joint disruption and instability with decreased contact between joint surfaces. Dislocation refers to complete loss of contact between joint surfaces. Both are described by the position of the distal bone in relation to its proximal articulation.

B. General management principles

  • Dislocation. All dislocated joints, especially in the setting of neurovascular compromise, should be reduced emergently. This can generally be accomplished via gentle longitudinal traction. Successful reduction reduces the risk and degree of soft-tissue injury (e.g., pressure necrosis) and neurovascular compromise. Postreduction radiographs are essential to confirm adequate reduction and to re-evaluate for associated fractures previously not visualized because of deformity associated with the dislocation. Persistently diminished or absent pulses may require arteriography and further evaluation. See specific injury sections for joint-specific issues.
  • Fracture. A diagnosis of fracture is suspected by history of injury, symptoms of pain, loss of motion, and swelling. Physical examination findings include crepitus, tenderness, swelling, and/or deformity. Confirmation of fracture is obtained via appropriate radiographs.

    • General treatment principles. Treatment of fractures first includes reduction, if indicated, and then appropriate immobilization. Appropriate immobilization helps to prevent further injury to the surrounding soft tissues and is usually required for fracture healing. Nondisplaced fractures and those that can be adequately reduced (with regard to fracture alignment) in a closed manner can often be treated without surgery. However, this requires sufficient stability to predictably maintain reduction through healing. Fractures that cannot be reduced closed, are too unstable to maintain adequate reduction, or have significant joint involvement are generally treated surgically with open reduction and either internal fixation (plates, screws, and wires), intramedulary nailing, external fixation, or, in some cases, primary joint arthroplasty

(joint replacement). Certain stable fractures, such as hip fractures, are usually treated surgically because of the increased morbidity associated with prolonged immobilization associated with nonoperative management. Open fractures have specific considerations and treatments that are discussed later (see Section VI.C).

    • Pediatric musculoskeletal fractures
      • Children, especially those with open growth plates, have a greater potential for bony remodeling than adults, and therefore a greater amount of malalignment is acceptable. Despite this, however, at least limited reduction of deformity is often necessary to decrease the risk of permanent deformity. As in the adult, inability to achieve and obtain an acceptable reduction is a relative indication for surgical treatment. Fracture evaluation principles of history, physical exam, and radiographs are the same as in the adult.
      • Physeal plate injuries (“growth plate”) are common because this is the weakest part of the bone. The Salter-Harris classification categorizes these fractures into five types of increasing severity and likelihood of future growth disturbance. Type I injuries involve a fracture through the growth plate without any metaphyseal or epiphyseal involvement. Type II injury occurs when disruption of the growth plate is associated with a metaphyseal fracture, and type III when it is associated with an epiphyseal fracture. Fracture through the metaphysis, across the growth plate, and exiting the epiphysis constitute a type IV injury. A type V injury is a severe crush injury to the growth plate.

    • Hazards in fracture management. Patients must be observed closely for possible compartment syndrome (see Section VI.B), especially those with leg and forearm injuries. Neurovascular compromise after plaster immobilization usually is secondary to swelling, and splints and bandages should be loosened to accommodate anticipated swelling. Circumferential casting in the acute setting should generally be avoided, but in a low-energy, nondisplaced fracture in a child, casting may be appropriate. If the patient is to return home, he or she should be instructed on the warning signs of early compartment syndrome and told to return to the hospital immediately if these symptoms develop.

IV. Soft-Tissue Injury
A. Principles of management
In general, isolated soft-tissue injuries, such as ligament sprains and muscle strains, are treated with rest, ice, compression bandage, and elevation (RICE therapy) with or without immobilization.

  • Skin lacerations/defects. All devitalized tissue should be débrided. If the wound cannot be closed due to excessive tension, it should be covered with a moist saline dressing, and a delayed primary closure or skin grafting should be planned.
  • Muscle
    • Mechanism. Strains of the musculotendinous unit are usually secondary to violent contraction or excessive stretch. Injury spans the range from stretch of the fibers to a complete tear with loss of function.
    • Physical examination. Swelling, tenderness, and pain with movement occur. A defect may be palpable. RICE-type treatment of the muscle involved is adequate for most such injuries.

  • Tendon. Lacerated, ruptured, or avulsed tendons, especially those of the upper extremity, should be surgically repaired because such injuries result in loss of function. Examination reveals loss of motion or weakness. Open wounds with a tendon laceration are irrigated thoroughly, débrided, and closed primarily with early planned repair of the tendon in the operating room. In grossly contaminated wounds, incision and débridement in the operating room are needed. Splints are applied with the extremity in a functional position.
  • Ligament. Ligament sprains range from mild stretch to complete tear and are commonly sports related. Pain, localized tenderness, and joint instability may be

present on examination. Radiographs may reveal joint incongruence. If the joint is clinically or radiographically unstable, treatment involves immobilization in a reduced position. If no evidence of instability is present, treatment based on the RICE principle is used, and early range of motion is encouraged.
V. Specific Injuries by Anatomic Location
A. Shoulder

  • Fractures: clavicle, scapula, and proximal humerus
    • Typical mechanism: a fall onto an outstretched hand or onto a shoulder. Proximal humerus fractures are commonly caused by a low-energy fall in the elderly. Scapula fractures are a marker of very high energy chest trauma, usually involving a motor vehicle.
    • Typical physical signs. A clavicle fracture is often palpable under the skin. Deformity is common with displaced fractures. Proximal humerus fractures can present with decreased range of motion, swelling, ecchymosis, and pain. The neurovascular exam is critical. Test for isometric (contraction without joint motion, usually against resistance) deltoid muscle function and lateral shoulder sensation to determine axillary nerve function. Median, radial, and ulnar nerve function is tested in the distal extremity. Observe for signs of pneumothorax or other chest trauma with scapula fractures.
    • Usual radiographic evaluation. Oblique radiographs of the clavicle are obtained to provide orthogonal views. Radiographic evaluation of the shoulder and proximal humerus should include three orthogonal views: an AP of the glenohumeral joint, scapular Y, and axillary. A dislocation can be missed if one relies solely on an AP and scapular Y-view, and an axillary view is mandatory. A scapula fracture is often first noted on chest computed tomography (CT) in the evaluation of coexisting chest injuries and is the best way to evaluate for joint involvement.
    • Typical management

      • Most clavicle fractures heal with nonoperative treatment and can be managed with a sling. Figure-of-eight splints offer no benefit over a sling, are usually poorly tolerated by patients, and therefore are usually not indicated.
      • Proximal humerus fractures, if nondisplaced and stable, can be treated with a sling and early, controlled mobilization. Significant comminution, especially of the greater and lesser tuberosities, and displacement place the humeral head at risk of avascular necrosis and are indications for surgical reduction and fixation, especially in the young. For such a fracture in the elderly, a primary shoulder arthroplasty (replacement) may be considered if stabile internal fixation cannot be achieved.
      • Scapula fractures are treated in a sling unless intra-articular glenoid displacement necessitates surgical fixation.

    • Pitfalls and pearls. A fracture-dislocation of the shoulder is difficult to reduce closed and may have associated neurovascular compromise. Often, a pneumothorax or other chest injuries are associated with high-energy chest trauma. The subcutaneous location of the clavicle places it at risk of an open fracture, and careful observation is necessary to avoid overlooking this component of the injury.

  • Dislocations (sternoclavicular, acromioclavicular, and glenohumeral)
    • Common mechanism. Same as with fractures (fall onto an outstretched hand or onto a shoulder). Anterior shoulder dislocations (most common, ~85%) occur with forced shoulder abduction or external rotation (or both). Less common posterior shoulder dislocations are associated with seizure and electrical shock. Most shoulder dislocations do not spontaneously reduce, which helps to distinguish between subluxation and dislocation.
    • Typical physical signs. Variable deformity and instability can be seen with acromioclavicular (AC) and sternoclavicular dislocations; side-to-side asymmetry must be evaluated. Pain with motion and tenderness to palpation are seen with sprains of the AC and sternoclavicular joints. Hoarseness, dyspnea,

dysphagia, or engorged neck veins are red flags for posterior sternoclavicular joint dislocations with neurovascular compromise and should prompt emergent evaluation and treatment. Shoulder dislocation presents with decreased and painful range of motion, and the humeral head may be palpable anteriorly or posteriorly. A “sulcus sign,” or indentation between the acromion and humeral head, is suggestive of dislocation. As with fractures, a thorough neurovascular examination is critical and should be documented prior to and following any reductions.

    • Usual radiographic evaluation. See fracture section. Stress views of the AC joint are taken holding 5- to 10-lb weights, comparing side to side for displacement; however, this can be quite uncomfortable and is not generally necessary. A CT scan may be indicated to evaluate the sternoclavicular joint to determine anterior or posterior displacement and to visualize adjacent neurovascular structures. If shoulder dislocation is suspected, radiographs must include an axillary view. Evidence of glenoid rim fractures or humeral head impaction fractures (Hill-Sach lesion) associated with shoulder dislocations should be sought.
    • Typical management
      • Anterior sternoclavicular dislocation can be treated with a sling or shoulder immobilizer, whereas posterior dislocations commonly require reduction because of potential neurovascular and airway compromise. This should be done in the operating room under general anesthesia with general or thoracic surgery backup in case of injury to the lung or great vessels.
      • AC joint sprains/dislocations (e.g., shoulder separation) can be treated with a sling and early motion in most cases. Significant displacement and deformity may require reduction and fixation, especially if the skin or soft tissue is tented or otherwise at risk.
      • Shoulder dislocations should be reduced and immobilized in the position of greatest stability: internal rotation for anterior dislocations and external rotation for posterior dislocations. Radiographs should be repeated to demonstrate reduction, and a postreduction neurovascular exam should be done. Reduction is performed under sedation with axial traction and bringing the arm up in to full abduction above the head. Fracture-dislocations frequently require open reduction and internal fixation. Closed reduction, if performed, should be done cautiously to avoid neurovascular injury and to avoid displacement of an otherwise nondisplaced fracture. The redislocation rate is inversely proportional to patient age and correlated with activity level and demand.

    • Pitfalls and pearls. Neurovascular and airway compromise often coexist with sternoclavicular joint dislocations. Posterior shoulder dislocations can be missed with traditional films if there is not an adequate axillary view. Care should be taken with the elderly with any reduction because it is possible to fracture osteoporotic bone with minimal force.

  • Soft-tissue injury
    • Rotator cuff tears. In the young, rotator cuff tears are caused by repetitive overuse (throwing in athletes) or by acute trauma. In the elderly, tears are commonly degenerative and chronic, but they can be acute. They are often associated with shoulder dislocation. History reveals shoulder pain and weakness, especially with overhead activities, and decreased range of motion. This is confirmed on examination with pain and weakness with shoulder abduction, forward elevation, and external rotation with decreased active as compared to passive shoulder motion. In the young, treatment consists of open or arthroscopic tendon repair. In the elderly, function may not be as severely affected, and physical therapy for improved strength and motion may suffice. Failure of nonoperative care is an indication for surgery.
    • Pectoralis major rupture. This is most often caused by heavy lifting or other injury. In addition to weakness and pain, there is often significant bruising, a

palpable defect, and a visibly changed muscle contour. Initial treatment consists of sling immobilization. An open repair gives best results when performed early.
B. Arm and elbow

  • Fractures (humeral shaft, distal humerus [supracondylar] and elbow)
    • Typical mechanism. Commonly caused by a fall onto an outstretched arm or directly onto the elbow. Supraconylar humerus fractures are the most common elbow fracture in both children and the elderly and are commonly caused by falls onto outstretched arms.
    • Typical physical signs. Humerus shaft fractures are often rotationally unstable and can demonstrate shortening. Olecranon fractures may have a palpable defect if displaced. Radial head fractures present with tenderness to palpation and pain with forearm rotation. Swelling and ecchymosis are often seen with supracondylar and other elbow fractures. The amount of swelling about the joint and of the muscle compartments should be carefully noted, as well as other signs of possible developing compartment syndrome (see Section VI.B). All displaced elbow fractures and dislocations place the neurovascular structures at risk, and a complete neurovascular exam should be performed testing both motor and sensory function of the radial, median, and ulnar nerves. In mid-diaphyseal fractures, the radial nerve is especially vulnerable to injury because it is directly adjacent to the posterior humeral shaft in this region.
    • Usual radiographic evaluation. Orthogonal views of the fracture should be obtained, as well as imaging of the joint above and below the site of injury. For supracondylar fractures in adults, stress views taken with gentle longitudinal traction can help to delineate the fracture pattern, especially in cases with significant comminution or deformity. A CT scan may be indicated for additional fracture characterization to aid in surgical planning. A CT can similarly be useful to evaluate the extent and nature of fractures involving the radial head. Nondisplaced elbow fractures in children may present only with a “sail sign” caused by the superior displacement of the anterior and posterior elbow fat pads by a joint effusion.
    • Typical management

      • Following reduction, humeral shaft fractures are initially immobilized with a coaptation splint for approximately 1 to 2 weeks with subsequent placement into a fracture brace. Operative fixation is indicated in cases of polytrauma (to afford use of the upper extremity to expedite and ease mobilization), open fracture, segmental fractures, ipsilateral forearm fracture, radial nerve palsy development after fracture reduction, and inadequate closed reduction or failed closed treatment.
      • Supracondylar fractures in children can be treated in a splint acutely if they are nondisplaced but require percutaneous pinning and casting if they are displaced. Significant swelling and neurovascular embarrassment are indications for urgent reduction followed by close observation. In adults, displaced fracture is an indication for open reduction with internal fixation.
      • Nondisplaced olecranon fractures are treated with a posterior splint followed by early range of motion, but when they are displaced, surgical fixation is indicated.
      • Radial head fractures with minimal involvement of the articular surface (<30%) can be treated nonoperatively in a splint followed by early range-of-motion exercises. Increasing head involvement is an indication for surgical management. Open reduction and internal fixation are performed when stable fixation is achievable (usually three or fewer fragments), or, in adults, excision or replacement is performed if comminution precludes adequate repair.

    • Pitfalls and pearls. Neurologic complications are possible and must be carefully looked for. Secondary (following closed reduction) radial nerve palsy is

considered an indication for surgical management to rule out incarceration of the nerve within the fracture. However, primary radial nerve dysfunction usually resolves spontaneously (over a period of months) and can be treated nonoperatively. A compartment syndrome may occur with a supracondylar fracture, and a high index of suspicion must be maintained both before and after any reduction or surgical treatment. Care should be exercised when placing splints because tight, circumferential dressings can contribute to a developing compartment syndrome or prevent adequate serial examinations.

  • Dislocations (elbow [ulnohumeral) and radial head)
    • Typical mechanism: fall onto an outstretched hand.
    • Typical physical signs. Examination reveals pain, swelling, bruising, and deformity with loss of elbow flexion and extension and forearm supination and pronation. Posterior dislocations are most common but can also occur anteriorly, medially, or laterally. The dislocated segment can often be palpated. As with other elbow injuries, signs of neurovascular complications must be sought. Ulnar shaft fractures associated with radial head dislocation are termed Monteggia injuries.
    • Usual radiographic evaluation. AP and lateral radiographs of the elbow confirm the diagnosis and reveal the direction of dislocation and major associated fractures. Postreduction radiographs are essential to demonstrate concentric joint reduction and more reliably identify any associated fractures. Coronoid process and radial head fractures can be seen with elbow dislocations, and ulna fractures can be seen with radial head dislocations. A CT scan may aid in complex fracture-dislocations.
    • Typical management. Initial treatment consists of prompt reduction (typically accomplished with axial traction and flexion) and assessment of stability. The joint should be splinted in a stable position. Postreduction radiographs are taken and neurovascular status documented. Associated fractures must be addressed for stability. Stable dislocations benefit from early, controlled motion, whereas unstable fractures may require surgical stabilization of fractures or ligament reconstruction. Most Monteggia fractures in children can be treated with closed reduction and splinting, but in adults and in unstable fractures in children, surgery is indicated.
    • Pitfalls and pearls. Beware of neurovascular compromise. Identify associated fractures, and ensure adequate reduction with adequate radiographs. After reduction, examine and document stable positions and range of motion to aid in treatment planning. Frequent follow-up evaluations are required to assure maintained stability.

  • Soft-tissue injury
    • Bicep tendon rupture/avulsion is usually secondary to violent contracture or excessive stretch. Loss of power, pain with resisted elbow flexion, local swelling, and ecchymosis are seen, along with an abnormal muscle contour, proximal retraction. Examine for side-to-side differences. Initial treatment is sling immobilization followed by early surgical repair.

C. Forearm and wrist

  • Fractures (radius and ulna fractures)
    • Typical mechanism. These are commonly caused by falls onto the elbow or outstretched arm and are common in both children and the elderly. A direct blow can cause fracture such as in the “night-stick fracture,” a typically midshaft fracture of the ulna caused by a forceful blow to the arm positioned to protect the face, often with a bat or club during an assault.
    • Typical physical signs. Examination reveals deformity, pain, and focal tenderness. Fractures involving the wrist joint result in painful and limited range of motion. Variable amounts of swelling can be seen, and diaphyseal fractures can cause a compartment syndrome, so careful, serial examination may be needed (see Section VI.B). A Galeazzi fracture is a fracture of the distal half of the radius associated with disruption of the distal radioulnar joint (DRUJ); this joint must be tested for stability. A distal fracture with spread of

the hematoma into the carpal tunnel may present as an acute carpal tunnel syndrome with associated median nerve sensory and motor dysfunction. Note wrist swelling and ecchymosis, and test two-point discrimination of the fingers (normally <5 to 7 mm) and test motor strength of the thumb abductors.

    • Usual radiographic evaluation. AP and lateral radiographs that include the entire forearm including the elbow and wrist are the minimum required. Splinted postreduction films are obtained to confirm reduction, and inspection of the DRUJ for involvement should be repeated. Rarely, a CT scan to evaluate a complex, comminuted intra-articular fracture is necessary.
    • Typical management. In children, most diaphyseal and wrist fractures can be managed with closed reduction and long-arm posterior splinting. Unstable growth-plate fractures or midshaft fractures may require operative reduction and fixation. In adults, shaft fractures that involve both bones are almost always surgically treated after initial closed reduction and splinting. Isolated radius and ulna fractures can be treated nonoperatively if they are minimally displaced. Wrist fractures require additional fixation if they are unstable, are inadequately reduced, or have displaced intra-articular fragments.
    • Pitfalls and pearls. An acute carpal tunnel syndrome requires urgent surgical release and will often be missed if not looked for specifically. Closed reduction of wrist factures can be greatly aided by hematoma blocks (see Section VII.B) and the use of finger traps. Watch for development of compartment syndrome in shaft fractures. Be vigilant to detect radial head dislocations associated with ulna fractures (Monteggia injury) and DRUJ disruption with radius fractures (Galeazzi injury).

D. Wrist and hand

  • Fractures
    • Typical presentation: a fall onto an outstretched hand or a crushing injury.
    • Typical physical signs. A scaphoid fracture is the most common of the carpal fractures and presents with local swelling, pain with wrist motion, and focal tenderness in the “anatomic snuffbox.” Metacarpal fractures present with swelling and bruising, often with flexion of the distal fragment causing the knuckle to be less prominent; the most common is the distal fifth metacarpal or so-called “boxer's” fracture. Check for rotational deformity by observing for finger divergence with flexion of the metacarpal phalangeal joints and comparing to the contralateral side. Distal phalanx fractures are often seen in the setting of nail-bed injuries.
    • Usual radiographic evaluation. Obtain AP and lateral radiographs of involved areas. Oblique views can be useful in evaluating the carpal bones.
    • Typical management. Nondisplaced scaphoid fractures are treated in a thumb spica splint. Fractures with greater than 1 mm of displacement are at risk of nonunion and avascular necrosis and benefit from internal fixation. Metacarpal fractures are reduced and splinted in a thumb spica or ulnar gutter splint, reexamining for rotational malalignment. Prefabricated aluminum splints are generally adequate for phalanx fractures. Intra-articular fractures and unstable or inadequately reduced fractures often require pinning or internal fixation.
    • Pitfalls and pearls. Scaphoid fractures are at risk of nonunion and/or avascular necrosis, especially with fractures of the proximal pole. It is critical to adequately immobilize even suspected fractures to minimize this risk. Metacarpal fractures generally heal reliably, but rotational malalignment is poorly tolerated.

  • Dislocations
    • Typical mechanism. Lunate and perilunate dislocations usually occur after forced wrist hyperextension. Fracture dislocations can occur at any metacarpal or interphalangeal joint but are most common at the base of the first and fifth metacarpals, occurring with forced hyperabduction.
    • Typical physical signs. Perilunate dislocations present with pain, limited wrist motion, tenderness, and possibly signs of median neuropathy caused

by compression of the median nerve in the carpal tunnel by the displaced lunate. Carpometacarpal dislocations are rare and difficult to diagnose clinically because of considerable swelling. Interphalangeal dislocations result in an obvious deformity.

    • Usual radiographic evaluation. AP and lateral views of involved joints are the minimum required. Oblique views aid in evaluating the position of displaced carpal bones. Scaphoid, capitate, and radial styloid fractures should be ruled out as associated injuries with lunate dislocations. Close examination of the carpal bones and their articulations will reveal an otherwise difficult-to-make diagnosis.
    • Typical management. Perilunate dislocations are reduced using axial traction and hyperextension of the wrist while pressure is applied to the lunate. These usually require surgical treatment with stabilization of associated fractures and disrupted intercarpal ligaments. Most other hand dislocations are reduced with longitudinal traction and splinted in a “safe” position (see Section VII.A.2.d). Irreducible and unstable dislocations may require open reduction to remove interposed soft tissue or to treat associated bony or ligamentous injury.
    • Pitfalls and pearls. Perilunate dislocations can be difficult to diagnose, and care is required to avoid missing such injuries. Any derangement in the position and orientation of the carpal bones should prompt further evaluation. Observe closely for signs of acute carpal tunnel syndrome. Avoid splinting the wrist in a flexed position because this increases risk of median nerve compression. Metacarpal-phalangeal joints should be splinted in flexion to avoid joint contractures.

  • Soft-tissue injury
    • Subungual hematomas are decompressed by burning a hole in the nail with electrocautery or with a large-bore needle after a digital block.
    • Nail-bed injuries require removal of the overlying nail with repair of the nail bed using absorbable suture and splinting open of the nail fold with sterile Vaseline-impregnated gauze or with the Betadine-soaked nail.
    • Tip amputations involving only soft tissue can often be allowed to heal by secondary intent or, if the area is greater than 1 cm2, treated with local flaps. Exposed bone is resected back to a level that allows soft tissue coverage.

E. Pelvic fractures

  • Typical mechanism. Pelvic fractures in the young are typically of very high energy, as from a motor vehicle collision or a fall from a height. In the elderly, low-energy falls from a standing height often cause pubic ramii fractures.
  • Typical physical signs. Crepitus, pelvic instability, or pain with iliac wing compression or distraction should alert the examiner to possible pelvic ring injury. Inspect for soft-tissue injury including a degloving injury. Rectal and vaginal examinations are performed to check for blood, open communication with a fracture, or a high-riding prostate. Blood at the urethral meatus at time of catheterization is a sign of lower urogenital injury. Pelvic bleeding may result in a loss of 2 to 3 L of blood or more, and signs of hypovolemic shock must be monitored along with aggressive fluid replacement. High-energy pelvic fractures rarely occur in isolation, and significant associated injuries are likely. Palpate for spinal tenderness or step-offs, and treat all patients initially with spinal precautions. A thorough primary and secondary survey must be undertaken and documented.
  • Usual radiographic evaluation. An AP pelvis view is part of the standard trauma panel. The use of an abdominal-pelvic CT scan is becoming standard part of the trauma workup and is extremely useful in evaluating pelvic, sacral, and lumbar spine fractures. An L5 transverse process fracture suggests posterior pelvic ligamentous disruption. Once stabilized, pelvic ring fractures are further evaluated with pelvic inlet and outlet views. If genitourinary injury is suspected, a retrograde urethrogram and cystogram should be obtained. Other standard radiographs such as chest and c-spine films should be reviewed.
  • Typical management

    • The initial treatment consists of adherence to standard trauma ABCs. Maintenance of adequate intravascular volume and systolic blood pressure is essential in the hemodynamically unstable patient. In the persistently unstable patient, sources of bleeding other than the pelvis should be ruled out followed by emergent fixation of the pelvic ring in the emergency department, usually with a linen sheet tied around the pelvis or with a specialized pelvic binder to reduce pelvic volume until an anterior pelvic external fixation can be applied. Angiogram and embolization of bleeding pelvic vessels may precede or follow operative placement of provisional external fixation. If the patient is hemodynamically and otherwise stable, surgical intervention can be delayed to allow complete assessment of associated injuries and resuscitation of the patient.
    • Fractures involving non–weight-bearing regions (e.g., pelvic rami) or those without pelvic ring disruptions are treated symptomatically with graduated weight bearing. Fractures in weight-bearing areas require protection from weight-bearing and possible surgical fixation. Sacral fractures and sacroiliac joint disruptions can often be treated with percutaneous screws. Unstable fractures may require external fixation while awaiting definitive surgical stabilization.

  • Pitfalls and pearls. Associated injuries (abdominal, pelvic, spinal, head, etc.) occur commonly with high-energy pelvic injuries and are the source of significant morbidity and mortality and should not be missed. An open pelvic fracture has a very high morbidity, and a diverting colostomy should be considered. Pelvic binders that remain in place for more than several hours must be often re-evaluated to rule out associated pressure necrosis of the skin. Because binders can cause increased patient discomfort and skin breakdown, they should be removed if patients remain hemodynamically stable or the fracture pattern does not allow decreased pelvic volume with lateral compression. Patients are at high risk of developing a deep venous thrombosis (DVT) in association with these injuries, and appropriate prophylaxis should be initiated.

F. Hip and femur

  • Fractures of the hip and femur (acetabular fractures, femoral neck fractures, peritrochanteric hip fractures)
    • Typical mechanism. Acetabular and femoral shaft fractures, like pelvic fractures, are generally the result of high-energy trauma. “Hip” fractures (femoral neck and peritrochanteric fractures) are commonly the result of low-energy falls or direct blows in the elderly, but in the young they are generally a result of more significant trauma. A stress fracture of the femoral neck typically presents as groin or medial thigh pain associated temporally with a recent increase in activity level or training.
    • Typical physical signs. Shortening of the limb may be seen in addition to pain with motion and the inability to bear weight. Rotational stability is typically lost with shaft and displaced hip fractures, with the leg falling into a shortened, externally rotated posture. A sciatic palsy is possible with a posterior acetabular dislocation that can occur with a fracture. A high index of suspicion must be maintained in the elderly after a low-energy fall presenting with complaints of groin or medial thigh pain (site of referred pain from the hip joint) because these may be the only signs of a nondisplaced hip fracture.
    • Usual radiographic evaluation. With regard to the hip, an AP pelvis view and hip films (AP and lateral views) are usually diagnostic. For acetabular fractures, oblique views of the pelvis (Judet views) are obtained in addition to a fine-sliced spiral CT scan. These are very useful in evaluating the fracture. Shaft fractures of the femur are evaluated with orthogonal views showing both the hip and knee. An ipsilateral femoral neck fracture must be excluded in patients with femoral shaft fracture. The femoral neck can easily be evaluated on a trauma pelvic CT if available. If history suggests a hip fracture in the elderly or a stress fracture in the young but no fracture is seen, magnetic

resonance imaging (MRI) or bone scan is indicated to rule out the occult fracture.

    • Typical management

      • Skeletal traction may be indicated for fractures of the acetabulum, depending on the size and location of the fracture and presence of an associated dislocation (see also Section V.F.2). Fractures involving the weight-bearing portion of the acetabulum are usually treated with surgical reduction and fixation.
      • Displaced femoral neck fractures in the young require urgent anatomic reduction and internal fixation to reduce the risk of avascular necrosis, whereas stress fractures are treated with protected weight bearing. In the elderly, surgical treatment is generally the rule for hip fractures. Stable femoral neck fractures are usually treated with internal fixation (most commonly, percutaneous screws) and unstable femoral neck fractures with hip arthroplasty (hemi- or total hip arthroplasty). Peritrochanteric fractures are treated with a variety of internal fixation methods, including the use of compression screw and plate or intramedulary nail. The utility of skin traction to increase patient comfort prior to surgery is controversial.
      • Femoral shaft fractures need initial long-leg splinting and occasionally skeletal traction to increase comfort and stability while maintaining length and protecting the soft tissues (traction splints placed by emergency personnel should be promptly removed at time of initial evaluation). Even closed femur fractures can be a source of significant blood loss, and appropriate blood replacement, especially in the multiply injured patient, is important. Serial exams for compartment syndrome should be performed. Most shaft fractures are treated with intramedullary nailing soon after the injury to allow early mobilization and decrease the risk of additional complications. In the unstable, multiply injured patient, external fixation may be the initial treatment of choice to minimize adverse systemic effects caused by the additional trauma of surgery.

    • Pitfalls and pearls. Any fracture can be sufficiently distracting to preclude the identification of additional injuries, and so secondary surveys and adequate radiographic examinations are critical. Pulmonary and other complications are decreased with early femoral shaft fracture treatment. Fat embolism can occur after any long-bone fracture and may be exacerbated with intramedullary nailing of such fractures; increased O2 requirements, dyspnea, and tachycardia are early signs. Arterial blood gas examination may show decreased O2 tension, whereas chest x-ray will show patchy infiltrates and an electrocardiogram may show inverted T waves, right-bundle-branch block, and depressed ST segments. Treat fat embolism with supportive measures including fluid resuscitation, appropriate respiratory support and close observation. Serial exams will prevent missing a developing compartment syndrome. DVTs are common after pelvic and leg bone fractures, so prophylaxis (mechanical with or without chemical) is essential. In the elderly with a hip fracture, no more than 10 lb of skin traction (Buck's) should be used, and skin breakdown or sloughing can occur. If traction causes discomfort, then it should be discontinued.

  • Dislocation (hip)
    • Typical mechanism: high-energy motor vehicle crash, often associated with acetabular fracture. In patients with previous hip replacement, dislocation is typically atraumatic, caused primarily by exceeding positioning precautions given after hip replacement.
    • Typical physical signs. Anterior dislocations typically leave the extremity abducted and externally rotated. Posterior dislocations cause greater shortening with an adducted and internally rotated posture. Sciatic nerve function should be assessed for palsy with posterior dislocations (the peroneal division is most commonly affected).
    • Usual radiographic evaluation. Obtain appropriate pelvic films to evaluate for acetabular, femoral head, or hip fracture (see previous section) and to determine the direction of dislocation (requires adequate lateral view). In hip replacement, check for component positioning, loosening, or periprosthetic fractures.
    • Typical management. Immediate closed reduction, operatively if unsuccessful, to reduce risk of avascular necrosis should be done. Stable range of motion and postreduction neurologic exam are necessary. Skeletal traction is indicated when the hip remains unstable. Postreduction radiographs, including AP, lateral, and Judet views, are needed to confirm reduction and assess for associated fractures. Associated fractures are stabilized surgically. Patients with dislocated hip arthroplasties can usually be reduced closed and benefit from abduction bracing.
    • Pitfalls and pearls. Time to reduction is critical. Closed reduction prior to obtaining additional imaging of the pelvis should be done. After reduction of posterior dislocations (most common), keep legs abducted with an abduction pillow, brace, or equivalent. Traumatic dislocations of native hips (without arthroplasty) typically reduce with longitudinal traction. The typical reduction maneuver for dislocated total hip arthroplasties includes in-line traction with hip flexion, internal rotation, and adduction. Most failed attempts at closed reduction are due to inadequate sedation and muscle relaxation, which are essential. Persistent failure of closed reduction can be caused by buttonholing of a prosthetic head through the capsule or fractured or displaced acetabular liners. In the case of fracture dislocations, incarcerated fracture fragments can commonly prevent concentric reduction.

G. Knee and tibia

  • Fractures (supracondylar femur, patellar, tibial plateau and shaft)
    • Typical mechanism: can be low energy in the elderly, generally higher energy in younger patients. Motor vehicle collision, fall from a height, direct blow, and pedestrian versus car are all common. Patella fractures are commonly caused by falling onto the knee or striking a dashboard. Spiral fractures of the tibia are caused by twisting injury.
    • Typical physical signs: deformity and swelling about the knee with loss of rotational stability. Patella fractures often have a palpable defect and have an associated inability to perform a straight-leg raise. The subcutaneous location of the tibia predisposes to open fractures. Observation and probing lacerations and skin defects for communication to underlying bone or fracture are necessary. Check nerve function and the presence of pulses and foot perfusion compared to the contralateral side. Plateau and tibial shaft fracture are particularly at risk for compartment syndrome and should be monitored appropriately (see Section VI.B).
    • Usual radiographic evaluation. Four views of the knee (AP, lateral, and two obliques) help to identify fractures involving the knee. Traction views taken with gentle longitudinal traction for comminuted and displaced periarticular fractures may be necessary to understand the fracture pattern. A CT scan may be helpful for preoperative planning for complex tibial plateau fractures. Tibial shaft fractures require an AP and lateral of the tibia and views of the knee and ankle. Diminished perfusion persistent after reduction should prompt an arteriogram.
    • Typical management

      • Displaced supracondylar femur fractures are treated operatively with open reduction internal fixation or with retrograde intramedullary nailing.
      • Patella fractures with displacement, joint incongruity, or loss of knee extension require reduction and surgical fixation. Nondisplaced fractures can be treated with a knee immobilizer and weight bearing as tolerated.
      • Tibial plateau fractures are treated with splinting and early motion if they are nondisplaced and stable but require reduction and internal fixation for articular incongruity, significant displacement, deformity, or

instability. Most plateau fractures associated with significant soft tissue swelling or compartment syndrome are treated with a temporary, spanning external fixator across the knee followed by open reduction internal fixation (ORIF) or circular external fixation as definitive management. Stable tibial shaft fractures can be treated with casting; however, most are treated with intramedulary nailing to allow early weight bearing and motion. Open tibial shaft fractures often require multiple surgical débridements and soft-tissue coverage.

    • Pitfalls and pearls. Be vigilant to detect a developing compartment syndrome. Strict elevation above the level of the heart is invaluable in managing such swelling.

  • Dislocations (patella and knee)
    • Typical mechanism. Patella dislocations are usually lateral and occur with a twisting force while in extension, often during sports. Most spontaneously reduce. Knee dislocations are very high energy injuries and require multiple ligamentous disruption to occur.
    • Typical physical exam. Patella dislocations cause a hemarthrosis, increased lateral translation of the patella while in extension, and tenderness to palpation about the patella and the femoral medial epicondyle. Knee dislocations present with deformity, shortening, ligamentous instability, and often signs of significant neurovascular compromise. Check side-to-side differences in pulse examination serially.
    • Usual radiographic evaluation. For suspected patellar fracture, AP, lateral, and merchant views should suffice. Look for associated fractures with knee dislocations with four views of the knee after reduction. Angiography is often performed with knee dislocations (see later comments). Obtain an MRI of the knee in the subacute setting to evaluate the associated ligamentous injuries.
    • Typical management. Most patella dislocations are treated nonoperatively unless recurrent instability ensues. A patella-centralizing brace may be used. Knee dislocations require immediate, emergent reduction. The incidence of concomitant vascular injury is approximately 30%, and pedal pulse examination has a low sensitivity (79%) for detecting significant vascular injury and a very low threshold for arteriography; a vascular surgery consultation is mandatory. If vascular repair is necessary, a spanning external fixator can be placed to stabilize the knee. After any vascular repair, prophylactic fasciotomy should be considered. Often, delayed ligamentous reconstruction is necessary to restore knee stability.
    • Pitfalls and pearls. Knee dislocations that spontaneously reduce are easier to miss. An exam demonstrating multiligamentous instability in the setting of significant trauma should be treated as a knee dislocation. As with other high-energy traumas, do not miss a developing compartment syndrome.

  • Soft-tissue injuries
    • Quadriceps and patellar tendon ruptures are caused by violent contraction or excessive stretch. Palpable defects and a high-riding (with patella tendon rupture) or low-riding (with quadriceps rupture) patella on physical exam or lateral radiographs are hallmarks. Partial tears that do not affect the integrity of the extensor mechanism can be managed without surgery with protected motion. Injuries affecting the extensor mechanism require surgical repair.
    • Knee ligament disruption is commonly seen with sports injuries involving a pivoting injury or a bending moment. A hemarthrosis is common. Physical exam demonstrates joint instability with testing. Common ligamentous injuries include anterior cruciate (ACL) and medial collateral ligaments.
    • Meniscal tears are more common than ligamentous injury and often occur in association with them. They present with a joint effusion, pain with deep flexion, and joint line tenderness. Rarely, a displaced segment can cause locking of the knee joint. Meniscal tears can be treated nonoperatively or, if symptoms persist, with arthroscopic débridement or repair.

H. Distal tibia and ankle

  • Fractures
    • Typical mechanism. Distal tibial intraarticular fractures (pilon fractures) are associated with an axial loading mechanism such as falls from a height or floor board injury from a motor vehicle accident. Ankle fractures are commonly caused by a twisting mechanism.
    • Typical physical exam. Note deformity and instability of the lower leg and ankle joint. Perform and document a neurovascular exam. Note soft-tissue injury, which is often significant with pilon injuries, including location of fracture blisters and whether blood filled (marker of deeper injury). With ankle fractures, note the precise location of tenderness and swelling.
    • Usual radiographic exam. Obtain three views of the ankle (AP, lateral, and mortise) for both pilon and ankle fractures. Foot films are used to evaluate for concomitant talus, calcaneous, or other foot fractures associated with high-energy pilon fractures. With ankle fractures of questionable joint stability, obtain a stress mortise view by stabilizing the distal tibia and externally rotating the patient's foot and look for widening of greater than 2 mm of the medial joint space. Comparison views to the uninjured ankle can be helpful. Traction views and a postreduction CT of pilon fractures help with fracture characterization and surgical planning.
    • Typical management
      • Pilon fractures with significant shortening, comminution, or soft-tissue injury are best managed initially with closed reduction and placement of a spanning external fixator. External fixation is then maintained until the soft tissues can tolerate a formal open procedure.
      • Stable, nondisplaced fractures of the ankle can be treated with immobilization and protected weight bearing. Unstable fractures (one with both medial and lateral injuries) and fractures with joint subluxation benefit from open reduction and internal fixation. All fractures should be reduced at presentation under adequate anesthesia (see Section VII.B) with postreduction radiographs demonstrating adequate joint and fracture reduction.

    • Pitfalls and pearls. Soft-tissue management is critical in the presence of these injuries, especially pilon fractures. If adequate joint reduction cannot be achieved or maintained, early surgical treatment is indicated to prevent further joint damage.

  • Dislocations (ankle)
    • Typical mechanism. Simple (not associated with fracture) ankle dislocations are uncommon. Fracture dislocations are caused by similar, but higher-energy, mechanisms as those in other ankle fractures.
    • Typical physical exam. Look for deformity and pain with inability to bear weight. Dislocations are often associated with open fractures about the ankle. Document a neurovascular exam because significant soft-tissue injury and deformity place neurovascular structures at risk.
    • Usual radiographic examination: same as for ankle fractures.
    • Typical management: urgent closed reduction under adequate anesthesia. Open injuries should be treated appropriately (see Section VI.C). Dislocations represent unstable injuries, and associated fractures are treated surgically. As with pilon fractures, spanning external fixation may be an appropriate initial treatment.
    • Pitfalls and pearls: similar to fractures.

  • Soft-tissue injuries
    • Ankle sprains are commonly caused by inversion or eversion of the foot. Patients present with swelling, ecchymosis, and maximal tenderness along the injured ligaments medially or laterally. Radiographs are normal or reveal insignificant cortical avulsions. Initial treatment based on the RICE principle (see Section IV.A) is usually adequate, followed by physical therapy for proprioceptive training to reduce the risk of reinjury.
    • A ruptured Achilles tendon usually occurs during running, jumping, or vigorous activity, with sudden pain and difficulty in walking. Examination can reveal a palpable defect, weak plantar flexion, and (if a complete rupture) no passive ankle plantar flexion on squeezing the patient's calf (positive Thompson sign). Nonoperative treatment in a splint with the ankle plantar flexed is associated with higher rerupture rates than surgical management.

I. Foot

  • Fractures (talus, calcaneous, metatarsal, and toe)
    • Typical mechanism. Calcaneous fractures are the most common tarsal fracture and are usually the result of an axillary load such as a fall from height, often in a young laborer. Talus fractures (the second most common) are also generally higher energy (motor vehicle collision or falls) and are usually caused by forced dorsiflexion (e.g., slamming on the brake at the time of impact). Metatarsal fractures can be seen with lower-energy trauma. Stress fractures can occur in runners or others who have recently increased their distance or activity.
    • Typical physical exam. Calcaneal fractures are associated with considerable swelling and blister formation, heel widening, and significant tenderness and ecchymosis extending to the arch. Associated fractures are common and include those seen with an axial loading mechanism. Talus fractures can also present with significant swelling, and when they are associated with a dislocation of the tibiotalar joint and/or the subtalar joint, a significant deformity can be present. A careful neurologic exam should be performed and followed. Stress fractures may present only with tenderness to palpation at the level of the injury.
    • Usual radiographic examination. Obtain three views each of the ankle and the foot. A Harris view evaluates the calcaneal width and profiles the subtalar joint. A CT scan is usually obtained with displaced calcaneal fractures and often with talus fractures to evaluate the myriad of articular surfaces of the tibiotalar and subtalar joints, which are difficult properly to evaluate with plain radiographs. Obtain lumbar spine films to evaluate for associated fracture. Metatarsal stress fractures, if suspected and not apparent on initial radiographs, may be seen on MRI or bone scan.
    • Typical management
      • Calcaneal fractures should be placed in a well-padded splint and observed for compartment syndrome. Significant subtalar joint depression and comminution may require open reduction with internal fixation once soft-tissue swelling allows. Regardless of treatment, outcomes are often disappointing and result in significant disability.
      • Talus fractures can be treated with cast immobilization if they are absolutely nondisplaced, but most talar neck fractures are treated with ORIF to decrease the risk of nonunion and avascular necrosis.
      • Metatarsal fractures can generally be treated nonoperatively with splinting. First metatarsal fractures may be treated operatively if displaced. Transverse fractures of the proximal fifth metatarsal diaphysis (Jones fracture), due to being in a vascular watershed region, are prone to healing complications and require more aggressive treatment than other metatarsal fractures, including either strict non-weight bearing with cast immobilization or surgery. An avulsion of the base of the fifth metatarsal, the so-called “pseudo-Jones fracture,” can be treated with early weight bearing.
      • Toe injuries are best treated by “buddy taping” to the adjacent digit and giving the patient a hard-soled shoe for more comfortable ambulation.

    • Pitfalls and pearls. The diabetic foot requires special attention and care. Because of neuropathic changes, casts and splints must be well padded and adapted to any deformity of the foot. Typically, foot and ankle fractures in the diabetic require twice the normal period of immobilization. A hot, swollen foot in a diabetic patient should be examined radiographically for neuropathic

fractures (the Charcot foot) and immobilized. This should be differentiated from cellulitis and infection with laboratory tests, although they can occur simultaneously.

  • Dislocations (talar, LisFranc)
    • Typical mechanism. The level of energy is similar to that for calcaneal and talar fractures. Talar dislocation occurs with forced foot inversion. LisFranc injuries are disruptions of the tarsal-metatarsal joints by either dislocation or fracture dislocation and are caused by a bending or twisting force through the midfoot.
    • Typical physical exam. With talar dislocations, there is often significant deformity. Dislocation of the talar body can commonly impinge on adjacent neurovascular structures and can be entrapped by tendons. Neurovascular compromise is possible and must be identified and treated emergently. Fracture-dislocations of the tarsometatarsal joint (LisFranc) are associated with significant swelling and midfoot tenderness. Both injuries can have associated compartment syndrome of the foot.
    • Usual radiographic evaluation. With a talus dislocation, obtain views of both the ankle and the foot. If it is associated with a fracture, perform imaging as noted previously. LisFranc fractures are diagnosed radiographically by incongruity of the tarsometatarsal joints, most commonly between the medial base of the second metatarsal and the medial edge of the middle cuneiform, which normally are collinear. A CT scan may be useful if a significant fracture component is present.
    • Typical management
      • Talar dislocations are treated with emergent reduction to decrease the risk of avascular necrosis, neurovascular injury, and skin compromise. Soft-tissue interposition can prevent closed reduction, in which case open reduction is required. Associated fractures must be anatomically reduced and stabilized as described previously.
      • LisFranc injuries are splinted, iced, and elevated in preparation for eventual operative reduction and fixation. An attempt at closed reduction should be made to help decrease soft-tissue swelling.

    • Pitfalls and pearls: Concerns are similar to those for fractures.

VI. Other Orthopedic Conditions
A. Infection
Infection must be considered in any patient with localized findings (pain, redness, swelling, warmth) or systemic findings (fever, malaise, and tachycardia). Acute infections often respond to medical treatment with appropriate antibiotic therapy (cellulitis) and surgical decompression (abscess, septic bursitis).
  • Septic arthritis usually occurs in association with immunosuppression, systemic infection, preexisting joint disease, previous joint surgery, or intravenous drug abuse. It is of special concern in patients with joint replacements.
    • Examination reveals tenderness, effusion, increased warmth, and pain with motion. Laboratory tests may demonstrate an elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and/or white blood cell (WBC) count. Diagnosis is confirmed by needle aspiration and laboratory analysis of synovial fluid for cell count and differential, Gram stain, routine aerobic and anaerobic cultures, and crystal analysis. Baseline radiographs are obtained at the time of presentation (note that significant changes occur late, after 7 to 10 days).
    • Treatment with broad-spectrum intravenous antibiotics (usually vancomycin, with or without gentamicin) should be initiated after adequate joint fluid specimens are obtained. If septic arthritis is diagnosed, some means of joint lavage should be performed (serial aspirations, arthroscopic or open débridement) to prevent progressive cartilage degradation and further systemic illness.

  • Osteomyelitis. Childhood osteomyelitis most commonly results from hematogenous spread of bacteria to the metaphysis. Adult osteomyelitis typically occurs from direct inoculation via surgery, an open fracture, or chronic soft-tissue

ulceration. Hematogenous spread may occur in cases of intravenous drug abuse, sickle cell disease, and immunosuppression.

    • Physical examination findings are similar to those in septic arthritis, if located about a joint, but may also reveal bony tenderness and drainage. Assess the soft tissues about the region. Examine for infective sources.
    • Appropriate imaging studies start with plain radiographs of the area. Bone scan, MRI, or tagged WBC scan may be useful to confirm the diagnosis. Laboratory examination includes ESR, CRP, peripheral WBC count, and blood cultures.
    • Treatment typically involves an extended course of empiric intravenous antibiotics (guided by cultures if available). Response to treatment is gauged clinically and with ESR and CRP. If response is inadequate, bone biopsy can be done to obtain further cultures for sensitivities. Débridement of the infected bone is sometimes required. Associated septic arthritis is treated as outlined previously.

  • Suppurative flexor tenosynovitis. Patients present with tenderness along the flexor sheath, the finger held in a semiflexed position, pain with finger extension, and fusiform swelling of the entire finger (Kanavel signs). Look for associated skin wounds (may appear quite innocuous). The patient's entire hand must also be examined because infection can extend into other spaces. Immediate surgical decompression, irrigation, and débridement are indicated in addition to initiation of intravenous antibiotics.
  • Abscess
    • Hand. Numerous potential spaces exist that can become infected. All present with pain, erythema, tense swelling, induration, and tenderness to palpation. Systemic signs of infection may or may not be present. Immediate surgical drainage is required.
    • Olecranon and prepatellar bursa can become infected and present with pain, redness, heat and fluctuance, often with a zone of cellulitis. Treatment is decompression and packing in addition to a course of oral antibiotics. A significant cellulitis may necessitate a brief course of intravenous antibiotics.
    • Others. Infection in the soft tissue may occur anywhere and presents with pain, tenderness, swelling, fluctuation, and induration. Fluid collections are often readily localized with large-bore needle aspiration. Surgical decompression can often be performed in the emergency department at presentation or nonurgently (unless clinically septic) in the operating room under anesthesia.

B. Compartment syndrome
Compartment syndrome is characterized by an increase in tissue pressure within a closed osteofascial space sufficient to compromise microcirculation, leading to irreversible damage to tissues within that compartment, including muscle and nerves. This can cause nerve dysfunction and muscle loss, which in turn can progress to rhabdomyolysis and acute renal failure. The end result can be a chronically wasted, contracted, paralytic extremity.
  • Location. Although it occurs most frequently in the anterior, lateral, or posterior compartments of the leg or the volar or dorsal compartments of the forearm, it can also occur about the elbow or in the thigh, hand, or foot.
  • Causes. Long-bone fracture, crush, or vascular injuries are common risk factors. Increased capillary permeability secondary to postischemic swelling, trauma, or burns may also contribute to compartment syndrome. Muscle hypertrophy, tight dressings, and pneumatic antishock garments (e.g., military antishock trousers) are less common causes.
  • Examination

    • Based on injury and physical findings, patients at risk for compartment syndrome should be identified early and examined frequently. The five “P's” are classically used to aide in diagnosis: Pain out of proportion to the injury, particularly an increasing and disproportionate narcotic demand and unexpectedly poor response to appropriate pain medication, and pain with passive motion of involved muscles or tendons traversing the involved compartment are relatively early signs. Paresthesias in the distribution of the

peripheral nerves traversing the involved compartment occur at an intermediate time. Paralysis, pallor, and pulselessness are late signs and likely indicate irreversible soft-tissue injury. If pulses are altered or absent, major arterial occlusion rather than compartment syndrome should be considered in the diagnosis.

    • In the awake patient, compartment syndrome is a clinical diagnosis. However, when the clinical picture and physical examination are sufficiently uncertain or in the unresponsive patient, compartment pressures should be measured. Multiple measurements should be taken in different locations. Comparison to uninvolved compartments may be helpful.

  • Treatment. Circumferential bandages, splints, or casts should be removed. Extremities should be elevated to above the level of the heart. Excessive elevation can be counterproductive. If the clinical picture deteriorates or physical examination worsens, then fasciotomy should be performed. Generally, if clinical suspicion warrants the measurement of compartment pressure, a fasciotomy is likely indicated. For pressures within 30 mm Hg of the diastolic blood pressure with equivocal clinical examination, fasciotomy is in order.

C. Open fractures and joints
Lacerations or wounds near fractures or joints can communicate and should be carefully evaluated. If exposed bone is not evident, wounds should be probed to determine whether communication to fracture is present. Joints may be distended with sterile saline to check for extravasation from adjacent wounds, but this method is associated with poor sensitivity. Air in the joint on x-ray and fat droplets in blood from the wound also confirm communication with a joint or fracture, respectively.

  • Treatment. Assess wounds, irrigate grossly contaminated wounds with normal saline, apply moist saline-soaked dressing, reduce the fracture or joint, and splint the extremity. Administer tetanus prophylaxis and intravenous antibiotics based on fracture severity. Type I open fractures, defined as having a skin opening less than 1 cm, require a first-generation cephalosporin. With type II and III injuries (skin opening >1 cm and significant soft-tissue stripping from bone), an aminoglycoside should be added. Farm injuries require administration of penicillin to cover for Clostridium perfringens.
  • Gunshot injuries

    • It is helpful to identify the weapon caliber and type. High-energy injuries (shotgun, rifle, or high-caliber (.357 or.44) handguns may require operative débridement secondary to severe soft-tissue or bony damage. With lower-energy injuries (most handguns, .22 rifles), débridement is generally not needed because less damage occurs.
    • Neurovascular status should be checked closely and followed in high-energy injuries. Deficits are usually due to concussive injury and not laceration, but developing deficits are a sign of compartment syndrome. Obtain radiographs to assess for bony involvement. If the wound is near a joint with concern for intra-articular involvement, aspirate to check for hemarthrosis and sterilely distend the joint capsule with saline, looking for extravasation from the wound. If the injury is not fresh, the track may have sealed and give a false-negative exam.
    • Treatment. Clean the skin, débride the wound edges, and irrigate thoroughly. Apply a dressing and splint the extremity if a fracture is found. If no neurovascular compromise or compartment syndrome exists, isolated soft-tissue injury is treated with local wound care with or without oral antibiotics.

  • Traumatic amputation. A team approach is needed to evaluate for possible reimplantation, and all necessary consultants should be contacted early.
    • Management. The proximal stump is cleaned, and a compressive dressing is applied. Tourniquets are not used. Amputated parts are wrapped in moist gauze, placed in a bag, and cooled by placing on ice (must avoid freezing damage). The amputated part can be sent to the operating room before the patient for preparation. Reimplantation is most likely to be successful with a sharp amputation and not likely possible with crush injuries or other injuries

with a wide zone of injury. Timing is of the essence, and a rapid and efficient evaluation is critical.
VII. Practical Procedures
A. Common splints and casts
Splints and casts stabilize bones and joints and limit further soft-tissue injury and swelling and help to minimize pain. They also facilitate further clinical and radiographic evaluation. Splints are not circumferential as cast are, and so splints allow for swelling better than casts but are less durable. Air splints are used only in the emergency setting because they increase pressure in the extremity and can compromise blood flow.

  • Preparation and application. Prefabricated splints and immobilizers can be used if available. Plaster splints consist of plaster and cast padding. The required length to include a joint above and below the injury is measured from the uninjured side. Two layers of soft roll are applied against the skin, and extra padding is placed over bony prominences. A ten-layer-thick stack of plaster splint material is wetted in cold to lukewarm water and squeezed until damp. Hot water should be avoided because increased water temperature leads to a decreased setting time and an increased setting temperature that can lead to burns. The splint is applied over the soft-roll padding and wrapped lightly with an elastic bandage. The extremity is held in the appropriate position (without making indentations that can lead to skin breakdown) until the plaster is firm.
  • Upper-extremity splints. Removal of all of the patient's jewelry is mandatory.
    • Commercial shoulder immobilizers, Velpeau dressing, and sling and swathe are used for shoulder dislocations, humerus fractures, and some elbow fractures. A pad is placed in the axilla to prevent skin maceration.
    • Figure-of-eight slings can be used for clavicle fracture stabilization but are often poorly tolerated by adults and offer little advantage over slings for these injuries.
    • Posterior and sugar tong splints are used in elbow, forearm, and wrist injuries. They are applied with the patient's elbow flexed to not greater than 90 degrees, the wrist in neutral to slight extension, and forearm in neutral rotation.
    • Thumb spica, ulnar/radial gutter, and volar/dorsal forearm splints are used for forearm, hand, and wrist injuries. Finger injuries may be treated with prefabricated aluminum splint material. For wrist and hand injuries, immobilization is performed with the patient's hand and wrist in a so-called safe position: the wrist in 20 to 30 degrees of extension, the metacarpophalangeal joints in 70 to 80 degrees of flexion, and the interphalangeal joints extended.

  • Lower-extremity splints
    • Thomas/Hare traction splints are used by primary responders for femur fractures. Traction is applied by an ankle hitch, with counter traction across the ischial tuberosity. The splint should not be left in place for longer than 2 hours because sloughing of the skin can occur around the ankle and groin.
    • A Jones dressing with or without plaster reinforcements is used in acute knee, ankle, calcaneous, and tibial pilon fractures or any other foot or lower leg injury where considerable swelling is expected. The injured extremity is wrapped with cotton, followed by a lightly wrapped elastic bandage. Plaster splints can be applied to the posterior, medial, and lateral aspects for added stability. Circumferential plaster should be avoided.
    • Short leg splints are used in acute leg or foot trauma. They extend from below the knee to the toes and include posterior, medial, and lateral plaster slabs. Posterior slabs alone are inadequate. The ankle should be immobilized in the neutral position.

  • Precautions. Bony prominences should be padded. Casts or circumferential splints are avoided in acute trauma when swelling is anticipated.

B. Anesthesia for fracture and joint reduction

  • Local anesthesia. Appropriate sterile technique must be used.
    • Digital nerve block: The digital nerves of the fingers or toes can be blocked by infiltrating 2 to 5 mL of lidocaine with or without the addition of a longer-acting agent (such as bupivacaine) into the web spaces adjacent to the injured digit ensuring infiltration to the palmar or plantar skin. Ring blocks are needed for the thumb and great toes and involve circumferential subcutaneous infiltration about the digit. Epinephrine-containing products are contraindicated in digits.
    • Hematoma block involves direct injection of lidocaine into a fracture site and is especially effective with fractures of the distal radius. A 21-gauge needle is inserted into the fracture site through the dorsal forearm. Aspiration of blood confirms the appropriate position of the needle in the fracture site. Approximately 8 to 10 mL of 1% of lidocaine without epinephrine is then infiltrated. A hematoma block in conjunction with light sedation often provides excellent analgesia and relaxation for reduction.
    • Intra-articular injection is used to provide analgesia for reduction of intraarticular fractures and dislocations. Under sterile conditions, the joint is entered with a needle with verification of placement by aspiration of blood (in the case of fracture) and the easy flow of the anesthetic from the syringe. The ankle may be entered anteriorly adjacent to either malleolus, and the elbow laterally in the triangle formed by the lateral epicondyle, radial head, and olecranon. Finally, the shoulder is entered either anteriorly 1 cm lateral to the coracoid process or posteriorly 2 cm distal and 2 cm medial to the posterolateral edge of the acromion aiming toward the corocoid.

  • Sedation. For safety reasons, the person performing a reduction cannot be in charge of the sedation and its monitoring. Midazolam (Versed) and fentanyl are administered intravenously slowly over 2 to 5 minutes to achieve easily arousable sedation and pain control (usually a total of 2 to 5 mg midazolam is needed). Close observation of respiratory status and monitoring with a pulse oximeter are required. Midazolam sedation is readily reversed with flumazenil (Romazicon) and fentanyl with naloxone hydrochloride (Narcan). Patients are generally monitored for 60 minutes after manipulation.

C. Technique for reduction of fracture or dislocation (see also specific injury sections)

  • Dislocation. After adequate analgesia and sedation as noted, longitudinal traction of the affected extremity (avoiding sudden, forceful movements) is applied. Start gently and progress with increasing force until reduction is achieved. The dislocated fragment is manipulated by applying pressure in the direction of reduction. Gentle rotation, flexion, or extension may help but is performed cautiously because long-bone fracture may occur. Great care should be taken in the elderly to avoid fracture.
  • Fracture. Traction is applied first in the direction of the angulation (recreating the injury to release the impaction of the bony ends) and then in-line with the long axis of the limb to correct the alignment, rotation, and length. Pressure is applied to the distal fragment in the direction of the reduced position. Postreduction x-rays are obtained in all cases, and the joint or extremity is immobilized in the reduced position.

Submit "34 Orthopedic Injuries" to Digg Submit "34 Orthopedic Injuries" to del.icio.us Submit "34 Orthopedic Injuries" to StumbleUpon Submit "34 Orthopedic Injuries" to Google Submit "34 Orthopedic Injuries" to Facebook Submit "34 Orthopedic Injuries" to Twitter Submit "34 Orthopedic Injuries" to MySpace

Tags: None Sửa Tags
Chuyên mục
Washington M.of Surgery

Bình luận

# Đăng bình luận qua Facebook