Fracture of radial shaft with disruption of distal radioulnar joint. Fracture on ulna with radial head dislocation

Transcription

1 Monteggia Fracture Galeazzi Fracture Fracture on ulna with radial head dislocation o o ORIF in adults Non op for children possible Fracture of radial shaft with disruption of distal radioulnar joint o 3x more common than Monteggia o Requires ORIF

2 Metacarpal Fractures o Metacarpal neck May need to be closed reduced Acceptable angulation for non op management o < 10 deg for 2nd and 3rd o < deg for 4th and 5 th (Boxers fracture) Casting for non op o Ulnar gutter splint/cast for 6 weeks Surgery o CRPP vs ORIF

3 Boxer s Fx

4 Metacarpal fractures Metacarpal shaft fractures o Non op management if < 10 deg dorsal angulation 2 nd and 3 rd If < 20 deg dorsal angulation 4 th and 5 th o Surgery Rotational deformity o (causes overlap of fingers)

5 Scaphoid Fractures Most common carpal fracture FOOSH injury Pain in anatomic snuffbox High potential for slow healing or non union based on location of fracture non op management o Thumb spica splint/cast 6-24 weeks Surgical consideration o o Any displacement or angulation Insertion of screw

6 Scaphoid Fractures

7 Common Wrist Problems Other carpal fractures o Sprains hook of hamate DeQuervain s tenosynovitis o o Positive Finkelstein test Tx: splint/injection Scapholunate Dissociation o o o carpal keystone FOOSH Letterman sign

8 Carpal Tunnel Syndrome Carpal Tunnel Syndrome o Compression of median nerve in carpal tunnel o Tinel s sign positive o Thenar muscle wasting o Hand wringing o Non operative Injection Wrist splinting o Surgical Carpal tunnel release

9 Common Hand Deformities Boutonniere deformity o Flexion of PIP & hyperextension of DIP o Rx: Surgical or leave as is Swan Neck Deformity o Seen in RA o Flexion of the DIP & hyperextension of the PIP o Surgical vs leave as is

10 Rupture of extensor tendon distal to DIP Axial load causing forced DIP flexion jammed finger PE: Unable to actively extend DIP Rx: Stax splint or DIP extension splint 24/7 for 6 weeks, mallet finger protocol Mallet Finger

11 Common Finger Deformities Bouchard s nodes o Involve PIP joint o OA or RA (less common) Heberden s Nodes o Involve DIP joint o OA

12 Cervical Spine

13 Cervical Spine AP, lateral o Oblique to look for foraminal stenosis o Odontoid view for upper c-spine Does it line up? o Anterior vertebral line o Posterior vertebral line o Spinolaminar line o Posterior spinous line Disc space heights even?

14

15 Common c-spine symptoms Pain radiating down arm Centralized pain with motion Upper extremity weakness following dermatomal pattern Altered reflexes compared to contralateral side Sensory changes

16 C-spine physical exam Sensory o C6 six shooter Motor o C4-shoulder shrug o C5-shoulder abduction o C6-elbow flex/wrist ext Biceps reflex o C7-elbow ext/wrist flex Triceps reflex o C8-thumb extension o T1-finger abduction

17 Common cervical injuries Fractures o Hangman s fracture most common C2 fx/dislocation Hyperextension usually o Jefferson fracture C1 burst fx Axial load

18 Cervical injuries Brachial plexus injury o burner / stinger o Shoulder depression/neck lateral flexion causing stretch injury Symptoms should resolve within minutes Strength should be normal before return to activity

19 Cervical injuries Cervical radiculopathy o Due to impingement on nerve root Herniated disc, OA o Exam Electricity pain down the arm in certain positions Positive Spurling s maneuver o Treatment PT Injections surgery

20 Lumbar Spine

21

22 Sensory Lumbar Motor/Sensory Motor o L2 hip flexion o L3 knee extension Patellar reflex o L4 ankle dorsiflexion o L5 toe extension o S1 ankle plantar flexion Achilles reflex

23 Low back (lumbar) strain/sprain Approximately 80% of low back injuries Most improve with time, NSAIDs, physical therapy Depending on mechanism, x-rays may not be indicated Symptoms: Pain/stiffness isolated to paraspinal muscles No radicular symptoms No sensory changes Treatment: NSAIDs, muscle relaxers Physical therapy!!! Activity modification

24 Herniated Nucleus Pulposus (HNP) AKA herniated disk Most common at L4-L5, L5-S1 Symptoms Unilateral leg pain/weakness Muscle atrophy Diagnosis Straight leg raise test positive MRI gold standard Treatment NSAIDs, prednisone Physical therapy Surgery if conservative tx fails Discectomy vs fusion

25 Lumbar spine fractures o Stable Wedge fracture (compression) o common in t-spine o Osteoporosis, lytic lesions, trauma o Kyphoplasty if symptomatic Spinous process o Usually trauma o Treated non op

26 Lumbar spine fractures Unstable o Burst fracture High energy axial load Bony fragments into spinal canal o Chance fracture Sudden high velocity forward flexion seat belt injury Anterior body, posterior ligaments/bony injury

27 Spondylolysis Fracture through pars interarticularis o scotty dog fracture o Best seen on oblique x-ray Athletes Increased pain w/ single leg stand with back extension and rotation to same side If bilateral, may progress to spondylolisthesis Treat non op: PT, bracing, no impact

28 Spondylolisthesis Slippage of one vertebra over the other Grade I V based on % slippage Best seen on lateral Also retrolisthesis Non op management preferable Surgical fusion may be necessary based on amount of slippage and associated symptoms/neuro deficit

29 Cauda Equina Syndrome Acute loss of function to lumbar plexus o o o Loss of sensation saddle distribution Bowel/bladder incontinence Sexual dysfunction o Causes Trauma Tumors/lesions Spinal stenosis inflammatory Treatment: o Emergent surgical decompression

30 BREAK

31 Hip/Pelvis

32 Hip osteoarthritis Characteristic symptoms include: o Pain with increased walking, painful limp o Decreased range of motion o >60 years of age o AVN from prolonged steroid use o Treatment Intraarticular steroid injections and PT to restore range of motion and increase strength Surgery for total hip arthroplasty or resurfacing if steroid injections do not adequately control symptoms

33

34 Hip fractures Main types o o o Femoral neck Intertrochanteric subtrochanteric Usually from falls Early surgical fixation to allow early mobilization o Important in older population to avoid secondary complications

35 Hip dislocations Due to high energy trauma Posterior more common (90%) o Common in total hip arthroplasty patients Early reduction important to avoid osteonecrosis of femoral head Closed treatment 2-4 weeks of ambulation with crutches until pain free

36 Slipped Capital Femoral Epiphysis (SCFE) Most common in boys 13-15, girls Most are overweight Many will get SCFE bilateral Symptoms include pain and antalgic gait Increased external rotation on affected side Diagnosis X-ray: AP and frog leg lateral Treatment Surgical stabilization of the physis with screw Usually stabilized in position it is discovered not reduced

37 Legg-Calve-Perthes Disease Idiopathic osteonecrosis of femoral head o Common in boys 4-8 o o Limping, worse w/ activity Many affected are delayed in bone age Diagnosis made by x-ray Revascularization occurs spontaneously o May lead to premature degneration Non op treatment o Goal is reestablishment of spherical femoral head bracing, activity restriction

38 Legg Calve Perthes Disease

39 KNEE DISORDERS

40

41 Knee Injuries Symptom Acute instability Mechanical symptoms (lock, catch) Acute swelling without injury incident Constant ache/swelling older pop. Anterior pain w/ steps, cruching Acute swelling after painful event Common Etiology Ligament disruption (ACL, MCL, LCL, PCL) Meniscus, unstable chondral lesion, loose body Articular cartilage osteochondritis dissecans Osteoarthritis, other inflammatory arthritis Patellofemoral dysfunction Fracture, patellar dislocation, ACL/PCL injury

42 Common Knee Exam Findings Positive Special test Lachman, Anterior Drawer, Pivot Shift Posterior Drawer, posterior sag Valgus stress test Varus stress test McMurray Apprehension test Injury ACL PCL MCL LCL Meniscus Patellar subluxation/dislocation

43 2 view AP, lateral 3 view AP, lateral, merchant Knee X-Rays

44 ACL Mechanism of Injury Plant and twist, hyperextension, collision Cutting Sports Soccer, football, basketball, skiing Associated bone bruising and meniscus tear common Exam: o Positive Lachman **gold standard**

45 Treatment Options Factors to Consider: Age Associated injuries Repairable meniscus tear Recreational activities Work demands Motivation Most Important: Patient s functional demands Consider Each Patient Individually!

46 Operative Treatment Arthroscopic Reconstruction ograft choices Bone-patellar tendon-bone; Hamstring autograft; cadaver allograft Physical Therapy 6 month minimum to return to cutting sports

47 Meniscal Tears Treatment depends on cause (traumatic vs. degenerative), severity of symptoms and location of tear If no significant mechanical symptoms, try conservative therapy first, then decide if surgery is indicated Many require arthroscopic evaluation with resection vs. repair o Factors include Age, type of tear, condition of adjacent chondral surfaces

48

49

50 Meniscus Repair

51 Osteoarthritis

52 Osteoarthritis Clinical Presentation Pain! Initially w/ activity only Stiffness and loss of range of motion Especially after periods of inactivity until joint loosens up Most commonly effects fingers, wrist, hip, knee, spine

53

54 Osteoarthritis

55 Osteoarthritis Treatment Activity modifications/physical Therapy Weight loss Acetaminophen/NSAIDS Intraarticular steroid injections/viscosupplementation (Synvisc, Orthovisc, Euflexxa) Arthroscopic debridement Joint replacement **Decision for joint replacement not based on radiographic findings. Decision Based on Subjective symptoms and failure of other therapies (PT, injections, activity modification, etc.)**

56 Total Knee Arthroplasty

57

58 Post Operative Treatment Initially o WBAT o NSAID s, ice o Physical Therapy Full ROM Functional use of leg Gradual return to activity

59 ANKLE DISORDERS

60 The Ankle Joint Calcaneus: articulates with Talus superiorly & cuboid distally. Talus: articulates with tibia & fibula in mortise, navicular distally, & calcaneus inferiorly. Tibia: forms medial malleolus & medial mortise. Fibula: forms lateral malleolus and lateral mortise.