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Orthopaedics Tutorial. 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

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describing a fracture
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)
a few buzz words
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
bony anatomy
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
compound s
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
treatment of fractures
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
fracture reduction
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
maintenance of reduction
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
complications of fractures
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
complications
# 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
complications1
# 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
scaphoid fractures
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
colles fractures
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
colles
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
hip fractures
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
hip fractures1
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
hip fractures2
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
the limping child
‘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
specific hip pathologies
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
cdh ddh
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