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Chapter 4: Orthopedics

Sarah Leeper

EVALUATION OF ORTHOPEDIC INJURIES

Definitions of Fractures and the Orthopaedic Trauma Association Classification System

  • Closed fractures: Break in the bone or cartilage with skin intact

  • Open fractures: Any fracture where there is a traumatic wound allowing the outside to communicate with the bone

    • High risk of infection

    • Treatment includes irrigation and debridement, prophylactic antibiotics with first-generation cephalosporin (add aminoglycoside if crush injury, contamination, or wound > 5 cm), tetanus prophylaxis, and emergent orthopedic consultation

image KEY FACT

All open fractures require emergent orthopedic consultation because of high risk of infection.

Components of the Orthopaedic Trauma Association (OTA) classification system of fractures (Figure 4.1):

  1. Bone: Describes the bone(s) that is/are involved, eg, radius.

  2. Segmental location: Anatomic location of a fracture in terms of bone segments: In adults, this is either proximal, diaphyseal (shaft), or distal. In children, the Salter-Harris classification (see Chapter 5, Pediatrics) describes fractures through the physis or growth plate.

  3. Type: Describes how many fragments are present (simple, wedge, or complex) and whether articular surfaces are involved (extra-articular, partial articular, or complete articular).

  4. Group: Describes the orientation of the fracture line, eg, transverse (perpendicular to long axis of the bone), oblique (oblique to long axis of the bone), or spiral (encircles the shaft in two different oblique directions).

    Torus (buckling injury without a break in the cortex), and greenstick (a bend in the bone on one side and a break in the cortex on the other) are terms applied to growing bones.

  5. Subgroup: Describes the relationship of fracture fragments to one another, eg, displacement (described in terms of the distal fragment relative to the proximal fragment), separation, shortening, angulation (described in terms of which direction the apex of the angle formed by the fracture fragments is pointing), and rotation.

Figure 4.1.

The AP view of the forearm shows a simple, transverse distal radial shaft fracture with approximately 90% displacement.

A radiograph of the hand reveals a radial fracture.
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Assessment of Neurovascular Structures

See Table 4.1 for common injuries and their associated neurovascular complications.

Table 4.1.Common Injuries and Associated Neurovascular Complications
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Table 4.1. Common Injuries and Associated Neurovascular Complications
TYPES OF FRACTURES OR DISLOCATIONS NEUROVASCULAR COMPLICATIONS CLINICAL SIGNS

Anterior shoulder dislocation

Axillary nerve injury

Axillary artery injury

Deltoid muscle paralysis—check by asking patient to abduct shoulder against resistance

Diminished pulse, expanding hematoma

Humeral shaft injury

Radial nerve injury

Loss of wrist extension, inability to give “thumb’s up”

Numbness of dorsal web space

Medial epicondylar fracture

Ulnar nerve injury

Inability to spread fingers against resistance

Numbness over dorsal and palmar surfaces of fourth/fifth digits

Supracondylar fracture/elbow dislocation

Brachial artery injury

Radial, ulnar, and median nerve injury

Diminished pulses at wrist, delayed cap refill or cyanosis of ...

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