Principles of Principles of Musculoskeletal Musculoskeletal Injuries Injuries Wiroon Laupattarakasem, M.D. Wiroon Laupattarakasem, M.D. Professor in Orthopaedics Professor in Orthopaedics Faculty of Medicine Faculty of Medicine Khon Kaen University Khon Kaen University
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Principles of Principles of MusculoskeletalMusculoskeletalInjuriesInjuriesWiroon Laupattarakasem, M.D.Wiroon Laupattarakasem, M.D.Professor in OrthopaedicsProfessor in Orthopaedics
Faculty of MedicineFaculty of Medicine
Khon Kaen UniversityKhon Kaen University
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Contents: Contents: Fractures and DislocationsFractures and Dislocations
■ Mechanisms of injuries■ Description or terminology■ Diagnosis■ Treatment■ Fracture healing
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DefinitionsDefinitions■ Fracture
◆ Displacement of fracture fragment■ Joint injuries
◆ Dislocation (luxation) --} loss of congruency◆ Subluxation (sub+luxation)◆ Instability◆ Sprain
■ Muscle and tendon injuries◆ Tear or rupture◆ Strain
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Transverse Oblique Spiral Comminuted
FractureFracture
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Subluxation Dislocation
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ข�อเคล!"อน (subluxation)
ข�อหล&ด (dislocation)
ข�อค("งเล!อด (haemarthrosis
)
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Rupture of Meniscus
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StrainStrain
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Muscle & tendon rupture
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Mechanisms of FractureMechanisms of Fracture
ForceForce● Direct● Indirect
FractureFracture
(failure)(failure)
● Brittle● Fatigue● Plastic
LoadLoad
● Tension (tensile)● Compression● Shear
StressStress
ConcentrationConcentration● (Stress> Strength)
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Fracture MechanismFracture Mechanism
by direct forces:
‘‘ ForceForce’ vs. ‘’ vs. ‘AreaArea’’ ■ Tapping fracture■ Crushed fracture■ Penetrating fracture
Description of FracturesDescription of Fractures■ Fracture■ Fracture of the right femur■ Fracture of the right femoral shaft■ Oblique fracture of the right femoral shaft with
anteromedial displacement■ Type II open oblique fracture of the right
femoral shaft with anteromedial displacement
Which one tells you more definitely ?
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Styles:Description of FracturesDescription of Fractures
➾ Fracture of the femur➾ Femoral fracture ➾ Fractured femur➾ Fracture, femur➽ Fracture femur
ใช�บอยในภาษาพ�ดแตไมถ�กหล�กตามภาษาเข"ยน
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Description of Bone and Joint Description of Bone and Joint InjuriesInjuries■ “Fracture” / “dislocation, etc.”
◆ Adding adjective, conjunction, preposition◆ Usually describing acute conditions
● Define otherwise old fracturemal-united fractureun-united fracturerecurrent dislocation
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Description of Bone and Joint Description of Bone and Joint InjuriesInjuries■ Described by telling
‘anterior’)◆ Eponym (Colles, Monteggia, Galeazzi)◆ Complication, cause (e.g., infected, fatigue,
pathological)
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Hair-line fractureTea-cup fracture
Green-stick fracture
Buckled fractureลองเอา
ก�#งไม�สดมาห�กด�
Incomplete Fractures
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Segmental
T-shaped Y-shaped
H-shaped
Comminuted Fractures
Double
segmental
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Description of Fractures
Example:Try your own!
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Description of FracturesDescription of Fractures
✎ Closed, segmental fracture of the right femoral diaphysis and type IIIB open comminuted fractures of the ipsilateral tibial shaft with bone loss
Example:
ลองประเม�นต�วเองด�วาเข�าใจ
ท'กค)าหร*อไม
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■ Closed, segmental fracture of the right femoral diaphysis
■ Type IIIB open comminuted fractures of the ipsilateral tibial shaft with bone loss
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Open fracturesOpen fractures
■ Open fracture = fracture + contamination
■ Classifications ---} prognosis◆ Type I: inside - out◆ Type II: outside - in◆ Type III: Type II + destruction
of other functional unit(s)
ไมใช Openedfracture
Type IIIA, B, C
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Type III Open FracturesType III Open Fractures■ Shotgun fracture■ High velocity gunshot fracture■ Displaced segmental fracture■ Diaphyseal segmental bone loss■ Farm yard / highly contaminated (wound) ■ Crushed fracture from high speed vehicle■ Associated major vascular injury
General principles of treatmentGeneral principles of treatment
■ Firstly do no harm■ Base treatment on an accurate diagnosis and
prognosis■ Select treatment for specific problems■ Cooperate with the laws of nature■ Be realistic and practical in treatment■ Select treatment for individual patient
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■ Definitive treatments of fracture / dislocation◆ Reduction (manipulation)◆ Immobilization
TreatmentTreatment
Retention of reduction
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Closed Closed VsVs Open Treatment Open Treatment
■ Joint immobilization■ Skin problems■ Socioeconomic problems■ Risks of surgery
Open reduction --} direct fixationOpen reduction --} direct fixation■ A closed fracture that closed reduction cannot be
obtained and/or subsequently maintained■ Open fracture, after sufficient debridement■ Stable or rigid fixation can be obtained by internal
fixation (osteosynthesis) ◆ plate, screws ◆ intramedullary nail or rod (other modified designs)◆ tension band wiring
■ ‘External fixator’ application
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Excision of a fracture fragment --} Excision of a fracture fragment --} + endoprosthesis replacement+ endoprosthesis replacement
■ Excisional arthroplasty■ High incidence of avascular necrosis, nonunion,
posttraumatic osteoarthritis ◆ femoral neck # in an elderly or being osteoporotic◆ comminuted radial head # in young adults◆ comminuted humeral head # (4-part #)◆ severe comminuted # of the patella
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LigamentotaxisLigamentotaxis■ Severe comminuted fractures of the joint not
feasible for open reduction and fixation ◆ severe comminuted # of distal radius
■ Distraction of the ligaments and capsule to hold the fracture fragments together as reduction
◆ using external fixator and encourage early motion
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Ligamentotaxis
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Bag-of-bone technique
■ Severely comminuted fractures of cancellous bone not feasible for open reduction and fixation
◆ severely comminuted calcaneal #■ Manipulative molding of the fragments as an