Ortho tips and tricks for closed reductions

-Purpose- to restore length, alignment, rotation

-Helps with patient comfort, protecting cartilage, keep neurovascular structures away from stress, prevent skin/wound complications

-Also trial of non-operative management

-Needs pre-reduction XR

-Recreate the deformity to “unhinge”

-Consider your deforming forces- what structures at risk, what muscles/forces pulling fracture, what will open joint space, etc.

-Tourniquets can get in the way, so try and take down if possible

-Molding- holds your reduction in place, 3 point mold (never mold over bony prominence)

-Purpose of CT is to evaluate joint

-Rare to obtain CT prior to reduction unless there is a block of some kind

-Every time a joint gets dislocated it will need to stressed to assess for stability- this will determine need for operative management

-Unstable hip dislocations need traction pins

-Elbow test flex/extension + varus and valgus stress

-Unstable dislocations get ex-fix EVEN IF NO FRACTURE

-Joint dislocation is emergent in the ortho world

-Shoulder reduction

              -Do not try alone if there is an associated fracture, TSA or rTSA in place

              -Milch maneuver

              -Stability exam

              -Scapular Y XR and axillary views

-Elbow Reduction- typically associated with ligamentous damage

              -Simple- no fracture, complex- fracture

              -Terrible triad injury- LUCL, radial head, coronoid

              -Inline traction, supination, flexion

              -Stress the joint

              -Neurovascular exam

              -Monteggia- Proximal 1/3 ulna + radiocapitellar jt- make sure that radial head is reduced!!

                            -Blocks to reduction- annular ligament, biceps tendon

                           -Stress- especially pronation and supination- need to splint in whichever is more stable

-Hip- posterior wall fracture

              -often associated with acetabular fracture- if it isn’t try not to cause one

              -Captain Morgan reduction, East Baltimore Lift

              -Flexion, adduction, internal rotation (for posterior dislocation)- Stress exam

              -Make sure to get pre-reduction XR

              -When to ask for help- traction pin, peri-prosthetic

-Knee dislocation- often associated with neurovascular injury

              -First steps- physical exam, doppler, ABI’s?, CTA’s? (not super sensitive for intimal flaps)- typically keep these for obs for 24 hours

              -Vascular consult?

-Subtalar Dislocation

              -Difficult reduction- try and call ortho for this

              -Different than the tibiotalar dislocation (standard ankle dislocation

              -Dislocation of the talus and calcaneus

              -need to relax gastrocnemius muscle- flex the knee

              -Plantar flex the ankle

              -Is the talonavicular joint in place after reduction? Can see on post reduction lateral films

-Remember 3- point mold, and do not mold over bony prominence

-When does it not matter

              -certain fractures- humerus, femur shaft/ distal femur, both bone forearm, tibia +/- fibula

              -Just need to get to length

Lightning Lectures

Dr. Kushner- Kids with a limp

-fractures, muscle/tendon/ligament injury, insect bite, hemarthrosis, transient synovitis, cellulitis/abscess, plantar wart

-SCFE- type I Salter harris fracture

              -most common hip pathology in adolescents

              -Usually happens during periods of rapid growth

              -Risk factors: obesity, family history, endocrine/metabolic disorder, down syndrome

              -Stable- able to bear weight with crutches

              -Unstable- not able to bear any weight

              -Work-up: XR (AP and frog leg), MRI, possible workup for kidney disease or endocrine disorder

              -Non-weight bearing, consult to ortho

              -Unstable needs to be admitted

              -Complications: osteonecrosis, chondrolysis, femoroacetabular impingement

-Legg Calves Perthe- Osteonecrosis of femoral head- idiopathic

              -10-15% will be bilateral

              -Ages 2-12 with peak 4-9

              -Pain in hip, groin, thigh, knee

              -may wax and wane over weeks to months

              -Goals: pain relief, protect femoral head shape, restore hip mvmnt

              -Non-weight bearing, NSAIDS and consult to ortho

-Septic Arthritis- most commonly hematogenous spread

              -most common in hip, knee, ankle

              -Staph aureus, respiratory pathogens, kingella, e coli, salmonella

              -Need to rule out adjacent joint involvement

              -FABER position- Flexion, Abduction, External rotation

              -Workup: CBC, CRP/ESR, blood cultures- possible swabs if suspect gonorrhea

              -XR AP and frog leg

              ->50k WBC and >75% polymorphonuclear cells in synovial fluid suggestive of SA

              -Kochers criteria- fever, non-weight bearing, ESR >40, WBC >12k

              -Consider LP if septic joint caused by H. flu- high incidence of meningitis

              -Try and hold on abx until aspirate and cultures can be obtained

-Transient Synovitis

              -Etiology unclear but typically proceeded by URI, trauma, bacterial infection

              -Treatment NSAIDS, heating pads

              -Should resolve in 1 to 2 weeks- close follow up for resolution

Dr. Aiello- Conus medullaris and Cauda Equina Syndromes

-Conus medullaris syndrome- CM injury typically at L1-L2

              -Findings: Urinary incontinence, fecal incontinence, decreased rectal tone, erectile dysfunction, saddle anesthesia

              -What sets apart from cauda equina- muscle weakness typically bilateral, + upper motor neuron signs, loss of patellar reflexes

-Cauda equina syndrome

              -Begins at L2 and extends to sacral nerve roots

              -Can be asymmetric

              -Usually more painful than conus medullaris

-Management-

              -if neoplasm suspected- dexamethasone 10 mg IV?, MRI w/ contrast

              -Spine consult, likely surgery

R2 Clinical Pathway- Traumatic Injuries of the Spine- Drs. Bishop and Alia

-Up to 25% of SCI occurs after initial insult- extraction, transport, handling, early mobilization

-Spinal tracts:

              -Descending Motor tracts: Lateral corticospinal, ventral corticospinal

              -Ascending sensory tracts: Dorsal columns (fine touch, proprioception, vibration), Lateral spinothalamic (pain, temp), Anterior spinothalamic (course touch, pressure)

-High dose steroids not recommended in spinal cord injury

-Brown-Sequard Syndrome- transverse hemi-section or unilateral compression

              -ipsilateral spastic paresis, loss of proprioception/vibration

              -contralateral pain and temperature loss

-Central Cord syndrome- squeezing of the cord affecting inner portions

              -Quadriparesis worse in upper extremities

              -Cape like distribution

              -Sacral sparing

              -MRI, NES/Spine

-Anterior Cord Syndrome

              -Direct compression or ischemia of anterior 2/3 of spinal cord

                           -disc protrusion, AAA, hyperflexion, emboli

              -Symptoms:

                           -paraplegia below lesion

                           -loss of pain and temp

                           -Bowel/bladder dysfunction

                            -Dysautonomia

-Spinal Shock- injury resulting in transient global loss of function w/ temp flaccid paralysis, bowel/bladder dysfunction, anesthesia, loss of reflexes

              -Resolves in days to weeks

-Neurogenic Shock- injury to spinal column resulting in hypotension, bradycardia, and hypothermia

              -occurs in <20% of SCI patients

              -injury level:

                           -Above T1- full sympathetic denervation

                           -T1-L3: partial denervation

              -Management:

                           -Exclude other causes of vital sign abnormalities

                            -MAP goals- first line pressor (MAP goal 85-90)

                           -Levo first line, can add phenylephrine as second line pressor

                           -Atropine, temp probe, bair hugger

-Unstable fractures:

              -Jefferson Bit Off A Hangman’s Thumb

                           -Jeffersons Burst Fracture- C1 fracture of anterior/posterior arches

                           -Bilateral cervical facet dislocation

                           -Odontoid Fracture, type II (full odontoid fracture) or III (vertebral body involvement)

                           -Atlanto-occipital dissociation

                           -Hangmans fracture- bilateral C2 pedicle fractures- displaces C2 anteriorly onto C3

                           -(Flexion) Tear drop fracture- associated with anterior cervical cord syndrome

-Remember Canadian C-spine, NEXUS criteria for clearing C-spine

-R2 Pathway on room9er

Dr. Jacobs- Life after Residency

-Show up 15 minutes (at least) early for your shifts

-Get to know the people you work with and be friendly

-Avoid arguments

-Flow is important- order everything you think you might need (within reason) right out of the gate- will speed things up ultimately

-Ask for help if you need to- case management, colleagues, PT/OT, nurse manager, etc.

-Don’t vent your anger in public- beware of being recorded

-Temper patient expectations- don’t over-promise, do what you can do

-Don’t get locked into a diagnosis and refuse to budge- avoid confirmation bias

-Listen to your nurses, involve them in care- will help with building relationships

-Recognize your feelings- if you need a minute to decompress or vent, do so before your feelings boil over

-Get a lawyer/accountant/financial advisor onboard early in your career so you can maximize your pre-tax deductions, retirement accounts, etc.