Program Information

1
Program Information
2
Skeletal System

• Shannon Carroll, MDSuresh Agarwal, MD

3
Skeletal System

• Common Skeletal System Pathology encountered in
  Critical Care
• Complications of Skeletal Injury

4
Skull
www.pycomall.com/images/P/skull.jpg
5
Skull Fractures

• 4 Major Types
• Linear
• Depressed
• Diastatic
• Basilar

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Linear Skull Fracture

• Most common type
• Over Lateral Convexities
• Over squamous area of temporal bone
• Damage to middle meningeal artery
• Epidural Hematoma

www.hawaii.edu/medicine/pediatrics/pemxray/v5c09h2
.jpg
7
Depressed Skull Fracture

• Displaced bone fragments pushed into the cranial
  vault
• From blunt force by object with small surface
  area
• Often damages underlying brain tissue
• Complex dura mater torn
• Contamination/Infection
• Often require surgery

anatpat.unicamp.br/minDsc35446.jpg
8
Diastatic Skull Fracture

• Fracture causes widening of suture
• Most commonly seen in infants and small children
• Seen in adults along the lambdoid suture

Pirouzmand F, Muhajarine N. Craniofac Surg. 2008
Jan19(1)27-36. Definition of topographic
organization of skull profile in normal
population and its implications on the role of
sutures in skull morphology. img.medscape.com/pi/
emed/ckb/radiology/336139-343764-9928.jpg
9
Basilar Skull Fracture

• From blunt force to the forehead or occiput
• Usually anterior
• Often involves cribriform plate
• Disruption of olfactory nerves
• Posterior
• Through petrous bone and internal auditory canal
• Disruption of the vestibulocochlear nerve and
  facial nerves
• CSF otorrhea/rhinorrhea

t0.gstatic.com/images?qtbnTuEw6pvP4iIG5Mhttp//
img.medscape.com/pi/emed/ckb/neurosurgery/247017-2
48108-4155.jpg
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Basilar Skull Fracture

• Raccoon Eyes

Battles Sign
image.absoluteastronomy.com/images/encyclopediaima
ges/b/bl/blackeye_pigmentation.jpg
www.itim.nsw.gov.au/images/Battle_Sign_s.jpg
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Vertebral Injuries

• Vertebral Column forms the Axial Skeleton
• Among All Trauma Patients
• 4.3 Cervical Spine Injury
• 6.3 Thoracolumbar Spine Injury
• 1.3 Spinal Cord Injury

www.eorthopod.com/images/ContentImages/spine/spine
_thoracic/anatomy/thoracic_spine_anatomy01.jpg
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Vertebral Injuries

• 7 Mechanisms of Injury
• Flexion compression
• Axial compression
• Flexion distraction
• Hyperextension
• Rotation
• Shear
• Avulsion

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Cervical Spine Injuries
www.physiotherapy-treatment.com/images/human-later
al-cervical-spine.jpg
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Cervical Spine Injuries

• 25 Occiput to C2
• 75 C3 to C7
• Occipto-cervical subluxation
• Rare
• Usually fatal
• Fractures of the Atlas
• Pain
• Decreased mobility
• Atlanto-axial dislocation
• High risk of neurologic deficit

www.springerlink.com/content/26ghau7p5nmpcjle/
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Fractures of the Odontoid

• Apical ligament avulsion fracture
• Stable
• Minimal if any external support

img.medscape.com/pi/emed/ckb/orthopedic_surgery/12
30552-1267150-1299.jpg
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Fractures of the Odontoid

• Waist of the odontoid
• Unstable
• Requires reduction or translation and angulation
• Requires stabilization
• Surgical
• Halo vest

img.medscape.com/pi/emed/ckb/orthopedic_surgery/12
30552-1267150-1299.jpg
17
Fractures of the Odontoid

• Extends below the waist into the body of C2
• Best treated with a halo vest
• 15 incidence of nonunion with other
  immobilization

img.medscape.com/pi/emed/ckb/orthopedic_surgery/12
30552-1267150-1299.jpg
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Thoracolumbar Spine Injuries

• L1 fracture 16
• Spondylolisthesis
• Subluxation or Slip of one vertebral body on
  another
• Most common in lumbar spine
• Treatment
• Conservative management
• Fusion

www.webinique.com/images/lumbar_spondylolisthesis_
grades.jpg
19
Spinal Instability

• Disruption of anatomic components, motion or
  supportive elements
• Excessive or abnormal spinal motion
• 3 Column Model
• In thoracolumbar spine
• Instability Injury to 2 or 3 columns

www.pgblazer.com/wp-content/uploads/2009/11/three-
column-concept-2.jpg
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Spinal Instability

• 50 Loss of Vertebral Body Height
• Angulation gt 20
• Compression Fractures
• Burst Fractures

www.pgblazer.com/wp-content/uploads/2009/11/three-
column-concept-2.jpg
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Non-operative Management of Spinal Injuries

• Stable injuries
• No neurologic deficits
• Immobilization

www.alsab.ca/images/collar2.jpg
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Spinal Immobilization

• C spine
• Head halter
• Tongs
• Halo

images.allegrocentral.com/9E/75/J-Tongs-Traction-T
ongs-557879-PRODUCT-MEDIUM_IMAGE.jpg
www.ossur.com/lisalib/getfile.aspx?itemid15083pr
oc3
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Spinal Immobilization

• T and L spine
• Bedrest
• Log rolling
• Rigid brace

www.optecusa.com/sites/default/files/imagecache/pr
oduct_list/products_01_B09.jpg
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Operative Management of Spinal Injuries

• Spinal Fusion
• Pedicle screws and rods
• Vertebroplasty
• Kyphoplasty

eldoradopainmanagement.net/mediac/450_0/media/Comp
ression_Render_Final.jpg
www.backpain-guide.com/Chapter_Fig_folders/Ch15_Ca
rpentry_Folder/Ch15_Images/15_3_Pedicle_Screws.jpg
www.vancouverspinedoctor.com/images/balloon_kyphop
lasty.jpg
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Cervical Spine Clearance

• The NEXUS Clinical Criteria
• 1. Tenderness at the posterior midline of the
  cervical spine
• 2. Focal neurologic deficit
• 3. Decreased level of alertness
• 4. Evidence of intoxication
• 5. Clinically apparent pain that might distract
  the patient from the pain of a cervical spine
  injury
• Any of the above -gt increased risk for cervical
  spine injury -gt requires radiographic evaluation
• Sensitivity 99.6
• NPV 99.9
• Specificity 12.9
• PPV 2.7

Hoffman JR, Mower WR, Wolfson AB, et al. Validity
of a set of clinical criteria to rule out injury
to the cervical spine in patients with blunt
trauma. National Emergency X-Radiography
Utilization Study Group. N Engl J Med.
200034394 99.
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Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying cervical
spine injuries following trauma. 2009.
27
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
28
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
29
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
30
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
31
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
32
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
33
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
34
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
35
Cervical Spine Clearance Algorithm
Como JJ, Diaz JJ, Dunham CM, et al. EAST practice
management guidelines for identifying
cervical spine injuries following trauma. 2009.
36
Chest Wall
www.chelseagoodchild.com/images/portfolio/traditio
nal/Rib_cage.jpg
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Rib Fractures

• Overall mortality 12
• High-Energy Injuries
• 1st or 2nd rib fractures
• Multiple rib fractures
• Scapula Fracture
• Rib Fractures in the Elderly (gt65)
• 2 5 x greater risk of morbidity/mortality
• 19 Increase in mortality per rib fx
• 27 Increase in pneumonia

image.wetpaint.com/image/1/XOMgDfktBYZImgBWx3Xc2g1
71569/GW537H600
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Rib Fractures

• Treatment Analgesia
• PCA
• Rib Blocks
• Epidural
• Intercostal/ IntrapleuralCatheter

www.learningradiology.com/caseofweek/caseoftheweek
pix2009-340/cow353-1lg.jpg
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Flail Chest
Paradoxical Motion

• 2 ribs fractured in 2 locations
• Significant morbidity from underlying pulmonary
  contusions
• Pendelluft
• Treatment
• Supplemental O2
• Analgesia
• Pulmonary Toilet
• ?Endotracheal Intubation
• ?Surgical Stabilization

upload.wikimedia.org/wikipedia/commons/3/39/Flail_
chest_mechaincs.jpg
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Surgical Stabilization

• Studies suggest
• Quickly restores normal chest wall mechanics
• Less pain
• Decreased mortality
• Decreased mechanical ventilation needs
• Shorter hospital stays
• Decreased long term morbidity

Gasparri MG, Almassi GH, Haasler GB (2003)
Surgical management of multiple rib fractures.
Chest 124295S
www.acuteinnovations.com/files/ribloc-overview1.20
090316-1712.jpg
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Suggested Indication for Surgical Treatment of
Rib Fractures

• Flail chest
• Reduction of pain and
• disability
• Chest wall deformity/defect
• Symptomatic rib fracture non-union
• Thoracotomy for other indications

Raminder Nirula1, Jose J. Diaz Jr.2, Donald D.
Trunkey3 and John C. Mayberry3. Rib Fracture
Repair Indications, Technical Issues, and Future
Directions. World Journal of Surgery 2009 33(1)
14-22
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Sternal Fractures

• Steering Wheel Syndrome
• Possible Associated Injury Blunt Cardiac
  Injury
• Most Common Associated Injuries
• Rib fractures
• Long bone fractures
• Head injuries
• Treatment
• Rest
• Analgesia
• Monitor for EKG changes

radiographics.rsna.org/content/21/5/1257/F42.mediu
m.gif
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Scapula Fractures

• From high energy trauma
• Rarely occur as an isolated injury
• Management
• Sling
• Pendulum exercises at 3 weeks
• Strengthening at 6 weeks

www.eorthopod.com/sites/default/files/images/adult
_shoulder_fx_type_scapular_blade.jpg
44
Indications for Surgical Repair of Scapula
Fractures

• If it is one of multiple shoulder fractures
• Displaced fracture of the glenoid neck
• Displaced fracture of the glenoid fossa
• Significant disruption of superior shoulder
  suspensory complex

www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi?book
physmedrehabpartA3412blobnamech4f4-30.jpg
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Clavicle Fracture

• Classification
• Proximal (rare)
• Central (80)
• Distal
• Risk of Nonunion (highest in distal fractures)
• Treatment
• Sling
• Pendulum exercises at 2 to 3 weeks
• Avoidance of heavy activity x 8 weeks

www.drdavidduckworth.com.au/css/images/clavicle-si
de.jpg
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Clavicle Fractures

• Indications for surgical fixation
• Distal clavicle
• Middle clavicle with gt2cm of shortening
• Open
• Symptomatic Nonunions
• Associated neurovascular injury
• Complex injuries of the shoulder
• Surgical Procedure
• Screw and Plate Fixation
• Intramedullary implants

images.google.com/imgres?imgurlhttp//assets.sbna
tion.com/assets/161691
assets.sbnation.com/assets/161691/clavicle_fractur
e_surgery_photo.gif
images.google.com/imgres?imgurlhttp//assets.sbna
tion.com/assets/161691
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Pelvis
www.exchange3d.com/cubecart/images/uploads/aff973/
Pelvis///Pelvis_thumb01.jpg
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Pelvic Fractures

• Most Common Etiologies
• Motorcycle collisions
• Pedestrian v. Motor vehicle
• Fall gt 15 feet
• Motor vehicle collision
• Mortality
• 7-14
• 30 w/ severe or open fractures
• Most deaths due to other traumatic causes

• Concomitant Injuries in gt90 of patients with
  pelvic fractures
• Most deaths due to
• Head Injury
• Non-pelvic hemorrhage
• Lung Injury
• Thromboembolic Events
• MSOF

49
Pelvic Fractures

• Mean transfusion requirement 8 units of packed
  red blood cells
• Minimize blood loss from pelvic fractures
• Early re-approximation and stabilization
• Bed Sheet
• Splint
• Clamp
• External Fixation
• Angiography
• Pelvic arterial disruption is source of
  hemorrhage 3 20

t3.gstatic.com/images?qtbnoc6jX5VKvtYoDMhttp//
www.vygia.com.vn/image/C-Clamp_02.jpg
publicsafety.com/article/photos/1129742911746_13.j
pg
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Pelvic Compression Fracture Vectors

• Lateral Compression
• Anterior-Posterior Compression
• Vertical Shear

images.google.com/imgres?imgurlhttp//www.aofound
ation.org/AOFileServerSurgery/MyPortalFiles3FFile
Path3D/Surgery/en/_img/surgery/01-Diagnosis/61/62
-A1-xrays-
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Lateral Compression Fracture

• Impact to lateral side of pelvic ring
• Shortens diameter across pelvis/decreases volume
  of pelvis
• Little risk of vascular or ligamentous injury

www.eorthopod.com/content/adult-pelvis-fractures-t
ypes
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Anterior-Posterior Compression Fractures

• Open Book
• Mechanisms
• Direct Impact to the Iliac Spines
• Transmitted through the femurs
• Can have ligamentous injury without fracture
• Increases diameter/volume of pelvis
• Significant risk of bleeding
• Unstable

www.eorthopod.com/sites/default/files/images/adult
_pelvis_fx_causes06.jpg
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Vertical Shear Pelvic Fractures

• Mechanism Fall/Jump landing on straight leg
• Disruption of ligaments
• Symphyseal
• Sacrospinous
• Sacrotuberous
• SI
• Increases Diameter/Volume of Pelvis
• Less bleeding than A-P fractures, but still
  significant risk

www.eorthopod.com/content/adult-pelvis-fractures-t
ypes
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Upper Extremity
www.buyamag.com/graphics/arm_ue200.jpg
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Shoulder Fractures/Dislocations

• Acromioclavicular dislocation
• Shoulder Separation
• Mechanism fall onto acromion
• Involved ligaments
• Acromioclavicular ligament
• Coracoclavicular ligament
• Complications
• Risk of Brachial Plexus Injury
• Risk of Subclavian Vessel Injury
• Treatment Sling

www.jurewitz.com/upload/shoulder_acromioclavicular
_separation_intro01.jpg
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Shoulder Fractures/Dislocations

• Floating Shoulder
• Glenoid neck fracture Clavicle fracture
• Glenohumeral joint without attachment to the
  rest of the skeleton
• Usually requires surgical fixation of one of the
  elements (clavicle)

Low CK, Lam AWM. Results of fixation of clavicle
alone in managing floating shoulder. Singapore
Med . 20004(19)452-453.
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Shoulder dislocation

• Anterior (85-95)
• Risk of axillary nerve injury
• Treatment Closed Reduction
• Posterior
• Mechanisms Seizures, Electrocution
• Risk of axillary artery injury
• Treatment Closed Reduction

http//www.sports-injury-info.com/image-files/shou
lder-dislocation.jpg
www.eorthopod.com/images/ContentImages/shoulder/sh
oulder_dislocation/shoulder_dislocation_anatomy12.
jpg
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Humerus Fractures

• Proximal Humerus Fractures
• Concomitant injuries
• Rotator cuff injuries
• Shoulder dislocation
• Risk of peripheral nerve injuries
• Risk of axillary artery injury
• Nondisplaced Fractures
• Sling for a short period
• Early Range Of Motion
• Displaced Fractures
• With impaction of humeral head Nonop
• Most 2 Part Fractures Closed reduction w/
  percutaneous fixation
• Most 3 Part Fractures ORIF

www.shouldersurgeon.com/graphics/4_parts_prox_hume
rus.jpg
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Humerus Fractures

• Midshaft Humerus Fractures
• Radial Nerve Injury
• 12 of Humeral Shaft Fractures
• with fractures of the distal 1/3 of the Humerus
• Runs in the spiral groove
• 70 resolve w/ conservative management
• Splint wrist and digits
• Nondisplaced Sling
• Displaced
• Reduction with long arm cast for gravity traction
• Fracture Brace
• Plate and Screw Fixation
• Intramedullary Nailing

www.eorthopod.com/sites/default/files/images/adult
_humeral_fx_brace.jpg
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Humerus Fractures

• Supracondylar Humerus Fractures
• Almost always require ORIF
• Volkmanns Contracture
• Supracondylar Humerus Fracture
• Anterior interosseus artery is occluded
• After reduction, perfussion is restored
• Reperfussion injury leads to Flexor Compartment
  Syndrome

www.unboundedmedicine.com/wp-content/Volkman.jpg
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Elbow Fractures/Dislocations

• Terrible Triad of the Elbow
• Elbow dislocation Radial Head Fx Coranoid
  Process of the Ulna Fx
• Requires surgery with repair or reconstruction
• Nursemaids Elbow
• Subluxation of Radius at Elbow
• Cause Traction to an extended, pronated arm
• Tx Closed Reduction

s3.beckshome.com/20060625-Nursemaids-Elbow.jpg
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Forearm Fractures

• Monteggia Fracture
• Proximal Ulna Fracture Radial Head Dislocation
• Treatment ORIF
• Galezzi Fracture-Dislocation
• Complex disruption of the distal radioulnar
  joint Unstable radius fracture
• Surgical repair is almost always necessary

www.wheelessonline.com/images/i1/mont1.jpg
www.learningradiology.com/caseofweek/caseoftheweek
pix2/cow157lg.jpg
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Forearm Fractures

• Night-stick Fracture
• Isolated Ulnar Shaft Fracture
• Nondisplaced Long arm cast for short period,
  then functional bracing
• Displaced Compression Plating
• Colles Fracture
• Fall on outstretched, extended wrist
• Distal Radius Fracture
• Treatment Closed Reduction
• Greenstick fracture
• Partially through bone
• Opposite side of bone bent

www.wheelessonline.com/image4/i1/nght1.jpg
z.about.com/d/orthopedics/1/0/2/1/fxapcolles.jpg
www.medscape.com/content/2002/00/44/65/446548/art-
ar446548.fig10.jpg
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Scaphoid Fracture

• ½ of all isolated carpal bone fractures
• Fracture locations
• Waist (75)
• Proximal Pole (20)
• Distal Pole (5)
• Blood supply from the ligaments at the distal
  pole
• Snuff Box tenderness
• Risk of Avascular Necrosis
• Operative Repair
• Open Screw Placement
• Percutaneous Screw Placement
• Cast to elbow

patientsites.com/media/img/1225/wrist_scaphoid_fra
cture_intro01.jpg
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Finger/Thumb Fractures

• Rolando fracture
• T- or Y-shaped
• Thumb metacarpal base
• Difficult to manage
• Phalangeal fractures
• Usual treatment Buddy taping or splint
  immobilization
• Intra-articular invovlement
• Closed reduction
• Fixation with percutaneous screws
• Fixation with Kirschner wires

radiographics.rsnajnls.org/content/vol20/issue3/im
ages/large/g00mc20l25x.jpeg
66
Lower Extremity
files.turbosquid.com/Preview/Content_2009_07_13__1
7_30_11/leg_bones.jpgf1dbe04a-ce4d-4150-9fc1-0fb10
43c8a87Large.jpg
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Femur Fracture

• Present in about 15 of seriously injured trauma
  patients
• 8-10 Bilateral
• Mortality
• Unilateral 10-12
• 20 in patients gt 65 years old
• Bilateral 26-33
• 90 due to concomitant injuries
• Decreased complications with surgical fixation
  within 24 hours

68
Hip Fractures

• 50 over 85years
• 6 month mortality of 20
• Preoperative Management of Unstable Fxs
• Bucks Traction
• Skeletal Traction

www.lancastergeneralcollege.edu/content/upload/Ass
etMgmt/images/College/conferences/Ortho_Traction_i
n_OrthopedicCare.pdf
69
Hip Fractures

• Femoral Neck Fractures
• Intracapsular
• High risk of Avascular Necrosis and Nonunion
• Intracapsular hematoma also may compromise
  perfusion
• Surgical emergency in young people
• Treatments
• Internal fixation
• Hip arthroplasty
• Extracapsular
• Dynamic Hip Screw (DHS)
• Early weight bearing/Rehab

www.orthomeditec.com/images/dynamichipscrew.jpg
70
Hip Fractures

• Trochanteric Fractures
• More stable than femoral neck fractures
• Require ORIF
• Early Ambulation/Rehab
• Subtrochanteric Fractures
• High risk of failure of surgical fixation
• Treatments
• ORIF
• Closed Reduction and Intramedullary Nailing
• Indirect reduction with blade-plate /screw-plate
  fixation

71
Hip Dislocations

• Reduction within 6 to 8 hours is crucial
• Posterior (85-95)
• Leg internally rotated and adducted
• Risk of sciatic nerve injury
• Treatment Closed Reduction
• Anterior
• Leg externally rotated and abducted
• Risk of femoral artery injury
• Treatment Closed Reduction

chestofbooks.com/health/anatomy/Human-Body-Constru
ction/images/Fig-515-Posterior-luxation-of-the-hip
-produced-by-rotati.jpg
i21.photobucket.com/albums/b286/flagady15/Bones/hi
p-fig1.jpg
72
Femoral Shaft Fractures

• Blood loss up to 1500 2000cc
• Important to reduce fracture and maintain
  alignment early
• Closed Reduction and Reamed, Interlocking
  Intramedullary Nail
• Ex-fix with Intramedullary Nail
• Days 5 to 10
• Associated Complications
• Fat Embolism Syndrome
• Acute Lung Injury/ARDS

nyic.stemlegal.com/wp-content/uploads/2009/01/femu
r-nailing.jpg
73
Patella Fractures

• Mechanism Direct blow to flexed knee
• Nondisplaced Long leg cast
• Comminuted
• Open reduction and internal fixation
• Lag screws
• Tension Banding
• Partial or total Patellectomy

www.aofoundation.org/AOFileServerSurgery/MyPortalF
iles?
www.aofoundation.org/AOFileServerSurgery/MyPortalF
iles?FilePath/Surgery/en/_img/surgery/05-RedFix/3
4/P90-tension-band-wiring/33_P90_i480L_C11_patella
.jpg
www.cahnlitigation.com/toetheslab/images/Post20Im
ages/fracture_of_patella_2.JPG
74
Knee Dislocation

• May involve
• Patello-femoral joint
• Tibio-femoral joint
• Usually Lateral
• Hemarthrosis or Effusion develops
• May be recurrent
• Treatment
• Closed Reduction
• Knee immobilization for 4 to 6 weeks
• Complete Knee Dislocation
• Anterior or Posterior
• Need angiogram to assess for Popliteal Artery
  injury

www.ajronline.org/content/vol186/issue3/images/lar
ge/00_04_0756_04b_cmyk.jpeg
75
Tibia-Fibula Fractures

• Proximal and Midshaft Tibia Fractures
• High risk for compartment syndrome
• Tibial Plateau Fractures
• Nondisplaced proximal tibia fractures hinged
  knee brace
• Displaced/Unstable patient External fixator
• Deformity/Instability Surgical Repair

www.rad.washington.edu/academics/academic-sections
/msk/teaching-materials/sundry-msk-computer-progra
ms/sundry-images-for-programs/3DCTS1_3DAP.jpg/imag
e
76
Calcaneus Fractures

• Require tremendous force to the heal
• Frequently occur w/ spine injuries
• Nondisplaced and extra-articular nonoperative
• Displaced and intra-articular ORIF 2-3 weeks
  after injury

www.fighttimes.com/magazine/images/8/l-medcell-xra
y5.jpg
www.mccainortho.com/Calcaneus20Post20Op20A.jpg
77
Talus Fractures

• Risk of Avascular Necrosis (AVN)
• Especially if fracture is at neck of talus
• Dislocation is a surgical emergency
• Closed reduction for most
• Severely displaced Precise reduction and
  fixation with Interfragmentary Screws

www.foothyperbook.com/images/hindfootTrauma/FxTalu
sNeck.gif
www.orthosupersite.com/images/content/obj/0802/sal
em_fig1b.jpg
78
Metatarsal Fractures

• Jones Fracture
• Mechanism Inversion of Foot
• 5th Metatarsal
• At risk for nonunion

www.eorthopod.com/content/adult-foot-fractures-typ
es
www.eorthopod.com/content/adult-foot-fractures-typ
es
79
Complications of Extremity Fractures

• Infection
• Findings often appear 10-21 days after infection
• Most common organism Staph. aureus
• Also common Pseudomonas aeruginosa and
  Enterobacteriaceae
• Diagnosis
• Physical findings
• Constitutional symptoms
• Radiography
• CT
• MRI
• 3-phase bone scan
• Radiolabeled WBC scan

80
Complications of Extremity Fractures

• Gas Gangrene
• Necrotizing fasciitis
• Treatment
• Early wide debridement
• Antibiotics (PCN)
• Tetanus
• Highest risk w/ farming accidents
• Treatment
• Supportive
• Debridement
• Immunization
• Antibiotics

www.meddean.luc.edu/lumen/MedEd/mech/cases/Gram_Po
sitive/slide1.jpg
www2.cedarcrest.edu/academic/bio/hale/bioT_EID/lec
tures/tetanus-pathogen2.jpg
amog.com/wp-content/uploads/2009/03/fasciitis.jpg
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Osteomyelitis

• Acute Osteomyelitis
• Hematogenous Spread
• Contiguous Spread
• Subacute Osteomyelitis
• Chronic Osteomyelitis

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4d485/ref/graphics/9712.jpg
82
Diagnosis of Osteomyelitis

• Requires 2 of the 4 following criteria
• Purulent material on aspiration of affected bone
• Bone tissue or blood culture positive
• Localized classic physical findings of bony
  tenderness, with overlying soft-tissue erythema
  or edema
• Positive radiological imaging study

www.medical-look.com/diseases_images/osteomyelitis
.jpg
83
Osteomyelitis

• Most Common Organisms
• Staphylococcus aureus
• Gram negative infections (vertebral bodies)
• Pseudomonas (IVDA)
• Fungal osteomyelitis (chronicallyill/TPN)
• Salmonella osteomyelitis (Sickle Cell Disease)
• Group B streptococcus (Infants 2-4 weeks old)
• Haemophilus influenzae (6 months to 4 years old)

upload.wikimedia.org/wikipedia/commons/5/59/Osterm
yelitis_Tibia.jpg
84
Osteomyelitis

• Treatment
• Surgical Debridement
• ? Limb Loss
• Antibiotics
• Broad Spectrum IV
• Tissue cultures to narrow
• Hyperbaric Oxygen for Refractory Osteomyelitis

Kindwall EP. Uses of hyperbaric oxygen therapy in
the 1990s. Cleve Clin J Med. Sep-Oct 199259(5)51
7-28
radiographics.rsna.org/.../g07nv10c18x.jpeg
85
Complications of Extremity Fractures

• Fat Embolism
• Approx. 5000 deaths per year
• Classic Triad
• Respiratory Compromise
• Change in Mental Status
• Petechiae
• Half of all cases present only with respiratory
  failure
• Treatment Supportive

img.medscape.com/pi/emed/ckb/vascular_surgery/4598
40-459841-460524-1723668tn.jpg
www.futurehealth.rochester.edu/dlp2/dlpdict/petech
iae.jpg
86
Thromboembolism

• Virchows Triad
• Hypercoagulability
• Endothelial Damage
• Venous Stasis
• More than 60 of DVTs are Asymptomatic
• PEs are the 3rd most common cause of death in
  trauma patients who survive past the first day

• DVT Prophylaxis
• SCDs
• Foot pumps
• Heparin
• LMWH
• Coumadin

87
Complications of Extremity Fractures

• Compartment Syndrome
• Diagnosis primarily clinical
• Pain
• Parasthesias
• Piokylothermia
• Pulseless
• Pain with passive range of motion

• Critical Pressures
• Compartment Pressure gt 30mmHg
• Diastolic BP Compartment Pressure lt 30mmHg

88
Complications of Extremity Fractures

• Rhabdomyolysis
• Treatment aggressive IVF
• Avoid buildup of myoglobin in renal tubules
• Prevent hyperkalemia

89
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