Orthopaedics Orthopaedics Tutorial Tutorial
Jan 21, 2016
Orthopaedics Orthopaedics TutorialTutorial
Describing a FractureDescribing a Fracture Closed or Open/CompoundClosed or Open/Compound Bone involvedBone 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 InvolvementIA Involvement
Deformity (displacement, angulation, rotation)Deformity (displacement, angulation, rotation) Grade or ClassificationGrade or Classification Complications (vascular, neurological, tissue loss)Complications (vascular, neurological, tissue loss)
A few buzz wordsA few buzz words Greenstick - incomplete # of long bone with cortical disruption on 1 Greenstick - incomplete # of long bone with cortical disruption on 1
side & deformity on the otherside & deformity on the other Torus - specific type of greenstick # in which the bone is Torus - specific type of greenstick # in which the bone is
compressed to form a ring (torus) of compressed injured bone but compressed to form a ring (torus) of compressed injured bone but little angular deformitylittle angular deformity
Impacted - broken ends of the bone are jammed together by the Impacted - broken ends of the bone are jammed together by the force of the injury force of the injury
Avulsion - fragment of bone tears away from the main mass of boneAvulsion - fragment of bone tears away from the main mass of bone
Pathological - # in of diseased bone Pathological - # in of diseased bone (osteoporosis/mets/osteomalacia)(osteoporosis/mets/osteomalacia)
Fracture dislocation - severe injury in which both fracture and Fracture dislocation - severe injury in which both fracture and dislocation take place simultaneously dislocation take place simultaneously
DeformityDeformity Displacement – distal fragment + %Displacement – distal fragment + % Angulation Angulation NOTNOT tilt – tilt – BE CAREFULBE CAREFUL – distal fragment…ant/post – distal fragment…ant/post
med/latmed/lat Rotation – distal part…internal or external rotationRotation – distal part…internal or external rotation
Bony AnatomyBony Anatomy HandsHands
8 Carpals bones8 Carpals bones
5 Metacarpals (Name wrt fingers) 5 Metacarpals (Name wrt fingers)
14 Phalanges14 Phalanges
Long BonesLong Bones Shaft/Diaphysis + epiphysis @ endsShaft/Diaphysis + epiphysis @ ends
Separated by Epiphyseal Growth PlateSeparated by Epiphyseal Growth Plate
Bone narrows at metaphysisBone narrows at metaphysis
CondylesCondyles
Compound #’sCompound #’s Gustillo ClassificationGustillo Classification
I – Wound clean & < 1cm I – Wound clean & < 1cm
II – Wound > 1cm…no tissue loss/flap lacerationsII – Wound > 1cm…no tissue loss/flap lacerations
III a - Extensive tissue loss/flap lacerationIII a - Extensive tissue loss/flap laceration
b - Bone exposureb - Bone exposure
c - Vascular injuryc - Vascular injury
MxtMxt Life B4 Limb…ATLS PrinciplesLife B4 Limb…ATLS Principles Analgesia (Reduce deformity & splint)Analgesia (Reduce deformity & splint) Wound Swab + Irrigate with Sterile saline + Cover with Wound Swab + Irrigate with Sterile saline + Cover with
IodineIodine BackslabBackslab IV A/b’s + TetanusIV A/b’s + Tetanus
Treatment of FracturesTreatment of Fractures Primary AimsPrimary Aims
Bony Union without deformity ASAPBony Union without deformity ASAP Restoration of function ASAPRestoration of function ASAP
Life before limb (ATLS Guidelines)Life before limb (ATLS Guidelines) ACBCACBC Temporary splintTemporary splint Reposition fragment immediately if skin @ riskReposition fragment immediately if skin @ risk If open A/b’s + TetanusIf open A/b’s + Tetanus Assess clinically & radiologicallyAssess clinically & radiologically
In ShortIn Short Analgesia + Reduction (Open or Closed)Analgesia + Reduction (Open or Closed) Maintain reduction (External or Internal)Maintain reduction (External or Internal) Rehabilitation/PhysioRehabilitation/Physio
Fracture ReductionFracture Reduction Why? - Cosmesis…Function…Prevent complicationsWhy? - Cosmesis…Function…Prevent complications
Is reduction necessary ?Is reduction necessary ? NO IF : NO IF :
UndisplacedUndisplaced Dsplacement likely to be corrected by remodellingDsplacement likely to be corrected by remodelling Patient not fit for a haircut !!! - Very elderlyPatient 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 #
ClosedClosed MUA MUA ± Traction± Traction
Open ifOpen if If open #If open # If closed methods failedIf closed methods failed If considered the best way to treat # ie. If internal fixation requiredIf considered the best way to treat # ie. If internal fixation required
Maintenance of Maintenance of ReductionReduction ExternalExternal
Plaster of Paris Plaster of Paris External TractionExternal Traction
Femoral #’s – Thomas splintFemoral #’s – Thomas splint External fixatorExternal fixator
Severe soft tissue damage/open/comminuted #’sSevere soft tissue damage/open/comminuted #’s Infected #’sInfected #’s Pelvic #’sPelvic #’s
Internal (screws/nails/plates/combination of latter)Internal (screws/nails/plates/combination of latter) AIAI
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
RIRI Earlier mobilisation/hospital d/c desiredEarlier mobilisation/hospital d/c desired
Complications of Complications of FracturesFractures
Surgery & Anaesthesia relatedSurgery & Anaesthesia related CVS + RespCVS + Resp
Tissue DamageTissue Damage Bleeding…infection…U&E imbalance… hypercatabolic Bleeding…infection…U&E imbalance… hypercatabolic
response to traumaresponse to trauma
Prolonged RecumbencyProlonged Recumbency Resp…DVT…muscle wasting…OP…UTI… Resp…DVT…muscle wasting…OP…UTI…
Constipation…Pressure soresConstipation…Pressure sores
Specific to #’sSpecific to #’s See next slideSee next slide
# Complications# Complications Union ProblemsUnion Problems
Slow…eventually → healingSlow…eventually → healing Delayed…may → healing or → non-unionDelayed…may → healing or → non-union Non…Non… Mal… → healing Mal… → healing BUTBUT affects aesthetics or function affects aesthetics or function
Joint StiffnessJoint Stiffness
Avascular necrosisAvascular necrosis scaphoid, femoral head, talusscaphoid, femoral head, talus
Sudeck’s atrophy/Complex regional pain syn/Reflex Sudeck’s atrophy/Complex regional pain syn/Reflex symp dystrophysymp dystrophy Wrist, ankle, foot, kneeWrist, ankle, foot, knee Pain, swelling, discoloration, stiffness, abn skin moisture, Pain, swelling, discoloration, stiffness, abn skin moisture,
tendernesstenderness PT/OT/Meds/SympathectomyPT/OT/Meds/Sympathectomy
Acute ischaemic limbAcute ischaemic limb
Nerve damageNerve damage Immediate…uncommon usually neuropraxia seldom Immediate…uncommon usually neuropraxia seldom
axonotmesis & rarely neurotmesisaxonotmesis & rarely neurotmesis Delayed…Carpel Tunnel SyndromeDelayed…Carpel Tunnel Syndrome
Delayed tendon rupture…Colles # (EPL)Delayed tendon rupture…Colles # (EPL)
OtherOther Fat embolismFat embolism OsteitisOsteitis Myositis ossificansMyositis ossificans
# Complications# Complications
Scaphoid FracturesScaphoid Fractures Scaphoid #’s are the most common carpal bone fracture Scaphoid #’s are the most common carpal bone fracture
and typically occur from a fall on the outstretched arm and typically occur from a fall on the outstretched arm with the wrist in dorsiflexionwith the wrist in dorsiflexion
Carefully scrutinize XraysCarefully scrutinize Xrays Scaphoid views…4 requiredScaphoid views…4 required Look for concomitant scapho-lunate ligament injuryLook for concomitant scapho-lunate ligament injury
TxtTxt If clinical or radiological evidence of a fracture…If clinical or radiological evidence of a fracture…
scaphoid POP + review in 10 daysscaphoid POP + review in 10 days If persistant symptoms + negative X Ray → bone If persistant symptoms + negative X Ray → bone
scan/MRIscan/MRI
ComplicationsComplications Non-union, avascular necrosis, OANon-union, avascular necrosis, OA
Normal WristNormal Wrist
Scaphoid CastScaphoid Cast
Scapho-Lunate Scapho-Lunate DislocationDislocation
Scaphoid FractureScaphoid Fracture
Colles FracturesColles Fractures Definition – distal radial # within 1’ of wristDefinition – distal radial # within 1’ of wrist Typical mechanism - Fall onto an Typical mechanism - Fall onto an
outstretched handoutstretched hand Young 2Young 2oo high-energy trauma while in older high-energy trauma while in older
22oo low-energy trauma to osteoporosis low-energy trauma to osteoporosis
4 Features4 Features Radial Distal fragmentRadial Distal fragment
Dorsal & Radial displacementDorsal & Radial displacement Dorsal & Radial tilt (palmar & ulnar angulation)Dorsal & Radial tilt (palmar & ulnar angulation) ImpactionImpaction
Ulnar # (if present)…significant injury!Ulnar # (if present)…significant injury! Avulsion of the ulnar styloidAvulsion of the ulnar styloid
Colles #Colles # Post injury/ # manipulation, pay close attention to Post injury/ # manipulation, pay close attention to
neurovascular status & beware of ACSneurovascular status & beware of ACS
TxtTxt Undisplaced…Analgesia + BackslabUndisplaced…Analgesia + Backslab Displaced…Reduce in A&E or MUADisplaced…Reduce in A&E or MUA
ComplicationsComplications AnaestheticAnaesthetic General – urinary retention/Resp TI/MI/CCF/DVTGeneral – urinary retention/Resp TI/MI/CCF/DVT SpecificSpecific
Union problemsUnion problems CTSCTS CRPSCRPS Delayed rupture Extensor pollicis longusDelayed rupture Extensor pollicis longus
Dinner Fork deformityDinner Fork deformity
Colles #Colles #
Colles #Colles #
Colles #Colles #
Hip FracturesHip Fractures Aet: Fall + OP in old dearsAet: Fall + OP in old dears # Sites# Sites
Intracapsular Intracapsular SubcapitalSubcapital TranscervicalTranscervical BasalBasal
ExtracapsularExtracapsular IntertrochantericIntertrochanteric SubtrochantericSubtrochanteric
DiagnosisDiagnosis Hx: Inability to WBHx: Inability to WB O/E: Ext rotation, shortened, tender ant/latO/E: Ext rotation, shortened, tender ant/lat XRay: AP + LatXRay: AP + Lat
Intracapsular (avascular necrosis + non-Intracapsular (avascular necrosis + non-union)union) Disrupt blood supply from diaphysis → risk Disrupt blood supply from diaphysis → risk
AVN femural headAVN femural head Garden ClassificationGarden Classification
I…Inferior cortex intact…undisplacedI…Inferior cortex intact…undisplaced II...Sup→Inf # lineII...Sup→Inf # line……undisplacedundisplaced III...Slight displacementIII...Slight displacement IV…Gross displacementIV…Gross displacement
Txt:Txt: AnalgesiaAnalgesia BloodsBloods Medical WorkupMedical Workup
Hip FracturesHip Fractures
Hip FracturesHip Fractures Specific fracture mxt – Age + Specific fracture mxt – Age +
DisplacementDisplacement Extracapsular #’sExtracapsular #’s
Subcapital, Introchanteric & basal cervival – Closed Subcapital, Introchanteric & basal cervival – Closed reduction + Dynamic Hip Screw (DHS)reduction + Dynamic Hip Screw (DHS)
Subtroch - ORIFSubtroch - ORIF
Intracapsular #’sIntracapsular #’s Garden I/IIGarden 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 mxtIf very old & confined to bed/chair → conservative mxt
Garden III/IVGarden III/IV If young & fit → ORIF but THR if ↑ risk complicationsIf young & fit → ORIF but THR if ↑ risk complications If ‘serior’ → Arthroplasty If ‘serior’ → Arthroplasty
Bipolar/Austin Moore/ThompsonBipolar/Austin Moore/Thompson
‘‘The Limping Child’The Limping Child’ Diff Dx:Diff Dx:
Cong or Acquired Causes (Vitamin D)Cong or Acquired Causes (Vitamin D) Specific Hip PathologiesSpecific Hip Pathologies
CDH…Perthes…SUFE…TS/HIS…CDH…Perthes…SUFE…TS/HIS…INFECTIONINFECTION
Hx:Hx: 10 Q’s re Pain…any trauma…age of child… recent 10 Q’s re Pain…any trauma…age of child… recent
flu/illness…other painsflu/illness…other pains O/E:O/E:
Temp…Gait…Compare both sides…foot FB… Temp…Gait…Compare both sides…foot FB… infection…rash….neuro exam + both lower limbinfection…rash….neuro exam + both lower limb
Tests:Tests: ESR/CRP/FBC/Xray both hips ESR/CRP/FBC/Xray both hips ± US/S Hip± US/S Hip
Specific Hip PathologiesSpecific Hip Pathologies SUFE (adolescentsSUFE (adolescents
Slip of epiphysis on metaphysis…M>F…hormonal imbalance Slip of epiphysis on metaphysis…M>F…hormonal imbalance of trauma)…Painful limb + florid hip signs…X Rays of trauma)…Painful limb + florid hip signs…X Rays abnormal (abnormal (Trethowan’s signTrethowan’s sign)…60% bilateral…)…60% bilateral…
Txt – refer orthoTxt – refer ortho
Perthes disease (3 – 10 yrs)Perthes disease (3 – 10 yrs) Aseptic necrosis of the capital epiphysis… M>F …PAINFUL Aseptic necrosis of the capital epiphysis… M>F …PAINFUL
limp…normal bloods but X Rays always abnormal…limp…normal bloods but X Rays always abnormal… Txt – Refer orthoTxt – Refer ortho
Transient Synovitis (All ages)Transient Synovitis (All ages) Commonest…Commonest…± Hx trauma/viral illness± Hx trauma/viral illness……LimpLimp…… well + ESR well + ESR
normalnormal……normal X Ray & US/S ± → effusionnormal X Ray & US/S ± → effusion…….. Txt Txt –– Rest + NSAID Rest + NSAID
CDH/DDHCDH/DDH Aet:Aet:
½ hips dislocated @ birth…F>M + breech½ hips dislocated @ birth…F>M + breech
ScreeningScreening Older ChildOlder Child
Gait/posture abn…limb shorteningGait/posture abn…limb shortening NeonateNeonate
Twice in 1Twice in 1stst 3 months (Ortholani + Barlow’s tests) 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)
MxtMxt Hip SpicaHip Spica OsteotomyOsteotomy
Salter Harris Salter Harris ClassificationClassification