Orthopedics 3

Bone, Articular Tissue, Connective Tissue

Cartilage, Synovium

Muscle, Ligaments, Tendons

80 in axial skeleton; 126 in appendicular skeleton; 27 in the hand

Epiphysis; Physis; Metaphysis; Diaphysis

above growth plate

growth plate

Shaft

is open (i.e., growth plate)

Cortical; Cancellous

Compact, makes up 80% of skeleton (e.g., diaphysis of long bones)

Spongy or trabecular ; more prominent in spine & pelvis (e.g., metaphysis of long bones)

Highly vascular membrane that covers bone; more prominent in children

Source of hematopoietic progenitor cells

Periosteum

Marrow

Red (active) marrow changes to yellow (fatty, inactive) marrow

Organic matrix composes 40% of bone dry wt

Type I Collagen, Proteoglycans, Noncollagenous matrix proteins, GFs & cytokines

90% of organic matrix

Type I Collagen (tensile strength); Proteoglycans (compressive strength)

mineralization & bone formation

Interleukins, transforming growth factor

Calcium hydroxyapatite; Osteocalcium phosphate (Brushite)

Mineral components compose 60% of the dry wt of bone

Arises from periarticular vascular plexus

Low pressure capillary system supplies outer 1/3 of diaphyseal cortex

Ca & PO4

99% of Ca & 85% of PO4 found in Bone

Vitamin D

PTH

16 to 25 y.o.

bone loss

Osteoporosis, FAS (amenorrhea, anorexia, osteoporosis)

1000-1500 mg/day

Cells that form bone, producing type I collagen

Cells that resorb bone

Cells that maintain bone; make up 90% of mature skeleton

Inflammation, Repair, Remodeling

Begins mid repair phase; continues for several months

Fibrocartilage, Elastic cartilage, Fibroelastic cartilage, Articular cartilage

Area for bone & tendon insertion

Nose, auricle

Menisci (functions to deepen articular surface & stabilize joint)

Hyaline (aids in load distribution & decreasing joint friction)

Membrane lines the joint; mediates exchange of nutrients between blood & joint fluid

Nourishes articular cartilage; lubricates articular surfaces

Fluid-filled potential space over areas of friction

Actin & Myosin filaments

muscle fibers

muscle fascicles

muscle body

Oxidative; Aerobic; Endurance

Glycolytic (ATP system); Anaerobic; Speed/ Strength

carried down axon to neuromuscular junction

ACTH released from pre-synaptic vesicles & diffuses across synapse to receptor on muscle

depolarization, releasing Ca

Troponin

Actin-myosin cross bridges form; muscle contracts

Constant tension through ROM

muscle shortens

muscle elongates

Muscle tension with length constant

Concentric or eccentric contraction at constant speed over ROM

Distal end of limb is free, isolates mx (i.e., seated leg extension, biceps curl)

Distal end is fixed, recruits accessory muscles (e.g., push-ups, squats)

Attaches mx to bone; transfers mx action to bone; enclosed within a tendon sheath

Attaches bone to bone; provides stability to the joint

femoral shaft fracture

Within several days of fracture

Breakdown of mx fibers with release of cellular contents into circulation

Muscle pain, dark urine

Myoglobinuria; CK elevated 5-10x normal (37-200)

Fluids; Correct imbalances; tx underlying cause

with distal radial Fx, or overuse

with elbow Fx / dislocation, or impingement

with hip, fibular head, or ankle fracture/dislocation

with L-S spine, pelvic, hip Fx, or HNP

Blunt injuries may produce nerve contusion

fracture; recovers in 6-12 weeks

Crush injury; also seen in traction injuries; recovers at 1mm/day or 1 inch/month

Sharp trauma results in a severed nerve; primary surgical repair indicated

Chronic Regional Pain Syndrome

Persistent pain & hyperesthesia after an injury

spine, pelvic, hip, femur fx.

Trauma, smoking, prolonged inactivity, hormone therapy, surgery

duplex Doppler venous ultrasound

Calf pain in post-op hip or knee patient deserves US

DVT

Heterotrophic bone formation

R/O osteosarcoma

Ice, compression; excision for impairment after stabilization in 6-8 months

Delayed union; Nonunion; Infxn; N/V injury

Slow callus formation

No clinical or radiographic signs of progression to bony union after 3 months

open fractures

S. aureus, Beta strep

Evaluate circulation & sensation distal to injury site.

Allergies, meds, Past Hx , Last meal, Events of trauma; PE

• CMC flex: 0-15;
• CMC ext: 0-30;
• MCP: 0-90;
• PIP: 0-100;
• DIP: 0-70

• Flexion: 0-150;
• Pronation/supination: 0-80

• Extension: 0-60;
• Flexion: 0-70;
• Ulnar deviation: 0-30;
• Radial deviation: 0-20

• Flexion: 0-100;
• Ext: 0-30;
• Abd: 0-40;
• Add: 0-20;
• IR: 0-40;
• ER: 0-70

Flex: 0-140

• Dorsiflexion: 0-20;
• Plantar flexion: 0-40;
• Inversion: 0-30;
• Eversion: 0-20

• Flexion: 0-45;
• Extension: 0-45;
• Lateral flexion: 0-45;
• Rotation: 0-80

• Flexion: 0-90;
• Extension: 0-30;
• Lateral flexion: 0-30;
• Rotation: 0-30

C1-2

C3

C4, CN XI

C5

C6

C7

C8

T1

Interosseous muscles

L1-L3

L4

L5

S1

C2-3

C4

C5

C6

C7

C8

T1

Radial nerve

Median

Ulna

L1

L2

L3

L4

L5

S1

L2-3

L4

C5

C6

C7

L 3,4

S1

Absent

Diminished

Average

Exaggerated

Clonus

2+

Normal, Unsteady, Cautious, Antalgic, Use of assisted devices

Moisture; Turgor; Trauma

Stretched or torn ligament

partial tear

partial/instability

complete tear

Musculo-tendinous unit injury; first, second, third degree; Pulled muscle

Bruise; Hematoma ; Abrasions, lacerations

Overuse, mechanical irritation of tendon

Supraspinatus

Medial/lateral epicondylitis

DeQuervain

Trigger finger

ITB

ITB, Patella, Quadriceps

Peroneal tendon, Posterior tibial tendon, Achilles

Plantar Fasciitis

HTN, GI, altered renal function, MI (ibuprofen and diclofenac)

impingement & inflammatory disorders

chronic tendonitis

Flector patch, Voltaren gel

soft tissue injury

cardiovascular effects

RA and OA

soft tissue injuries & as opioid sparing combination

APAP/ASA/Caffeine

ASA/Caffeine/Salicylamide

4 per year, per site

a septic joint or thru cellulitic skin

Analgesic effect & cartilage repair for OA; no support for soft tissue injury

NSAIDs, ROM, Glucosamine

Early, sudden onset, bilateral & symmetric; Bony erosion; systemic illness

DMARDs, steroids

Ankylosing Spondylitis

Consider joint above & below injury

Defines bony anatomy

Defines soft tissues

Help define tumors, etc

Evaluates denervation of muscle units

Evaluate conduction velocities

diaphysis, metaphysis, epiphysis

transverse, oblique, spiral

comminuted, incomplete

closed, open, open joint

displaced, angulated

greenstick, torus, Salter-Harris

Straight

Above

Lower

Through

Ram

Incomplete fx w/ valgus impaction; ORIF

Complete fx w/o displacement; ORIF

Complete fx / partial displacement; prosthetic replacement

Complete fx w/ total displacement; prosthetic replacement

Undisplaced

Displaced

Comminuted

Dislocated

Anatomic location; Region; Direction of fracture; Condition of bone

Plaster or ready to use (Orthoglass); acutely, 10 thick, use padding

Fiberglass; after swelling subsides, check NV status

Hematoma block, digital block, exaggeration of Fx & reduction with traction

(open/closed reduction percutaneous pinning)

Screws, plates

act as framework for new bone growth

from same patient

from another species

from cadaveric bone bank

Autograft; Xenograft; Allograft; Ceramics

Benign bone tumors common; malignant tumors rare

Pts > 40 y.o.

Osteoblastoma, Osteoid osteoma

Ewing sarcoma, Osteosarcoma, Chondrosarcoma

Ganglia, giant cell tumor, lipoma, hemangioma, angiomyoma

Fibrosarcoma, liposarcoma, rhabdomyosarcoma

Heterozygote (Aa) manifests dz (Marfan; Achondroplasia)

Homozygote (AA) manifests dz (Hurler Syndrome, osteogenesis Imperfecta type II & III)

Nutrient Artery System; Metaphyseal-Epiphyseal System; Periosteal System

Nutrient a. enters diaphyseal cortex thru nutrient foramen into medullary canal

Osteoclasts resorb bone followed by new bone deposition by osteoblasts

Increase in external stress leads to bone formation; removal of external stress leads to bone resorption

Hematoma forms at fracture site; Osteoclasts remove necrotic bone; Hematopoietic cells in clot secrete growth factors

Soft callus stage: fibrous tissue unites fragments; Hard callus stage: callus converts to bone

Embolic marrow fat damaging pulmonary capillary beds leading to ARDS

hypoxemia, dyspnea, altered mental status, tachycardia, and petechia

Maintain perfusion with O2, inotropics, maintain hematocrit, correct metabolic acidosis; mechanical ventilation may be required.

Blunt trauma, seizures, burns, strenuous exercise, electric shock, drugs (Lipitor), viruses

Hypovolemia, Hyperkalemia, Metabolic acidosis, Acute renal failure, DIC

Carpal tunnel syn; Ulna n. palsy; peroneal n. palsy; sciatic n. neurapraxia

Intense burning pain, edema, stiffness, skin discoloration and atrophy

Early referral to a pain specialist; neuroleptic pain meds (Neurontin, Lyrica); Regional sympathetic nerve blocks; PT

Anticoagulation; prophylactic anticoagulation in trauma admissions & certain ortho surgeries

Focal trauma to mx; calcification of hematoma in 3 months, ossification in 5 months

Flexion: 0-170; Extension: 0-40; Abduction: 0-150; Adduction: 0-30; External rotation: 0-90; Internal Rotation: 0-80

Conservative therapy: Relative rest, stretch, ice, NSAIDs, correct biomechanics; PT/ OT; ROM, Iontophoresis; Corticosteroid Injection

Obtaining dx samples; assess pain relief as a dx tool; administer meds for pain/ inflammation

Intra-tendinous injections (future rupture likely); drug allergies; steroids are immunosuppressive

Ethyl chloride spray, Marcaine/Lidocaine, Kenalog

• Protect/ prevent damage;
• Rest 24-48 hr;
• Ice 20 min q 1-4 hr ASAP & for 2-3 d;
• Compression/ prevent more swelling;
• Elevation to drain fluid;
• Motion early/ speed recovery;
• Meds;
• Modalities: Iontophoresis, US, etc

Tendon rupture, Infection, Hypopigmentation, Fat atrophy, Steroid flare; caution in diabetics

Application of electric current to skin to transport anti-inflammatory drugs across skin to affected tendon

Application of ultrasound to skin to create pores for transport of anti-inflammatory drugs across skin to affected tendon

Extracorporeal shock wave tx; provides local anesthesia & promotes neovascularization (Plantar Fasciitis)

Injection of sclerosant (phenol of hypertonic glucose); no support for soft tissue injuries; low level support for back pain and OA

Inhibits neurotransmitters & mx contraction; low level evidence for chronic lateral epicondylitis

>40 y/o, asymmetric, hands, weight bearing joints; AM stiffness < 1 hour; decreased joint space and bony spurring

Corticosteroids, Visco-supplementation (Synvisc : 3 weekly injection, Hyalgan (hyaluronate): 5)

Gout (monosodium urate crystals); CPPD: Ca pyrophosphate deposition (pseudogout)

Heterozygote (XX or XY) manifests condition (Vitamin D resistant rickets)

Heterozygote male (XY) is affected; hetero female (XX) not affected (Duchenne MD; Hunter Syndrome)

Abnormality in specific region of a chromosome or an abnormal number of chromosomes (Down Syndrome & Polydactyly)