Orthopaedics Tutorial

1. Orthopaedics Tutorial

2. Describing a Fracture • Closed or Open/Compound • Bone involved • Side (LHS & RHS) • # Position (proximal/middle/distal 1/3) • # Type (simple, comminuted oblique, spiral) • IA Involvement • Deformity (displacement, angulation, rotation) • Grade or Classification • Complications (vascular, neurological, tissue loss)

3. A few buzz words • Greenstick - incomplete # of long bone with cortical disruption on 1 side & deformity on the other • Torus - specific type of greenstick # in which the bone is compressed to form a ring (torus) of compressed injured bone but little angular deformity • Impacted - broken ends of the bone are jammed together by the force of the injury • Avulsion - fragment of bone tears away from the main mass of bone • Pathological - # in of diseased bone (osteoporosis/mets/osteomalacia) • Fracture dislocation - severe injury in which both fracture and dislocation take place simultaneously • Deformity • Displacement – distal fragment + % • Angulation NOT tilt – BE CAREFUL – distal fragment…ant/post med/lat • Rotation – distal part…internal or external rotation

8. Bony Anatomy • Hands • 8 Carpals bones • 5 Metacarpals (Name wrt fingers) • 14 Phalanges • Long Bones • Shaft/Diaphysis + epiphysis @ ends • Separated by Epiphyseal Growth Plate • Bone narrows at metaphysis • Condyles

11. Compound #’s • Gustillo Classification I – Wound clean & < 1cm II – Wound > 1cm…no tissue loss/flap lacerations III a - Extensive tissue loss/flap laceration b - Bone exposure c - Vascular injury • Mxt • Life B4 Limb…ATLS Principles • Analgesia (Reduce deformity & splint) • Wound Swab + Irrigate with Sterile saline + Cover with Iodine • Backslab • IV A/b’s + Tetanus

12. Treatment of Fractures • Primary Aims • Bony Union without deformity ASAP • Restoration of function ASAP • Life before limb (ATLS Guidelines) • ACBC • Temporary splint • Reposition fragment immediately if skin @ risk • If open A/b’s + Tetanus • Assess clinically & radiologically • In Short • Analgesia + Reduction (Open or Closed) • Maintain reduction (External or Internal) • Rehabilitation/Physio

13. Fracture Reduction • Why? - Cosmesis…Function…Prevent complications • Is reduction necessary ? • NO IF : • Undisplaced • Dsplacement likely to be corrected by remodelling • Patient not fit for a haircut !!! - Very elderly • YES IF : • Slight displacement in functionally vital area (articular surface) • Significant displacement/angulation/rotation – criteria vary for each # • Closed • MUA ± Traction • Open if • If open # • If closed methods failed • If considered the best way to treat # ie. If internal fixation required

14. Maintenance of Reduction • External • Plaster of Paris • External Traction • Femoral #’s – Thomas splint • External fixator • Severe soft tissue damage/open/comminuted #’s • Infected #’s • Pelvic #’s • Internal (screws/nails/plates/combination of latter) • AI • If closed reduction impossible (soft tissue interposition) • If closed reduction maintenance not possible (# NOF) • If accuracy vital (articular surfaces) • Multiple injuries • RI • Earlier mobilisation/hospital d/c desired

17. Complications of Fractures • Surgery & Anaesthesia related • CVS + Resp • Tissue Damage • Bleeding…infection…U&E imbalance… hypercatabolic response to trauma • Prolonged Recumbency • Resp…DVT…muscle wasting…OP…UTI… Constipation…Pressure sores • Specific to #’s • See next slide

18. # Complications • Union Problems • Slow…eventually → healing • Delayed…may → healing or → non-union • Non… • Mal… → healing BUT affects aesthetics or function • Joint Stiffness • Avascular necrosis • scaphoid, femoral head, talus • Sudeck’s atrophy/Complex regional pain syn/Reflex symp dystrophy • Wrist, ankle, foot, knee • Pain, swelling, discoloration, stiffness, abn skin moisture, tenderness • PT/OT/Meds/Sympathectomy

20. # Complications • Acute ischaemic limb • Nerve damage • Immediate…uncommon usually neuropraxia seldom axonotmesis & rarely neurotmesis • Delayed…Carpel Tunnel Syndrome • Delayed tendon rupture…Colles # (EPL) • Other • Fat embolism • Osteitis • Myositis ossificans

21. Scaphoid Fractures • Scaphoid #’s are the most common carpal bone fracture and typically occur from a fall on the outstretched arm with the wrist in dorsiflexion • Carefully scrutinize Xrays • Scaphoid views…4 required • Look for concomitant scapho-lunate ligament injury • Txt • If clinical or radiological evidence of a fracture…scaphoid POP + review in 10 days • If persistant symptoms + negative X Ray → bone scan/MRI • Complications • Non-union, avascular necrosis, OA

22. Normal Wrist

23. Scaphoid Cast

24. Scapho-Lunate Dislocation

25. Scaphoid Fracture

26. Colles Fractures • Definition – distal radial # within 1’ of wrist • Typical mechanism - Fall onto an outstretched hand • Young 2o high-energy trauma while in older 2o low-energy trauma to osteoporosis • 4 Features • Radial Distal fragment • Dorsal & Radial displacement • Dorsal & Radial tilt (palmar & ulnar angulation) • Impaction • Ulnar # (if present)…significant injury! • Avulsion of the ulnar styloid

27. Colles # • Post injury/ # manipulation, pay close attention to neurovascular status & beware of ACS • Txt • Undisplaced…Analgesia + Backslab • Displaced…Reduce in A&E or MUA • Complications • Anaesthetic • General – urinary retention/Resp TI/MI/CCF/DVT • Specific • Union problems • CTS • CRPS • Delayed rupture Extensor pollicis longus

28. Dinner Fork deformity

29. Colles #

30. Colles #

31. Colles #

32. Hip Fractures • Aet: Fall + OP in old dears • # Sites • Intracapsular • Subcapital • Transcervical • Basal • Extracapsular • Intertrochanteric • Subtrochanteric • Diagnosis • Hx: Inability to WB • O/E: Ext rotation, shortened, tender ant/lat • XRay: AP + Lat

34. Hip Fractures • Intracapsular (avascular necrosis + non-union) • Disrupt blood supply from diaphysis → risk AVN femural head • Garden Classification • I…Inferior cortex intact…undisplaced • II...Sup→Inf # line…undisplaced • III...Slight displacement • IV…Gross displacement • Txt: • Analgesia • Bloods • Medical Workup

35. Hip Fractures • Specific fracture mxt – Age + Displacement • Extracapsular #’s • Subcapital, Introchanteric & basal cervival – Closed reduction + Dynamic Hip Screw (DHS) • Subtroch - ORIF • Intracapsular #’s • Garden I/II • Aged < 55/60 → ORIF (DHS) • Aged > 60 + fit ORIF (DHS) • If very old & confined to bed/chair → conservative mxt • Garden III/IV • If young & fit → ORIF but THR if ↑ risk complications • If ‘serior’ → Arthroplasty • Bipolar/Austin Moore/Thompson

37. ‘The Limping Child’ • Diff Dx: • Cong or Acquired Causes (Vitamin D) • Specific Hip Pathologies • CDH…Perthes…SUFE…TS/HIS…INFECTION • Hx: • 10 Q’s re Pain…any trauma…age of child… recent flu/illness…other pains • O/E: • Temp…Gait…Compare both sides…foot FB… infection…rash….neuro exam + both lower limb • Tests: • ESR/CRP/FBC/Xray both hips ± US/S Hip

38. Specific Hip Pathologies • SUFE (adolescents • Slip of epiphysis on metaphysis…M>F…hormonal imbalance of trauma)…Painful limb + florid hip signs…X Rays abnormal (Trethowan’s sign)…60% bilateral… • Txt – refer ortho • Perthes disease (3 – 10 yrs) • Aseptic necrosis of the capital epiphysis… M>F …PAINFUL limp…normal bloods but X Rays always abnormal… • Txt – Refer ortho • Transient Synovitis (All ages) • Commonest…± Hx trauma/viral illness…Limp… well + ESR normal…normal X Ray & US/S ± → effusion…. • Txt – Rest + NSAID

39. CDH/DDH • Aet: • ½ hips dislocated @ birth…F>M + breech • Screening • Older Child • Gait/posture abn…limb shortening • Neonate • Twice in 1st 3 months (Ortholani + Barlow’s tests) • + US if high risk (breech, FH, clicking hip, other abn’s) • Mxt • Hip Spica • Osteotomy

40. Salter Harris Classification