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0R5 Orthopaedic Surgery Toronto Notes 2023
Table 2. Muscle and Compartment Review of the Limbs
Arm Forearm Thigh Leg
Anterior Compartment Biceps Bractrii
Brachialis
Coracobracilialis
PronatorIeres
fleior CarpiBabralis
Palmarrs Loogus
Fleior CarpiUlnaris
Fleior Drgitorum
Superficialis
Fleior Drgitorum Profundus
Fleior Pollers longus
Pronator Ouadratus
Brachioradialis
Eitensor Carpi Badialis
longus
Eitensor Carpi Radiahs
Brens
Eitensor Carpi Ulnarrs
Eitensor Digrtorum
Eitensor Digiti Minimi
Abductor Pollicis Longus
Eitensor Pollicis longus
Eitensor Pollicis Brevis
Eitensor Indrcis
Supinator
Sartorius
Ouadriceps
Bectus Femoris
Vastus Lateralis
Vastus Intermedius
Vastus Medralis
Tibialis Anterior
Eitensor Hallucis Longus
Eitensor Drgitorum Longus
Peroneus tertius
Posterior Compartment Triceps
Aconeus
Hamstrings
Semitendinosus
Semimembranosus
BicepsFemoris
Superficial
Gastrocnemius
Soleus
Plantaris
Deep
Popliteus
Flexor Hallucis Longus
Flexor Digitorum longus
Tibialis Posterior
Medial Compartment Adductor Longus
Adductor Brevis
Adductor Magnus
Sracilis
Pectineus
Lateral Compartment Peroneuslongus
Fibularis Brevis
Fractures-General Principles
Fracture Description
Displacement
Refers to position of the distal fragment
relative to the proximal fragment
1. Name of Injured Bone
2. Integrity of Skin/Soft Tissue
• closed:skin/soft tissue over and near fracture is intact
• open:skin/soft tissue over and near fracture islacerated or abraded,such that fracture site can
communicate with contaminants(Le.outside environment or bowel)
• signs:continuous bleeding from puncture site,or fat dropletsin blood are suggestive of an open
fracture
Varus/Valgus Angulation
Refers to the distal segment of the bone
compared to the proximal segment
Varus ~ Apex away from midline
3. Location Valgus - Apex toward midline
• epiphyseal:end of bone,forming part of the adjacent joint
• metaphyseal: the tlared portion of the bone at the ends of the shaft
• diaphyseal: the shaft of a long bone (proximal, middle,distal )
• physis: growth plate
4. Orientation/Fracture Pattern (see figure -t, OK6)
• transverse:fracture line perpendicular (<30° of angulation) to long axis of bone; result of direct high
energy force
• oblique:angular fracture line (30°-60°of angulation);result of angulation and compressive force, high
energy
• butterfly: triangular or wedge-shaped fragment resembling a butterfly;commonly between the two
main fracture fragments in comminuted long bone fractures
• segmental: a separate segment of bone bordered by fracture lines;often the result of high-energy force
• spiral: complex, multi-planar fracture line; result of rotational force,low energy
• comminuted/multi-fragmentary:>2 fracture fragments
• intra-articular:fracture line crosses articular cartilage and enters joint
• compression: impaction of bone:typical sites are vertebrae or proximal tibia
• torus: compression of bony cortex on one side while the other remains intact, often seen in children
(see figure 50, UR45)
• screenstick:compression of one side with fracture of the opposite cortex, often seen in children (see
figure 50, OR45 )
• pathologic:fracture through abnormal bone weakened by disease (e.g.tumour)
Quick Upper Extremity Motor Nerve
Exam
“Thumbs Up”:PIN (Radial Nerve)
“OK Sign": AIN (Median Nerve)
“Spread Fingers":Ulnar Nerve
X-Ray Rule of 2s
2 sides - bilateral
2 views AP lateral
2 joints -joint above below
2 times - before *
after reduction
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Sample Fracture Description
Closed (overlying skin integrity) spiral
fracture (fracture pattern) of the distal
third (location) of the left tibia (injured
bone),with mild varus angulation,lateral
translation and angulation (alignment of
fracture fragments).The fracture does
not extend to the joint surface
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0R6 Orthopaedic Surgery Toronto Notes 2023
5. Alignment of Fracture Fragments (see Figure 5)
• non-displaced: fracture fragments are in anatomic alignment
• displaced:fracture fragments are not in anatomic alignment
• distracted:fracture fragments are separated by a gap (opposite of compression)
• translated: percentage of overlapping bone at fracture site
• angulated: direction of fracture apex (e.g. varus/valgus)
• rotated: fracture fragment rotated about long axis of bone
• shortened: fracture fragments are compressed, resulting in shortened bone
• avulsion: tendon or ligament tears/pulls off bone fragment
ir
“t A \
U V F
Spongy
/ bone
, V
_
Proximal -
epiphysis
B. Oblique C. Butterfly D. Segmental E.Spiral F. Comminuted t
Articular
- vj cartilage
^""Epiphyseal line
v Periosteum
N © Lisa Qiu 2019. alter 3Carly Vanderlee 2011 A.Transverse
Figure 4. Orientation/fracture pattern Compact bone
-- Medullary
haphysrs
A. Translated B. Angulated C. Rotated D. Sliorlened E. Avulsion
SiLisa Qiu 2019.altar © Carly Vanderlaa 2011 epiphysis
Orstal —
Figure 6. Schematic diagram of the
long bone
Figure 5. Alignment of fracture fragments
Approach to Fractures
I . Clinical Assessment Reasons for Closed Reduction and
Splinting
• Pain control
• Reduces further damage to vessels,
nerves, and skin and may improve
neurovascular status
• Reduces point loading on articular
surfaces
• Decreases risk of inadvertently
converting closed to open fracture
• Facilitates patient transport
ABCs, primary survey, and secondary survey (Advanced Trauma Life Support (AT'
LS) protocol)
assess for life threatening Injury
assess for open and other fractures
• AMPLE- E history (minimum): Allergies, Medications, Past medical history. Last meal, Events
(mechanism of injury),function pre-injury
previoussignificant injury orsurgery to affected area
consider pathologic fracture with history of only minor trauma
• physical exam:inspect (deformity,soft tissue integrity); palpate (maximal tenderness, N VSdocument best possible neurovascular exam, avoid ROM/moving injured area to prevent
exacerbation)
2. Analgesia
• oral, IV, or local (e.g. hematoma block)
3. Imaging (seeOrthopaedic X - Ray Imaging, ORR)
I. Reduction:closed vs. open
• closed reduction (with IV sedation and muscle relaxation if necessary)
apply traction in the long axis of the limb
reverse the mechanism that produced the fracture
open reduction
“NO CAST" (see sidebar)
other indications include
- failed closed reduction
- unable to cast or apply traction due to site
- pathologic fractures
- potential for improved function and/or outcomes with OR1E
• ALWAYS re-check and document N VS after reduction and obtain post-reduction x-ray
Indicationsfor Open Reduction
NO CAST
Nonunion
Open fracture
Neurovascular Compromise
Displaced intra-Articular fracture
Salter-Harris 3,4,5
PolyTrauma
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0R7 Orthopaedic Surgery TorontoNotes 2023
5.Immobilization
externalstabilization:splints, casts,traction, external fixator
internal stabilization:percutaneous pinning,extramedullary fixation (screws, plates, wires),IM
fixation (rods)
6. Follow-up
evaluate stages of bone healing (see Fracture Healing)
7.Rehabilitation
recommend rehabilitation when appropriate to regain function and avoid joint stiffness
Buck's Skin Traction
A system of weights,pulleys,and
ropes that are attached to the end of
a patient's bed exerting a longitudinal
force on the distal end of a fracture,
improving its length,alignment and
rotation temporarily while awaiting
fixation (typically used for lower
extremity fractures)
Fracture Healing
Normal Healing
Weeks 0-3 Hematoma,macrophages surround fracture site
Wolffs Law
Bone adapts to the amount of force
applied by increasing or decreasing its
mass to resist the applied stress
Weeks 3-6 Osteoclasts remove sharp edges, callus forms within hematoma
Weeks 6-12 Bone forms within the callus, bridging fragments
Months 6-12 Cortical gap is bridged by bone
Years 1-2 Normal architecture is achieved through remodelling
Figure 7. Stages of bone healing
Evaluation of Healing:Tests of Union
• clinical: no longer tender to palpation, no mobility, minimal or no deformity on physical exam
• x-ray: trabeculae crossfracture site,visible callus bridging site on at least 3 of 4 cortices
General Fracture Complications
Fracture Blister
Formation of vesides or buBae that
occur on edematous skin overlying a
Table 3.General Fracture Complications fractured bone
Early Late
Compartment syndrome
Neurological injury
Vascular injury
Infecbon
Implant failure
fracture blisters
Local Mai-,
'
non-union
AVN
Osteomyelitis
Heterotopic ossification
Post-traumatic OA
Joint stiffness/adhesive capsulitis
CUPS typel/RSD
Heterotopic Ossification
The formation of bone in abnormal
locations (e.g.in musde). secondary to
pathology
Systemic Sepsis
DVT
PE
CRPSRSD
Sustained sympathetic activity
characterized by pain out of proportion
to physical exam findings:symptoms of
hyperalgesia and alodynia. and signs
of autonomic dysfunction (temperature
asymmetry,mottling,hair or nai
changes)
ASOS secondary to fat embolism
Hemorrhagic shock
Articular Cartilage
Properties
• hyaline cartilage
• 2-4 mm layer covering ends of articulating bones, provides nearly frictionlesssurface
• avascular (nutrition from synovial fluid), aneural,alymphatic Avascular Necrosis
Ischemia of bone due to disrupted
blood supply,most commonly affecting
the femoral head,talus,or proximal
scaphoid
ARTICULAR CARTILAGE DEFECTS
Etiology
• overt trauma,repetitive minor trauma (such as repetitive ankle sprains or patellar maltracking)
• degenerative conditions such as early stage OA or osteochondritis dissecans
Osteochondritis Dissecans
Avascular necrosis of subchondral
bone most often occurraig in children
and adolescents and causing pain and
potentially hindering joint motion
Clinical Features
• part of OA presentation:pain with movement, decreased range of motion, joint line pain with possible
effusion
• have predisposing factorssuch as:ligament injury; malalignment of the joint (e.g. varus or valgus);
obesity; AVN;and inflammatory arthropathy
• may have mechanicalsymptoms of locking or catching related to the torn/displaced cartilage
Investigations
• x-ray (to rule out bony defects and check alignment)
• MR1 (if x-ray is normal; MR1 is not needed to assess cartilage loss associated with osteoarthritis)
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0R8 Orthopaedic Surgery Toronto Notes 2023
Table 4. Outerbridge Classification of Chondral Defects
Grade Chondral Damage
Softening and swelling of cartilage
Fragmentation and fissuring <l/2"in diameter
Fragmentation and fissuring >112*
in diameter
Frosion of cartilage down to bone
I
II
III
IV
Treatment
• individualized
• patient factors (age,skeletal maturity, activity level,etc.)
• defect factors (OuterbridgeClassification,subchondral bone involvement, etc.)
• non-operative
• rest,COX2 inhibitors, NSAIDs, bracing, physiotherapy, intra-articular corticosteroids
• operative
• microfracture, osteochondral grafting (autograft or allograft),autologous chondrocyte
implantation
Orthopaedic X-Ray Imaging
General Principles - “Rule of 2s”
• x-ray 1 joint above and 1 below
• obtain at least 2 orthogonal views ± specialized views
• 2 sides, as needed for comparison
When reading a radiograph consider
• open or closed fracture (air/gasseen in the soft tissue)
• the view
• anatomical location
• laterality (right vs.left)
• skeletally mature vs. immature
• intra-articular vs. extra-articular
• joint congruent,subluxed or dislocated
• rotation
• angulation
• displacement
• shortening
Sample radiograph description:
“There is a simple transverse fracture of
the proximalright humerus diaphysis.
There is1cm of shortening.The distal
fragment is medially angulated 70
degrees"
Table 5. Orthopaedic X-Ray Imaging
Site Injury X-Ray Views
Shoulder Anterior dislocation
Posterior dislocation
AC separation
AP
Axillary t stress mew with10 lbinhand
Trans-scapular
Tanca view (10-15 cephalic tilt)
Arm Humerus A AP
Lateral
Supracondylar A
Radial head A
Monteggia A
Nightstick A
Galeazzi A
Colies'A
Smith A
Scaphoid A
Pelvic A
Elbow/Forearm AP
Lalecal
Wrist AP
lateral
ClenchedFist (foe scaphotunate dissociation)
AP pelvis
Inlet and outlet views
Judet mews (obturator and iliac oblique for acetabular A)
Pelvis
Hip Femoral head'neck A
Intertrochanteric A
Arthritis
AP
lateral
Frog-leglateral
SCFE Ounr
FAI False profile
Developmental dysplasia of the hip (DDH|
Knee dislocation
Femur/tibia A
Patella A
Patella dislocation
Patella femoral syndrome
Tibia shaft A
Fibula shaft A
ri
Knee AP standing,lateral
Skyline (tangenbalnew with knees flexed at 45°to see patellofemoral joint)
<- J
Leg AP +
lateral
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0R9 Orthopaedic Surgery Toronto Notes 2023
Table 5. Orthopaedic X-Ray Imaging
Site Injury X-Ray Views
Ankle Ankle S AP
Lateral
Mortise view (ankle at15° of internal rotation)
Talart
Calcaneal t
Foot AP
lateral
Oblique
lateral. Karris,anal
AP spine
AP odontoid
lateral
Oblique
Swnmmec'
jnew (lateral view with arm abducted 180'
to evalua te C7-I1
junction if lateral viewisinadequate)
lateral Reuorv’eilensionnew: evaluate subluxation of cervical vertebrae
MTI
lisftanc injuries
Compression i
Burstt
Cervical spine A
Spine
Orthopaedic Emergencies
Trauma Patient Workup
Etiology
• high energy trauma (e.g. MVC,fall from height)
• may be associated with spinal injuriesor life-threatening visceral injuries
Clinical Features
• comminuted, open fractures with significant soft tissue injury
• localswelling, tenderness,deformity of the limbs, and instability of the pelvis or spine
• decreased level of consciousness,hypotension,hypovolemia
• consider involvement of EtOH or other psychoactive substances
Orthopaedic Emergencies
VON CHOP
Vascular compromise
Open fracture
Neurological compromise/cauda
equina syndrome
Compartment syndrome
Hip dislocation
Osteomyelitis/septic arthritis
Unstable Pelvic fracture
Investigations
• trauma survey (see Emergency Medicine. ER2)
• x-rays:lateral cervical spine, AP chest,AP pelvis,AP and lateral of all bones suspected to be injured
CT is also utilized to inspect for musculoskeletal injuries in the trauma setting
• other views of pelvis:AP,inlet,and outlet; )udet viewsfor acetabular fracture (see Table 19, OR30)
Treatment
• ABCDEs:initiate resuscitation for life-threatening injuries(ATLS protocol)
• assess genitourinary injury (rectal exam/vaginal exam mandatory)
• external or internal fixation of all fractures
• if patient unstable then Damage Control Orthopaedics- use of external fixation for fractures initially
and then bring patient back to OR for definitive fixation (1M nail or OR1E) once hemodynamically
stable
• DVT prophylaxis once stable
Controversies in Initial Management of Open
Fractures
Scar,dJSurg2014;103(2):132-137
Study:Literaturereview exam icing the initial
management of open fractures. 40 studies ir.duded.
Findings:
•A first-generation cephalosporin (or clindavlyda}
should be administered upon arnvaL In general.24
h of antibiotics after each debridement issufficient
to reduce infection rates.
•Although cultures ate taken from delayed (»24 h|
or infected injuries, it may not be necessary to
routinely take post-debridenent cultures open
fractures.
•Open fracturesshould be debrided assoon as
possible,although the'
6 h rule' Complications is not generally
• hemorrhage -life-threatening (may produce signs and symptoms of hypovolemic shock)
• fat embolism syndrome - SOB, hypoxemia, petechial rash, thrombocytopenia, and neurological
symptoms
• venous thromboembolism - DVT and PE
• bladder/urethral/bovvel injury
• neurological and vascular damage
• persistent pain/stiffness/limp/vveaknessin affected extremities
• post-traumatic OA of joints with intra-articular fractures
• sepsis and/or tetanus infection especially if missed open fracture
valid.
•Wo undo should be closed w.thi.n 7 d once soft tissue
hasstood red and all non- nob e tissue removed.
•Negative pressure wound therapy (HPWT) has
been shown to decrease infectkm totes in open
froctores.
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ORIO Orthopaedic Surgery Toronto Notes 2023
Open Fractures
•fractured bone and hematoma in communication with the external or contaminated environment
33% of patients with open fractures have
Emergency Measures multiple injuries
•ABCs, primary survey,and resuscitate as needed
•remove obvious foreign material once in a controlled hospital environment
•irrigate with normal saline if grossly contaminated
•cover wound with sterile dressings
•immediate IV antibiotics
•tetanus toxoid or immunoglobulin as needed (see Plastic Surgery. PL28)
•N PO and prepare for OR (blood work, consent, ECC>,CXR)
operative irrigation and debridement within 6-8 h to decrease risk of infection
OKI I
traumatic wound may be left open to drain with vacuum-assisted closure if necessary
re-examine with repeat irrigation and debridement in -18 h if necessary
Antibiotic Prophylaxisin the Management of
Open Fractures
J8JS Reviews:2019 Feb:7(2|:e1
Purpose: Provide current practice recommendations
on prophylaxis for patients with open fractures of
the extremities.
Methods: Systematic survey of plications from
January 200)to June 201),and search of WohdCat for
textbooks and websites for institutional guidelines.
Results: Most recommendationssuggested
Cram-positive antibiotics up to 3 dpostxnjury
for less severe injuries.For more severe injr es.
most recommendations included broad spectrum
antibiotics for 2-3 d.A s well,most sources
recommend immediately administration of
antibiotics.
Conclusions:Current practice recommendations
supportearlysystemx prophylaxis for patents
with open fractures of the extremities.However,
differences are seen across antibiotic regimens,
doses,and duration of administration.
Table 6. Gustilo Classification of Open Fractures
Gustilo Grade Length of
Open Wound
Description Prophylactic Antibiotic Regimen
I Minimal contamination and soft tissue injury
Simple or minimaly comminuted fracture
First generationcephalosporin (cefa zolin) 2 g IV q8
h for 2 d
If allergy use clindamycin 300 mg IV q8 h
If MRSA positive use vancomycin15 mgi'kg IV q12 h
As per GradeI
«1cm
II 1-10 cm Moderate contamination
Moderate soft tissue injury
IIIA:Extensive soft tissue mjury with adequate First generation cephalosporin (cefazolin)for 2
ability of soft tissue to cover wound
IIIB:Extensive soft tissue injury with periosteal ceftriaxone) for at least 3 d
For soil or fecal contamination,metronidazoleis
added for anaerobic coverage r penicillin G
If MRSA positive use vancomycin16 mgi'kg IV q12 h
III* >10 cm
d plus Gram-negative coverage Igentamidn or
stripping and bone exposure:inadequate soft
tissue to cover wound
NIC:Vascular injury- compromise
'Anyhigh energy,comminuted fracture,shot gun.tarmysntsoilwater contemirstjor.exposure to oral flora,or fracture >8 hold is immediately
classified as Grade III
Cauda Equina Syndrome
• see Neurosurgery. NS32
Compartment Syndrome
• increased interstitial pressure in an anatomical compartment (forearm, calf) where muscle and tissue
are bounded by fascia and bone (fibro-osseous compartment),with little room for expansion
• interstitial pressure exceeds capillary perfusion pressure,leading to irreversible muscle necrosis (in
4-6 h) and eventually nerve necrosis
Etiology
• intracompartmental
• fracture (particularly tibialshaft or paediatric supracondylar and forearm fractures)
• reperfusion injury, crush injury,or ischemia
• extracompartmental:constrictive dressing (circumferential cast), poor position during surgery,
circumferential burn
Most important sign is increased pain
with passive stretch. Most important
symptom is pain out of proportion to
injury
Increased pressure from blood
and intracompartmental swelling"
*
1
5 Ps of Compartment Syndrome
Pa in: out of proportion for injury and
not relieved by analgesics
• Increased pain with passive stretch
of compartment muscles
Pallor:late finding
Paresthesia
Paralysis:late finding
Pulselessness:late finding
Decreased venous *
drainage
Decreased lymphatic drainage surrounding compartment
Transudation into tissue
Intracompartmental pressure
greater than perfusion pressure
Leaky basement
membranes
Musc^
and
"
^nerve necrosis
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Muscle and
nerve anoxia Acidosis 4-
Figure 8.Pathogenesis of compartment syndrome
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0R11 Orthopaedic Surgery Toronto Notes 2023
Clinical Features
• pain out of proportion to injury (typically first and mostsignificant symptom)
• pain with active contraction of compartment
• pain with passive stretch (most sensitive sign )
• swollen, tense compartment
• suspicious history
Plain Film Findings of Osteomyelitis
• Soft tissue swelling
• Lytic bone destruction"
• Periosteal reaction (formation of new
bone, especially in response to •)"
'Generally not seen on plain filmsunU10-12 dafter
onset olinlection
• 5 Ps: late sign -do not wait for these to develop to make the diagnosis!
Investigations
• compartmentsyndrome is a clinical diagnosis; investigations usually not necessary
• in children, unconscious patients, or associated peripheral nerve injury where clinical exam is
unreliable, compartment pressure monitoring with catheter (normal = 0 mmHg;elevated >30 mmHg
or [dBP -measured pressurej <30 mmHg)
Treatment
• non-operative
remove constrictive dressings (casts,splints), elevate limb to the level of the heart
• operative
urgent fasciotomv
• 48-72 h postoperative:necrotic tissue debridement + wound closure
• may require delayed closure and/or skin grafting
Rapid progression of signs and
symptoms (over hours) necessitates
need for serial examinations
Acute osteomyelitis is a medical
emergency which requires an early
diagnosis and appropriate antimicrobial
and surgical treatment Complications
• Volkmann’
sischemic contracture: ischemic necrosis of muscle;followed by secondary fibrosis; and
finally calcification - especially following supracondylar fracture of humerus
• rhabdomyolysis,renal failure secondary to myoglobinuria
Joints most commonly affected by septic
arthritis in descending order
knee - hip »elbow - ankle *
sternoclavicular joint
Osteomyelitis
•bone infection with progressive inflammatory destruction
Etiology
•most commonly caused by S. aureus
•mechanism ofspread:hematogenous (most common) vs.direct-inoculation vs.contiguousfocus
•risk factors:recent trauma/surgery, immunocompromised patients, DM, IV drug use, poor vascular
supply, peripheral neuropathy
Plain Film Findings ina Septic Joint
• Early (0-3 d): usually normal:may
show soft-tissue swelling or joint
space widening from localized
edema
• Late (4-6 d):joint space narrowing
and destruction of cartilage Clinical Features
•symptoms:pain and fever
•on exam:erythema, tenderness, edema common ± abscess/draining sinustract; impaired function/
VVB
Serial C reactive protein (CRP) can be
Diagnosis used to monitor response to therapy
•see Medical Imaging, MI24 and M127
•workup may include: WBC and differential, ESR,CRP, blood culture, aspirate culture/bone biopsy
Docs This Adult Patient Have Septic Arthritis?
JAMA 2007:297(13|:1478-t488
Purpose: To review the accuracy and pretss:
- of:
*
e
clinical evaluatin'
! for the diagnosis of nongrscocca
bacterial arthritis.
Methods: Devew of t4 studies mehiling 6242
patients of which 653 had positive srnova: cu tire
(gold standard diagnostic tnol forseptx afnts).
Results:Age,diabetes nelStos.rbearztod
arthritis, jointsurgery, hip or knee prosthesis,sc r
infection, and human immunodeficiency erastype
t infection significantly increase the proPati ity of
septic arthritisJoint pain, history of joctswtfrg.
and fever are found m >50
*
of cases.The presence
ol inoeased WBC increasesthe Iiielzood rano for
counts <2SOOO/pL:W,0.32;95
*
a.0.23 0.43
for counts >25000/pL LR.2.9:95
*0.2J-3.4:foe
counts elOOOOOipL:IR.2B.0:95
*
0,C.0-66.C|.A
polymorphonuclear cell count of ?90
* mueasesoe
IR of septic arthritis hy 3.4.*
!e a PMI cel coat of
<90% reducestheLR by 0.34.
Conclusions Clinical findings may pe used a idem ’
patients with monoarticular arthritis who may
have septic arthritis,laboratory findingsfrom as
arthrocentesis are also required and helpful poor a
Oram stain and culture.
Table 7. Treatment of Osteomyelitis
Acute Osteomyelitis Chronic Osteomyelitis
IV antibiotics 4-6 wk:started empirically and adjusted alter obtaining Surgical debridement
blood and aspiratecultures
± surgery (liD)for abscess or significant involvement
* hardware removal(if present)
Antibiotics:both local(e.g.antibiotic beads) and systemic (IV)
Septic Arthritis
•joint infection with progressive destruction if left untreated
Etiology
•most commonly caused by S.aureus in adults
•consider coagulase-negative Staphylococcus in patients with prior joint replacement
•consider,V.gonorrhocac in sexually active adults, and newborns
•most common route of infection is hematogenous
•risk factors: young/elderly (age >80 yr), prosthetic joint, recent joint surgery,skin infection/ulcer,
IV drug use,recent intra-articular corticosteroid injection, immunocompromised (cancer, DM,
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0R12 Orthopaedic Surgery Toronto Notes 2023
Clinical Features
• inability/refusal to hear weight, localized joint pain, erythema, warmth,swelling, pain on active and
passive ROM, ± fever Posterior Shoulder Dislocation
Up to 60-80% are missed on initial
presentation dueto poor physical exam
and radiographs
Investigations
• x-ray (to rule out fracture, tumour, metabolic bone disease), ESR,CRP, WBC, blood cultures
• joint aspirate: cloudy yellow fluid, WBC >50000 with >90% neutrophils, protein level >4.4 rng/dL,
joint glucose level <60% blood glucose level, no crystals, positive Gram stain results
• listen for heart murmur (if concern for infective endocarditis, use Duke Criteria)
There are 4Joints inthe Shoulder
Glenohumeral.AC.sternoclavicular (SC),
scapulothoradc
Treatment
• IV antibiotics, empiric therapy (based on age and risk factors), adjust following joint aspirate C&S
results
• non-operative
• therapeutic joint aspiration,serially if necessary
• operative
• arthroscopic or open irrigation and drainage
Shoulder passive ROM:abduction180°,adduction - 45°.flexion -180°.
extension - 45°.int rotation -level of
T4,ext.rotation -‘
90°likely more...
Shoulder
Factors Causing Shoulder Instability
, Shallow glenoid
• Loose capsule
• Ligamentous laxity
Frequency of Dislocations
. Anterior shoulder >Posterior
shoulder
• Posterior hip>Anterior hip
• The glenohumeral joint is the most
commonly dislocated joint in the
body since stability is sacrificed for
motion
Shoulder Dislocation
•complete loss of continuity between the two articular surfaces of the glenohumeral joint; may be
anterior or posterior
Investigations
- anterior dislocation x-rays: AP, trans-scapular, and axillary views ofthe shoulder
•posterior dislocation x-rays: AP, trans-scapular, and axillary views of the shoulder; orCT scan
Table 8. Anterior and Posterior Shoulder Dislocation
Anterior Shoulder Dislocation (>90%) Posterior Shoulder Dislocation(5%)
MECHANISM
Adducted,internally rotated,flexedarm
FOOSK
3Es (epilepticseizure. EtOH.electrocution)
Blow to anterior shoulder
Abducted externally rotated/hyperextended arm
Blow toposterior shoulder
Involuntary,usually Iraumalic; voluntary,atraumatic
CLINICAL FEATURES
Symptoms Pain,arm slightly abducted and externally rotated with
inability to internally rotate
Pain,arm is held in adduction and internal rotation;
externalrotation is blocked
"Squared off shoulder
Positiveapprehension test: palientlooks apprehensive
with gentle shoulder abduction and externalrotation to 90”
Positiveposterior apprehension (“jerk") test:with
as humeral head is pushed anteriorly and recreates feeling patientsupine.flex elbow 90° and adduct,internally
rotate the arm while applying a posterior force to the
shoulder;patient will“jerk* back with the sensation of
Anterior shoulder flattening,prominent coracoid,
palpable mass posterior to shoulder
Shoulder Exam
1.Manubrium
2.Sternoclavicular joint
3.Clavicle
4.Coracoid process
5.AC joint
6.Acromion
7.Humerus
8.Glenohumeral joint
,9.Scapula
Figure 9. Shoulder joints
of anterior dis'ocation
Positiverelocation test:a posteriorly directed force
applied durmgthe apprehension test relieves apprehension subluxaton
since anterior subluxation is prevented
Positivesulcus sign:presence of subacromial indentation recurrent posterior instability.NOT lor acute injury
with distal traction on humerus indicates inferior shoulder
Note:the posterior apprehension test is used to test for :
er
§
instability e
These tests are more commonly used for chronic recurrent
instability
Axillary nerve:sensory patch over deltoid and deltoid
contraction
Musculocutaneous nerve: sensory patch on lateral
forearm and biceps contraction
FullRenovascular exam as per anterior shoulder
dislocation
Neurovascular Exam
Including
Coracoid
V process
RADIOGRAPHIC FINDINGS
Axillary View
Trans scapular 'Y° View Humeral head is anterior to the center of the "MercedesBent"sign
Sub- coracoid lie of the humeral head is most common
Acromion
Humeral headis posterior /
Humeral headis posterior tocenter of "Mercedes-Bent*
Humeral head is anterior
sign 2
AP View Partial vacancy of glenoid fossa (vacant glenoid sign) and
>6 mm space between anterior glenoidrim and humeral
head (positive rim sign),humeral head may resemble a
lightbulb due to internal rotation (lightbulb sign)
tReverseHill-Sachs lesion (75% of cases):divot in
anterior humeral head
*Reverse bony Bankart lesion:avulsion of the posterior
glenoid labrum from the bony glenoid rim
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1_ Humcru Hill-Sachs and Bony
Bankart Lesions
? Hill-Sachs lesion:compression fractureof posterior
humeral head due to forceful impaction of ananteriorly
dislocated humeralhead against the glenoid rim
- Bony Bankart lesion:avulsion of the anterior glenoid
labrum (with attached bone fragments) from the glenoid
-
1
+ I
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rim Figure 10. Mercedes-Benz
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OR13 Orthopaedic Surgery TorontoNotes 2023
Table 8. Anterior and Posterior Shoulder Dislocation Bankart
Anterior Shoulder Dislocation(>90%) Posterior Shoulder Dislocation (5%)
TREATMENT
Closed reduction withIV sedation and muscle relaxation
Traction-countertraction: assistant stabilizes torso with
a folded sheet wrapped across the chest while the surgeon
applies gentle steady traction
Stimson:while patient lies prone with arm hanging over
table edge,hang a 5 lb weight on wrist lor 15-20 min
Hippocratic method:place heel into patient’s axilla and
apply traction to arm
Cunningham'smethod:gentle longitudinal support
and traction of the arm at the patient's side,massage/
relaxation of deltoid,trapezius,and biceps to allow
atraumatic shoulder reduction,low-risk,low pain;if not
successful try above methods
Obtain post-reduction x-rays
Check post-reduction MVS
Sling x 3 wk (avoid abduction and external rotation),
followed by shoulder rehabilitation (dynamic stabilizer
strengthening)
Closed reduction with IV sedation and muscle relaxation
Interior traction on a Hexed elbow with pressure on the
back of the humeral head
Obtain post-reduction x-rays
Check post-reduction NVS
Sling in abduction and external rotation x 3 wk.
followed by shoulder rehabilitation [dynamic stabilizer
strengthening)
Hill-Sachs
Figure 11. Posterior view of anterior
dislocation causing Hill-Sachs and
Bankart lesions
Prognosis
• recurrence rate depends on age of first dislocation
• <20 yr 65-95%; 20-40 yr = 60-70%;>40 yr 2- 4%
Specific Complications
• recurrent dislocation (most common complication)
• unreduced dislocation
• shoulder stiffness
• rotator cuff or capsular or labral tear (Bankart/SLAP lesion)
• injury to axillary nerve/artery,brachial plexus
I
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§
I
-
-5 a
s
—«
r.
O
Antorior apprehension sign Sulcus sign
s
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s >-
5 4
e
Posterior apprehension sign Traction-countertraction
Figure 12. Shoulder maneuvers
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OR!l Orthopaedic Surgery Toronto Notes 2023
Supraspinatus
\ ligament
Acromion L
—
Rotator Cuff Disease
Coracoid
• rotator cuff consists of 4 muscles that act to stabilize the humeral head within the glenoid fossa process 4k
Table 9. Rotator Cuff Muscles (SITS)
Muscle Muscle Attachments Nerve Supply Muscle Function
Proximal Distal
Scapula Greater tuberosity ol
humerus
Greater tuberosity of
humerus
Greater tuberosity ol
humerus
lesser tuberosity of
humerus
Supraspinatus Suprascapular nerve Abduction
Infraspinatus Scapula Suprascapular nerve Eitemal rotation 1
--
Teres Minor Scapula Axillary nerve filernalrotation ASubscapularis I
-
Joint capsule
capular body j
Subscapularis Scapula Subscapular nerve Internal rotation and
adduction
Infraspinatus
Teres minor 5
SPECTRUM OF DISEASE: IMPINGEMENT. TENDONITIS, MICRO OR MACRO TEARS
Figure 13. Lateral view of the
muscles of the rotator cuff
Etiology
• narrowing ofsubacromial space
• most commonly due to a relative imbalance of rotator cuff and larger shoulder muscles,allowing for
superior translation and subsequent wear of the rotator cuff muscle tendons
• glenohumeral (rotator cuff) muscle weaknessleading to abnormal motion of humeral head
scapular muscle weakness leading to abnormal motion of acromion - poor posture
• acromial abnormalities,such as congenital narrow space or osteophyte formation or Type Ill
acromion morphology
1. outlet/subacromial impingement:
“
painful arc syndrome,” compression of rotator cuff
tendons (primarily supraspinatus) and subacromial bursa between the head of the humerus
and the undersurface of acromion, AC joint, and CA ligament
2. bursitis and tendonitis
3. rotator cuff thinning and tear if left untreated
Bigliani Classification of Acromion
Morphology
• Type I -flat
• Type II - curved
• Type III - hooked
Screening Out Rotator Cuff Tears
• No night pain (SN 87.7%)
• No painful arc (SN 97.5%)
• No impingementsigns(SN 97.2%)
• No weakness
Returning to the bedside;Using the
history and physical examination to
identify rotator cuff tears
J Am eeriatr Sac 2m«:K33-K37
Clinical Features
• insidious onset, but may present as an acute exacerbation of chronic disease, night pain,and difficulty
sleeping on affected side
• pain worsens with active motion (especially overhead); passive movement generally permitted
• weakness and loss of ROM, especially between 90-130°(e.g. trouble with overhead activities)
• tenderness to palpation over greater tuberosity
• rule out bicep tendinosis (Speed’s test) and SLAP lesions (O'
Brien’s test)
Investigations
• x-ray:AP view may show sclerosis of the undersurface of the acromion or greater tuberosity, high
riding humerus relative to glenoid, indicating large tear, evidence of chronic tendonitis
• MR1:coronal/sagittal, oblique, and axial orientations are useful for assessing full/partial tears and
tendinopathy ± arthrogram: geyser sign (injected dye leaks out of joint through rotator cuff tear)
• arthrogram: not commonly used but can assess full thicknesstears, difficult to assess partial tears
• ultrasound:may be a useful adjunct but limited ability to evaluate other intra-articular pathology
Treatment
• non-operative
first line treatment, rotator cuff injury treatment begins with physiotherapy (regardless ofseverity
on MR1 findings)
• physiotherapy, activity modification, non-narcotic analgesia ± steroid injection
• mild or moderate cases frequently improve
• progression to surgery if necessary
• operative
severe tear or impingement that is refractory to 2-3 mo physiotherapy and 1 -2 corticosteroid
injections
arthroscopic or open surgical repair (i.e. acromioplasty, rotator cuff repair)
Ruling in Rotator Cuff Tears-98%
probability of rotator cuff tear if all 3of
the following are present:
• Supraspinatus weakness
• External rotation weakness
• Positive impingementsign(s)
Diagnosis of rotator cuff tears.
Uriel 2001:357:765-770
Does thisPatient with Shoulder Faia have Rotator
Cull Disease’The Rational Clinical Euniaation
Systematic Review
JAMA 2013:310:837-847
Study: 5 studies of suficien:gcalty netd ‘
3
30-203 shouldersand a peeve e
*
te of ICO ranging
from 33-81%.
Results/Condosions: Jmong pan prpvocatiotesis, a positive pairfal ait test fad the gaetes:
specificity aid sensitnrty (SP 81%.SI 21%).Amrg
strength tests,a positveeftrael rotetion lag as:
and internal rotation lag as!were the nnstamiraa
fnr fidl-thicknesstears$P47%.SI 94%:SP 92%.
SH 83% respectively).The Menal rotation legtesJ
was therefore also the mast accs-aa far Meutdywg
patients without a ful-tticksess aar.
A positive drop arm test is helpful to ; dertify patients
with RCD (SN 24%. SP93%L
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0R15 Orthopaedic Surgery Toronto Notes 2023
Table 10. Rotator Cuff Special Tests
Test Examination Positive Test
Supraspinatus:place the shoulder in90’of
adduction and 30’of horizontal flexion (from
the scapular plane) and internally rotate the
arm so that the thumb is pointing toward
the floor
Subscapularis:internally rotate arm so dorsal
surface of hand rests on lower back;patient
instructed to actively lift hand away from back
against examiner resistance (use Belly Press
Test if too painful)
Infraspinatus and teres minor;arm positioned
at patient's side in 90" of flexion:patient
instructed to externally rotate arm against the
resistance of the examiner
Rotator cuff impingement;passive shoulder
flexion
Rotator cuff impingement: shoulder flexion to
90’and passive internal rotation
Rotator cuff tendinopathy: patient instructed
to actively abduct the shoulder
Apply resistance to the forearm when the arm
is in forward flexion with the elbows fully
extended
SLAP lesion:forward flexion of the arm to
90’while keeping the arm extended.Arm is
adducted 10-15"
Internally rotate the arm so thumbis facing
down and apply a downward force.Repeat the
test with arm externally rotated
Jobe'
s Test (i.e.Empty Can Test) Weakness withactnre resistance suggests a
supraspinatustear
lift-off Test Inability to actively lift hand away from back
suggests a subscapularis tear
Posterior-Cuff Test Weakness withactive resistance suggests
posterior cuff tear
Pam elicited between130-170" suggests
impingement
Painwithinternalrotation suggests
impingement
Pain withabduction >90’suggests
tendinopathy
Pam in thebicipital groove
fleer's Test
Hawkins-Kennedy Test
Painful Arc Test
Speed's Test
O'Brien's Test Pain or clicking in the glenohumeral joint in
internalrotation but not externalrotation
r
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/
Jobe s test Lift-off test Posterior cuff test
2
Neer's test s
r
-
Ur
£
130-170"
i
0
Hawkins-Kennedy test I
CM
1Z.
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Figure 14. Rotator cuff tests
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