Supracondylar Fracture Humerus & Circulation

The neurovascular status must be examined in patients with supracondylar fractures. Avoid treating the patient with a cast that may cause hyperflexion of the elbow. Bending the elbow too much may affect the brachial artery. It may not be acceptable to reduce the fracture at 90° of elbow flexion. In these cases, choose a different alternative to casting, such as pinning (closed or open technique).

It is important to remember that Volkmann’s ischemic contracture may occur due to injury to the brachial artery. You have to make sure that you restore the circulation.

A few scenarios to go over

1.       The Patient has good circulation with no radial pulse (hand perfused)

a.    In this case, you would do a closed reduction and pinning as well as in-patient monitoring for 24-48 hours in order to assess the circulation of the extremity

2.       Cold Cyanotic Hand (no perfusion or you may have underperfusion)

a.       This may occur before or after attempting reduction

b.      The patient must immediately go to the operating room for closed or open reduction and pinning (No matter if the hand is underperfused or perfused at all)

c.       Monitor the circulation for anticipation of improvement

d.      If there is no immediate improvement, explore the antecubital fossa in order to explore the brachial artery

e.      Have the help of a vascular surgeon

f.        Assess the circulation

You want to think of this scenario like a knee dislocation. If you have pulses or no pulses with a knee dislocation, then you reduce the knee dislocation. It is the same with supracondylar fractures: pulses or no pulses, pink or not pink hand, cold cyanotic hand—do closed reduction and pinning. It is a more urgent condition if there are perfusion problems.

3.       Perfusion Disappears During Reduction or Monitoring

a.       If the perfusion gets worse after reduction of the fracture, then you need to find out what has happened.

b.      You will need to perform an open exploration and without an arteriogram

4.       Circulation Disappears After Closed Reduction and Pinning

a.       Reduction caused harm to the patient

b.      The pins need to be removed, the fracture needs to be unreduced and check the circulation.

c.       Check to make sure that the neurovascular bundle does not become trapped in the fracture gap after closed reduction and pinning. 

Orthopaedic Emergencies Part III

Open Fractures

Open fractures are categorized with the Gustilo-Anderson Classification. A Grade I Injury indicated a clean wound, less than one centimeter long with minimal injuries to the soft tissue and minimal bone comminution. A Grade II injury consists of a moderately contaminated wound greater than one centimeter long with moderate tissue injury and moderate bone comminution. A highly contaminated wound, usually greater than ten centimeters, segmental fractures, farm yard injuries, high velocity gunshot wounds and fractures occurring in a highly contaminated environment regardless of the size of the wound.

Grade III injuries are classified further into A, B, and C. Grade III A is a severe soft tissue injury with a crushing comminuted fracture; soft tissue coverage of bone possible. Grade IIIB consists of a very severe loss of soft tissue cover with poor bone coverage and variable—may be moderate to severe bone comminution. Grade IIIB usually requires a soft tissue reconstructive surgery in the form of local or distant flaps. Grade IIIC fractures consists of a vascular injury requiring repair or amputation. There is a very severe loss of soft tissue cover with moderate to severe bone comminution. Injury of the femoral artery from the posteriorly displaced proximal fragment of a Grade III C open supracondylar fracture of the femur. Grade III C has a high rate of amputation, nonunion and infection.

Hip Infection (Septic Arthritis)

An infection in the hip is a serious disease especially in children. The intraarticular structures will be inflamed and the increased intracapsular pressure will decrease the blood supply to the femoral head. Infection is associated with a high risk of avascular necrosis. The position of the limb in the stage of effusion, flexion, abduction, and external rotation. Complications are severe and much more common in children. Complications include: pathological dislocation, avascular necrosis, osteomyelitis, and pelvic abscesses. Urgent aspiration followed by drainage of the hip joint combined with intravenous antibiotics are the typical treatment for hip infections.  

Necrotizing Fasciitis

Necrotizing Fasciitis is an insidiously advancing soft tissue infection characterized by widespread tissue necrosis. The most common causative organism—group A beta—hemolytic streptococcus. There is a high mortality rate with sepsis and renal failure. Amputation and the mortality rate is increased due to a delay in diagnosis. Predisposing factors for necrotizing fasciitis include: trauma, surgery, as well we urogenital and anogenital infections. There are three types of necrotizing fasciitis: Type I—which is Polymicrobial, Type II—which is a Group A beta-hemolytic streptococcus, and Type III—which is gas gangrene-clostridial myonecrosis. Treatment consists of an immediate surgical debridement combined with intravenous antibiotics and hyperbaric oxygen if necessary.

Fracture with Soft Tissue Compromise

Soft tissue compromise associated with fracture blisters, ecchymosis, and severe bruising which indicate a greater degree of deep soft tissue damage. Blood filled fracture blisters are associated with high wound complications. Initial management involves application of a spanning external fixator with the fracture dislocation held in reduction with traction. The definitive management involves replacing the spanning external fixation with a hybrid fixator or plate once the soft tissue edema is resolved and the skin is wrinkled, usually in one to three weeks. Spanning external fixation can often be combined with percutaneous fixation of large articular fragments. A soft tissue compromise is more common with tibial plateau fractures and tibial pilon fractures with diaphyseal extension. A calcaneal avulsion fracture is considered an emergency. Urgent reduction and fixation is mandatory to avoid soft tissue complications. Type I—is a “sleeve” type tuberosity fracture. This pressure will create skin necrosis and significant soft tissue complication.

Stay tuned for Orthopaedic Emergencies Part IV!

Orthopaedic Emergencies Part II

Knee Dislocations

Dislocations at the knee occur as a result of a violent trauma. For example, a Posterior Dislocation—the dashboard injury, is the most common mechanism of injury which includes exaggerated hyperextension of the knee and dashboard (posteriorly directed force with the knee flexed at 90 degrees). Posterior dislocation is associated with a high incidence of popliteal artery injury. With an established popliteal artery injury and resultant ischemia, blood flow must be restored within 6 hours. Posterior tibialis and dorsalis pedis pulses should be carefully evaluated in any patient with a knee dislocation. Look for any evidence of ischemia, diminished blood flow, or compartment syndrome. Incidence of nerve injury range from 14 percent to 35 percent. Be cautious of spontaneously reduced knee dislocations and its associated pathology.

Urgent reduction of the knee dislocation is mandatory. Once the reduction is complete, it is important to reevaluate circulation. If the circulation is normal, serial follow-up up to 48 hours with clinical examination and non-invasive studies (ABI). If the circulation is abnormal, an arteriography should be performed. If no pulses are palpable, immediate exploration will need to be initiated. The arterial injury is treated, circulation restored, and prophylactic fasciotomy may be necessary.

Posterior Sternoclavicular Joint Dislocation

A Posterior Sternoclavicular Joint Dislocation typically results from either a direct force applied to the front of the medial clavicle or an indirect force applied to the posterolateral aspect of the shoulder. Posterior dislocation of the sternoclavicular joint could be missed. It is imperative to look for compression of the trachea, esophagus, or great vessels of the neck. A posterior dislocation is difficult to diagnose by x-ray so a CT scan is the preferred method for diagnosing the dislocation and any associated complications. An urgent reduction is mandatory in order to assure that a closed reduction is successful and stable. Open reduction may be performed if a closed reduction is unsuccessful. If an open reduction is decided, during the operation, a cardiac surgeon will be waiting standby.

Scapulothoracic Dissociation

Scapulothoracic Dissociation is a rare entity that consists of disruption of the scapula-thoracic articulation. It is a closed avulsion of the scapula with associated clavicular fracture or disruption of its articulations and severe soft tissue injury. This injury has been described as a closed, traumatic fore-quarter amputation. It is a traumatic lateral displacement of the scapula with intact skin. It is associated with upper extremity fractures such as fractures of the scapula, clavicle, and humerus. Most often, there are varying degrees of injury to the brachial plexus and the subclavian artery, resulting in a flail and pulseless upper extremity. An arteriogram should be performed to diagnose a vascular injury. A chest x-ray shows significant lateral displacement of the scapula; however, the injury can be missed!

First method of treatment consists of advanced trauma life support (airway breathing, circulation), followed by an arteriogram for evaluation of the vascular injury and repair of the arterial injury, if possible.

Fat Embolism

Fat embolism syndrome is a clinical diagnosis with non-specific or insensitive diagnostic tests. This occurs in trauma patients with multiple long bone fractures or pelvic fractures. Suspect fat embolism syndrome with the appropriate signs and underlying risk factors. The clinical signs usually develop within 24-72 hours of the injury. A fat embolism will develop earlier than a pulmonary embolism. Early stabilization of the fractures decreases the rate of incidence of this complication.

Major signs of a fat embolism include: confusion, agitation, petechial rash—axillae, conjunctivae, palate, and shortness of breath. Minor signs are listed as: tachycardia, fever, anemia, thrombocytopenia, and fat in the urine. For a diagnosis of a fat embolism, there must be one major sign and four minor signs, as mentioned above. Treatment of the fat embolism consists of diagnostic tests—however these are non-specific and insensitive, supportive treatment—such as intubation and oxygenation, and prevention (stabilization of long bone fractures).

Femoral Fracture in the Multiply Injured Patient

In a multiply injured patient, early skeletal stabilization of a femoral fracture within 24 hours results in decreased incidence of pulmonary complications and fat embolisms. The effect of reamed intramedullary nailing for femoral fractures on the incidence of pulmonary complications in a multiply injured patient or patients with concomitant chest injury is controversial. Multiple studies have shown that reamed intramedullary nailing for the acute stabilization of femoral fractures in the multiply injured patient with a thoracic injury did not increase the occurrence of pulmonary complications. External fixation is indicated for early stabilization of femoral fractures in severely injured patients as a form of damage control in orthopedics and as a temporary bridge to femoral nailing. External fixation is also indicated in the presence of an associated vascular injury requiring stabilization before repair and in the presence of severe soft tissue injuries with extensive contamination.

Hip fractures in an elderly patient

Nonoperative treatment in elderly patients with hip fractures results a high complication rate including pneumonia, thromboembolism, urinary tract infection, and decubitus ulcers, resulting in a high mortality rate.

The mortality rate is 25% in the first year following the fracture. Early surgery within 48 hours of an injury has been shown to be associated with a decreased one-year mortality rate. 

Complications in Hip Fractures

Dislocations occur more in total hip arthroplasty than in hemiarthroplasty. Too much retroversion causes posterior dislocation. Total hip arthroplasty is done is physiologically active elderly patients with a displaced femoral neck fracture. Although it may increase the risk of dislocation, there is a lower revision rate and a superior long term future outcome.

Failure of fixation

Quality and maintenance of reduction of the fracture is important. Closed reduction can be attempted, however the reduction must be anatomic. If it is not anatomic reduction, then open reduction should be done. Open reduction can be done through an anterior approach or a Watson-Jones approach. When the fixation fails, you can attempt to repeat ORIF or you may do prosthetic replacement. It is important to note that in elderly patients, treatment of displaced femoral neck fractures with screws may have failures and revision rates of up to 40%.

Fracture Distal to the Fixation

This is probably due to screw placement at or below the lesser trochanter and poor bone quality, especially if you start anteriorly and not laterally. It is also possible that this may be due to the poor angle of the screw fixation and multiple attempts at drilling or guide pins. Treatment typically consists of a refixation of the femoral neck and the subtrochanteric fracture.

Nonunion of the fracture

Femoral neck fractures are considered to be intracapsular fractures which are at a high risk of developing a nonunion. The femoral neck fracture is surrounded by synovial fluid and there is no extraosseous blood supply, no periosteum, or callus formation. The fracture healing occurs by intraosseous bone healing alone. It can present itself as groin or buttock pain, pain with hip extension, or with weight bearing. It can occur in about 5% of nondisplaced fractures and about 25% of displaced fractures. If it occurs in an elderly patient, an arthroplasty must be done. If it occurs in a young patient, a valgus intertrochanteric osteotomy. A vascularized fibular graft may benefit the patient as well. Nonunion fractures occur more in the vertically oriented fracture pattern with loss of reduction and varus collapse. In younger patients, we may possibly reorient the fracture line to be more horizontal by doing the osteotomy. Usually, the nonunion is apparent by about twelve month; however, there may be trouble in seeing the nonunion due to the fact that there is no periosteum and no callus in the femoral neck.

Medical Complications

There is an increased risk of DVT of up to 80%. Some form of prophylaxis is indicated, both mechanical and pharmacological for the patient. It is imperative to consult the medical team for co-management. The aim of treatment is early immobilization of the patient with pulmonary toilet. There is a high mortality rate in the elderly—approximately 30% in one year. A surgical delay of more than 72 hours will increase the risk of one year mortality. After completion of the treatment, treating the osteoporosis is needed to decrease the incidence of other fragile fractures.

Osteonecrosis (AVN)

The patient will have groin, buttock, or proximal thigh pain. It occurs in 10% of nondisplaced fractures and in 30% of displaced fractures. AVN could occur due to interruption of terminal branch of the medial femoral circumflex artery by the fracture. The medial femoral circumflex artery is the predominant blood supply to the femoral head. Usually, AVN is diagnosed by an MRI or it can be obviously on the x-ray. Not all cases of AVN develop evidence of radiographic collapse. AVN can be clinically significant when it is followed by late segmental collapse.

Late segmental collapse can be seen as early as 6-9 months following the fracture, but it is usually recognized by the second year. Segmental collapse can be excluded if it does not occur by the third year. AVN may occur due to an increase in the initial displacement, increase in the time to reduction, or nonanatomic reduction. Treatment for AVN in younger patients with less than 50% femoral head involvement may qualify for a valgus intertrochanteric osteotomy. A free vascularized fibular graft or a total hip replacement may be considered if the involvement of the femoral head is more than 50%. In an elderly patient, a total hip arthroplasty will probably be necessary.

Penetration of the screws into the hip joint.

Another possible complication is the penetration of the screws into the hip joint. The screws should be placed within 5mm of the articular cartilage. You can use multiple fluoroscopy images to confirm that there is no penetration. The screws must be parallel so that it can allow the fracture to be compressed. Make sure the threads of the screws cross the fracture site, otherwise the threads will distract the fracture. You may use long threads or short threads based on the situation.

Shortening

Femoral neck shortening after fracture fixation with multiple cancellous screws can be a problem. The healed femoral neck fracture with shortening is usually associated with a poor functional outcome. 

Lesions of the Shoulder—Everything You Need to Know (PASTA)

PASTA Lesions

The acronym “PASTA”, stands for: Partial- The tear has not gone all the way through the tendon; Articular surface- the inner-side of the tendon (not the bursal side); Supraspinatus Tendon- tear on the underside of the rotator cuff tendon; Avulsion- usually a traumatic injury which is caused by a pulling force.

PASTA lesions are difficult to diagnose but, an arthrogram may help in the diagnosis. The tear can be seen on an ultrasound or an MRI. The MRI arthrogram is done in the ABER position (abduction/external rotation) and is more accurate in showing this lesion; the arm will be above the head in the scanner.

A normal rotator cuff is about 10-12 mm in thickness. If exposed bone between the rotator cuff and the articular margin is more than 7mm, then there is an at least 50% thickness tear—this is a classic indication for surgery. When the lesion is less than 50% and painful, you can debride it. If the lesion is more than 50% and painful, you can repair it. A physician may complete a tear to become a full thickness tear, in order to repair it.

Rotator tears can be full thickness or partial thickness tears. The partial can be a partial articular-sided supraspinatus tendon avulsion (PASTA) which is an articular tear—the most common type. Another type of PASTA tear—the Bursal Tear—also referred to as a reverse pasta lesion or, it could be a Concealed Interstitial Delamination (CID) or an inter substance tear.

PASTA tears may be associated with internal impingement, which is different than external impingement. In the external impingement there is a subacromial impingement (bursal pathology). In internal impingement, the pathology is on the under surface of the cuff, so PASTA tears may be associated with the internal impingement. 

Gout, Arthritis and Joint Pain

The most common joint affected by gout is the 1^st metatarsophalangeal joint. The most common joint affected by pesudogout is the knee joint (Figure 1). Gout and pseudogout are similar problems with different causes.

Gout is caused by the buildup of uric acid and the deposit of uric acid crystals inside a joint. The best test to diagnose gout is with a joint fluid analysis. Elevated uric acid is not a good criteria. 90% of patients suffering from gout are men between the ages of 40-60 years. Gout crystals are needle shaped and negatively birefringent. When placed under polarized light they will be yellow (Figure 2).

Uric acid builds up the body by two main mechanisms. These two mechanisms are excessive urate production and diminished urate clearance. Uric acid is produced from the breakdown of proteins inside the body and from the proteins of food that is eaten.

Precipitating Factors:

The sudden attack of gout can be brought on by anything that increases the level of uric acid in the blood such as dehydration, increased consumption of alcohol, eating large amount of meat or seafood, and trauma/surgery.

Diagnostic Testing:

Aspiration and analysis of the joint fluid is the best method for diagnosis (Figure 3). There are blood tests such as white blood cell count, C-reactive protein, erythrocyte sedimentation rate, and uric acid level that are helpful in supporting the diagnosis if elevated, but if normal, it cannot definitively rule out gout or pseudogout.

Pesudogout or chondrocalcinosis is the deposition of calcium pyrophosphate dehydrate crystals in the hyaline cartilage or fibrocartilage (CPPD). Pseudogout is a metabolic disease where calcium pyrophosphate dehydrate crystals (CPPD) are formed within the joint space. It most often affects the knee and occurs more in older patients. It is a calcification of fibrocartilage (chondrocalcinosis). Pseudogout crystals are rhomboid shaped and positively birefringent. Crystals will be blue when placed under polarized light (Figure 4). Associated conditions are hyperparathyroidism, rheumatoid arthritis and gout.

Gout and pseudogout both show a sudden onset of pain, redness and swelling typically affecting a single joint in 80% of the cases. Gout symptoms include joint pain, swelling and arthritis. Patients with gout have periarticular erosions along with the formation of uric acid soft tissue masses in and around the joint which can be seen on x-ray. Soft tissue tophus deposition with periarticular erosions called “punch-out” lesions (Figure 5).

X-rays in pseudogout will show this calcification in the articular cartilage or menisci, with involvement of the patellofemoral joint (Figure 6). Calcifications of the synovium, tendon, and ligaments can also be seen.

Treatment of Gout and Pseudogout:

Acute gout can be treated with indocine and colchicine (be aware of peptic ulcer). In cases of chronic gout the patient will be treated with allopurinol (xanthine oxidase inhibitor) and colchicine. Uricosuric drugs such as Probenecid may increase uric acid excretion by the kidneys may be helpful. Pseudogout is treated with NSAIDs and intra-articular injections.

Precious Blood Supply of Bones

There are five major bones with previous blood supply. Fractures in these bones can interrupt this peculiar blood supply, causing a threat of death of the bone and nonunion of the fracture. Fractures in these areas usually occur as a result of trauma or stress related injuries.

These areas are the proximal humerus, scaphoid, proximal femur, talus, and fifth metatarsal. Interruption of the blood supply causes death of the bone and nonunion.

 

There are three types of fractures at the fifth metatarsal; avulsion fracture, Jones fracture, and mid-shaft fractures. The avulsion and mid-shaft fractures have good healing due to a sufficient blood supply. The Jones fracture compromises the blood supply which leads to nonunion of the fracture. Treatment can be achieved by non-weight bearing immobilization or may require intramedullary screw fixation in athletes and active individuals.