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  1. Approach To Medicine
  2. Surgical Specialties
  3. Orthopedics

Orthopedics

Modified 00:59, 9 Sep 2013 by jmoktar | Page History
    Table of Contents
    1. 1. Orthopaedic Trauma Managment
        1. 1.1.1. Management in ER:
        2. 1.1.2. Management in OR:
    2. 2. Open Fractures
        1. 2.1.1. Gustilo and Anderson classification
        2. 2.1.2. Prophylactic Antibiotic Regimen
        3. 2.1.3. Tetanus Prophylaxis
    3. 3. Septic Arthritis
    4. 4. Distal Radius Fractures

    Orthopaedic Trauma Managment

    Management in ER:

    1. Complete primary survery and resuscitiation
    2. Begin prophylactic antibiotic treatment
    3. Control bleeding with direct pressure or tourniquet
    4. Apply saline soaked sterile dressing over open wound
    5. Split/stabilize
    6. Appropriate xray views 

     

    Management in OR:

    1. Aggresive debridement and irrigation
    2. Low pressure saline lavage
    3. Remove loose bony fragments
    4. Fracture stabilization
    5. Debridement and irrigation every 24-48 hours
    6. Soft-tissue and wound coverings

    Open Fractures

    Gustilo and Anderson classification

    • Grade I: < 1cm non contamination incision

    • Grade II: 1-10cm incision with some contamination and soft tissue injuryI

    • Grade III: > 10cm incision with gross contamination from soil, bowel or farm injuries, or crush injury

      • ​IIIA: Extenstive injury but bone repairs covered with soft tissue

      • IIIB: Extensive injury and inability to close wound

      • IIIC: Vascular Injury/compromise

     

    Prophylactic Antibiotic Regimen

    Initiate antibiotics as soon as possible, rates of infections drastically decrease within 3 hours of administration. Continue therapy for 24-72 hours. 

     

    • Grade I: Cefazolin (Ancef) 1g IV q8h. If MRSA +ve use vancomycin 

    • Grade II: Cefazolin (Ancef) 1g IV q8h + Gentamycin 4mg/kg IV q4h

    • Grade III: As per Grade II  + Anerobic coverage: Penicillin 2.4million units IV

     

    Tetanus Prophylaxis

     

    • Prophylaxis is given based on charactersitics of wound, if and when primary series has been completed
    • Primary series is 3 doses of DTap, DTP, Tdap or DT.

     

    • DTap:  children 6 month - 7 years
    • Td : children 7-9 and > 65
    • Tdap: (Adacel) for 11-65, or Boosterix for 10 +

    • TIG: Tetanus immune globin:

      • < 5 years: 75U

      • 5-10 years: 125U

      • >10 years: 250U

         

         

         

         

         

    Tetanus Prophylaxis

     
     

    Has completed primary Td series

    Has not have vaccine, or unsure

    Small, clean wound

    None, if > 10 years give Td vaccine

    Give Td vaccine

    Large, contaiminated, or puncture

    None, if > 5 years give Td vaccine

    Give TIG

     

     

    Septic Arthritis

     

    • Most commonly affected joints: knee > hip > elbow > ankle > sternoclavicular joint

     

    • Etiology of infection:
      • Bactermia (hematogenous spread)
      • Direct from trauma or surgery
      • Contigious from adjacent otseomylitis 

     

    • Most common organisms include
      • Staphyloccus aureus (most common cause) 
      • Streptococcus
      • Neisseria Gonorrhea (most common in young, otherwise healthy and sexually active adults)
      • H. influenza 
      • Salmonella 
      • Pseudomonas aeruginosa (IV drug use)
      • Immunocompromised hosts may present with fungal septic arthritis as well
      •  
    • Presentation includes pain, inability to bear weight, fever,  decreased ROM
    • Physical exam: Pain with PROM, effusion, warmth, joint is often "open" position to maximize volume

     

    Distal Radius Fractures

    • Fall outstretched hand.
    • Cast below elbow keeping the thumb and fingers mobile.
    • Follow-up:
      • Return in 7 days for assessment:
        • Xray: displaced?  if displaced consult ortho (unstable)
        • Cast too tight? or unhappy? (redo cast)
      • Return in 6 weeks for removal:
        • Remove cast + assess 3 things:
    1. Xray - displaced? callus formation?
    2. Point tenderness over the fracture? (should not be any)
    3. Appropriate amount of time in cast?
    • t/hen decide if to put cast back on or consult ortho or leave it.
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