Orthopedics notes

Always give adequate analgesia + temporary splint BEFORE doing x-ray.

ALWAYS do neurovascular examination BEFORE you do anything (and document it so you
have evidence if the nerve damage was because of the injury itself or the reduction/surgery)
If you are not sure if this is the physis or fracture in children, x-ray the other side
UL – general rule: Always attempt closed reduction with percutaneous pinning (wiring)  does
not work  ORIF (except intraarticular fractures, always fix surgically)
Dislocations – Shoulder MC anterior, Elbow MC posterior, Hip MC posterior
 Anterior dislocation of shoulder
 X-ray  head of the humerus is more medial
 Do closed reduction and splint for 2-3 weeks (position the arm as if it is
scratching the other shoulder)
 Reduction maneuver using Kocher or Hippocrate’s method under analgesia
 Axillary nerve injury is the most common
 Hill sachs lesion on X-ray is seen mostly in recurrent dislocations
 Clavicle fracture  most commonly treated conservatively using figure 8 splint (unless it is
open, neurovascular compromise is present, …)
 Types of displacement – anterior posterior medial lateral translation, overlap, angulation,
rotation (ALWAYS ask for at least 2 views to comment fully on displacement)
 Avulsion Olecranon fracture
 Treatment – tension band wiring using k wire to make figure 8 (also done in
patellar fracture)
 Condylar fracture of humerus  closed reduction with percutaneous pinning
 Supracondylar fracture
 Most common in children
 Tx – closed reduction with percutaneous pinning  persists  ORIF
 Complications
 Immediate – Volkmann contracture
 Late – Malunion (cubitus varus)  correct varus with osteotomy
 Elbow dislocation
 Reduction under sedation
 Backslab for 2-3 weeks
 Colle’s & smith
 Closed reduction with pinning  if inadequate  ORIF
 Scaphoid fracture
 MC complication – avascular necrosis of proximal part (because the blood supply
starts distally)
 Displaced – percutaneous k wire
  Non displaced – splint
 Monteggia and Galeazzi fractures are always corrected with ORIF
 Hip dislocation 4 signs (OSCE)
 Positioning – shortening, flexion of hip and knee, adduction and internal rotation
of hip
 Dashboard injury
 Pain and reduced ROM
 Emptiness sign – cannot palpate femoral artery because there is no bone behind it
 Intertrochanteric fracture – Dynamic hip screw
 Fracture of neck of femur – Pinning with screws
 DDH X ray (know how it looks like)
 Green stick X ray  Tx reduce and back slab

Management of a fracture in the ER:

 ABCs (specially in case of polytrauma)
 Neurovascular examination
 Obtain IV access and give adequate analgesia
 Splint the affected limb; usually use a back slab, Thomas splint for femoral fractures
(with traction)
 X-ray

X-ray interpretation:
 Start with demographics (This is the X-ray of Mr/Ms XY taken on this and that date…)
 Site and view and what bones are seen (… AP/lateral/frog leg lateral view showing the
[ex:] distal humerus, elbow joint, radius, and ulna...)  mention what bones and joints
are shown on the x-ray
 Describe the site of the fracture (proximal, middle, distal third of the metaphysis/shaft)
 Shape of the fracture (transverse, oblique, spiral, segmental, comminuted)
 Comment on the displacement based on the distal segment, using at least 2 views
 Comment on segments/avulsion, if any, and on joint involvement
 If you are not sure of the growth plates in children, ask for the opposite side