Dr John Trantalis
Dr John Trantalis
How To Examine a Joint
LookScars, alignment, wasting, redness, swelling
FeelTenderness (Location!!!!!)
MoveActive movementPassive movement
Passive vs Active Motion
ACTIVE MOTIONPatient moves the
joint on their own
For active motion to be intact:The joint must be
mobile.The “motor” must
be working
PASSIVE MOTIONThe examiner moves
the joint for the patient
For passive motion to be intactThe joint must be
mobile The “motor” does not
need to be working.
“Motor”= tendon, muscle, nerve, plexus, roots, spinal cord, brain
PASSIVE vs ACTIVE motion
Loss of active MotionPreserved Passive Motion
Joint OKMotor is broken
Loss of both Active and Passive Motion
Joint Stiffness
8 yo girl Fall from monkey bars Off-ended # distal humerus
Pale handPulseless
Pre-post operative assessment after an elbow injury Arteries
Compartment syndrome
Nerve Damage
Skin etc.
Pulseless Fractured Limb
Management: Why?
The elbow joint: arteries crossing the joint Brachial artery
If damaged:6 hours till amputationWhite handNo pulsesCap Ref >2 secsPain
Super Urgent
Prevent This !!
25yo, cast applied yesterday after fracture radius : now severe pain
Xray OK position
Unable to move fingers
Sensation and pulses intact
Compartment syndrome
Only clue is PAIN
Pulses normal Cap Refill normal
Unable to move fingers
When you move them for the patient Severe PAIN !!!!
Compartment syndrome
Broken arm: should still be able to move fingers
6 hours to save the arm
Otherwise: amputation
Missed Forearm compartment syndrome: useless arm
Compartment Syndrome
Why are the Pulses normal and the Fingers Pink? Ischaemia to muscles
Capillaries 5mmHg- shut down with small rise in compartment pressue
Radial ArteryPressure of 120/80mmHg. Therefore it stays open and hand stays pink
Therefore….
Only need one thing to diagnose compartment syndrome…..
PAIN
How can we differentiate normal fracture pain from Compartment Syndrome?
Active Finger (or Toe) MovementNo compartment syndrome
What to do if you suspect Compartment Syndrome….
CALL FOR HELP!!!!!!!!!!!!Speak to the orthopaedic team urgentlyDo not leave messagesYou 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
How Do We Surgically Treat Compartment SyndromeUrgent Fasciotomy (less than 6 hours)
Allows muscles to bulge out of wound and blood supply to return.
If you miss the diagnosis AMPUTATION
Clinical case 56 yo male, 24 hour h/o right
knee painNo traumaCan’t walkOtherwise well
Exam: temp 37.0C Swollen Knee (patella tap) No redness Markedly reduced ROM active
and passive
Provisional Diagnosis?Septic Arthritis
Differential Diagnosis?GoutPseudogoutHaemarthosis
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.
The Work-Up Bloods:
FBC, EUC, CRP, ESR, UA, Cultures
ECG, MSU, fast NBM
XRAYUsually normal
Joint Aspirate
Inflammatory Markers
CRPC Reactive ProteinVery Sensitive for inflammation or infectionIndicative of what was happening in the body
1 day ago
ESRErythrocyte Sedimentation RateIndicative of what was happening in the body
3 days ago.
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.
Septic Arthritis: Treatment Joint Washout (arthroscopic)
Removes the enzymes from white cells which otherwise destroy the articular cartilage
IV antibioticsEmpirical: cover Staph Aureus
Risk Factors: Elderly, Female, Osteoporosis
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
Presentation Fall Can’t walk Pain in Groin
Exam: LegShortenedExternally rotated
The Work-up Xrays
Pelvis and hip
Pre-opFBC. EUC, G&HECGCXR
Fast Patient
Analgesia, Fluids, Pressure care, IDC
XRAYS
Subcapital Fracture Trochanteric Fracture
Hip Anatomy Acetabulum
Femoral head
Neck of femur
Trochanters
2 common types of Hip Fractures
Subcapital fracture
Intertrochanteric or Pertrochanteric fractures
We Treat these differently
Why treat these fractures differently?
Blood Supply to the head of femur
Disrupted with a Displaced Subcapital Fracture
Intact with a displaced trochanteric fracture
Hip Joint Capsule
The blood vessels run up through the capsule
Hence the terms:
Intracapsular # (subcapital)
Extracapsular #(trochanteric)
What are the aims of Surgical Treatment Relieve Pain
Every time patient moves in bed- pain
Regain MobilityPatient should be
able to Fully weight bear after surgery
Improve Quality of Life
Before the 1970’s3 months Traction for
everybody50% mortalityPneumonia, pressure
sores etc
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.
Subcapital Fractures: 2 typesNon-Displaced
Screws
DisplacedHip replacement
○ Half (hemiarthroplasty) ○ Total Hip Replacement
Non Displaced Subcapital Fractures
Blood supply not likely to be affected
Fix with screws and hope that it heals
Displaced Subcapital Fracture Blood supply is disrupted to
femoral head# won’t healAvascular Necrosis likely
Therefore: replace the headHalf replacement
(hemiarthroplasty)
Total Hip Replacement for the more mobile patients
Hemiarthroplasty
Total Hip Replacement
Intertrochanteric Fractures
Dynamic Hip Screw (DHS)
Short femoral NailIntertroch #
• Internally Fixed to allow early weight bearing• Plate• Nail
Post-Op Care
NV Obs Analgesia DVT prophylaxis Bloods Mobilise FWB Pressure area care
Dr John TrantalisOrthopaedic Surgeon
Dr John TrantalisOrthopaedic Surgeon
Dislocated Joints Should all be reduced ASAP
Pressure off NV structures
Pain XRAY 2 views alwaysCT if you are unsure
Beware LOC○ Trauma, Head injury Secondary survey
You will detect decreased ROM
○ Seizures, electrocution
43 yo F soccer player Painful swollen leg after tackle.
?Management
Why?
Managing The Injured Limb in ED
Managing The Injured Limb in ED
Managing the Injured Limb in ED Analgesia /
Sedation
Reduce the deformity, splint the limb
Backslabs only- NEVER apply a full POP in ED.
Managing the Injured Limb in ED
Dress the wounds
THEN… get Xrays.
Tet tox, IV antib, Fast patient
Pre-op work-up.
How do we reduce the deformity? It’s very complicated……..
JUST PULL!!
How to describe a fracture
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?
Principles of fractures and joint injuries
How fractures are displaced
Principles of fractures and joint injuries
Direct healing - If fracture absolutely immobile, eg. Fixed with metal fracture healing occurs directly between fragments.
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
Clinical signs of fracture Union
No tenderness, movement or crepitus at a fracture site.
The injured limb – Clinical features
Clinical Features
If you remember nothing else about examining a limb…
LOOK FEEL MOVE
Clinical Features
LookAny 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?
Clinical Features
FeelTenderness
Swelling
Crepitus
Vascular and neurological examination before and after treatment
Clinical Features
MoveActive and passive movement
distal to the injuryAbsolutely criticalKnow your anatomy
The injured limb - Imaging
Clinical Features
XraysRemember 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 #
Beware Ipsilateral injuries
For any # or dislocation- always image to joint above and below
Clinical Features
Special ImagingCan’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)
The injured limb – Management principles
Treatment of Closed Fractures
Reduction
Putting the bone into an acceptable position
Two methods – open or closed
Treatment of closed fractures
Closed reduction
Sedation / Anaesthesia
Pull the limb into alignment
Splint the limb
Treatment of closed fractures
Closed reductionIn 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
Treatment of closed fractures
Open reduction○ Articular fractures – want anatomical
reduction○ Need bone to heal in perfect position;
eg. Adult forearm shaft fractures
Fracture Immobilisation
Following reduction, the available methods of holding are…
1) cast splintage2) Internal Fixation (plates, screws, nails)3) external fixation4) Traction
Fracture Immobilisation
Continuous tractionCan be applied by
○ Gravity, eg. Hanging cast○ Skin ○ Skeletal, ie. Via pin inserted into
bone
Cast splintage
Plaster of Paris commonly usedSpeed 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
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
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”
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
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
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.
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%
Complications of fractures
Types of Non UnionHypertrophic Atrophic
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 reductiongradual collapse of comminuted or osteoporotic
bone
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
Common Upper Limb Injuries
Common Fractures and Joint injuries
Clavicle Fractures
Common Fractures and Joint injuries
Shoulder Dislocation• most common direction = anteroinferior•Don’t forget xray rule of 2’sEg. Posterior dislocation•If unsure on AP and lateral views, then demand an axillary view!!!•Don’t forget to check axillary n.
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!!
Common Lower Limb Injuries
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 arthroplastyNeck of femur Intertrochanteric
Common Fractures and Joint injuries
Common fractures around the knee
Patella fracture
Tibial plateau fracture
Supracondylar femur fracture
Common Fractures and Joint injuries
Common foot/ankle fractures
Simple ankle fracture Calcaneus fracture
“Lisfranc” fracture/dislocationComplex “Pilon” fracture
Neck of talus fracture
“Jones” fracture
Common Paediatric Injuries
Common Fractures and Joint injuries
Common Paediatric Upper Limb Fractures
Fat pad sign
Supracondylar humerus
Lateral condyle fracture
Monteggia #/dislocation
Galeazzi #/dislocation
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!!!