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Dr John Trantalis. How To Examine a Joint  Look Scars, alignment, wasting, redness, swelling  Feel Tenderness (Location!!!!!)  Move Active movement.

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Presentation on theme: "Dr John Trantalis. How To Examine a Joint  Look Scars, alignment, wasting, redness, swelling  Feel Tenderness (Location!!!!!)  Move Active movement."— Presentation transcript:

1 Dr John Trantalis

2 How To Examine a Joint  Look Scars, alignment, wasting, redness, swelling  Feel Tenderness (Location!!!!!)  Move Active movement Passive movement

3 Passive vs Active Motion  ACTIVE MOTION Patient moves the joint on their own  For active motion to be intact: The joint must be mobile. The “motor” must be working  PASSIVE MOTION The examiner moves the joint for the patient  For passive motion to be intact The joint must be mobile The “motor” does not need to be working. “Motor”= tendon, muscle, nerve, plexus, roots, spinal cord, brain

4 PASSIVE vs ACTIVE motion Loss of active Motion Preserved Passive Motion Joint OK Motor is broken Loss of both Active and Passive Motion Joint Stiffness

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6  8 yo girl  Fall from monkey bars  Off-ended # distal humerus Pale hand Pulseless

7 Pre-post operative assessment after an elbow injury  Arteries  Compartment syndrome  Nerve Damage  Skin etc.

8 Pulseless Fractured Limb Management: Why?

9 The elbow joint: arteries crossing the joint  Brachial artery  If damaged: 6 hours till amputation White hand No pulses Cap Ref >2 secs Pain Super Urgent

10 Prevent This !!

11 25yo, cast applied yesterday after fracture radius : now severe pain  Xray OK position  Unable to move fingers  Sensation and pulses intact

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13 Compartment syndrome  Only clue is PAIN Pulses normal Cap Refill normal  Unable to move fingers  When you move them for the patient Severe PAIN !!!!

14 Compartment syndrome  Broken arm: should still be able to move fingers  6 hours to save the arm  Otherwise: amputation

15 Missed Forearm compartment syndrome: useless arm

16 Compartment Syndrome

17 Why are the Pulses normal and the Fingers Pink?  Ischaemia to muscles Capillaries 5mmHg- shut down with small rise in compartment pressue  Radial Artery Pressure 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) Movement No compartment syndrome

20 What to do if you suspect Compartment Syndrome….  CALL FOR HELP!!!!!!!!!!!! Speak to the orthopaedic team urgently Do not leave messages You must speak to somebody urgently Then… ○ Remove all encircling bandages… A tight bandage or plaster can cause compartment syndrome But 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 No trauma Can’t walk Otherwise well  Exam: temp 37.0C  Swollen Knee (patella tap)  No redness  Markedly reduced ROM active and passive

23  Provisional Diagnosis? Septic Arthritis  Differential Diagnosis? Gout Pseudogout Haemarthosis

24 Key Clinical Sign for Septic Arthritis in any Joint  Decreased active and passive motion  The joint is very inflamed and painful. Patient’s muscles spasm when movement is attempted.

25 The Work-Up  Bloods: FBC, EUC, CRP, ESR, UA, Cultures  ECG, MSU, fast NBM  XRAY Usually normal  Joint Aspirate

26 Inflammatory Markers  CRP C Reactive Protein Very Sensitive for inflammation or infection Indicative of what was happening in the body 1 day ago  ESR Erythrocyte Sedimentation Rate Indicative 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 cartilage  IV antibiotics Empirical: cover Staph Aureus

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30 Risk Factors: Elderly, Female, Osteoporosis

31 One Year Mortality Rate for a Fractured NOF  30%  Within 1 year, 30% or patients who sustain a fractured NOF will pass away. Due to comorbidities usually

32 Presentation  Fall  Can’t walk  Pain in Groin  Exam: Leg Shortened Externally rotated

33 The Work-up  Xrays Pelvis and hip  Pre-op FBC. EUC, G&H ECG CXR Fast Patient Analgesia, Fluids, Pressure care, IDC

34 XRAYS Subcapital Fracture Trochanteric Fracture

35 Hip Anatomy  Acetabulum  Femoral head  Neck of femur  Trochanters

36 2 common types of Hip Fractures  Subcapital fracture  Intertrochanteric or Pertrochanteric fractures  We Treat these differently

37 Why treat these fractures differently?  Blood Supply to the head of femur Disrupted with a Displaced Subcapital Fracture Intact 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 Pain Every time patient moves in bed- pain  Regain Mobility Patient should be able to Fully weight bear after surgery  Improve Quality of Life  Before the 1970’s 3 months Traction for everybody 50% mortality Pneumonia, pressure sores etc

40 The Surgery Relieves Pain  Patient with # NOF in bed…The fracture ends grind and cause pain with every movement  Even 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-Displaced Screws  Displaced Hip replacement ○ Half (hemiarthroplasty) ○ Total Hip Replacement

42 Non Displaced Subcapital Fractures  Blood supply not likely to be affected  Fix with screws and hope that it heals

43 Displaced Subcapital Fracture  Blood supply is disrupted to femoral head # won’t heal Avascular Necrosis likely  Therefore: replace the head Half replacement (hemiarthroplasty) Total Hip Replacement for the more mobile patients Hemiarthroplasty Total Hip Replacement

44 Intertrochanteric Fractures Dynamic Hip Screw (DHS) Short femoral Nail Intertroch # Internally Fixed to allow early weight bearing Plate Nail

45 Post-Op Care  NV Obs  Analgesia  DVT prophylaxis  Bloods  Mobilise FWB  Pressure area care

46 Dr John Trantalis Orthopaedic Surgeon Dr John Trantalis Orthopaedic Surgeon

47 Dislocated Joints  Should all be reduced ASAP Pressure off NV structures  Pain  XRAY 2 views always CT if you are unsure  Beware  LOC ○ Trauma, Head injury  Secondary survey You will detect decreased ROM ○ Seizures, electrocution

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49  43 yo F soccer player  Painful swollen leg after tackle. ?Management Why?

50 Managing The Injured Limb in ED

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52 Managing the Injured Limb in ED  Analgesia / Sedation  Reduce the deformity, splint the limb  Backslabs only- NEVER apply a full POP in ED.

53 Managing the Injured Limb in ED  Dress the wounds  THEN… get Xrays.  Tet tox, IV antib, Fast patient  Pre-op work-up.

54 How do we reduce the deformity?  It’s very complicated……..

55 JUST PULL!!

56 How to describe a fracture

57 Principles of fractures and joint injuries Questions to ask… - Open or closed? - Which bone? - Location in bone? - Pattern of Fracture - Joint 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 etc Fracture Factors: which bone, type of fracture etc Can 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.

62 The injured limb – Clinical features

63 Clinical Features If you remember nothing else about examining a limb… LOOK FEEL MOVE

64 Clinical Features  Look Any Swelling? Any Bruising? Any obvious Deformity? Is the skin intact? Where is the wound? And, what size is the wound? What colour is the skin?

65 Clinical Features  Feel Tenderness Swelling Crepitus Vascular and neurological examination before and after treatment

66 Clinical Features  Move Active and passive movement distal to the injury Absolutely critical Know your anatomy

67 The injured limb - Imaging

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 lateral ○ 2 joints – joints above and below the fracture, eg. Monteggia/Galeazzi #’s ○ 2 limbs – in children, appearance of immature physis may confuse diagnosis of fracture ○ 2 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 scaphoid ○ MRI, CT, or bone scan. CT scans useful in complex or intra-articular fractures (eg. Calcaneal, Tibial plateau)

71 The injured limb – Management principles

72 Treatment of Closed Fractures  Reduction Putting the bone into an acceptable position Two methods – open or closed

73 Treatment of closed fractures  Closed reduction Sedation / Anaesthesia Pull the limb into alignment Splint the limb

74 Treatment of closed fractures  Closed reduction In general, closed reduction is used for… ○ For most fractures in children ○ For fractures that are stable after reduction and can be held in a splint or cast

75 Treatment of closed fractures  Open reduction ○ Articular fractures – want anatomical reduction ○ Need bone to heal in perfect position; eg. Adult forearm shaft fractures

76 Fracture Immobilisation  Following reduction, the available methods of holding are… 1) cast splintage 2) Internal Fixation (plates, screws, nails) 3) external fixation 4) Traction

77 Fracture Immobilisation  Continuous traction Can be applied by ○ Gravity, eg. Hanging cast ○ Skin ○ Skeletal, 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 sooner Generally need to immobilise joint above and below to provide stability However, 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 damage ○ Fractures with associated nerve/vessel injury ○ Severely comminuted/unstable fractures ○ Non-unions – can be excised and compressed, sometimes combined with elongation ○ Pelvis fractures ○ Infected fractures ○ Severe multiple injuries: Provides rapid stabilisation with minimal surgery = “damage control orthopaedics”

81 Complications of fractures Early Complications, including: ○ Vascular injury ○ Nerve injury ○ Compartment syndrome ○ Infection ○ Fracture blisters (elevation of superficial layers of skin by oedema) Late Complications, including: ○ Delayed/Non-union ○ Malunion ○ Avascular necrosis ○ Growth disturbance ○ Stiffness, CRPS, post traumatic osteoarthritis, etc

82 Complications of fractures Common nerve injuries ○ Shoulder dislocation = axillary nerve ○ Humerus shaft fracture = radial nerve ○ Humerus supracondylar fracture = radial or median nerves ○ Hip dislocation = sciatic nerve ○ Knee 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 Union Delayed union = prolonged time to fracture union Non Union = failure of bone to unite Factors – multiple: Smoking increases risk 30%

85 Complications of fractures Types of Non Union Hypertrophic 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 fracture failure to hold reduction gradual 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 dislocation 2) Scaphoid – particularly with more proximal fractures, as blood supply is from distal to proximal 3) Talus – similar to scaphoid, blood supplies bone from distal to proximal, therefore body talus at risk AVN

88 Common Upper Limb Injuries

89 Common Fractures and Joint injuries Clavicle Fractures

90 Common Fractures and Joint injuries Shoulder Dislocation most common direction = anteroinferior Don’t forget xray rule of 2’s Eg. Posterior dislocation If 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 fractures not all are Colles fractures!! “Colles” = low energy osteoporotic fracture “Smith’s” = reversed Colles Radial styloid Comminuted intra-articular fracture in young adults Numerous different management options!!

92 Common Lower Limb Injuries

93 Common Fractures and Joint injuries Hip fractures – “# NOFs” generally used term to describe proximal femur fractures Strictly = Neck of Femur (versus Intertrochanteric #) Risk of AVN with #NOF, not intertrochanteric # Clinically leg is shortened and externally rotated in both Managed with either fixation or arthroplasty Neck of femurIntertrochanteric

94 Common Fractures and Joint injuries Common fractures around the knee Patella fracture Tibial plateau fracture Supracondylar femur fracture

95 Common Fractures and Joint injuries Common foot/ankle fractures Simple ankle fractureCalcaneus fracture “Lisfranc” fracture/dislocation Complex “Pilon” fracture Neck of talus fracture “Jones” fracture

96 Common Paediatric Injuries

97 Common Fractures and Joint injuries Common Paediatric Upper Limb Fractures Fat pad sign Supracondylar humerus Lateral condyle fracture Monteggia #/dislocation Galeazzi #/dislocation

98 Common Fractures and Joint injuries Common Paediatric Lower Limb Fractures Avulsion fractures - tibial tuberosity and ACL Physeal fractures around the knee and ankle Femur # in children under 2 years – think child abuse!!!

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