principles of fractures dr.david samaroo mbbs,ms department of orthopedic surgery georgetown public...

PRINCIPLES OF PRINCIPLES OF FRACTURESFRACTURES

Dr.David SamarooDr.David Samaroo MBBS,MSMBBS,MS

Department of Orthopedic Surgery Department of Orthopedic Surgery

Georgetown Public Hospital Corporation, Georgetown Public Hospital Corporation, University of Guyana School of Medicine.University of Guyana School of Medicine.

Mechanism of InjuryMechanism of InjuryTypes of TraumaTypes of Trauma

Mechanism of InjuryMechanism of InjuryTypes of ForceTypes of Force

GENERAL CONSIDERATIONS IN MUSCULOSKELETAL GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMATRAUMA

Assessment & treatment,principles of splintingAssessment & treatment,principles of splinting Signs of a Fracture……dislocations,sprains/strainsSigns of a Fracture……dislocations,sprains/strains Classification of fracturesClassification of fractures ImagingImaging NonunionNonunion MalunionMalunion Complications of fracturesComplications of fractures

COST OF MUSCULOSKELETAL COST OF MUSCULOSKELETAL TRAUMATRAUMA

Trauma is the “neglected disease”Trauma is the “neglected disease” Leading cause of death for people aged 1 to 44 yrs Leading cause of death for people aged 1 to 44 yrs

of all races & social levelsof all races & social levels More than 100,000 persons in USA die from More than 100,000 persons in USA die from

accidents; 500,000 are permanently disabledaccidents; 500,000 are permanently disabled Cost over $40 billion per yearCost over $40 billion per year Generates over 3.5 million admissions to acute-Generates over 3.5 million admissions to acute-

care hospitals per yearcare hospitals per year Local figures unavailable,you are the ones to make Local figures unavailable,you are the ones to make

them availablethem available

Penetrating TraumaPenetrating Trauma

Compression (Blunt) TraumaCompression (Blunt) Trauma

Bending TraumaBending Trauma

HyperflexionHyperflexion

HyperextensionHyperextension



Penetrating TraumaPenetrating TraumaCompression (Blunt) TraumaCompression (Blunt) TraumaBending TraumaBending Trauma

HyperflexionHyperflexionHyperextensionHyperextension

Severe Contusion of FootSevere Contusion of Foot

CervicalCervical(C5-C6) (C5-C6) Fracture Fracture

DislocationDislocation

Dorsal Dorsal Dislocation, Dislocation, Long Finger Long Finger Middle JointMiddle Joint(PIP Joint)(PIP Joint)


Rotational TraumaRotational TraumaDistraction TraumaDistraction TraumaCrush TraumaCrush TraumaDeceleration TraumaDeceleration TraumaAcceleration TraumaAcceleration Trauma

Normal Normal Tibia Tibia Left Left

SpiralSpiral

FractureFracture

Tibia Tibia

RightRight

Brachial plexus injury/Dislocation of Right Brachial plexus injury/Dislocation of Right ShoulderShoulder

Crush Injury, LegCrush Injury, Leg

Car struck from behind “accelerates” passengers, Car struck from behind “accelerates” passengers, producing an extension injury producing an extension injury

to the neck!to the neck!

Acceleration TraumaAcceleration Trauma


Direct ForceDirect Force Indirect ForceIndirect ForceTwisting ForceTwisting ForceHigh Energy ForceHigh Energy Force

DirectDirectMid-Shaft Fracture, FemurMid-Shaft Fracture, Femur

IndirectIndirectPosterior Dislocation, ElbowPosterior Dislocation, Elbow

TwistingTwistingSubtalar Dislocation, AnkleSubtalar Dislocation, Ankle

High EnergyHigh EnergyFractured PelvisFractured Pelvis

GENERAL CONSIDERATIONS IN GENERAL CONSIDERATIONS IN MUSCULOSKELETAL TRAUMAMUSCULOSKELETAL TRAUMA

Assessment & treatment priorities are Assessment & treatment priorities are established according to type of injury, established according to type of injury, stability of vital signs, & mechanism of injurystability of vital signs, & mechanism of injury

Assessment:1)Rapid primary evaluationAssessment:1)Rapid primary evaluation 2)Restoration of vital function2)Restoration of vital function

3)Detailed secondary 3)Detailed secondary evaluationevaluation

4)Definitive care4)Definitive care


ABCs of Trauma Care:ABCs of Trauma Care: Airway maintenance (with c spine control)Airway maintenance (with c spine control) Breathing and ventilationBreathing and ventilation Circulation (with hemorrhage control)Circulation (with hemorrhage control) Disability (neurologic status)Disability (neurologic status) Exposure & environmental control (undress pt but Exposure & environmental control (undress pt but

prevent hypothermia)prevent hypothermia)


Pre-Hospital Principles:Pre-Hospital Principles: Joints above & below fracture should be immobilizedJoints above & below fracture should be immobilized Splints can be improvised with pillows, blankets, or Splints can be improvised with pillows, blankets, or

clothingclothing Immobilization doesn’t need to be absolutely rigidImmobilization doesn’t need to be absolutely rigid Overt bleeding should be tamponaded with dressing & firm Overt bleeding should be tamponaded with dressing & firm

pressurepressure Tourniquets should be avoided, unless it is obvious that pts Tourniquets should be avoided, unless it is obvious that pts

life is in dangerlife is in danger

Injury ManagementInjury ManagementSplinting Immobilizes the Injury Splinting Immobilizes the Injury Reduces PainReduces Pain

Prevents further damage to blood Prevents further damage to blood vessels, nerves and skin adjacent to vessels, nerves and skin adjacent to the injurythe injury

Decreases BleedingDecreases Bleeding

Facilitates TransportFacilitates Transport

Principles of SplintingPrinciples of Splinting Dress all woundsDress all wounds Immobilize the joints above and below a Immobilize the joints above and below a

suspected fracturesuspected fracture With injuries at or near joints, immobilize With injuries at or near joints, immobilize

the bones above and below the injurythe bones above and below the injury Stabilize the injury site during splint Stabilize the injury site during splint

application application

Principles of SplintingPrinciples of Splinting

Use gentle in-line manual traction to realign Use gentle in-line manual traction to realign displaced long bone fracturesdisplaced long bone fractures

Expect to encounter increased pain and some Expect to encounter increased pain and some resistance when attempting to realign a resistance when attempting to realign a deformed limbdeformed limb

Immobilize all suspected spinal injuries Immobilize all suspected spinal injuries in a in a neutral in-line positionneutral in-line position on a spineboard on a spineboard

Principles of SplintingPrinciples of Splinting

If the patient demonstrates major signs of If the patient demonstrates major signs of shock, align the limb as close to its normalshock, align the limb as close to its normal anatomic alignment as possible on a anatomic alignment as possible on a spineboard (immobilization of total body), and spineboard (immobilization of total body), and provide rapid transport provide rapid transport

Total Body ImmobilizationTotal Body Immobilization

When in doubt:When in doubt:

SPLINT!SPLINT!

Rigid SplintsRigid Splints Quick Splint Cardboard SplintQuick Splint Cardboard Splint

Ladder Splint SAM Splint Ladder Splint SAM Splint

Soft SplintsSoft Splints Air Splint Vacuum SplintAir Splint Vacuum Splint

Sling and Swathe Blanket Roll Sling and Swathe Blanket Roll

Traction SplintTraction Splint

When standard splints When standard splints are unavailable, are unavailable,

improvisation improvisation is better than doing nothing!is better than doing nothing!

UPPER UPPER EXTREMITYEXTREMITY

All fractures can be All fractures can be immobilized by immobilized by

securing the securing the extremity to the extremity to the

chest!chest!

LOWER EXTREMITYLOWER EXTREMITYAll fractures can be immobilized by All fractures can be immobilized by securing the injured extremity to the securing the injured extremity to the

opposite lower extremity!opposite lower extremity!


ORTHOPEDIC EXAMORTHOPEDIC EXAM Assess axial skeleton, pelvis, & extremitiesAssess axial skeleton, pelvis, & extremities Depends on overall central neurologic statusDepends on overall central neurologic status Assess for swelling, hematomas, open woundsAssess for swelling, hematomas, open wounds Palpate entire spine, pelvis, & each jointPalpate entire spine, pelvis, & each joint Exam pelvis by compression of iliac wings in mediolateral Exam pelvis by compression of iliac wings in mediolateral

direction & pubisdirection & pubis Must document neurologic status to fullest extent possible, Must document neurologic status to fullest extent possible,

motor & sensory, all major nerves & dermatomes inupper motor & sensory, all major nerves & dermatomes inupper & lower extremities& lower extremities

Must document all reflexes Must document all reflexes

Signs of a FractureSigns of a Fracture

TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb

Seven Seven Signs of FractureSigns of Fracture


Fractured PatellaFractured Patella

AngulatedAngulated Fracture, Fracture, Radius and UlnaRadius and Ulna

CrepitusCrepitusIn a complete fracture, In a complete fracture, the sounds of bone the sounds of bone

ends clicking or rubbing against each other;ends clicking or rubbing against each other; denotes an unstable fracture!denotes an unstable fracture!

Open Ankle FractureOpen Ankle Fracture

Seven Seven Signs of FractureSigns of Fracture TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb

False MotionFalse MotionThe unusual visual sensation of The unusual visual sensation of

observing motion at a long bone fracture observing motion at a long bone fracture site wheresite where

““there is no joint!” there is no joint!”

Seven Seven Signs of FractureSigns of Fracture TendernessTenderness Swelling and EcchymosisSwelling and Ecchymosis DeformityDeformity CrepitusCrepitus Exposed FragmentsExposed Fragments False MotionFalse Motion Inability to Use the LimbInability to Use the Limb

Fracture, Right Clavicle Fracture, Right Clavicle Right Arm ProtectedRight Arm Protected

Seven Signs of FractureSeven Signs of Fracture

The presence of The presence of

any oneany one

of the of the

seven fracture signs just listed seven fracture signs just listed

is sufficient to assess this injury!is sufficient to assess this injury!

Types of Injury Types of Injury DislocationDislocation

Disruption of a joint such that the bone Disruption of a joint such that the bone ends are no longer in contactends are no longer in contact

Must have torn ligaments and joint Must have torn ligaments and joint capsulecapsule

Signs of DislocationSigns of Dislocation

TendernessTenderness Deformity (usually marked)Deformity (usually marked) Swelling and EcchymosisSwelling and Ecchymosis Loss of normal joint motionLoss of normal joint motion

Common DislocationsCommon Dislocations

ShoulderShoulderFingerFingerHipHipElbowElbow

Anterior Dislocation, Right ShoulderAnterior Dislocation, Right Shoulder

Dislocation, Middle Joint Dislocation, Middle Joint (PIP Joint), Ring Finger(PIP Joint), Ring Finger

Posterior Hip DislocationPosterior Hip Dislocation


ShoulderShoulder FingerFinger HipHip ElbowElbow

Posterior Elbow DislocationPosterior Elbow Dislocation

Types of InjuryTypes of Injury Fracture-DislocationFracture-Dislocation

A combined injury with joint A combined injury with joint dislocation and an adjacent bone dislocation and an adjacent bone fracturefracture

Fracture–Dislocation, AnkleFracture–Dislocation, Ankle

Types of Injury Types of Injury SprainSprain

Partial or completePartial or completetemporarytemporary joint dislocationjoint dislocation

Ligaments are torn Ligaments are torn partially or completelypartially or completely

May produce as much structural May produce as much structural damage as a dislocationdamage as a dislocation

Sprain, Left AnkleSprain, Left Ankle

Types of InjuryTypes of InjuryStrainStrain

““Muscle Pull”Muscle Pull”

Stretching or tearing of muscle, Stretching or tearing of muscle, or muscle fascia (covering)or muscle fascia (covering)

Occurs frequently in the lower Occurs frequently in the lower back secondary to poor posture back secondary to poor posture and poor abdominal muscle and poor abdominal muscle controlcontrol

Types of InjuryTypes of InjuryFractureFracture

• Any break in the continuity of a Any break in the continuity of a bonebone

• May vary from a simple crack to a May vary from a simple crack to a completely shattered bonecompletely shattered bone

FRACTURE FRACTURE CLASSIFICATIONCLASSIFICATION

Location of boneLocation of bone-Epiphyseal -Metaphyseal -Diaphseal-Epiphyseal -Metaphyseal -Diaphseal

Integrity of skin & soft tissue envelopeIntegrity of skin & soft tissue envelope

-Open vs. Closed-Open vs. Closed

Amount of displacementAmount of displacementNondisplaced AngulatedNondisplaced Angulated Displaced DistractedDisplaced Distracted

Incomplete/CompleteIncomplete/Complete

----

FRACTURE CLASSIFICATIONFRACTURE CLASSIFICATION

Orientation/Extension of Fracture LineOrientation/Extension of Fracture Line-Transverse-Transverse -Torus -Torus-Comminuted-Comminuted -Greenstick-Greenstick-Oblique-Oblique -Impaction-Impaction-Segmental-Segmental -Compression-Compression-Spiral-Spiral -Depression-Depression-Intra-articular-Intra-articular -Stress (Fatigue)-Stress (Fatigue)-Pathologic -Linear-Pathologic -Linear

Closed Fracture,Closed Fracture,

Base of ThumbBase of Thumb

ClosedClosed Dorsally Dorsally Angulated Angulated

Forearm FractureForearm Fracture

Open Fracture, TibiaOpen Fracture, Tibia

Open Fracture, ForearmOpen Fracture, Forearm

Open Fracture, ForearmOpen Fracture, Forearm

Open Fractures Are More Open Fractures Are More Serious!Serious!

Blood lossBlood loss

Potential contamination with Potential contamination with risk of infectionrisk of infection

Fracture ClassificationFracture Classification

Closed/OpenClosed/Open


Displaced/DisplacedDisplaced/Displaced

Incomplete Fracture, Incomplete Fracture, Distal RadiusDistal Radius

Complete Fracture, FemurComplete Fracture, Femur

Fracture ClassificationFracture Classification

Closed/OpenClosed/Open


Non-Displaced/DisplacedNon-Displaced/Displaced

Non-Displaced Fracture, Non-Displaced Fracture, Distal Tibia and FibulaDistal Tibia and Fibula

Displaced/Angulated Forearm Displaced/Angulated Forearm FracturesFractures

Types of FractureTypes of Fracture

Comminuted – fractured into more Comminuted – fractured into more than two segmentsthan two segments

Pathologic – fracture through Pathologic – fracture through diseased bonediseased bone

Epiphyseal – fracture passes through Epiphyseal – fracture passes through the growth platethe growth plate

Comminuted Femur FractureComminuted Femur Fracture

Types of Fracture

Comminuted – fractured into more than two segments

Pathologic – fracture through diseased bone

Epiphyseal – fracture passes through the growth plate

PathologicPathologicLytic lesion (darker = tumor) in Lytic lesion (darker = tumor) in proximal phalanx of finger, with proximal phalanx of finger, with

associated transverse fractureassociated transverse fracture

Other Types of Fracture

Comminuted – fractured into many pieces

Pathologic – fracture through diseased bone

Epiphyseal – fracture through the growth plate

Epiphyseal (growth-line) Fracture, Epiphyseal (growth-line) Fracture, Distal Femur Distal Femur


CONFIGURATION OF FRACTURES:CONFIGURATION OF FRACTURES: Intra-articular (fx line crosses articular cartilage & Intra-articular (fx line crosses articular cartilage &

involves joint)involves joint) Displaced (expressed in mm or cm or Displaced (expressed in mm or cm or %% in in

direction of displacement of distal fragment)direction of displacement of distal fragment) NondisplacedNondisplaced Angulated (expressed in degrees in direction of Angulated (expressed in degrees in direction of

apex)apex) Comminuted (more than 1 piece at one fx location)Comminuted (more than 1 piece at one fx location)


IMAGING STUDIES:IMAGING STUDIES: Polytrauma pts: c-spine, chest, pelvisPolytrauma pts: c-spine, chest, pelvis Long bone fx requires complete evaluation of Long bone fx requires complete evaluation of joint joint

proximally & distally to fxproximally & distally to fx Long bone x-rays, minimum of 2 views Long bone x-rays, minimum of 2 views AP & LateralAP & Lateral CT scans visualize complex fx patterns esp with joint CT scans visualize complex fx patterns esp with joint

involvementinvolvement MRI scans give soft tissue detailsMRI scans give soft tissue details Bone scan: indicative of blood flow & therefore of bone Bone scan: indicative of blood flow & therefore of bone

formation or destructionformation or destruction


““Clearing” the Cervical Spine:Clearing” the Cervical Spine: X-ray: A-P views, Lateral views, Open mouth X-ray: A-P views, Lateral views, Open mouth

odontoid viewodontoid view Open mouth: lateral masses of C1 should line up Open mouth: lateral masses of C1 should line up

with body of C2with body of C2

Must see down to C7, if can’t then Swimmer’s Must see down to C7, if can’t then Swimmer’s view, lateral cervical spine x-ray with arm abducted view, lateral cervical spine x-ray with arm abducted & elevated& elevated

May need flex/ext views to determine ligamentous May need flex/ext views to determine ligamentous stabilitystability


““Clearing” the Cervical Spine:Clearing” the Cervical Spine: Amount of total overhang of C1 over C2 should be Amount of total overhang of C1 over C2 should be

less than 3 mmless than 3 mm

Lateral view, anterior border of bodies of cervical Lateral view, anterior border of bodies of cervical segments should describe an arcsegments should describe an arc

No diastasis of spinous processesNo diastasis of spinous processes

Joints & facet joints should all be visibleJoints & facet joints should all be visible

Watch orientation from one cervical spine level to Watch orientation from one cervical spine level to another, r/o cervical fx, jumped facets, or dislocationsanother, r/o cervical fx, jumped facets, or dislocations


NONUNION:NONUNION:Nonunion: fx that fails to show progressive healing ,there are permanent radiologic Nonunion: fx that fails to show progressive healing ,there are permanent radiologic

signs the situation is permanentsigns the situation is permanent

CLASSIFICATION OF NONUNIONS:CLASSIFICATION OF NONUNIONS: Hypertrophic: “elephant’s foot ”, “horse’s foot ”Hypertrophic: “elephant’s foot ”, “horse’s foot ”

flared out with viable bone ends,fracture visible ,fracture filled with cartilage and flared out with viable bone ends,fracture visible ,fracture filled with cartilage and fiberous tissuefiberous tissue

Atrophic: nonviable bone ends,rounded,osteoporoticAtrophic: nonviable bone ends,rounded,osteoporotic

If left untreated, may develop into pseudoarthrosis (false joint)If left untreated, may develop into pseudoarthrosis (false joint)

Causes of non unionCauses of non union

GeneralGeneral

SpecificSpecific

Diastasis of fx fragmentDiastasis of fx fragment

Compromise blood supplyCompromise blood supply

Excessive motionExcessive motion

InfectionInfection


CAUSES OF NONUNION:CAUSES OF NONUNION:

1) General: age, nutrition, steroids, anticoagulants, radiation, burns, 1) General: age, nutrition, steroids, anticoagulants, radiation, burns, immunosupression -predisposure to nonunionimmunosupression -predisposure to nonunion

2)Diastasis of fx fragment2)Diastasis of fx fragment

a. Soft tissue interpositiona. Soft tissue interposition

b. Distraction from traction or internal fixationb. Distraction from traction or internal fixation

c. Malposition d. Loss of bonec. Malposition d. Loss of bone


3)Compromised blood supply3)Compromised blood supply

a. Damage to nutrient vesselsa. Damage to nutrient vessels

b. Stripping or injury to periosteum & muscleb. Stripping or injury to periosteum & muscle

c. Free fragments; severe comminutionc. Free fragments; severe comminution

d. Avascularity due to internal fixation devicesd. Avascularity due to internal fixation devices

CAUSES OF NONUNIONCAUSES OF NONUNION:


CAUSES OF NONUNIONS:CAUSES OF NONUNIONS:

4) Excessive motion: inadequate immobilization4) Excessive motion: inadequate immobilization

5) Infection5) Infection

a) Bone death (sequestrum)a) Bone death (sequestrum)

b) Osteolysis (Gap)b) Osteolysis (Gap)

c) Loosening of implants (motion)c) Loosening of implants (motion)


NONUNION OF FRACTURES:NONUNION OF FRACTURES: Delayed union: fx that has not gone on to full bony Delayed union: fx that has not gone on to full bony

healing after 6 monthshealing after 6 months Areas prone to nonunion:Areas prone to nonunion:

Distal tibial diaphysisDistal tibial diaphysis Proximal diaphysis of 5Proximal diaphysis of 5thth metatarsal metatarsal Segmental fxSegmental fx Transcervical hip fx,scaphoid,talusTranscervical hip fx,scaphoid,talus


TREATMENT OF NONUNIONS:TREATMENT OF NONUNIONS: Correction of cause, if possibleCorrection of cause, if possible Stabilization of bone endsStabilization of bone ends Eradication of infectionEradication of infection Restoration of blood supplyRestoration of blood supply Surgical excision of interposing tissuesSurgical excision of interposing tissues Bone graft of fracture gaps at time of internal Bone graft of fracture gaps at time of internal

fixationfixation


MALUNION OF FRACTURE:MALUNION OF FRACTURE: Fx that has healed with unacceptable amt of Fx that has healed with unacceptable amt of

angulation, rotation,or overridingangulation, rotation,or overriding Shortening is better tolerated in upper ext than Shortening is better tolerated in upper ext than

lower extlower ext Angular deformity better tolerated in humerus than Angular deformity better tolerated in humerus than

femur or tibiafemur or tibia Shortening more than 1 inch is poorly tolerated in Shortening more than 1 inch is poorly tolerated in

lower extremitylower extremity


COMPLICATIONS:COMPLICATIONS: Compartment SyndromeCompartment Syndrome Acute Respiratory Distress Syndrome (Fat Acute Respiratory Distress Syndrome (Fat

Embolism Syndrome)Embolism Syndrome) Thromboembolic DiseaseThromboembolic Disease AtelectasisAtelectasis Ectopic (Heterotopic) Bone FormationEctopic (Heterotopic) Bone Formation


COMPARTMENT SYNDROME:COMPARTMENT SYNDROME: Pathologic developments in a closed space in body Pathologic developments in a closed space in body

caused by buildup of pressurecaused by buildup of pressure Pressure rises from edema or bleeding within Pressure rises from edema or bleeding within

compartment, compromising circulation to compartment, compromising circulation to compartment, can result in necrosis of muscle & compartment, can result in necrosis of muscle & nerve damagenerve damage

Causes: Fracture, soft-tissue injury, arterial injury, Causes: Fracture, soft-tissue injury, arterial injury, burn, abnl external compression from burn, abnl external compression from immobilization immobilization


COMPARTMENT SYNDROME:COMPARTMENT SYNDROME: Characteristics: PainCharacteristics: Pain

PulselessnessPulselessness

PallorPallor

ParesthesiasParesthesias

ParalysisParalysis

-Pulses generally remain intact until late-Pulses generally remain intact until late

-Paresthesias occur only when significantly advanced-Paresthesias occur only when significantly advanced

-Paresis, if present, is an unreliable finding-Paresis, if present, is an unreliable finding

-Pain with passive stretching is subjective-Pain with passive stretching is subjective


COMPARTMENT SYNDROMECOMPARTMENT SYNDROME Pressure is key componentPressure is key component Palpation of soft compartment doesn’t rule out Palpation of soft compartment doesn’t rule out

compartment syndromecompartment syndrome Intracompartmental pressure readings greater than Intracompartmental pressure readings greater than

30-40 mmHg are indications for fasciotomy30-40 mmHg are indications for fasciotomy Late fasciotomy may result in muscle damage or Late fasciotomy may result in muscle damage or

possible necrosis with resulting infectionpossible necrosis with resulting infection


COMPARTMENT SYNDROME:COMPARTMENT SYNDROME: Forearm: Extensile volar incision to permit Forearm: Extensile volar incision to permit

complete release, including carpal tunnel distally complete release, including carpal tunnel distally & lacertus fibrosis proximally; Dorsally, a & lacertus fibrosis proximally; Dorsally, a longitudinal incision is usedlongitudinal incision is used

Calf: Two incisions are used to release the four Calf: Two incisions are used to release the four compartments of legcompartments of leg

Longitudinal incision over anterior intermuscular Longitudinal incision over anterior intermuscular septum for anterior & lateral compartmentsseptum for anterior & lateral compartments

Posteromedially, second incision for superficial & deep Posteromedially, second incision for superficial & deep posterior compartmentsposterior compartments


Fat Embolism Syndrome:Fat Embolism Syndrome: Special ortho manifestation of ARDSSpecial ortho manifestation of ARDS Caused by release of marrow content into circulation e.g. Caused by release of marrow content into circulation e.g.

s/p fractures/p fracture Lungs show fat droplets, usually diffusely distributed Lungs show fat droplets, usually diffusely distributed

throughout pulmonary vasculaturethroughout pulmonary vasculature Can occur when medullary canal of a long bone is Can occur when medullary canal of a long bone is

pressurized during IM alignment jigs of TKApressurized during IM alignment jigs of TKA Dx: Decrease in arterial Po2, Increase systemic Pco2, Dx: Decrease in arterial Po2, Increase systemic Pco2,

infiltrates on chest X-ray, presence of petechiae, & mental infiltrates on chest X-ray, presence of petechiae, & mental confusionconfusion

Rx: Minimize hypoxemia with ventilatory supportRx: Minimize hypoxemia with ventilatory support


HETEROTOPIC BONE FORMATIONHETEROTOPIC BONE FORMATION Occurs in 10% of trauma casesOccurs in 10% of trauma cases May cause pain or joint motion restriction or ankylosisMay cause pain or joint motion restriction or ankylosis Without head trauma can be seen on x-ray 1-2 months after Without head trauma can be seen on x-ray 1-2 months after

traumatrauma Much more common in head injury pts, release of humeral Much more common in head injury pts, release of humeral

modulatorsmodulators Resection may be indicated by 6 months if NL alkaline Resection may be indicated by 6 months if NL alkaline

phosphatase & mature x-ray appearancephosphatase & mature x-ray appearance May benefit from low dose radiation (7Gy) & May benefit from low dose radiation (7Gy) &

indomethacin for 3-6 weeksindomethacin for 3-6 weeks

principles of fractures dr.david samaroo mbbs,ms department of orthopedic surgery georgetown public...

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