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Orthopedics

Links

• Local: C-spine series, dermatomes and nerve roots, nasal fractures (ENT), rheumatology (sore shoulder), peripheral nerve exams, vasculitides
• Radiographic Anatomy of the Skeleton (Wash Radiology)
• Joint Injection (images and directions)

Describing X-Rays

• open vs. closed
• location (shaft, intra-articular)
• displacement in mm
• shortening in mm
• impaction if present
• angulation, degree and direction (midshaft - direction of apex, end - direction of terminal fragment)
• Salter classification (pedes)

Special Views

Errors

ref: Commonly Missed Orthopedic Problems AFP 1998: Anterior cruciate, slipped capital femoral epiphysis, femoral neck stress fracture, scaphoid fracture, UCL/Gamekeeper’s Thumb, achilles tendon, posterior tibial tendon rupture.

All

• neurovascular compromise: esp with dislocation of shoulder, tibiofemoral

Pediatric

• Monteggia fracture: fracture of ulna (mid) with anterior dislocation of head of radius. See loss of passive supination at the elbow. X-ray both elbow and wrist. Refer.
• Buckle fracture of distal radius: no deformity, normal passive but not active motion. Wrist ext. & forearm pro/sup -> pain. Point tenderness 1.5” proximal to the wrist. X-ray shows buckle fracture: very hard to see. Heals well, but should splint.
• spiral fracture of tibia: minimal findings, but child who is afebrile and refuses to walk and has normal joint exams. Bone scan or 45 degree oblique x-ray may show fracture. Immobilize in cast for 3-4 weeks. Child abuse considered.

Galeazzi Fracture

radius fracture with radioulnar dislocation. Wrist tender. Lateral wrist may show dorsal angulation of radius compared to ulna.

Lisfranc injury

midfoot-forefoot disruption: compartment syndrome from loss blood supply to forefoot. Massive swelling can be seen. Subtle x-ray, need comparison film to see 1st-2nd metatarsal shaft widening or proximal shift of 5th metatarsal base.
Ref: Lisfranc Injury of the Foot - July 1998 - AFP

Fractures and Related Injuries

See also Osteoporotic vertebral fracture (compression).

Common Errors

1. reliance on x-ray rather than exam.

Salter Classification (pedes)

1. separate epiphysis from metaphysis. Good prognosis. Seen most commonly in birth injury.
2. along epiphysis then out through metaphysis. Most common of all fractures, age often > 10. Reduction -> good prognosis.
3. intra-articular, from joint space through epiphyseal plate, then to periphery. Good prognosis if surgical repair or if excellent closed reduction. Usually a fracture of the distal tibial epiphysis, see Tillaux fracture.
4. intra-articular, from joint space through metaphysis. Growth arrest common, open repair.
5. compression of epiphyseal plate. Not seen on x-ray. Uncommon. Suspect if persistent pain/compression mechanism and negative film.

Facial, orbital and related

• Zygomatic arch: trismus, left periorbital swelling, usually tripod with TMJ pain
• Inferior orbit: numbness of cheek (infraorbital nerve), may have limited upward gaze
• medial orbit: blowout fracture, limitation of abduction
• basal skull: racoon eyes
• nasal fracture: beware nasal septal hematoma -> necrosis septal cartilage

Cervical Spine

See: Cervical spine series. Rx: methylprednisolone 30 mg per kg IV over 1 hour then 5.4 mg/kg per hour

Clavicle

middle third - management

• restrict shoulder motion to < 45 degrees abduction. Pt needs to tighten figure-of-8 splint regularly, use arm slign. Immobilize to no tenderness/crepitus over fracture site. Elbow ROM.
• clinical union 6-12 wk (3-6 child), x-ray 12 wk. Do final film. Avoid reinjury 2-3 months

distal third - management

• look like AC separation. May require stress films to see or even MRI (fracture through AC joint)
• Type II has AC ligs attached to distal part, proximal goes upwards. Needs referral. Immobilize.

proximal third

• 45 degree cephalic tilt
• treat with sling, heal 6-8 weeks.

Humeral head

Immobilize arm against chest for 6 weeks. Start ROM ex. at 3 weeks. If young and only piece off surgery. ALWAYS test pinch (ulnar) and sensation (median).

Elbow (pediatric)

• 67% supracondylar (axial loading with locked elbow). Posterior fat pad may be only sign.
• 17% lateral condylar: need oblique views. Suspect when lateral side elbow sore/swolllen. Growth arrest.
• always do comparison views
• order 3 views: AP, lateral, and internal oblique (supinate palm)
• line drawn down anterior surface of radius should bisect capitellum on lateral view
• capitellum ossification 1-2 yrs, radial head 3-5, olecranon 9-10
• neurovasc: pulses, hand temp, refill, nerves
• immobilize at 70° (90° may compress brachial artery)

Wrist

Inspection X-ray

• AP: radius and radial styloid, ulnar and ulnar styloid, navicular (most common fx), metacarpal base
• lateral: alignment of radius, lunate, capitate - line from radial shaft pass through middle of lunate, capitate

Scaphoid (Navicular) Fractures: fall on the outstretched hand

• most common wrist fracture
• pain, swelling, very tender snuff box
• cast/splint immobilization and repeat radiographs 2-3 weeks post-injury. If not fracture but markedly tender recheck in 3-4 weeks. If better then remove splint. (Fracture requires up to 3-4 months in cast.)

Reduction

If reduce use 8-10 ml .25% marcaine at fx site, apply trcn to medial side of thumb and finger, then restore angle. Keep up in air with splint before casting (dec. swelling). Short arm cast must end proximal to distal metacarp-phalangeal joint. Warn pt: WILL LOSE MOTION. Get AP, lateral, and oblique navicular view -- if snuff box tender splint x 2w, if still tender re x-ray, if nec. do bone scan.

Fingers and thumb

1. Mallet finger: avulsion of extensor tendon from distal phalanx. Unable to extend DIP. -- splint in extension x 6-8w. If fx metacarp-phalang immobilize in flexion.
2. Dislocation -- reduce in ER, test collateral lig. If dorsal dislocn splint bent 15 deg. & flexd for 2w. If ventrl splint straight.

UCL/Gamekeeper’s Thumb

1st MCP ulnar collateral ligament strain: forced abd and ext. Ulnar collateral ligament is on dorsal side of MCP when hand is flat on table. R/O fx, then stress test positive if 20 deg more radial (dorsal) deviation than other side.

Immobilize with Spica cast or thumb splint in 30 degree flexion for 4-6 week, with active ROM at 3-4 weeks.  If healing then can use a tape loop from thumb to index finger to prevent abduction, extension of thumb. Refer if associated fracture or large deviation on stress test.

Lisfranc (above)

Hip

Slipped Capital Femoral Epiphysis

• Slipped Capital Femoral Epiphysis - May 1 1998 - AFP and Commonly Missed Orthopedic Problems AFP 1998
• average age 12 in girls, 13.5 in boys, often bilateral, usually obese
• stable: weeks of progressive external rotation & shortening of involved leg
• unstable: extreme pain. Do not move leg.
• AP and lateral films., do frog-lateral if stable. Bilateral! On AP view compare portion of femoral head that is above a line drawn along superior femoral neck (Klein's line)

Ankle & Foot

• Jones fx is most common - proximal 5th metatarsal. High incidence non-union.
• Snowboarder's Ankle: Fracture of lateral process of talus. Rare outside snowboarding. Risk avascular necrosis. Look on mortise view distal lateral malleolus with foot internally rotated. Consider if "sprain" does not respond -> CT.

Referral Fractures/Dislocations

• Salter III or above
• clavicle: distal third
• humerus: > 1 cm displacement or rotation/angulation > 33 degrees, mid-shaft fracture especially
• radial head: Type II - large articular surface > 30% fragmented or > 3 mm displacement. If elbow dislocation high risk urgent neurovascular compromise.
• ulna: > 50% displacement nightstick fracture, unstable or not isolated
• wrist: anything but a nondisplaced nonangulated Colles fracture that can be reduced to neutral position or slight posterior inclination. Dislocation of carpal bones requires immediate orthopod exam.
• proximal phalanx, intra-articular
• scaphoid: any complicated fracture.
• femur: anything but an isolated fracture of greater trochanter
• patella: an unstable or displaced fracture that prevents patient doing a straight leg raise
• fibula: nonisolated or unstable fractures

Dislocation

Shoulder (see views)

Anterior

• hold in adduction with slight internal rotation, hollow glenoid, can palpate head along anterior axillary fold
• check axillary and muculotendinous nerves and radial pulse
• reduce: external rotation, pt. face up, elbow on bed. Abduct to 90°, gentle traction. Obtain post-reduction film

Posterior

• can't abduct the shoulder at all! Easy to miss ...

Radial Head

• pull with arm extended or hyperextended
• dislocates anteriorly, usually arm partly flexed
• bilateral x-ray and neurovascular exam first
• warn parents, will hurt for a moment
• supinate and fully flex, then gently extend, thumb on radial head
• recheck in 5 minutes for function

Finger: MCP

• proximal phalanx usually dorsal, results from forced hyperextension
• signs may require open reduction (complex dislocation):
  • MP joint only slightly hyperextended (usually is 90 deg)
  • palmar dimple (volar plate attached to palmar tissue)
  • widened joint space on x-ray (interposed tissue)
  • sesamoid bone in jt space (pathognomic, sesamoid part of volar plate)
• if simple dislocation, can reduce. Use wrist block. NO TRACTION. Flex DIP and PIP and wrist & hyperextend MP to 90 deg, maintain contact between prox phalanx and metacarpal, and push forward into place, then gently flex. Splint in mild flexion and refer for f/u.

Other Hand/Wrist Dislocation

• PIP dorsal dislocation: immobilize in gentle flexion for 2-3 weeks
• PIP volar dislocation middle phalanx: check no boutonniere deformity (avulsion extensor from base of middle phalanx) Some hand surgeons will do primary repair immediately.
• lunate is most frequently dislocated hand bone, 2nd most common fx.

Patella (lateral dislocation)

• ref: Functional Treatment of Patellar Dislocation in an Athletic Population ($)
• medial dislocation: contact orthopedics
• lateral occurs when foot planted, bearing wt, knee flexed, valgus, and externally rotated.
• confirm by displace patella laterally with knee flexed 30 deg, tenderness medial retinaculum
• r/o coexistent ACL tear
• x-ray AP, lateral, tunnel of involved knee, Merchant view both knees
• arthrocentesis if large blood or knee persistently displaced

traditional mgt

• initial immobilization. Used to be immobilized for 7 weeks, newer protocols do earlier rehab.
• surgery for atheletes.

early rehab (non-surgical)

• ice for 48 hours
• immediate straight leg raises, knee sleeve with lateral padding
• 3-8 weeks of quadriceps rehab
• 2/3 with initial subluxation good results at 2 years with conservative mgt. Results worse in women, esp if bilateral laxity.

Back pain (and similar hip/bursa pains)

Diagnosis

• ask for history of CA, infection, prostate symptoms
• buttock and leg pain: if internal rotation of the hip is preserved significant DJD hip is ruled out. (int. rotn. is 1st to go; sx of groin pain.).
• trochanteric bursitis: a treatable cause of pain referred to the back, groin or hip. Worse with standing, better sitting.
• L5 lesion: weak extension of the great toe, loss of ankle jerk. L4: loss of knee jerk, pain down shin, pain on ext. of hip. L3: loss of knee jerk, pain to knee.

meds

• flexeril 10 mg po tid (cntrl musc. rel. very similar to tricyclic adps.) or valium 2 or 5 mg tid.
• fiorinal 1-2 po q4h (325 mg asa + butalbitol [a barbiturate!] + caffeine), #3 (+30 mg codeine).
  • * - parafon forte 250-500 mg tid-qid. A sedative "muscle relaxant". NO tylenol.
• motrin 400-600 mg tid-qid
• cochicine, both IV and PO, has been used for severe back pain. There are few references, but it gets a "B" grade in back pain guidelines. Mechanism unknown.

Knee Injury

ref: Ottawa Rules

Hx and Exam

• Lachman test for ACL injury: Flex 15-30 deg., femur still, pull tibia anterior, feel for solid thud of ligmt. If incr. motion, no thud, then torn.
• acute swollen knee
  • bleeding into joint --> POP and swelling within 3 hours. ACL ruptured (women most vulnerable). Lachman (Flex 15-30 deg., femur still, pull tibia anterior, feel for solid thud of ligmt. If incr. motion, no thud, then torn.) pos; but usually cannot do well when knee swollen. Need reconstruct -- do any time. Aspirate for pain control prn. D/DX fracture, patellar dislcn (pain on latrl motion patella). "Segund" fracture: avulsion lateral aspect proximal tibia
  • meniscal tear --> slow modest effusion with diffuse tenderness. "POP" + slow swelling + inability to extend knee --> arthroscopy. Intermediate effusion with locking and medial jt line tenderness --> flap tear Rx Sx. (McMurray: knee and hip well flexed, extend and stress altrnt sides while feel area of menisci. Degree of knee extnsn at which click occurs is propt. to how far antr. tear is.)
• lateral collateral: test at 30 degrees flexion
• lots of MRIs done now, but unclear as to logic
• x-ray rules (fx): age>55, tender head fibula, isolated patellar tenderness, inability to flex to 90deg, inability to bear weight both immediately and in UC. Recheck 5-7 days if not better.

Therapy

• seven days of rehab for 1 day immobilization.
• medial collateral strain (gr 1-2): immobilize x 3 weeks?? (seems too long). If gr 1 can use BCB brace (vi) and running after 2 weeks, wear brace x 3-5 weeks. If gr 2.0 no sports until pain free. Gr. 3 (totally unstable) --> operate.
• medial meniscal tear: use McMurray test. Degree of extension of knee at which click occuis propt. to how far anterior the tear is.
• severe abuction injury: complex. Tear deep and superficial medial ligament, medical meniscus and anterior cruciate.

Hand

• see MCP Dislocation & Hand/WristDislocations

Deformities

• Mallet finger: flexion of DIP from avulsion of external tendon (splint in extension)
• Boutonniere: flexion of PIP, extension DIP from rupture central slip PIP. If suspect, splint PIP only in full extension.
• Swan neck: hyperextension of PIP with flexion of DIP from RA, old mallet or PIP volar plate injury
• Claw hand: hyperextension of MCP, flexion DIP/PIP from ulnar nerve injury

Ankle Injuries

• The Injured Ankle (AFP 1/98)
• subtalar joint does all the supination or pronation (normally), tibiofibular ligament is critical to mortice stability
• peroneal tendon (longus mostly, also brevis) is a major contributor to stability, prevents dynamic inversion
• forceful dorsiflexion or external rotation: talus separates tib-fib. Very forceful inversion: talar dome fx.
• if "pop" then more significant ligamentous damage, prior ankle sprain: more aggressive rehab
• anterior drawer useful (pull forward, backward) for severe disruption, squeeze test: squeeze mid-lower leg, see if pain referred to interosseus structures, talar tilt not useful, stress fractures rarely done
• Ottawa ankle rules (adults)  x-ray ankle if:
  • unable to bear weight both immediately and in ER
  • bone tenderness over posterior distal 3 cm of lat/mid fibula

Therapy

• early range of motion even for fairly severe injury - do the alphabet
• NSAIDs may slow healing?
• grade III injuries: today less surgery, ankle stabilize devices rather than casting such as sugar tong or heavy boot splint, refer to therapy for rehab
• nondisplaced lateral malleolus fracture (blow to malleolus): cast boot for 3 weeks.
• splint with AirCast initially then lace up stabilizer - laces should be .5-1" apart, relace after initial use (Swedo) for long term.
• range of motion: pretty immediate
• progressive exercise: swimming, exercise bike, mini-tramp, Nordic track, walking, gradual increase running, sport
• proprioception: balance on leg with eyes closed
• persistent pain, swelling months later -- talar dome fracture.
• High-ankle sprain - syndesmosis talo-fib strain: 4-6 weeks of rehab

High ankle sprains - Syndesmotic

• football injury: dorsiflexion and eversion
• tear tib/fib ligaments and interosseous membrane -> chronic instability
• squeeze test: mid-calf tib/fib compression -> pain in anterior tib/fib ligament. Other: external rotation stress test, crossed-leg test
• confirm by MRI
• treat with longterm semirigid support (plastic splint)

Fractures (associated)

5th metatarsal

• Jones fracture (proximal diaphysis of 5th metatarsal) - high likelihood of non-union. Refer.
• avulsion of peroneal brevis where it inserts in 5th metatarsal: heals very well

distal fib/talar dome fracture

• beware displacement -- needs surgery even if only a few mm laterally
• look for hidden talar dome fracture. May need MRI. Osteochondritis dessicans. Usually orth removes fragment.
• Tillaux fracture: Salter III fracture of distal tibial epiphysis
  • occurs only in adolescents during time that distal tibial epiphysis is closing; girls 12-14 and boys 15-18.

Sports Injuries

• Stress fx: very common. Need bone scan. RARE stress fx femoral neck -- prsnt as groin pain in runner early sprng trng. Pain on hip rotn. NEEDS PINNED FAST. Pars Interarticularis stress fx cause back pain (extnsn > flexn) in young dancers.
• "Dead arm syndrome": transnt loss strnth arm due sublxatn shoulder. Need refer to repair.
• Child with sore elbow: r/o osteochondritis dessicans.
• Persistent tennis elbow: r/o post. osseus nerve entrapment.
• Fx hook of hamate: usually while swinging bat/club. Need to remove broken piece.
• iliotibial band syndrome: runner with tenderness over distal lateral femoral condyle.
  • Noble compression test: Pt supine, place thumb over the lateral epicondyle, pt flex/extend -- look for maximal pain @ 30 degrees of flexion

DVT Prophylaxis (hip, knee)

Francis et al. Jama 249:3.p374: Likely no longer valid.

• coumadin 0.5-3.0 mg/qD for 10 days pre-op to keep PT 1.5-3.0 seconds over control
• coumadin increased post-op to give PT 1.5 times control (3.0-5.0 mg/qD)
  • evening after surgery
  • continue until ambulatory

Heel Pain

Causes

• plantar fascia: fasciitis (common), enthesopathies (achilles tendon calcification in overweight adolescent males)
• soft tissues: bursitis, etc
• calcaneous: stress fracture (tender on mediolateral compression), Paget's, other
• nerve: tarsal tunnel*, abductor digiti quinti muscle nerve entrapment*, S1 radiculopathy

* Tinel's sign positive - percussion of medial aspect of heel causes pain or paresthesia

Plantar fasciitis

Can be very hard to treat, if initial interventions fail (8 week trial!) refer to podiatrist or interested orthopod.

• good shoes, not barefoot walking
• heel cup (works better than it should) or heel lift
• stretching exercises of achilles tendon (tight/short tendon stresses the fascia more -- wonder if moderately heeled shoes help?)
• shoe orthotics
• steroid injection (rupture risk)

Splints, braces, and more hardware

• aircast: excellent mobile ankle splint ($35-40). USE FOR ALL ANKLE "SPRAIN".
• BCB splint: good short-term splint for medial collateral ligamentous tears. ($50)
• Bledsoe splint: post-op for anterior cruciate tears ($350-450)
• knee immobilizer: good ER measure pending eval. TEN DAY "WINDOW" FOR LIGAMENT REPAIR.
• back brace: Raney flexion jacket

Orthotic prescription - Diabetes

1. Lightweight Oxford style soft leather, high toe box, extra depth, deep inlay, arch support, relief area for distal toe, molded plastizote insert for metatarsal pad.  (@ $250.00)
2. Cotton socks. Cornstarch if will wash feet reg.
3. diabetic ankle ulcer: UNNA boot preparations good -- calamine soaked bandage wrap. Change q 5-7 days (less edema, drying)

Osteoporosis, Osteomalacia and Paget's

See Bisphosphonates Safety and Efficacy in the Treatment and Prevention of Osteoporosis - May 1, 2000 - AFP. Long term safety of the biphosphanates is unknown -- use only when indicated.

Osteoporotic vertebral fracture (compression)

• analgesics
• intranasal calcitonin said to decrease pain

Fracture prophylaxis (esp. nursing home)

• Calcium 1.2 gm daily
• Vitamin D 800 IU daily