Orthopaedics
Tutorial
Describing a Fracture
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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)
A few buzz words
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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
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Impacted - broken ends of the bone are jammed together by the force of the injury
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Avulsion - fragment of bone tears away from the main mass of bone
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Pathological - # in of diseased bone (osteoporosis/mets/osteomalacia)
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Fracture dislocation - severe injury in which both fracture and dislocation take
place simultaneously
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Deformity
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Displacement – distal fragment + %
Angulation NOT tilt – BE CAREFUL – distal fragment…ant/post med/lat
Rotation – distal part…internal or external rotation
Bony Anatomy
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Hands
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8 Carpals bones
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5 Metacarpals (Name wrt fingers)
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14 Phalanges
Long Bones
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Shaft/Diaphysis + epiphysis @ ends
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Separated by Epiphyseal Growth Plate
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Bone narrows at metaphysis
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Condyles
Compound #’s
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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
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Mxt
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Life B4 Limb…ATLS Principles
Analgesia (Reduce deformity & splint)
Wound Swab + Irrigate with Sterile saline + Cover with Iodine
Backslab
IV A/b’s + Tetanus
Treatment of Fractures
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Primary Aims
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Life before limb (ATLS Guidelines)
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Bony Union without deformity ASAP
Restoration of function ASAP
ACBC
Temporary splint
Reposition fragment immediately if skin @ risk
If open A/b’s + Tetanus
Assess clinically & radiologically
In Short
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Analgesia + Reduction (Open or Closed)
Maintain reduction (External or Internal)
Rehabilitation/Physio
Fracture Reduction
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Why? - Cosmesis…Function…Prevent complications
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Is reduction necessary ?
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Closed
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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 #
MUA ± Traction
Open if
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If open #
If closed methods failed
If considered the best way to treat # ie. If internal fixation required
Maintenance of Reduction
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External
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Plaster of Paris
External Traction
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Femoral #’s – Thomas splint
External fixator
 Severe soft tissue damage/open/comminuted #’s
 Infected #’s
 Pelvic #’s
Internal (screws/nails/plates/combination of latter)
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AI
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If closed reduction impossible (soft tissue interposition)
If closed reduction maintenance not possible (# NOF)
If accuracy vital (articular surfaces)
Multiple injuries
RI
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Earlier mobilisation/hospital d/c desired
Complications of Fractures
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Surgery & Anaesthesia related
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Tissue Damage
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Bleeding…infection…U&E imbalance… hypercatabolic response to
trauma
Prolonged Recumbency
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CVS + Resp
Resp…DVT…muscle wasting…OP…UTI… Constipation…Pressure
sores
Specific to #’s
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See next slide
# Complications
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Union Problems
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Slow…eventually → healing
Delayed…may → healing or → non-union
Non…
Mal… → healing BUT affects aesthetics or function
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Joint Stiffness
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Avascular necrosis
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scaphoid, femoral head, talus
Sudeck’s atrophy/Complex regional pain syn/Reflex symp
dystrophy
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Wrist, ankle, foot, knee
Pain, swelling, discoloration, stiffness, abn skin moisture, tenderness
PT/OT/Meds/Sympathectomy
# Complications
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Acute ischaemic limb
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Nerve damage
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Immediate…uncommon usually neuropraxia seldom axonotmesis &
rarely neurotmesis
Delayed…Carpel Tunnel Syndrome
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Delayed tendon rupture…Colles # (EPL)
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Other
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Fat embolism
Osteitis
Myositis ossificans
Scaphoid Fractures
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Scaphoid #’s are the most common carpal bone fracture and typically occur
from a fall on the outstretched arm with the wrist in dorsiflexion
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Carefully scrutinize Xrays
 Scaphoid views…4 required
 Look for concomitant scapho-lunate ligament injury
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Txt
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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
Normal Wrist
Scaphoid Cast
Scapho-Lunate Dislocation
Scaphoid Fracture
Colles Fractures
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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
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Radial Distal fragment
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Dorsal & Radial displacement
Dorsal & Radial tilt (palmar & ulnar angulation)
Impaction
Ulnar # (if present)…significant injury!
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Avulsion of the ulnar styloid
Colles #
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Post injury/ # manipulation, pay close attention to neurovascular
status & beware of ACS
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Txt
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Undisplaced…Analgesia + Backslab
Displaced…Reduce in A&E or MUA
Complications
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Anaesthetic
General – urinary retention/Resp TI/MI/CCF/DVT
Specific
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Union problems
CTS
CRPS
Delayed rupture Extensor pollicis longus
Dinner Fork deformity
Colles #
Colles #
Colles #
Hip Fractures
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Aet: Fall + OP in old dears
# Sites
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Intracapsular
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Extracapsular
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Subcapital
Transcervical
Basal
Intertrochanteric
Subtrochanteric
Diagnosis
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Hx: Inability to WB
O/E: Ext rotation, shortened, tender ant/lat
XRay: AP + Lat
Hip Fractures
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Intracapsular (avascular necrosis + non-union)
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Disrupt blood supply from diaphysis → risk AVN femural
head
Garden Classification
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I…Inferior cortex intact…undisplaced
II...Sup→Inf # line…undisplaced
III...Slight displacement
IV…Gross displacement
Txt:
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Analgesia
Bloods
Medical Workup
Hip Fractures
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Specific fracture mxt – Age + Displacement
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Extracapsular #’s
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Subcapital, Introchanteric & basal cervival – Closed reduction +
Dynamic Hip Screw (DHS)
Subtroch - ORIF
Intracapsular #’s
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Garden I/II
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Aged < 55/60 → ORIF (DHS)
Aged > 60 + fit ORIF (DHS)
If very old & confined to bed/chair → conservative mxt
Garden III/IV
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If young & fit → ORIF but THR if ↑ risk complications
If ‘serior’ → Arthroplasty
 Bipolar/Austin Moore/Thompson
‘The Limping Child’
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Diff Dx:
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Cong or Acquired Causes (Vitamin D)
Specific Hip Pathologies
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Hx:
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10 Q’s re Pain…any trauma…age of child… recent
flu/illness…other pains
O/E:
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CDH…Perthes…SUFE…TS/HIS…INFECTION
Temp…Gait…Compare both sides…foot FB…
infection…rash….neuro exam + both lower limb
Tests:
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ESR/CRP/FBC/Xray both hips ± US/S Hip
Specific Hip Pathologies
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SUFE (adolescents
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Perthes disease (3 – 10 yrs)
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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
Aseptic necrosis of the capital epiphysis… M>F …PAINFUL limp…normal
bloods but X Rays always abnormal…
Txt – Refer ortho
Transient Synovitis (All ages)
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Commonest…± Hx trauma/viral illness…Limp… well + ESR
normal…normal X Ray & US/S ± → effusion….
Txt – Rest + NSAID
CDH/DDH
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Aet:
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½ hips dislocated @ birth…F>M + breech
Screening
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Older Child
 Gait/posture abn…limb shortening
Neonate
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Twice in 1st 3 months (Ortholani + Barlow’s tests)
+ US if high risk (breech, FH, clicking hip, other abn’s)
Mxt
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Hip Spica
Osteotomy
Salter Harris Classification