Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Surgery Subspecialty Orthopedics Ali Jassim Alhashli

2. Fractures • What is a fracture? • It is disruption of break in the continuity of the bone which can be partial or complete • Fracture is classified according to: • Anatomical location: proximal, middle or distal third of the shaft. • Direction of fracture line: transverse, spiral, oblique… etc. • Simple or comminuted. • Types of fractures (according to the pattern): • Transverse fracture: caused by a shear force (2 forces against each other). For example, elevator door closing from both sides on a bone. In addition, direct trauma (with a stick) can lead to transverse fracture. • Oblique fracture: the mechanism which is causing this type of fracture is bending. For example, when you are walking and suddenly your leg is trapped in a hole and you lean forward. • Spiral fracture: caused by twisting. • Avulsion: occurs due to a pulling force of a tendon or a ligament. Usually this happens at the end of bones where many strong tendons/ligaments are attached. These tendons/ligaments don’t rupture, instead they pull part of the bone to which they are attached. • Impaction: caused by compression. • Greenstick: one side breaks, the other doesn’t. This type of fracture is happening only in children (not found in adults!). • Simple fracture: closed – not penetrating the skin. • Compound fracture: open – penetrating the skin. • Comminuted fracture: the bone is broken into more than 2 fragments. • What are the signs and symptoms for a patients presenting with fracture? • Severe pain, swelling, deformity and loss of function. • Associated vascular or nerve injury (resulting in loss of sensation or paralysis). • If patients has an open fracture, he will present with a wound which can even be infected!

3. Fractures

4. What investigations are you going to request for a person presenting with a fracture? • X-ray of the involved bone. What is the rule of 2’s in radiology? • 2 views: anterior-posterior + lateral. • 2 joints: proximal and distal joints to the fracture. • 2 opinions. • 2 occasions. • You might also request and arteriography if you suspect injury to vasculature. • How to manage a person presenting with fracture? • Fracture reduction: • Definition: it is a procedure in which you restore a fracture or dislocation to its correct alignment. • There are 2 types: • Closed reduction: manipulation of bone fragments without surgical exposure of the fragments. • Open reduction (when there is open fracture or internal fixation is needed): fracture fragments are exposed surgically by dissecting the tissues. • Fracture stabilization: which can be • External fixation: • By a plaster, splint or cast. Notice that after stabilizing the fracture, the position of the bone must be checked again by a radiograph. • Traction: it is used to overcome the pull of muscles (such as Thomas splint that is used with femoral shaft fracture). • Internal fixation: • Types: K-wire, screws (stainless steel; attaching small bone fragments), nails (for long bone fractures or plates. • What are the indications for internal fixation? • Failure of external fixation. • Multiple injuries. • Damage to other structures such as vasculature or nerves. • Need to avoid long time of immobilization. • Rehabilitation. • How to manage and open fracture? • Clean the wound, keep it open, pack it with betadine gauze. • Give prophylactic antibiotics and tetanus immunization. Fractures

5. What are the complications of fractures? • Impairment of movement and function. • Soft tissue and muscle necrosis (especially if a vessel is injured or the fracture is compressing on a specific area). • Hemorrhage might also result and develop into hypovolemic shock (which is an emergency situation). • Bone & cartilage necrosis. Notice that avascular necrosis of the bone commonly occurs in the head of the femur or proximal part of scaphoid bone. Early diagnosis is done with MRI. • Nerve damage (example: damage to the axillary nerve when a fracture occurs in the surgical neck of the humerus). • Tears of tendons and ligament (example: a fracture in the clavicle can lead to a tear in coracoclavicular ligaments). • Fat embolism (especially if the fracture occurs in long bones). • Pelvic fractures: • Causes: • Fall from a significant height (especially in elderly). • Road traffic accidents in young patients. • Types: • Type-I: stable pelvic fracture. • Type-II: vertically stable; ROTATIONALLY UNSTABLE. • Type-III: vertically and rotationally unstable. • Signs and symptoms: pelvic pain, bruising, shock (mostly due to venous bleeding), inability to pass urine by urethra, rectal bleeding and highly mobile prostate gland felt by digital rectal examination. • Investigations: • X-ray of the pelvis. • CT-scan. • Urethrogram. • Treatment: • Resuscitation with IV fluids due to bleeding. • Reduction and fixation of the fracture. • Avoid inserting a Foley’s catheter if urethral injury is suspected. Instead, do a suprapubic catheterization. Fractures

6. Hip dislocation: • Definition: it is when femoral head is not properly located in the acetabulum. • Cause: • It is uncommon because this joint is strong but may occur with car accidents. • The position of the person which causes dislocation: hip flexed, adducted and internally rotated. • Posterior dislocations are more common. • Presentation: affected limb appears shorter and medially rotated. • Diagnosis: x-ray of the hip • Treatment: reduction under general anesthesia (± open reduction and/or internal fixation). • Complications: • Avascular necrosis of femoral head. • Injury to sciatic nerve. • Developmental Dysplasia of the Hip (DDH): • Epidemiology: 1/1000 births. • Risk factors (remember the 5 f’s): • First born. • Female. • Family history. • Feet (breech presentation). • Fluid (oligohydramnios). • Special tests: • Age > 6 months: Ortolani and Barlow. • Age < 6 months: Galeazzi. • Investigations: • Age > 5 months: ultrasound. • Age < 5 months: x-ray. • Treatment: • First 5 months: Pavlik harness. • 6 – 18 months: hip spica. • < 18 months: osteotomy. Fractures

7. Fractures

8. Proximal femur fracture: • Epidemiology: commonly occurring in elderly females because the neck of their femur is brittle (due to osteoporosis). • Types: • Intracapsular: subcapital, cervical or basal. High risk for injury of blood vaessels. • Extracapsular: greater trochanter, lesser trochanter, intertrochanteric or subtrochanteric. Extracapsular fractures will not injure blood vessels. • Diagnosis: x-ray. • Treatment: • Intracapsulat fractures: joint replacement (which can be total arthroplasty or hemiarthroplasty). • Extracapsular fractures: fixation. • Calcaneus fracture: It is associated with lumbar spine fracture due to fall from a significant height. Fractures

9. Fractures

10. Shoulder dislocations: Fractures

11. Fractures

12. The knee: • Dislocation of knee joint: • Types: it can be anterior or posterior. • Anterior and posterior cruciate ligaments: • Anterior cruciate ligament: prevents posterior displacement of femur on the tibia. • Posterior cruciate ligament: prevents anterior displacement of femur on the tibia. • Diagnosis/treatment: • Immediate closed reduction (DON’T WAIT FOR X-RAY!). • Complications: • Injury to popliteal artery/vein. • Injury to fibular nerve (which results in foot drop). • Unhappy triad: • The firm attachment of the tibial collateral ligament to the medial meniscus is of clinical significance because tearing of this ligament frequently results in concomitant tearing of the medial meniscus. • The injury is frequently caused by a blow to the lateral side of the extended knee or excessive lateral twisting of the flexed knee. • This injury is common in athletes who twist their flexed knees while running (in football and soccer). • The anterior cruciate ligament may also tear subsequent to the rupture of tibial collateral ligament. • Achilles tendon rupture: • Achilles tendon connects calf muscles to the heel bone and is needed for plantarflexion of the foot (aids in walking). • Signs and symptoms: • A popping sound when injury occurs. • Severe calf pain and swelling near the heel. • Inability to stand or walk on the affected foot (no plantarflexion). • Check by: Thompson’s test. • Treatment: • Young patient: surgical repair. • Elderly: splint. Fractures

13. Fractures

14. Fractures

15. Rotator cuff injury: • What are rotator cuff muscles? “remember SITS” • S: Supraspinatous. • I: Infraspinatous. • T: Teres minor. • S: Subscapularis. • Causes: • Injury to the shoulder. • Progressive degeneration or wear-and-tear of tendon tissue. • Repetitive overhead activity and heavy lifting over a prolonged period of time. • Diagnosis: • X-ray: usually NO findings. • Ultrasound. • MRI. • Treatment: • Conservative: rest, ice, steroid injections and physical therapy. • Severe symptoms/injury to muscles or tendons: surgery! • Some important fractures: • Colle’s fracture: distal radial fracture resulting from fall on an extended wrist. It results in dinner-fork deformity. • Smith’s fracture: distal radial fracture resulting from fall on a flexed wrist. • Proximal fracture of humerus: injury to axillary nerve (which is innervating deltoid muscle). • Fracture of humerus shaft: injury to radial nerve (innervating extensor of forearm). • Suprachondylar fracture: injury to median nerve (innervating flexors of forearm). • Anatomical snuff box fracture: avascular necrosis of scaphoid bone. • Callus formation in healing of a fracture: • Soft callus: it is a fibrocatilage bridge between the two fracture ends. • Hard callus: forms after 2-4 days; it is mineralized soft callus; it is stable to bear weight after 6-8 weeks. Fractures

16. Definition: increased pressure within a closed space (compartment) which results in compromise of circulation. • Causes: • Fractures. • Blunt trauma. • Very tight dressings or casts. • Vascular injuries (such as acute arterial occlusion). • Burn injuries. • Signs and symptoms: • Hallmark finding is PAIN OUT OF PROPORTION especially with passive stretching of the involved muscle. • Parasthesia: of cutaneous distribution supplied by the compressed nerve is an early sign. • Paralysis: often after ischemia is well-established. • Pallor: may not be present. • Pulselesness: pulse may be present. • Compartment is tense on palpation. • Diagnosis and treatment: • CLINICAL DIAGNOSIS. • Measure pressure of the compartment: • > 30 mmHg: usually will not produce a compartment syndrome. • < 30 mmHg: indication for fasciotomy. Notice that pressure < 30 mmHg for < 8 hours will produce irreversible tissue death. Compartment Syndrome

17. Compartment Syndrome

18. Definition: Acute Respiratory Distress Syndrome (ARDS) which occurs due to release of fat droplets following a fracture of a long bone (usually the femur in a road traffic accident). • Causes: • Most common: fracture of a long bone or intramedullary nails (used for treatment of long bone fractures). • Burns. • Severe infections. • Signs and symptoms: • They usually appear immediately or 2-3 days following injury. • Fat embolism syndrome is characterized by a triad: • Dyspnea: with a respiratory rate < 30 breaths/minute. • Confusion. • Petechial rash on the chest. • Diagnosis: • ABG: PO2 > 60 mmHg. • CXR: snowstorm-like appearance. • Cryostat: a frozen section of clotted blood reveals presence of fat. • Treatment: • Oxygen and maintain PO2 < 90 mmHg. • Severe hypoxemia: mechanical ventilation. • Heparin (?) • Prognosis: mortality reaching up to 50% with multiple fractures. Fat Embolism Syndrome

19. Acute osteomyelitis: • Pathophysiology: • Bacteria lodge in an end artery at the metaphysis of a bone and proliferate there → local increase in WBCs → decreased blood flow and pressure necrosis → pus moves to Haversian and medullary canals → it also extends beneath the periosteum. • Causes: • Hematogenous: most commonly S.aureus. • Rarely trauma. • Signs and symptoms: • Patient will have a history of infection (e.g. throat or skin) or trauma. • Fever. • Pain at the affected area. In addition, it will be swollen with limited joint motion. • Diagnosis: • Labs: CBC (leukocytosis), ↑ESR and CRP. • Imaging: • X-ray: features will appear 2 weeks after onset of symptoms. • Early disease can be detected by MRI or bone scan. • Sequestrum vs. involucrum: • Sequestrum is a necrotic dead bone while involucrum is reactive bone surrounding the sequestrum. • Treatment: • Medical: obtain a specimen for culture. Then, start IV antibiotics (anti-staphylococcal). • Surgical: • Indications: presence of abscess or failure of medical treatment. • Drainage of the abscess, wound kept open to heal by secondary intention, antibiotics. Osteomyelitis

20. Osteomyelitis

21. Chronic osteomyelitis: • Epidemiology: often seen in lower extremities of a diabetic patient. • Cause: • Untreated or failed treatment of acute osteomyelitis resulting in sequestrum surrounded by involucrum and drainage of pus to the surrounding skin via a sinus tract. • Occasionally can be caused by: surgery or trauma. • Organism(s): polymicrobial. • Signs and symptoms: • Most common: persistent drainage following an episode of acute osteomyelitis or onset of inflammation/cellulitis around an open fracture. • Fever (not always present). • Pain. • Diagnosis: • X-ray: irregular areas of destruction + periosteal thickening. • Bone scan might be useful if x-rays are not diagnostic. • Treatment: • EXTENSIVE DEBRIDEMENT of all necrotic and granulation tissue. • Reconstruction of bone and soft tissue. • Antibiotics. Osteomyelitis

22. Definition: it is a chronic, non-inflammatory disease affecting the joints. It results in destruction of cartilage of the joint with secondary remodeling and hypertrophy of the bone. • Epidemiology: • OA affecting knee joint is the most common cause of chronic disability among elderly population. • Risk factors for OA: advanced age, female sex, genetic factors, major trauma to the joint, repetitive stress to the joint and obesity. • Classification: • Idiopathic (most common). • Secondary to other underlying conditions such as: • Gout. • Diabetes and acromegaly. • Valgus or varus deformity • Clinical presentation: • Most commonly involved joint is the knee joint. • Monoarticular, asymmetric joint involvement. • Joint pain increases with exercise and relieved with rest. • Joint involvement is slow, progressive and irreversible. • Physical examination of the joint: no signs of inflammation but there will be crepitations with the movement of the joint. • Diagnosis: clinical + x-ray findings (osteophytes, narrowing of joint space, hypertrophy of subchondral bone with formation of a cyst). • Treatment: • Start patient on acetaminohpen (to relieve his pain). • If it doesn’t work, move to NSAIDs (e.g. ibuprofen). • If still pain cannot be controlled, try intra-articular injections of hyaluronic acid. • If medical therapy fails and patient’s quality of life is decreased → knee replacement surgery. Osteoarthritis

23. Etiology: • Young female (age > 40 years) → most common cause of septic arthritis is gonorrhea. This is especially seen during: menses and pregnancy. • Older patients with pre-existing destruction of the joint (e.g. patient has RA) → S.aureus is the most common cause. • Clinical presentation: • Patient might present with fever and monoarthritis with signs of inflammation of the joint involved (warm, red, swollen and painful with decreased range of motion). • Diagnosis: • Synovial fluid analysis: <50,000 WBCs/mm3. Culture and Gram-stain is usually NEGATIVE in gonococcal arthritis (thus you rely on cell count). Culture is positive for septic arthritis caused by other organisms: Staph, Strept, and other Gram-negatives. • Treatment: • Gonococcal arthritis: ceftriaxone. • S. aureus arthritis: nafcillin or vancomycin. Septic Arthritis