The Bone Book. An Orthopedic Pocket Manual 9781461430902, 9781461430919

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Sumon Nandi Selvon F. St. Clair

The Bone Book An Orthopedic Pocket Manual

123

The Bone Book

Sumon Nandi • Selvon F. St. Clair

The Bone Book An Orthopedic Pocket Manual

Sumon Nandi, MD, MBA Chief of Adult Reconstruction Department of Orthopedic Surgery University of Maryland School of Medicine Baltimore, MD USA Selvon F. St. Clair, MD, PhD Orthopedic Institute of Ohio Lima, OH USA

ISBN 978-1-4614-3090-2    ISBN 978-1-4614-3091-9 (eBook) https://doi.org/10.1007/978-1-4614-3091-9 © Springer Science+Business Media, LLC, part of Springer Nature 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Science+Business Media, LLC part of Springer Nature The registered company address is: 1 New York Plaza, New York, NY 10004, U.S.A

To my residents and students, whom I have watched flourish and from whom I have learned, this book was written to ease the challenge of the steep early learning curve in orthopedics that you will surely overcome, but never forget. To my wife, who inspires and encourages me to do my very best, your love and support make everything possible. To my children, time with you is my life’s meaning and visions of your future are my hope. To my parents, this book is a monument to your sacrifice that began decades ago in a land far away and continues to this day. –Sumon Nandi This book is dedicated to my wonderful wife, Amy, and loving daughters Cyan, Kaya, and Eva: the absolute joys of my life. –Selvon F. St. Clair

Foreword

I have had the privilege of working with Dr. Sumon Nandi as a colleague and co-author. I enjoy watching, with great satisfaction, his rising star status in orthopedics. I ask you, the reader: Who better to author a book seeking to bridge the gap between senior and junior house staff and students than a rising star? A rising star retains the memory of his formative years as a young surgeon supplemented by the experience forged by time and effort. In my position as Chief of Adult Reconstruction at the Rothman Institute, I have a deep understanding of the educational challenges our students and house staff endure while caring for patients. As Deputy Editor of the Journal of the American Academy of Orthopedic Surgeons, I understand that while research is the foundation of the principles by which we care for patients, the data are often conflicted and not useful to house staff seeking an immediate and correct resolution for patients under their care. Practical information in medicine is often hard to come by quickly and concisely. The Bone Book by Sumon Nandi, MD, and Selvon St. Clair, MD, PhD, fills a glaring void in musculoskeletal education for those students and junior house staff providing orthopedic care to patients. It is a compendium of pragmatic knowledge typically passed down from the senior to junior house staff but rarely addressed in standard textbooks. Drs. Nandi and St. Clair cover essential anatomy, physical examination, and the diagnosis and treatment of vii

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Foreword

emergencies in musculoskeletal care. Preparing the patient for the operating room and the proper performance of basic procedures are also comprehensively covered. I believe that The Bone Book will be the first source that junior house staff and students will reach for when seeking an accurate solution to the issue at hand. The Bone Book should be an essential part of the library of every budding orthopedist. It supplies pearls of wisdom we all wish we had when we were on-call and were long on questions and short on answers. Drs. Nandi and St. Clair should be congratulated for providing those answers. I certainly wish I had The Bone Book when I was in that lonely position! Matthew S. Austin, MD Adult Reconstruction Division Chief Adult Reconstruction Fellowship Director Professor of Orthopedic Surgery Sidney Kimmel Medical College Rothman Institute Philadelphia, PA, USA

Contents

1 Anatomy Essentials ���������������������������������������������������������   1 Upper Extremity�������������������������������������������������������������    1 Shoulder���������������������������������������������������������������������    1 Arm ���������������������������������������������������������������������������    6 Elbow�������������������������������������������������������������������������   10 Forearm���������������������������������������������������������������������   13 Wrist���������������������������������������������������������������������������   18 Hand���������������������������������������������������������������������������   22 Lower Extremity�������������������������������������������������������������   28 Pelvis �������������������������������������������������������������������������   28 Hip�����������������������������������������������������������������������������   33 Femur�������������������������������������������������������������������������   37 Knee���������������������������������������������������������������������������   42 Lower Leg�����������������������������������������������������������������   46 Ankle�������������������������������������������������������������������������   51 Foot����������������������������������������������������������������������������   56 Spine���������������������������������������������������������������������������������   60 Cervical Spine�����������������������������������������������������������   60 Thoracic Spine�����������������������������������������������������������   65 Lumbar Spine�����������������������������������������������������������   67 Sacrum�����������������������������������������������������������������������   69 2 Physical Exam Fundamentals�����������������������������������������  71 Principles�������������������������������������������������������������������������   71 Upper Extremity�������������������������������������������������������������   73 Shoulder���������������������������������������������������������������������   73 ix

x

Contents

Elbow�������������������������������������������������������������������������   79 Hand and Wrist���������������������������������������������������������   81 Lower Extremity�������������������������������������������������������������   86 Hip and Pelvis�����������������������������������������������������������   86 Knee���������������������������������������������������������������������������   89 Foot and Ankle���������������������������������������������������������   92 Spine���������������������������������������������������������������������������   94 3 Managing the Floor ���������������������������������������������������������  99 Postoperative Check/Rounding�������������������������������������   99 Lab Abnormalities ��������������������������������������������������������� 101 4 Orthopedic Emergencies������������������������������������������������� 119 Definition�������������������������������������������������������������������������  119 Septic Joint�����������������������������������������������������������������������  119 Suppurative Flexor Tenosynovitis���������������������������������  122 Necrotizing Fasciitis �������������������������������������������������������  123 Compartment Syndrome �����������������������������������������������  125 Open Fracture�����������������������������������������������������������������  127 Cauda Equina Syndrome�����������������������������������������������  129 5 Emergency Room Consultations ����������������������������������� 133 Emergency Room Consults�������������������������������������������  133 High-Energy Trauma Patient and Fracture Management �������������������������������������������������������������������  133 Pediatric Fractures ���������������������������������������������������������  139 Dislocations���������������������������������������������������������������������  155 Spinal Cord Injury (SCI)�����������������������������������������������  161 Tendon Rupture/Laceration �����������������������������������������  163 Fingertip Amputation�����������������������������������������������������  164 Postoperative Complications�����������������������������������������  165 Other Common ER Consults:���������������������������������������  166 6 Sports Injuries������������������������������������������������������������������� 167 Team Physician Responsibilities�����������������������������������  167 Team Bag�������������������������������������������������������������������������  168 General�����������������������������������������������������������������������������  169 Upper Extremity�������������������������������������������������������������  170 Lower Extremity�������������������������������������������������������������  173 Neurologic/Spine�������������������������������������������������������������  179 Return to Play�����������������������������������������������������������������  183

Contents

xi

7 Operating Room Basics��������������������������������������������������� 185 Getting the Patient Ready���������������������������������������������  185 Getting the OR Ready���������������������������������������������������  188 Positioning, Prepping, Draping, and Sterile Technique�������������������������������������������������������������������������  189 Principles�������������������������������������������������������������������������  192 Documentation���������������������������������������������������������������  193 Medical Student/Intern Tips & Tricks���������������������������  194 8 Techniques in Orthopedics ��������������������������������������������� 195 Splinting���������������������������������������������������������������������������  195 Joint Aspiration/Injection ���������������������������������������������  212 Regional Blocks �������������������������������������������������������������  219 Index����������������������������������������������������������������������������������������� 223

Chapter 1 Anatomy Essentials

In this chapter we discuss essential orthopedic anatomy. Knowledge of anatomy is the foundation for diagnosis through physical examination and surgical approaches. Key osseous, muscular, and neurovascular structures are discussed. A workhorse surgical approach is offered for each major anatomic region.

Upper Extremity Shoulder Bones The shoulder joint is comprised of an articulation between the humeral head and glenoid, the lateral prominence of the scapula (Fig. 1.1). The coracoid process is an anterior prominence of the scapula, while the acromion is a superolateral prominence that extends from the scapular spine posteriorly. The anterior aspect of the acromion articulates with the lateral aspect of the clavicle, while the medial aspect of the clavicle articulates with the sternum.

© Springer Science+Business Media, LLC, part of Springer Nature 2020 S. Nandi, S. F. St. Clair, The Bone Book, https://doi.org/10.1007/978-1-4614-3091-9_1

1

2

Chapter 1.  Anatomy Essentials Clavicle

Acromion Scapula Coracoid process Humeral head

Manubrium of sternum

Glenoid Humerus

Figure 1.1  Bones of shoulder girdle.

Muscles The muscles of the rotator cuff include the supraspinatus, infraspinatus, subscapularis, and teres minor (Fig. 1.2). The muscles that attach to the coracoid process include the coracobrachialis, pectoralis minor, and short head of the biceps brachii. The deltoid muscle originates on the coracoid process and inserts on the humerus.

Upper Extremity Subscapularis muscle Deltoid muscle (cut) Short head Pectoralis major muscle (cut)

Pectoralis major muscle (cut)

Pectoralis minor muscle Coracobrachialis muscle Biceps brachii muscle

Bicipital aponeurosis Anterior Supraspinatus muscle

Infraspinatus muscle Teres minor muscle

Posterior

Figure 1.2  Shoulder muscles.

3

4

Chapter 1.  Anatomy Essentials

Neurovascular Structures The musculocutaneous nerve and axillary artery are medial to coracoid process. Axillary nerve is inferior to joint capsule of glenohumeral articulation (Fig. 1.3). Subclavian artery

Axillary nerve

Axillary artery Musculocutaneus nerve

Figure 1.3  Neurovascular structures of shoulder.

Upper Extremity

5

Surgical Approach Deltopectoral approach (Fig. 1.4): Superficial interval

Between deltoid laterally and pectoralis major medially. Cephalic vein lies in between and can be retracted laterally with deltoid.

Deep dissection

Retract coracobrachialis and short head of biceps (which attach to coracoid process) medially. Release subscapularis with cuff of tendon or with segment of lesser tuberosity and enter joint through joint capsule.

Deltoid muscle

Cephalic vein

Tendon of short head of biceps brachii muscle

Tendon of subscapularis muscle

Coracobrachialis muscle

Figure 1.4  Deltopectoral approach.

Shoulder joint

6

Chapter 1.  Anatomy Essentials

Arm Bones Humeral head is proximal, which articulates with glenoid to form shoulder joint (Fig. 1.5). Proximally, lesser tuberosity anteriorly and greater tuberosity superiorly and posteriorly are attachment sites for rotator cuff. Distally, lateral epicondyle is where extensors in the forearm originate. Medial epicondyle is where flexors in the forearm originate.

Head of humerus Greater tubercle Glenoid Lesser tubercle

Humerus Scapula

Lateral epicondyle Capitulum

Medial epicondyle Trochlea Anterior

Figure 1.5  Bony anatomy of the arm.

Upper Extremity

7

Muscles Biceps brachii, brachialis, and coracobrachialis flex the elbow (Fig. 1.6). Triceps brachii extends the elbow. Long head Short head

Deltoid muscle (reflected) Pectoralis major muscle (reflected) Long Biceps head brachii muscle Short head

Biceps brachii tendons (cut)

Brachialis muscle Biceps brachii tendon (cut)

Coracobrachialis muscle

Anterior

Coracobrachialis muscle Brachialis muscle (cut) Biceps brachii muscle (cut)

Deltoid muscle (cut and reflected) Triceps Lateral head brachii Long head muscle

Anconeus muscle

Figure 1.6  Arm muscles.

Lateral head of triceps brachii (cut) Medial head of triceps brachii

Posterior

Long head of triceps brachii

8

Chapter 1.  Anatomy Essentials

Neurovascular Structures Radial nerve runs posterior to the humerus, while median nerve, ulnar nerve, and brachial artery run anteromedial to the humerus (Fig. 1.7).

Brachial artery Median nerve

Ulnar nerve Radial nerve

Figure 1.7  Neurovascular structures of the arm.

Upper Extremity

9

Surgical Approach Posterior approach (allows direct visualization of radial nerve, the structure most at risk) (Fig. 1.8): Superficial interval

Between lateral head of triceps laterally and long head of triceps medially.

Deep dissection

Split the medial (deep) head of triceps in the midline down to the bone.

Lateral head of triceps Fascia over lateral head of triceps

Fascia over long head of triceps

Triceps tendon

Triceps tendon

Lateral head of triceps Radial nerve

Longhead of triceps

Long head of triceps

Long head of triceps Lateral head of triceps

Profunda brachii artery

Radial nerve

Medial (deep) head of triceps

Posterior approach

Figure 1.8  Posterior approach to the humerus.

Profunda brachii artery radial Medial (deep) head of triceps Humerus covered with periosteum

10

Chapter 1.  Anatomy Essentials

Elbow Bones Elbow joint is formed by the distal humerus articulating with radial head and proximal ulna (Fig. 1.9).

Humerus

Radial head

Radius

Figure 1.9  Bony anatomy of the elbow.

Ulna

Upper Extremity

11

Muscles Discussed in the ARM and FOREARM sections.

Neurovascular Structures The brachial artery and median nerve run anteromedially, ulnar nerve runs posterior to medial epicondyle of the humerus, and deep branch of radial nerve pierces supinator to become posterior interosseous nerve (PIN) (Fig. 1.10).

Brachial artery

Radial nerve Ulnar nerve

Median nerve

Figure 1.10  Neurovascular structures surrounding elbow.

12

Chapter 1.  Anatomy Essentials

Surgical Approach Posterolateral Approach (Fig. 1.11): Superficial interval

Between extensor carpi ulnaris anteriorly and anconeus posteriorly.

Deep dissection

Incise capsule to enter joint. Make capsular incision at, but not posterior to, longitudinal axis of radius to preserve integrity of radial collateral ligament. Avoid dissecting distal to annular ligament to prevent trauma to PIN. Common extensor origin

Fascia

Supinator

Extensor carpi ulnaris muscle

Extensor carpi ulnaris muscle

Anconeus

Radial head

Capitulum Anconeus

Anconeus

Figure 1.11  Posterolateral approach to the elbow.

Upper Extremity

13

Forearm Bones Radius and ulna are bones of the forearm. Radial head is proximal, while ulnar head is distal (Fig. 1.12).

Radial head

Radius Ulna

Ulnar head

Figure 1.12  Bony anatomy of the forearm.

Chapter 1.  Anatomy Essentials

14

Muscles The wrist and digit flexors are in volar (anterior) c­ ompartment, while the wrist and digit extensors are in dorsal (posterior) compartment (Fig. 1.13).

Humeral head of pronator teres Common flexor tendon

Pronator teres (cut)

Ulnar head of pronator teres

Flexor carpi radialis

Palmaris longus

Common flexor tendon (cut) Flexor digitorum superfecialis

Flexor carpi ulnaris Flexor pollicis longus Pronator quadratus

Superficial-Anterior

Deep-Anterior

Brachioradialis Anconeus (cut)

Extensor digiti minimi Extensor carpi ulnaris

Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum

Extensor carpi radialis longus (cut) Supinator Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis

Superficial-Posterior

Figure 1.13  Forearm muscles.

Deep-Posterior

Common flexor tendon (cut) Flexor digitorum superfecialis (cut) Flexor digitorum profundus

Upper Extremity

15

Neurovascular Structures Median, ulnar, and superficial branches of radial nerve course through the forearm. Median nerve is central, ulnar nerve is medial, and radial nerve is lateral (Fig. 1.14). Radial and ulnar arteries course through the forearm after branching off the brachial artery at the cubital fossa. Radial artery runs laterally, while ulnar artery runs medially.

Brachial artery

Radial nerve (superficial branch)

Ulnar nerve Median nerve

Radial artery Ulnar artery

Figure 1.14  Neurovascular structures of the forearm.

16

Chapter 1.  Anatomy Essentials

Surgical Approach Volar Approach to Radius (Fig. 1.15): Superficial interval

Distally, between flexor carpi radialis medially and brachioradialis laterally; proximally, between pronator teres medially and brachioradialis laterally.

Deep dissection

Distally, elevate pronator quadratus and flexor pollicis longus off radius from lateral to medial; middle third of shaft, release pronator teres and flexor digitorum superficialis from lateral to medial; and proximally, release supinator from medial to lateral.

Fascia over extensor carpi ulnaris

a Fascia over anconeus

Fascia over flexor carpi ulnairs Extensor capi ulnaris

Periosteum covering ulna

Anconeus

Ulna

Flexor carpi ulnaris

Figure 1.15  (a) Volar approach to radius and (b) approach to ulna.

Upper Extremity

b

17

Lateral antebrachial cutaneous nerve

Radial artery Brachioradialis

Flexor carpi radialis

Extensor carpi radialis longus

Pronator teres tendon

Superficial radial nerve

Brachioradialis

Radius Supinator

Supinator

Brachioradialis

Pronator quadratus

Flexor digitorum superficialis

Superficial branch of radial nerve

Flexor carpi radialis

Pronator teres Periosteal incision

Radial artery

Supinator

Flexor carpi radialis

Brachioradialis

Radius Superficial branch of radial nerve

Biceps tendon

Radial artery

Flexor carpi radialis

Figure 1.15  (continued)

Approach to Ulna: Superficial Between flexor carpi ulnaris and extensor interval carpi ulnaris. Deep dissection

Dissect subperiosteally around ulna.

18

Chapter 1.  Anatomy Essentials

Wrist Bones Mnemonic, which conveys names and relative orientation of carpal bones: Radial to ulnar, proximal row, and then distal (Fig. 1.16). MNEMONIC DISTAL

Trapezium / Trapezoid / Capitate / Hamate

RADIAL

That

They

Some

Lovers

Can’t Try

Handle Positions

Scaphoid / Lunate / Triquetrum / Pisiform

PROXIMAL

Trapezoid Trapezium

Capitate Hamate

Carpal bones

Pisiform

Scaphoid Lunate

Triquetrum

Dorsal view

Figure 1.16  Bony anatomy of the wrist.

ULNAR

Upper Extremity

19

Muscles Extensor Tendons at Wrist (Fig. 1.17): Compartment 1 Abductor pollicis longus and extensor pollicis brevis Compartment 2 Extensor carpi radialis brevis and extensor carpi radialis longus. Compartment 3 Extensor pollicis longus Compartment 4 Extensor digitorum and extensor indicis Compartment 5 Extensor digiti minimi Compartment 6 Extensor carpi ulnaris Transverse fibers of extensor expansions (hoods)

Dorsal interosseous muscles

Radial artery in anatomical snuffbox Extensor pollicis brevis Compartment 1

Compartment 2

Compartment 3

Abductor pollicis longus Extensor carpi radialis longus Extensor carpi radialis brevis Extensor pollicis longus

Figure 1.17  Extensor tendons at the wrist.

Intertendinous connections Abductor digiti minimi Extensor indicis

Compartment 4

Extensor digitorum Extensor digiti minimi

Compartment 5

Extensor carpi ulnaris

Compartment 6

Extensor retinaculum

20

Chapter 1.  Anatomy Essentials

Neurovascular Structures Radial artery courses from the volar aspect of the lateral wrist and heads dorsally across the base of the anatomical snuff box (Fig. 1.18).

Superficial branch of radial nerve Lateral branch Medial branch Extensor retinaculum Dorsal carpal branch of radial artery Extensor carpi radialis brevis tendon Extensor carpi radialis longus tendon Radial artery

1st dorsal interosseous muscle

Deep fascia (cut)

Figure 1.18  Neurovascular structures of the wrist.

Dorsal digital branches of radial nerve Scaphoid Radial artery in anatomical snuffbox Trapezium Insertion of abductor pollicis longus tendon 1st metacarpal bone Insertion of extensor pollicis brevis tendon Insertion of extensor pollicis longus tendon

Upper Extremity

21

Surgical Approach Dorsal Approach to Wrist (Fig. 1.19): Superficial interval

Between extensor digitorum communis and extensor indicis proprius.

Deep dissection

Incise joint capsule to expose carpus.

a

b

Extensor retinaculum

c

Extensor Digitorum communis

d

Dorsal radiocarpal ligament

Extensor Digitorum communis

Extensor retinaculum

Lunate

e Distal radius

Figure 1.19  Dorsal approach to the wrist.

22

Chapter 1.  Anatomy Essentials

Hand Bones Metacarpals and phalanges for the thumb (1st digit), index finger (2nd digit), long finger (3rd digit), ring finger (4th digit), and small finger (5th digit) (Fig. 1.20). Proximal, middle, and distal phalanges exist for all digits except the thumb, which does not have a middle phalanx. Ring 4th

Middle Index 3rd 2nd

Little 5th Distal Phalanges

Thumb 1st

Middle Distal Proximal

Digit

Phalanges Proximal Digit

Metacarpal

Figure 1.20  Bones of the hand.

Metacarpal

Upper Extremity

23

Muscles Intrinsic muscles of the hand are in four compartments (Fig. 1.21): Thenar compartment

Primarily responsible for thumb opposition

Adductor compartment

Contains adductor pollicis, which is responsible for thumb adduction.

Hypothenar compartment

Responsible for small finger motor function

Central compartment

Contain lumbricals (metacarpophalangeal joint flexion and interphalangeal joint extension) and interossei (Dorsal interossei ABduct digits, Palmar interossei ADduct digits).

Mnemonic

DAB and PAD

24

Chapter 1.  Anatomy Essentials

Deep transverse metacarpal ligaments

Lumbrical muscles (reflected) 1st dorsal interosseous muscle

Flexor digiti minimi muscle (cut)

Adductor pollicis muscle

Opponens digiti minimi muscle

Flexor pollicis brevis muscle

Abductor digiti minimi muscle (cut)

Abductor pollicis brevis muscle (cut) Dorsal interossei

Opponens pollicis muscle

Pisiform Flexor carpi ulnaris tendon

Flexor retinaculum (transverse carpal ligament) (reflected)

Pronator quadratus muscle

Radius Palmar view

Dorsal view

Lumbricals

Palmar interossei

Opponens digiti minimi Hypothenar

Flexor digiti minimi brevis (cut) Abductor digiti minimi (cut)

Figure 1.21  Hand muscles.

Flexor pollicis brevis (cut) Opponens pollicis Abductor pollicis brevis (cut)

Thenar

Upper Extremity

25

Neurovascular Structures Median and ulnar nerves innervate muscles of the hand, while the radial nerve provides only sensory innervation to the hand (Fig. 1.22). The radial artery supplies the deep palmar arch, while the ulnar artery supplies the superficial palmar arch.

Superificial branch of radial nerve

Median nerve Ulnar nerve

Radial artery

Ulnar artery

Figure 1.22  Neurovascular structures of the hand.

Chapter 1.  Anatomy Essentials

26

Surgical Approach Approach to Carpal Tunnel (Fig. 1.23): Superficial dissection

Skin incision along radial border of the ring finger on volar aspect of the hand extending 4 cm distally from wrist crease.

Deep dissection

Incise palmar fascia, and then transverse carpal ligament.

a

b

Palmar fascia

c

Median nerve Transverse carpal ligament

Figure 1.23  Approach to the carpal tunnel.

Upper Extremity

Approach to Flexor Tendons (Fig. 1.24): Dissection

Skin incision traversing volar aspect of digit in a zigzag pattern with angles between limbs of incision at 90° angles to one another. Elevate the skin with underlying fat to expose flexor tendon lying in its sheath.

Flexor tendon sheath

Figure 1.24  Approach to flexor tendons.

27

28

Chapter 1.  Anatomy Essentials

Lower Extremity Pelvis Bones Ilium, ischium, and pubis join at the acetabulum to form each hemi-pelvis. Left and right hemi-pelves join anteriorly at the pubic symphysis and posteriorly at the sacrum to form the pelvis (Fig. 1.25).

Ilium

Sacrum

Acetabulum Ischium

Pubic symphysis

Ilium Ischium Pubis

Figure 1.25  Bony anatomy of pelvis.

Lower Extremity

29

Muscles Gluteus maximus originates at the sacrum and ilium. Hip abductors, the gluteus medius and minimus, originate on the outer table of the ilium. Direct head of rectus femoris originates at the anterior inferior iliac spine, while reflected head of rectus femoris originates at the superior lip of the acetabulum. Hamstrings originate at the ischial tuberosity. Hip adductors originate at the adductor tubercle on the inferior pubic ramus (Fig. 1.26).

Gluteus minimus

Gluteus maximus

Obturator externus Iliopsoas (cut) Pectineus muscle (cut) Adductor brevis (cut) Adductor longus muscle (cut)

Gluteus medius (cut)

Pectineus muscle (cut) Adductor longus muscle (cut) Adductor brevis (cut) Adductor minimus Adductor magnus Gracilis muscle (cut)

Hip abductors

Hip adductors

Rectus femoris (cut)

Semitendinosus

Semimembranosus Short head of biceps femoris Long head of biceps femoris

Hamstring muscles

Figure 1.26  Pelvic musculature.

30

Chapter 1.  Anatomy Essentials

Neurovascular Structures Structures passing through greater sciatic foramen (Fig. 1.27): Piriformis is the largest structure and landmark for others passing through foramen. Superior gluteal neurovascular bundle passes superior to piriformis, while inferior gluteal neurovascular bundle passes inferior to piriformis. Additional structures passing inferior to piriformis include Posterior femoral cutaneous nerve, Nerve to quadratus femoris, Pudendal nerve, Internal pudendal vessels, Nerve to obturator internus, and Sciatic nerve. Mnemonic: Pilferers Nab PINS Structures passing through lesser sciatic foramen: Pudendal nerve, Internal pudendal vessels, Nerve to obturator internus, and Tendon of obturator internus. Mnemonic: PINT

Superior gluteal artery Superior gluteal nerve Piriformis muscle Pudendal nerve Internal pudendal artery Nerve to obturator internus

Inferior gluteal artery Inferior gluteal nerve Sciatic nerve Posterior femoral cutaneous nerve

Figure 1.27  Neurovascular structures of pelvis.

Lower Extremity

31

Surgical Approach Anterior approach to the iliac crest and sacroiliac joint (Fig. 1.28): Superficial dissection

Skin incision and subcutaneous dissection in line with iliac crest.

Deep dissection

Dissect subperiosteally along the inner table of the ilium.

a

b

Abdominal fascia Crest of ilium

Figure 1.28  (a and b) Anterior approach to the iliac crest.

Chapter 1.  Anatomy Essentials

32

c

Iliacus

Sacrum Abdominal muscles Sacroiliac joint Iliac crest Gluteus medius Inner surface of ilium

Figure 1.28  (continued)  (c) Deeper dissection to sacroiliac joint.

Lower Extremity

33

Hip Bones The hip joint is comprised of an articulation between the femoral head and the acetabulum (Fig. 1.29).

Femoral head

Figure 1.29  Bony anatomy of the hip.

Acetabulum

34

Chapter 1.  Anatomy Essentials

Muscles The primary stabilizers and source of power for the hip joint are the abductors and the gluteus medius and minimus (Fig. 1.30). Iliopsoas is the primary hip flexor, gluteus maximus is the primary hip extensor, and adductors (adductor longus, brevis, magnus, and gracilis) adduct hip.

Iliopsoas

Psoas major muscle Iliacus muscle

Adductor brevis (cut) Adductor longus (cut) Adductor magnus Gracilis (cut)

Gluteus minimus

Gluteus maximus

Gluteus medius (cut)

Figure 1.30  Hip musculature.

Lower Extremity

35

Neurovascular Structures Superior gluteal neurovascular bundle is 5 cm superior to tip of greater trochanter (Fig. 1.31). Obturator nerve passes through the obturator foramen, in close proximity to the acetabulum. Femoral neurovascular bundle is anterior to hip joint, while sciatic nerve is posterior to hip joint.

Internal iliac artery Obturator nerve Femoral artery Femoral nerve

Superior gluteal artery and nerve Inferior gluteal artery and nerve Sciatic nerve

Figure 1.31  Neurovascular structures of the hip.

36

Chapter 1.  Anatomy Essentials

Surgical Approach Posterior approach (Fig. 1.32): Superficial dissection

Split iliotibial band over greater trochanter and gluteus maximus fibers more proximally/ posteriorly.

Deep dissection

Peel short external rotators off posterior aspect of femur. Release capsule off femoral head and neck in trapezoidal fashion to enter hip joint.

a

b

Fascia lata

Vastus lateralis

c

d

Greater trochanter

Tendon of gluteus medius

Posterior joint capsule

Gluteus medius Vastus lateralis

Short external rotators

Fascia lata

Gluteus maximus

Fascia lata Gluteus maximus

Quadratus femoris

e Joint capsule Femoral head Acetabulum

Figure 1.32  Posterior approach to the hip.

Quadratus femoris Short rotators

Lower Extremity

37

Anterior approach: Superficial interval

Between sartorius and tensor fascia lata. Beware of lateral femoral cutaneous nerve and ascending branch of lateral femoral circumflex artery.

Deep interval

Between rectus femoris and gluteus medius, down to hip joint capsule.

Direct lateral approach: Superficial dissection

Split iliotibial band longitudinally over greater trochanter.

Deep dissection

Anterior 1/3 of gluteus medius and minimus proximally and anterior 1/3 of vastus lateralis distally are released in continuous sleeve off greater trochanter and hip joint capsule. Beware of superior gluteal neurovascular bundle 5 cm proximal to tip of greater trochanter.

Femur Bones Femoral head is proximal, which articulates with the acetabulum to form the hip joint (Fig. 1.33). Proximally, the greater trochanter is the insertion site of the abductors, while the lesser trochanter is the insertion site of the iliopsoas tendon. Distally, the medial and lateral condyles form the articular surfaces of the knee and are the origins of the medial and lateral collateral ligaments, respectively.

38

Chapter 1.  Anatomy Essentials

Acetabulum Femoral head Greater trochanter Femoral neck

Distal fermur

Lesser trochanter

Lateral condyle Medial condyle

Figure 1.33  Bony anatomy of femur.

Muscles Quadriceps femoris is in anterior compartment of the thigh, hamstrings are in posterior compartment of the thigh, and adductors are in medial compartment of the thigh (Fig. 1.34).

Lower Extremity

Sartorius (cut)

Rectus femoris (cut)

Vastus intermedius

Vastus lateralis

Rectus femoris (cut)

Figure 1.34  Muscles surrounding femur.

Vastus medialis

Sartorius (cut)

39

40

Chapter 1.  Anatomy Essentials

Neurovascular Structures The femoral neurovascular bundle begins anteromedially in the proximal thigh, courses medially, and then passes through the adductor canal to run in the popliteal fossa. The terminal branch of the femoral nerve that runs in the adductor canal is the saphenous nerve (Fig. 1.35).

Femoral nerve

Femoral artery

Saphenous nerve

Figure 1.35  Neurovascular structures surrounding femur.

Lower Extremity

Surgical Approach Lateral approach (Fig. 1.36): Superficial dissection

Split iliotibial band.

Deep dissection

Incise vastus lateralis fascia, retract vastus lateralis muscle belly anteriorly, and dissect down to bone.

Fascia lata

Vastus lateralis

Fascia lata Vastus lateralis

Proximal femur

Figure 1.36  Lateral approach to femur.

41

42

Chapter 1.  Anatomy Essentials

Knee Bones The distal femur, tibial plateau, and patella articulate to form the knee joint (Fig. 1.37).

Distal femur

Patella Tibial plateau

Tibia Fibula

Figure 1.37  Bony anatomy of the knee.

Lower Extremity

43

Muscles Quadriceps femoris tendon inserts onto proximal patella. Gastrocnemius muscle originates proximal to distal femoral condyles (Fig. 1.38).

Vastus medialis muscle

Vastus lateralis muscle

Rectus femoris tendon (quadriceps femoris tendon)

Anterior view of knee

Medial head of gastrocnemius

Lateral head of gastrocnemius

Posterior view of knee

Figure 1.38  Knee musculature.

44

Chapter 1.  Anatomy Essentials

Neurovascular Structures Femoral artery bifurcates at knee into anterior and posterior tibial arteries (Fig. 1.39). Sciatic nerve bifurcates at knee into common peroneal and tibial nerves.

Tibial nerve

Popliteal artery

Common peroneal nerve Anterior tibial artery

Peroneal artery

Posterior tibial artery

Figure 1.39  Neurovascular structures of the knee.

Lower Extremity

45

Surgical Approach Medial parapatellar approach (Fig. 1.40): Superficial dissection

Dissect subcutaneously to level of retinaculum

Deep dissection

Incise quadriceps tendon longitudinally immediately lateral to vastus medialis obliquus (VMO). Carry dissection distally through retinaculum just medial to patella and patellar tendon.

Quadriceps tendon

Fascia over vastus medialis Medial retinaculum

Patellar tendon

Quadriceps tendon

Vastus medialis

Articular surface of patella

Medial femoral condyle Patellar tendon

Quadriceps tendon

Infrapatellar fatpad

Lateral meniscus

Figure 1.40  Medial parapatellar approach.

Anterior cruciate ligament

Tibial plateau Patellar tendon

46

Chapter 1.  Anatomy Essentials

Lower Leg Bones The tibia is the primary load-bearing bone of the lower leg. Proximally, the tibial plateau helps form the knee joint. The fibula is posterolateral to the tibia and distally is one of the key components of the ankle joint (Fig. 1.41).

Fibular head

Fibula

Lateral malleolus

Figure 1.41  Bones of the lower leg.

Tibial plateau

Tibia

Medial malleolus

Lower Extremity

47

Muscles Anterior compartment muscles are responsible for ankle and digit dorsiflexion. Lateral compartment muscles evert the foot. Superficial posterior compartment muscles plantarflex the foot. Muscles of the deep posterior compartment flex the digits and invert the foot (Fig. 1.42).

Tibialis anterior (cut)

Tibialis anterior

Extensor digitorum longus (cut)

Extensor digitorum longus

Extensor hallucis longus

Peroneus brevis

Peroneus longus (cut)

Peroneus tertius

Anterior compartment

Anterior compartment

Lateral compartment

Plantaris Gastrocnemius (cut)

Popliteus Flexor digitorum longus

Soleus

Tibialis posterior Flexor hallucis longus

Superfecial posterior compartment

Figure 1.42  Muscles of the lower leg.

Deep posterior compartment

48

Chapter 1.  Anatomy Essentials

Neurovascular Structures Anterior tibial artery runs in anterior compartment. Posterior tibial artery branches off into peroneal artery, and both run in posterior compartment (Fig. 1.43). Tibial nerve runs in posterior compartment, deep peroneal nerve runs in anterior compartment, and superficial peroneal nerve runs in lateral compartment.

Posterior tibial artery

Anterior tibial artery

Peroneal artery

Anterior view

Figure 1.43  Neurovascular structures of the lower leg.

Lower Extremity

Tibial nerve

Common Peroneal nerve

Posterior view

Figure 1.43  (continued)

49

50

Chapter 1.  Anatomy Essentials

Surgical Approach Anterior approach to tibia (Fig. 1.44):

Fascia over tibialis anterior

Periosteum

Tibialis anterior

Figure 1.44  Anterior approach to tibia.

Tibia

Lower Extremity

51

Superficial dissection

Skin incision parallel to tibial crest and one fingerbreadth lateral to it. Dissect through subcutaneous tissues to tibialis anterior fascia laterally and periosteum overlying tibia medially.

Deep dissection

Medial border of tibia is immediately below subcutaneous tissues. Dissect subperiosteally along lateral border of tibia, and retract tibialis anterior laterally.

Ankle Bones Distal tibia, distal fibula, and talus articulate to form the ankle joint (Fig. 1.45).

Distal fibula

Distal tibia Talus

Figure 1.45  Bony anatomy of the ankle.

52

Chapter 1.  Anatomy Essentials

Muscles Peroneus longus and brevis tendons wrap around the distal fibula to insert on the base of the 1st metatarsal and base of the 5th metatarsal, respectively (Fig. 1.46). From superficial to deep, posterior tibial tendon, flexor digitorum longus tendon, posterior tibial artery, and flexor hallucis longus tendon pass deep to the medial malleolus. Mnemonic Tom, Dick, and Harry Posterior view

Peroneus brevis tendon

Flexor digitorum longus Peroneus longus tendon

Flexor hallucis longus

Posterior tibial tendon

Figure 1.46  Ankle musculature.

Lower Extremity

53

Neurovascular Structures Posterior tibial artery runs posterior to the medial malleolus (Fig. 1.47).

Flexor digitorum longus tendon

Soleus muscle inserting into calcaneal (achilles) tendon

Tibialis posterior tendon

Peroneus longus tendon

Posterior tibial artery and vein

Peroneus brevis tendon Calcaneal (achilles) tendon

Medial malleolus Tibial nerve

Lateral malleolus

Flexor hallucis longus tendon

Superior peroneal retinaculum

Flexor retinaculum Calcaneal branch of posterior tibial artery

Peroneal artery Calcaneal tuberosity

Calcaneal branches of peroneal artery

Figure 1.47  Neurovascular structures surrounding the ankle.

54

Chapter 1.  Anatomy Essentials

Surgical Approach Anterior approach to ankle (Fig. 1.48): Superficial interval

Incise extensor retinaculum medial to tibialis anterior tendon

Deep dissection

Incise capsule to enter ankle joint

Extensor retinaculum Tibialis anterior under extensor retinaculum

Tibialis anterior Distal tibia Joint capsule of ankle

Figure 1.48  Anterior approach to the ankle.

Lower Extremity

55

Approach to lateral malleolus (distal fibula) (Fig. 1.49): Superficial dissection

Incise the skin and subcutaneous tissues along longitudinal axis of fibula.

Deep dissection

Dissect subperiosteally around distal fibula.

Fascia over peroneus tertius

Fascia over peronei

Sheath over peronei

Periosteum

Lateral malleous

Figure 1.49  Approach to lateral malleolus.

Chapter 1.  Anatomy Essentials

56

I Distal Phalanges Proximal

II

Distal III

Middle IV

Phalanges

Proximal V

Forefoot

Metatarsals

Medial Cuneiforms Midfoot

Intermediate Lateral Navicular Cuboid

Talus Hindfoot Calcaneus

Figure 1.50  Bones of the foot.

Foot Bones The talus and calcaneus comprise the hindfoot; the navicular, cuboid, and cuneiforms (medial, intermediate, and lateral) comprise the midfoot; and the metatarsals and phalanges comprise the forefoot (Fig. 1.50).

Muscles The four muscle layers on the plantar aspect of the foot are responsible for flexion, adduction, and abduction of the digits and the integrity of the arch of the foot (Fig. 1.51).

Lower Extremity

57

Adductor hallucis Transverse Oblique head head

Flexor hallucis longus Lumbricals Flexor digitorum longus

Abductor hallucis Flexor digitorum brevis

Quadratus plantae

Abductor digiti minimi

Plantar -first muscle layer

Flexor hallucis brevis

Flexor digiti minimi

Plantar - second muscle layer

Plantar interossei

Plantar - fourth muscle layer

Plantar - third muscle layer

Dorsal interossei

Dorsal - fourth muscle layer

Figure 1.51  Muscles of the foot.

Neurovascular Structures On the dorsum of the foot, the femoral nerve terminates as the saphenous nerve and tibial and common peroneal nerve branches combine to form the sural nerve. On the plantar aspect of the foot, the tibial nerve terminates as the medial and lateral plantar nerves (Fig. 1.52). The anterior tibial artery terminates as the dorsal artery of the foot that runs to the space between the 1st and 2nd metatarsals.

58

Chapter 1.  Anatomy Essentials

Sural nerve Dorsalis pedis artery Lateral plantar nerve

Medial plantar nerve

Figure 1.52  Neurovascular structures surrounding the foot.

Lower Extremity

59

Surgical Approach Anterolateral approach to foot (Fig. 1.53): Superficial interval

Peroneal tendons laterally and peroneus tertius/ extensor digitorum longus medially.

Deep dissection

Release extensor digitorum brevis proximally, and retract distally to expose joint capsules.

Superior extensor retinaculum

Superficial peroneal nerve

Inferior extensor retinaculum

Interosseus membrane

Anterior inferior tibiofibular ligament

Extensor retinaculum

Tendons of extensor digitorum longus

Sinus tarsi fat pad Tendon of peroneus tertius

Distal tibia

Distal fibula

Joint capsule of ankle

Extensor digitorum brevis

Extensor retinaculum Interosseous membrane Anterior inferior tibiofibular ligament Lateral malleolus Posterior talocalcaneal joint Sinus tarsi fat pad Calcaneocuboid joint Extensor digitorum brevis

Figure 1.53  Anterolateral approach to the foot.

Extensor digitorum longus and peroneus tertius Distal tibia Dome of talus Anterior talofibular ligament Cervical ligament Talonavicular joint

60

Chapter 1.  Anatomy Essentials

Spine Cervical Spine Bones Seven vertebrae form the cervical spine (Fig. 1.54). C1, the atlas, is ring-shaped with no spinous process or body. C2, the axis, is distinguished by the presence of the dens, or odontoid process, a bony prominence extending superiorly from the body of C2 into the ring of C1. C7 has a large spinous process that can be palpated subcutaneously. Dens Superior articular facet

C2

Spinous processes

C3

Foramen transversarium

C4 Articular pillar formed by articular processes and interarticular parts (pars interarticularis)

Intervertebral foramina for spinal nerves

C5 C6

Groove for spinal nerve in transverse process

C7 Spinous process of C7 (vertebra prominens)

Zygapophyseal (facet) joints

T1

Costal facets (for 1st rib)

Superior articular surface for occipital condyle

Dens Atlas (C1) Axis (C2)

Posterior articular facet (for transverse ligament of atlas)

C3 C4

Figure 1.54  Bony anatomy of C1 articulating with C2.

Spine

61

Neurovascular Structures The vertebral artery passes through the transverse foramen of C1–C6 (Fig. 1.55). The first seven cervical nerve roots pass superior to their respective vertebral level (e.g., C5 nerve root passes above the C5 vertebral body). The 8th cervical nerve root passes between C7 and T1. a Capsule of atlantooccipital joint Posterior atlantooccipital membrane Ligamenta flava

Ligamentum nuchae

Anterior atlantooccipital membrane Atlas (C1) Body of axis (C2) Intervertebral discs (C2-3 and C3-4) Zygapophyseal joints (C4-5 and C5-6)

Spinous process of C7 vertebra (vertebra prominens)

Anterior tubercle of C6 vertebra (carotid tubercle) Vertebral artery T1 vertebra

Figure 1.55  (a, b) Neurovascular structures surrounding the cervical spine.

62

Chapter 1.  Anatomy Essentials

b Base of skull

Cervical enlargement

Lumbar enlargement

C1 C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1

Conus medullaris (termination of spinal cord) Cauda equina Filum terminale internum Termination of dural sac Filum terminale externum (coccygeal ligament)

L2 L3 L4 L5

C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12

C8 spinal nerve exits below C7 vertebra (there are 8 cervical nerves but only 7 cervical vertebrae)

L1 L2 L3 L4 L5 Sacrum S1 S2 S3 S4 S5 Coccygeal nerve Coccyx

Cervical nerves Thoracic nerves Lumbar nerves Sacral and coccygeal nerves

Figure 1.55  (continued)

C1 spinal nerve exits above C1 vertebra

Spine

63

Surgical Approach (Fig. 1.56) Anterior approach: Superficial dissection

Incise platysma and then fascia along anterior aspect of sternocleidomastoid.

Deep dissection

Bluntly enter plane between the carotid sheath and trachea/esophagus. Elevate longus coli off vertebral body.

Posterior approach: Superficial dissection

Dissect through the skin and subcutaneous tissue to the tip of spinous process.

Deep dissection

Elevate paraspinous muscles subperiosteally off spinous processes, and dissect along lamina.

Anterior approach to the cervical spine

Fascia over platysma

Deep cervical fascia

Platysma

Platysma

Deep cervical fascia over sternocleidomastoid

Sternocleidomastoid and carotid sheath

Longus coli

Prevertebral fascia overlying anterior longitudinal ligament

Prevertebral fascia, anterior longitudinal ligament Vertebral body

Longus coli

Figure 1.56  Anterior and posterior approaches to the cervical spine.

64

Chapter 1.  Anatomy Essentials Posterior approach to the cervical spine Third occipital nerve

Fascia

Ligamentum Interspinous Lamina flavum ligament

Facet joint capsules

Figure 1.56  (continued)

Spinous process

Spine

65

Thoracic Spine Bones Twelve thoracic vertebrae form the thoracic spine (Fig. 1.57). Body Vertebral foramen

Superior costal facet

Superior costal facet

Body

Superior articular process and facet Pedicle Transverse costal facet

Pedicle

Superior vertebral notch (forms lower margin of intervertebral foramen)

Transverse process

Transverse costal facet Inferior costal facet

Superior articular Spinous facet rocess

Inferior Inferior vertebral articular notch process

Lamina Vertebral canal Superior articular process and facet

7th rib T7

T8

Spinous process of T7 vertebra

T9 Transverse process of T9 vertebra

Lamina

Inferior articular process (T9) Spinous process (T9)

Figure 1.57  Bony anatomy of thoracic spine vertebrae.

Spinous process

66

Chapter 1.  Anatomy Essentials

Neurovascular Structures The thoracic nerve roots pass below the corresponding vertebral level.

Surgical Approach Posterior approach (Fig. 1.58): Superficial dissection

Dissect through skin and subcutaneous tissue to tip of spinous process.

Deep dissection

Elevate paraspinous muscles subperiosteally off spinous processes, and dissect along lamina.

Lumbodorsal fascia Lamina

Interspinous ligament Lumbodorsal fascia

Spinous process

Descending articular process

Lamina Ligamentum flavum Facet joint Mamillary process of ascending articular capsule process

Figure 1.58  Posterior approach to the thoracic spine.

Spine

67

Lumbar Spine Bones Five lumbar vertebrae form the lumbar spine (Fig. 1.59). Vertebral canal

Superior articular process

Vertebral body

Mammillary process Transverse process L3

Accessory process

Spinous process of L3 vertebra

Pars interarticularis L4

Lamina

Inferior articular process Pedicle

Superior articular process Transverse process

Vertebral body

L1

Intervertebral disc

L2

Inferior articular process

L3

Intervertebral (neural) foramen

L4

L5

Spinous process

Lamina

Articular facet for sacrum

Figure 1.59  Bony anatomy of lumbar spine vertebrae.

68

Chapter 1.  Anatomy Essentials

Neurovascular Structures The lumbar nerve roots pass below the corresponding vertebral level.

Surgical Approach Posterior approach (Fig. 1.60): Superficial dissection

Dissect through skin and subcutaneous tissue to tip of spinous process.

Deep dissection

Elevate paraspinous muscles subperiosteally off spinous processes, and dissect along lamina.

Lumbodorsal (thoracolumbar) fascia

Spinous process

Lumbodorsal Ligamentum Spinous (thoracolumbar) process flavum fascia

Inter Ligamentum spinous flavum ligament Spinous apophysis

Spinous process

Interior articulating process Transverse process

Superior Paraspinal edge of muscles lamina

Site of perforating segmental vessels

Mamillary process of ascending articular process

Lamina

Figure 1.60  Posterior approach to the lumbar spine.

Interspinous ligament

Spine

69

Sacrum Bones Five fused sacral vertebrae form the sacrum (Fig. 1.61).

Neurovascular Structures Sacral nerve roots exit through four pairs of sacral foramina. Lumbosacral articular surface Ala Promontory S1 S2 Anterior sacral foramina

S3

(S1 to S5) body of sacral vertebrae

S4 S5 Coccyx

Figure 1.61  Bony anatomy of sacrum with sacral nerve roots.

Chapter 2 Physical Exam Fundamentals

In this chapter we discuss fundamentals of the orthopedic physical examination, which are essential to accurate diagnosis and should be a part of every patient evaluation.

Definition Examination of the musculoskeletal system through inspection, palpation, manipulation, and specialized maneuvers.

Principles All musculoskeletal examinations follow the same basic sequence: 1. Inspection –– Observe the patient for gait and posture. –– Look at the affected anatomic area for the presence of erythema (=infection or hematoma), discoloration (=sequelae of direct trauma or inflammation), swelling

© Springer Science+Business Media, LLC, part of Springer Nature 2020 S. Nandi, S. F. St. Clair, The Bone Book, https://doi.org/10.1007/978-1-4614-3091-9_2

71

72

Chapter 2.  Physical Exam Fundamentals

(=joint effusion or mass), muscle wasting (=disuse atrophy or denervation), or deformity (=fracture or chronic degenerative change). 2. Palpation –– Observe the patient’s facial expressions during palpation to determine the degree of tenderness. –– Pay attention to areas of warmth or swelling (=inflammation or infection) or lumps (=benign or malignant tumor). –– Crepitus (feels like Rice Krispies underneath your hand) within a joint suggests degenerative change, while crepitus in the soft tissues suggests a gas-­producing bacterial infection as can be observed with necrotizing fasciitis (see Chapter 4: Orthopedic Emergencies). 3. Manipulation –– Range of Motion (ROM) (a) Instruct the patient to perform active movements through entire ROM. (b) When painful or limited active ROM is present, guide the patient through passive ROM. Pearl: Joint pain with small-arc (10°) ROM suggests infection or crystalline arthropathy (gout or pseudogout), whereas pain with large-arc ROM suggests mechanical source of pain. –– Motor Strength: Grade from 0 to 5 out of 5 (Table 2.1) Pearl: Isolate the joint about which you are testing strength. For example, if you are testing shoulder flexion strength, provide resistance against the patient’s arm, not forearm. If you hold the forearm, you are testing strength across two joints (shoulder and elbow) and two sets of flexors.

Upper Extremity

73

Table 2.1  Muscle strength grading scale Muscle grade Description 0/5 No active motion 1/5

Muscle contraction (twitch) without motion

2/5

Motion with gravity eliminated

3/5

Motion against gravity

4/5

Motion against gravity with some resistance

5/5

Motion against full resistance (normal strength)

4. Specialized Maneuvers –– Useful for diagnoses unique to an anatomic location (e.g., meniscal tears of the knee, shoulder instability). Pearl: Always compare to the contralateral side!

Upper Extremity Shoulder The shoulder is comprised of three joints (sternoclavicular joint, acromioclavicular joint, and glenohumeral joint) and one articulation (scapulothoracic). 1. Inspection Anterior –– Hanging shoulder and adduction or abduction of the arm, internally rotated and adducted position—Erb’s palsy (C5-6 injury) (Fig. 2.1). –– Clavicle deformity (fracture) or deltoid wasting. –– Prominent anterior shoulder contour (shoulder dislocation).

Chapter 2.  Physical Exam Fundamentals

74

Affected eyelid droops (“ptosis”)

Smaller pupil Horner syndrome

Erb’s palsy

Cervical scoliosis

Shoulder rotated forward Affected arm diminished in length and girth

“Bird-winging” of the effected scapula Lumbar scoliosis

Muscle atrophy of the affected arm “Waiter-tip” deformity of the affected wrist

Figure 2.1  Erb’s palsy.

Posterior –– Scapular asymmetry, which may indicate winging, Sprengel’s deformity, or spinal deformity. 2. Palpation Posterior –– Acromion and scapular spine. Anterior –– Acromioclavicular (AC) joint. –– Bicipital groove, best palpated with arm externally rotated. –– With arm extended, palpate rotator cuff underneath anterior acromion. 3. Manipulation Range of Motion (Normal in Parentheses) –– Abduction (180°). –– Adduction (45°). –– Extension (60°). –– Flexion (180°).

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–– Internal rotation (90°). –– External rotation (90°). –– Assess gross ROM by asking patient to reach both hands over their head. –– Test external rotation and abduction by having patient place their hand behind the head and touch the opposite scapula—Apley Scratch Test (Fig. 2.2). –– Test internal rotation and adduction by asking patient to reach across and hold opposite shoulder or reach behind back to touch inferior pole of opposite ­scapula—Apley Scratch Test (Fig. 2.2). –– Test internal and external rotation with shoulder abducted to 90° and elbow flexed to 90°. –– If patient has limited active ROM, test passive range of motion to determine if muscle weakness, infection/crystalline arthropathy (pain with small-­arc ROM), or contractures are present.

Figure 2.2  Apley scratch test.

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Motor Strength –– Supraspinatus With patient’s elbow fully extended, thumb pointed down, and arm with 90° of forward flexion and 45° of abduction, resist further forward flexion of arm with pressure applied at the ulnar aspect of the wrist. –– Subscapularis With patient’s hand on their umbilicus, ask them to push lateral aspect of the elbow anteriorly against your resistance. –– Infraspinatus and teres minor Stand in front of the patient, ask them to anchor their elbow flexed to 90° against their thorax, and instruct them to move their wrist laterally against your resistance. –– Deltoid Stand behind the patient, stabilize his/her shoulder with one hand, and ask the patient to push their elbow flexed to 90° laterally as you provide resistance. 4. Specialized Maneuvers Speed’s Test –– With patient’s elbow fully extended, forearm supinated, and arm forward flexed 60°, resist further forward flexion of patient’s arm. –– Pain suggests inflammation along the long head of the biceps tendon, or a superior glenoid labral tear at the point where the long head attaches, known as a superior labrum anterior and posterior (SLAP) lesion.

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O’Brien’s Test –– With patient’s elbow fully extended, arm forward flexed 90° and adducted 10°, resist further forward flexion of arm, first with patient’s thumb pointed down and then up. –– Pain with patient’s thumb pointed down that resolves with thumb pointed up suggests SLAP tear. Neer Impingement Sign –– Flex shoulder with thumb pointing down. –– Pain suggests rotator cuff tendonitis or subacromial impingement (picture). Hawkins Test –– With patient’s shoulder abducted 90° and elbow flexed 90°, internally rotate the shoulder. –– Pain suggests rotator cuff tendonitis or subacromial impingement. Hornblower’s Sign –– Detects tears in the posterior rotator cuff. –– With shoulder abducted 90° and externally rotated 90°, the patient is asked to maintain this position. Test is positive when shoulder internally rotates and the forearm drops.

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Shoulder Apprehension –– Use to test for shoulder instability. –– Anterior Instability: With shoulder abducted 90° and externally rotated 90°, apply anteriorly directed force against the proximal humerus. Positive test for apprehension results in pain and sense that “something is about to happen” (Fig. 2.3). –– Jerk Test for Posterior Instability: With shoulder forward flexed 90° and internally rotated 90°, apply posteriorly directed force at the elbow. Positive test for apprehension results in pain and sense that “something is about to happen.”

Anterior apprehension sign

Figure 2.3  Shoulder anterior apprehension sign.

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Elbow The elbow is comprised of three articulations: humeroulnar, humeroradial, and radioulnar. 1. Inspection (a) Evaluate carrying angle, angle formed by axis of humerus and forearm (normally 5–15° of valgus, greater in women than in men). (b) Valgus deformity of the elbow, cubitus valgus, may result from lateral condyle humerus fracture malunion. Varus deformity of the elbow, cubitus varus or “gunstock deformity” (Fig.  2.4), may result from malunion of supracondylar humerus fracture. (c) Swelling over olecranon bursa suggests bursitis.

Figure 2.4  Gunstock deformity.

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2. Palpation (a) Olecranon is palpated posteriorly with elbow flexion as it moves out of its fossa. (b) Radial head is identified by grasping the patients hand and pronating/supinating the forearm while palpating just distal to the lateral epicondyle of the humerus. The radial head can be felt to rotate in place against the capitellum. (c) With 90° of elbow flexion and biceps contracted, the distal biceps tendon can be palpated in the antecubital fossa. With distal biceps tendon rupture, which requires surgical repair, no discrete tendon can be appreciated. (d) With lateral epicondylitis, or “tennis elbow,” the common extensor origin at the lateral epicondyle is tender. With medial epicondylitis, or “golfer’s elbow,” the common flexor origin at the medial epidondyle is tender. 3. Manipulation Range of Motion (Normal in Parentheses) –– Flexion (150°) –– Extension (0°) –– Forearm pronation (90°) –– Forearm supination (90°) Motor Strength –– Flexion Stand in front of the patient, place hand around supinated distal forearm, and ask patient to “make a muscle.” –– Extension With hand position the same as above, ask patient to push you away.

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–– Pronation With the elbow against the thorax and hand in “handshake” position (thumb pointed up), grasp patient’s hand, and ask that they move palm downward against your resistance. –– Supination With the elbow against the thorax and hand in “handshake” position (thumb pointed up), grasp patient’s hand and ask that they move palm upward against your resistance. 4. Specialized Maneuvers Tinel’s Sign –– With the elbow flexed to 30°, percuss over cubital tunnel, just lateral to medial epicondyle of humerus. –– Paresthesias radiating to small and ring fingers suggest ulnar nerve compression at the site, or cubital tunnel syndrome. Collateral Ligament Test –– To test integrity of ulnar collateral ligament, apply valgus stress to the elbow at 10° of flexion with fingers at level of joint line. –– To test integrity of lateral collateral ligament, apply varus stress to the elbow at 10° of flexion with fingers at level of joint line. –– Pain without gapping is Grade I ligament tear, gapping with firm endpoint is Grade II tear, and gapping without endpoint is Grade III tear.

Hand and Wrist 1. Inspection (a) Thenar and hypothenar wasting suggests compromised innervation by median and ulnar nerves, respectively. (b) Blood underneath nail suggests nail bed injury.

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Figure 2.5  The “attitude” of the hand (flexor tendon sheath laceration).

(c) Observe the relationship of the fingers to one another, or “attitude” of the fingers, in a position of rest. • With flexor tendon disruption, the affected finger has an attitude of extension at rest (Fig. 2.5). • With extensor tendon disruption, the affected fingertip droops and is termed “mallet finger.” (d) Skin-colored nodular swellings at proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints may be osteoarthritic Bouchard’s or Heberden’s nodes, respectively, rheumatoid nodules, or gout tophi. 2. Palpation (a) Cords comprised of thickened palmar fascia, extending most commonly into the ring and small fingers, form in Dupuytren’s contracture. With disease progression, flexion contractures of the digits develop. (b) A tender nodule on the volar aspect of the hand at the level of the MCP joints can be a sign of trigger finger. Finger extension from a fully flexed position resulting in a catching sensation and palpable click volarly at the level of the MCP confirms the diagnosis.

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3. Manipulation Range of Motion (Normal in Parentheses) (a) Wrist –– Ulnar deviation (30°). –– Radial deviation (20°). –– Extension (70°). –– Flexion (80°). (b) Fingers –– Digits 2–5 MCP flexion (90°). –– Digits 2–5 MCP hyperextension (45°). –– Digits 2–5 PIP flexion (100°). –– Digits 2–5 DIP flexion (80°). –– Digits 2–5 DIP hyperextension (10°). –– Thumb CMC abduction (70°). –– Thumb CMC flexion (15°). –– Thumb CMC extension (20°). –– Thumb CMC opposition (thumb tip to small finger MCP or tip). –– Thumb MCP flexion (50°). –– Thumb IP flexion (80°). Motor Exam –– Median nerve Ask patient to oppose the thumb to the small finger. –– Anterior interosseous nerve Ask patient to flex index DIP. –– Ulnar nerve Ask patient to flex the small finger DIP. –– Radial nerve Ask patient to extend the wrist. –– Posterior interosseous nerve Ask patient to give “thumbs up” sign.

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4. Specialized Maneuvers Tinel’s Sign –– Percuss on volar aspect of wrist crease in line with radial aspect of ring finger. –– Paresthesias radiating to the radial three digits suggest median nerve compression at the site, or carpal tunnel. Phalen’s Sign –– Hyperflex both wrists by compressing the dorsa of both hands against one another (Fig. 2.6). Flexor Tendon Integrity –– Test flexor digitorum superficialis tendon by grasping all digits except one to be tested and having patient flex that digit. If digit can be flexed, tendon is intact (Fig. 2.7).

Figure 2.6  Phalen’s test.

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Figure 2.7  Test for flexor digitorum superficialis tendon.

Figure 2.8  Test for flexor digitorum profundus tendon.

–– Test flexor digitorum profundus tendon by grasping middle phalanx of digit to be tested and having patient flex digit tip. If digit tip can be flexed, tendon is intact (Fig. 2.8). Finkelstein Test –– Have patient grasp the thumb of the affected hand with other digits and ulnarly deviate the hand. Pain on radial aspect of the wrist suggests De Quervain’s tenosynovitis—inflammation of the abductor pollicis longus and extensor pollicis brevis tendons, as well as their sheath.

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Lower Extremity Hip and Pelvis The hip joint is comprised of the femoral head articulating with the acetabulum. The ilium, ischium, and pubis converge to form each hemi-pelvis (and acetabulum), which are connected in the center by the sacrum to form the pelvis. 1. Inspection Assess Gait –– Antalgic gait, shorter stance phase of painful extremity. –– Trendelenburg gait, upper body leans toward side with weak abductors. –– Shuffling gait, with Parkinson’s disease. –– Spastic gait, with cerebral palsy. 2. Palpation Anterior –– Provide posteriorly directed stress to bilateral anterior superior iliac spines to assess stability of the pelvis. Lateral –– Palpate greater trochanters to assess for trochanteric bursitis. Posterior –– Palpate sacroiliac joint to assess for degenerative joint disease or sacroiliitis, particularly if FABER test is positive (see below). –– Palpate ischial tuberosity; defect immediately distal suggests proximal hamstring rupture. 3. Manipulation Range of Motion of the Hip (Normal in Parentheses) –– Flexion, with knee flexed (120°). –– Flexion, with knee extended (90°). –– Extension (30°).

Lower Extremity

–– –– –– ––

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Abduction (45°). Adduction (30°). Internal rotation (45°). External rotation (45°).

Motor Strength –– Flexion With patient seated, ask that the knee be lifted up while providing resistance on anterior aspect of distal thigh. –– Abduction With patient lying on side opposite to that being tested, ask that the leg be lifted toward sky with knee extended while providing resistance against lateral aspect of the distal thigh. 4. Specialized Maneuvers Internal rotation of the hip with hip flexed to 90° –– Groin, lateral hip, or deep buttocks pain suggests degenerative change. Hip labral stress maneuvers (click or pain suggests labral tear) –– Flexion, adduction, and internal rotation. –– Starting with hip flexed to 90°, abducted, and externally rotated, take the hip through large arc of motion with full hip flexion, internal rotation, and adduction (roll hip medially). Then reverse this motion (roll hip laterally) to end at starting position. –– McCarthy’s sign: With hip fully flexed, externally rotate and extend the hip; repeat this maneuver, but now internally rotate and extend the hip. Trendelenburg test for abductor weakness –– If patient stands on one leg and the ipsilateral abductors are weak, then the contralateral pelvis droops; if the ipsilateral abductors are normal, then the contralateral pelvis remains level.

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Thomas test for hip flexion contracture –– Inability to extend the hip in supine position with contralateral hip flexed is positive test. Flexion abduction external rotation (FABER) test –– With patient supine, place the leg in figure-of-four position (flex hip to 90°, and then abduct and externally rotate the hip with foot resting on contralateral distal thigh), and push down on the knee to stress SI joint. Barlow’s and Ortolani’s tests for congenital hip dislocation (Fig. 2.9). –– With patient supine, flex hips and knees to 90°, place your thumbs on medial aspect of proximal thighs with middle fingers on greater trochanters. Adduct hips and press downward to dislocate hips (Barlow’s test); abduct hips while pulling anteriorly to relocate hips (Ortolani’s test). A “clunk” should be palpable with dislocation and relocation.

Barlow maneuver

Ortolani maneuver

Figure 2.9  Barlow and Ortolani’s maneuvers.

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Knee The knee, the largest joint of the body, is comprised of the tibiofemoral articulation and patellofemoral joint. 1. Inspection –– Sulcus superior or inferior to patella suggests quadriceps or patellar tendon rupture, respectively. Alignment –– Coronal (patient facing you): –– Valgus, knock-kneed. –– Varus, bow-legged. –– Sagittal (patient facing your left or right with side turned to you): –– Flexion contracture, the knee is bent and cannot be passively extended. –– Hyperextension, the knee is posterior to midline. Gait –– Varus thrust, the knee moves laterally during gait. –– Valgus thrust, the knee moves medially during gait. 2. Palpation –– Fluid immediately underneath the skin overlying patella suggests prepatellar bursitis. –– With the knee in extension, when patella is grasped and downward force is applied to the patella, the patella will strike the patellar surface of the femur and then float off it when an intra-articular effusion is present. This is referred to as a “ballotable” patella. –– Palpate medial and lateral joint lines, which are at the level of the inferior aspect of the patella. Tenderness suggests either meniscal tear or degenerative change. –– Palpate anterior aspect of medial and lateral femoral condyles. Tenderness suggests degenerative change. –– Palpate pes anserine bursa (insertion of hamstring tendons). Tenderness suggests bursitis.

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3. Manipulation Range of Motion (Normal in Parentheses) –– Flexion (135°) –– Extension (0°) Motor Strength –– Flexion/Extension. Test against resistance in sitting position by having patient flex or extend the knee with your hand against posterior or anterior aspect of the lower leg, respectively. 4. Specialized Maneuvers Lachman test (Fig. 2.10) –– With the knee flexed 20°–30° and the hip externally rotated, grasp tibia medially, and pull anteriorly while securing distal thigh with contralateral hand placed laterally. –– Increased tibial excursion compared to the contralateral side without firm “endpoint” is a positive test for ACL tear.

Figure 2.10  Lachman’s test for ACL tear.

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Anterior drawer test –– With the knee flexed to 90°, apply anteriorly directed force to proximal tibia. –– Increased tibial excursion compared to the contralateral side is a positive test for ACL tear. Pivot-shift test (Fig. 2.11) –– Proximal tibia is internally rotated, while valgus stress is applied to the knee in extension. This produces anterior tibial subluxation with a torn ACL. Flexion of the knee with valgus stress results in reduction of the tibial subluxation, which is a positive test for ACL tear. Posterior drawer test –– With the knee flexed to 90°, apply posteriorly directed force to proximal tibia. –– Increased tibial excursion compared to the contralateral side is a positive test for PCL tear. a

b

c

Figure 2.11  Pivot-shift test for ACL tear. (a) With knee in extension, internal rotation and valgus stress producing anterior tibial subluxation; (b) knee flexion with valgus stress; and (c) palpable reduction of tibia with knee flexion.

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McMurray’s test –– With fingers on medial and lateral joint lines, flex the hip and knee, and apply varus stress to the knee while bringing the hip and knee into extension; repeat maneuver while applying valgus stress to the knee. –– Palpable click or pain suggests a meniscal tear on the side of the positive test (medial or lateral). Collateral ligament test –– To test integrity of medial collateral ligament, apply valgus stress to the knee at 30° of flexion with fingers at level of the joint line. –– To test integrity of lateral collateral ligament, apply varus stress to the knee at 30° of flexion with fingers at level of the joint line. –– Pain without gapping is Grade I ligament tear, gapping with firm endpoint is Grade II tear, and gapping without endpoint is Grade III tear.

Foot and Ankle The ankle is comprised of the distal tibia and fibula articulating with the talus. The foot is comprised of the hindfoot (talus and calcaneus), midfoot (cuboid, navicular, and three cuneiforms), and forefoot (metatarsals and phalanges). The articulation between the talus and calcaneus is the subtalar joint, the articulation between the hindfoot and midfoot is the transverse tarsal (or midtarsal or Chopart’s) joint, and the articulation between the midfoot and forefoot is the tarsometatarsal joint. 1. Inspection –– Observe patient while weight-bearing from behind to determine if the heel leans medially (pes planus) or laterally (pes cavus). 2. Palpation –– Common sites of fracture (medial and lateral malleoli, base of 5th metatarsal, Lisfranc joint, proximal fibula to evaluate for Maisonneuve fracture).

Lower Extremity

Fibula

Tibia Anterior inferior tibiofibular ligament

Posterior inferior tibiofibular ligament

Talus

Posterior talofibular ligament

Calcaneofibular ligament

Anterior talofibular ligament

Figure 2.12  Ankle ligaments.

–– Commonly injured ankle ligaments (Fig. 2.12). –– Achilles tendon for defect secondary to tear. 3. Manipulation Range of Motion (Normal in Parentheses) –– –– –– –– ––

Ankle Dorsiflexion (20°). Plantarflexion (50°). Inversion (35°). Eversion (15°).

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Motor Strength –– Ankle/Great Toe Dorsiflexion Ask patient to point their ankle and toes toward their nose. Provide resistance against the dorsum of the patient’s ankle and great toe. –– Ankle Plantarflexion Ask patient to push down like a gas pedal. Provide resistance against the plantar aspect of the patient’s foot. 4 . Specialized Maneuvers Anterior Drawer –– Stabilize the distal tibia, grasp the heel, and pull foot anteriorly. –– Excursion of greater than 8 mm suggests tear of anterior talofibular ligament. Squeeze Test –– Squeeze the tibia and fibula together one hand-­breadth proximal to the ankle joint. –– Painful with syndesmotic injury. Thompson Test –– Squeeze gastroc-soleus (calf) muscle belly. –– Test is positive if foot does not plantarflex, signifying ruptured Achilles tendon.

Spine 1. Inspection Symmetry –– Observe patient with back exposed. –– Normal findings: (a) Head directly over gluteal cleft. (b) Both shoulders, scapulae, and iliac crests at equal heights.

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2. Palpation –– Spinous processes Visible or palpable step-off may indicate spondylolisthesis (anterior slippage of a vertebrae) or fracture in context of significant trauma. –– Iliac crest (typically at L4–L5) –– Sacroiliac joint Tender in sacroiliitis due to degenerative joint ­disease, infection, or spondyloarthropathies (e.g., ankylosing spondylitis). 3. Manipulation Range of Motion –– Flexion –– Ask patient to bend forward, and measure distance from tip of fingers to ground (requires relaxation of the anterior longitudinal ligament). –– Extension –– Ask patient to bend backward while providing lumbar support with your hand, which serves as a fulcrum (requires relaxation of the posterior longitudinal ligament). –– Lateral bending –– With your hands on the patient’s iliac crests, ask them to bend to each side, noting any differences. –– Rotation –– While standing behind the patient, stabilize one hemipelvis by holding the iliac crest, and rotate the contralateral shoulder posteriorly. Motor Strength –– A neurologic examination should be performed if the patient complains of bowel/bladder symptoms (incontinence or retention), saddle paresthesias, or extremity pain, weakness, numbness, or tingling. –– Perform according to Tables 2.2 and 2.3, with muscle strength graded according to Table 2.1.

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Table 2.2  Cervical levels Nerve Sensation root C3 Occiput

Motor

Reflex

None

None

C4

Supraclavicular space

None

None

C5

Lateral arm

Deltoid

Biceps, brachioradialis

C6

Lateral forearm

Biceps and wrist extension

Biceps, brachioradialis

C7

Long finger

Triceps and wrist flexion

Triceps

C8

Medial forearm

Finger flexion

None

T1

Medial arm

Finger abduction

None

Table 2.3  Lumbar levels Nerve Sensation root L2 Superomedial thigh

Motor

Reflex

Hip flexion

Patellar

L3

Inferomedial thigh

Knee extension

Patellar

L4

Medial lower leg

Dorsiflexion of foot

Patellar

L5

Lateral lower leg and medial foot

Great toe extension

None

S1

Lateral foot

Plantar flexion of foot

Achilles

4. Specialized Maneuvers Spurling’s Test –– Patient is asked to extend the neck and rotate the head toward symptomatic arm. –– This test for cervical radiculopathy is positive when it reproduces the patient’s arm pain.

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Hoffman’s Sign –– Hold the patient’s relaxed hand, and flick the distal phalanx of their long finger. –– This test for cervical myelopathy (the spinal cord changes secondary to compression) is positive when the thumb flexes at the interphalangeal joint. Clonus –– With patient seated or supine, briskly dorsiflex the patient’s foot, and then relax pressure on the foot. –– This test for myelopathy (cervical, thoracic, or lumbar) is positive when the patient, in response, plantarflexes the foot in a pulsatile fashion. Each time the patient’s foot plantarflexes is termed a “beat” of clonus. One to two beats of clonus can be normal and even less concerning if symmetric. The patient can have clonus not only with myelopathy but also with conditions/lesions of the brain. Straight Leg Raise –– With patient lying supine, flex their hip with knee extended (30–60°). Dorsiflexion of foot and extension of great toe helps elicit pain. –– This test for low lumbar radiculopathy is positive when pain is felt below the knee. Femoral Nerve Stretch Test –– With patient laying on their side with the knee flexed to 90°, hold the patient’s ankle, and extend their hip. –– This test for high lumbar radiculopathy is positive if pain is felt in the anterior compartment of the thigh (L2–L4).

Chapter 3 Managing the Floor

In this chapter we discuss floor management of orthopedic patients. While operative management is the mainstay of orthopedics, outstanding postoperative care is essential to optimize surgical outcomes.

Postoperative Check/Rounding  postoperative check is a brief exam that is performed A within the hours following surgery. It allows the practitioner to ensure that the patient is recovering properly from anesthesia and there are no issues that necessitate a return to the OR or emergent medical intervention. Daily rounding allows the practitioner to ensure that the patient is medically stable, achieving his/her physical therapy milestones, and the surgical site is healing appropriately. A daily postoperative exam of an orthopedic patient should consist of the following: 1. Interview (“How are you doing? How is physical therapy going?”) 2. Distal neurovascular exam of the operative extremity (pulses, motor, and sensation).

© Springer Science+Business Media, LLC, part of Springer Nature 2020 S. Nandi, S. F. St. Clair, The Bone Book, https://doi.org/10.1007/978-1-4614-3091-9_3

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3. Inspection of the dressing/incision and local operative site for erythema or drainage. 4. Assessment for evidence of DVT by examination of feet for swelling and squeezing of calves. The following should be documented: Sample Note for Upper Extremity Postoperative Check Comfortable. AVSS (afebrile, vital signs stable). R UE (right upper extremity): Radial pulse palpable. Sensation and motor intact m/r/u/ax (median, radial, ulnar, axillary). Shoulder and arm soft (this is important to note and conveys there is no evidence of hematoma or impending compartment syndrome). Incision c/d/i (clean/dry/intact). Imp/plan: s/p R TSA (right total shoulder arthroplasty). Stable. Continue to monitor. Sample Note for Lower Extremity Postoperative Check Comfortable. AVSS (afebrile, vital signs stable). R LE (right lower extremity): DP (dorsalis pedis) and PT (posterior tibial pulses) palpable. SILT (sensation intact to light touch) L4–S1. DF/EHL/PF 5/5 (dorsiflexion, extensor hallucis longus, plantar flexion motor). Thigh and leg soft (this is important to note and conveys there is no evidence of hematoma or impending compartment syndrome). Dressing c/d/i (clean/dry/intact).

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Imp/plan: s/p R TKA. Stable. Continue to monitor.

Lab Abnormalities Postoperative lab abnormalities occur secondary to the surgery itself (e.g., anemia) or medical interventions (e.g., fluids, drugs) and may result in altered physiology. If not corrected in a timely fashion, significant morbidity and even mortality may result.

ANEMIA Definition Low hemoglobin/hematocrit (i.e., hemoglobin 90 mm Hg: • Administer a 250 cc normal saline fluid bolus over 1 h • Obtain a complete blood count (CBC) • Transfuse per the protocol in “Lab Abnormalities/Anemia” For a symptomatic patient (e.g., light-headed or dizzy) or a patient with a systolic pressure  100, start with furosemide 5–10 mg × 1 dose). • The assistance of internal medicine is helpful in diagnosing and treating pulmonary congestion due to cardiac dysfunction. Hypoxia + Tachycardia

Pulmonary embolus (PE)

+/- Tachypnea Or pleuritic chest pain

Workup • If PE is suspected, order a STAT chest CT. Treatment • For PE, anticoagulation will be required with the assistance of vascular medicine or hematology. Full anticoagulation may be accomplished with warfarin as well as another agent for bridging until the INR is therapeutic (goal INR 2.0–3.0). Bridging agents include enoxaparin 1 mg/kg subcutaneous injection q12 hours or IV heparin.

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Pearl If IV heparin is chosen as a bridging agent, do not administer a bolus dose to avoid increased risk of hematoma at the operative site.

TACHYCARDIA Definition Rapid heart rate (heart rate greater than 100 beats per minute). Tachycardia results in decreased coronary artery filling time, leading to cardiac ischemia. Tachycardia can also be the first sign of other medical aberrations.

Tachycardia Normal O2 Saturation Hgb ≥10 g/dL or hct ≥ 30%

1) Assess Pain Control 2) Obtain Ekg If Rate Irregular * 3) Accompanying Hypotension Should Prompt Urgent Medical Intervention *may represent atrial fibrillation

Tachycardia Normal 02 Saturation 7.0 g/dL < Hgb ≤ 1O g/dL

1) Administer 250–500cc Ns Bolus 2) If unresolved, transfuse 1 unit prbcs* 3) Transfuse additional units blood until tachycardia resolves or Hgb ≥ 10g/dL

Tachycardia + Hypoxia (02 Saturation < 92% on Room Air)

Pulmonary Embolus

+/- Tachypnea or pleuritic chest pain

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Workup • If PE is suspected, order a STAT chest CT. Treatment • For PE, anticoagulation will be required with the assistance of vascular medicine or hematology. Full anticoagulation may be accomplished with warfarin as well as another agent for bridging until the INR is therapeutic (goal INR 2.0–3.0). Bridging agents include enoxaparin 1 mg/kg subcutaneous injection q12 h or IV heparin. Pearl If IV heparin is chosen as a bridging agent, do not administer a bolus dose to avoid increased risk of hematoma at the operative site.

FEVER Definition Elevated temperature (oral temperature greater than 101.3F or 38.6C). Fever suggests the presence of an underlying pathology in the postoperative patient that should be addressed. These pathologic entities include: • • • •

Atelectasis Infection Deep vein thrombosis Drug/transfusion reaction

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Causes of Fever:

Up To 3rd Post-operative Day, Atelectasis

Transfusion of a blood product (PRBCs, PLTs, fresh frozen plasma)

Drug Reaction

Incentive Spirometry 10x/hr + Pulmonary Toilet With Respiratory Therapy

-Stop Transfusion -Notify Blood Bank -Diphenhydramine 25–50mg Po/iv X 1 -Acetaminophen 1gm Po X 1 -Monitor Vitals

If Possible, Discontinue Any New Medications

After the 3rd postoperative day, consider: Urinary tract infection

Send urinalysis and urine culture in patients with dysuria

Wound infection

Examine incision for signs of infection (drainage/erythema)

Deep vein thrombosis

-Look for calf/foot swelling or calf tenderness -Obtain duplex ultrasound of lower extremity

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Pearl Swelling in the vicinity of the operative site is normal (e.g., calf swelling often occurs following knee surgery), so examine the distal most aspect of the extremity for swelling to determine if there is suspicion for DVT. Calf swelling in the absence of foot swelling is unlikely to be due to DVT as a block to venous return will cause swelling at every point distal to the blockage.

LOW URINE OUTPUT (OLIGURIA) Definition Urine output less than 0.5 cc/kg/h. Low urine output of prerenal, intrarenal, or post-renal etiology may lead to renal failure. Treatment First administer a 250 cc normal saline bolus over 1 h. If UOP responds, then give another bolus if necessary to achieve appropriate weight-based UOP. If patient does not respond to fluid bolus, flush Foley catheter to ensure there is no blockage. If there is a blockage, change Foley catheter. If patient does not have a Foley catheter, patient discomfort in the suprapubic region or discomfort with palpation of the suprapubic region suggests urinary retention. Alternatively, perform bladder scan to determine if there is urinary retention. If there is evidence of urinary retention on physical exam or the bladder has greater than 400 cc or urine, place a Foley catheter.

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If hemoglobin is 50,000

stat Gram stain

Joint aspirate crystals

Positive or negative

Positive or negative

Suppurative Flexor Tenosynovitis

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Caveats Positive stat Gram stain  =  septic joint independent of any other results. Negative stat Gram stain does not rule out septic joint (e.g., aspirate WBC >50,000, negative crystals, negative stat Gram stain = septic joint). Joint aspirate WBCs can be greater than 50,000 in crystalline arthropathy. WBC>50,000 and positive crystals = crystalline arthropathy until there is a positive culture (do not go to OR without positive culture in this case). However, crystalline arthropathy and septic joint CAN occur concurrently (aspirate with crystals and positive stat Gram stain = septic joint). Imaging None

Treatment Emergent I & D in OR with drain. Immobilization in early post-op period with IV Abx for 6–8 wks via PICC line. Open arthrotomy is the gold standard. Arthroscopic I & D of the knee is acceptable, but more than one trip to the OR may be necessary to clear the infection. Pearl Every painful joint should be ruled out for septic arthritis. Make the patient NPO until you have a diagnosis. Order CBC, ESR, and CRP.  If there is pain on small-arc motion, aspirate the joint through an area of skin without cellulitis so as not to seed the joint with bacteria. Range all other joints to make sure the patient does not have multiple joints that are affected. Treatment plan is based on labs and aspirate.

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Suppurative Flexor Tenosynovitis Definition Hand infection involving the flexor sheath of a digit.

Why Is this Emergent? Suppurative flexor tenosynovitis can result in flexor tendon destruction, finger stiffness, and rapid spread of infection through the deep spaces of the hand.

Causes • Penetrating injury to flexor sheath • High-pressure injection injury • Spread of infection from finger pulp (felon)

Diagnosis History Pain in a digit following trauma or adjacent infection. Physical exam Kanavel’s signs are diagnostic—(1) tenderness along flexor sheath, (2) digit fixed in flexed position, (3) pain on passive extension, and (4) sausage (swollen) digit. Labs Elevated WBC, ESR, and CRP

Treatment Emergent I & D in OR with drain. Postoperative splinting, elevation, soaks in Betadine/Hibiclens, and IV antibiotics. Continuous irrigation on floor may be considered.

Necrotizing Fasciitis

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Pearl The diagnosis of this condition is purely clinical. If the patient has all four Kanavel’s signs, take the patient to the OR emergently.

Necrotizing Fasciitis Definition Necrotizing fasciitis is a rapidly progressive, tissue-destroying infection that spreads along fascial planes.

Why Is this Emergent? Necrotizing fasciitis can cause death within hours.

Causes • Almost always a polymicrobial infection • Most common single isolate is group A beta-hemolytic streptococcus (Streptococcus pyogenes) • Immunocompromised hosts are particularly vulnerable (HIV, cancer, diabetes, elderly)

Diagnosis History Trauma, surgery, and severe pain out of proportion to initial appearance of soft tissues. Physical exam Fever, hypotension, and tachycardia. Rapidly progressive erythema and subcutaneous crepitus. Labs Elevated WBCs

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Figure 4.1  Plain film of left femur demonstrating soft tissue gas in patient with necrotizing fasciitis.

Imaging Subcutaneous air on plain X-rays. MRI or CT (faster to perform in systemically ill patient) showing fluid (purulence) along fascial planes (Figs. 4.1 and 4.2).

Treatment Emergent I & D in OR with wide debridement of all nonviable tissue, fasciectomy, and IV antibiotics. Fascia must be sent to pathology for definitive diagnosis. ICU care and mul-

Compartment Syndrome

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Figure 4.2 Axial CT image of the left thigh demonstrating gas tracking along fascial plane in the same patient.

tiple I & Ds will likely be necessary. Amputation may be required as a life-saving measure. Pearl A systemically ill patient with rapidly progressive erythema (always outline erythema with magic marker on every patient upon initial exam) should be presumed to have necrotizing fasciitis. Begin IV antibiotics after blood culture. If the patient’s clinical condition allows, perform an MRI or CT to confirm the diagnosis prior to taking them to the OR for I & D. If unstable, take patient to OR emergently.

Compartment Syndrome Definition Compartment syndrome is elevation of interstitial pressure within a fascial compartment sufficient to cause tissue necrosis.

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Why Is this Emergent? Compartment syndrome can cause tissue necrosis and permanent limb dysfunction.

Causes • Trauma • Surgery • Reperfusion injury following a period of ischemia

Diagnosis History Increasing pain or pain medication requirement (particularly in children) possibly accompanied by paresthesias. Neurologic deficits and absent pulses are late findings that herald irreversible tissue damage. Physical exam Rock-hard compartment upon palpation that is not manually compressible. Pain on passive range of motion (PROM) of muscles in affected compartment (e.g., for the forearm and lower leg, pain on PROM of digits). Diagnostic Studies Compartment pressure greater than 30  mm Hg or within 30 mm Hg of diastolic blood pressure. The former is a more sensitive measure, while the latter is more specific. Labs None Imaging None

Open Fracture

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Treatment Emergent fasciotomy of involved limb compartments Pearl Compartment syndrome should be suspected in any patient with increasing pain following trauma or surgery. The diagnosis should first be made clinically and then confirmed with compartment pressure measurement. Fasciotomy is associated with a high risk of infection.

Open Fracture Definition A fracture that communicates with an open wound. Open fractures are classified in Table 4.2.

Why Is this Emergent? With open fractures, there is a high risk of deep infection that may result in osteomyelitis, fracture nonunion, and ultimately loss of limb.

Table 4.2  Gustilo and Anderson open fracture classification Description Type I Skin opening 1 cm, minimal-moderate crush injury

Type III

Severe crush injury

 Type IIIA

Adequate soft tissue coverage of bone

 Type IIIB

Exposed bone with massive contamination

 Type IIIC

Vascular injury requiring repair

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Causes • Trauma

Diagnosis History High-energy trauma with open wounds Physical exam Open, bleeding wound in close proximity to the fracture site Imaging Plain films demonstrating fracture

Treatment Upon presentation, administration of antibiotics and tetanus prophylaxis (Table 4.3). Gross debris should be removed. Table 4.3  Antibiotic prophylaxis for open fractures Antibiotic prophylaxis regimen Type I Cefazolin 2 g IV loading dose and then 1 g IV q8h × 24 h Type II

Cefazolin 2 g IV loading dose and then 1 g IV q8h until 48 h after wound closure

Type III

Cefazolin 2 g IV loading dose and then 1 g IV q8h; gentamicin 5.1 mg/ kg IV daily. Continue until 48 h after wound closure

Farm injuries, vascular compromise, extensive soft tissue crush injury

Aqueous penicillin G 2–4 million units IV q4h until 48 h after wound closure

Cauda Equina Syndrome

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From the wound, it should be dressed with Betadine-soaked gauze, and the fracture should be splinted. Urgent/emergent I&D of the wound/fracture, fracture stabilization, vascular repair as needed, and wound care (e.g., primary closure, dressing changes, VAC dressing) follow. Pearl A fracture with a skin abrasion over or near it with punctate dermal bleeding is not an open fracture.

Cauda Equina Syndrome Definition Cauda equina syndrome is the characteristic pattern of lower extremity neuromuscular and/or urogenital symptoms due to mechanical compression of the cauda equina (Fig. 4.3).

Why Is this Emergent? Cauda equina syndrome may result in lower extremity paralysis, as well as permanent loss of bowel/bladder/sexual function.

Causes • • • • • •

Herniated disc, usually at L4/5 or L5/S1 (most common) Infection (epidural abscess) Tumor (prostate cancer in men) Trauma (fracture/subluxation, penetrating injury) Spinal stenosis Iatrogenic (aberrant instrumentation, continuous spinal anesthesia)

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Chapter 4.  Orthopedic Emergencies { C1 spinal nerve exits C1 above C1 vertebra C2

Base of skull C1

2 3 4 5 6 7 8

Cervical enlargement T1

C3 C4 C5 C6 C7 T2

4 5 6 7

T6 T7 T8 T9

12 L1

S1 Sacral nerves Conus medullaris (termination of spinal cord)

T4 T5

9 11

Lumbar enlargement

T3

8 10

2 3 4 5 2 3 4 5

T10 T11 T12 L1 L2

L3

Cauda equina

L4

Internal terminal filum (pial part) Termination of dural sac External terminal filum (dual part)

Figure 4.3  Cauda equina.

C8 spinal nerve exits { below C7 vertebra (there are 8 cervical nerves but only 7 cervical vertebrae)

T1

2 3

L5 Sacrum S1 S2 S3 S4 S5 5 { Coccygeal nerve Coccyx

Cauda Equina Syndrome

131

Diagnosis History Bowel/bladder/sexual dysfunction (urinary retention most common, but subsequent overflow incontinence does occur). Saddle area (perineal) numbness/paresthesias. Lower extremity pain, weakness, and decreased sensation. Physical exam Lower extremity motor weakness and reduced/absent reflexes. Decreased perianal sensation and rectal tone. Post-void residual (patient voids, Foley inserted, urine collected is residual) greater than 100–200 mL. Imaging MRI or CT myeloGram showing mechanical compression of cauda equina (Fig. 4.4).

Treatment Emergent surgical decompression of the cauda equina. This must occur within 48 h of symptom onset to avoid permanent loss of function. Pearl Any patient presenting with urinary retention, incontinence without sensation of voiding, bowel incontinence, or saddle paresthesias in association with lower extremity neurologic deficits should have an emergent lumbar spine MRI to rule out cauda equina syndrome. If the MRI demonstrates compression of the cauda equina, emergent surgical decompression must be performed.

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a

b

Figure 4.4  Saggital T2 (a) and axial T2 (b) images of large central disc herniation in a patient with cauda equina syndrome (CES).

Chapter 5 Emergency Room Consultations

Emergency Room Consults In this chapter we discuss management of orthopedic conditions for which patients present to the emergency room (ER) and steps to be taken while the patient is in the ER.

 igh-Energy Trauma Patient and Fracture H Management I. With trauma team, evaluate A, B, C, D, and E: –– AIRWAY: Confirm open upper airway and establish as needed (intubation or tracheostomy). –– BREATHING: Confirm adequate ventilation and address pulmonary pathology as needed. –– CIRCULATION: Confirm hemodynamic stability and administer fluids, blood, or pressors as needed. –– DISABILITY: Assess neurologic function and ask patient to “Wiggle toes!” to rapidly assess gross function. –– EXPOSURE: Visualize every inch of the skin on patient for injuries.

© Springer Science+Business Media, LLC, part of Springer Nature 2020 S. Nandi, S. F. St. Clair, The Bone Book, https://doi.org/10.1007/978-1-4614-3091-9_5

133

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II. Evaluate screening radiographs: –– Chest X-ray (proximal humerus, clavicle, scapula) –– C-spine (cervical fractures/dislocations) –– AP pelvis (pelvic ring injuries and/or hip fractures) III. Examine the patient: –– If responsive, ask patient: “Where do you hurt?” –– Whether patient is responsive or not, palpate all long bones and spinous processes; range all joints; and, in patient without apparent pelvic ring injury on AP pelvis X-ray, assess stability of the pelvis by applying posterior pressure to bilateral anterior superior iliac spines (ASIS). Pain or crepitus suggests possible fracture and warrants imaging. –– Order appropriate radiographs of suspected sites of injury (Table 5.1). Pearl: Image joint immediately above and below the fracture site once patient is stabilized to fully elucidate fracture, identify associated injuries, and facilitate operative planning (e.g., mode of fixation). IV. Urgent Interventions: –– Dress open fractures (sterile saline to wash out gross debris, betadine-soaked 4X4s to wound secured with Kerlix), and administer antibiotic/tetanus prophylaxis. –– Immobilize fractures with splints (see Chapter 8). –– Keep patient NPO until treatment plan is finalized. –– Formulate treatment plan for fracture (Tables 5.2, 5.3, 5.4, 5.5, and 5.6). Pearl: Open fractures require internal fixation. A cast or brace is ineffective as it must be frequently removed for wound care. –– If appropriate, prepare patient for OR (see Chapter 7). –– Skeletal traction stabilizes acetabular and femur fractures while facilitating fracture reduction in the OR. Apply as needed (Table 5.7) (Figs. 5.1 and 5.2). –– Start DVT prophylaxis if hemodynamically stable, there is no head or spine injury, and patient is not going to OR the same day as presenting to ER. –– Evaluate for compartment syndrome pre- and postoperatively.

High-Energy Trauma Patient and Fracture Management

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Table 5.1  Trauma imaging Anatomic location Shoulder

Imaging

Pearls

X-ray: AP and axillary views

Cannot adequately evaluate for shoulder dislocation without axillary view. Axillary view can be performed by supporting arm in a supine patient with shoulder in as little as 30° of abduction Obtain CT scan to evaluate great vessels/mediastinum with posterior sternoclavicular (SC) joint dislocation

Humeral shaft

X-ray: AP and lateral views

Elbow

X-ray: AP and lateral views

Forearm

X-ray: AP and lateral views

Wrist/hand

X-ray: AP, lateral, and oblique views

Obtain scaphoid view (ulnar deviation PA view) if indicated by other imaging/physical exam

Pelvis

X-ray: AP pelvis view (screening) X-ray: inlet view for anterior-­posterior disruption; outlet view for superiorinferior disruption X-ray: Judet views (iliac and obturator oblique) to evaluate acetabular fracture CT to assess posterior pelvis as needed

Acronym “IPCAW”: Iliac oblique view demonstrates Posterior Column and Anterior Wall Conversely, obturator oblique view demonstrates anterior column and posterior wall

Plain films of contralateral elbow helpful in distinguishing ossification center versus fracture in pediatric patients

(continued)

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Table 5.1  Trauma imaging (continued) Anatomic location Hip

Imaging

Pearls

X-ray: AP pelvis view and cross-­table lateral view of hip

Do not get frog lateral X-ray of hip, as nondisplaced femoral neck fracture may become displaced

Femoral shaft

X-ray: AP and lateral views

Check for femoral neck fractures

Knee

X-ray: AP and lateral views CT scan for tibial plateau fractures

Tibial shaft

X-ray: AP and lateral views

Foot

X-ray: AP, lateral, and oblique views, weight-bearing if possible CT scan as needed to better characterize fracture

Cervical spine

X-ray: AP and lateral views CT scan for odontoid and difficult to visualize fractures

Thoracolumbar spine

X-ray: AP and lateral views CT scan for operative fractures

Harris view for calcaneus fracture MRI for suspected Lisfranc sprain or stress fractures

High-Energy Trauma Patient and Fracture Management

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Table 5.2  Upper extremity fracture management Fracture

Fracture temporization Sling

Definitive treatment Nonoperative versus plate/ screws with greater than 100% displacement

Proximal humerus

Sling

Nonoperative (1part/minimally displaced), plate/ screws (young), or arthroplasty (old)

Humeral shaft

Coaptation splint

Fracture brace, plate/screws, or intramedullary nail (pathologic fracture)

ORIF indications uncommon: vascular injury, neurologic injury, floating elbow with ipsilateral forearm fracture, morbid obesity that promotes varus angulation at fracture site

Distal humerus

Posterior long arm splint

Nonoperative if nondisplaced, plate/screws if displaced, total elbow replacement in elderly with severe comminution

Jones dressing if high-energy injury

Olecranon

Posterior long arm splint

Plate/screws or tension band for displaced

Clavicle

Pearls ORIF with skin tenting. Never use intramedullary pin/nail due to risk of hardware migration

(continued)

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Table 5.2  Upper extremity fracture management (continued) Fracture

Fracture temporization Sling

Definitive treatment Plate/screws for 3 or less fragments, prosthetic replacement if fixation unstable/ unreliable

Pearls

Radial or ulnar shaft

Sugar tong

Plate/screws for displaced

Monteggia fracture: proximal ulna fracture with radial head dislocation Galeazzi fracture: fracture at junction of middle and distal third of radial diaphysis with disruption of distal radioulnar joint

Distal radius

Sugar tong

Plate/screws for displaced, unstable, intra-­ articular

Carpus

Sugar tong (add thumb spica for scaphoid and trapezium)

Nonoperative versus K-wires or screw for displaced

Radial head

Assess for block to motion, which is indication for ORIF regardless of fracture pattern. Examine ipsilateral forearm and wrist for Essex-­Lopresti lesion (associated interosseous ligament and distal radioulnar joint [DRUJ] injury).



Pediatric Fractures

139

Table 5.2  Upper extremity fracture management (continued) Fracture Metacarpal

Phalanges

Fracture temporization Radial gutter (1st or 2nd), ulnar gutter (4th or 5th), or anterior and posterior slabs (3rd)

Definitive treatment Nonoperative versus K-wires or plate/screws for unstable/ displaced

Digit extension/ aluminum splint

Nonoperative versus K-wires or plate/screws for unstable or intraarticular

Pearls

Pediatric Fractures Salter-Harris classification (using distal femur, e.g., with well-­ known, previously described mnemonic): Type I: S, straight across physis. Type II: A, above physis. Type III: L, low or below physis. Type IV: TE, through everything (above and below physis). Type V: R, rammed or crushed physis.

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Table 5.3  Pediatric upper extremity fracture management Fracture

Fracture temporization Sling

Definitive treatment Nonoperative unless older than 12 and fracture 100% displaced

Proximal humerus

Sling

Nonoperative unless older than 12 and fracture displaced >30% width of shaft

Humeral shaft

Coaptation splint Fracture brace Long arm cast

Clavicle

Elbow (please see various fracture types below)

Supracondylar humerus

Pearls If skin tented, needs reduction

If necessary, obtain plain films of contralateral elbow to distinguish between ossification center and fracture Long arm splint

Lateral or Long arm splint medial condylar physis

Nonoperative for nondisplaced (line along anterior aspect of humerus should intersect capitellum), percutaneous pinning for displaced Nonoperative for nondisplaced, open reduction with pinning for displaced

Arthrogram may help determine if there is displacement

Pediatric Fractures

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Table 5.3 Pediatric upper extremity fracture management (continued) Fracture Olecranon

Fracture temporization Long arm splint

Definitive treatment Nonoperative for nondisplaced: tension band or screws for displaced

Radial head

Long arm splint

Closed management preferred; percutaneous pinning for unstable fractures, open reduction with >60° angulation or > 4 mm displacement

Radial or ulnar shaft

Sugar tong splint

Reduction with long arm cast; age > 10: flexible nails, plate/screw in skeletally mature or with severe comminution

Distal radius

Sugar-tong splint

Long arm cast

Carpus

Sugar tong (add thumb spica for scaphoid and trapezium)

Nonoperative versus K-wires or screw for displaced

Pearls

Monteggia: closed reduction of ulna for plastic deformation, flexible nail or K-wire for complete fracture Galeazzi: if unstable, K-wire, flexible nail, or plate/screw

(continued)

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Table 5.3 Pediatric upper extremity fracture management (continued) Fracture Metacarpals

Phalanges

Fracture temporization Radial gutter (1st or 2nd), ulnar gutter (4th or 5th), or anterior and posterior slabs (3rd) Digit extension/ aluminum splint

Definitive Pearls treatment Nonoperative versus K-wires for unstable/displaced

Nonoperative versus K-wires or screws for unstable or intraarticular

Fracture Management

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Table 5.4  Lower extremity fracture management Fracture

Fracture temporization

Definitive treatment

Pearls

Pelvis fracture: Unstable

Pelvic binder, to Plate/screws OR for external fixator

May require pelvic vessel embolization in interventional radiology

Acetabulum

None/Buck’s Toe-touch weighttraction/skeletal bearing or plate/ traction screws

Nonoperative: Anterior) –– Attitude of the leg with posterior dislocation: shortened with the hip flexed, internally rotated, and adducted –– Attitude of the leg with anterior dislocation: shortened with hip externally rotated –– Conscious sedation: propofol works best –– Reduction technique (Allis technique, Fig. 5.5)

Traction Counter traction

Adduction and internal rotation Figure 5.5  Allis hip reduction technique (supine).

Dislocations

159

Pearl: Examine ipsilateral knee for ligamentous injury before performing maneuver. –– Posterior dislocation: • Stand over patient lying supine, flex the hip and knee to 90°, grasp distal femur with one arm with other arm in popliteal fossa, adduct and internally rotate the hip, and apply traction anteriorly, while assistant applies posterior pressure to ipsilateral ASIS. –– Anterior dislocation: • Stand at the foot of patient lying supine, grasp ipsilateral distal tibia; externally rotate the leg/ hip; apply traction longitudinally, while assistant applies posterior pressure to ipsilateral ASIS until the leg is out to length (compare position of foot/malleoli with contralateral leg); and then internally rotate femoral head into acetabulum. Pearl: This technique works for posterior dislocation as well. Just reverse rotation of the leg/hip, while at foot of bed, internally rotate, apply traction, and externally rotate to reduce when out to length. Postreduction Management –– Postreduction radiographs: AP and cross-table lateral of hip to confirm reduction. CT scan the hip to evaluate for intra-articular bony fragments. –– Apply femoral traction pin if concomitant acetabular fracture does not allow femoral head to sit concentrically within joint. –– For dislocated total hip arthroplasty: • Range hip to determine position of instability, which guides bracing and offers prognosis of nonoperative management. • Posterior dislocation, place knee immobilizer and abduction pillow until fitted for hip-kneeankle-foot orthosis (HKAFO). • Anterior dislocation, no knee immobilizer or abduction pillow, fit for HKAFO.

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IV. Knee Dislocation (Anterior > Posterior) –– Neurovascular exam is essential as the risk of injury to popliteal artery and peroneal nerve is high. –– Consult vascular surgery for ABI