Orthopaedics Tutorial

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Orthopaedics Tutorial
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Describing a Fracture

• Closed or Open/Compound
• Bone involved
• Side (LHS RHS)
• Position (proximal/middle/distal 1/3)
• Type (simple, comminuted oblique, spiral)
• IA Involvement
• Deformity (displacement, angulation, rotation)
• Grade or Classification
• Complications (vascular, neurological, tissue
  loss)

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A few buzz words

• Greenstick - incomplete of long bone with
  cortical disruption on 1 side deformity on the
  other
• Torus - specific type of greenstick in which
  the bone is compressed to form a ring (torus) of
  compressed injured bone but little angular
  deformity
• Impacted - broken ends of the bone are jammed
  together by the force of the injury
• Avulsion - fragment of bone tears away from the
  main mass of bone
• Pathological - in of diseased bone
  (osteoporosis/mets/osteomalacia)
• Fracture dislocation - severe injury in which
  both fracture and dislocation take place
  simultaneously
• Deformity
• Displacement distal fragment
• Angulation NOT tilt BE CAREFUL distal
  fragmentant/post med/lat
• Rotation distal partinternal or external
  rotation

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Bony Anatomy

• Hands
• 8 Carpals bones
• 5 Metacarpals (Name wrt fingers)
• 14 Phalanges
• Long Bones
• Shaft/Diaphysis epiphysis _at_ ends
• Separated by Epiphyseal Growth Plate
• Bone narrows at metaphysis
• Condyles

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Compound s

• Gustillo Classification
• I Wound clean lt 1cm
• II Wound gt 1cmno tissue loss/flap lacerations
• III a - Extensive tissue loss/flap laceration
• b - Bone exposure
• c - Vascular injury
• Mxt
• Life B4 LimbATLS Principles
• Analgesia (Reduce deformity splint)
• Wound Swab Irrigate with Sterile saline Cover
  with Iodine
• Backslab
• IV A/bs Tetanus

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Treatment of Fractures

• Primary Aims
• Bony Union without deformity ASAP
• Restoration of function ASAP
• Life before limb (ATLS Guidelines)
• ACBC
• Temporary splint
• Reposition fragment immediately if skin _at_ risk
• If open A/bs Tetanus
• Assess clinically radiologically
• In Short
• Analgesia Reduction (Open or Closed)
• Maintain reduction (External or Internal)
• Rehabilitation/Physio

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Fracture Reduction

• Why? - CosmesisFunctionPrevent complications
• Is reduction necessary ?
• NO IF
• Undisplaced
• Dsplacement likely to be corrected by remodelling
• Patient not fit for a haircut !!! - Very elderly
• YES IF
• Slight displacement in functionally vital area
  (articular surface)
• Significant displacement/angulation/rotation
  criteria vary for each
• Closed
• MUA Traction
• Open if
• If open
• If closed methods failed
• If considered the best way to treat ie. If
  internal fixation required

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Maintenance of Reduction

• External
• Plaster of Paris
• External Traction
• Femoral s Thomas splint
• External fixator
• Severe soft tissue damage/open/comminuted s
• Infected s
• Pelvic s
• Internal (screws/nails/plates/combination of
  latter)
• AI
• If closed reduction impossible (soft tissue
  interposition)
• If closed reduction maintenance not possible (
  NOF)
• If accuracy vital (articular surfaces)
• Multiple injuries
• RI
• Earlier mobilisation/hospital d/c desired

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Complications of Fractures

• Surgery Anaesthesia related
• CVS Resp
• Tissue Damage
• BleedinginfectionUE imbalance hypercatabolic
  response to trauma
• Prolonged Recumbency
• RespDVTmuscle wastingOPUTI
  ConstipationPressure sores
• Specific to s
• See next slide

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Complications

• Union Problems
• Sloweventually ? healing
• Delayedmay ? healing or ? non-union
• Non
• Mal ? healing BUT affects aesthetics or function
• Joint Stiffness
• Avascular necrosis
• scaphoid, femoral head, talus
• Sudecks atrophy/Complex regional pain syn/Reflex
  symp dystrophy
• Wrist, ankle, foot, knee
• Pain, swelling, discoloration, stiffness, abn
  skin moisture, tenderness
• PT/OT/Meds/Sympathectomy

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Complications

• Acute ischaemic limb
• Nerve damage
• Immediateuncommon usually neuropraxia seldom
  axonotmesis rarely neurotmesis
• DelayedCarpel Tunnel Syndrome
• Delayed tendon ruptureColles (EPL)
• Other
• Fat embolism
• Osteitis
• Myositis ossificans

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Scaphoid Fractures

• Scaphoid s are the most common carpal bone
  fracture and typically occur from a fall on the
  outstretched arm with the wrist in dorsiflexion
• Carefully scrutinize Xrays
• Scaphoid views4 required
• Look for concomitant scapho-lunate ligament
  injury
• Txt
• If clinical or radiological evidence of a
  fracturescaphoid POP review in 10 days
• If persistant symptoms negative X Ray ? bone
  scan/MRI
• Complications
• Non-union, avascular necrosis, OA

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Normal Wrist
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Scaphoid Cast
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Scapho-Lunate Dislocation
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Scaphoid Fracture
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Colles Fractures

• Definition distal radial within 1 of wrist
• Typical mechanism - Fall onto an outstretched
  hand
• Young 2o high-energy trauma while in older 2o
  low-energy trauma to osteoporosis
• 4 Features
• Radial Distal fragment
• Dorsal Radial displacement
• Dorsal Radial tilt (palmar ulnar angulation)
• Impaction
• Ulnar (if present)significant injury!
• Avulsion of the ulnar styloid

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Colles

• Post injury/ manipulation, pay close attention
  to neurovascular status beware of ACS
• Txt
• UndisplacedAnalgesia Backslab
• DisplacedReduce in AE or MUA
• Complications
• Anaesthetic
• General urinary retention/Resp TI/MI/CCF/DVT
• Specific
• Union problems
• CTS
• CRPS
• Delayed rupture Extensor pollicis longus

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Dinner Fork deformity
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Colles
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Colles
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Colles
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Hip Fractures

• Aet Fall OP in old dears
• Sites
• Intracapsular
• Subcapital
• Transcervical
• Basal
• Extracapsular
• Intertrochanteric
• Subtrochanteric
• Diagnosis
• Hx Inability to WB
• O/E Ext rotation, shortened, tender ant/lat
• XRay AP Lat

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Hip Fractures

• Intracapsular (avascular necrosis non-union)
• Disrupt blood supply from diaphysis ? risk AVN
  femural head
• Garden Classification
• IInferior cortex intactundisplaced
• II...Sup?Inf lineundisplaced
• III...Slight displacement
• IVGross displacement
• Txt
• Analgesia
• Bloods
• Medical Workup

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Hip Fractures

• Specific fracture mxt Age Displacement
• Extracapsular s
• Subcapital, Introchanteric basal cervival
  Closed reduction Dynamic Hip Screw (DHS)
• Subtroch - ORIF
• Intracapsular s
• Garden I/II
• Aged lt 55/60 ? ORIF (DHS)
• Aged gt 60 fit ORIF (DHS)
• If very old confined to bed/chair ?
  conservative mxt
• Garden III/IV
• If young fit ? ORIF but THR if ? risk
  complications
• If serior ? Arthroplasty
• Bipolar/Austin Moore/Thompson

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The Limping Child

• Diff Dx
• Cong or Acquired Causes (Vitamin D)
• Specific Hip Pathologies
• CDHPerthesSUFETS/HISINFECTION
• Hx
• 10 Qs re Painany traumaage of child recent
  flu/illnessother pains
• O/E
• TempGaitCompare both sidesfoot FB
  infectionrash.neuro exam both lower limb
• Tests
• ESR/CRP/FBC/Xray both hips US/S Hip

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Specific Hip Pathologies

• SUFE (adolescents
• Slip of epiphysis on metaphysisMgtFhormonal
  imbalance of trauma)Painful limb florid hip
  signsX Rays abnormal (Trethowans sign)60
  bilateral
• Txt refer ortho
• Perthes disease (3 10 yrs)
• Aseptic necrosis of the capital epiphysis MgtF
  PAINFUL limpnormal bloods but X Rays always
  abnormal
• Txt Refer ortho
• Transient Synovitis (All ages)
• Commonest Hx trauma/viral illnessLimp well
  ESR normalnormal X Ray US/S ? effusion.
• Txt Rest NSAID

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CDH/DDH

• Aet
• ½ hips dislocated _at_ birthFgtM breech
• Screening
• Older Child
• Gait/posture abnlimb shortening
• Neonate
• Twice in 1st 3 months (Ortholani Barlows
  tests)
• US if high risk (breech, FH, clicking hip,
  other abns)
• Mxt
• Hip Spica
• Osteotomy

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Salter Harris Classification