Orthopaedics & Neurosurgery Chapters

8/10/2019 Orthopaedics & Neurosurgery Chapters

1/37

Ch. 7 pg. 299-314

Trauma

-Subluxation = partially displaced apposing joint suraces !"ay be transient#-$islocation = co"pletely displaced apposing joint suraces

-%ractures!x# described by type& site& pattern& and degree o displace"ent

--'ype( open = bro)en s)in or "ucosa& conta"inated by deinition* closed = no bro)ens)in or "ucosa* stress = repeated "icroscopic xs !ar"y recruits#* pathologic =

"ini"al stress+trau"a

--Site( bone aected* epiphysis !suggests intraarticular x#& "etaphysis& diaphysis--,attern( transerse !nightstic) x#& spiral or obliue& co""inuted& i"pacted&

co"pression& greenstic)

--$isplace"ent( $escribed in ter"s o apposition& angulation& rotation& and length* distal

rag"ent al/ays na"ed relatie to proxi"al* arus = deor"ity apex a/ay ro""idline* algus = apex to/ard "idline !ig. 7-9 pg. 303#

Salter-Harris Classification of Growth Plate Fxs (fig. 7-10 g. !0"#

--type 1 = separation o epiphysis ro" "etaphysis

--type 2 = x through gro/th plate exiting through "etaphysis--type 3 = x through gro/th plate exiting the epiphysis into joint

--type 4 = x ro" "etaphysis through gro/th plate and exiting epiphysis--type = crushing o gro/th plate

--type 3 and 4 hae highest incidence o gro/th disturbance

-aluation o "usculos)eletal trau"a = inspect entire extre"ity& assess ascularintegrity and neuro status

-Co"plete radiologic eal. = 2 ie/s at right angles& include joint aboe and belo/&

)no/n injury associations /arrant special radiographic exa" !ie. c-spine il"s or

pts. /ith acial+head injuries#& treat as i xd i clinical suspicion high /ith neg. il"s

Stages of fx healing (fig. 7-1 g. !0$#

--1. e"ato"a !i""ediate#--2. nla""ation and cell. prolieration !hours to /ee)s#--3. Sot callus !2 days to 5 /ee)s#

--4. ard callus !1-4 "onths#

--. 6one re"odeling !2-24 "onths#

Fx management

--Splint including joint aboe and belo/ x in ield to preent "otion& li"it blood loss&

and decrease pain

--pen or closed reduction to restore apposition+align"ent--""obili8ation /ith casting& traction& unctional bracing& external or internal ixation*

continuous s)in traction runs ris) o s)in brea)do/n* s)eletal traction reuires pin

place"ent usually in proxi"al tibia or olecranon process* excessie traction can causenonunion and peripheral n. injury* internal ixation deices include scre/s& plates&

/ires or bands& and intra"edullary rods* external ixation is "ini"ally inasie /ith

s"all scre/s and an external outrigger ra"e* indications or internal+external ixationon pg. 30 tables 7-2+7-3

--:ehabilitation o unction( li"b is i""obili8ed in position o "ax. unction* iso"etric

exercises* range o "otion or adjacent joints

-Clinically& healing is eident /hen the x is no longer tender to palpation or stress


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-:adiographically& healing is eident /hen distinct bony trabeculae are seen crossing the

x site

%ocal comlications of fx healing

--nection& delayed union& nonunion& "alunion& aascular necrosis& gro/th disturbances

--;onunion "ay result in or"ation o synoial "e"brane around xpseudarthrosis

--


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transerse "ed. "alleolus x suggests abduction !eersion# orce* transerse lat.

"alleolus x suggests adduction !inersion# orce* perect open reduction /+ internal

ixation re. or displaced an)le x-Spinal xspinal stability is critical* co"plete and detailed neuro assess"ent S,*

any injury aboe claicle = spinal injury until proen other/ise* "inor /edge

co"pression x o lo/er thoracic or lu"bar spine oten de. ileus ro" retroperitonealbleeding and pt. shouldnAt be ed enterally until ileus resoled

-,elic xassociated /+ "assie blood loss and "ultiorgan syste" injuries* e"ergency

pelic stabili8ation essential to trau"a resuscitation* blood at external urethral "eatusor inability to pass urine indicates retrograde urethrogra" b+ ind/elling catheter is

placed* blood in rectu" or agina "ay indicate open pelic x


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rtho !314-32#(

. 'rau"atic "putation F :eplantation

a. >eneral rule( greater the a"t. o "uscle tissue on a"putated part = poorer

prognosis !"uscle is sensitie to ische"ia#b. Gids s. dults( )ids do better H reattach at any leel in )ids !li"ited in

adults#

c. C.. or replantation(i. Iarge crush+aulsion co"ponents

ii. 6ody parts that hae been a"putated at "any leels

iii. ndiidual digits !except thu"b#

i. "putations in elderly /ith other "edical F "ental conditionsd. 'issue iable or 5 hours !35oC# or 15 hours !10oC# H neer use dry ice

. Co"part"ent Syndro"e !pressure @30-40 ""g#

a. Caused by( ractures& "uscle contusions& or acute ascular occlusion

b. Co""on in(supracondylar distal hu"erus& radius F ulna !Ddouble boneorear"#& F proxi"al third tibial ractures

c. 4 ,As( ,ain& paresthesia& paralysis& pallor !pulselessness ;' included#. Sports njuries

a. Stress x( occur /hen people hae increased leels or changes in habits F

trainingi. 'hought to occur as result o atigue H "uscle are tired F donAt

proide Dstress-shieldingE or the bones

ii. igh radiographic alse neg rate* need to get bone scan

b. Iateral epicondylitis !'ennis elbo/#( injury o /rist extensor "uscleorigin !at lateral hu"eral epicondyle# Hextension needed or po/er grip F

to dissipate orce /hen hand-held object is used or stri)ing

i. 'x( "ainly non-operatie !rest& heat& anti-inla""atories& ,'#ii. ccasionally& granulation tissue needs to be re"oed

c. :otator cu 'endonitis( as shoulder abducts& rotator cu "uscles contract

under coracoacro"ial arch& arch beco"es narro/er F i"pinges upon"uscle tendons

i. $x /+ arthrogra"& J+S&


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i. ,ain is anterior& aggraated by extensor+uadriceps "otions !going

up+do/n stairs& arising ro" chair& suatting& etc#

ii. 'x( rest& anti-inla" "eds& D)nee sleees&E straight leg raises tostrengthen uads !aoid exercises oer ull range o "otion#

. xercise co"part"ent syndro"e !shin splints#( due to decreased blood

lo/ during contraction o "uscles F "ore perusion during relaxationi. :ecreational runner( pain in ant. co"part"ent o leg& /orse /+

exercise

ii. Co"petitie runner( in deep post. co"part"ent o legg. Sprains( liga"ent injury& injured under tensile or stretching load

i. >rades o da"age

1. ( "icroscopic da"age H tenderness but no change in joint

laxity2. ( rupture o entire ascicles o liga"ent !partial tear# H

joint laxity /hen stressed

3. ( >rossly disrupted !co"plete tear# /+ total loss o joint

stabilityii. n)le( lateral liga"ents "ost co""on !inersion stress#

1. bnor"al anterior dra/er test o an)le F inersion talar tilt2. 'x( ice& eleation& co"pression& early /eight-bearing&

balance-board proprioceptor retraining !reduce recurrence#

iii. Gnee(1. Collateral liga"ents( da"aged by trau"atic iolence

a. $etected by "ediolateral laxity !usually in )nee

extension#

b. Iat. H concurrent peroneal n. injury !closeproxi"ity#& oten injured /+ a cruciate lig.

c.


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i. cro"ioclaicular !shoulder# separation( injured ater blo/ or all onto

acro"ion

i. Class K !not in boo)#ii. Class ( a.c. liga"ent alone is torn& claicle is subluxed ro"

acro"ion

iii. Class ( 6oth a.c F coracoclaicular liga"ents torn F jointdislocated

1. 'x H both surgical F non-surgical euiocal

j. >a"e)eeperAs thu"b( injury to ulnar collateral lig. o


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,ediatric


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Flat feetH co""on s)eletal ariation.


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,resenting s+s( Ii"p& pain locali8ed to )nee or groin& aected leg held externally

rotated& internal hip rotation is painul.

$isplace"ent "ore apparent on lateral radiograph H e"oral head appears posterioly

on e"oral nec).

Jntreated H e"oral head+nec) slippage continues until gro/th ceases.

'reat"ent( e"oral head ixed /ith "ultiple pins Congenital Clu2 Foot!a)a talipes euinoarus# tiology un)no/n.


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2. Conta"inated ro" open racture

3. ,ost-operatie bone procedure

4. xtension ro" contiguous inected oci

cute e"atogenous steo"yelitis H causatie agents( 0-3 "onths = colior"s

ro" birth canal& up to 3 yrs = . inluen8a ro" otitis "edia& all ages = S. aureus.


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1. ngular osteoto"y or joint realign"ent( realigns extre"ity& corrects

deor"ity& and shits /eight-bearing orces ro" /orn joint suraces to

healthier cartilage. Considered or younger patients /ith ocal arthrosis.2. 'otal joint replace"ent( replace"ent o articulating suraces /ith lo/-

riction polyethylene suraces. ,rooundly reliees pain in "ore than 90

o cases. :esered or older patients /ith seere arthrosis.3. Ooint rthrodesis( conerts painul arthritic joint into a painless used

joint. ndicated in young actie patients /ith isolated joint inole"ent.

6heumatoi' 4rthritis chronic polyarthritis /ith relapsing& re"ittent course that

ulti"ately leads to progressie joint destruction& deor"ity& and incapacitation.

%@< = 3(1. ,ersons /ith a I-$:3 haplotype are at high ris).

utoi""une disease- 0 hae autoantibodies to %c region o g>. 'his gCS = 3-4 on ad"ission 0-100 "ortality rate

>CS = -5 on ad"ission 2-5 "ortality rate

>CS = 7- on ad"ission 10-2 "ortality rate

/aluation of 4cute 5n*uries


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try to deter"ine(

brain+other injuries

presence o clots

intracranial ';

presence o s)ull x presence o CS% lea)

actors that justiy hospitali8ation(

abnor"al C' scan

seere headache

prolonged unconsciousness

lac) o responsible obserers

associated injuries

i sent ho"e& patient should return to hospital in case o( he"iparesis

pupillary ineuality

in headache

sleepiness

T in consciousness

persistent o"iting

6CAs o pri"ary ealuation applyU

respiration oten decreased ater brain injury /hen consciousness depressed

end-tidal C2deter"ination H use to "onitor entilationV use ;>' to e"pty sto"ach i cribrior" plate or paranasal s)ull x suspected d+t ris)

o introducing tube into cranial caity

hypotension in a pt. /+ head injury H d+t signiicant blood loss else/here in bodyi C, enough to induce ';& this can "as) hypotension caused by blood loss

expand a depleted circulatory olu"e in the neurosurgical patient /+ colloids !not

crystalloids H "ay exacerbate cerebral ede"a R C,#

neuro ealuation assesses(

consciousness

papillary response

"otor unction

sei8ures C, and he"orrhage

tx /+ B dia8epa"& slo/ inusion o phenytoin

brain ste" xn ealuation(

dollAs eyes !oculocephalic response#

corneal relex


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gag relex

caloric testing

duration o co"a R posttrau"atic a"nesia H "easures o seerity o injuryCS% lea)( central red and peripheral pin) !target# sign on a paper to/el* also& sugar

basal s)ull x R CS% lea)(

blood in external ear /+ ruptured ear dru"

blood behind an intact eardru"

raccoon eyes

loss o sense o s"ell

battle sign H ecchy"oses oer "astoid process

loss o hearing+acial "otion on one side

C' scan or head injuryU

"onitor C, in patients /+ >CS?

Treatment of 4cute 5n*uries

diuse axonal injury can result ro" concussion !brie loss o consciousness ollo/ed by

rapid return to nor"al#

intracranial he"ato"as(

epidural

subdural

intraparenchy"al H unusual

cranioto"y or eacuation o subdural+epidural he"ato"as"ost co""on he"ato"as inole rontal R te"poral regions

closed linear s)ull x H intact scalp* V direct tx necessary !unless x located oer ascular

channel#co"pound x o s)ull H oerlying s)in is lacerated* x extends to base o s)ull R inoles

paranasal sinuses+"astoid air cells#

depressed x H inner table o s)ull is displaced to greater extent than outer tabledepressed x beneath laceration( eleate R debride in : !urgent# /+in 5 hours

basilar s)ull x(

intracranial inection i dura torn

CS% lea) !aulsion o olactory bulbs+axons#

intracranial air

V operate on these i""ediately H )eep on bedrest& eleate head to 4o& aoid

actiities that dierence bet/een C, R at"ospheric pressure

lu"bar spinal subarachnoid drainage or persistent CS% lea)

Treatment of Su2acute < Chronic 5n*uries


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chronic subdural he"ato"a

occur in young R elderly

d+t rupture o bridging eins

clots liuey R hae thic)& riable& asculari8ed outer "e"brane and thin& lucent

inner "e"brane inancy H enlarged head& intracranial ';& sei8ures

adults H elderly& de"ented R alcoholics !brain atrophy#

ris) o transtentorial herniation

lesions are lucent relatie to brain tissue !can also enhance "e"branes /+ B

contrast#

"idline shit is noted on i"aging

6urr hole drainage is tx

cerical carotid injury

"ay ta)e or" o thro"bosis& dissection& aneurys" co"plication is e"boli8ation

onset @12 hours ater injury

da"age to surrounding sy"pathetic neres s"all pupil on side o injury R

contralateral to side o "ajor "otor /ea)ness

carotid-caernous istula

arterio-enous shunting includes ophthal"ic einspulsatile blood o arterial

pressurepulsing exophthal"os /+ bruit

head injury residua

"otor deicits

cognitie deects

behaioral changes

posttrau"atic syndro"e( headache& di88iness& ertigo& atigability& inability to

concentrate* use a"itriptyline

Cere2ro/asular isease

stro)e( sudden or rapid !seconds to hours# occurrence o neurologic dysunction or loss o

consciousness b+c o cerebroascular diseasestro)e cause by ';& carotid atherosclerosis /+ e"boli& interacerebral atherosclerosis&

heart disease& coagulopathy& polycythe"ia& drug abuse& diabetes

2 types o stro)e

ische"iche"orrhagic

use C' to dierentiate bet/een 2 types o stro)e

tx "oderate+large he"ato"as R cerebellar he"orrhage /+ early eacuation !open


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cranioto"y or C' guided stereotaxic aspiration#

cerebellar he"orrhage H headache& diplopia& ipsilateral congujate ga8e palsy&

6abins)i sign& cerebellar deicits& eoling lethargy R co"aintracerebral clot deelops ro" so"e aneurys"s or B


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nec) stiness /+ subarachnoid he"orrhage

eects usually donAt resole uic)ly& i at all

i""ediate "ortality H 70

suspect aneurys" i clot borders on anterior circle o Lillis or Sylian issure

asospas" seere co"plication o aneurys"al subarachnoid he"orrhage

leads to brain inarction+death

occurs 3-9 days ater S

tx /+ he"odilution& hyperole"ia& 6, /+ drugs& Ca2Rchannel bloc)er

aneurys"s

saccular dilatations o branch points !berry#

deect o "edia R elastica

branch points o anterior circle o Lillis& esp. posterior internal carotid R

co""unicating artery "ultiple aneurys"s in 20 o cases

can cause unilateral 3rdnere paresis !papillary dilation& lid droop& loss o

"edial ga8e in sa"e eye#

"ycotic aneurys"s H 2oto septice"ia arise peripherally& discoered

ater they bleed

trau"atic aneurys"s H rare& usu. caused by penetrating injuries

annual bleeding rate o unruptured aneurys"s H 1.

0 o patients /+ bleeding aneurys"s die

li)ely to rebleed early ater repair H 3-4 /+in 4 /ee)s /+ 0 "ortality

operatie


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rain Tumors (!7!-!="#

Classiication Hrelation to brain tissue !ex+intrinsic# extrinsic "ore benign and excisable

site !supratentorial . post ossa# inra = hydrocephalus R increased C,

age !ped s adult# peds = inra adults = supraSy"pto"s(

"ost co""on = headache !4# but only 1 headache hae tu"or

%ocal neurologic deicit or "ental change in 5 at diagnosisSei8ures 25

$iagnosis(

C' or lioblasto"a


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Io/-grade strocyto"a( benign& "ild hyperplasia& possible in children& year

0-7* early re"oal& can beco"e >6<

ligodendroglio"a( contain calciu" !C'#& sei8ures!50#& surial related to

Sx duration& surgery& year = 50-

pendyo"a( supra+inra tentoriu"& histologically benign year only 3

tract& s)in. g surial = 5 "ose"angioblasto"a( cerebellar& blood essel& 1+3 are Bon ippel-Iindau&

:CJ:& re"oed /ithout biopsy b+c possibility o he"orrhage

iagnostic

istory& physical& CQ:& C'+


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coustic neuro"as( lose hearing on translabyrinth resection* posterior ossa

cranioto"y can presere hearing in so"e patients

,rolactino"as H bro"ocriptine shrin) tu"ors and suppress secretory:adiation H control residual tu"or

Pe'iatric rain Tumorsntrinsic 'u"ors( "ost glial except "edulloblato"a = neuronal

iagnosis

%ocal neurologic oten absent.


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Surgery+trau"a 10* Cranial inections !Sinusitis& dental inection# 20* Cardiac

!bypass lungs# 20.

,resentation( H4& eer !?0#& ocal neuron deicit. ,ossible conusion& sei8uresaluation( istory !inection& surgery& i""une& cardiac& B#. C'+


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Cord is /ithin Canal or"ed by Spinal Colu"n& bro)en do/n into seg"ents& and each

seg"ent(

--receies sensory input ro" paired dorsal roots--relayed to the brain ia

scending :eticular and Ie"niscal Syste"--sends output through paired entral roots--under oluntary control by descending

supraseg"ental syste"s

--bilaterally sy""etric--innerates speciic body seg"ent( $er"ato"e& Scleroto"e&


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SP584% C36 @4584T538

,alpation or deor"ity& tenderness& spas"


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--:e"e"ber to /atch s)in or decubitus ulcers

--ris) o utono"ic yperrelexia /ith '; in response to sti"ulation !eg oley# belo/leel o co"plete lesion

--ris) o late brain he"orrhage

SP584% 5S4S

$isc $isease(--$egeneration d+t nucleus pulposus dessication or erniation d+t nucleus pulposus

extruding thru annulus tear.

--usually postlaterally R co"presses nere root !i thoracic or cerical can co"press cord#

--degeneration oten asy"pto& herniation can hae local& radicular and+or "yelopathicpain

erniations(

--9 at I4- !co"presses I# R I-S1 !causes lo/er bac)& sciaticposterior+lateral leg pain& /orse /ith /eight# !ddx( claudiication hernia& etc#

--Cerical co""on at C-5 R C5-7 !cause nec)& scapula& ar"& hand pain& ddx(angina& others#

--'horacic rare& but can cause paraplegia

--ll usually hae ,ain in spine R one extre"ity& /orsened by strain& cough&snee8e& "otion

--alutation( gait& neuro exa"& point tenderness& paraspinal "uscle spas"&

li"ited spinal "otion. Straight leg raise& particularly crossed contra !asy"pto# raise&

pathogno"ic or lu"bar herniation--i paraparesis& sphincter dysxn& sudden bilateral leg pain+nu"bness[e"ergent

radiologic dx R tx !C's not ideal& better


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--i central cord syndro"e( Jxt /ea)ness

--i anterior cord syndro"e(


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--less co""on adults !ependyo"a& can be cut out easily#

--so"eti"es large cyst !ddx is syrnix#

--10 are he"angioblasto"as[are cystic& can be re"oed& ris) o bleeding--der"oids& epider"oids& lipo"as in cord or at+belo/ conus o cauda euina

ntradural xtra"edullary /ithin dural tube& outside o cord--in cerical+thoracic can co"press cord+roots

--in lu"bar are /ithin cauda euina roots R cause polyradicular signs

--usually benign thereore long hx--"ost co""on( ;euroibro"as[can be large& i near spine& ealuate /ith radiograpy

--


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c. 'reat"ent(

i. Sharp transactions repaired i""ediately* usually ascicular repair

/ith perineural suturesii. stretch injuries "ay be helped by "uscle transers

iii. painul neuro"as "ay be resected once& but li)ely to ail any/ay

d. Co"pression syndro"es(i.


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d. co"plications are shunt in and "alxn& do xrays& tap shunt to sa"ple CS%

or in !usually s.epid#

2. Spina biidaa. ;onclosure o neural tube& ertebra& sot tissue

b. Spina biida occulta( "ost co""on& least bad& no neural deect& incidental

xray inding& "aybe lipo"a assocc.


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Orthopaedics & Neurosurgery Chapters