The Bone Book an Orthopedic Pocket Manual

Sumon Nandi Selvon F. St. Clair

The Bone Book An Orthopedic Pocket Manual

123 The Bone Book Sumon Nandi • Selvon F. St. Clair

The Bone Book

An Orthopedic Pocket Manual Sumon Nandi, MD, MBA Chief of Adult Reconstruction Department of Orthopedic Surgery University of Maryland School of Medicine Baltimore, MD USA

Selvon F. St. Clair, MD, PhD Orthopedic Institute of Ohio Lima, OH USA

ISBN 978-1-4614-3090-2 ISBN 978-1-4614-3091-9 (eBook) https://doi.org/10.1007/978-1-4614-3091-9

© Springer Science+Business Media, LLC, part of Springer Nature 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of transla- tion, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimi- lar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Science+Business Media, LLC part of Springer Nature The registered company address is: 1 New York Plaza, New York, NY 10004, U.S.A To my residents and students, whom I have watched flourish and from whom I have learned, this book was written to ease the challenge of the steep early learning curve in orthopedics that you will surely overcome, but never forget. To my wife, who inspires and encourages me to do my very best, your love and support make everything possible. To my children, time with you is my life’s meaning and visions of your future are my hope. To my parents, this book is a monument to your sacrifice that began decades ago in a land far away and continues to this day. –Sumon Nandi This book is dedicated to my wonderful wife, Amy, and loving daughters Cyan, Kaya, and Eva: the absolute joys of my life. –Selvon F. St. Clair Foreword

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

vii viii Foreword emergencies in musculoskeletal care. Preparing the patient for the operating room and the proper performance of basic procedures are also comprehensively covered. I believe that The Bone Book will be the first source that junior house staff and students will reach for when seeking an accurate solution to the issue at hand. The Bone Book should be an essential part of the library of every budding orthopedist. It supplies pearls of wisdom we all wish we had when we were on-call and were long on ques- tions and short on answers. Drs. Nandi and St. Clair should be congratulated for providing those answers. I certainly wish I had The Bone Book when I was in that lonely position!

Matthew S. Austin, MD Adult Reconstruction Division Chief Adult Reconstruction Fellowship Director Professor of Orthopedic Surgery Sidney Kimmel Medical College Rothman Institute Philadelphia, PA, USA Contents

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

ix x Contents

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

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

Index ��223 Chapter 1 Anatomy Essentials

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

Upper Extremity

Shoulder

Bones

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

Clavicle

Acromion Scapula Coracoid process Manubrium of sternum Humeral head

Glenoid

Humerus

Figure 1.1 Bones of shoulder girdle.

Muscles

The muscles of the rotator cuff include the supraspinatus, infraspinatus, subscapularis, and teres minor (Fig. 1.2). The muscles that attach to the coracoid process include the coracobrachialis, pectoralis minor, and short head of the biceps brachii. The deltoid muscle originates on the coracoid process and inserts on the humerus. Upper Extremity 3

Subscapularis muscle Deltoid muscle (cut) Short head Pectoralis major Pectoralis muscle (cut) major Pectoralis muscle (cut) minor muscle Coracobrachialis muscle Biceps brachii muscle

Bicipital aponeurosis

Supraspinatus muscle

Infraspinatus muscle

Teres minor muscle

Posterior Figure 1.2 Shoulder muscles. 4 Chapter 1. Anatomy Essentials

Neurovascular Structures

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

Subclavian artery

Axillary nerve

Axillary artery

Musculocutaneus nerve

Figure 1.3 Neurovascular structures of shoulder. Upper Extremity 5

Surgical Approach

Deltopectoral approach (Fig. 1.4): Superficial Between deltoid laterally and pectoralis major interval medially. Cephalic vein lies in between and can be retracted laterally with deltoid. Deep Retract coracobrachialis and short head of biceps dissection (which attach to coracoid process) medially. Release subscapularis with cuff of tendon or with segment of lesser tuberosity and enter joint through joint capsule.

Tendon of short Deltoid Cephalic head of biceps Tendon of Shoulder muscle vein brachii muscle subscapularis muscle joint

Coracobrachialis muscle

Figure 1.4 Deltopectoral approach. 6 Chapter 1. Anatomy Essentials

Arm

Bones

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

Head of humerus

Greater tubercle Glenoid

Lesser tubercle

Humerus

Scapula

Lateral epicondyle Medial epicondyle

Capitulum Trochlea Anterior

Figure 1.5 Bony anatomy of the arm. Upper Extremity 7

Muscles

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

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

Biceps brachii Coracobrachialis tendon muscle (cut) Anterior

Coracobrachialis muscle

Brachialis muscle (cut) Biceps brachii muscle (cut)

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

Long head Anconeus of triceps muscle brachii Posterior

Figure 1.6 Arm muscles. 8 Chapter 1. Anatomy Essentials

Neurovascular Structures

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

Brachial artery

Median nerve

Ulnar nerve Radial nerve

Figure 1.7 Neurovascular structures of the arm. Upper Extremity 9

Surgical Approach

Posterior approach (allows direct visualization of radial nerve, the structure most at risk) (Fig. 1.8): Superficial interval Between lateral head of triceps laterally and long head of triceps medially. Deep dissection Split the medial (deep) head of triceps in the midline down to the bone.

Lateral head of triceps

Fascia over Fascia over Long head lateral head long head of triceps of triceps of triceps

Triceps Triceps tendon tendon

Long head of triceps Lateral head Longhead of triceps of triceps Lateral head Profunda of triceps brachii artery Radial nerve Profunda Radial radial brachii artery nerve Medial (deep) head of triceps Medial (deep) head of triceps Humerus covered with periosteum

Posterior approach

Figure 1.8 Posterior approach to the humerus. 10 Chapter 1. Anatomy Essentials

Elbow

Bones

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

Humerus

Radial head

Radius Ulna

Figure 1.9 Bony anatomy of the elbow. Upper Extremity 11

Muscles

Discussed in the ARM and FOREARM sections.

Neurovascular Structures

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

Brachial artery

Radial nerve

Ulnar nerve

Median nerve

Figure 1.10 Neurovascular structures surrounding elbow. 12 Chapter 1. Anatomy Essentials

Surgical Approach

Posterolateral Approach (Fig. 1.11): Superficial Between extensor carpi ulnaris anteriorly and interval anconeus posteriorly. Deep Incise capsule to enter joint. Make capsular incision dissection at, but not posterior to, longitudinal axis of radius to preserve integrity of radial collateral ligament. Avoid dissecting distal to annular ligament to prevent trauma to PIN.

Common extensor origin

Fascia Anconeus

Extensor carpi Extensor carpi Supinator ulnaris muscle ulnaris muscle Radial head

Capitulum

Anconeus Anconeus

Figure 1.11 Posterolateral approach to the elbow. Upper Extremity 13

Forearm

Bones

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

Radial head

Radius

Ulna

Ulnar head

Figure 1.12 Bony anatomy of the forearm. 14 Chapter 1. Anatomy Essentials

Muscles

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

Humeral head of pronator teres Common flexor Common flexor Common flexor tendon tendon (cut) tendon (cut) Pronator teres (cut) Ulnar head of Flexor digitorum pronator teres Flexor digitorum superfecialis (cut) Flexor carpi Palmaris longus superfecialis radialis Flexor Flexor carpi digitorum ulnaris profundus Flexor pollicis longus

Pronator quadratus

Superficial-Anterior Deep-Anterior

Brachio- radialis Extensor carpi Extensor radialis longus (cut) Anconeus (cut) carpi radialis Supinator longus Extensor digiti Extensor Abductor pollicis minimi carpi radialis longus brevis Extensor carpi Extensor Extensor pollicis ulnaris digitorum brevis Extensor pollicis longus Extensor indicis

Superficial-Posterior Deep-Posterior

Figure 1.13 Forearm muscles. Upper Extremity 15

Neurovascular Structures

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

Brachial artery

Radial nerve Ulnar nerve (superficial branch) Median nerve

Radial artery Ulnar artery

Figure 1.14 Neurovascular structures of the forearm. 16 Chapter 1. Anatomy Essentials

Surgical Approach

Volar Approach to Radius (Fig. 1.15): Superficial Distally, between flexor carpi radialis medially interval and brachioradialis laterally; proximally, between pronator teres medially and brachioradialis laterally. Deep dissection Distally, elevate pronator quadratus and flexor pollicis longus off radius from lateral to medial; middle third of shaft, release pronator teres and flexor digitorum superficialis from lateral to medial; and proximally, release supinator from medial to lateral.

Fascia over a extensor carpi ulnaris Fascia over anconeus

Fascia over flexor carpi ulnairs

Extensor capi ulnaris

Periosteum covering ulna Flexor carpi ulnaris Anconeus Ulna

Figure 1.15 (a) Volar approach to radius and (b) approach to ulna. Upper Extremity 17

Lateral antebrachial cutaneous nerve b Radial artery Brachioradialis

Flexor carpi radialis

Pronator Superficial Brachioradialis Superficial teres radial nerve Radius tendon branch of Extensor Supinator Supinator radial nerve carpi radialis longus Brachioradialis Pronator quadratus Flexor Pronator carpi teres Radial radialis Flexor Periosteal artery incision Flexor carpi digitorum radialis superficialis

Supinator Brachioradialis

Radius Superficial branch of radial nerve Biceps tendon

Radial Flexor artery carpi radialis

Figure 1.15 (continued)

Approach to Ulna: Superficial Between flexor carpi ulnaris and extensor interval carpi ulnaris. Deep Dissect subperiosteally around ulna. dissection 18 Chapter 1. Anatomy Essentials

Wrist

Bones

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

MNEMONIC DISTAL

Trapezium / Trapezoid / Capitate/ Hamate

RADIAL That TheyCan’t Handle ULNAR

Some Lovers TryPositions

Scaphoid/ Lunate/ Triquetrum/Pisiform

PROXIMAL

Trapezoid Capitate Trapezium Hamate Carpal bones Pisiform Scaphoid Lunate Triquetrum

Dorsal view

Figure 1.16 Bony anatomy of the wrist. Upper Extremity 19

Muscles

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

Transverse fibers of extensor expansions (hoods) Intertendinous connections Dorsal interosseous muscles Abductor digiti minimi Extensor Radial artery indicis Compartment 4 in anatomical Extensor snuffbox digitorum Extensor pollicis brevis Extensor digiti Compartment 5 minimi Compartment 1 Abductor pollicis longus Extensor carpi Compartment 6 ulnaris Extensor carpi radialis longus Compartment 2 Extensor Extensor carpi retinaculum radialis brevis Extensor Compartment 3 pollicis longus

Figure 1.17 Extensor tendons at the wrist. 20 Chapter 1. Anatomy Essentials

Neurovascular Structures

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

Superficial branch of radial nerve

Lateral branch Medial branch Dorsal digital branches Extensor retinaculum of radial nerve Scaphoid Dorsal carpal branch of radial artery Radial artery in anatomical snuffbox Extensor carpi radialis brevis tendon Trapezium Insertion of abductor Extensor carpi radialis pollicis longus tendon longus tendon 1st metacarpal bone Radial artery Insertion of extensor pollicis brevis tendon 1st dorsal interosseous muscle Insertion of extensor pollicis longus tendon

Deep fascia (cut)

Figure 1.18 Neurovascular structures of the wrist. Upper Extremity 21

Surgical Approach

Dorsal Approach to Wrist (Fig. 1.19): Superficial interval Between extensor digitorum communis and extensor indicis proprius. Deep dissection Incise joint capsule to expose carpus.

a b

Extensor retinaculum

Dorsal radio- Extensor carpal ligament c Digitorum communis d

Extensor Extensor Digitorum retinaculum communis

Lunate e

Distal radius

Figure 1.19 Dorsal approach to the wrist. 22 Chapter 1. Anatomy Essentials

Hand

Bones

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

Middle 3rd Index Ring 2nd 4th

Little 5th

Distal Thumb 1st Phalanges Middle Distal Proximal Phalanges Digit Proximal Digit

Metacarpal Metacarpal

Figure 1.20 Bones of the hand. Upper Extremity 23

Muscles

Intrinsic muscles of the hand are in four compartments (Fig. 1.21): Thenar Primarily responsible for thumb opposition compartment Adductor Contains adductor pollicis, which is responsible compartment for thumb adduction. Hypothenar Responsible for small finger motor function compartment Central Contain lumbricals (metacarpophalangeal joint compartment flexion and interphalangeal joint extension) and interossei (Dorsal interossei ABduct digits, Palmar interossei ADduct digits). Mnemonic DAB and PAD 24 Chapter 1. Anatomy Essentials

Deep transverse Lumbrical muscles metacarpal (reflected) ligaments 1st dorsal Flexor digiti interosseous muscle minimi muscle (cut) Adductor pollicis Opponens digiti muscle minimi muscle Flexor pollicis brevis Abductor digiti muscle minimi muscle Abductor pollicis brevis (cut) muscle (cut) Dorsal Pisiform Opponens pollicis muscle interossei Flexor carpi Flexor retinaculum ulnaris tendon (transverse carpal ligament) (reflected) Pronator quadratus muscle Radius Palmar view Dorsal view

Palmar Lumbricals interossei

Opponens digiti Flexor pollicis brevis minimi (cut)

Flexor digiti Opponens pollicis Hypothenar minimi brevis Thenar (cut) Abductor digiti Abductor pollicis minimi (cut) brevis (cut)

Figure 1.21 Hand muscles. Upper Extremity 25

Neurovascular Structures

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

Superificial branch of radial nerve

Median nerve

Ulnar nerve Radial artery

Ulnar artery

Figure 1.22 Neurovascular structures of the hand. 26 Chapter 1. Anatomy Essentials

Surgical Approach

Approach to Carpal Tunnel (Fig. 1.23): Superficial dissection Skin incision along radial border of the ring finger on volar aspect of the hand extending 4 cm distally from wrist crease. Deep dissection Incise palmar fascia, and then transverse carpal ligament.

abPalmar fascia

Median nerve

Transverse carpal ligament

Figure 1.23 Approach to the carpal tunnel. Upper Extremity 27

Approach to Flexor Tendons (Fig. 1.24): Dissection Skin incision traversing volar aspect of digit in a zigzag pattern with angles between limbs of incision at 90° angles to one another. Elevate the skin with underlying fat to expose flexor tendon lying in its sheath.

Flexor tendon sheath

Figure 1.24 Approach to flexor tendons. 28 Chapter 1. Anatomy Essentials

Lower Extremity

Pelvis

Bones

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

Ilium

Sacrum

Acetabulum

Ischium

Pubic symphysis

Ilium Ischium Pubis

Figure 1.25 Bony anatomy of pelvis. Lower Extremity 29

Muscles

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

Obturator Pectineus muscle externus (cut) Iliopsoas (cut) Adductor Pectineus longus muscle Gluteus muscle (cut) (cut) minimus Gluteus maximus Adductor Adductor brevis (cut) brevis (cut) Adductor Adductor minimus longus muscle (cut) Gluteus Adductor medius magnus (cut) Gracilis muscle (cut)

Hip abductors Hip adductors

Semitendinosus Rectus femoris (cut)

Semimembranosus

Short head of biceps femoris

Long head of biceps femoris

Hamstring muscles

Figure 1.26 Pelvic musculature. 30 Chapter 1. Anatomy Essentials

Neurovascular Structures

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

Superior gluteal artery Superior gluteal nerve

Piriformis muscle

Inferior gluteal Pudendal artery nerve Inferior gluteal Internal pudendal nerve artery Nerve to obturator Sciatic nerve internus

Posterior femoral cutaneous nerve

Figure 1.27 Neurovascular structures of pelvis. Lower Extremity 31

Surgical Approach

Anterior approach to the iliac crest and sacroiliac joint (Fig. 1.28): Superficial dissection Skin incision and subcutaneous dissection in line with iliac crest. Deep dissection Dissect subperiosteally along the inner table of the ilium.

Abdominal fascia Crest of ilium

Figure 1.28 (a and b) Anterior approach to the iliac crest. 32 Chapter 1. Anatomy Essentials

c Iliacus

Sacrum

Abdominal muscles

Sacroiliac joint

Iliac crest

Gluteus medius Inner surface of ilium

Figure 1.28 (continued) (c) Deeper dissection to sacroiliac joint. Lower Extremity 33

Hip

Bones

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

Femoral head Acetabulum

Figure 1.29 Bony anatomy of the hip. 34 Chapter 1. Anatomy Essentials

Muscles

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

Psoas major muscle Iliopsoas Iliacus muscle

Adductor brevis (cut) Adductor longus (cut)

Adductor magnus

Gracilis (cut)

Gluteus Gluteus maximus minimus

Gluteus medius (cut)

Figure 1.30 Hip musculature. Lower Extremity 35

Neurovascular Structures

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

Internal iliac artery Obturator nerve Femoral artery

Femoral nerve

Superior gluteal artery and nerve

Inferior gluteal artery and nerve Sciatic nerve

Figure 1.31 Neurovascular structures of the hip. 36 Chapter 1. Anatomy Essentials

Surgical Approach

Posterior approach (Fig. 1.32): Superficial Split iliotibial band over greater trochanter dissection and gluteus maximus fibers more proximally/ posteriorly. Deep Peel short external rotators off posterior aspect dissection of femur. Release capsule off femoral head and neck in trapezoidal fashion to enter hip joint.

ab Fascia lata

Vastus lateralis

cdGreater Posterior trochanter joint capsule

Tendon of gluteus Gluteus Fascia lata medius medius Vastus Short lateralis Gluteus external maximus rotators

Fascia lata Quadratus femoris Gluteus Quadratus Short maximus femoris rotators e

Joint capsule

Femoral head Acetabulum

Figure 1.32 Posterior approach to the hip. Lower Extremity 37

Anterior approach: Superficial Between sartorius and tensor fascia lata. Beware interval of lateral femoral cutaneous nerve and ascending branch of lateral femoral circumflex artery. Deep interval Between rectus femoris and gluteus medius, down to hip joint capsule.

Direct lateral approach: Superficial Split iliotibial band longitudinally over greater dissection trochanter. Deep Anterior 1/3 of gluteus medius and minimus dissection proximally and anterior 1/3 of vastus lateralis distally are released in continuous sleeve off greater trochanter and hip joint capsule. Beware of superior gluteal neurovascular bundle 5 cm proximal to tip of greater trochanter.

Femur

Bones

Femoral head is proximal, which articulates with the acetabulum to form the hip joint (Fig. 1.33). Proximally, the greater trochanter is the insertion site of the abductors, while the lesser trochanter is the insertion site of the iliopsoas tendon. Distally, the medial and lateral condyles form the articular surfaces of the knee and are the origins of the medial and lateral collateral ligaments, respectively. 38 Chapter 1. Anatomy Essentials

Acetabulum Femoral head Greater trochanter

Femoral Lesser neck trochanter

Lateral condyle Distal fermur Medial condyle

Figure 1.33 Bony anatomy of femur.

Muscles

Quadriceps femoris is in anterior compartment of the thigh, hamstrings are in posterior compartment of the thigh, and adductors are in medial compartment of the thigh (Fig. 1.34). Lower Extremity 39

Sartorius (cut)

Rectus femoris (cut)

Vastus intermedius

Vastus Vastus lateralis medialis

Sartorius Rectus (cut) femoris (cut)

Figure 1.34 Muscles surrounding femur. 40 Chapter 1. Anatomy Essentials

Neurovascular Structures

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

Femoral nerve

Femoral artery

Saphenous nerve

Figure 1.35 Neurovascular structures surrounding femur. Lower Extremity 41

Surgical Approach

Lateral approach (Fig. 1.36): Superficial dissection Split iliotibial band. Deep dissection Incise vastus lateralis fascia, retract vastus lateralis muscle belly anteriorly, and dissect down to bone.

Fascia lata

Vastus lateralis

Fascia lata

Vastus lateralis

Proximal femur

Figure 1.36 Lateral approach to femur. 42 Chapter 1. Anatomy Essentials

Knee

Bones

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

Distal femur

Patella

Tibial plateau

Tibia

Fibula

Figure 1.37 Bony anatomy of the knee. Lower Extremity 43

Muscles

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

Vastus medialis Vastus lateralis muscle muscle Rectus femoris tendon (quadriceps femoris tendon)

Anterior view of knee

Lateral head Medial head of gastrocnemius of gastrocnemius

Posterior view of knee

Figure 1.38 Knee musculature. 44 Chapter 1. Anatomy Essentials

Neurovascular Structures

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

Popliteal Tibial nerve artery

Common peroneal nerve

Anterior tibial artery

Posterior Peroneal tibial artery artery

Figure 1.39 Neurovascular structures of the knee. Lower Extremity 45

Surgical Approach

Medial parapatellar approach (Fig. 1.40): Superficial Dissect subcutaneously to level of retinaculum dissection Deep Incise quadriceps tendon longitudinally immediately dissection lateral to vastus medialis obliquus (VMO). Carry dissection distally through retinaculum just medial to patella and patellar tendon.

Quadriceps Fascia over tendon vastus medialis

Medial retinaculum Patellar tendon

Quadriceps Vastus Quadriceps tendon medialis tendon Anterior cruciate Articular ligament Medial femoral surface of condyle patella Infrapatellar Patellar fatpad Lateral Tibial plateau tendon meniscus Patellar tendon

Figure 1.40 Medial parapatellar approach. 46 Chapter 1. Anatomy Essentials

Lower Leg

Bones

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

Tibial plateau Fibular head

Fibula Tibia

Lateral Medial malleolus malleolus

Figure 1.41 Bones of the lower leg. Lower Extremity 47

Muscles

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

Tibialis anterior Tibialis (cut) anterior Extensor Extensor digitorum digitorum longus (cut) longus Peroneus Extensor Peroneus longus hallucis (cut) longus brevis Peroneus tertius

Anterior Anterior Lateral compartment compartment compartment

Plantaris Gastrocnemius (cut) Popliteus Flexor Soleus digitorum longus Tibialis posterior Flexor hallucis longus

Superfecial Deep posterior posterior compartment compartment

Figure 1.42 Muscles of the lower leg. 48 Chapter 1. Anatomy Essentials

Neurovascular Structures

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

Anterior tibial Posterior tibial artery artery

Peroneal artery

Anterior view

Figure 1.43 Neurovascular structures of the lower leg. Lower Extremity 49

Tibial nerve

Common Peroneal nerve

Posterior view

Figure 1.43 (continued) 50 Chapter 1. Anatomy Essentials

Surgical Approach

Anterior approach to tibia (Fig. 1.44):

Fascia over tibialis anterior

Periosteum

Tibialis anterior Tibia

Figure 1.44 Anterior approach to tibia. Lower Extremity 51

Superficial Skin incision parallel to tibial crest and one dissection fingerbreadth lateral to it. Dissect through subcutaneous tissues to tibialis anterior fascia laterally and periosteum overlying tibia medially. Deep Medial border of tibia is immediately below dissection subcutaneous tissues. Dissect subperiosteally along lateral border of tibia, and retract tibialis anterior laterally.

Ankle

Bones

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

Distal Distal tibia fibula Talus

Figure 1.45 Bony anatomy of the ankle. 52 Chapter 1. Anatomy Essentials

Muscles

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

Posterior view

Flexor digitorum longus Peroneus brevis tendon Peroneus Flexor hallucis longus tendon longus

Posterior tibial tendon

Figure 1.46 Ankle musculature. Lower Extremity 53

Neurovascular Structures

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

Flexor digitorum Soleus muscle longus tendon inserting into calcaneal (achilles) tendon

Tibialis posterior Peroneus tendon longus tendon

Posterior tibial Peroneus artery and vein brevis tendon

Medial malleolus Calcaneal (achilles) tendon Tibial nerve Lateral malleolus

Flexor hallucis Superior peroneal longus tendon retinaculum

Flexor retinaculum Peroneal artery

Calcaneal branch Calcaneal branches of posterior Calcaneal of peroneal tibial artery tuberosity artery

Figure 1.47 Neurovascular structures surrounding the ankle. 54 Chapter 1. Anatomy Essentials

Surgical Approach

Anterior approach to ankle (Fig. 1.48): Superficial interval Incise extensor retinaculum medial to tibialis anterior tendon Deep dissection Incise capsule to enter ankle joint

Extensor retinaculum

Tibialis anterior under extensor Tibialis retinaculum anterior Distal tibia

Joint capsule of ankle

Figure 1.48 Anterior approach to the ankle. Lower Extremity 55

Approach to lateral malleolus (distal fibula) (Fig. 1.49): Superficial Incise the skin and subcutaneous tissues along dissection longitudinal axis of fibula. Deep dissection Dissect subperiosteally around distal fibula.

Fascia over peroneus Fascia over tertius peronei

Sheath over peronei

Periosteum

Lateral malleous

Figure 1.49 Approach to lateral malleolus. 56 Chapter 1. Anatomy Essentials

I II Distal III Middle Phalanges Distal IV Proximal Phalanges Proximal V

Forefoot

Metatarsals

Medial Cuneiforms Intermediate

Midfoot Lateral

Navicular Talus Cuboid Hindfoot Calcaneus

Figure 1.50 Bones of the foot.

Foot

Bones

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

Muscles

The four muscle layers on the plantar aspect of the foot are responsible for flexion, adduction, and abduction of the digits and the integrity of the arch of the foot (Fig. 1.51). Lower Extremity 57

Adductor hallucis

Transverse Oblique head head

Flexor hallucis longus Lumbricals Flexor hallucis Flexor Flexor brevis Abductor hallucis digitorum digiti longus minimi Flexor digitorum brevis Quadratus Abductor digiti plantae minimi

Plantar -first muscle Plantar - second muscle Plantar - third muscle layer layer layer

Plantar Dorsal interossei interossei

Plantar - fourth muscle Dorsal - fourth muscle layer layer

Figure 1.51 Muscles of the foot.

Neurovascular Structures

On the dorsum of the foot, the femoral nerve terminates as the saphenous nerve and tibial and common peroneal nerve branches combine to form the sural nerve. On the plantar aspect of the foot, the tibial nerve terminates as the medial and lateral plantar nerves (Fig. 1.52). The anterior tibial artery terminates as the dorsal artery of the foot that runs to the space between the 1st and 2nd metatarsals. 58 Chapter 1. Anatomy Essentials

Sural nerve

Dorsalis pedis artery

Lateral plantar nerve Medial plantar nerve

Figure 1.52 Neurovascular structures surrounding the foot. Lower Extremity 59

Surgical Approach

Anterolateral approach to foot (Fig. 1.53): Superficial Peroneal tendons laterally and peroneus tertius/ interval extensor digitorum longus medially. Deep Release extensor digitorum brevis proximally, dissection and retract distally to expose joint capsules.

Superior extensor Superficial retinaculum peroneal nerve Inferior extensor retinaculum

Interosseus membrane Anterior inferior Distal tibia tibiofibular ligament Extensor retinaculum Distal Joint capsule Tendons of fibula of ankle Sinus tarsi extensor fat pad digitorum longus Tendon of Extensor peroneus digitorum tertius brevis

Extensor digitorum longus Extensor and peroneus tertius retinaculum Interosseous Distal tibia membrane Anterior inferior Dome of talus tibiofibular ligament Anterior Lateral malleolus talofibular ligament Posterior talocalcaneal joint Cervical ligament

Sinus tarsi Talonavicular fat pad joint

Calcaneocuboid joint Extensor digitorum brevis

Figure 1.53 Anterolateral approach to the foot. 60 Chapter 1. Anatomy Essentials

Spine

Cervical Spine

Bones

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

Dens

Superior articular facet Spinous processes C2

C3 Foramen transversarium C4 Intervertebral foramina Articular pillar formed by for spinal nerves articular processes and C5 interarticular parts (pars interarticularis) C6 Groove for spinal nerve in transverse process C7 Spinous process of C7 (vertebra Zygapophyseal (facet) prominens) T1 joints

Costal facets (for 1st rib)

Dens Superior articular surface for Atlas (C1) occipital condyle

Axis (C2)

Posterior articular C3 facet (for transverse ligament of atlas) C4

Figure 1.54 Bony anatomy of C1 articulating with C2. Spine 61

Neurovascular Structures

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

Capsule of atlantooccipital joint Anterior atlantooccipital membrane Posterior atlantooccipital membrane Atlas (C1)

Ligamenta flava Body of axis (C2)

Intervertebral discs (C2-3 and C3-4) Ligamentum nuchae Zygapophyseal joints (C4-5 and C5-6)

Anterior tubercle of C6 vertebra (carotid tubercle) Spinous process of C7 vertebra (vertebra prominens) Vertebral artery

T1 vertebra

Figure 1.55 (a, b) Neurovascular structures surrounding the cervical spine. 62 Chapter 1. Anatomy Essentials

Base of skull C1 C1 C1 spinal nerve exits C2 C2 above C1 vertebra C3 C3 C4 C4 Cervical enlargement C5 C5 C6 C6 C7 C7 T1 C8 C8 spinal nerve exits T2 T1 below C7 vertebra (there T3 T2 are 8 cervical nerves but T4 T3 only 7 cervical vertebrae) T5 T4 T6 T5 T7 T6 T8 T7 T9 T8 T10 T9 T11 T10 T11 T12 Lumbar enlargement T12 L1 L1 Conus medullaris L2 (termination of spinal L2 cord) L3 L3 Cauda equina L4 L4 L5 Filum terminale L5 internum Sacrum S1 Termination of S2 dural sac S3 S4 Filum terminale externum S5 (coccygeal ligament) Coccygeal nerve Coccyx

Cervical nerves Thoracic nerves Lumbar nerves Sacral and coccygeal nerves

Figure 1.55 (continued) Spine 63

Surgical Approach (Fig. 1.56)

Anterior approach: Superficial Incise platysma and then fascia along dissection anterior aspect of sternocleidomastoid. Deep dissection Bluntly enter plane between the carotid sheath and trachea/esophagus. Elevate longus coli off vertebral body. Posterior approach: Superficial dissection Dissect through the skin and subcutaneous tissue to the tip of spinous process. Deep dissection Elevate paraspinous muscles subperiosteally off spinous processes, and dissect along lamina.

Anterior approach to the cervical spine

Fascia over Deep cervical platysma fascia Platysma Platysma Deep cervical fascia over sternocleidomastoid

Sternocleidomastoid Prevertebral fascia, and carotid sheath anterior longitudinal ligament Prevertebral fascia overlying anterior longitudinal Longus ligament Vertebral body coli

Longus coli

Figure 1.56 Anterior and posterior approaches to the cervical spine. 64 Chapter 1. Anatomy Essentials

Posterior approach to the cervical spine

Third occipital nerve Fascia

Ligamentum Interspinous Spinous flavum Lamina ligament process

Facet joint capsules

Figure 1.56 (continued) Spine 65

Thoracic Spine

Bones

Twelve thoracic vertebrae form the thoracic spine (Fig. 1.57).

Body Superior costal Superior articular Vertebral Body facet process and facet Superior foramen costal facet Pedicle

Transverse costal facet Superior vertebral Pedicle notch (forms lower Transverse margin of process intervertebral Transverse foramen) costal facet Spinous Inferior Inferior Inferior process costal vertebral articular facet notch process Superior articular Spinous Lamina facet rocess Vertebral canal Superior articular process and facet

7th rib

T8 Spinous process of T7 vertebra T9

Transverse process Lamina of T9 vertebra

Inferior articular process (T9)

Spinous process (T9)

Figure 1.57 Bony anatomy of thoracic spine vertebrae. 66 Chapter 1. Anatomy Essentials

Neurovascular Structures

The thoracic nerve roots pass below the corresponding vertebral level.

Surgical Approach

Posterior approach (Fig. 1.58): Superficial Dissect through skin and subcutaneous tissue to dissection tip of spinous process. Deep Elevate paraspinous muscles subperiosteally off dissection spinous processes, and dissect along lamina.

Lumbodorsal fascia

Lamina

Interspinous ligament Lumbodorsal Spinous fascia process Lamina Descending articular process

Ligamentum flavum

Mamillary process Facet joint of ascending articular capsule process

Figure 1.58 Posterior approach to the thoracic spine. Spine 67

Lumbar Spine

Bones

Five lumbar vertebrae form the lumbar spine (Fig. 1.59).

Superior articular Vertebral process canal Vertebral body Mammillary process

Transverse process Accessory L3 Spinous process process of L3 vertebra Pars interarticularis L4 Lamina

Inferior articular process

Superior articular Pedicle process

Transverse process

Vertebral body L1 Spinous process

Intervertebral L2 disc Inferior articular process

L3 Intervertebral (neural) foramen

Lamina L4

L5 Articular facet for sacrum

Figure 1.59 Bony anatomy of lumbar spine vertebrae. 68 Chapter 1. Anatomy Essentials

Neurovascular Structures

The lumbar nerve roots pass below the corresponding vertebral level.

Surgical Approach

Posterior approach (Fig. 1.60): Superficial Dissect through skin and subcutaneous tissue to tip dissection of spinous process. Deep Elevate paraspinous muscles subperiosteally off dissection spinous processes, and dissect along lamina.

Lumbodorsal (thoracolumbar) fascia

Spinous process

Inter Lumbodorsal Ligamentum spinous Ligamentum Spinous (thoracolumbar) flavum ligament flavum process fascia

Spinous apophysis

Spinous Interior process articulating process

Transverse process

Superior Paraspinal Site of Mamillary Lamina Interspinous edge of muscles perforating process of ligament lamina segmental ascending vessels articular process

Figure 1.60 Posterior approach to the lumbar spine. Spine 69

Sacrum

Bones

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

Neurovascular Structures

Sacral nerve roots exit through four pairs of sacral foramina.

Lumbosacral articular surface

Ala Promontory

S2 Anterior sacral foramina S3 (S1 to S5) body of sacral vertebrae S4 S5 Coccyx

Figure 1.61 Bony anatomy of sacrum with sacral nerve roots. Chapter 2 Physical Exam Fundamentals

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

Definition

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

Principles

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

(=joint effusion or mass), muscle wasting (=disuse atrophy or denervation), or deformity (=fracture or chronic degenerative change). 2. Palpation –– Observe the patient’s facial expressions during palpation to determine the degree of tenderness. –– Pay attention to areas of warmth or swelling (=inflammation or infection) or lumps (=benign or malignant tumor). –– Crepitus (feels like Rice Krispies underneath your hand) within a joint suggests degenerative change, while crepitus in the soft tissues suggests a gas-producing bac- terial infection as can be observed with necrotizing fasciitis (see Chapter 4: Orthopedic Emergencies). 3. Manipulation –– Range of Motion (ROM) (a) Instruct the patient to perform active movements through entire ROM. (b) When painful or limited active ROM is present, guide the patient through passive ROM. Pearl: Joint pain with small-arc (10°) ROM suggests infection or crystalline arthropathy (gout or pseudogout), whereas pain with large-arc ROM suggests mechanical source of pain.

–– Motor Strength: Grade from 0 to 5 out of 5 (Table 2.1)

Pearl: Isolate the joint about which you are testing strength. For example, if you are testing shoulder flexion strength, provide resistance against the patient’s arm, not forearm. If you hold the forearm, you are testing strength across two joints (shoulder and elbow) and two sets of flexors. Upper Extremity 73

Table 2.1 Muscle strength grading scale Muscle grade Description 0/5 No active motion 1/5 Muscle contraction (twitch) without motion 2/5 Motion with gravity eliminated 3/5 Motion against gravity 4/5 Motion against gravity with some resistance 5/5 Motion against full resistance (normal strength)

4. Specialized Maneuvers –– Useful for diagnoses unique to an anatomic location (e.g., meniscal tears of the knee, shoulder instability).

Pearl: Always compare to the contralateral side!

Upper Extremity

Shoulder

The shoulder is comprised of three joints (sternoclavicular joint, acromioclavicular joint, and glenohumeral joint) and one articulation (scapulothoracic). 1. Inspection Anterior –– Hanging shoulder and adduction or abduction of the arm, internally rotated and adducted position—Erb’s palsy (C5-6 injury) (Fig. 2.1). –– Clavicle deformity (fracture) or deltoid wasting. –– Prominent anterior shoulder contour (shoulder dislocation). 74 Chapter 2. Physical Exam Fundamentals

Affected eyelid droops (“ptosis”)

Smaller pupil Horner syndrome Erb’s palsy Cervical scoliosis Shoulder rotated forward

“Bird-winging” of Affected arm the effected diminished in scapula length and girth

Lumbar scoliosis Muscle atrophy of the affected arm

“Waiter-tip” deformity of the affected wrist

Figure 2.1 Erb’s palsy.

Posterior –– Scapular asymmetry, which may indicate winging, Sprengel’s deformity, or spinal deformity. 2. Palpation Posterior –– Acromion and scapular spine. Anterior –– Acromioclavicular (AC) joint. –– Bicipital groove, best palpated with arm externally rotated. –– With arm extended, palpate rotator cuff underneath anterior acromion. 3. Manipulation Range of Motion (Normal in Parentheses) –– Abduction (180°). –– Adduction (45°). –– Extension (60°). –– Flexion (180°). Upper Extremity 75

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

Figure 2.2 Apley scratch test. 76 Chapter 2. Physical Exam Fundamentals

Motor Strength –– Supraspinatus With patient’s elbow fully extended, thumb pointed down, and arm with 90° of forward flexion and 45° of abduction, resist further forward flexion of arm with pressure applied at the ulnar aspect of the wrist. –– Subscapularis With patient’s hand on their umbilicus, ask them to push lateral aspect of the elbow anteriorly against your resistance. –– Infraspinatus and teres minor Stand in front of the patient, ask them to anchor their elbow flexed to 90° against their thorax, and instruct them to move their wrist laterally against your resistance. –– Deltoid Stand behind the patient, stabilize his/her shoulder with one hand, and ask the patient to push their elbow flexed to 90° laterally as you provide resistance. 4. Specialized Maneuvers Speed’s Test –– With patient’s elbow fully extended, forearm supinated, and arm forward flexed 60°, resist further forward flexion of patient’s arm. –– Pain suggests inflammation along the long head of the biceps tendon, or a superior glenoid labral tear at the point where the long head attaches, known as a superior labrum anterior and posterior (SLAP) lesion. Upper Extremity 77

O’Brien’s Test –– With patient’s elbow fully extended, arm forward flexed 90° and adducted 10°, resist further forward flexion of arm, first with patient’s thumb pointed down and then up. –– Pain with patient’s thumb pointed down that resolves with thumb pointed up suggests SLAP tear. Neer Impingement Sign –– Flex shoulder with thumb pointing down. –– Pain suggests rotator cuff tendonitis or subacromial impingement (picture). Hawkins Test –– With patient’s shoulder abducted 90° and elbow flexed 90°, internally rotate the shoulder. –– Pain suggests rotator cuff tendonitis or subacromial impingement. Hornblower’s Sign –– Detects tears in the posterior rotator cuff. –– With shoulder abducted 90° and externally rotated 90°, the patient is asked to maintain this position. Test is positive when shoulder internally rotates and the forearm drops. 78 Chapter 2. Physical Exam Fundamentals

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

Anterior apprehension sign

Figure 2.3 Shoulder anterior apprehension sign. Upper Extremity 79

Elbow

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

Figure 2.4 Gunstock deformity. 80 Chapter 2. Physical Exam Fundamentals

2. Palpation (a) Olecranon is palpated posteriorly with elbow flexion as it moves out of its fossa. (b) Radial head is identified by grasping the patients hand and pronating/supinating the forearm while palpating just distal to the lateral epicondyle of the humerus. The radial head can be felt to rotate in place against the capitellum. (c) With 90° of elbow flexion and biceps contracted, the distal biceps tendon can be palpated in the antecubital fossa. With distal biceps tendon rupture, which requires surgical repair, no discrete tendon can be appreciated. (d) With lateral epicondylitis, or “tennis elbow,” the common extensor origin at the lateral epicondyle is tender. With medial epicondylitis, or “golfer’s elbow,” the common flexor origin at the medial epidondyle is tender. 3. Manipulation Range of Motion (Normal in Parentheses) –– Flexion (150°) –– Extension (0°) –– Forearm pronation (90°) –– Forearm supination (90°) Motor Strength –– Flexion Stand in front of the patient, place hand around supinated distal forearm, and ask patient to “make a muscle.” –– Extension With hand position the same as above, ask patient to push you away. Upper Extremity 81

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

Hand and Wrist

1. Inspection (a) Thenar and hypothenar wasting suggests compromised innervation by median and ulnar nerves, respectively. (b) Blood underneath nail suggests nail bed injury. 82 Chapter 2. Physical Exam Fundamentals

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

(c) Observe the relationship of the fingers to one another, or “attitude” of the fingers, in a position of rest. • With flexor tendon disruption, the affected finger has an attitude of extension at rest (Fig. 2.5). • With extensor tendon disruption, the affected fingertip droops and is termed “mallet finger.” (d) Skin-colored nodular swellings at proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints may be osteoarthritic Bouchard’s or Heberden’s nodes, respectively, rheumatoid nodules, or gout tophi. 2. Palpation (a) Cords comprised of thickened palmar fascia, extending most commonly into the ring and small fingers, form in Dupuytren’s contracture. With disease pro- gression, flexion contractures of the digits develop. (b) A tender nodule on the volar aspect of the hand at the level of the MCP joints can be a sign of trigger finger. Finger extension from a fully flexed position resulting in a catching sensation and palpable click volarly at the level of the MCP confirms the diagnosis. Upper Extremity 83

3. Manipulation Range of Motion (Normal in Parentheses) (a) Wrist –– Ulnar deviation (30°). –– Radial deviation (20°). –– Extension (70°). –– Flexion (80°). (b) Fingers –– Digits 2–5 MCP flexion (90°). –– Digits 2–5 MCP hyperextension (45°). –– Digits 2–5 PIP flexion (100°). –– Digits 2–5 DIP flexion (80°). –– Digits 2–5 DIP hyperextension (10°). –– Thumb CMC abduction (70°). –– Thumb CMC flexion (15°). –– Thumb CMC extension (20°). –– Thumb CMC opposition (thumb tip to small finger MCP or tip). –– Thumb MCP flexion (50°). –– Thumb IP flexion (80°). Motor Exam –– Median nerve Ask patient to oppose the thumb to the small finger. –– Anterior interosseous nerve Ask patient to flex index DIP. –– Ulnar nerve Ask patient to flex the small finger DIP. –– Radial nerve Ask patient to extend the wrist. –– Posterior interosseous nerve Ask patient to give “thumbs up” sign. 84 Chapter 2. Physical Exam Fundamentals

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

Figure 2.6 Phalen’s test. Upper Extremity 85

Figure 2.7 Test for flexor digitorum superficialis tendon.

Figure 2.8 Test for flexor digitorum profundus tendon.

–– Test flexor digitorum profundus tendon by grasping middle phalanx of digit to be tested and having patient flex digit tip. If digit tip can be flexed, tendon is intact (Fig. 2.8). Finkelstein Test –– Have patient grasp the thumb of the affected hand with other digits and ulnarly deviate the hand. Pain on radial aspect of the wrist suggests De Quervain’s tenosynovitis—inflammation of the abductor pollicis longus and extensor pollicis brevis tendons, as well as their sheath. 86 Chapter 2. Physical Exam Fundamentals

Lower Extremity

Hip and Pelvis

The hip joint is comprised of the femoral head articulating with the acetabulum. The ilium, ischium, and pubis converge to form each hemi-pelvis (and acetabulum), which are con- nected in the center by the sacrum to form the pelvis. 1. Inspection Assess Gait –– Antalgic gait, shorter stance phase of painful extremity. –– Trendelenburg gait, upper body leans toward side with weak abductors. –– Shuffling gait, with Parkinson’s disease. –– Spastic gait, with cerebral palsy. 2. Palpation Anterior –– Provide posteriorly directed stress to bilateral anterior superior iliac spines to assess stability of the pelvis. Lateral –– Palpate greater trochanters to assess for trochanteric bursitis. Posterior –– Palpate sacroiliac joint to assess for degenerative joint disease or sacroiliitis, particularly if FABER test is positive (see below). –– Palpate ischial tuberosity; defect immediately distal suggests proximal hamstring rupture. 3. Manipulation Range of Motion of the Hip (Normal in Parentheses) –– Flexion, with knee flexed (120°). –– Flexion, with knee extended (90°). –– Extension (30°). Lower Extremity 87

–– Abduction (45°). –– Adduction (30°). –– Internal rotation (45°). –– External rotation (45°). Motor Strength –– Flexion With patient seated, ask that the knee be lifted up while providing resistance on anterior aspect of distal thigh. –– Abduction With patient lying on side opposite to that being tested, ask that the leg be lifted toward sky with knee extended while providing resistance against lateral aspect of the distal thigh. 4. Specialized Maneuvers Internal rotation of the hip with hip flexed to 90° –– Groin, lateral hip, or deep buttocks pain suggests degenerative change. Hip labral stress maneuvers (click or pain suggests labral tear) –– Flexion, adduction, and internal rotation. –– Starting with hip flexed to 90°, abducted, and externally rotated, take the hip through large arc of motion with full hip flexion, internal rotation, and adduction (roll hip medially). Then reverse this motion (roll hip laterally) to end at starting position. –– McCarthy’s sign: With hip fully flexed, externally rotate and extend the hip; repeat this maneuver, but now internally rotate and extend the hip. Trendelenburg test for abductor weakness –– If patient stands on one leg and the ipsilateral abductors are weak, then the contralateral pelvis droops; if the ipsilateral abductors are normal, then the contralateral pelvis remains level. 88 Chapter 2. Physical Exam Fundamentals

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

Barlow maneuver Ortolani maneuver

Figure 2.9 Barlow and Ortolani’s maneuvers. Lower Extremity 89

Knee

The knee, the largest joint of the body, is comprised of the tibiofemoral articulation and patellofemoral joint. 1. Inspection –– Sulcus superior or inferior to patella suggests quadriceps or patellar tendon rupture, respectively. Alignment –– Coronal (patient facing you): –– Valgus, knock-kneed. –– Varus, bow-legged. –– Sagittal (patient facing your left or right with side turned to you): –– Flexion contracture, the knee is bent and cannot be pas- sively extended. –– Hyperextension, the knee is posterior to midline. Gait –– Varus thrust, the knee moves laterally during gait. –– Valgus thrust, the knee moves medially during gait. 2. Palpation –– Fluid immediately underneath the skin overlying patella suggests prepatellar bursitis. –– With the knee in extension, when patella is grasped and downward force is applied to the patella, the patella will strike the patellar surface of the femur and then float off it when an intra-articular effusion is present. This is referred to as a “ballotable” patella. –– Palpate medial and lateral joint lines, which are at the level of the inferior aspect of the patella. Tenderness suggests either meniscal tear or degenerative change. –– Palpate anterior aspect of medial and lateral femoral condyles. Tenderness suggests degenerative change. –– Palpate pes anserine bursa (insertion of hamstring tendons). Tenderness suggests bursitis. 90 Chapter 2. Physical Exam Fundamentals

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

Figure 2.10 Lachman’s test for ACL tear. Lower Extremity 91

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

Figure 2.11 Pivot-shift test for ACL tear. (a) With knee in extension, internal rotation and valgus stress producing anterior tibial subluxation; (b) knee flexion with valgus stress; and (c) palpable reduction of tibia with knee flexion. 92 Chapter 2. Physical Exam Fundamentals

McMurray’s test –– With fingers on medial and lateral joint lines, flex the hip and knee, and apply varus stress to the knee while bringing the hip and knee into extension; repeat maneuver while applying valgus stress to the knee. –– Palpable click or pain suggests a meniscal tear on the side of the positive test (medial or lateral).

Collateral ligament test –– To test integrity of medial collateral ligament, apply valgus stress to the knee at 30° of flexion with fingers at level of the joint line. –– To test integrity of lateral collateral ligament, apply varus stress to the knee at 30° of flexion with fingers at level of the joint line. –– Pain without gapping is Grade I ligament tear, gapping with firm endpoint is Grade II tear, and gapping without endpoint is Grade III tear.

Foot and Ankle

The ankle is comprised of the distal tibia and fibula articulating with the talus. The foot is comprised of the hindfoot (talus and calcaneus), midfoot (cuboid, navicular, and three cuneiforms), and forefoot (metatarsals and phalanges). The articulation between the talus and calcaneus is the subtalar joint, the articulation between the hindfoot and midfoot is the transverse tar- sal (or midtarsal or Chopart’s) joint, and the articulation between the midfoot and forefoot is the tarsometatarsal joint. 1. Inspection –– Observe patient while weight-bearing from behind to determine if the heel leans medially (pes planus) or laterally (pes cavus). 2. Palpation –– Common sites of fracture (medial and lateral malleoli, base of 5th metatarsal, Lisfranc joint, proximal fibula to evaluate for Maisonneuve fracture). Lower Extremity 93

Fibula Tibia

Posterior Anterior inferior inferior tibiofibular tibiofibular ligament ligament Talus

Posterior talofibular ligament

Calcaneofibular Anterior talofibular ligament ligament

Figure 2.12 Ankle ligaments.

–– Commonly injured ankle ligaments (Fig. 2.12). –– Achilles tendon for defect secondary to tear. 3. Manipulation Range of Motion (Normal in Parentheses) –– Ankle –– Dorsiflexion (20°). –– Plantarflexion (50°). –– Inversion (35°). –– Eversion (15°). 94 Chapter 2. Physical Exam Fundamentals

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

Spine

1. Inspection Symmetry –– Observe patient with back exposed. –– Normal findings: (a) Head directly over gluteal cleft. (b) Both shoulders, scapulae, and iliac crests at equal heights. Lower Extremity 95

2. Palpation –– Spinous processes Visible or palpable step-off may indicate spondylolisthesis (anterior slippage of a vertebrae) or fracture in context of significant trauma. –– Iliac crest (typically at L4–L5) –– Sacroiliac joint Tender in sacroiliitis due to degenerative joint disease, infection, or spondyloarthropathies (e.g., ankylosing spondylitis). 3. Manipulation Range of Motion –– Flexion –– Ask patient to bend forward, and measure distance from tip of fingers to ground (requires relaxation of the anterior longitudinal ligament). –– Extension –– Ask patient to bend backward while providing lumbar support with your hand, which serves as a ful- crum (requires relaxation of the posterior longitudinal ligament). –– Lateral bending –– With your hands on the patient’s iliac crests, ask them to bend to each side, noting any differences. –– Rotation –– While standing behind the patient, stabilize one hemi- pelvis by holding the iliac crest, and rotate the contralateral shoulder posteriorly. Motor Strength –– A neurologic examination should be performed if the patient complains of bowel/bladder symptoms (incontinence or retention), saddle paresthesias, or extremity pain, weakness, numbness, or tingling. –– Perform according to Tables 2.2 and 2.3, with muscle strength graded according to Table 2.1. 96 Chapter 2. Physical Exam Fundamentals

Table 2.2 Cervical levels Nerve Sensation Motor Reflex root C3 Occiput None None C4 Supraclavicular None None space C5 Lateral arm Deltoid Biceps, brachioradialis C6 Lateral forearm Biceps and Biceps, wrist extension brachioradialis C7 Long finger Triceps and Triceps wrist flexion C8 Medial forearm Finger flexion None T1 Medial arm Finger None abduction

Table 2.3 Lumbar levels Nerve Sensation Motor Reflex root L2 Superomedial thigh Hip flexion Patellar L3 Inferomedial thigh Knee extension Patellar L4 Medial lower leg Dorsiflexion of Patellar foot L5 Lateral lower leg and Great toe None medial foot extension S1 Lateral foot Plantar flexion Achilles of foot

4. Specialized Maneuvers Spurling’s Test –– Patient is asked to extend the neck and rotate the head toward symptomatic arm. –– This test for cervical radiculopathy is positive when it reproduces the patient’s arm pain. Lower Extremity 97

Hoffman’s Sign –– Hold the patient’s relaxed hand, and flick the distal phalanx of their long finger. –– This test for cervical myelopathy (the spinal cord changes secondary to compression) is positive when the thumb flexes at the interphalangeal joint. Clonus –– With patient seated or supine, briskly dorsiflex the patient’s foot, and then relax pressure on the foot. –– This test for myelopathy (cervical, thoracic, or lumbar) is positive when the patient, in response, plantarflexes the foot in a pulsatile fashion. Each time the patient’s foot plantarflexes is termed a “beat” of clonus. One to two beats of clonus can be normal and even less concerning if symmetric. The patient can have clonus not only with myelopathy but also with conditions/lesions of the brain. Straight Leg Raise –– With patient lying supine, flex their hip with knee extended (30–60°). Dorsiflexion of foot and extension of great toe helps elicit pain. –– This test for low lumbar radiculopathy is positive when pain is felt below the knee. Femoral Nerve Stretch Test –– With patient laying on their side with the knee flexed to 90°, hold the patient’s ankle, and extend their hip. –– This test for high lumbar radiculopathy is positive if pain is felt in the anterior compartment of the thigh (L2–L4). Chapter 3 Managing the Floor

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

Postoperative Check/Rounding

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

3. Inspection of the dressing/incision and local operative site for erythema or drainage. 4. Assessment for evidence of DVT by examination of feet for swelling and squeezing of calves.

The following should be documented: Sample Note for Upper Extremity Postoperative Check Comfortable. AVSS (afebrile, vital signs stable). R UE (right upper extremity): Radial pulse palpable. Sensation and motor intact m/r/u/ax (median, radial, ulnar, axillary). Shoulder and arm soft (this is important to note and conveys there is no evidence of hematoma or impending compartment syndrome). Incision c/d/i (clean/dry/intact). Imp/plan: s/p R TSA (right total shoulder arthroplasty). Stable. Continue to monitor.

Sample Note for Lower Extremity Postoperative Check Comfortable. AVSS (afebrile, vital signs stable). R LE (right lower extremity): DP (dorsalis pedis) and PT (posterior tibial pulses) palpable. SILT (sensation intact to light touch) L4–S1. DF/EHL/PF 5/5 (dorsiflexion, extensor hallucis longus, plantar flexion motor). Thigh and leg soft (this is important to note and conveys there is no evidence of hematoma or impending compartment syndrome). Dressing c/d/i (clean/dry/intact). Lab Abnormalities 101

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

Lab Abnormalities

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

ANEMIA

Definition Low hemoglobin/hematocrit (i.e., hemoglobin<10.0 g/dL, hematocrit<30.0%).

Treatment If hemoglobin is greater than 7.0 g/dL or hematocrit is greater than 21.0% and the patient is asymptomatic, there is no need to transfuse blood.

7.0g/dL < Hgb < 10.0g/dL OR Begin with 250cc normal saline bolus 21.0% < Hct < 30.0% If patient remains symptomatic, + transfuse 1 unit PRBCs* Symptomatic patient (hypotensive/dizzy/lightheaded) *Packed Red Blood Cells

Transfuse 1 unit PRBCs

Hgb <7.0 g/dL OR Hct < 30.0% Transfuse even if asymptomatic, as blood counts are likely to trend down with time.

102 Chapter 3. Managing the Floor

Pearls For each unit of packed red blood cells transfused, the expected increase in hemoglobin is 1.0 g/dL, and the expected increase in hematocrit is 3.0%. A symptomatic patient with a hemoglobin > 10.0 g/dL or hematocrit > 30.0% is unlikely to be symptomatic because of his/her blood count.

HYPOGLYCEMIA

Definition Low glucose.

Treatment For glucose less than 60 mg/dL, administer dextrose 50% solution (D50). A symptomatic patient with glucose between 60 mg/dL and 150 mg/dL may be given orange juice to drink.

HYPONATREMIA

Definition Low sodium.

Treatment Most postoperative hyponatremia is dilutional. Restrict oral free water intake to 1 L per day. Administer normal saline (NS), but not too quickly to avoid central pontine myelinoly- sis (order: NS at 80 cc/h × 1 L). For patients with preoperative hyponatremia due to SIADH, restrict free water but do not administer more fluid. Lab Abnormalities 103

Pearl To prevent hyponatremia, order 5% dextrose in normal saline (D5NS) for postoperative fluids, not D5½NS, or lac- tated Ringer’s (LR). The sodium concentration in D5½NS and LR is lower than that of D5NS.

HYPERKALEMIA

Definition High potassium.

Treatment Sodium polystyrene 15–30 g orally × 1, provided patient has had a bowel movement (BM). May order a maximum of 15 g PO qid until patient has BM.

HYPOKALEMIA

Definition Low potassium.

Treatment • 10 mEq potassium orally for each 0.1 mmol/L increase in serum potassium desired. • To bring serum potassium from 3.1 to 3.5 mmol/L, order 40 mEq potassium PO/IV × 1. • If a larger dose of potassium is required, order 40 mEq potassium PO/IV × 1 now, 40 mEq potassium PO/IV 6 h from now. 104 Chapter 3. Managing the Floor

HYPOTENSION

Definition Low blood pressure (systolic less than 100 mmHg). Hypotension may result in insufficient perfusion of vital organs, including the brain, heart, and kidneys. The first potential cause of postoperative hypotension that should be investigated is active bleeding at the operative site. Other causes include: • Sepsis • Myocardial infarction • Pulmonary embolus • Adrenal insufficiency • Medication reaction (antihypertensives and opiates)

Treatment For an asymptomatic patient with a systolic pressure > 90 mm Hg: • Administer a 250 cc normal saline fluid bolus over 1 h • Obtain a complete blood count (CBC) • Transfuse per the protocol in “Lab Abnormalities/Anemia”

For a symptomatic patient (e.g., light-headed or dizzy) or a patient with a systolic pressure < 90 mm Hg: • If the patient is awake, alert, and responsive, initiate a 500 cc normal saline fluid bolus over 1 h and consult internal medicine urgently • Obtain a stat CBC • Transfuse per the protocol in “Lab Abnormalities/Anemia” • If the patient has systolic < 80 mm Hg or does not respond to a fluid challenge, obtain an intensive care unit (ICU) consult • If the patient has altered mental status, call a Code emergently Lab Abnormalities 105

Palpate the operative site to determine if it is tensely swollen. If so, there may be active bleeding at the operative site neces- sitating return to the operating room. Palpate distal pulses—their absence may signify vascular injury. Stop all antihypertensives and opiates until the patient’s blood pressure stabilizes. If the patient was taking steroids preoperatively, make sure they have been continued postoperatively.

Fever/ Consider Hypotension + Tachycardia sepsis

Sepsis requires antibiotics as well as fluid and pressor support. Obtain an ICU consult emergently if sepsis is suspected.

Consider Hypotension + Chest pain myocardial infarction

Obtain an EKG as well as cardiac enzymes (CK, CK-MB, and troponin I) to determine if the patient has had a myocardial infarction. Obtain cardiology consult if this is confirmed.

Consider Tachycardia/ Hypotension pulmonary + Hypoxia embolus

A STAT chest CT should be performed if pulmonary embolus (PE) is suspected. 106 Chapter 3. Managing the Floor

HYPOXIA

Definition Low oxygen saturation (pulse oximeter oxygen saturation less than 92% on room air). Hypoxia is decreased oxygen- ation of blood, resulting in decreased oxygen delivery to tissues. This may hamper wound healing and ultimately result in organ failure. Several clinical scenarios involving hypoxia may arise:

Hypoxia Atelectasis (without tachycardia or (collapse of the respiratory distress) alveoli)

Treatment • Incentive spirometry 10×/h. • Pulmonary toilet with respiratory therapy.

Hypoxia + Fever (unresolved with Pneumonia incentive spirometry)

Workup

• Obtain a chest X-ray (AP and lateral if possible or porta- ble if more expedient) to determine if there is lung consoli- dation or infiltrate suggestive of pneumonia. Treatment

• Pneumonia will require prompt initiation of antibiotic therapy, not only for treatment of the underlying pathology but also to prevent hematogenous spread of infection to the operative site.

Hypoxia + Labored breathing and/or Heart failure cough

Lab Abnormalities 107

Causes of Heart Failure

• Fluid overload (if fluid intake far exceeds output). • Poor cardiac function (due to preoperative abnormality such as valvular dysfunction). • Acute onset atrial fibrillation. • Myocardial infarction. Workup

• Obtain a chest X-ray to determine if there is evidence of pulmonary congestion suggestive of heart failure. Treatment

• Heart failure due to fluid overload may be treated with a diuretic such as furosemide. • Titrate dose to blood pressure (for systolic pressure > 100, start with furosemide 5–10 mg × 1 dose). • The assistance of internal medicine is helpful in diagnosing and treating pulmonary congestion due to cardiac dysfunction.

Hypoxia + Pulmonary embolus (PE) Tachycardia

+/- Tachypnea Or pleuritic chest pain

Workup

• If PE is suspected, order a STAT chest CT. Treatment

• For PE, anticoagulation will be required with the assistance of vascular medicine or hematology. Full anticoagulation may be accomplished with warfarin as well as another agent for bridging until the INR is therapeutic (goal INR 2.0–3.0). Bridging agents include enoxaparin 1 mg/kg subcutaneous injection q12 hours or IV heparin. 108 Chapter 3. Managing the Floor

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

TACHYCARDIA

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

1) Assess Pain Control Tachycardia 2) Obtain Ekg If Rate Irregular * Normal O2 Saturation 3) Accompanying Hypotension Should Hgb ≥10 g/dL or hct ≥ Prompt Urgent Medical Intervention 30% *may represent atrial fibrillation

1) Administer 250–500cc Ns Bolus Tachycardia 2) If unresolved, transfuse 1 unit prbcs* Normal 02 Saturation 3) Transfuse additional units blood 7.0 g/dL < Hgb ≤ 1O g/dL until tachycardia resolves or Hgb ≥ 10g/dL

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

+/- Tachypnea or pleuritic chest pain

Lab Abnormalities 109

Workup

• If PE is suspected, order a STAT chest CT.

Treatment

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

FEVER

Definition Elevated temperature (oral temperature greater than 101.3F or 38.6C). Fever suggests the presence of an underlying pathology in the postoperative patient that should be addressed. These pathologic entities include: • Atelectasis • Infection • Deep vein thrombosis • Drug/transfusion reaction 110 Chapter 3. Managing the Floor

Causes of Fever:

Incentive Spirometry 10x/hr Up To 3rd Post-operative Day, + Pulmonary Toilet With Atelectasis Respiratory Therapy

-Stop Transfusion Transfusion of a blood -Notify Blood Bank product (PRBCs, PLTs, -Diphenhydramine 25–50mg Po/iv X 1 fresh frozen plasma) -Acetaminophen 1gm Po X 1 -Monitor Vitals

If Possible, Discontinue Any New Drug Reaction Medications

After the 3rd postoperative day, consider:

Urinary tract Send urinalysis and urine culture infection in patients with dysuria

Examine incision for signs of infection Wound infection (drainage/erythema)

-Look for calf/foot swelling or calf tenderness Deep vein thrombosis -Obtain duplex ultrasound of lower extremity Lab Abnormalities 111

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

LOW URINE OUTPUT (OLIGURIA)

Definition Urine output less than 0.5 cc/kg/h. Low urine output of prer- enal, intrarenal, or post-renal etiology may lead to renal failure.

Treatment

First administer a 250 cc normal saline bolus over 1 h. If UOP responds, then give another bolus if necessary to achieve appropriate weight-based UOP. If patient does not respond to fluid bolus, flush Foley catheter to ensure there is no blockage. If there is a blockage, change Foley catheter. If patient does not have a Foley catheter, patient discomfort in the suprapubic region or discomfort with palpation of the suprapubic region suggests urinary retention. Alternatively, perform bladder scan to determine if there is urinary retention. If there is evidence of urinary retention on physical exam or the bladder has greater than 400 cc or urine, place a Foley catheter. 112 Chapter 3. Managing the Floor

If hemoglobin is < 7.0 g/dL or hematocrit is < 21%:

Transfuse 1 unit of packed red blood cells.

• If hemoglobin is ≥ 10.0 g/dL or hematocrit is ≥ 30% • No evidence of urinary retention • Normal creatinine • No response to fluid bolus

Administer furosemide 5–10mg IV X 1 to overcome SIADH the patient may have developed post-operatively.

If patient’s UOP remains low, consult medicine/renal service to evaluate for intrarenal causes of oliguria.

DELIRIUM

Definition Acute disruption of consciousness and impairment of attention with fluctuating course. Delirium may result in behavior dangerous to the patient themselves or healthcare personnel. The consequences of delirium include: • Increased length of stay • Delay in mobilization • Need for discharge to a rehabilitation facility • Cognitive and functional decline • Increased rates of morbidity/mortality Lab Abnormalities 113

Treatment Delirium may be due to hypoxia, hypotension, or hypoglycemia. Please refer to the appropriate sections above for treatment of these conditions.

• Minimize narcotics. • Do not administer benzodiazepines, which have been shown to exacerbate delirium. • Frequent reorientation and a family member staying with the patient are helpful.

Pearl For a severely agitated patient that is a danger to himself or others, restraints or Haldol (1 mg IM × 1) may be necessary.

SEIZURE

Definition A seizure is an outward manifestation of abnormal electrical activity within the brain. Patients may display behaviors rang- ing from a blank stare to violent convulsions. Seizures may be due to serious underlying conditions such as tumor, arteriovenous malformations, intracranial hemor- rhage, or electrolyte abnormalities. Seizures may result in aspiration, falls, or brain damage if sufficiently prolonged and sustained. If untreated, seizures may recur.

Treatment • Remove any objects nearby that may hurt the patient. • Ensure the patient’s respiratory function is not compromised. • Try to turn the patient on his/her side to avoid aspiration. 114 Chapter 3. Managing the Floor

• For seizure activity lasting longer than 5 min, administer lorazepam 0.1 mg/kg IV over 1 min. • Consult neurology.

CHEST PAIN

Definition Pain within the chest that is not reproduced with palpation.

Pearls Chest pain that is reproduced with palpation is due to a musculoskeletal cause, such as soft tissue contusion secondary to intraoperative patient positioning. Chest pain is a symptom of potentially life-threatening conditions such as myocardial infarction and pulmonary embolus.

Workup

• Obtain an EKG. • Order cardiac enzymes (CK, CK-MB, and troponin I). If these are suggestive of cardiac ischemia, cardiology should be consulted.

Pleuritic chest pain Pulmonary embolus

+/- Tachypnea, hypoxia, or tachycardia

Workup

• If PE is suspected, order a STAT chest CT. Treatment

• Anticoagulation will be required with the assistance of vascular medicine or hematology. Full anticoagulation may Lab Abnormalities 115

be accomplished with warfarin as well as another agent for bridging until the INR is therapeutic (goal INR 2.0–3.0). Bridging agents include enoxaparin 1 mg/kg subcutaneous injection q12 h or IV heparin.

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

PAIN MANAGEMENT

Postoperative pain control allows effective participation in physical therapy. Increasing pain following a fracture or surgery could herald impending compartment syndrome.

Consider Increasing post- compartment operative pain syndrome*

* Chapter 4, Orthopedic Emergencies

Increased pain after Obtain x-ray to a fall evaluate for fracture

Once the above have been ruled out, the patient’s pain can be treated symptomatically. Postoperative pain regimens typically include one agent from each of the following categories (see Table 3.1). 116 Chapter 3. Managing the Floor

Table 3.1 Common pain medications and adult dosages PO narcotics IV/IM/SC narcotics PO miscellaneous In order of In order of decreasing potency decreasing potency Hydromorphone Hydromorphone Acetaminophen* 2–4 mg PO 1–2 mg SC/IM q3 h 1 gm PO q3 h prn pain prn pain q6 h Morphine 2–4 mg Celecoxib 200 mg IM/IV PO BID q3 h prn pain Oxycodone/ Fentanyl 25–50mcg Skelaxin 800 mg acetaminophen* IV PO TID prn muscle 5/325 mg 1–2 q 3 h prn pain spasm tablets PO q4–6 h prn pain Oxycodone 5–10 mg PO q3 h prn pain Hydrocodone/ *Maximum acetaminophen dose should acetaminophen* not exceed 4 gm in a 24-h period 5/325 mg 1–2 tablets PO q4–6 h prn pain Tramadol 50–100 mg PO q4–6 h prn pain *Maximum acetaminophen dose

Wound Issues

Wound issues in the acute postoperative period include erythema, drainage, and dehiscence. All of these may indicate the presence of infection, and some may result in infection, perhaps the most adverse operative site event apart from compartment syndrome. Lab Abnormalities 117

ERYTHEMA

Peri-incisional erythema in the acute postoperative period may be part of the normal wound healing process or may be due to hematoma or infection. • Outline the border of any concerning erythema with a marker and record the date of the examination directly on the skin. If the area of erythema does not extend beyond the outlined border over time and resolves with elevation, continue to monitor as this is likely due to hematoma. If the erythema extends beyond the outlined border over time, and if the region of erythema is more tender than non-erythematous peri-incisional areas, then infection is more likely.

DRAINAGE

Wound drainage demonstrates the presence of a conduit for infection to enter the operative site. Persistent wound drainage (>7 days) carries with it a high likelihood for develop- ment of infection. • If there is wound drainage, perform daily or twice daily dressing changes depending on the degree of drainage. Paint the incision with betadine during dressing changes to prevent infection. If drainage persists for greater than 7 days, take the patient back to the operating room for incision and drainage and revision wound closure to prevent infection.

DEHISCENCE

Wound dehiscence may occur as a result of trauma, vigorous activity, or infection. If infection is not the cause of wound dehiscence, then the operative site may become infected if tissue coverage is not achieved promptly. • For wound dehiscence, the patient should be taken back to the operating room as soon as possible for incision and drainage and revision wound closure. Chapter 4 Orthopedic Emergencies

In this chapter we discuss orthopedic emergencies, which should be on the differential diagnosis for every patient in order to minimize the likelihood they go unrecognized.

Definition

An orthopedic emergency is a situation where loss of life, limb, or irreversible musculoskeletal injury is imminent without emergent treatment that is often surgical.

Septic Joint

Definition

A septic joint is an infection occupying a joint space.

Why Is this Emergent?

Septic joint can result in systemic sepsis, irreversible chondral injury from proteolytic enzymes released by neutrophils, and subsequent arthritis.

Causes

• Hematogenous spread of infection (e.g., UTI, pneumonia, infectious diarrhea) • Direct spread of osteomyelitis (esp. hip, ankle, shoulder, elbow in children, where metaphysis is intracapsular • Gonorrhea (monoarticular in young patient) • Traumatic arthrotomy

Diagnosis

History Severe, acute joint pain. Chronic joint pain may be present in certain patients (immunocompromised) or with certain bacteria (TB).

Physical exam Erythema and warmth over joint. Joint effusion. Exquisite pain on small-arc (0°–10°) passive range of motion (ROM) of joint.

Labs Please see Table 4.1.

Table 4.1 Laboratory test results for a septic native joint Test Joint aspirate Joint stat Joint Serum aspirate Gram aspirate WBC ESR CRP WBC stain crystals Result Normal High High >50,000 Positive Positive in or high or or septic negative negative joint Suppurative Flexor Tenosynovitis 121

Caveats Positive stat Gram stain = septic joint independent of any other results. Negative stat Gram stain does not rule out septic joint (e.g., aspirate WBC >50,000, negative crystals, negative stat Gram stain = septic joint). Joint aspirate WBCs can be greater than 50,000 in crystalline arthropathy. WBC>50,000 and positive crystals = crystalline arthropathy until there is a positive culture (do not go to OR without positive culture in this case). However, crystalline arthropathy and septic joint CAN occur concurrently (aspirate with crystals and positive stat Gram stain = septic joint).

Imaging None

Treatment

Emergent I & D in OR with drain. Immobilization in early post-op period with IV Abx for 6–8 wks via PICC line. Open arthrotomy is the gold standard. Arthroscopic I & D of the knee is acceptable, but more than one trip to the OR may be necessary to clear the infection.

Pearl Every painful joint should be ruled out for septic arthritis. Make the patient NPO until you have a diagnosis. Order CBC, ESR, and CRP. If there is pain on small-arc motion, aspirate the joint through an area of skin without cellulitis so as not to seed the joint with bacteria. Range all other joints to make sure the patient does not have multiple joints that are affected. Treatment plan is based on labs and aspirate. 122 Chapter 4. Orthopedic Emergencies

Suppurative Flexor Tenosynovitis

Definition

Hand infection involving the flexor sheath of a digit.

Why Is this Emergent?

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

Causes

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

Diagnosis

History Pain in a digit following trauma or adjacent infection.

Physical exam Kanavel’s signs are diagnostic—(1) tenderness along flexor sheath, (2) digit fixed in flexed position, (3) pain on passive extension, and (4) sausage (swollen) digit.

Labs Elevated WBC, ESR, and CRP

Treatment

Emergent I & D in OR with drain. Postoperative splinting, elevation, soaks in Betadine/Hibiclens, and IV antibiotics. Continuous irrigation on floor may be considered. Necrotizing Fasciitis 123

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

Necrotizing Fasciitis

Definition

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

Why Is this Emergent?

Necrotizing fasciitis can cause death within hours.

Causes

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

Diagnosis

History Trauma, surgery, and severe pain out of proportion to initial appearance of soft tissues.

Physical exam Fever, hypotension, and tachycardia. Rapidly progressive erythema and subcutaneous crepitus.

Labs Elevated WBCs 124 Chapter 4. Orthopedic Emergencies

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

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

Treatment

Emergent I & D in OR with wide debridement of all nonvi- able tissue, fasciectomy, and IV antibiotics. Fascia must be sent to pathology for definitive diagnosis. ICU care and mul- Compartment Syndrome 125

Figure 4.2 Axial CT image of the left thigh demonstrating gas tracking along fascial plane in the same patient. tiple I & Ds will likely be necessary. Amputation may be required as a life-saving measure.

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

Compartment Syndrome

Definition

Compartment syndrome is elevation of interstitial pressure within a fascial compartment sufficient to cause tissue necrosis. 126 Chapter 4. Orthopedic Emergencies

Why Is this Emergent?

Compartment syndrome can cause tissue necrosis and permanent limb dysfunction.

Causes

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

Diagnosis

History Increasing pain or pain medication requirement (particularly in children) possibly accompanied by paresthesias. Neurologic deficits and absent pulses are late findings that herald irreversible tissue damage.

Physical exam Rock-hard compartment upon palpation that is not manually compressible. Pain on passive range of motion (PROM) of muscles in affected compartment (e.g., for the forearm and lower leg, pain on PROM of digits).

Diagnostic Studies Compartment pressure greater than 30 mm Hg or within 30 mm Hg of diastolic blood pressure. The former is a more sensitive measure, while the latter is more specific.

Labs None

Imaging None Open Fracture 127

Treatment

Emergent fasciotomy of involved limb compartments

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

Open Fracture

Definition

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

Why Is this Emergent?

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

Table 4.2 Gustilo and Anderson open fracture classification Description Type I Skin opening <1 cm Type II Skin opening >1 cm, minimal-moderate crush injury Type III Severe crush injury Type IIIA Adequate soft tissue coverage of bone Type IIIB Exposed bone with massive contamination Type IIIC Vascular injury requiring repair 128 Chapter 4. Orthopedic Emergencies

Causes

• Trauma

Diagnosis

History High-energy trauma with open wounds

Physical exam Open, bleeding wound in close proximity to the fracture site

Imaging Plain films demonstrating fracture

Treatment

Upon presentation, administration of antibiotics and tetanus prophylaxis (Table 4.3). Gross debris should be removed.

Table 4.3 Antibiotic prophylaxis for open fractures Antibiotic prophylaxis regimen Type I Cefazolin 2 g IV loading dose and then 1 g IV q8h × 24 h Type II Cefazolin 2 g IV loading dose and then 1 g IV q8h until 48 h after wound closure Type III Cefazolin 2 g IV loading dose and then 1 g IV q8h; gentamicin 5.1 mg/ kg IV daily. Continue until 48 h after wound closure Farm injuries, vascular Aqueous penicillin G 2–4 million compromise, extensive units IV q4h until 48 h after wound soft tissue crush injury closure Cauda Equina Syndrome 129

From the wound, it should be dressed with Betadine-soaked gauze, and the fracture should be splinted. Urgent/emergent I&D of the wound/fracture, fracture stabilization, vascular repair as needed, and wound care (e.g., primary closure, dressing changes, VAC dressing) follow.

Pearl A fracture with a skin abrasion over or near it with punctate dermal bleeding is not an open fracture.

Cauda Equina Syndrome

Definition

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

Why Is this Emergent?

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

Causes

• Herniated disc, usually at L4/5 or L5/S1 (most common) • Infection (epidural abscess) • Tumor (prostate cancer in men) • Trauma (fracture/subluxation, penetrating injury) • Spinal stenosis • Iatrogenic (aberrant instrumentation, continuous spinal anesthesia) 130 Chapter 4. Orthopedic Emergencies

{ C1 spinal nerve exits Base of skull C1 above C1 vertebra C1 C2 2 C3 3 4 C4 5 C5 Cervical 6 7 C6 enlargement 8 C7 T1 C8 spinal nerve exits { 2 T1 below C7 vertebra (there are 8 cervical 3 T2 nerves but only 7 4 T3 cervical vertebrae) 5 T4 6 T5 7 8 T6 9 T7 10 T8 11 T9 12 L1 T10 2 Lumbar 3 T11 enlargement 4 5 S1 T12 2 Sacral 3 nerves 4 L1 5 Conus medullaris L2 (termination of spinal cord) L3 Cauda equina L4

Internal terminal filum (pial part) L5

Sacrum Termination S1 of dural sac S2 External terminal S3 filum (dual part) S4 S55 { Coccygeal nerve Coccyx

Figure 4.3 Cauda equina. Cauda Equina Syndrome 131

Diagnosis

History Bowel/bladder/sexual dysfunction (urinary retention most common, but subsequent overflow incontinence does occur). Saddle area (perineal) numbness/paresthesias. Lower extremity pain, weakness, and decreased sensation.

Physical exam Lower extremity motor weakness and reduced/absent reflexes. Decreased perianal sensation and rectal tone. Post-void residual (patient voids, Foley inserted, urine collected is residual) greater than 100–200 mL.

Imaging MRI or CT myeloGram showing mechanical compression of cauda equina (Fig. 4.4).

Treatment

Emergent surgical decompression of the cauda equina. This must occur within 48 h of symptom onset to avoid permanent loss of function.

Pearl Any patient presenting with urinary retention, incontinence without sensation of voiding, bowel incontinence, or saddle paresthesias in association with lower extremity neurologic deficits should have an emergent lumbar spine MRI to rule out cauda equina syndrome. If the MRI demonstrates compression of the cauda equina, emergent surgical decompression must be performed. 132 Chapter 4. Orthopedic Emergencies

Figure 4.4 Saggital T2 (a) and axial T2 (b) images of large central disc herniation in a patient with cauda equina syndrome (CES). Chapter 5 Emergency Room Consultations

Emergency Room Consults

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

High-Energy Trauma Patient and Fracture Management

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

© Springer Science+Business Media, LLC, 133 part of Springer Nature 2020 S. Nandi, S. F. St. Clair, The Bone Book, https://doi.org/10.1007/978-1-4614-3091-9_5 134 Chapter 5. Emergency Room Consultations

II. Evaluate screening radiographs: –– Chest X-ray (proximal humerus, clavicle, scapula) –– C-spine (cervical fractures/dislocations) –– AP pelvis (pelvic ring injuries and/or hip fractures) III. Examine the patient: –– If responsive, ask patient: “Where do you hurt?” –– Whether patient is responsive or not, palpate all long bones and spinous processes; range all joints; and, in patient without apparent pelvic ring injury on AP pelvis X-ray, assess stability of the pelvis by applying posterior pressure to bilateral anterior superior iliac spines (ASIS). Pain or crepitus suggests possible fracture and warrants imaging. –– Order appropriate radiographs of suspected sites of injury (Table 5.1). Pearl: Image joint immediately above and below the fracture site once patient is stabilized to fully elucidate fracture, identify associated injuries, and facilitate operative plan- ning (e.g., mode of fixation). IV. Urgent Interventions: –– Dress open fractures (sterile saline to wash out gross debris, betadine-soaked 4X4s to wound secured with Kerlix), and administer antibiotic/tetanus prophylaxis. –– Immobilize fractures with splints (see Chapter 8). –– Keep patient NPO until treatment plan is finalized. –– Formulate treatment plan for fracture (Tables 5.2, 5.3, 5.4, 5.5, and 5.6). Pearl: Open fractures require internal fixation. A cast or brace is ineffective as it must be frequently removed for wound care. –– If appropriate, prepare patient for OR (see Chapter 7). –– Skeletal traction stabilizes acetabular and femur fractures while facilitating fracture reduction in the OR. Apply as needed (Table 5.7) (Figs. 5.1 and 5.2). –– Start DVT prophylaxis if hemodynamically stable, there is no head or spine injury, and patient is not going to OR the same day as presenting to ER. –– Evaluate for compartment syndrome pre- and postoperatively. High-Energy Trauma Patient and Fracture Management 135

Table 5.1 Trauma imaging Anatomic Imaging Pearls location Shoulder X-ray: AP and Cannot adequately evaluate for axillary views shoulder dislocation without axillary view. Axillary view can be performed by supporting arm in a supine patient with shoulder in as little as 30° of abduction Obtain CT scan to evaluate great vessels/mediastinum with posterior sternoclavicular (SC) joint dislocation

Humeral shaft X-ray: AP and lateral views

Elbow X-ray: AP and Plain films of contralateral lateral views elbow helpful in distinguishing ossification center versus fracture in pediatric patients

Forearm X-ray: AP and lateral views

Wrist/hand X-ray: AP, lateral, Obtain scaphoid view (ulnar and oblique views deviation PA view) if indicated by other imaging/physical exam

Pelvis X-ray: AP pelvis Acronym “IPCAW”: Iliac view (screening) oblique view demonstrates X-ray: inlet view for Posterior Column and Anterior anterior-posterior Wall disruption; outlet Conversely, obturator oblique view for superior- view demonstrates anterior inferior disruption column and posterior wall X-ray: Judet views (iliac and obturator oblique) to evaluate acetabular fracture CT to assess posterior pelvis as needed (continued) 136 Chapter 5. Emergency Room Consultations

Table 5.1 Trauma imaging (continued) Anatomic Imaging Pearls location Hip X-ray: AP pelvis Do not get frog lateral X-ray view and cross-table of hip, as nondisplaced femoral lateral view of hip neck fracture may become displaced

Femoral shaft X-ray: AP and Check for femoral neck lateral views fractures

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

Tibial shaft X-ray: AP and lateral views

Foot X-ray: AP, lateral, Harris view for calcaneus and oblique views, fracture weight-bearing if MRI for suspected Lisfranc possible sprain or stress fractures CT scan as needed to better characterize fracture

Cervical spine X-ray: AP and lateral views CT scan for odontoid and difficult to visualize fractures Thoracolumbar X-ray: AP and spine lateral views CT scan for operative fractures High-Energy Trauma Patient and Fracture Management 137

Table 5.2 Upper extremity fracture management Fracture Fracture Definitive Pearls temporization treatment Clavicle Sling Nonoperative ORIF with skin versus plate/ tenting. Never use screws with intramedullary greater pin/nail due to than 100% risk of hardware displacement migration

Proximal Sling Nonoperative (1- humerus part/minimally displaced), plate/ screws (young), or arthroplasty (old)

Humeral Coaptation Fracture brace, ORIF indications shaft splint plate/screws, or uncommon: intramedullary vascular injury, nail (pathologic neurologic injury, fracture) floating elbow with ipsilateral forearm fracture, morbid obesity that promotes varus angulation at fracture site

Distal Posterior long Nonoperative Jones dressing if humerus arm splint if nondisplaced, high-energy injury plate/screws if displaced, total elbow replacement in elderly with severe comminution

Olecranon Posterior long Plate/screws or arm splint tension band for displaced (continued) 138 Chapter 5. Emergency Room Consultations

Table 5.2 Upper extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Radial head Sling Plate/screws for 3 Assess for block or less fragments, to motion, which prosthetic is indication for replacement if ORIF regardless fixation unstable/ of fracture pattern. unreliable Examine ipsilateral forearm and wrist for Essex-Lopresti lesion (associated interosseous ligament and distal radioulnar joint [DRUJ] injury).

Radial or Sugar tong Plate/screws for Monteggia ulnar shaft displaced fracture: proximal ulna fracture with radial head dislocation Galeazzi fracture: fracture at junction of middle and distal third of radial diaphysis with disruption of distal radioulnar joint

Distal radius Sugar tong Plate/screws for displaced, unstable, intra- articular

Carpus Sugar tong (add Nonoperative thumb spica for versus K-wires scaphoid and or screw for trapezium) displaced Pediatric Fractures 139

Table 5.2 Upper extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Metacarpal Radial gutter Nonoperative (1st or 2nd), versus K-wires ulnar gutter or plate/screws (4th or 5th), or for unstable/ anterior and displaced posterior slabs (3rd) Phalanges Digit extension/ Nonoperative aluminum splint versus K-wires or plate/screws for unstable or intra- articular

Pediatric Fractures

Salter-Harris classification (using distal femur, e.g., with well- known, previously described mnemonic): Type I: S, straight across physis. Type II: A, above physis. Type III: L, low or below physis. Type IV: TE, through everything (above and below physis). Type V: R, rammed or crushed physis. 140 Chapter 5. Emergency Room Consultations

Table 5.3 Pediatric upper extremity fracture management Fracture Fracture Definitive Pearls temporization treatment Clavicle Sling Nonoperative If skin tented, unless older than needs reduction 12 and fracture 100% displaced Proximal Sling Nonoperative humerus unless older than 12 and fracture displaced >30% width of shaft Humeral shaft Coaptation splint Fracture brace Long arm cast Elbow (please If necessary, see various obtain plain fracture types films of below) contralateral elbow to distinguish between ossification center and fracture Supracondylar Long arm splint Nonoperative for humerus nondisplaced (line along anterior aspect of humerus should intersect capitellum), percutaneous pinning for displaced Lateral or Long arm splint Nonoperative Arthrogram may medial condylar for nondisplaced, help determine physis open reduction if there is with pinning for displacement displaced Pediatric Fractures 141

Table 5.3 Pediatric upper extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Olecranon Long arm splint Nonoperative for nondisplaced: tension band or screws for displaced Radial head Long arm splint Closed management preferred; percutaneous pinning for unstable fractures, open reduction with >60° angulation or > 4 mm displacement Radial or ulnar Sugar tong splint Reduction Monteggia: shaft with long arm closed cast; age > 10: reduction of flexible nails, ulna for plastic plate/screw in deformation, skeletally mature flexible nail or with severe or K-wire comminution for complete fracture Galeazzi: if unstable, K-wire, flexible nail, or plate/screw Distal radius Sugar-tong splint Long arm cast Carpus Sugar tong (add Nonoperative thumb spica for versus K-wires scaphoid and or screw for trapezium) displaced (continued) 142 Chapter 5. Emergency Room Consultations

Table 5.3 Pediatric upper extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Metacarpals Radial gutter (1st Nonoperative or 2nd), ulnar versus K-wires for gutter (4th or unstable/displaced 5th), or anterior and posterior slabs (3rd) Phalanges Digit extension/ Nonoperative aluminum splint versus K-wires or screws for unstable or intra- articular Fracture Management 143

Table 5.4 Lower extremity fracture management Fracture Fracture Definitive Pearls temporization treatment Pelvis fracture:

Unstable Pelvic binder, to Plate/screws May require OR for external pelvic vessel fixator embolization in interventional radiology

Acetabulum None/Buck’s Toe-touch weight- Nonoperative: traction/skeletal bearing or plate/ <2 mm traction screws displacement, <20% posterior wall, secondary congruence of joint and advanced age

Pubic ramus None Weight-bearing as tolerated with walker

Hip:

Femoral neck None/Buck’s Nondisplaced: 3 To use 3 parallel traction parallel cannulated cannulated screws screws, must be Displaced: nondisplaced on Hemiarthroplasty cross-table lateral versus total hip X-ray but may be arthroplasty valgus impacted on AP view

Basicervical/ None/Buck’s Screw plate Lesser trochanter intertrochanteric traction device versus involvement, cephalomedullary reverse obliquity nail fracture, or subtrochanteric extension requires cephalomedullary nail (continued) 144 Chapter 5. Emergency Room Consultations

Table 5.4 Lower extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Femur:

Subtrochanteric None/Buck’s Cephalomedullary High rate of traction nail nonunion

Shaft None/Buck’s Antegrade nail Antegrade traction/skeletal nail has higher traction union rate than retrograde

Distal Knee Retrograde nail If involves joint immobilizer versus plate/screws or is too distal, must use plate/ screws

Patella Knee Able to perform immobilizer straight leg raise and minimally displaced, knee immobilizer articular displacement, unable to perform straight leg raise/actively extend knee/tension band or screws/wires for comminution

Tibia:

Plateau Knee Plate/screws Low-energy, knee immobilizer immobilizer; versus external high-energy, fixator ex-fix

Shaft Long leg splint Cast (rarely) or nail Cast labor versus plate/screws intensive for patient

Pilon Long leg splint Plate/screws Soft tissue and then external swelling must fixator resolve prior to definitive fixation Fracture Management 145

Table 5.4 Lower extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Ankle Short leg splint Walking boot/cast Lateral malleolus (posterior slab versus plate/screws fracture without with stirrup/U) involvement of medial structures can be treated in walking boot/cast perform stress view of ankle to determine if medial injury present

Tarsus Short leg splint Walking boot/cast (Posterior slab) versus K-wires/plate/ screws for displaced

Metatarsal Short leg splint Walking boot/cast 5th metatarsal (1st metatarsal) or fracture treated hard-soled shoe with hard- 2nd–4th) versus soled shoe; plate/screws for zone 2 (Jones displaced/unstable fracture) and zone 3 fracture treatment short leg cast vs. ORIF (controversial) (Fig. 5.1) Lisfranc injury: ligamentous or bony injury to tarsometatarsal joint, ORIF for displaced Phalanges Hard-soled Hard-soled shoe Unstable shoe and buddy and buddy taping proximal phalanx taping to to adjacent digit fracture of great adjacent digit toe: K-wires/ screw (continued) 146 Chapter 5. Emergency Room Consultations

Table 5.5 Pediatric lower extremity fracture management Fracture Fracture Definitive Pearls temporization treatment Hip:

Transepiphyseal None Closed vs. open reduction with pin fixation

Transcervical None Nondisplaced: hip spica cast vs. in situ pinning Displaced: closed vs. open reduction with pinning that does not cross the physis

Cervicotrochanteric None Nondisplaced: hip (basicervical) spica cast vs. in situ pinning. Displaced: Open reduction with pinning that does not cross the physis

Intertrochanteric None Nondisplaced: traction followed by hip spica cast Unstable: ORIF

Femur:

Shaft None/traction Age 0–4: hip spica No piriformis pin cast entry nails due Age 4–12: flexible to risk of femoral nails or plate/ head AVN screw Age > 12: trochanteric entry nail vs. plate/screw Fracture Management 147

Table 5.5 Pediatric lower extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Distal femur Knee Nonoperative in immobilizer long leg cast for nondisplaced/ stable reduction, screws for Salter- Harris II (if irreducible), III, and IV

Tibia:

Proximal physeal Long Nonoperative in leg splint long leg cast for with knee nondisplaced, flexed 30° smooth pins across physis for unstable Salter-Harris I or II, pins or screws for Salter-Harris III or IV

Tibial tubercle Long leg Nonoperative in splint long leg cast for nondisplaced, smooth pins/ screws/tension band for displaced

Tibial spine Knee Nonoperative immobilizer in long leg cast in extension unless completely displaced or comminuted (fix with sutures/pins/ screws)

(continued) 148 Chapter 5. Emergency Room Consultations

Table 5.5 Pediatric lower extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Patella Nonoperative If operative, in cylinder cast must also fix in extension for retinaculum. nondisplaced, Sleeve fractures cerclage wire/ (large cartilage tension band/ fragment) must sutures/screws for be reduced and displaced secured with fixation

Proximal Long Nonoperative Apply varus mold metaphyseal leg splint in long leg cast to cast in extension for nondisplaced, closed vs. open reduction and long leg cast in extension for displaced

Shaft Long Closed reduction Operative leg splint (as needed) and management long leg cast with rare (severe knee flexed 45° comminution, and ankle plantar floating knee, flexed cerebral palsy or head injury) may use pins, plate/ screw, flexible nails, intramedullary nail (skeletally mature) Fracture Management 149

Table 5.5 Pediatric lower extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Distal tibial Long Closed reduction Pins, plate/screw, metaphysis leg splint (as needed) flexible nails rarely and long leg for comminuted cast with ankle fractures plantarflexed; unstable fractures require percutaneous pinning as well

Ankle:

Lateral malleolar Short Closed reduction leg splint and short leg cast (posterior for Salter-Harris I slab with and II stirrup/U) Closed vs. open reduction and pinning for Salter- Harris III or IV

Medial malleolar Short Closed reduction leg splint vs. open reduction (posterior and screw/K-wire slab with with long leg cast stirrup/U) for Salter-Harris I or II Open reduction and screw with short leg cast for displaced Salter- Harris III or IV

Juvenile Tillaux Long leg Closed reduction ssplint and long leg cast; unstable fracture requires pinning as well. Persistent displacement requires open reduction and screw

(continued) 150 Chapter 5. Emergency Room Consultations

Table 5.5 Pediatric lower extremity fracture management (continued) Fracture Fracture Definitive Pearls temporization treatment Triplane Long Nonoperative in leg splint long leg cast with knee flexed to 30° for nondisplaced closed vs. open reduction and pin/ screw for displaced

Tarsus Short Long leg cast for leg splint nondisplaced, (Posterior K-wires/ screws for slab) displaced

Metatarsal Short leg Short leg cast, Intramedullary splint closed vs. open screw an option reduction and for 5th metatarsal pinning for fracture at unstable metaphyseal- diaphyseal junction Lisfranc injury: closed reduction with short leg cast, K-wires if unstable; rarely, open reduction and K-wires with short leg cast Phalanges Hard-soled Hard-soled shoe Unstable proximal shoe and and buddy taping phalanx fracture of buddy taping to adjacent digit great toe: K-wires to adjacent digit Fracture Management 151

Table 5.6 Spine fracture management Fracture Fracture Definitive Pearls temporization treatment Unstable C1 Hard C-collar C1–C2 or or C2 occiput-C3 posterior fusion

Odontoid Hard C-collar Halo fixation, Younger odontoid screw, or patients with C1–C2 posterior appropriate fusion fracture pattern: odontoid screw

Subaxial Hard C-collar Anterior cervical For skull cervical spine or skull traction decompression and traction, place (C3–C7) with tongs fusion (ACDF), or pins in line posterior fusion with auditory meatus MRI may be used to rule out traumatic disc herniation before applying traction

Thoracic Thoracic TLSO or posterior TLSO for lumbosacral spinal fusion osteoporotic orthosis vertebral (TLSO) brace compression fracture Lumbar Lumbosacral Anterior or Foley and bed orthosis (LSO) posterior spinal rest for all or TLSO for fusion for unstable fractures until thoracolumbar fractures or stable stabilized or fracture fractures with cleared neurologic deficit 152 Chapter 5. Emergency Room Consultations

Table 5.7 Tibial and femoral skeletal traction pins Proximal tibial traction pin (Fig. 5.1) Femoral traction pin (Fig. 5.2) Sterilely prep site of pin insertion and Sterilely prep site of pin administer local anesthetic from skin insertion and administer local down to periosteum. anesthetic from skin down to Insertion site is at level of tibial periosteum. tuberosity. Insertion site is one Insert lateral to medial to avoid common fingerbreadth proximal to personal nerve injury (pearl: go from patella with knee extended. known to unknown). Confirm placement Insert medial to lateral to avoid with radiographs. femoral artery injury (pearl: go Release skin with scalpel around pin from known to unknown), 90° entry/exit sites. to shaft. Confirm placement Contraindicated in floating knee with radiographs. (ipsilateral femoral and tibial fractures), Release skin with scalpel ligamentous injuries of the knee, and around pin entry/exit sites. children (to avoid physeal injury)

2cm

1-2cm

Figure 5.1 Proximal tibial traction pin insertion. Fracture Management 153

Medial

Figure 5.2 (a–c): Femoral traction pin insertion. 154 Chapter 5. Emergency Room Consultations

Figure 5.2 (continued). Dislocations 155

Dislocations

Definition At least 100% displacement of the bones articulating to form a joint. 100% displacement = dislocation. <100% displacement = subluxation –– Dislocated joint must be urgently reduced (restoration of normal relationship of bones forming a joint) to minimize cartilage injury and avoid neurovascular compromise. –– If neurovascular compromise is present, reduction is emergent. –– If closed reduction fails, open reduction in the OR is required. Pearls: 1. Reduce grossly dislocated joint before waiting for plain films. 2. Use fluoroscopy to guide a difficult reduction and confirm reduction. This is more efficient than sending patient for formal postreduction films after splint application only to find joint remains dislocated. 3. Document neurovascular exam before and after reduction, and monitor for compartment syndrome. I. Shoulder Dislocation (95% Are Anterior) –– Conscious sedation. –– Reduce dislocation using one of the techniques below: (a) Traction-countertraction (preferred by authors, Fig. 5.3). –– Lay patient supine on stretcher. Roll hospital bedsheet along its length to make a long tube. –– From contralateral side, while holding one end of sheet, assistant will pass other end of bedsheet across the chest, posteriorly through axilla, across back, and then grasp both ends of sheet together. 156 Chapter 5. Emergency Room Consultations

Figure 5.3 Traction-countertraction technique for anterior shoulder dislocation.

–– With arm abducted 45° and elbow flexed 90°, traction is applied to the shoulder in a direction along long axis of humeral shaft. Assistant applies countertraction with sheet in a direction opposite to traction. (b) Stimson/Gravity technique. –– Lay patient prone on stretcher and hang affected arm over side of bed. –– Tie 5 lb weight to distal forearm. –– Reduction occurs over 20 min with muscle fatigue (Fig. 5.4). Dislocations 157

Figure 5.4 Stimson/gravity technique.

Postreduction Management –– Postreduction radiographs: AP and axillary views to confirm reduction. –– Apply sling/swathe and discharge home with close follow-up. II. Elbow Dislocation (80% Are Posterior/Posterolateral) –– Conscious sedation or intra-articular block. –– Standing in front of patient with affected elbow flexed to 90°, shake hands with patient, and apply traction anteriorly while pushing posteriorly with your contralateral hand at the anterior aspect of the patient’s distal humerus. –– Range elbow for stability as follows: • If elbow is stable from 0° to 90° of flexion, splint with elbow flexed to 90° with forearm in neutral rotation. • If elbow is unstable from 0° to 30° of flexion, pro- nate the forearm, and determine if the elbow 158 Chapter 5. Emergency Room Consultations

becomes stable (important for rehabilitation protoco.l). Either way, splint with the elbow flexed to 90° with the forearm pronated. • If the elbow is unstable with >30° of flexion, admit for OR.

Pearl: Terrible triad injury (elbow dislocation, coronoid fracture, and radial head fracture) is associated with increased risk of instability and complications. Postreduction Management –– Postreduction radiographs: AP and lateral –– Apply long-arm posterior splint with the elbow flexed to 90°, and discharge home with close follow-up. III. Hip Dislocation (Posterior > Anterior) –– Attitude of the leg with posterior dislocation: short- ened with the hip flexed, internally rotated, and adducted –– Attitude of the leg with anterior dislocation: short- ened with hip externally rotated –– Conscious sedation: propofol works best –– Reduction technique (Allis technique, Fig. 5.5)

Traction

Counter traction

Adduction and internal rotation

Figure 5.5 Allis hip reduction technique (supine). Dislocations 159

Pearl: Examine ipsilateral knee for ligamentous injury before performing maneuver. –– Posterior dislocation: • Stand over patient lying supine, flex the hip and knee to 90°, grasp distal femur with one arm with other arm in popliteal fossa, adduct and internally rotate the hip, and apply traction anteriorly, while assistant applies posterior pressure to ipsilateral ASIS. –– Anterior dislocation: • Stand at the foot of patient lying supine, grasp ipsilateral distal tibia; externally rotate the leg/ hip; apply traction longitudinally, while assistant applies posterior pressure to ipsilateral ASIS until the leg is out to length (compare position of foot/malleoli with contralateral leg); and then internally rotate femoral head into acetabulum.

Pearl: This technique works for posterior dislocation as well. Just reverse rotation of the leg/hip, while at foot of bed, internally rotate, apply traction, and externally rotate to reduce when out to length. Postreduction Management –– Postreduction radiographs: AP and cross-table lateral of hip to confirm reduction. CT scan the hip to evaluate for intra-articular bony fragments. –– Apply femoral traction pin if concomitant acetabular fracture does not allow femoral head to sit concentrically within joint. –– For dislocated total hip arthroplasty: • Range hip to determine position of instability, which guides bracing and offers prognosis of nonoperative management. • Posterior dislocation, place knee immobilizer and abduction pillow until fitted for hip-knee- ankle-foot orthosis (HKAFO). • Anterior dislocation, no knee immobilizer or abduction pillow, fit for HKAFO. 160 Chapter 5. Emergency Room Consultations

IV. Knee Dislocation (Anterior > Posterior) –– Neurovascular exam is essential as the risk of injury to popliteal artery and peroneal nerve is high. –– Consult vascular surgery for ABI < 0.9 or weak/ absent pulses (*emergent intervention is required). –– Reduction techniques (avoid pressure to popliteal fossa and vessels): (a) Anterior: Axial traction and push distal femur anteriorly. (b) Posterior: Axial traction and push proximal tibia anteriorly. Postreduction Management –– Postreduction radiographs: AP and lateral. –– Long leg splint with the knee in 20° of flexion. –– With grossly unstable knee or vascular repair, use ex-fix. –– MRI to evaluate injured structures. –– Perform serial neurovascular exams as intimal tear of vessel may cause ischemia even days after dislocation. V. Ankle Dislocation –– Intra-articular block (see Chapter 8). –– Reduce dislocation. Pearl: First exaggerate the injury to unlock the joint before applying force in a direction that restores the normal relationship of the bones. –– Apply short leg splint with posterior and stirrup (U) slabs; mold splint to resist redislocation (create inden- tation medially for medial dislocation and vice versa). Postreduction Management –– Postreduction radiographs: AP, lateral, and mor- tise views to confirm reduction –– Strict elevation and non-weight-bearing with crutches/walker Spinal Cord Injury (SCI) 161

–– If fracture is stable, patient is reliable, and soft tissues are not excessively swollen (wrinkles present in skin), may discharge patient home with close follow-up. If any of the above are not true, admit to hospital.

Spinal Cord Injury (SCI)

Definition Damage to spinal cord resulting in its dysfunction

Mechanisms of SCI –– Motor vehicle accident –– Contact sports (e.g., football) –– Fall –– Gunshot –– Diving into shallow water –– Spine fracture secondary to osteoporosis or metastatic lesion –– Degenerative change I. Examination—note the following findings: –– Motor –– Sensation –– Bowel and/or bladder function –– Hyperreflexia or spasms –– Pain or paresthesias –– Hypotension with bradycardia –– Anal sphincter tone and bulbocavernosus reflex, which returns when spinal shock resolves (typically within 24 h after injury)

American Spinal Injury Association (ASIA) ASIA classification of SCI describes the extent/severity of spinal cord injury and is predictive of rehabilitation potential. 162 Chapter 5. Emergency Room Consultations

Grade A (complete): Complete absence of motor and sensation below level of injury (including the perianal region) Grade B (incomplete): Sensation, but not motor, spared below level of injury (including perianal sensation) Grade C (incomplete): Motor spared below level of injury, but more than 50% of muscles below level of injury cannot move against gravity (motor <3/5) Grade D (incomplete): Motor spared below level of injury, but more than 50% of muscles below level of injury can move against gravity (motor >3/5) Grade E (normal): All motor and sensation spared Zone of SCI→ Higher level of injury leads to more dysfunction High-Cervical Nerves (C1–C4) –– Paralysis in arms, hands, trunk, and legs (quadriplegia) –– Typically require ventilator support Low-Cervical Nerves (C5–C8) C5 Injury –– Able to raise arms or bend elbows –– Paralysis of hands, wrists, trunk, and legs –– Difficulty with independent breathing C6 Injury –– Retains C5 function and also able to extend wrists –– Paralysis of hands, trunk, and legs –– Highest injury level at which patients may potentially function without attendant C7 Injury –– Retains C6 function and elbow extension –– Highest injury level at which patients may live independently Tendon Rupture/Laceration 163

C8 Injury –– Retains C7 function and finger flexion –– Able to grasp and release objects Thoracic Nerves –– Upper extremity motor normal and lower extremity motor compromised (paraplegia) Lumbar and Sacral Nerves –– Some loss of function of hips and legs; symptoms may be unilateral –– Little or no voluntary control of the bowel or bladder

Tendon Rupture/Laceration

–– Quadriceps tendon: Palpable defect superior to patella, unable to actively extend knee from flexed position. Straight leg raise unreliable, as ruptured tendon and intact retinaculum will allow for straight leg raise –– ER management: Knee immobilizer and discharge with close follow-up –– Definitive management: Partial tear, knee immobilizer. Complete tear, repair in OR –– Patellar tendon: Palpable defect inferior to patella, unable to actively extend knee from flexed position. Straight leg raise unreliable, as ruptured tendon and intact retinaculum will allow for straight leg raise –– ER management: Knee immobilizer and discharge with close follow-up –– Definitive management: Partial tear, knee immobilizer. Complete tear, repair in OR –– Achilles tendon: Palpable defect between calf and posterior aspect of calcaneus. If ankle plantar flexes with Thompson test (squeeze calf), then Achilles intact –– ER management: Posterior short leg splint in equinus and discharge with close follow-up 164 Chapter 5. Emergency Room Consultations

–– Definitive management: Partial tear, equinus boot. Complete tear, equinus casting vs. repair in OR –– Flexor/extensor tendon: Test digit extension, flexion of distal phalanx (flexor digitorum profundus), and flexion of isolated digit (flexor digitorum superficialis) –– ER management: For contaminated wounds, open fractures, and violated joint capsule, emergent OR. In absence of above, I&D, loose wound closure, and follow-up within 7 days –– Definitive management: Repair in OR

Fingertip Amputation

No exposed Ancef 2 g IV X 1 bone: Copious irrigation

Apply iodine-impregnated petrolatum gauze and soft dressing

d/c on Keflex 500 mg po qid until follow-up

Exposed bone: Ancef 2 g IV X 1

Copious irrigation

Rongeur tip of distal phalanx without compromising bony support of nail bed (if not possible, admit for flap reconstruction)

Close primarily if contour of nail bed remains unaffected (distal nail bed should not be placed on stretch and directed volarly)

If nail bed contour would be compromised with attempted primary closure, then perform V–Y advancement flap (Fig. 5.6)

d/c on Keflex 500 mg po qid until follow-up Postoperative Complications 165

Figure 5.6 V–Y advancement flap for fingertip amputation.

Postoperative Complications

–– Wound drainage: Check INR if on warfarin. Stop/ reverse anticoagulation. Local wound care; consider incisional wound VAC dressing. If drainage has per- sisted for more than 7 days, consider irrigation and debridement (I&D) with revision wound closure. –– Hematoma: Check INR if on warfarin. If incision is not challenged (no wound separation), stop/reverse anticoagulation, apply compressive dressing, and rest operative site. If incision is challenged, head to OR for I&D, hematoma evacuation, and revision wound closure with drains. 166 Chapter 5. Emergency Room Consultations

–– Cellulitis: Evaluate for deep infection at operative site. Once this is ruled out or operative site cultures are obtained, admit and start IV antibiotics. Transition to oral antibiotics as appropriate. –– Stitch abscess: Sterilely prep site, remove stitch, copi- ously irrigate, and apply antibiotic ointment and sterile dressing and oral antibiotics.

Other Common ER Consults:

Compartment syndrome (see Chapter 4). Cauda equina syndrome (see Chapter 4). Septic joint (see Chapter 4). Chapter 6 Sports Injuries

In this chapter, we discuss diagnosis and management of common orthopedic injuries sustained on the playing field. Please refer to Chapter 2, Physical Exam Fundamentals, as needed.

Definition

Sports injuries are injuries that occur during athletic activity due to acute trauma or repetitive stress.

Team Physician Responsibilities

1. Be available before and after game to care for athletes. 2. Observe the game from a good vantage point to identify injuries when they happen. 3. After injury triage by the athletic trainer, work with them to administer field treatment, make decisions regarding return to play, and arrange for higher-level care if necessary. 4. Communicate with parents and coaching staff.

Team Bag

Prepare a team bag that has the equipment you may need to address any foreseeable injury on the field. A suggested list of items is below:

Team bag essentials Contents Administrative Trainer contact information, team game information schedule, local emergency room phone numbers, medication log, pen/notepad Diagnostic tools Stethoscope, penlight, tongue depressors, face mask removal tool First aid Bandages, gauze, ACE wraps, paper tape, athletic tape, nasal packing material, silver nitrate sticks (to coagulate veins in epistaxis), trauma shears, mouth-to- mouth masks Procedural equipment Gloves, alcohol swabs, 1% lidocaine without epinephrine, 22 gauge needles, 10 cc syringes, elastic tourniquet, sterile drapes, scalpel, 3-0 nylon suture, sterile saline (250 cc bottles), red biohazard bags, sharps disposal container, procedure kit (forceps, scissors, needle driver) Braces/splints Sling, aluminum finger splint, cock-up wrist splint, stirrup ankle splint, knee immobilizer, cast padding (3”, 4”, 6” plaster rolls), crutches, cervical collar Medications Epinephrine (anaphylaxis), antihistamines (allergy), antibiotic ointment (abrasions), albuterol inhaler (asthma), sublingual nitroglycerin (0.4 mg) and aspirin 81 mg (chest pain), oral glucose tabs (hypoglycemia), acetaminophen/ibuprofen (pain) Pearl: Always know the location of automated external defibrillator (AED). Definition 169

General

I. Heat Injury A. Definition –– With excessive heat and dehydration, sweating becomes ineffective at cooling the body. Heat cramps, heat exhaustion, or heat stroke may then occur. B. Results from –– Strenuous exercise, dehydration, high heat/ humidity. C. Symptoms Heat cramps ––Cramping of the abdomen or extremities Heat exhaustion ––Nausea, vomiting, and weakness Heat stroke ––Confusion, seizures, loss of consciousness, coma D. Exam Heat cramps ––Body temperature normal Heat exhaustion ––Body temperature elevated but less than 104°F Heat stroke ––Body temperature greater than 104°F E. Management Heat cramps ––Stop exercise, stretch, drink water/electrolyte fluid activity 170 Chapter 6. Sports Injuries

Heat exhaustion –– Stop exercise, remove clothing –– Move athlete to shaded location and cool with fans/water spray/cold, wet towels –– Oral/IV hydration Heat stroke –– Remove clothing and immerse athlete in ice bath or apply ice packs to neck, axillae, and groin –– Call 911

Upper Extremity

I. Distal Biceps Tendon Rupture A. Definition –– Rupture of the distal biceps tendon from insertion at proximal radius (radial tuberosity) B. Results from –– Eccentric contraction (lengthening during contraction) of biceps C. Symptoms –– Anterior elbow pain and ecchymoses –– Defect in antecubital fossa and bulge in anterior arm D. Exam –– Test supination and elbow flexion strength against resistance –– MRI E. Management –– Surgery Definition 171

II. Acromioclavicular (AC) Joint Separation A. Definition –– Injury to the coracoclavicular ligaments B. Results from –– Direct trauma to the shoulder or fall on out- stretched hand –– Common in football, hockey C. Symptoms –– Shoulder pain D. Exam –– Deformity (bump) upon inspection of the AC joint –– Tenderness to palpation of AC joint –– X-rays, hold weight in hand of affected side to accentuate deformity E. Management –– Sling –– Surgery for greater than 100% displacement of clavicle III. Elbow Ulnar Collateral Ligament (UCL) Rupture A. Definition –– Disruption of UCL, which originates at medial epicondyle of humerus and inserts onto ulna B. Results from –– Repetitive valgus stress to the elbow –– Poor throwing technique increases stress through the elbow –– Common in pitchers, quarterbacks, javelin throw- ers, and water polo players C. Symptoms –– “Pop” felt or heard at time of injury –– Medial elbow pain 172 Chapter 6. Sports Injuries

–– Paresthesias in distribution of ulnar nerve (medial aspect of the forearm to 4th and 5th digits) –– Decreased speed and accuracy of throw D. Exam –– Apply valgus stress with elbow flexed to 30° (laxity and pain with injury) –– Palpate medial epicondyle of humerus (UCL origin) and just distally –– X-rays and MRI E. Management –– Sling, rest, PT, and throwing program –– Surgical UCL reconstruction (Tommy John surgery) for elite throwing athlete IV. Jersey Finger A. Definition –– Rupture of flexor digitorum profundus (FDP) tendon B. Results from –– Forced extension of the distal phalanx during FDP contraction –– Athlete sustains injury by grabbing opposing player’s jersey, which is forcibly removed from grasp during play –– Ring finger is most commonly affected C. Symptoms –– Unable to flex distal interphalangeal joint D. Exam –– Grasp middle phalanx of affected finger and ask athlete to bend finger (unable to flex distal phalanx of injured finger) E. Management –– Surgery Definition 173

V. Skier’s/Game Keeper’s Thumb A. Definition –– Tear of ulnar collateral ligament (UCL) of thumb metacarpophalangeal (MCP) joint –– Acute injury is termed “skier’s thumb”; chronic injury is termed “game keeper’s thumb” B. Results from –– Hyperextension or hyperabduction of thumb MCP C. Symptoms –– Pain at medial aspect of thumb MCP D. Exam –– Tenderness with possible bulge (torn ligament) at medial aspect of thumb MCP –– Instability with radial deviation of thumb MCP in 30° flexion –– MRI if exam unclear E. Management –– Thumb spica splint –– Surgery when (1) laxity of thumb MCP with radial deviation is 20° more than that with ulnar deviation and (2) adductor aponeurosis is interposed between UCL and bone (Stener lesion)

Lower Extremity

I. Hip Pointer A. Definition –– Contusion of soft tissues surrounding iliac crest B. Results from –– Direct blow to iliac crest C. Symptoms –– Pain along iliac crest 174 Chapter 6. Sports Injuries

D. Exam –– Ecchymoses and tenderness over iliac crest –– Pain with hip flexion or sit-up E. Management –– Rest, ice, PT II. Hamstring Injury A. Definition –– Injury to the semitendinosus, semimembranosus, or biceps femoris muscles (hamstrings) and possible avulsion of associated tendons

B. Results from –– Hyperflexion of the hip, eccentric contraction (lengthening during contraction) of the hamstrings –– Common in track, soccer, dance, basketball, and waterskiing

C. Symptoms –– Posterior thigh pain/ecchymoses –– Hamstring weakness –– With hamstring avulsion from ischial tuberosity, palpable defect at inferior buttocks, and muscle bulge of posterior thigh

D. Exam –– Tenderness to palpation of posterior thigh –– Weakness with resisted knee flexion –– MRI

E. Management –– Rest, ice, compression, and elevation (RICE) and immobilization –– Surgery for hamstring avulsion Definition 175

III. Sports Hernia (Athletic Pubalgia) A. Definition –– Injury to the tendons of the abdominal external/ internal obliques and adductor longus B. Results from –– Twisting of trunk with planted foot (extension and abduction of leg) –– Common in ice hockey, football, wrestling, and soccer C. Symptoms –– Groin pain D. Exam –– Pain reproduced with sit-up –– Tender over adductor longus –– No palpable bulge as with inguinal hernia –– MRI E. Management –– Rest, PT, steroid injection –– Surgery for refractory symptoms IV. Anterior Cruciate Ligament (ACL) Tear A. Definition –– Disruption of the ACL with associated loss of function B. Results from –– Sudden change in speed or direction while running –– Landing after a jump –– Direct blow to knee –– Common in football, basketball, soccer C. Symptoms –– “Pop” is felt or heard, swelling, instability 176 Chapter 6. Sports Injuries

D. Exam –– Lachman’s and pivot shift tests –– MRI E. Management –– Remove player from game and place in knee immobilizer –– Surgery V. Meniscal Tear A. Definition –– Tearing of the medial and/or lateral menisci B. Results from –– Twisting of the flexed knee while bearing weight C. Symptoms –– Clicking, catching, locking (mechanical symptoms) D. Exam –– Medial and/or lateral joint line tenderness –– McMurray’s test –– MRI E. Management –– Remove player from game if knee is painful, locking, or unstable –– Rest, ice, compression, elevation (RICE) –– Surgery for refractory mechanical symptoms VI. Knee Medial Collateral Ligament (MCL) Sprain A. Definition –– Injury to MCL, ligament originating at medial epicondyle of distal femur and inserting onto tibia B. Results from –– Valgus stress to knee (direct blow to lateral aspect of knee) Definition 177

C. Symptoms –– Medial knee pain –– Instability D. Exam –– With knee in 30° of flexion, apply valgus stress to knee –– Grade I sprain: pain, no laxity, ligament injured but not torn –– Grade II sprain: pain, laxity with endpoint, ligament partially torn –– Grade III sprain: pain, laxity without endpoint, ligament completely torn E. Management –– Immediate management: Remove from play, knee immobilizer, crutches –– Hinged knee brace, surgery for Grade III refractory to nonoperative treatment/multiligamentous injury VII. Achilles Tendon Rupture A. Definition –– Disruption of tendon connecting gastrocnemius and soleus muscles to calcaneus B. Results from –– Sudden increase in Achilles tendon loading/ forced gastroc-soleus contraction –– Common during basketball, running C. Symptoms –– Hear or feel “pop” in calf at time of injury –– Inability to push off or stand on tiptoes with injured leg D. Exam –– Palpate tendon for defect –– If foot plantarflexes with squeezing of the calf (Thompson test), then tendon is intact –– MRI 178 Chapter 6. Sports Injuries

E. Management –– Remove player from game, posterior short leg splint in equinus, non-weight-bearing with crutches –– Nonoperative treatment in cast/walking boot versus surgery VIII. Ankle Sprain A. Definition –– Injury to ligaments about the ankle B. Results from –– Forceful inversion, eversion, dorsiflexion, or plantarflexion of the foot C. Symptoms –– Pain, swelling, ecchymoses –– Inability to bear weight D. Exam –– Palpate medial malleolus, lateral malleolus, base of 5th metatarsal, and proximal fibula (Maisonneuve fracture). Squeeze tibia and fibula together mid- calf (squeeze test) to detect syndesmotic injury –– X-ray for bony tenderness E. Management –– Rest, ice, compression, elevation (RICE) –– May not return to play with difficulty bearing weight or bony tenderness –– Protected weight-bearing with crutches, air or gel stirrup splint/walking boot IX. Turf Toe A. Definition –– Injury of the great toe MTP collateral ligaments or plantar tissues B. Results from –– Forced hyperextension of great toe –– Common in football players on artificial turf Definition 179

C. Symptoms –– Great toe pain, difficulty with pushing off and weight-bearing with great toe D. Exam –– Palpate plantar aspect of great toe, gently dorsiflex at MTP –– Test collateral ligament stability of great toe MTP –– X-rays and MRI E. Management –– Rest, ice, compression, and elevation (RICE) protocol –– Taping/hard-soled shoe/walking boot –– Surgery for severe injuries

Neurologic/Spine

I. Concussion A. Definition –– Traumatic insult to the brain resulting in tempo- rarily compromised function B. Results from –– Direct blow to the head or force exerted that results in violent motion of the head –– Common in football, ice hockey, wrestling, and soccer C. Symptoms –– Confusion, drowsiness, dizziness, headache, impaired speech/balance/memory, and loss of consciousness –– Nausea and vomiting D. Exam –– Check orientation to person/place/time, memory for name of opposing team in last game, and abil- ity to concentrate during serial sevens (count backward from 100 by 7s) 180 Chapter 6. Sports Injuries

–– Extraocular movements, gross motor in upper and lower extremities –– Romberg test (positive if player loses balance while standing with feet together and eyes closed) E. Management –– If there is evidence of concussion, player must be removed from game. –– Complete physical and mental rest –– A concussed player must be asymptomatic and cleared by a physician before returning to play. –– Computerized cognitive test results compared to pre-injury baseline to evaluate injury severity and healing II. Burners/Stingers A. Definition –– Electric shock-like sensation radiating down the arm due to stretch of the brachial plexus B. Results from –– A blow that depresses the shoulder and bends the neck toward the contralateral shoulder, stretching the brachial plexus –– Common in contact sports, such as football and wrestling C. Symptoms –– Typically unilateral and short-lived (seconds to minutes) –– Burning or electric shock sensation, at times associated with numbness and/or weakness D. Exam –– Examine median, radial, ulnar, and axillary nerves E. Management –– Remove athlete from the game until symptoms have completely resolved and there is painless neck range of motion. –– If weakness or neck pain is present, athlete may not return to play. Definition 181

III. Cervical Fractures and Dislocations A. Definition –– Disruption of the normal structure and alignment of the cervical spine secondary to trauma B. Results from –– Sudden twisting of the neck or severe blow to the head/neck –– Common in contact sports such as ice hockey, wrestling, football/rugby (spearing) –– Common in noncontact sports such as skiing, swimming, diving, surfing, power weightlifting, and horseback riding C. Symptoms –– Neck or arm pain with or without numbness/ paresthesias –– Swelling, bruising of neck –– Decreased feeling in the arms, legs, or trunk –– Diffuse muscle weakness, paralysis of arms or legs –– Breathing difficulty –– Difficulty ambulating D. Exam –– Can ask patient to “move ankles up and down” to quickly assess gross neurologic function –– Assess motor function of C5-T1 and L2-S1, check for Hoffman’s sign and clonus (Chapter 2, p. 95) –– Immediate X-ray, CT, or MRI

Pearl: Never remove the helmet as this will cause undesired motion of the potentially injured cervical spine. Remove face mask only. E. Management –– Immobilize neck immediately. Log roll onto stretcher for transportation. –– Stable fractures are typically treated in a hard cervical collar. –– Surgery for unstable fractures 182 Chapter 6. Sports Injuries

IV. Spondylolysis and Spondylolisthesis A. Definition –– Spondylolysis is a stress fracture of the pars interarticularis, most commonly L5. It is the most common cause of low back pain in the young athlete. –– Spondylolisthesis is the anterior slippage of the injured vertebra relative to the caudal vertebra. B. Results from –– Repetitive hypertension stress on the pars –– Common in weight lifting, gymnastics, and football C. Symptoms –– Low back pain at a point just lateral to midline that the player points to is highly suggestive of spondylolysis. –– Hamstring tightness and associated crouched gait with spondylolisthesis –– Lower extremity radicular pain (shooting pain extending below the knee) that may be self-limited D. Exam –– Assess gait and ROM of the lumbar spine. –– L2-S1 motor exam –– Palpate for step off or area that reproduces the athlete’s pain. –– For spondylolysis without spondylolisthesis, CT or MRI is often needed to confirm diagnosis. E. Management –– Rest, NSAIDs, brace, and physical therapy –– Surgery for persistent symptoms or high-grade spondylolisthesis Definition 183

Return to Play

Unless otherwise specified above, an athlete may return to play following an injury once they are asymptomatic and can perform sport-/position-specific maneuvers with the vigor required during competition. Following return to play, the athlete must be closely monitored. Chapter 7 Operating Room Basics

In this chapter we discuss operating room basics, procedures that allow patients to be taken to the operating room and undergo surgery safely and efficiently.

Getting the Patient Ready

Checklist

1. Perform and document a complete history and physical examination of the patient. In addition to the relevant musculoskeletal exam, auscultate the heart and lungs, and palpate the abdomen.

Relevant past medical history and home medications include the presence of a pacemaker or defibrillator that needs to be interrogated or deactivated preoperatively, immunosuppressants that may require adjustment periop- eratively, and anticoagulants that must be reversed preoperatively (see Pearls below).

2. Discuss the risks, benefits, and alternatives of the surgery. Obtain and document informed consent. Requirements for documentation of informed consent will vary with each institution.

Sample Informed Consent

After being explained the risks, benefits, and alternatives, the patient has elected to proceed with (type of surgery). The risks as explained to and accepted by the patient include, but are not limited to, bleeding, infection, injury to vessels/nerves/bone, and further surgery. Risks unique to each surgery can be added to the statement above (e.g., dislocation with total hip arthroplasty, stiffness with total knee arthroplasty, use of bone graft). 3. For urgent/emergent surgeries, mark the operative site at time of initial exam to increase preoperative efficiency. 4. The patient may not have food or drink (NPO) 8 hours before surgery to avoid aspiration secondary to anesthesia. It is advisable to make patients NPO at midnight the night before urgent surgery so it is possible to operate earlier than scheduled if there is OR availability. 5. Obtain the following labs/tests, and make sure they are within normal limits: CBC, BMP, PT/INR, PTT, type and cross (2 units of packed red blood cells for surgery <2 h duration, 4 units for com- plex or revision surgery), urinalysis with culture and sensi- tivity, CXR, and EKG 6. Consult internal medicine and anesthesia for preoperative medical clearance. For significant comorbidities, consult the appropriate service (e.g., cardiology for history of cardiac stent or coronary artery bypass graft, pulmonary for pulmonary fibrosis).

Pearls –– In anticipation of intraoperative blood loss, patients should undergo transfusion until the hemoglobin is 10 g/dL or the hematocrit is 30%. Getting the Patient Ready 187

–– If a patient was immobile for several days prior to admission, obtain bilateral lower extremity ultrasound to determine if the patient has deep venous thrombosis (DVT). If the patient does have DVT, have interventional radiology place an inferior vena cava (IVC) filter preoperatively to prevent pulmonary embolus. –– If the patient is not going to surgery the same day of admission, and there is no significant risk of bleeding (e.g., risk of epidural hematoma with spine trauma), administer 40 mg of enoxaparin subcutaneously (sc) for DVT prophylaxis. For patients with renal insufficiency, administer heparin 5000 units sc instead of enoxaparin. –– For elective procedures, preoperative anticoagulation must be reversed prior to surgery. Surgery should be performed at least 12 h after enoxaparin or unfractionated heparin administration and 2–3 days after administration of the newer-generation anticoagulants (e.g., direct thrombin inhibitors such as dabigatran, factor Xa inhibitors such as rivaroxaban). Warfarin should be discontinued 5 days prior to surgery, at which time INR should be 1.5 or less. Tip/Trick: For urgent reversal of warfarin, we favor the following protocol: • Administer 10mg of vitamin K orally upon presentation and ask lab to thaw 4 units of fresh frozen plasma (FFP). • Six hours prior to surgery, if INR is greater than 1.5, transfuse 1 unit of FFP. • Begin transfusing 2nd unit of FFP and send stat INR at the same time. • If INR is 1.5 or less, stop FFP. If INR greater than 1.5, finish second unit of FFP. • Begin transfusing 3rd unit of FFP and send stat INR at the same time. • Repeat sequence as needed to achieve INR < 1.5 This is an efficient procedure for reversal of anticoagulation as FFP transfusion is not stopped while waiting for INR results from the lab.

–– Patients on chronic steroids will require a stress dose intra- operatively. Communicate with the anesthesia team to ensure this occurs. 188 Chapter 7. Operating Room Basics

Getting the OR Ready

Scheduling

1. As soon as you know a patient will require surgery, call the OR to place the patient on the surgery schedule. This will allow you the greatest flexibility in scheduling the surgery, and the OR also benefits from ample advance notice for equipment/personnel allocation. 2. If the surgery is a true emergency and other surgeries are already scheduled, communicate directly with the other surgeons/surgical teams to discuss your case, so all patients’ needs can be addressed in a timely fashion.

Equipment

1. When calling the OR to schedule surgery, also request equipment that you will need. Identify instruments, tables (e.g., flat Jackson table for spine/trauma to allow for easy use of fluoroscopy, fracture table for hip fractures), implants, grafts, and other materials (e.g., cell saver for revision hip surgery, irrigation for infection) specific to the case to be performed. 2. Notify the product representative for any implants to be used during surgery to ensure availability.

Pearl While waiting for the patient to come to the OR, perform a last minute check to make sure all necessary equipment is ready.

Miscellaneous

1. Pull up relevant radiographs for surgery on OR computer. Positioning, Prepping, Draping, and Sterile Technique 189

Positioning, Prepping, Draping, and Sterile Technique

Positioning

Definition Positioning the patient appropriately will facilitate prepping, draping, and execution of the surgery by allowing desired access and free range of motion of the affected area. Positions 1. Supine: Patient lies face up on the OR table. Most surgeries are performed supine, including total knee arthroplasty, total hip arthroplasty via the anterior approach, anterior cervical discectomy and fusion (ACDF), most upper extremity surgeries, most foot and ankle surgeries, as well as femoral and tibial intramedullary nailing. 2. Prone: Patient lies face down on the OR table. Most spine surgeries are performed prone, as well as Achilles tendon repair. 3. Lateral decubitus: Patient lies with the left or right side down on the OR table. Total hip arthroplasty via the anterolateral, direct lateral, or posterior approaches are performed in this position, as are some shoulder arthroscopies. 4. Sloppy lateral: Patient is supine, tilted to the right or left. Femoral intramedullary nailing and distal femur open reduction and internal fixation may be performed in this position. 5. Beach chair: Patient is in a seated position. Many shoulder surgeries are performed in this position.

General Principles

1. Pad all bony prominences to prevent pressure ulcers. 2. Make sure superficial nerves vulnerable to compression are free of any contact with the OR table. 190 Chapter 7. Operating Room Basics

Pearls In the lateral decubitus position: Place a 1 liter saline bag wrapped in a towel inferior to the axilla to prevent brachial plexus injury. Place two blankets underneath the distal femur of the down leg and another two blankets underneath the distal 2/3 of the tibia to prevent injury to the peroneal nerve. In the supine and beach chair positions: Place two blankets underneath the distal 2/3 of the tibia to prevent injury to the peroneal nerves. In the prone position: Avoid abducting the shoulders greater than 90° to prevent brachial plexus injury. Flex the elbows 90° and keep the forearms pronated. Elevate the patient’s head 10°–15° to reduce periorbital edema, and avoid direct pressure on the eyes to minimize the risk of postoperative visual loss.

Prepping

Definition “Prepping” refers to the process by which the operative extremity/site is cleansed in preparation for the surgery. 1. Remove hair to prevent interference with the incision site and to facilitate adherence of adhesive drapes. Use clippers only, not a razor, to avoid injuries to the skin that may serve as portals of entry for bacteria, thereby increasing the risk of infection. 2. Use alcohol or a chlorhexidine scrub brush to remove gross debris from the operative extremity/site. 3. A variety of topical antiseptics can be used on the skin, with evidence favoring use of alcohol-based solutions over aqueous solutions, and chlorhexidine over povidone-iodine. Positioning, Prepping, Draping, and Sterile Technique 191

4. When prepping an extremity, always start with the hand or foot, considered the dirtiest part of the limb. Then, use a different sponge or prep stick to prep the remainder of the extremity. 5. To prepare the operative field, start cleaning where the incision is to be located and then apply the antiseptic in larger and larger concentric circles centered at the incision site.

Draping

Definition Draping is the use of cloth or disposable sheets (drapes) to isolate the sterile operative field from surrounding nonsterile areas. 1. Draping protocols vary by procedure and surgeon. The principle common to all draping practices is the use of at least two layers of drapes to isolate the operative field. This is so that incidental penetration of the superficial layer of drapes does not result in contamination of the operative field.

Sterile Technique

Definition Intraoperative practices and procedures utilized to minimize the risk of surgical site infection.

Scrubbing Sterile technique begins outside of the OR with a hand cleansing process unique to the OR, termed “scrubbing.” This process should be at least 3 min in duration, and aqueous chlorhexidine may be a more effective disinfecting agent than aqueous povidone-iodine. It is generally accepted that an aqueous scrub should be performed at the beginning of a 192 Chapter 7. Operating Room Basics surgical day, while an alcohol rub may be used between surgical cases, in the absence of gross debris present on the hands, with equivalent disinfecting efficacy. The “scrubbing” process is described below: 1. Use the bristles of the scrub brush against the fingertips for 30 s. 2. Use the bristles of the scrub brush against the dorsal aspect of the 2nd through 5th digits for 30 s. 3. Use the bristles of the scrub brush against the dorsal and radial aspect of the thumb for 10 s and then the ulnar aspect of the thumb for 10 s. Cleanse the radial and ulnar aspects of the 2nd through 5th digits, each for 10 s in duration. 4. Use the bristles of the scrub brush against the palm and ventral aspect of the digits for 10 s. 5. Use the soft side of the scrub brush against the dorsal aspect of the hand for 10 s. 6. Use the soft side of the scrub brush against the ventral, radial, dorsal, and ulnar aspects of the distal half of the forearm, each for 10 s. 7. Use the soft side of the scrub brush against the ventral, radial, dorsal, and ulnar aspects of the proximal half of the forearm, extending slightly above the elbow, each for 10 s. 8. Repeat the above process for the other hand. 9. Wash off all soap, keeping hands above the elbows, and without touching anything.

Principles

1. OR tables are sterile at or above the level of the table. 2. Surgical personnel are sterile along the front of their gowns, from the chest to the waist and from the hands to slightly above the elbows. 3. Nonsterile personnel or items should not cross through a sterile field. 4. Edges/corners of sterile drapes are not considered sterile. Positioning, Prepping, Draping, and Sterile Technique 193

5. A sterile object is contaminated when it touches a nonsterile object or area (e.g., sterile gloved hand touching the back of a surgical gown). 6. Contaminated items must be removed immediately from the sterile field, contaminated gloves must be changed, and contaminated areas must be covered with sterile drapes.

Documentation

Sample Brief Operative Note

Preoperative diagnosis: Right hip degenerative joint disease Postoperative diagnosis: Same Procedure: Right total hip arthroplasty Surgeon: Dr. X Assistant: Dr. Y Anesthesia: General Complications: None Estimated blood loss (EBL): 300 cc Fluids: 1 l of crystalloid Specimens: Femoral head

Template for Dictated Operative Note

Preoperative diagnosis: Failed left total knee arthroplasty Postoperative diagnosis: Same Procedure: Left knee arthroplasty revision Surgeon: Dr. X Assistant: Dr. Y Complications: None Estimated Blood Loss: 100 cc Specimen: Tissue for culture and pathology Drains: One Hemovac drain with two limbs Operative indication: Include age of patient, indications for surgery such as failure of conservative treatment or infection, statement of procedure that patient has elected to proceed with, and a list of risks that the patient under- stands and has accepted 194 Chapter 7. Operating Room Basics

Operative procedure: Include information on marking the operative site preoperatively, type of anesthesia, preoperative antibiotics, patient positioning, tourniquet use, sterile prepping and draping, and time out to verify the operative site. Then, describe details of the surgery chronologically, starting with the incision and ending with a description of the closure with application of sterile dressing. Finally, include information on emergence from anesthesia, destination of patient immediately after surgery, and use of DVT prophylaxis postoperatively. Implants: Include information on all prostheses used, including manufacturer and size. I, as the responsible surgeon, attest that I was present for all critical portions of the above procedure.

Medical Student/Intern Tips & Tricks

Preoperative

1. Know the history of the patient, relevant anatomy, and basic surgical technique for the case. 2. Know where commonly used orthopedic equipment and supplies are kept, and know how to set them up (e.g. fracture table). 3. Be early to the OR. 4. Introduce yourself to OR personnel. 5. Open your own gloves. 6. Assist with transfer of patient to the OR table. 7. Place Foley catheter. 8. Perform skin prep.

Postoperative

1. Help transfer the patient from the OR table to the hospital bed. 2. Assist in preparing patient for transfer to recovery room. 3. Assist anesthesia and nursing staff in bringing patient to recovery room. Chapter 8 Techniques in Orthopedics

In this chapter we discuss fundamental techniques in orthopedics that are used on a daily basis in the outpatient clinics, the ER, and the OR.

Splinting

Definition

Splinting is non-circumferential immobilization of a bone or joint to allow for post-traumatic or postsurgical swelling.

Principles

1. We favor custom splints made with cast padding and plaster. These splints are most easily contoured to patient anatomy, thus providing the most effective immobilization. We have also found them to be the least harmful to fragile skin. 2. Inspect skin carefully before applying a splint. Look for: –– Open wounds (open fracture) –– Abrasions (local wound care may include irrigation and iodine-impregnated Vaseline gauze dressing) –– Skin tenting (impending open fracture—depending on anatomic location requires immediate surgery or reduction)

3. Apply cast padding as shown in the images below. –– The roll of cast padding should always be in contact with the extremity during application to avoid over-tensioning. –– Two layers thick in children. Thick cast padding makes plaster immobilization less effective and can result in loss of reduction. Children typically do not have fragile skin and do not need more padding. –– Four to five layers thick in adults. Concern for skin integrity supercedes any increased risk of loss of reduction. –– Pad all bony prominences with extra cast padding or abdominal pads to avoid skin ulcers. –– Debulk all flexion creases (e.g., antecubital and popliteal fossae, anterior ankle) to avoid neurovascular compromise. –– Plaster 8 layers thick in children, 12 layers thick in adults. –– Dunk plaster in lukewarm water before application, NEVER hot water, as this may burn the skin. –– Molding techniques are reviewed with each splint type below. 4. Apply plaster over cast padding and mold splint to counter fracture angulation/deforming forces. Wrap ACE bandage around finished splint. Splinting 197

APPLYING CAST PADDING

Figure 8.1 Begin wrapping cast padding at wrist (ankle for lower extremity) to prevent it from unraveling at the distal or proximal ends of the splint.

Figure 8.2 Avoid wrinkles! They irritate the skin. 198 Chapter 8. Techniques in Orthopedics

Figure 8.3 Eliminate wrinkles in cast padding by briskly pulling on the wrinkle.

Figure 8.4 Wrinkle is gone. Splinting 199

CREATING CUFFS

Figure 8.5 (a) To create cuffs that prevent the distal and proximal ends of the splint from digging into the skin, begin by rolling out two layers of cast padding. (b) Once cuff is of desired length, briskly pull cast padding roll with counter traction. 200 Chapter 8. Techniques in Orthopedics

Figure 8.6 Fold cast padding longitudinally to create a long strip four layers thick.

Figure 8.7 Apply cuff to distal and proximal ends of splint. Splinting 201

Figure 8.8 Cast padding with cuff. 202 Chapter 8. Techniques in Orthopedics

PADDING FOR BONY PROMINENCES

Figure 8.9 To begin to create padding for bony prominences, roll out four layers of cast padding. Splinting 203

Figure 8.10 To make cast padding moldable to contours of bony prominences, remove edges by firmly grabbing as shown.

Figure 8.11 Pull edge briskly with countertraction.

Figure 8.12 Repeat above sequence for contralateral edge to pro- duce a long strip of easily moldable cast padding. 204 Chapter 8. Techniques in Orthopedics

Figure 8.13 Apply padding to bony prominences such as the olecranon and distal humeral epicondyles.

DEBULK FLEXION CREASES

Figure 8.14 Debulk all flexion creases (antecubital fossa, popliteal fossa, anterior ankle) and apply a single layer of cast padding to avoid neurovascular compromise.

Tips/Tricks

• Measure out the length of plaster needed using the contralateral (non-painful) extremity. Add some length to what was measured, as the plaster shrinks after it is wet. • Beginners should dunk plaster in cold water as it allows more molding time before the splint hardens. • After the wet plaster is applied to the limb, wrap one layer of cast padding around the plaster before applying the ACE bandage. This way the ACE bandage does not stick to the plaster, and it is easier to remove from an already painful extremity at follow-up. • The most commonly used splints appear on the next page. Splinting 205

UPPER EXTREMITY Sugar tong

Figure 8.15 Sugar-tong splint.

Posterior

Figure 8.16 Posterior splint. 206 Chapter 8. Techniques in Orthopedics

Figure 8.17 Posterior splint with medial/lateral slab for varus/valgus support at the elbow.

Figure 8.18 Apply cast padding as shown above for ulnar gutter, radial gutter, clamshell, and thumb spica splints. Splinting 207

Ulnar Gutter

Figure 8.19 Ulnar gutter splint.

Figure 8.20 To prepare to apply a radial gutter or thumb spica splint, tear a 6 inch slab of plaster longitudinally along the center halfway down its length. 208 Chapter 8. Techniques in Orthopedics

Radial Gutter

Figure 8.21 Radial gutter splint.

Thumb Spica

Figure 8.22 (a) Fold 4-inch-wide cast padding longitudinally to create a cuff two layers thick. Wrap around the thumb as shown. (b) Thumb spica splint. Splinting 209

Clamshell

Figure 8.23 Clamshell splint.

Coaptation

Figure 8.24 Start at proximal forearm and wrap cast padding proximally to the shoulder. Create three moldable padding strips— apply one to the elbow and two to the shoulder in orthogonal fashion as shown. 210 Chapter 8. Techniques in Orthopedics

Figure 8.25 Measure out an appropriate length of plaster against the patient’s arm. Cut a length of stockinette that is 4 feet longer than the plaster. Place the plaster in the lumen of the stockinette centrally along its length. Cut the ends of the stockinette longitudinally as shown.

Figure 8.26 Place splint along arm and shoulder as shown. From the end of the splint in the axilla, bring one limb of stockinette anteriorly, the other posteriorly, and tie them together on the contralateral aspect of the neck. From the end of the splint on the shoulder, bring one limb of stockinette around each side of the neck and tie around the wrist.

LOWER EXTREMITY

Figure 8.27 Begin wrapping cast padding at the ankle for lower extremity splints to prevent unraveling at the proximal and distal ends. Apply moldable cast padding strips to the heel and malleoli as shown. Splinting 211

Posterior

Figure 8.28 Posterior splint.

Short Leg

Figure 8.29 Short leg splint (posterior splint with stirrups). 212 Chapter 8. Techniques in Orthopedics

Long Leg

Figure 8.30 For long leg splint, extend cast padding used for short leg splint to proximal thigh. Extend posterior slab and stirrups of short leg splint proximally as well.

Joint Aspiration/Injection

Definition

Joint aspiration is removal of fluid (synovial fluid, blood, pus) from a joint using a needle and syringe. Aspiration can be therapeutic, in the case of hematoma, or it can be diagnostic, in the case of infection. Joint injection is the instilling of fluid (saline, steroid, local anesthetic, radiopaque dye) into a joint using a needle and syringe. This can be therapeutic, as with steroid injection into an arthritic joint, or it can be diagnostic, as with injection of local anesthetic into a joint to determine if it is the source of pain.

Principles

1. Aspiration/injection of a native joint should be performed after sterile preparation of the site (removal of gross debris Joint Aspiration/Injection 213

using alcohol and then betadine or chlorhexidine skin preparation). 2. Aspiration/injection of a replaced joint should be performed after sterile preparation and draping of the site, as a replaced joint is more susceptible to infection than a native joint. 3. Ethyl chloride spray can be used as a topical anesthetic (spray site until skin turns white). This avoids use of yet another needle to inject site with local anesthetic. 4. Use an 18 gauge needle for larger joints so that synovium is less likely to impede aspiration/injection. Use at least a 30 cc syringe (60 cc for knee) to minimize likelihood of needing to change syringes mid-procedure. 5. Following aspiration/injection, cover the site with a bandage.

Pearl The only circumstances in which a replaced joint should be injected are (1) injection of local anesthetic to aid in determining etiology of pain and (2) injection and aspiration of sterile saline to be sent for culture following dry tap as part of infection workup.

Tips/Tricks

Below are the most reliable sites to enter a joint with a needle for aspiration/injection.

HIP (Usually Performed in OR Under Fluoroscopic Guidance)

With patient supine, entry point is 2.5 cm distal and 2.5 cm lateral to point along the groin crease where femoral artery is palpated. Aim needle 45° medially and 30° toward the floor. 214 Chapter 8. Techniques in Orthopedics

Femoral nerve Femoral artery Femoral vein

Figure 8.31 2.5 cm lateral and 2.5 cm inferior to femoral artery pulse palpated at groin crease, advance needle proximally and medially into the joint at 45° angle to the skin. Fluoroscopic guidance is helpful.

KNEE

With patient supine, soft spot immediately posterior to quadriceps tendon insertion onto patella on lateral aspect of knee. Aim straight across with needle.

Figure 8.32 To aspirate or inject the knee, sublux the patella laterally and insert the needle at the soft spot posterior to the quadriceps tendon at the level of the superior pole of the patella. Joint Aspiration/Injection 215

ANKLE

Soft spot just medial to tibialis anterior tendon. Aim 30° laterally with needle.

Figure 8.33 To inject or aspirate the ankle joint, insert the needle at the soft spot medial to the tibialis anterior tendon and aim posterolaterally. 216 Chapter 8. Techniques in Orthopedics

SHOULDER

Soft spot on posterior aspect of shoulder 3 cm inferior and 2 cm medial to posterolateral border of acromion. Aim toward coracoid process.

posterolateral acromion

3 cm

posterior shoulder 2 cm aspiration/injection site

Figure 8.34 Posterior site for intraarticular shoulder injection/aspiration. Joint Aspiration/Injection 217

ELBOW

With the elbow flexed to 90° and the wrist in neutral rotation, soft spot on lateral aspect of the elbow at center of the triangle formed by tip of olecranon, lateral epicondyle, and radial head. Aim 22 gauge needle 30° toward the distal aspect of the forearm.

Figure 8.35 To inject or aspirate the elbow, insert the needle at the soft spot located centrally within the triangle formed by the olecranon, lateral epicondyle, and radial head. 218 Chapter 8. Techniques in Orthopedics

WRIST

Soft spot just distal and lateral to Lister’s tubercle on dorsal aspect of the wrist. With patient’s fingers pointed toward ceil- ing, aim 10° toward floor with 22 gauge needle.

Figure 8.36 To inject or aspirate the wrist joint, insert the needle at the soft spot just distal and ulnar to Lister’s tubercle. Regional Blocks 219

SMALL JOINTS (e.g., Metatarsophalangeal, Metacarpophalangeal, Interphalangeal)

Introduce 22 gauge needle down to the bone proximally or distally to the joint using a dorsomedial or dorsolateral approach to avoid neurovascular structures and tendons. Walk the needle toward the joint until a “give” is felt, which signifies entry into the joint.

Regional Blocks

Definition

A regional block provides anesthesia to an anatomic area pre- or post-procedure. General anesthesia (pre-procedure) is avoided, and pain (intra- and post-procedure) is controlled.

Principles

1. Regional blocks target the innervation to an anatomic area (e.g., femoral nerve block for anterior knee, interscalene block for the shoulder). 2. Regional blocks can facilitate orthopedic care in the emergency room. 3. The local anesthetic is administered after sterile preparation of the site (removal of gross debris using alcohol and then betadine or chlorhexidine skin preparation). 4. Due to its efficacy and availability in most emergency rooms, lidocaine without epinephrine is the local anesthetic of choice. We prefer to avoid epinephrine as the affected area has been traumatized and epinephrine may further compromise the soft tissues. The dose of lidocaine without epinephrine is 4.5 mg/kg body weight up to a maximum of 300 mg. 220 Chapter 8. Techniques in Orthopedics

Tips/Tricks

The most common regional blocks in orthopedics are described herein.

Hematoma Block for Distal Radius Fracture

With the patient in finger traps, walk a 22 gauge needle distally, starting proximal to the fracture site on the dorsal aspect of the radius. When a “give” is felt, the needle has entered the fracture site. Then aspirate—if blood enters the syringe, there is confir- mation that the needle is in the fracture site. Inject 5–10 cc of 1% lidocaine without epinephrine, depending on patient size.

Pearl If desired, needle placement at the fracture site may be confirmed using the mini C-arm used to facilitate/confirm fracture reduction.

Block for Periarticular Fracture/Dislocation

For ankle fractures/dislocations, injection of local anesthetic (10 cc of 1% lidocaine, without epinephrine) into the ankle joint can allow for reduction without general anesthesia. Please see “Joint Aspiration/Injection” section for technique.

Pearl Joint injection of local anesthetic can also be used for reduction of shoulder or elbow dislocations. This is particularly useful in a medically unstable patient.

Digital Block for Hand/Foot

For finger and toe procedures performed in the emergency room, a digital block provides excellent anesthesia. After sterile preparation and draping of the site (see “OR Basics Regional Blocks 221

Chapter”), use a 22 gauge needle to inject the volar aspect of the webspace on either side of the digit. Aim the needle toward the digit to be anesthetized. 2–3 cc of 1% lidocaine without epinephrine in each webspace is adequate.

Pearl An alternate technique to administer a digital block involves injecting 3–5 cc of 1% lidocaine without epinephrine in the immediate subcutaneous space on the volar aspect of the metacarpophalangeal or metatarsophalangeal joints. This technique achieves a digital block with only one needle stick. Index

A B Achilles tendon rupture, 91, Barlow’s and Ortolani’s 161–162, 175–176 maneuvers, 86 Allis hip reduction technique, 156 Burners/stingers, 178, 179 American Spinal Injury Association (ASIA), 159 Anemia, 99–100 C Ankle, 213 Cast padding, 194, 199 bones, 50 Cauda equina syndrome, dislocation, 158 127–130, 163 ligaments, 91 Cellulitis, 163 muscles, 51 Central disc herniation, 130 neurovascular structures, 52 Cervical fractures and physical examination, 90–92 dislocations, 179 sprain, 176 Cervical spine surgical approach, 53 bones, 58, 59 Anterior cruciate ligament neurovascular structures, (ACL) tear, 173, 174 59, 60 Anterior drawer test, 89, 92 surgical approach, 61, 62 Anticoagulation, 105, 107, Chest pain, 112, 113 112, 185 Clamshell splint, 207 Apley scratch test, 73 Clonus, 95 Arm Collateral ligament bones, 6 test, 79, 90 muscles, 7 Compartment syndrome, neurovascular structures, 8 123–125, 163 surgical approach, 9 Concussion, 177–178

D tibial and femoral skeletal Dehiscence, 115 traction pins, 150 Delirium, 110–111 trauma imaging, 133–134 Dislocations, 140, 153, 155–158 Erb’s palsy, 71, 72 Distal biceps tendon rupture, 168 Erythema, 114, 115, 118 Distal radius fracture, hematoma block for, 217 Drainage, 115, 163 F Draping, operating room Femoral nerve stretch test, 95 basics, 189 Femoral traction pin insertion, 151 Femur E bones, 36, 37 Elbow, 214, 215 muscles, 37, 38 bones, 10 neurovascular structures, 39 dislocation, 154 surgical approach, 40 muscles, 11 Fever, 107, 109 neurovascular structures, 11 Fingertip amputation, 150, 162 physical examination, 77–79 Finkelstein test, 83 surgical approach, 12 Flexion abduction external ulnar collateral ligament rotation (FABER) rupture, 169, 170 test, 86 Emergency room consults, 131 Flexor digitorum profundus dislocations, 140, 153, tendon, 83, 162, 170 155–158 Flexor digitorum superficialis fingertip amputation, 162 tendon, 82, 83, 162 high-energy trauma patient Flexor/extensor tendon, 19, 162 and fracture Flexor tendon integrity, 82 management, 131, 132 Foot lower extremity fracture bones, 54, 55 management, 141–143 muscles, 55, 56 pediatric fractures, 137 neurovascular structures, pediatric lower extremity 56, 57 fracture management, physical examination, 90–92 144–148 surgical approach, 57, 58 pediatric upper extremity Forearm fracture management, bones, 13 135–140 muscles, 14 postoperative complications, neurovascular structures, 15 163 surgical approach, 16 SCI, 159–161 Fracture spine fracture management, cervical and dislocations, 149 179–180 tendon rupture/laceration, distal radius, hematoma block 161, 162 for, 217–218 Index 225

management, 131–137 Hoffman’s sign, 95 open fracture, 125–127 Hornblower’s sign, 75 antibiotic prophylaxis Hyperkalemia, 101 for, 126 Hypoglycemia, 100 classification, 125 Hypokalemia, 101 pediatric, 137 Hyponatremia, 100, 101 lower extremity fracture Hypotension, 102, 103 management, 141–148 Hypoxia, 103–105, 111 upper extremity fracture management, 135–140 periarticular fracture/ I dislocation, regional Informed consent, 184, 185 block, 218 spine fracture management, 149 Fresh frozen plasma (FFP), 185 J Jerk test, 76 Joint aspiration/injection G ankle, 213 Gluteus maximus, 28, 33 definition, 210 Gunstock deformity, 77 elbow, 214, 215 hip, 211, 212 knee, 212 H principles, 210 Hamstring injury, 172 shoulder, 213 Hand small joints, 216 bones, 22 wrist, 215, 216 muscles, 23 neurovascular structures, 24 surgical approach, 25 K Hand and wrist, 79, 81, 83 Knee, 212 Hand/foot, digital block for, 218 bones, 41 Hawkins test, 75 dislocation, 157 Heart failure, 104 MCL sprain, 174, 175 Heat injury, 167–168 muscles, 42 Hematoma, 98, 107, 113, 163 neurovascular High-energy trauma, 131–137 structures, 43 Hip, 211 physical examination, 87, bones, 32 88, 90 dislocation, 156 surgical approach, 44 labral stress maneuvers, 85 muscles, 33 neurovascular structures, 34 L physical examination, 84–86 Lab abnormalities, 99 pointer, 171, 172 anemia, 99, 100 surgical approach, 35 chest pain, 112, 113 226 Index

Lab abnormalities (cont.) neurovascular structures, 47 dehiscence, 115 surgical approach, 49 delirium, 110, 111 Lumbar spine drainage, 115 bones, 66 erythema, 115 neurovascular structures, 66 fever, 107, 109 surgical approach, 66 hyperkalemia, 101 hypoglycemia, 100 hypokalemia, 101 M hyponatremia, 100, 101 Medial collateral ligament hypotension, 102, 103 (MCL) sprain, knee, hypoxia, 103–105 174, 175 low urine output, 109, 110 McMurray’s test, 90 pain management, 113, 114 Meniscal tear, 71, 174, 174 seizure, 111, 112 tachycardia, 106, 107 wound issues, 114 N Lachman’s test, 88, 174 Necrotizing fasciitis, 121–123 Long leg splint, 142, 145, 147, Neer impingement sign, 75 148, 210 Neurologic/spine Lower extremity, 89, 90 burners/stingers, 178, 179 Achilles tendon rupture, cervical fractures and 175, 176 dislocations, 179 ACL tear, 173, 174 concussion, 177, 178 ankle, 50–53, 90, 92 spondylolysis and ankle sprain, 176 spondylolisthesis, femur, 36–40 180, 181 foot, 54–58, 90, 92 fracture management, 141–148 O hamstring injury, 172 O’Brien’s test, –73, 75 hip, 32–35 Oliguria, 109–110 and pelvis, physical Open fracture, 125–127 examination, 84–86 antibiotic prophylaxis for, 126 pointer, 171, 172 classification, 125 knee, 41–44, 87, 89, 90 Operating room basics lower leg, 45–47, 49 documentation, 191, 192 MCL sprain, 174, 175 draping, 189 meniscal tear, 174 medical student/intern tips/ pelvis, 26–30 tricks physical examination, 90, 92 postoperative, 192 sports hernia, 173 preoperative, 192 turf toe, 176, 177 OR ready, getting Lower leg equipment, 186 bones, 45 miscellaneous, 186 muscles, 46 scheduling, 186 Index 227

patient ready, getting P checklist, 183 Pain management, 113, 114 sample informed consent, Patellar tendon, 87, 161 184, 185 Pediatric fractures, 137 positioning, 187, 188 Pediatric lower extremity prepping, 188, 189 fracture management, principles, 190 144–148 sterile technique, 189 Pediatric upper extremity Orthopedic emergency fracture management, cauda equina syndrome, 138–140 127, 129 Pelvis compartment syndrome, bones, 26, 27 123–125 muscles, 28 definition, 117 neurovascular structures, 29 necrotizing fasciitis, 121–123 physical examination, open fracture, 125–127 84–86 septic joint, 117–119 surgical approach, 30 suppurative flexor Periarticular fracture/dislocation, tenosynovitis, 119, 120 regional block, 218 Orthopedics techniques Phalen’s sign, 82 joint aspiration/injection Physical examination, 78 ankle, 213 cervical levels, 94 definition, 210 definition, 69 elbow, 214, 215 lower extremity hip, 211, 212 foot and ankle, 90, 92 knee, 212 hip and pelvis, 84–86 principles, 210 knee, 87, 89, 90 shoulder, 213 lumbar levels, 94 small joints, 216 muscle strength grading wrist, 215, 216 scale, 70 regional block principles, 69, 71 definition, 217 spine, 92, 93, 95 distal radius fracture, upper extremity hematoma block elbow, 77–79 for, 217 hand and wrist, 79–83 hand/foot, digital block shoulder, 71, 72, 74–76 for, 218 Pivot-shift test, 89 periarticular fracture/ Pneumonia, 104 dislocation, 218 Positioning, 187, 188 principles, 217 Posterior drawer test, 89 splinting Posterior splint, 203, definition, 193 204, 209 principles, 193–198, 201, 202 Postoperative check/rounding, tips/tricks, 210 97–99 upper extremity, 203, 208 Prepping, 188–189 228 Index

Q cervical spine, 58–62 Quadriceps femoris, 37, 42 concussion, 177, 178 Quadriceps tendon, 42, 161, 212 fracture management, 149 lumbar spine, 66 physical examination, 92, R 93, 95 Radial gutter splint, 206 sacrum, 66, 67 Range of motion (ROM), 70–72, spondylolysis and 78, 81, 84–85, 88, 91, 93 spondylolisthesis, Reduction techniques, 156, 158 180, 181 Regional block thoracic spine, 63–65 definition, 217 Splinting distal radius fracture, definition, 193 hematoma block principles, 193–198, 201, 202 for, 217 tips/tricks, 210 hand/foot, digital block upper extremity, 203, 208 for, 218 Spondylolisthesis, 180–181 periarticular fracture/ Spondylolysis, 180–181 dislocation, 218 Sports hernia, 173 principles, 217 Sports injuries heat injury, 167, 168 lower extremity S Achilles tendon rupture, Sacrum 175, 176 bones, 66, 67 ACL tear, 173, 174 neurovascular structures, 66 ankle sprain, 176 Seizure, 111–112 hamstring injury, 172 Septic joint, 117–119, 163 hip pointer, 171, 172 Septic native joint, 118 MCL sprain, 174, 175 Short leg splint, 143, 147, 148, meniscal tear, 174 209, 210 sports hernia, 173 Shoulder turf toe, 176, 177 apprehension, 76 neurologic/spine bones, 1, 2 burners/stingers, 178, 179 dislocation, 153–154 cervical fractures and muscles, 2, 3 dislocations, 179 neurovascular structures, 4 concussion, 177, 178 physical examination, 71, spondylolysis and 73–76 spondylolisthesis, surgical approach, 5 180, 181 Small joints, 216 return to play, 181 Speed’s test, 74 team bag, 166 Spinal cord injury (SCI), 159–161 team physician Spine responsibilities, 165 burners/stingers, 178, 179 upper extremity cervical fractures and acromioclavicular joint dislocations, 179 separation, 168, 169 Index 229

distal biceps tendon U rupture, 168 Ulnar gutter splint, 137, 204, 205 elbow ulnar collateral Upper extremity, 71, 72, 74–76 ligament rupture, acromioclavicular joint 169, 170 separation, 168, 169 jersey finger, 170 arm, 6–9 skier’s/game keeper’s distal biceps tendon thumb, 171 rupture, 168 Spurling’s test, 94 elbow, 10–12 Squeeze test, 92 elbow ulnar collateral Sterile technique, 189–190 ligament rupture, Stimson/gravity technique, 153, 154 169, 170 Stitch abscess, 163 forearm, 13–16 Straight leg raise, 95 hand, 22–25 Sugar-tong splint, 203 jersey finger, 170 Suppurative flexor tenosynovitis, physical examination 119–120 elbow, 77–79 hand and wrist, 79–83 shoulder, 71, 72, 74–76 T shoulder, 1–5 Tachycardia, 106–107 skier’s/game keeper’s Tendon rupture/laceration, thumb, 171 161–162 splinting, 203 Achilles, 175–176 wrist, 17–21 distal biceps, 168 Upper extremity fracture Thomas test, 86 management, 135–140 Thompson test, 92, 161–162 Urine output, 109, 110 Thoracic spine bones, 63 neurovascular structures, 63 W surgical approach, 64, 65 Warfarin, 105, 107, 113, 163, 185 Tibial and femoral skeletal Wound drainage, 115, 163 traction pins, 150 Wound issues, 114 Tinel’s sign, 79, 82 Wrist, 215, 216 Traction pin, 150, 151 bones, 17, 18 Traction-countertraction muscles, 19 technique, 154, 155 neurovascular structures, 20 Trauma, 115, 118, 124, 127, surgical approach, 21 131–134 Trendelenburg test, 85 Turf toe, 176, 177