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Orthopaedics Tutorial. Describing a Fracture Closed or Open/Compound Closed or Open/Compound Bone involved Bone involved Side (LHS & RHS) Side (LHS &

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Presentation on theme: "Orthopaedics Tutorial. Describing a Fracture Closed or Open/Compound Closed or Open/Compound Bone involved Bone involved Side (LHS & RHS) Side (LHS &"— Presentation transcript:

1 Orthopaedics Tutorial

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

3 A few buzz words Greenstick - incomplete # of long bone with cortical disruption on 1 side & deformity on the other 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 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 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 Avulsion - fragment of bone tears away from the main mass of bone Pathological - # in of diseased bone (osteoporosis/mets/osteomalacia) Pathological - # in of diseased bone (osteoporosis/mets/osteomalacia) Fracture dislocation - severe injury in which both fracture and dislocation take place simultaneously Fracture dislocation - severe injury in which both fracture and dislocation take place simultaneously Deformity Deformity Displacement – distal fragment + % Displacement – distal fragment + % Angulation NOT tilt – BE CAREFUL – distal fragment…ant/post med/lat Angulation NOT tilt – BE CAREFUL – distal fragment…ant/post med/lat Rotation – distal part…internal or external rotation Rotation – distal part…internal or external rotation

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

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11 Compound #’s Gustillo Classification Gustillo Classification I – Wound clean & < 1cm II – Wound > 1cm…no tissue loss/flap lacerations III a - Extensive tissue loss/flap laceration b - Bone exposure b - Bone exposure c - Vascular injury c - Vascular injury Mxt Mxt Life B4 Limb…ATLS Principles Life B4 Limb…ATLS Principles Analgesia (Reduce deformity & splint) Analgesia (Reduce deformity & splint) Wound Swab + Irrigate with Sterile saline + Cover with Iodine Wound Swab + Irrigate with Sterile saline + Cover with Iodine Backslab Backslab IV A/b’s + Tetanus IV A/b’s + Tetanus

12 Treatment of Fractures Primary Aims Primary Aims Bony Union without deformity ASAP Bony Union without deformity ASAP Restoration of function ASAP Restoration of function ASAP Life before limb (ATLS Guidelines) Life before limb (ATLS Guidelines) ACBC ACBC Temporary splint Temporary splint Reposition fragment immediately if risk Reposition fragment immediately if risk If open A/b’s + Tetanus If open A/b’s + Tetanus Assess clinically & radiologically Assess clinically & radiologically In Short In Short Analgesia + Reduction (Open or Closed) Analgesia + Reduction (Open or Closed) Maintain reduction (External or Internal) Maintain reduction (External or Internal) Rehabilitation/Physio Rehabilitation/Physio

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

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

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17 Complications of Fractures Surgery & Anaesthesia related Surgery & Anaesthesia related CVS + Resp CVS + Resp Tissue Damage Tissue Damage Bleeding…infection…U&E imbalance… hypercatabolic response to trauma Bleeding…infection…U&E imbalance… hypercatabolic response to trauma Prolonged Recumbency Prolonged Recumbency Resp…DVT…muscle wasting…OP…UTI… Constipation…Pressure sores Resp…DVT…muscle wasting…OP…UTI… Constipation…Pressure sores Specific to #’s Specific to #’s See next slide See next slide

18 # Complications Union Problems Union Problems Slow…eventually → healing Slow…eventually → healing Delayed…may → healing or → non-union Delayed…may → healing or → non-union Non… Non… Mal… → healing BUT affects aesthetics or function Mal… → healing BUT affects aesthetics or function Joint Stiffness Joint Stiffness Avascular necrosis Avascular necrosis scaphoid, femoral head, talus scaphoid, femoral head, talus Sudeck’s atrophy/Complex regional pain syn/Reflex symp dystrophy Sudeck’s atrophy/Complex regional pain syn/Reflex symp dystrophy Wrist, ankle, foot, knee Wrist, ankle, foot, knee Pain, swelling, discoloration, stiffness, abn skin moisture, tenderness Pain, swelling, discoloration, stiffness, abn skin moisture, tenderness PT/OT/Meds/Sympathectomy PT/OT/Meds/Sympathectomy

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20 Acute ischaemic limb Acute ischaemic limb Nerve damage Nerve damage Immediate…uncommon usually neuropraxia seldom axonotmesis & rarely neurotmesis Immediate…uncommon usually neuropraxia seldom axonotmesis & rarely neurotmesis Delayed…Carpel Tunnel Syndrome Delayed…Carpel Tunnel Syndrome Delayed tendon rupture…Colles # (EPL) Delayed tendon rupture…Colles # (EPL) Other Other Fat embolism Fat embolism Osteitis Osteitis Myositis ossificans Myositis ossificans # Complications

21 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 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 Carefully scrutinize Xrays Scaphoid views…4 required Scaphoid views…4 required Look for concomitant scapho-lunate ligament injury Look for concomitant scapho-lunate ligament injury Txt Txt If clinical or radiological evidence of a fracture…scaphoid POP + review in 10 days If clinical or radiological evidence of a fracture…scaphoid POP + review in 10 days If persistant symptoms + negative X Ray → bone scan/MRI If persistant symptoms + negative X Ray → bone scan/MRI Complications Complications Non-union, avascular necrosis, OA Non-union, avascular necrosis, OA

22 Normal Wrist

23 Scaphoid Cast

24 Scapho-Lunate Dislocation

25 Scaphoid Fracture

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

27 Colles # Post injury/ # manipulation, pay close attention to neurovascular status & beware of ACS Post injury/ # manipulation, pay close attention to neurovascular status & beware of ACS Txt Txt Undisplaced…Analgesia + Backslab Undisplaced…Analgesia + Backslab Displaced…Reduce in A&E or MUA Displaced…Reduce in A&E or MUA Complications Complications Anaesthetic Anaesthetic General – urinary retention/Resp TI/MI/CCF/DVT General – urinary retention/Resp TI/MI/CCF/DVT Specific Specific Union problems Union problems CTS CTS CRPS CRPS Delayed rupture Extensor pollicis longus Delayed rupture Extensor pollicis longus

28 Dinner Fork deformity

29 Colles #

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

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34 Intracapsular (avascular necrosis + non-union) Intracapsular (avascular necrosis + non-union) Disrupt blood supply from diaphysis → risk AVN femural head Disrupt blood supply from diaphysis → risk AVN femural head Garden Classification Garden Classification I…Inferior cortex intact…undisplaced I…Inferior cortex intact…undisplaced II...Sup→Inf # line … undisplaced II...Sup→Inf # line … undisplaced III...Slight displacement III...Slight displacement IV…Gross displacement IV…Gross displacement Txt: Txt: Analgesia Analgesia Bloods Bloods Medical Workup Medical Workup Hip Fractures

35 Specific fracture mxt – Age + Displacement Specific fracture mxt – Age + Displacement Extracapsular #’s Extracapsular #’s Subcapital, Introchanteric & basal cervival – Closed reduction + Dynamic Hip Screw (DHS) Subcapital, Introchanteric & basal cervival – Closed reduction + Dynamic Hip Screw (DHS) Subtroch - ORIF Subtroch - ORIF Intracapsular #’s Intracapsular #’s Garden I/II Garden I/II Aged < 55/60 → ORIF (DHS) Aged < 55/60 → ORIF (DHS) Aged > 60 + fit ORIF (DHS) Aged > 60 + fit ORIF (DHS) If very old & confined to bed/chair → conservative mxt If very old & confined to bed/chair → conservative mxt Garden III/IV Garden III/IV If young & fit → ORIF but THR if ↑ risk complications If young & fit → ORIF but THR if ↑ risk complications If ‘serior’ → Arthroplasty If ‘serior’ → Arthroplasty Bipolar/Austin Moore/Thompson Bipolar/Austin Moore/Thompson

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37 ‘The Limping Child’ Diff Dx: Diff Dx: Cong or Acquired Causes (Vitamin D) Cong or Acquired Causes (Vitamin D) Specific Hip Pathologies Specific Hip Pathologies CDH…Perthes…SUFE…TS/HIS…INFECTION CDH…Perthes…SUFE…TS/HIS…INFECTION Hx: Hx: 10 Q’s re Pain…any trauma…age of child… recent flu/illness…other pains 10 Q’s re Pain…any trauma…age of child… recent flu/illness…other pains O/E: O/E: Temp…Gait…Compare both sides…foot FB… infection…rash….neuro exam + both lower limb Temp…Gait…Compare both sides…foot FB… infection…rash….neuro exam + both lower limb Tests: Tests: ESR/CRP/FBC/Xray both hips ± US/S Hip ESR/CRP/FBC/Xray both hips ± US/S Hip

38 Specific Hip Pathologies SUFE (adolescents SUFE (adolescents Slip of epiphysis on metaphysis…M>F…hormonal imbalance of trauma)…Painful limb + florid hip signs…X Rays abnormal (Trethowan’s sign)…60% bilateral… Slip of epiphysis on metaphysis…M>F…hormonal imbalance of trauma)…Painful limb + florid hip signs…X Rays abnormal (Trethowan’s sign)…60% bilateral… Txt – refer ortho Txt – refer ortho Perthes disease (3 – 10 yrs) Perthes disease (3 – 10 yrs) Aseptic necrosis of the capital epiphysis… M>F …PAINFUL limp…normal bloods but X Rays always abnormal… Aseptic necrosis of the capital epiphysis… M>F …PAINFUL limp…normal bloods but X Rays always abnormal… Txt – Refer ortho Txt – Refer ortho Transient Synovitis (All ages) Transient Synovitis (All ages) Commonest…± Hx trauma/viral illness … Limp … well + ESR normal … normal X Ray & US/S ± → effusion …. Commonest…± Hx trauma/viral illness … Limp … well + ESR normal … normal X Ray & US/S ± → effusion …. Txt – Rest + NSAID Txt – Rest + NSAID

39 CDH/DDH Aet: Aet: ½ hips birth…F>M + breech ½ hips birth…F>M + breech Screening Screening Older Child Older Child Gait/posture abn…limb shortening Gait/posture abn…limb shortening Neonate Neonate Twice in 1 st 3 months (Ortholani + Barlow’s tests) Twice in 1 st 3 months (Ortholani + Barlow’s tests) + US if high risk (breech, FH, clicking hip, other abn’s) + US if high risk (breech, FH, clicking hip, other abn’s) Mxt Mxt Hip Spica Hip Spica Osteotomy Osteotomy

40 Salter Harris Classification


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