Orthopedic Surgery

  1. Clubfoot Talipes equinovarus *mettarsus adductus, equinus-plantar flexion, varus-supination *1:1000 *50% bilateral *20% have DDH *affected foor and calf always smaller *rx: pneti casting/ surg
    • DDH Developmental dysplasia of hip *spectrum of abnorm of the hip joint, ranging from shallowness of the acetabulum, to capsular laxity and instability, to frank dislocation *1:1000 *risk: firstborn, female, breech, ligamentous laxity, FH *clunks-ortolani-relocates dislocated hip *Barlow- dislocates a subluxatiion *doesn’t casue disability, but Tx will prevent early arthritis
    • DDH workup &Tx When exam is equivocal *US at 2-4 wks *Xray- 4-6 mo *6 mo-pavlik harness *6 mo-1yr- traction and casting *1 yr-18mo= gray sone *>18mo surgery
    • Traumatic Fracture patterns in kids are diff than those in adults *keep in mind: child abuse, esp in kids under walking age *growth plait is weakes structure *children tend to fracture rather than sprain ligaments *salter-harris classification-most widely used for growth plate fractures *bc of ongoing growth, children can remodel deformity
    • Neoplastic Benign, malignant, metastatic
    • Infectious More prone to infection of bones-osteomyelitis- and joints-septic arthritis- than adults bc of anatomy and immature bones a jts
    • Neuromuscular Cerebral palsy, myelomengingocele, dystrophies, multfactorial eti *multidisc tx
  2. Shoulder Ball and socket, scapula *4 problems: stiffness, strength, stability, smoothness
    • Rotatory cuff 4 msucles in coordinated mvmts *supraspinatus, infraspinatus, teres minor, subscapularis
    • Radio shoulder Antpost, axiallar lateral
    • Shoulder injuries Instability- younger, athlete *RCT- older, degerative
    • Should maintenance Flexibility, strength-after have full ROM, pendulum-ROM,
    • Injury care Acute and conservative *MOST will get better w a simple, approo program *stretch, time, rest, anti-inflamm, progressive *rehab is KEY
    • Elbow Hinge joint, three bones-humerous, ulna, radius (ulnar nerve) *4S’s- stiffness, strength, stability, smoothness *forearm rotation-supination=palm up *AP and lateral radiograph
  3. ACL 1/3000, 70% in sport *women at greater risk *2 bundles-antmed, postlat *branches of meiddle geniculate artery *tibial-ant and btw intracondylare eminance *femoral-post medal aspect of lateral fem condyle *restraint to ant translation of the tibia, secondary streain to tibial rotation and varus/valgus stress *mech: flow energy-direc contact, indirect non contal OR high energy
    • ACL triad ACL injury, MCL injury, lateral meniscus tear *rapid onset of knee effusion *acute hemarthoriss:paterlla instab, PCL injury, meniscal tears, fracture, popliteus avulsion, osteochondral injuries
    • ACL exam Medial and lateral jt lines-may elicit pain the presence of concomitant meniscal injury, patella borderal, medial and lateral coll lig *laxity testing-lachman, ant drawer, pivot shift
    • ACL Tx Prevent further injury and forestall progression of post-traumatic osteoarthritis, return fct *non-op: hamstring strengthening, modification of activities, fctl brace, older sed pt, higher failure in active population *operative:grafts-hamstring, patellar, quad tendong, allograft
    • Stress fractures Partial of complete fracture from repetitive application of a stress *cyclic stress elicits remodeling response-ground reaction, joint reaction, muscle forces *microdamage in bone- bone modeling activated
    • Stress fracture clinical Diffuse, dull pain-worse w training, better w rest, as injury progresses, on et of pain is quicker and time to relief in longer *pts report chg in activity level *+/- swelling, tenderness *passive and active ROM usu painless *imaging: radiographs, CT, MRI, bone scintigraphy
    • Stress fracture Tx Rest, avoidance, bracing *surgery only for fractures that don’t improve w conservative mgmt
  4. Anatomy foot & ankle Forefoor-tarsometatarkat, lis franc jt *midfoot- transverse tarsal jt, chopart jt *hindfoot
    • Physical exam foot and ankle Observe pt waling *limp patterns: antalgic gain, steppage gait *observe standing *seated0 deformity, varicositiy, chronic venous stasis, hair, edema, atrophy *ROM- dorsifelcion, plantar flextion, subtalar jt (inversion and eversion) *midfoot-supination and pronation *X ray- AP, oblique, lateral, mortise=internally rotate up *CT-fine detail of bone, articular surgace *MRI- fine detail of tendons, ligaments, cartilage, bone marrow, nerve, vessels
    • Intra-art injury Cause IREVdamage to articular surgace→ post traumatic arthritis
    • Pilon fracture Dial tibia/fibular fracture *high energy→ORIF
    • Talar neck fracture Poor vascular supply= risk of SVN
    • Calcaneous fracture Lumbar spine fractures common
    • Arthrodesis Eliminates motion of arthritic joint *intended for pain relief/NOT normal *more stress on adjacent joint⇒ compensatory arthritis over time
    • Ankle sprains Lateral ankle ligaments most commonly torn= ATFL/ joint capsule swelling +/- CFL *xray to rule out fracture *RICE (90% resolve)
    • Congenital Clubfoot, charcot-marie-tooth dz, polio, cerebral palsy, peroneal tears
    • Charcot-marie-tooth Hereditary motor sensory neuropathy *progressive muscular atrophy, onset in 1st and 2nd decades of life *auto dom, lumbar spine, hands, feet *cavovarus/ clawtoe deformities *unopposed pull of intact tendons muscles→ deformity *Tx: neutralizine braces to maintain plantigrade feet, if unbracealbe-surgery
    • Hallux valgus Shoe wearing-wester workl *hereditary component *surgery-depends on pain and cosmetics
    • Neuropathic wounds DM, RA, carcot marie tooth, idiopathic peripheral neuropathy, SCI, periphn injury *take 1 hr to develop wound *off loading, shoe modification, debridment, amputation
  5. Total joint inda OA, RA, post-traumatic, AVN, congenital/developmental derformity *NEED: pain,disability, failure of non-surgical tx
    • Cement fixation PMMA *mech interlock of methymethacrylate to interstices of bone-static *if microfractures in cement occur w cyclic loading, cemen doesn’t remodel, prothesis will eventually loosen
    • Cementless Biologic fixation-dynamic *lower rate of loosening *when microfracure occurs, bone can remodel forming potentiall life liong bond *press fit technique
    • Hip resurfacing Not less invasive, bigger incision, more difficult, higher complication rate, no improvement in long term results, does preserve bone for a future hip replacement
    • Bearing surface Metal head on plastic liner, metal on metal, ceramic on ceramic, ceramic on plastic
    • UHMWPE High MW *particulate debris→ osteolyis *high yield strength, high wear resist, ghih impact resistance
    • Ceramic Dec wear *fracture risk, audible squeaking, expensive
    • Metal on metal Dec wear, larger head0dec dislocation *metal allergy, not for women of child bearing age, not in kidney pts, remote site metal despostion
    • Complication Early-infection, VTE, medical, dislocation, neovasc injury, malpositioning *late- wear, pain, stiffness, infection, periprosthetic fracture, component loosening
    • Activity after Recommend- cycling stationary, golf, walking, swim, tennis doubles, dancing, shooting, croquet *in moderation- cycling road, hiking, horseback riding, crosscounrty skiing, tennis singles, low impact aerobics, roller skating, weight lifting, rowing *no- baseball, football, hockey, gymnastics, jogging, soccer, squash, volleyball, basketball, ice skating, skiing, aerobics, etc
  6. Sprain Ligament tear
    • Varus Distal aspect angling toward the midline
    • Lagus Distal aspect angling away from midline
    • Trauma ortho More complex fractures esp pelves, acetabulum, non unions, malunions, infection
    • Open fracture Laceration communicating w fracture
    • Xrays Taken at 90 deg, xray to include joint above and below fracture *angulation, displacement, fracture pattern, bone involved
    • Transverse Produced by a distracting or tensile force *rare
    • Spiral Produced a torsional force
    • Bending wedge Or butterfly *pure bending
    • Comminuted Broken in many pieces-high energy w combined forces
    • Displacement % of bone contact on either view
    • Angulation Distal fragment relative to prox-varus, valgus, ant, post *apex of angle formed by gragments- ant, post, medial, lateral
    • Location Described in thirds *if at two levels=segmental *shaft, metaphysis, intra-articular
    • ATLS Airway, breath, circ, disability, expose entire pt *primary and secondary survey *ortho in second
    • Emergent skeletal issues Hemorrhage control from pelvis fracture w labile flood press-close pelvic vol, from open freacture-direct press *restore pulses by realigned fractures and dislocation
    • Urgen skeletal issue Irrigation and debridement of open fracture, reduction of dislocation, splinting fractures, fixation of femur fractures, addressing compartment syn
    • Compartment synd Inc press w a closed anatomical compartment w a potentioal to cause irrev damage to the content of the compartment *eti- burn, high press injection, trauma, iatrogenic *clinical dx-intense pain or with press measurements *6p’s: pressure, pain-out of proportion, paresthesias, paralysis, pallor, poikilothermia later *pulseless=not char *gluteal, thigh, calf, foot, hand, forearm, arm
    • CS tX Must decompress all compartments at risk *skin, fat, fascia, widely decompressed, debridement of necrotic tissue
    • Fracture fixation Delayed until pts is stable *femur fracture has priority-fat embolus *goals is to stabilized skeleton to allow mobilixatoin *casts and splints *traction-pts who are too sick for surgery *external fixation-open gracture or pelvis fracture, temp stabilization *open reduction and internal fixation- useful for joint fracture *intramedullar nails-tibia and femur fractures, used in selected humerus and forearm fractures *joint replacement-displaced femoral neck fractures in geriatrics, allow for early ambulation, geriatrics w shoulder and elbow communitcated fracture
Card Set
Orthopedic Surgery
Key words and concepts for M2 orthopedics lectures at UNMC