Orthopedic Study Notes

Course Introduction

• Focus on Orthopedics

  • Two classes scheduled for coverage

  • Topics can be overwhelming; many are unfamiliar to students

  • Primary source: John Muthek's chapters on Orthopedics

  • Additional reference: JEM (John Muthek, 8th edition)

Fractures and Dislocations

Base of the Skull Fracture

• Signs and Symptoms:

  • Common in head injuries from trauma (e.g., motor vehicle accidents)

  • Symptoms include:

  • CSF rhinorrhea (bleeding from the nose)

  • CSF otorrhea (bleeding from the ears)

  • Raccoon eyes (bruising around the eyes)

  • Battle sign (bruising on the mastoid bone)

• Diagnosis:

  • CT or MRI is necessary to confirm a base skull fracture.

• Management:

  • Look for signs of intracranial infection.

  • Avoid excessive interference with nose or ears (e.g., advise against blowing nose).

  • Avoid NG tube packing.

  • No routine antibiotic prophylaxis unless infection is present.

  • Symptomatic management is typically required.

  • Consult neurosurgeon for severe cases.

Malar Fracture (Zygomatic Maxillary Complex)

• Causes:

  • Common in contact sports or altercations.

• Features:

  • Swelling of face/cheek.

  • Circumocular hematoma.

  • Subconjunctival hemorrhage.

  • Palpable deformity on infraorbital margin if displaced.

  • Paresthesia from infraorbital nerve injury (most common symptom).

  • Potential for difficulty opening the mouth due to pain.

• Management:

  • Exclude head injuries and ocular trauma (check visual acuity).

  • Refer for reduction under general anesthesia if displaced. Conservative management if not displaced.

Thoracolumbar Fracture

• Types:

  • Stable vs. Unstable fractures.

• Definition:

  • Stable fracture: Compression fracture <50% height loss (common in elderly, particularly with osteoporosis).

• Treatment:

  • For stable fractures: Bed rest and back brace.

  • Monitor for complications (e.g., kidney injury from L1 fracture).

  • Check for hematuria.

• Unstable Fractures:

  • Require immediate referrals and may necessitate surgical intervention.

Analgesics and Initial Management of Fractures

• Pain Management: Always conduct initial assessment with analgesics unless vascular or nerve injury requires immediate intervention.

• Bed Rest: Only prescribed for thoracolumbar compression fractures; otherwise, mobility is encouraged.

• Bone Density Scan: Important for assessing osteoporosis in patients with compression fractures.

• Radial Nerve Assessment: Ensure no injury in upper extremity fractures (especially humerus and clavicle).

Common Upper Limb Fractures

Clavicular Fracture

• Mechanism: Fall on outstretched hand or direct blow.

• Signs: Extreme shoulder pain, arm held at elbow, swelling, common fracture site at the middle third.

• Assessment: Rule out neurovascular injuries (check radial pulse).

• Treatment: Use an St. John’s sling for 3-6 weeks. Surgery may be needed for open or severely displaced fractures.

Humerus Fractures

• Management: Similar to clavicular fractures; surgical intervention may be needed for severely displaced fractures.

• Supracondylar Fractures: Particularly in children, can lead to complications such as brachial artery injury. Management focuses on careful monitoring.

Fracture of Scaphoid Bone

• Signs and Symptoms: Pain at the anatomical snuffbox.

• Diagnosis: Risk of false negatives in initial X-rays. Treatment may still be needed for suspected fractures.

• Management: If fracture is suspected but not visible, immobilize in a scaphoid cast for 10 days, then reassess with imaging.

• Complications: Risk of avascular necrosis if untreated.

Metacarpal Fracture

• Common injuries from punching or falls; often treated with manipulation and splinting.

Lower Limb Fractures

Pelvic Fractures

• Differentiate between stable and unstable fractures.

• Unstable fractures require surgical intervention due to the risk of visceral injury.

Femoral Fractures

• Common in the elderly, especially neck of femur fractures.

• Management varies based on displacement; stable fractures may be pinned, while severely displaced may require hip replacement.

Tibia and Fibula Fractures

• Fractures require full leg casting if minimal displacement; surgical intervention for displaced fractures.

Stress Fractures

• Common in athletes. Clinical assessment is more critical than initial imaging.

Low Back Pain

• Most Common Cause: Mechanical low back pain due to vertebral dysfunction.

• Red Flags for Serious Disorders:

  • Age <20 or >50, history of cancer, fever, unexplained weight loss, or neurological deficits.

• Initial Management: Analgesics (e.g., paracetamol), activity encouragement, physiotherapy when appropriate.

• Types of Pain: Differentiate between inflammatory pain (improves with activity) and mechanical pain (worsens with activity).

Neck Pain

• Common Causes: Similar to low back pain (vertebral dysfunction, red flags for serious conditions).

• Initial Management: Analgesics, activity encouragement, physiotherapy as needed; avoid unnecessary imaging unless red flags present.

Shoulder Pain

• Key Pathologies:

  • Rotator cuff tendinopathy (supraspinatus injury)

  • Adhesive capsulitis (frozen shoulder)

• Diagnosis and Management:

  • Painful arc syndrome indicates subacromial space issue.

  • Management often involves ultrasound, strengthening exercises, and pain control medications.

  • Surgical intervention may be warranted after conservative measures fail.

Conclusion

• Comprehensive understanding of common orthopedic injuries and their management is crucial for effective clinical practice. Essential to grasp key diagnostic features and treatment strategies for exams and real-world applications.

Course Introduction

• Focus on Orthopedics

  • Two classes scheduled for coverage

  • Topics can be overwhelming; many are unfamiliar to students

  • Primary source: John Muthek's chapters on Orthopedics

  • Additional reference: JEM (John Muthek, 8th edition)

Fractures and Dislocations

Base of the Skull Fracture

• Signs and Symptoms:

  • Common in head injuries from trauma (e.g., motor vehicle accidents)

  • Symptoms include:

  • CSF rhinorrhea (bleeding from the nose)

  • CSF otorrhea (bleeding from the ears)

  • Raccoon eyes (bruising around the eyes)

  • Battle sign (bruising on the mastoid bone)

• Diagnosis:

  • CT or MRI is necessary to confirm a base skull fracture.

• Management:

  • Look for signs of intracranial infection.

  • Avoid excessive interference with nose or ears (e.g., advise against blowing nose).

  • Avoid NG tube packing.

  • No routine antibiotic prophylaxis unless infection is present.

  • Symptomatic management is typically required.

  • Consult neurosurgeon for severe cases.

Malar Fracture (Zygomatic Maxillary Complex)

• Causes:

  • Common in contact sports or altercations.

• Features:

  • Swelling of face/cheek.

  • Circumocular hematoma.

  • Subconjunctival hemorrhage.

  • Palpable deformity on infraorbital margin if displaced.

  • Paresthesia from infraorbital nerve injury (most common symptom).

  • Potential for difficulty opening the mouth due to pain.

• Management:

  • Exclude head injuries and ocular trauma (check visual acuity).

  • Refer for reduction under general anesthesia if displaced. Conservative management if not displaced.

Thoracolumbar Fracture

• Types:

  • Stable vs. Unstable fractures.

• Definition:

  • Stable fracture: Compression fracture <50% height loss (common in elderly, particularly with osteoporosis).

• Treatment:

  • For stable fractures: Bed rest and back brace.

  • Monitor for complications (e.g., kidney injury from L1 fracture).

  • Check for hematuria.

• Unstable Fractures:

  • Require immediate referrals and may necessitate surgical intervention.

Analgesics and Initial Management of Fractures

• Pain Management: Always conduct initial assessment with analgesics unless vascular or nerve injury requires immediate intervention.

• Bed Rest: Only prescribed for thoracolumbar compression fractures; otherwise, mobility is encouraged.

• Bone Density Scan: Important for assessing osteoporosis in patients with compression fractures.

• Radial Nerve Assessment: Ensure no injury in upper extremity fractures (especially humerus and clavicle).

Common Upper Limb Fractures

Clavicular Fracture

• Mechanism: Fall on outstretched hand or direct blow.

• Signs: Extreme shoulder pain, arm held at elbow, swelling, common fracture site at the middle third.

• Assessment: Rule out neurovascular injuries (check radial pulse).

• Treatment: Use an St. John
  ’s sling for 3-6 weeks. Surgery may be needed for open or severely displaced fractures.

Humerus Fractures

• General Management: Similar to clavicular fractures; surgical intervention may be needed for severely displaced fractures or those with neurovascular compromise.

• Proximal Humerus Fractures:

  • Common in elderly patients, often due to falls on an outstretched hand.

  • Can be managed conservatively with sling immobilization if minimally displaced.

  • Surgical options (e.g., open reduction internal fixation, arthroplasty) for significantly displaced or angulated fractures, especially in younger patients.

• Humeral Shaft Fractures:

  • Often caused by direct trauma or torsion.

  • Risk: High incidence of radial nerve injury (wrist drop, sensory loss over dorsum of hand). Neuropraxia often resolves spontaneously.

  • Treatment: Functional bracing is often effective for closed shaft fractures. Surgical fixation may be indicated for open fractures, segmental fractures, pathological fractures, or those with associated vascular injury.

• Supracondylar Fractures:

  • Particularly in children, often due to fall onto hyperextended elbow.

  • Complications: Can lead to brachial artery injury (Volkmann's ischemic contracture) or median/radial nerve injury.

  • Management: Careful monitoring for vascular compromise (compartment syndrome) is crucial. Often requires closed reduction and percutaneous pinning.

Fracture of Scaphoid Bone

• Signs and Symptoms: Pain at the anatomical snuffbox.

• Diagnosis: Risk of false negatives in initial X-rays. Treatment may still be needed for suspected fractures.

• Management: If fracture is suspected but not visible, immobilize in a scaphoid cast for 10 days, then reassess with imaging.

• Complications: Risk of avascular necrosis if untreated.

Metacarpal Fracture

• Common injuries from punching or falls; often treated with manipulation and splinting.

Lower Limb Fractures

Pelvic Fractures

• Differentiate between stable and unstable fractures.

• Unstable fractures require surgical intervention due to the risk of visceral injury.

Femoral Fractures

• Overview: Common and often serious injuries due to the significant force required to fracture the femur.

• Causes: High-energy trauma (e.g., motor vehicle accidents) in younger patients, and low-energy falls (e.g., ground-level falls) in elderly patients, especially those with osteoporosis.

• Types and Management:

  • Neck of Femur (NOF) Fractures:

  • Common in the elderly. Classified based on location (subcapital, transcervical, basicervical) and displacement (e.g., Garden classification).

  • Blood Supply: Critical concern due to risk of disruption of the blood supply to the femoral head, leading to avascular necrosis (AVN) or non-union, particularly with displaced subcapital fractures.

  • Treatment:

    • Non-displaced/Minimally Displaced: Often managed with internal fixation (e.g., pinning, cannulated screws) to preserve the femoral head.

    • Displaced: In younger, active patients, attempts are made to preserve the femoral head via open reduction and internal fixation (ORIF). In elderly, less active patients, hip replacement is often favored:

    • Hemiarthroplasty: Replaces the femoral head only.

    • Total Hip Arthroplasty (THA): Replaces both the femoral head and the acetabulum.

  • Intertrochanteric Fractures:

  • Occur between the greater and lesser trochanters. Common in elderly patients, generally extracapsular with good blood supply, thus lower risk of AVN.

  • Treatment: Typically managed surgically with devices such as an intramedullary nail (e.g., gamma nail) or a dynamic hip screw (DHS) to provide stable fixation and allow early mobilization.

  • Subtrochanteric Fractures:

  • Occur below the lesser trochanter. Often high-energy injuries in younger patients or pathological fractures in the elderly.

  • Treatment: Almost always require surgical intervention, usually with intramedullary nailing due to the complex biomechanics of this region.

  • Femoral Shaft Fractures:

  • Result from high-energy trauma. Associated with significant blood loss ($1-2L$) and risk of fat embolism, compartment syndrome.

  • Treatment: Standard treatment is intramedullary nailing, which provides strong internal fixation, allowing for early weight-bearing and rehabilitation.

  • Distal Femur Fractures:

  • Occur in the metaphyseal and epiphyseal regions near the knee joint. Can be intra-articular.

  • Treatment: Often require ORIF with plates and screws, especially if intra-articular, to restore joint congruity and stability.

• Complications: Avascular necrosis, non-union, infection, deep vein thrombosis (DVT), pulmonary embolism (PE), fat embolism, compartment syndrome, malunion.

• Rehabilitation: Post-operative rehabilitation is crucial for restoring strength, range of motion, and weight-bearing capabilities.

Tibia and Fibula Fractures

• Fractures require full leg casting if minimal displacement; surgical intervention for displaced fractures.

Stress Fractures

• Common in athletes. Clinical assessment is more critical than initial imaging.

Low Back Pain

• Most Common Cause: Mechanical low back pain due to vertebral dysfunction, often stemming from muscle strain, ligamentous sprain, facet joint arthritis, degenerative disc disease, or minor postural issues. It is typically self-limiting.

• Red Flags for Serious Disorders: These indicate potential underlying serious conditions requiring urgent investigation and are crucial to identify:

  • Age <20 or >50: Suggests a higher likelihood of systemic disease, tumor, or infection.

  • History of cancer: Raises suspicion for metastatic disease to the spine.

  • Fever, chills, night sweats: May indicate spinal infection (e.g., osteomyelitis, discitis).

  • Unexplained weight loss: A common symptom of malignancy or chronic infection.

  • Neurological deficits: Progressive motor weakness, saddle anesthesia, bowel or bladder dysfunction (urinary retention/incontinence) suggest cauda equina syndrome or severe spinal cord compression.

  • IV drug use or immunosuppression: Increased risk of spinal infections.

  • Trauma: High-energy trauma can cause fractures or dislocations.

  • Steroid use: Increases risk of osteoporosis and vertebral compression fractures.

• Initial Management:

  • Analgesics: Over-the-counter pain relievers such as paracetamol or NSAIDs (e.g., ibuprofen) are primary. Muscle relaxants may be considered for acute muscle spasms.

  • Activity Encouragement: Gentle, progressive return to normal activities is more beneficial than prolonged bed rest, which can worsen deconditioning. Avoid activities that exacerbate pain significantly.

  • Physiotherapy: When appropriate, provides structured exercise programs, manual therapy, and education on posture and body mechanics to strengthen core muscles and improve flexibility.

  • Heat/Cold Therapy: Can provide symptomatic relief.

  • Avoid Unnecessary Imaging: Imaging (X-rays, MRI) is generally not recommended for acute, uncomplicated low back pain without red flags, as findings might be incidental and lead to unnecessary interventions.

• Types of Pain: Differentiate between inflammatory pain and mechanical pain:

  • Inflammatory Pain: Often characterized by morning stiffness lasting
    >30 minutes, improvement with activity, and worsening with rest/inactivity (common in conditions like ankylosing spondylitis).

  • Mechanical Pain: Typically worsens with specific movements or activity, improves with rest, and may not have significant morning stiffness.

Neck Pain

• Common Causes: Similar to low back pain (e.g., muscle strain, ligament sprain, degenerative disc disease, facet joint arthritis, poor posture, stress). Whiplash injuries from trauma are also frequent causes.

• Red Flags for Serious Disorders: Similar to low back pain, indicating potential serious underlying conditions:

  • Age <20 or >50, history of cancer, fever, unexplained weight loss, night sweats.

  • Neurological deficits (progressive motor weakness, gait disturbance, numbness, tingling in all four limbs) suggesting myelopathy or severe nerve compression.

  • Severe, unremitting pain, especially at night or unrelieved by rest.

  • History of trauma (especially high-energy).

  • IV drug use or immunosuppression (risk of infection).

• Nerve Root Involvement (Radiculopathy): Compression or irritation of cervical nerve roots can cause pain, numbness, tingling, and weakness radiating into the shoulders, arms, and hands.

  • Common causes: Cervical disc herniation (often acute onset after strain), spinal stenosis (gradual onset due to degenerative changes), and osteophytes (bone spurs).

  • Clinical Presentation: Symptoms follow a dermatomal and myotomal pattern (e.g., $C5$ for deltoid weakness/shoulder pain, $C6$ for biceps weakness/radial forearm pain, $C7$ for triceps weakness/middle digit pain, $C8$ for intrinsic hand muscle weakness/ulnar hand pain).

  • Neurological Examination: Assessment of motor strength, sensory discrimination, and deep tendon reflexes (biceps $C5/C6$, brachioradialis $C5/C6$, triceps $C7$) helps localize the affected nerve root.

• Myelopathy: This is a more serious condition where there is compression of the spinal cord itself, leading to upper motor neuron signs (e.g., gait disturbance, spasticity, hyperreflexia, positive Babinski sign) in addition to potential radicular symptoms. Requires urgent referral.

• Initial Management:

  • Analgesics: Paracetamol, NSAIDs, and sometimes muscle relaxants for acute muscle spasms.

  • Activity Encouragement: Maintain normal activity as tolerated; avoid prolonged immobility. Gentle stretching and range-of-motion exercises.

  • Physiotherapy: Once acute pain settles, focus on therapeutic exercises to strengthen neck and upper back muscles, improve posture, and enhance flexibility. Manual therapy techniques can also be beneficial.

  • Imaging: Avoid unless red flags are present, symptoms are progressive, or conservative treatment fails after several weeks. X-rays, CT or MRI may be used to identify fractures, significant degenerative changes, disc herniation, or spinal cord compression.

  • Cervical Collar: Short-term use (a few days) may provide comfort for acute injuries like whiplash, but prolonged use can lead to muscle weakness and stiffness.

  • Referral: Neurosurgical or orthopedic consultation for severe neurological deficits, myelopathy, or intractable pain despite conservative management