16“Look, Feel, Move”Pain, tendernessSwelling… bruisingLoss of functionCrepitusSigns of blood lossInjury to other structures
17History Examination X-ray Isotope Bone Scan Specialised Imaging C.T. M.R.I.
18Two planes Two joints Two occasions Two limbs Two opinions
19Two planes Two joints Two occasions Two limbs Two opinions AP and Lateral+/- special views e.g. scaphoidTwo planes Two joints Two occasions Two limbs Two opinions
20Two planes Two joints Two occasions Two limbs Two opinions Joint above and below for shaft fracturesTwo planes Two joints Two occasions Two limbs Two opinions
21Two planes Two joints Two occasions Two limbs Two opinions Repeat X-rays after an interval may show a fracturee.g. scaphoid, hip
22Two planes Two joints Two occasions Two limbs Two opinions Comparative views of opposite limb e.g. elbow injuries in children
23Two planes Two joints Two occasions Two limbs Two opinions Ask a radiologist or senior colleague!
24haematomainflammatory exudatenew blood vessels (2-3 days)bone forming cellsbridge of callus (cartilage, bone, fibrous tissue)framework for bridging the gapreplaced by woven boneremodelling along lines of stress
25callus is the response to movement at fracture site callus does not develop if the fracture is rigidly fixed with no movement: primary bone healing
26Depends on many factors agebonetype of fractureinfectionnutritionstimulation
27Full assessment Reduction Immobilisation Maintenance of reduction Rehabilitation
28restoring “normal” anatomy not always necessary open/closed anaesthesialocal/regional/general
32Open Fractures problem: infection prophylactic antibiotics appropriate to the injuryanti-tetanus coverirrigation“the solution to pollution is dilution”debridement: remove all dead tissueskin cover
33non-union/delayed union multiple fracturespathological fracturesfractures likely to slipintra-articular fracturesnursing difficulties
34Initial TreatmentInitial treatment – splinting and analgesia. Compound injuries – Antibiotic cover (usually cephalosporin +/- aminoglycoside if contaminated). -Tetanus cover.
35Further TreatmentCompound injuries must be debrided ASAP, should be within 6 hours.Bone should be covered with tissue to prevent dessication.Delayed primary closure of the wound, or “second look” procedure.
36TreatmentAims – obtain union, maintain relative positions of knee and ankle joints.Treatment options include:Conservative.Open Reduction and Internal Fixation.Intra medullary nailing.External fixation.
37Conservative Treatment Casting may be considered if:Isolated tibial fracture (fibula not involved).>50% cortical overlap at # site. Closed reduction of displaced #’s and casting leads to significant incidence of non-union.Less than 2cm initial shortening.
38ORIFUsually used for intra–articular #’s involving knee or ankle rather than shaft #’s.Periosteal stripping required.Fracture site must be opened.May be useful in Rx of non-union +/- bone grafting.
40NailingProbably preferred Rx of closed displaced tibial shaft fractures.Union rates of near 100% for closed injuries.Fracture site not opened during the procedure, reduced chance of infection.More difficult in proximal shaft fractures.
42External Fixation Minimal soft tissue trauma. Little foreign material in body, may be preferred in compound fractures.Comminuted injuries.Uniplanar, circular or combination of both (hybrid) fixators.
45Complications Compartment syndrome. Pressure in muscular compartments rises above capillary pressure, ischaemia of tissues in affected compartment.Patients complain of pain unrelieved by splinting and analgesia.
46Compartment SyndromePain on passive stretching is classic physical sign.Normal distal pulses and neurology DO NOT exclude compartment syndrome.Incidence NOT reduced in compound fractures (up to 9%).? May complicate nailing of fracture.
53Fractured Neck of Femur Subcapital Femoral Fracture.Over 100,000/year in the UK
54Key Points Common in osteoporotic bone. Majority of blood supply to head comes from the neck.Elderly.Almost 90% occur in >65 years.Almost 75% occur in females.
55Hip Joint - AnatomyThe fibres are reflected back along the neck of the femur to the articular margin of the femoral head.The reflected part constitutes the retinacular fibres, which bind down the nutrient arteries from the trochanteric anastomosis, along the neck to supply the head.
56About the blood supplyThe head and intracapsular part of the neck receive blood from the trochanteric anastomosis.Formed by descending superior gluteal artery with ascending branches of the medial and lateral circumflex femoral arteries.Branches pass along the femoral neck with the retinacular fibres of the capsule.
64Complications Avascular necrosis of femoral head Blood supply lost through thrombosis or interrossoeus hypertension.Marrow of head is replaced by fat, bone dies.Zone of revascularisation, incomplete if large avascular area.Zone of reossification – joint may collapse.May -> secondary arthritis.
65Complications Avascular necrosis of femoral head X-rays – may appear normal.Radioisotope – dead area of femoral head surrounded by hyperaemic area of revascularisation.MRI – one or more avascular areas.
66Initial Management ATLS principals of resuscitation Co-morbidity Work-up for theatreRelevant Radiology - DiagnosisDecide surgical/anaesthetic managementInformed ConsentProphylactic AntibioticsAnticoagulationEarly MobilizationDischarge arrangements
67Surgical Treatment Age and displacement Co-Morbidity Undisplaced (Garden 1 & 2):1. Cannulated Hip Screws.2. DHS.3. Hemi-ArthroplastyDisplaced (Garden 3 & 4):1. Hemi-Arthroplasty.2. Total Hip Replacement occasionally if pre-existing OA.
68Garden 1 - Treatment AO Screws to hold femoral head in position Indications for Closed Reduction and Fixation:Physiologically young patient: age < 65, working patient, good bone stock;Demented elderly patient that requires total care;Adequate closed reduction with no comminution or femoral neck defects;Patient should be aware that with an inadequate closed reduction, then an open reduction or hemiarthroplasty will be required
69Garden 2-3 Older patients – Hemiarthroplasty Especially in Life Expectancy<5 yearsOne definitive operation.Fractures may progressively displace.
70DHS - Richards Undisplaced Garden 1+2 – no vascular disruption Lateral ApproachX-ray controlFirst part is a heavy plate fixed to lateral cortex of femur with cortical screws.Second part is a rod which passes into the femoral head.The threaded end crosses the fracture line to engage and hold the fracture line.As the patient weight bears on the healing fracture the broken ends of the bone collapse into each other and compress the fracture.The sliding-rod mechanism allows this to happen without the hip falling into varus.
71Complications Avascular Necrosis Non-Union General DVT/PE Infection UlcersAnaemia
72Garden 4 Femoral Head survival unlikely. Under fifty – reduce and pin immediately.Older: <65 THR>65 Hemiarthroplasty
73Treatment – Hemiarthroplasty Austin Talley Moore, MDSouth CarolinaIn September 1940, Austin Tally Moore and Harold Ray Bohlman, replaced the proximal 12 inches of a femur destroyed by a recurrent giant cell tumor with a custom-made prosthesis, Dr. Moore was encouraged to develop a new femoral head with a short stem for intramedullary fixation, and, the now legendary Austin Moore Hip was introduced in 1950.CementedFrederick Roeck Thompson, MDTexasSon of the renowned reconstructive surgeon Dr. James E. Thompson of the University of Texas Medical Branch, Frederick R. Thompson, MD, designed - one of the first metal hips for use in hip fractures and salvage arthroplasties. The first F.R. Thompson Hip was implanted in January 1951, and is still in worldwide use today.Uncemented
74Indications – AMP/Thompson Poor general health that would prevent a second operation;pathologic hip fracturesParkinson's disease, hemiplegia, or other neurological disease;Physiologic age > 70 yrs;Severe osteoporosis without loss of primary trabeclae in femoral headInadequate closed reduction;Displaced fracture which is several days old;Pre-existing hip disease (DJD, RA, AVN);Contraindications:Pre-existing sepsisYoung patientFailure of internal fixation devices;Pre-existing disease of the acetabulum;Even without normal preoperative cartilagenous space, many patients will become symptomatic at 5 years due to metal induced degradation;
76ComplicationsMortality - mortality after hemiarthroplasty is 10 to 40%Fracture of the Femur: 4.5%almost all fractures occur when surgeon attempts to reduce prosthesis;most are non displaced and involve either greater trochanter or neck;with femoral shaft fracture consider methy methacrylate combined with a long stem prosthesis;Post-op: sepsis: 2% to 20%more common w/ posterior surgical approach;infections may be superficial or deepLoosening and migrationpresence of a radiolucent zone around the prosthesis;if clinical signs and symptoms are present and loosening or migration is present, then consider revision to THR;erosion tends to occur in active pts with cemented Thompson hemiarthroplasty;
77Complications Dislocation less than 10%. more common with too much anteversion or retroversion, posterior capuslectomy, & excessive postoperative flexion or rotation with hip adducted
78OutcomeMobility:41% of elderly walk as well as pre-injury (Koval, Clin Orthop 1995).Mortality:3% to 27% in first 3 months.15-30% die within 1 year of fracture.
79Treatment of extra-capsular hip fractures. The goal of operative treatment isStrong ,stable fixation of the fracture fragments.
80Treatment of extra-capsular hip fractures. Dynamic Hip Screw:Shorter plate (e.g2-hole) can be used for some undisplaced intra- capsular #s.Varying angles to suit angle at femoral neck.Sliding compression screw device allows collapse into position of stability.
81Treatment of extra-capsular hip fractures. Dynamic Condylar Screw (95 °):Used in (paticularly) sub-troch #s.In certain inter-trochanteric #s.
83Complications Other Complications: Pressure sores. Nerve palsies. Prosthesis Dislocation.Failure to mobilise & death.
84Outcome Mobility: 41% of elderly walk as well as pre-injury (Koval, Clin Orthop 1995).Mortality: 3% to 27% in first 3 months.15-20% die within 1 year of fracture.Mortality risk over age-matched controls for up to 1 year post injury.Inter-trochanteric #s associated with greater morbidity & mortality.
86Important Exam Topics - Clinical Examination Hip :Thomas test for fixed flexion deformity
87Important Exam Topics - Clinical Examination Hip :Trendelenburg test
88OsteoarthritisMay be Primary due to intrnsic defect (mechanical,immune, vascular, cartilage)Secondary - trauma, infection, congenital disorders.Get loss of the bearing surface, followed by development of osteophytes and breakdown of the osteochondral junction
89Radiographic Features Subchondral cysts ( from microfractures)Osteophyte formationJoint space narrowingSclerotic bone formation
90Degenerative Changes in the Hip Subchondral cystsJoint space narrowingSclerosis
91Indications for Surgery- Joint Replacement Pain is the main + best indicationDegenerative joint disease – OA 1o or 2oRheumatoid ArthritisIntractable painStiffnessDeteriorating function