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