42 -- Orthopedic Principles

7/29/2019 42 -- Orthopedic Principles

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ED APPROACH TO ORTHOPEDIC TRAUMA

GENERAL APPROACH TO FRACTURES DIAGNOSIS: Hx, Px, Xrays (splint obvious fractures b/f Xrays)

REDUCTION: Increase deformity, traction, replace, MUST do post reduction Xray

IMMOBILIZATION: Non-operative (cast, splint), Operative (internal, external fixation)

REHABILITATION

CLINICAL FEATURES

History Pay particular attention to mechanism of injury MOI crucial b/c some injuries are not evident on Xray

Physical LOOK: swelling, deformity, open fracture site

FEEL: pain, tenderness, swelling (palpate well away from injury) MOVE: ROM, loss of function, crepitus NEUROVASCULAR examination

PLAIN RADIOLOGY

Obvious fractures should be splinted before Xray

Xrays do NOT r/o fracture May not appear until the # margins absorb Absorption will widen the radiolucent line and the defect will present at 7-

10d New bone beneath the fracture will accentuate the defect Treat as fracture and reXray at 7-10d if suspicions

Rule of Twos 2 views: AP + lateral (MUST have both) 2 joints: joint above and below 2 times: b/f and a/f reduction 2 sides: opposite sides esp. in children to compare growth plates

CODE of Xray Quality C...coverage (joint above and below) O...orthogonal views DE...decent exposure

ABCs of reading the Xray Alignment, Bones, Cartilage, Soft tissues, Second abnormality, Stability

Description of Fractures: O-S-T-L-A-R-D-O

O...open(simple)/closed(compound) S...site (exact anatomic location) T...type (transverse, oblique, spiral, comminuted, segmented, torus, green-

stick) L...length A...angulation (deviation from longitudinal axis; describe amount in

degrees; describe direction of apex if in midshaft and direction of distalfragment if at end)

A....intra-articular (% of joint surface involved) R....rotation (clinical examination) D....dislplacement (% of offset) O....other (impaction, avulsion, pathologic, valgus, varus)
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Definitions Pathologic: tumors, osteomalacia, Rickets, scurvy, osteogenesis

imperfecta, osteoporosis as a result of another condition (polio)

Valgus: angled away from midline Varus: angled toward midline

Fracture mimicers Nutrient artery: fine, sharply marginated, oblique course through cortex,

less radiolucent than fracture Pseudo#: soft tissue folds, overlying material, Mach effect (artifact) Avulsion (irregular, uncorticated surface, defect in adjacent bone) versus

accessory ossicle or sesamoid bones (smooth, corticated surface)

OTHER RADIOLOGY

Bone scan: TC99, osteomyelitis, fractures, tumors; fracture must be 1-2 days old(preferably 10), lacks specificity b/c will pick up inflammation

CT: good if uncertain or for description of articular surfaces MRI: soft tissues

AVOIDING ORTHOPEDIC PROBLEMS

History and MOI will predict most injuries

Normal Xrays do NOT r/o fracture

Do NOT accept inadequate films

Xray and examine joint above and below

Xray before reduction unless vascular compromise

N.V. examination essential before and after ANY manipulation

Splint while waiting Xrays and ortho

Specific discharge instructions


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CLOSED FRACTURES

GENERAL CARE Splint all fractures ASAP (prevents further injury and conversion to open # as well as

relieves pain and facilitates trnpt) Gentle traction to align limb b/f splinting if malaligned Immobilize joint above and below Do not remove splint in ER; loosen and reapply if neurovasc injury Every XR should have splint Definitive care = reduction and immobilization

NONOPERATIVE FRACTURE CARE

Most #s managed nonoperatively

Indications = NO indication for operative management

Non-displaced or minimally displaced #s: immobilization Non-articular displaced #s: closed reduction and immobilization

Methods of immobilization Plaster of Paris: most common, main use for upper extremities and below

mid thigh, slabs or circumferential cast, watch out for tight cast causing acompartment syndrome

Fiberglass: lighter, strong, water resistant, difficult to mold, expensive Traction: skin or skeletal traction, most commonly used for femur #s and

some pelvis #s (vertical shear), traction pins in distal femur, proximal tibia,olecranon, C-spine

Slings, splints, bandaging

Complications of Casts

Pressure sores (warning is pain, decreased LOC :. require Sx) Compartment syndrome from tight cast (split immediately) Joint stiffness Neuroparaxia esp w/ below knee cast pressing peroneal n. DVT from immobilization

Complications of Traction Bed confinement Pressure sores Peroneal nerve palsy when knee rests against side of splint Neurovasc str damaged by traction pins Pin infection or loosening

Discharge instructions

RICE Rest Ice Elevation: MUST be above the level of the heart Dont rest plaster on anything b/c it takes 24hrs to fully set Watch fingers and toes for excessive swelling, decreased sensation, cyanosis Follow up instructions

OPERATIVE FRACTUE CARE

Strong, stable fixation by Sx allows earlier mobilization because it limits loss of function due to


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scarring and secondary joint stiffness prevented by early mobilization

General Indications for operative treatment Anatomical reduction is reqd: intraarticular #s, prevents deformity and post-

traumatic arthritis, closed reduction rarely produces anatomical reduction Multi-traumatized Pt Immobilization is undesirable (elderly b/c of complications Failure on non-operative Tx (failure to obtain or maintain reduction) Open fractures (require debridement) Fractures known to be unstable Femur Fracture Floating Knee/Elbow Compartment syndromes or vascular injuries Pathological # secondary to bone mets: internal fixation relieves pain and allows

return to home Economics

Methods of operative treatment Internal fixation: screws, plates, wires, staples, intramedullary devices External fixation Amputaiton

Complications of operative tx Further injury Neurovascular injury Infection Bone too weak for good fixation Delay in # healing, failure of hardware, loss of stability Second operation risks when hardware is removed Refracturing of bone if hardware removed too early or if another injury occurs b/f

screws stable (6wks)

OPEN FRACTURES

INTRODUCTION

Open = Compound = communication b/w bone and outside env

Comminuted = many fragments

Limb threatening :. surgical emergency Most important management factor is prevention of infection

Infection rate rises w/i 6hrs and debridement should be done w/i this time

Bone and Soft tissue injuries are usu worse than w/ closed #s

They tend to have a great deal of periosteal striping and devascularization of bone leading todead bone which is at high risk for infection

Any fracture with a wound MUST be assumed to be an open fracture even if the wound isnot located right overtop the suspccted fracture site. Dont do the paper clip trick.

MANAGEMENT

ALL require debridement thus EMERGENT orthro consult

Treat wound and fracture simultaneously


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Thorough debridement is the MOST IMPORTANT first step

Describe wound: location, size, contamination, extent of muscle damage, neurovascular exam

Gross Debridement; pick out gross contamination only; further debridement is done in OR

Neverprobe a wound in the ER to determine if it is down to bone Attempt reduction if the bone protrudes through the skin

Apply sterile dressing and DO NOT REMOVE IT

Splint, elevate, remove constrictive clothing, jewelry

Tetanus prophylaxis and Analgesia

Keep patient NPO

Antibiotics Start ASAP after swabs obtained CLEAN: d of c is first generation cephalosporin such as cefazolin (Ancef) which

gives wide coverage including staph DIRTY: add aminoglycoside for gross contamination to cover gram -ves

(Gentamycin/Tobramycin) FARM: add Pen G if high risk of gas gangrene (C. perfringens) such as farm

injury Antibiotics never take the place of debridement

Stabilization internal/external fixation decreases mvmt thus prevents further soft tissue

damage and decreases infection rate wounds are also easier to debride, change dressings, and graft than working

around a traction device fixation allows for earlier mvmt and rehab wounds should be left open and undergo a delayed primary closure or

coverage (skin graft/flap) when it is sure that there is no infection (7/7)

COMPLICATIONS

Same as for closed fractures but more frequent b/c injuries are more severe

DISLOCATIONS

DEFINITIONS:

LUXATION=Dislocation = complete disruption of the joint so that the articular surfaces are nolonger intact

SUBLUXATION = partial disruption where a portion of the articular surface remains in contact

Defined by joint involved; in three bone joints, defined by the lesser joint involved

Should be described by the direction of the distal fragment

Fracture dislocation denotes associated fracture

Also described as open or closed

SIGNS AND SYMPTOMS

Pain

Deformity: may not be obvious (ex: posterior shoulder0

Skin disruption

Position - hip: flexed, adducted, internal rotated

Neurovasc injury: common with certain dislocations (knee and popliteal artery)

Loss of active and passive mvmt: test gentle ROM but do not force


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MANAGEMENT

General principles: the sooner the better b/c swelling and muscle spasm make reduction moredifficult with time; analgesia aids reduction; some joints cannot be reduced in ED

Vascular compromise ............reduction attempted BEFORE Xrays Otherwise .............................Xrays done BEORE reduction

Reduction accomplished by traction in the line of the deformity and then gentle manipulation

EMERGENCY...........many are limb threatening

MUST repeat Xrays after reduction to assess reduction and look for fractures

FRACTURE PRINCIPLES

BONE STRUCTURE

Matrix - mostly collagen which gives tensile strength, collagen offers NO resistance tocompression

Mineral - hydroxyapatite resists both tensile and compressive forces, stronger in compressionthan in tension

FRACTURE MECHANISM

Many fractures are on the tensile side of the bone b/c bone is more resistant to compressivethan tensile forces.

Viscoelasticity makes the RATE of application of stress a major factor in determining thefracture pattern and soft tissue injury

HIGH energy high strain, dissipation produces xplosion LOW energy low strain, produces linear fracture

DIRECT BENDING: transverse fracture, triangular fragment (wedge fragment or butterfly) maybe extruded on the compression side

BENDING + AXIAL COMPRESSION: oblique fracture

TWISTING: spiral fracture

PURE COMPRESSION: seen in cancellous bone with a thin cortical shell (metaphysis,vertebral bdies, os clacis), cortical bone is resistant, fracture b/cms more fragmented as Eincreases

TENSILE: occurs in thin cortex subject to high forces (patella, olecranon when musclecontracts while limb is flexed). Also, medial malleolus pulled off by the deltoid ligament aseversion and external rotation forces are applied to the ankle. Fractures are transverse,occurring at right angles to the tensile force and producing only 2 fragments

COMBINATIONS

FRACTURE HEALING

Healing by Callus fromation Inflammatory Phase (10% of total time): bleeding, clot formation , acute

inflammatory rxn, VD, exudation, histiocytes, mast cells Reparitive Phase (40% of time):bone ends dead and do not participate

hematoma organization, invasion of fibrovascular tissue from cambium layer ofperiosteum, endosteal bone surface, and soft tissue ----- replacement of clotw/collagen and matrix, mineralization of this forms the PRIMARY CALLUSwhich is woven bone; cartilage forms in the callus periphery which will later beconverted to bone by endochondral ossification; similar process occurs in the


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medulla until union occurs Remodelling Phase (70%): begins b/f union achieved and continues for years;

same as in normal bone: osteoclastic resorption and laying down of new bone

along the lines of force (Wolffs Law) Primary (Direct) bone healing

Contact healing occurs when surfaces are held together under conditions thatdo NOT allow mvmt (usu by plates and screws)

Occurs WITHOUT callus formation Cutting cones (heads) have osteoclasts which drill holes into long axis and are

followed by osteoblasts creating new osteons Forms new lammellar bone along the lines of force Bone remains weaker for 18mo

FRACTURE COMPLICATIONSHEALING COMPLICATIONS

Nonunion = fragments fail to unite, mechanical dysfuction and pain

Psuedoarthosis = nonunion results in a false joint

Delayed union = takes extra time to unite and may progress to nonunion

Malunion = bone heals in an undesirable position b/c the initially acceptable reductiondisplaces

Intraarticular malunion leads to post traumatic arthriits Nonarticular malunion leads to malalignment (imp in femur and tibia), loss of

mvmt, and function

INFECTIONS Open fractures are surgical emergency b/c of risk of infection

Cover wounds with sterile dressing and give IV abx ASAP

Grade I: ancef iv (add gentamycin for Grade II/III)

Usefulness of culture and sensitivity of wound doubtful

Box 42-2

HEMORRHAGE

Pelvic fracture: 1500 - 3000 ml

Femur fracture: 1000 ml

Tibia/fibular: 500 ml

Humerus: 250 ml

Radius/ulna: 200 ml

VASCULAR INJURY

Vascular examination critical

Examination may be difficult with massive swelling

Document presence of pulse AND capillary refill

Look for pallor, pulseless, polar, paresthesias, paralysis, pain

Incomplete and subclinical vascular injuries can be initially asymptomatic and undetectable

Doppler should be used if pulses are not palpable

Distal pulses may be present in 10 - 15% of significant arterial injuries

Arteriography or exploration may be necessary

Complications: thrombosis, AV fisutula, aneurysm, false aneurysm, ischemia, Volkkmans


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ischemic contracture, infarction, loss of limb, rhabdomyolysis, compartment syndrome

AVASCULAR NECROSIS

Necrosis due to poor blood supply after fracture Especially is fracture comminuted, untreated for any length of time

Risky areas Femoral head, Talus, Scaphoid, Capitate

COMPLICATIONS OF IMMOBILIZATION

Pneumonia, DVT, PE, UTI, wound infection, decubitus ulcers, muscle atrophy, stress ulcers,GI hemorrhage, psychiatric disorder,

NERVE INJURY

Neuropraxia Contusion of a nerve with disruption of ability to transmit impulses Paralysis if present is transient and sensory loss is minimal Normal function usually returns w/i weeks to months

Axonotmesis More severe crush injury to a nerve Injury to nerve fibers occurs w/i their sheaths Schwann tubes remain in continuity :. spontaneous healing is possible but slow

Neurotmesis Severing of a nerve usually requiring surgical repair Classic associations ......

Elbow injury median or ulnar nerve

Shoulder dislocation axillarySacral fracture cauda equinaAcetabular fracture sciaticHip dislocation femoralKnee dislocation tibial or peronealLateral tibial plateua peroneal

Severed nerve: all function will be absent; all sensory and motor

Less severe injuries often have preservation of function

Light touch is a good screening test

Two-point discrimination more sensitive and should be routinely done in digits (less useful inchildren, uncooperative, comatose, severe pain)

ORiain wrinkle test for sympathetic nerve function: soak digits in warm saline for 20 min will

cause the digital pulps to wrinkle through a mechanism not well understood; wrinkling denotesintact nerve function; absence is more difficult to interpret

Ninhydrin sweat test: sudomotor test for nerve funtion but not practical for emerg

FAT EMBOLISM SYNDROME

Fat globules embolize to lung and through peripheral circulation

Subclinical FES likely very common; clinical syndrome fairly uncommon

1% of long bone fractures and 5-10% of multiple trauma patients

Long bone fractures (Tibia and fibula) in young adults

Hip fractures in elderly

Symptoms 1 - 2 days after injury or surgery

Triad ofdecreased LOC, respiratory distress, petechiae


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Respiratory distress: earliest symptom, most common and severe

Decreaesed LOC: restlessness, confusion, seizure

Petechial rash from thrombocytopenia

Other: fever, tachycardia, jaundice, retinal changes, fat in urine in 50% by day3 Management supportive; no specific therapy

FRACTURE BLISTERS

Tense blister or bullae in areas of minimal skin coverage like the ankle, elbow, foot, knee

These areas contain fewer hair follicles and sweat glands to anker the skin

Occur with high underlying pressure and may be a marker for compartement syndrome

Early surgery and minimizing tissue pressure reduces the incidence

COMPLEX REGIONAL PAIN SYNDROMES

Reflex sympathetic dystrophy (RSD) and Causalgia = terms used to define pain syndromesthat sometines follow fractures, ortho surgery, and other limb ins

Many other names: Sudecks atrophy, shoulder-hand syndrome, postinfarction sclerodactyly

International association called RSD = Complex Regional Pain Syndrome type I(CRPS I) Pain syndrome after an initiating noxios event, extends beyond the distribution

of a single peripheral nerve and is usally disproportionate to the inciting event Site is most often the distal end of the affected extremity with distal to proximal

gradient Associated with edema, poor blood flow to skin, abnormal sudomotor activity,

allodyna (pain from proximal stimulus), hyperpathia (pain after mild lightpressure), or hyperalgesia

Causalgia = CRPS II Identical to RSD except that there is demonstrable peripheral nerve injury

Pathogenisis Not well known Sympathetic nervous system involved in some but not all Pathological tissue changes demonstrated in most; usually not malingering Does occur in pediatrics

Diagnosis No correlation b/w severity of initial trauma and symptom severity Early diagnosis is difficult especially with minimal trauma Earlier treatment is more effective RSD symptoms abolished with sympathetic blockers very suggestive 9 point clinical scale: 1 point if present, point if equivical ---------> RSD if > 5

Allodyna or Hyperpathia Burning sensation Edema Color or hair growth changes Sweat changes Temperature changes Xray changes (demineralization) Vasomotor or sudomotor quantitative measurement change Triple phase bone scan consistent

Treatment Controversial Sympathetic blockade, regional anesthesia, surgical sympathectomy Calcitonin, vitC, TCA, indomethacin have been tried


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COMPARTMENT SYNDROME

Introduction Defintion - pressure w/i compartment > pressure of capillary bed producing local

ischemial and may result in necrosis if not treated

6 hour limit b/f necrosis MC sites: forearm, leg Other sites: thigh, foot, buttock, shoulder, arm, hand MCC is direct trauma and fracture Closed fractures more common that open fractures

Compartment syndromes can occur in open fractures Most common location is closed fracture of the tibia but is well described in

thigh, forearm, hand, foot Can occur with soft tissue injury w/o fracture (shin splints, limb compression

while unconscious, etc) ------> one study had 30% with NO fracture (STI only) Unusual causes: lithotomy position, tuck position, spontaneous hemorrhage,

MAST trausers, excessive traction for treatment of a fracture Other causes: soft tissue injury w/o # (crush injury), post ischemic swelling

following restoration of blood flow a/f arterial repair, embolectomy, tourniquetrelease, drug OD w/ prolonged limb compprssion, extremity burns espcircumferencial escar

Etiology (Box 42-2): Increased Compartment Content

Bleeding: vascular injury, coagulopathy, anticoagulant Rx Increased capillary filtration

trauma: fracture, contusion, convulsion

excessive muscle use: excersize, seizure,eclampsia, tetany

burns: thermal, electrical

reperfusion injury: bypass, embolectomy,coronary cath, lying on limb, ergotamineingestion

intraarterial drug injection

ortho surgery

snakebites Increased capillary pressure

intensive use of muscles

venous obstruction: phlegmasia cerulea dolens

ill - fitting leg brace venous ligation

diminished serum osmolarity (nephriticsyndrome)

Decreased Compartment Volume- Closure of fascial compartments Excessive traction on fractured limb

External Pressure Cast, Dressing, Splint, Lying on limb

Miscellaneous- Infiltration, pressure transfusion, leaky dialysis cannula, muscle

hypertrophy, popliteal cyst


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Pathophysiology Tissue pressure rises, venous pressure rises, compromise of local blood flow

and hypoxia occurs Occurs at pressures that are above diastolic pressure but below arterial

pressure b/c of reduced arteriovenous gradient at the tissue level Body responds by increased blood flow to area; inflammatory mediators cause

membrane permeability, fluid leak, and increasing edema and pressure Pressure increases above capillary perfusion pressure and venous flow is

impaired Finally arterial flow is compromised ----------> ischemia and necrosis Elevation of limb may exacerbate compartment syndrome: elevation of a limb

decreases arterial pressure (0.8mmHg/cm) but venous pressure does notdecrease (because it is essentially the same as the compartement pressure) ----------> decrease in arterial - venous gradient and decrease perfusion :. level of

heart is best Vascular spasm plays a minimal role Normal compartement pressure is 0 mmHg Compartment pressures that lead to compartment sydrome vary b/w

individuals; in general, ischemia develops when compartment pressure is w/i10 - 30 mmHg of diastolic pressure

Ischemia depends on pressure AND duration Measuring compartment pressures :. are not 100% reliable

History Onset from hrs to days a/f injury Pain out of proportion to injury is KEY feature that should raise suspicion

(BEWARE OF THE WIMP - request for more anesthesia is a clue)

Pain is the first symptom; may be described as a tightness, burning, deep Obviously unreliable in decreased LOC, intoxicaiton, etc Paresthesias

Physical Findings Limited active movement (b/c of pain) Passive streching causes pain Hypesthesia and paresthesia: decreased two pt discrimination in the

distribution of the nerve running through that particular compartment Swelling and Tenderness of entire compartment Firm compartment: soft compartment extremely unlikely to be this

Absence of peripheral pulses and five Ps: VERY LATE FINDING and is a verypoor diagnostic sign; only occurs when there is irreversible ischemia, occurs

when compartment P > SBP Diagnosis

Clinical diagnosis Stryker device: hand-held digital display, must zero, must hit appropriate

compartment, pressures < 30 will generally not produce syndrome, P > 30 orw/i 30 of systolic pressure are operative indications; serial measurements ifunsure

Doppler not useful Angiography: do if suspecting any arterial injury

** MUST re-examine patient b/c it may not be present initially **** Just b/c they dont have one initially DOES NOT mean a compartment synd wont devp**


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Management

Place limb at heart level (NOT higher b/c aterial pressure will dec; venousdoesnt)

Cut casts and dressing along length; remove do not improve w/i 30-60 min Sugical decompression (complete fasciotomy) indicated for high clinical

suspicion (even w/o compartment pressure measurement)** BE AGRESSIVE - a few needless fasciotomies better than missed dx**

Complications Infection, gangrene, limb amputation Fibrosis: major local complication if untreated or delayed tx; muscle fibrosis

and joint contractures and impaired nerve function; fibrotic muscle incision,contracture release, neurolysis, tendon transfers help but do NOT return a

normal limb Crush Syndrome: large amount of ischemia/necrosis, myoglobin release,

urine turns red-brown, precipiation of myoglobin in renal tubules andACUTE RENAL FAILURE, can be fatal

SOFT TISSUE INJURIES

SPRAINS

Definitions Sprain = ligamentous injury resulting form an abnormal motion of a joint Injury to the fibers of a supporting ligament of a joint

First degree: minor tearing with resultant hemorrhage and swellin, minimalpoint tenderness, stressing produces some pain but NO opening orabnormal joint motion

Second degree: partial tear involving more fibers, moderate hemorrhageand swelling, painful motion, abnormal motion, loss of function, may betendancy toward persistent instability and recurrence

Third degree: complete disruption of ligament, more bleeding/swelling,more painful motion/abnormal motion/loss of function, stressing the joint willreveal grossly abnormal joint motion; chronic instability common

Assessment Snap or pop sound sometimes heard MOI important Xray to r/o fracture in majority of cases Examination should include stressing the joint to demonstrate abnormal

motion Avulsion fractures common with sprains

Management NSAIDs, Ice, rest, elevation Immobilization: early immobilization, reexamination at 3 days to assess

injury Complete, 3

rddegree sprains: f/u with ortho in one week

Admission for elderly who cannot ambulate safely Sprains can be significant, have long duration of recovery, have permanent

complications so dont minimize to patients


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STRAINS

Nomenclature Strain = injury to a musculotendinous unit (pulled muscle)

First degree: minor tearing, swelling, tenderness, loss of function Second degree: more fibers involved but not complete disruption Third degree: complete disruption separating muscle from muscle, muscle

from tendon, tendon from bone Avulsion fractures can occur

Assessment Pain, swelling, echymosis, tenderness Stretch force to muscle, active or passive, will reproduce pain Palpable defect sometimes present Common in overuse in those who are unfit Mechanism gives clue to injury: push off and achilles strain

Management

First degree: rest, ice, elevation, NSAIDs Second degree: similar but longer time before return to activity Third degree: ortho consult b/c some can be operatively repaired; some

managed with immobilization

TENDINITIS

Tendinitis = inflammatory condition characterized by pain at tendinous insertions into boneoccurring with overuse

More complex pathophysiology than simply oversuse

Aging, poor blood supply, decreased tensile strength, muscle weakness, muscleimbalance, poor flexibility, obesity, malalignment, training errors, improper equipment,

PMHx: DM, CRF, RA, SLE, steroids

Tendinosis may be better term for chronic conditions Calcium deposits along the tendon can result in calcific tendinitis

Pain, limited motion, tenderness, crepitus over tendon

Forced muscle strength testing against resistance should increase pain

Xrays may show avulsion, calcium deposits

Ultrasound can demonstrate tendonitis

Rest, Ice, NSAIDs followed by rehab and training

No evidence that NSAIDs alter pathophysiology of condition

Corticosteroid injection

BURSITIS

Bursitis = inflammation of the bursa that may be traumatic or infections

Olecranon, greater troch of femur, prepatellar are most common

Tenderness, swelling, warmth, erythema

Aspiration if infection suspected

Conservative tx unless infected

TREATMENT MODALITIES

SPLINTING AND BANDAGING

Splinting suspected fractures/dislocations prevents further damage, may restore blood flowto ischemic tissue by removing pressure, relieves pain by preventing movement

Prehospital


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Splint should be applied in field Commercial splints available Some avoid air splints b/c of contribution to compartment syndrome

Splint before patient is moved Severly angulated fractures should be straightened b/f they are splinteed Immobilized joint above and below, pad skin to avoid necrosis, avoid

constriction

Sling-and-Swath Bandage and Velpeau Bandage: immobilize shoulder, humerus, elbow

Clavicle splint: figure of eight has not been shown to be better than simple sling

Plaster splints: good for elbow, forearm, wrist, hand

Femur and hip Hare traction splint or similar device: apply prehospital Sager splint: more acceptable for use in the presence of pelvic # and avoids

compression on sciatic nerve

Knee

Comercial devices Jones compression dressing

Ankle: plaster splint, adhesive strapping, aircast

CASTS

Too tight: swelling, pain, coolness, change in color of distal skin parts; bivalve the cast andinspect the skin; think of compartment syndrome, infection,

THERMAL THERAPY

Cryotherapy

Vasoconstriction, limiting blood flow, decreasing hemorrhage and edeam,decreased metabolic requirement, less histamine and inflammatorymediator release

Contraindications: cold allergy, Raynauds phenomenon Relative contraindications: RA, paroxysmal cold hemoglobinuria Four stages of senstation

cold sensation for 1-3 min burning or aching sensation for 2-7 min local numbness and aneshtesia from 5-12min reflex deep vasodilation without a correspoding increase in

metabolism (similar to rewarming shock) at 12-15 min THUS: maximum of 15 min recommended, must endure the

burning/aching phase to achieve benefit Heat

Increased blood flow, metabolic demands May feel better but doesnt help acute injury

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42 -- Orthopedic Principles