orthopaedics & neurosurgery chapters
TRANSCRIPT
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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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