Orthopedics focuses on the musculoskeletal system. Learn about the diagnosis, treatment, and rehabilitation of bone, joint, ligament, and muscle conditions.
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The diagnostic phase in orthopedic traumatology is a rapid, structured process designed to identify all injuries, plan the reconstruction, and prevent missed diagnoses. In high energy trauma, the evaluation follows the Advanced Trauma Life Support (ATLS) protocols, prioritizing life over limb. Once survival is assured, the focus shifts to the meticulous assessment of the musculoskeletal system.
Modern imaging technology allows surgeons to visualize fractures in three dimensions, creating a digital map of the damage. This diagnostic precision is the foundation of successful surgical planning.
In the trauma bay, the Primary Survey focuses on the ABCDEs (Airway, Breathing, Circulation, Disability, Exposure). Orthopedic surgeons assist in controlling hemorrhage from pelvic fractures or open wounds during this phase.
The Secondary Survey is a head to toe examination performed once the patient is stable. This is where the orthopedist palpates every limb and joint to detect swollen, deformed, or tender areas that indicate a fracture. This thorough exam prevents “missed injuries” in unconscious patients.
Before any X-ray is taken, the status of the nerves and blood vessels must be documented. A fracture that cuts off blood supply is a “vascular emergency” requiring immediate realignment.
The surgeon checks pulses (radial, dorsalis pedis) and capillary refill. Motor and sensory function are tested to see if nerves like the radial nerve (humerus fracture) or the peroneal nerve (knee dislocation) are working.
Plain X rays are the workhorse of trauma diagnosis. The “Rule of Twos” applies: Two views (AP and Lateral), two joints (imagine the joint above and below the fracture), two limbs (compare to the normal side in children), and two occasions (repeat X-rays over time).
X-rays show the bone alignment and the type of fracture. They are fast, cheap, and available in every trauma bay. However, they are 2D representations of 3D structures and can miss subtle fractures.
CT scans have revolutionized trauma care. They use X-rays to create cross sectional slices of the body. In trauma, CT is routine for the spine, pelvis, and complex intra articular fractures (like the knee or ankle).
CT scans reveal the fine details of the joint surface, showing exactly how many pieces there are and how much the cartilage is depressed. This information is critical for surgical planning.
Modern CT software can take the slice data and build a rotating 3D model of the fractured bone. Surgeons can remove the hip or spine to see the fracture in isolation.
This digital model allows for “virtual surgery.” The surgeon can place digital screws and plates on the screen to see what size fits best. This “templating” reduces trial and error in the operating room.
MRI is less common in acute trauma, but it is vital for specific questions. It excels at seeing soft tissues. It is used to diagnose ligament tears (like ACL) associated with knee fractures or to check the spinal cord in vertebral fractures.
MRI is also the gold standard for diagnosing “occult” fractures—hip fractures in the elderly that are painful but show up normal on X-rays and CT scans due to lack of displacement.
When pulses are absent or a knee is dislocated, blood vessel injury is suspected. CT Angiography (CTA) involves injecting dye into the veins and doing a CT scan. It creates a map of the arteries.
CTA can show if an artery is torn, kinked, or clotted. If a vessel injury is found, vascular surgeons are called immediately. This is a limb saving diagnostic tool.
Compartment syndrome is a clinical diagnosis, but in unconscious patients, objective data is needed. A needle connected to a pressure monitor is inserted into the muscle belly.
Normal pressure is near zero. Pressures rising within 30 mmHg of the patient’s diastolic blood pressure indicate compartment syndrome. This objective number supports the decision to perform a fasciotomy.
In patients with delayed healing or previous open fractures, infection is a constant concern. Diagnosing bone infection (osteomyelitis) involves blood tests like ESR and CRP, which measure inflammation.
If these are elevated, the surgeon may aspirate fluid from the fracture site or use nuclear medicine scans (WBC scan) to locate the infection. Diagnosing infection early is key to saving the hardware.
Sometimes a bone isn’t broken, but the ligaments are torn, causing instability. Stress X rays involve taking a picture while the doctor physically pushes or pulls on the joint (e.g., pulling the ankle sideways).
If the joint opens up significantly more than the healthy side, it proves ligamentous incompetence. This is crucial for diagnosing syndesmotic ankle injuries and elbow instability.
Diagnosis continues in the operating room. The C arm is a portable X-ray movie machine. It allows the surgeon to see the bone in real time while manipulating it.
Surgeons use fluoroscopy to guide the reduction of the fracture and to ensure the screws are not too long. It is the GPS of the operating room, confirming that the reconstruction matches the plan.
Real time X ray imaging in the OR
Guidance for reduction and hardware placement
Verification of joint surface restoration
Contrast studies for joint congruity
In elderly trauma patients, diagnosing the underlying cause is part of the workup. A DEXA scan measures bone density to diagnose osteoporosis.
Identifying poor bone quality alerts the surgeon that they need to use specialized locking screws or cement augmentation to prevent the hardware from pulling out of the soft bone.
Nerves can be stretched or compressed during trauma. After the acute phase, if a patient still has weakness (e.g., foot drop), EMG/NCS tests are used to check the electrical function of the nerve.
This test determines if the nerve is cut (neurotmesis) or just bruised (neurapraxia). It helps predict if the nerve will recover on its own or if nerve graft surgery is needed.
Ultrasound is gaining popularity for rapid bedside diagnosis. It can detect fluid in the abdomen (FAST exam) and can also diagnose tendon ruptures (like the Achilles) or locate non radiopaque foreign bodies (like wood or glass).
It provides authentic time images without radiation and allows the doctor to check blood flow using Doppler.
In patients with multiple fractures or bones that won’t heal, metabolic testing is performed. Levels of Calcium, Vitamin D, and Parathyroid Hormone are checked.
Genetic testing may be done for conditions like Osteogenesis Imperfecta (brittle bone disease). Treating the metabolic deficiency is essential for getting the fracture to unite.
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A standard CT looks like slices of bread. A reconstruction takes those slices and stacks them digitally to create a 3D model of your bone. The surgeon can rotate this model on the screen to see the fracture from every angle, helping them choose the right plate and screw.
The doctors are checking your sensation and circulation. Swelling from a broken leg can compress the nerves and blood vessels. By poking your foot and checking your pulse, they are making sure your foot is still alive and getting enough blood.
Not necessarily. CT is the king for looking at bone detail and fracture lines. MRI is better for soft things like ligaments, disks, and spinal cords. For a shattered bone, the CT is usually the preferred test.
This diagnosis means the bone broke not because of a brutal hit, but because the bone itself was weak. This could be from osteoporosis, a cyst, or a tumor. The doctor will need to treat the underlying bone disease in addition to fixing the break.
Blood work checks for signs of infection, anemia (blood loss), and your blood’s ability to clot. It also helps the anesthesiologist make sure your kidneys and liver are healthy enough to handle the anesthesia medications during surgery.
Nearly 50 million Americans have surgery each year. They wonder if they should rest or move to recover better. The choice greatly affects their healing
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