Presentation on theme: "Dr John Trantalis Orthopaedic Emergencies Care of the Injured Limb Hip fractures in the elderly."— Presentation transcript:
1 Dr John TrantalisOrthopaedic Emergencies Care of the Injured Limb Hip fractures in the elderly
2 How To Examine a Joint Look Feel Move Scars, alignment, wasting, redness, swellingFeelTenderness (Location!!!!!)MoveActive movementPassive movement
3 Passive vs Active Motion Patient moves the joint on their ownFor active motion to be intact:The joint must be mobile.The “motor” must be workingPASSIVE MOTIONThe examiner moves the joint for the patientFor passive motion to be intactThe joint must be mobileThe “motor” does not need to be working.“Motor”= tendon, muscle, nerve, plexus, roots,spinal cord, brain
4 PASSIVE vs ACTIVE motion Loss of active MotionPreserved Passive MotionJoint OKMotor is brokenLoss of both Active and Passive MotionJoint Stiffness
17 Why are the Pulses normal and the Fingers Pink? Ischaemia to musclesCapillaries 5mmHg- shut down with small rise in compartment pressueRadial ArteryPressure of 120/80mmHg.Therefore it stays open and hand stays pink
18 Therefore….Only need one thing to diagnose compartment syndrome…..PAIN
19 How can we differentiate normal fracture pain from Compartment Syndrome? Active Finger (or Toe) MovementNo compartment syndrome
20 What to do if you suspect Compartment Syndrome…. CALL FOR HELP!!!!!!!!!!!!Speak to the orthopaedic team urgentlyDo not leave messagesYou must speak to somebody urgentlyThen…Remove all encircling bandages…A tight bandage or plaster can cause compartment syndromeBut it can also occur without anything wrapped around the limb… skin & fascia
21 How Do We Surgically Treat Compartment Syndrome Urgent Fasciotomy (less than 6 hours)Allows muscles to bulge out of wound and blood supply to return.If you miss the diagnosis AMPUTATION
22 Clinical case 56 yo male, 24 hour h/o right knee pain Exam: temp 37.0C No traumaCan’t walkOtherwise wellExam: temp 37.0CSwollen Knee (patella tap)No rednessMarkedly reduced ROM active and passive
24 Key Clinical Sign for Septic Arthritis in any Joint Decreased active and passive motionThe joint is very inflamed and painful.Patient’s muscles spasm when movement is attempted.
25 The Work-Up Bloods: ECG, MSU, fast NBM XRAY Joint Aspirate FBC, EUC, CRP, ESR, UA, CulturesECG, MSU, fast NBMXRAYUsually normalJoint Aspirate
26 Inflammatory Markers CRP ESR C Reactive Protein Very Sensitive for inflammation or infectionIndicative of what was happening in the body 1 day agoESRErythrocyte Sedimentation RateIndicative of what was happening in the body 3 days ago.
27 Joint Aspirate Before any antibiotics are given. Never through red skin (can introduce skin infection into the joint)Send off for MCS, crystals, cell count.
28 Septic Arthritis: Treatment Joint Washout (arthroscopic)Removes the enzymes from white cells which otherwise destroy the articular cartilageIV antibioticsEmpirical: cover Staph Aureus
35 Hip AnatomyAcetabulumFemoral headNeck of femurTrochanters
36 2 common types of Hip Fractures Subcapital fractureIntertrochanteric or Pertrochanteric fracturesWe Treat these differently
37 Why treat these fractures differently? Blood Supply to the head of femurDisrupted with a Displaced Subcapital FractureIntact with a displaced trochanteric fracture
38 Hip Joint Capsule The blood vessels run up through the capsule Hence the terms:Intracapsular # (subcapital)Extracapsular #(trochanteric)
39 What are the aims of Surgical Treatment Relieve PainEvery time patient moves in bed- painRegain MobilityPatient should be able to Fully weight bear after surgeryImprove Quality of LifeBefore the 1970’s3 months Traction for everybody50% mortalityPneumonia, pressure sores etc
40 The Surgery Relieves Pain Patient with # NOF in bed…The fracture ends grind and cause pain with every movementEven with very ill patients, we still try to complete their surgery asap to relieve their pain and improve their quality of life (nursing etc)The faster the patient gets to surgery the less chance of pneumonia / pressure sores developing.
41 Subcapital Fractures: 2 types Non-DisplacedScrewsDisplacedHip replacementHalf (hemiarthroplasty)Total Hip Replacement
42 Non Displaced Subcapital Fractures Blood supply not likely to be affectedFix with screws and hope that it heals
43 Displaced Subcapital Fracture HemiarthroplastyBlood supply is disrupted to femoral head# won’t healAvascular Necrosis likelyTherefore: replace the headHalf replacement (hemiarthroplasty)Total Hip Replacement for the more mobile patientsTotal Hip Replacement
44 Intertrochanteric Fractures Internally Fixed to allow early weight bearingPlateNailDynamic Hip Screw (DHS)Short femoral NailIntertroch #
45 Post-Op Care NV Obs Analgesia DVT prophylaxis Bloods Mobilise FWB Pressure area care
46 Dr John Trantalis Orthopaedic Surgeon The injured LimbDr John TrantalisOrthopaedic Surgeon
47 Dislocated Joints Should all be reduced ASAP Pain XRAY 2 views always Pressure off NV structuresPain XRAY 2 views alwaysCT if you are unsureBeware LOCTrauma, Head injury Secondary surveyYou will detect decreased ROMSeizures, electrocution
57 Principles of fractures and joint injuries Questions to ask…Open or closed?Which bone?Location in bone?Pattern of FractureJoint involvement?Displaced or non-displaced?Type of displacement?
58 Principles of fractures and joint injuries How fractures are displaced
59 Principles of fractures and joint injuries Direct healing - If fracture absolutely immobile, eg. Fixed with metal fracture healing occurs directly between fragments.
60 Principles of fractures and joint injuries How Long Does It Take To for a Fracture to Heal?Depends on……Patient Factors: Age, Comorbidities etcFracture Factors: which bone, type of fracture etcCan take up to 6 months for a tibia versus 2 weeks for a phalanx.Healing seen on XRAY always takes longer than clinical union
61 Clinical signs of fracture Union No tenderness, movement or crepitus at a fracture site.
68 Clinical Features Xrays Remember the rule of 2’s!!! 2 views – a fracture or dislocation may not be evident on a single film, at least 2 views mandatory – usually AP and lateral2 joints – joints above and below the fracture, eg. Monteggia/Galeazzi #’s2 limbs – in children, appearance of immature physis may confuse diagnosis of fracture2 injuries – severe force often causes trauma at more than one level, eg. Calcaneal or femur #, important to xray pelvis and spine.2 occasions – some lesions notoriously difficult to detect immediately after injury, eg. Scaphoid #
69 Beware Ipsilateral injuries For any # or dislocation- always image to joint above and below
70 Clinical Features Special Imaging Can’t see a # on XRAY but suspiscious eg scaphoidMRI, CT, or bone scan.CT scans useful in complex or intra-articular fractures (eg. Calcaneal, Tibial plateau)
72 Treatment of Closed Fractures ReductionPutting the bone into an acceptable positionTwo methods – open or closed
73 Treatment of closed fractures Closed reductionSedation / AnaesthesiaPull the limb into alignmentSplint the limb
74 Treatment of closed fractures Closed reductionIn general, closed reduction is used for…For most fractures in childrenFor fractures that are stable after reduction and can be held in a splint or cast
75 Treatment of closed fractures Open reductionArticular fractures – want anatomical reductionNeed bone to heal in perfect position; eg. Adult forearm shaft fractures
76 Fracture Immobilisation Following reduction, the available methods of holding are…cast splintageInternal Fixation (plates, screws, nails)external fixationTraction
77 Fracture Immobilisation Continuous tractionCan be applied byGravity, eg. Hanging castSkinSkeletal, ie. Via pin inserted into bone
78 Cast splintage Plaster of Paris commonly used Speed of union similar to traction, but allows patient to go home soonerGenerally need to immobilise joint above and below to provide stabilityHowever, joints can become stiff – leading to “fracture disease”Functional bracing is an alternative in some situations, allows joint movement
79 Internal Fixation Types… Pins Wires Plate/screws Intramedullary nails Holds fracture securely, so that movement can be introduced early and “fracture disease” abolished** Even though fixation provides mechanical stability, biological union can in fact be slower
80 External Fixation External fixation particularly useful for: Fractures associated with severe soft tissue damageFractures with associated nerve/vessel injurySeverely comminuted/unstable fracturesNon-unions – can be excised and compressed, sometimes combined with elongationPelvis fracturesInfected fracturesSevere multiple injuries:Provides rapid stabilisationwith minimal surgery= “damage control orthopaedics”
81 Complications of fractures Early Complications, including:Vascular injuryNerve injuryCompartment syndromeInfectionFracture blisters (elevation of superficial layers of skin by oedema)Late Complications, including:Delayed/Non-unionMalunionAvascular necrosisGrowth disturbanceStiffness, CRPS, post traumatic osteoarthritis, etc
82 Complications of fractures Common nerve injuriesShoulder dislocation = axillary nerveHumerus shaft fracture = radial nerveHumerus supracondylar fracture = radial or median nervesHip dislocation = sciatic nerveKnee dislocation = peroneal nerve
83 Injuries of the growth plate Childrens bones grow longer at either end via Growth Plates.If a Growth plate is damaged, it can result in abnormal (crooked) growth.
84 Complications of fractures Delayed Union and Non UnionDelayed union = prolonged time to fracture unionNon Union = failure of bone to uniteFactors – multiple: Smoking increases risk 30%
85 Complications of fractures Types of Non UnionHypertrophic Atrophic
86 Complications of fracture healing Malunion = when fragments heal in unsatisfactory position, ie. unacceptable angulation, rotation or shortening.Due to either…poor reduction of fracturefailure to hold reductiongradual collapse of comminuted or osteoporotic bone
87 Complications of fracture healing Avascular Necrosis (AVN)Certain fractures/injuries are notorious for their propensity to develop ischemia and subsequent bone necrosis…1) Femoral head - #femoral neck (#NOF) or hip dislocation2) Scaphoid – particularly with more proximal fractures, as blood supply is from distal to proximal3) Talus – similar to scaphoid, blood supplies bone from distal to proximal, therefore body talus at risk AVN
89 Common Fractures and Joint injuries Clavicle Fractures
90 Common Fractures and Joint injuries Shoulder Dislocationmost common direction = anteroinferiorDon’t forget xray rule of 2’sEg. Posterior dislocationIf unsure on AP and lateral views, then demand an axillary view!!!Don’t forget to check axillary n.
91 Common Fractures and Joint injuries Distal radius fracturesnot all are Colles fractures!!“Colles” = low energy osteoporotic fracture“Smith’s” = reversed CollesRadial styloidComminuted intra-articular fracture in young adultsNumerous different management options!!
93 Common Fractures and Joint injuries Hip fractures – “# NOFs”generally used term to describe proximal femur fracturesStrictly = Neck of Femur (versus Intertrochanteric #)Risk of AVN with #NOF, not intertrochanteric #Clinically leg is shortened and externally rotated in bothManaged with either fixation or arthroplastyNeck of femurIntertrochanteric
94 Common Fractures and Joint injuries Common fractures around the kneeSupracondylar femur fracturePatella fractureTibial plateau fracture
95 Common Fractures and Joint injuries Common foot/ankle fractures“Jones” fractureSimple ankle fractureCalcaneus fracture“Lisfranc” fracture/dislocationNeck of talus fractureComplex “Pilon” fracture
97 Common Fractures and Joint injuries Common Paediatric Upper Limb FracturesMonteggia #/dislocationSupracondylar humerusGaleazzi #/dislocationLateral condyle fractureFat pad sign
98 Common Fractures and Joint injuries Common Paediatric Lower Limb FracturesPhyseal fractures around the knee and ankleFemur # in children under 2 years – think child abuse!!!Avulsion fractures - tibial tuberosity and ACL