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Chapter 40: Orthopedic Surgery

Chapter 40. Orthopedic Surgery

Open fractures, defined as a break in the bone with violation of the skin and soft tissues requires the following management:

A. Splinting

B. Bedside irrigation and splinting

C. Formal irrigation and debridement in the operating room with stabilization of fracture and antibiotics

D. VAC dressing

E. Plastic surgery consultation

C. An open fracture is defined as an osseous disruption with a break in the overlying skin and soft tissues resulting in communication between the fracture and the external environment. Open fractures can be classified using the Gustillo and Anderson classification: Grade 1, clean skin opening less than 1.0 cm, Grade 2, traumatic wound greater than 1.0 cm but less than 10 cm in size, and Grade 3, extensive soft tissue injury requiring flap and/or vascular repair. Antibiotic treatment, tetanus prophylaxis and urgert irrigation and debridement in the operation is necessary. Fractures should be stabilized with internal or external fixation and/or splinting to minimize additional soft tissue injury.

A 37-year-old man is involved in a motor cycle accident at a high rate of speed. Upon arrival to the emergency room he reports that he has no feeling below the waist and cannot move his legs. The bulbocavernosis reflex is intact. According to the American Spinal Injury Association, he would be considered:

A. Asia A

B. Asia B

C. Asia C

D. Asia D

E. Asia E

C. The clinical findings in spinal cord injury depend on the level, mechanism and severity of injury. Injuries are classified as complete or incomplete. A complete spinal cord injury refers to lack of motor or sensory function below the level of the lesion. Incomplete spinal cord injuries may demonstrate a variable pattern of sensory and motor preservation. The American Spinal Injury Association published a scale to classify the severity of SCI: ASIA A – complete, ASIA B- sensory incomplete, ASIA C- motor incomplete, ASIA D- motor incomplete, more than half muscles below lesion have > grade 3 strength, ASIA E – normal. Spinal shock is a spinal cord dysfunction due to physiologic disruption, resulting in hypotonia, areflexia and paralysis. Resolution usually occurs within 24 hours and the bulbocavernosis reflex is the first to come back.

A 57-year-old woman is involved in a motor vehicle collision. She is transferred to the Emergency Department where radiographs confirm a closed pelvic fracture with symphyseal widening. She becomes acutely hypotensive in the resuscitation bay. The next important step in her treatment is:

A. Immediate transfusion

B. Exploratory laparotomy

C. Move blood pressure cuff to the leg

D. Apply sheet or pelvic binder around the patient

E. Obtain more x-rays

D. Pelvic fractures are among the most serious orthopaedic injuries, resulting in life-threatening hemorrhage, neurologic and genitourinary injury. Hemodynamically unstable patients have a mortality of 40-50%. Immediate care of the patient with a pelvic fracture must address the retroperitoneal hemorrhage, pelvic ring stability and injuries to the GU system. General resuscitation principles are applied and active bleeding from the pelvic can be controlled by wrapping a pelvic binder or sheet circumferentially around the pelvis to close down the pelvic volume.

A 23-year-old man presents to the Emergency Room with an acute injury to his left knee sustained playing football. He is unable to weight bear and on exam demonstrates anterior dislocation of the tibia. The next steps in management include:

A. Emergent reduction, splinting, vascular studies, and neurologic exam

B. Knee immobilizer and outpatient follow-up

C. Urgent MRI

D. Transport to operating room for open reduction of the knee

E. Reduction and casting

A. Traumatic knee dislocations can be limb-threatening because of disruption to the popliteal vasculature. If the knee remains dislocated at presentation, immediate reduction should be performed. Postreduction neurologic and vascular exam is critical. If there is any indication of abnormal arterial inflow (ABI < 0.9, diminished or absent pulses, delayed capillary refill) then arteriography is indication. If the limb is frankly ischemic, emergent vascular exploration is indicated.

A 3-year-old child fell from the monkey bars sustaining an acute injury to her left elbow. She demonstrates good strength with the exception of the anterior interosseous nerve. Radiographs confirm a displaced supracondylar humerus fracture. Parents are informed:

A. Splint will be applied and patient can return for outpatient follow-up.

B. Patient will require closed reduction and pinning of the elbow in the operating room. The AIN will require exploration and repair.

C. Patient will require closed reduction and pinning of the elbow in the operating room. The AIN will recover in most cases with observation over the next 3-6 months.

D. Patient can be observed for recovery of nerve overnight in the emergency room.

E. AIN is rarely injured with this type of fracture.

C. Supracondylar humerus fractures are among the most common injuries in children ages 4-8 years. The typical mechanism is a hyperextension injury after a fall onto an outstretched arm. If displaced, supracondylar fractures require urgent reduction and stabilization in the operating room. The anterior interosseous nerve is the most commonly injured with extension type fractures. Most nerve injuries represent neuropraxias that resolve with observation over the subsequent 3-6 months.

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Chapter 40: Orthopedic Surgery

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Chapter 40. Orthopedic Surgery

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