Chapter 28

Orthopedic Surgery

1 What orthopedic fractures are associated with the highest mortality rate?

Pelvic fractures because patients can bleed to death. If the patient’s condition is unstable, consider heroic measures such as military antishock trousers (MAST trousers) and an external fixator.

2 Why should areas distal to the fracture site be assessed by physical examination?

Areas distal to the fracture site should be assessed for neurologic and vascular compromise, either of which may be an emergency.

3 Distinguish between an open and a closed fracture

With an open (compound) fracture, the skin is broken over the fracture site. In closed fractures, the skin is intact over the fracture site.

4 Explain the difference in management of open and closed fractures

With closed fractures, closed reduction and casting generally can be done. With open fractures, you should give antibiotics with coverage for gram-positive and gram-negative organisms (cefuroxime is appropriate; fluoroquinolones are an alternative). If the patient is at risk for methicillin-resistant Staphylococcus aureus (MRSA) infection, add vancomycin. Do surgical debridement, give a tetanus vaccine booster, lavage fresh wounds (if less than 8 hours old), and perform open reduction and internal fixation (ORIF). The main risk in open fractures is infection, which usually is not a problem with closed fractures because the skin is intact.

5 What are the indications for open reduction other than an open fracture?

 Intraarticular fractures or articular surface malalignment

 Nonunion or failed closed reduction

 Compromise of blood supply

 Multiple trauma (to allow mobilization at the earliest possible point)

 Need for perfect reduction to optimize extremity function (e.g., professional athletes)

6 What type of radiographs should you order if you suspect a fracture?

For any suspected fracture, order two views (usually anteroposterior and lateral) of the site, and consider radiographs of the joints above and below the fracture site.

7 How should you treat a patient with severe pain after trauma and negative x-rays?

Treat the patient conservatively. Assume that there is a fracture and have the patient rest the injured area. Splinting may be appropriate for distal extremity injuries. Obtain follow-up radiographs 7 to 14 days after the injury if symptoms persist; many occult fractures become visible at that time. The exception to waiting is a suspected hip fracture in an older adult—proceed to computed tomography (CT) or magnetic resonance imaging (MRI) of the hip to allow earlier diagnosis and treatment (Fig. 28-1), which decrease operative morbidity and length of hospital stay compared with delayed diagnosis and treatment.

8 Define compartment syndrome. What is the cause?

Compartment syndrome is a problem of muscle compartments, which are limited by the fascia in which they are contained. It is seen in the extremities (most commonly in the calf) when edema or hemorrhage causes swelling inside a muscle compartment. Rising pressure inside the fascial compartment can result in permanent nerve damage and muscle necrosis.

The three common clinical scenarios in which compartment syndrome is seen are fractures (classically midshaft tibial fractures or supracondylar fractures of the humerus in children), burns (especially electrical and circumferential burns), and vascular compromise (or after vascular surgery procedures).

9 What are the symptoms and signs of compartment syndrome? How is it treated?

 Pain (especially pain on passive movement out of proportion to the injury)

 Paresthesias, hypesthesia, and numbness (decreased sensation and two-point discrimination)

 Cyanosis or pallor

 Firm-feeling muscle compartment

 Paralysis (late, ominous sign)

 Elevated compartment pressure (>30-40 mm Hg)

On the USMLE, the diagnosis of compartment syndrome often has to be made clinically without a pressure reading. Although pulses may be slightly decreased, they usually are palpable (or detectable with Doppler ultrasound) with compartment syndrome. Lack of palpable pulses is an ominous, late sign. Compartment syndrome is an emergency, and quick action can save an otherwise doomed limb. Treatment is immediate fasciotomy; incising the fascial compartment relieves the pressure.

10 Cover the right-hand columns of the following table and specify the motor and sensory functions of the following peripheral nerves. In what common clinical scenarios are they often damaged?

NERVE	MOTOR FUNCTION	SENSORY FUNCTION	CLINICAL SCENARIO
Radial	Wrist extension (watch for wrist drop)	Back of forearm, back of hand (first 3 digits)	Humeral fracture
Ulnar	Finger abduction (watch for “claw hand”)	Front and back of last 2 digits	Elbow dislocation or fracture
Median	Pronation, thumb opposition	Palmar surface of hand (first 3 digits)	Carpal tunnel syndrome, humeral fracture
Axillary	Abduction, lateral rotation	Lateral shoulder	Upper humeral dislocation or fracture
Peroneal	Dorsiflexion, eversion (watch for foot drop)	Dorsal foot and lateral leg	Knee dislocation, fibula fracture

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