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OR l Orthopaedic Surgery Toronto Notes 2023

ANTERIOR VIEW POSTERIOR VIEW

Common iliac artery

Lateral cutaneous nerve of

the thigh

Femoral nerve

External iliac artery

Internal iliac artery

Deep circumflex iliac artery

Superficial circumflex iliac

artery

Medial cutaneous

nerve of the thigh

Lateral circumflex femoral

artery

Obturator nerve

.

Superior gluteal nerve

-Inferior gluteal nerve

•Sciatic nerve

-Posterior cutaneous

nerve of the thigh

Lateral circumflex

femoral artery

-Medial circumflex

femoral artery

Profunda Prolunda lemoris artery femoris artery

Femoral artery

Descending branch

Femoral artery

Intermediate cutaneous

nerve of the thigh Hiatus in adductor magnus

-Tibial nerve

-Common fibular

(peroneal) nerve

-Popliteal artery Saphenous nerve

Common fibular

(peroneal) nerve

Deep fibular (peroneal)

nerve

Superficial libular

(peroneal) nerve

-Posterior tibial artery

-Anterior tibial artery

Sural nerve Anterior tibial artery

Calcaneal branch

Medial plantar nerve

Medial plantar artery

Lateral plantar nerve

Lateral plantar artery

Plantar artery

Dorsalis pedis artery 2 m

IS -

I

UJ

a

©

Figure 3. Nerves and arteries of lower limbs

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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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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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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