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LMCC Orthopedic Review Lecture

LMCC Orthopedic Review Lecture. April, 2013 “Back to Basics” Dr. P.R. Thurston. &. Dislocations. Fractures. Definitions. Fracture:- A discontinuity in the structural integrity of a bone. Infraction:- An incomplete fracture.

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LMCC Orthopedic Review Lecture

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  1. LMCC Orthopedic Review Lecture April, 2013 “Back to Basics” Dr. P.R. Thurston

  2. & Dislocations Fractures

  3. Definitions Fracture:-A discontinuity in the structural integrity of a bone. Infraction:- An incomplete fracture. Dislocation:- Complete loss of contact of the articular surfaces of a joint. Subluxation:- Non-concentric joint surfaces. Reduction:- Returning a fracture or dislocation to an anatomical alignment. Comminution:- Multiple fragments.

  4. Fractures Definition :- A discontinuity in the structural integrity of a bone. A fracture occurs because the force applied exceeds the breaking strength of the bone so that the Load can no longer be transferred across that zone of the bone.

  5. Fractures All fractures ultimately begin with kinetic energy, released by misadventure and applied to the human body. Some of that energy is absorbed and some is transmitted to the surroundings. Absorbed energy must be dissipated, ie. distributed, through the soft tissues and bones. Fractures occur when the bone can not dissipate all of the energy absorbed.

  6. Fractures Mechanical Properties of Bone Bone is a two-phase material :- Calcium HydroxyApatite Ca10(PO4)6(OH)2 = mineral Osteoid Collagen type I and III = fibrous Calcium is strong in compression, but weak in tension. Osteoid is strong in tension, but weak in compression.

  7. Fractures BUT :- (for adult bone) Calcium is stronger in compression than Osteoid is in tension And therefore :- Bone always fails first in tension

  8. Fractures A bone consists of three areas :- the Diaphysis the Metaphysis the Epiphysis. Each region has its own fracture characteristics.

  9. Fractures Bending Torque Direct Traction Compression Intra-articular Pediatric Oblique Diaphyseal Spiral Transverse Metaphyseal Epiphyseal Mixed

  10. Salter-Harris Classification Fractures I II III IV V

  11. Salter-Harris Classification Fractures 1) Fractures interfering with growing bones. 2) Worse prognosis with increasing number. 3) Probability of surgery increases with number.

  12. Fractures A fracture can occur in :- normal bone subject to abnormal forces. = Traumatic Fractures. abnormal bone subject to normal forces. = Pathologic Fractures. normal bone subject to cyclic forces. = Fatigue or Stress Fractures.

  13. Fracture Description Thisfracture is angulated laterally, since it points laterally. The distal fragment is tilted medially

  14. Description Medially Displaced Closed Comminuted Short Oblique Fracture of the Proximal Humerus Caused by a direct fall

  15. Fracture Description 1) The distal fragment is always described with relation to the proximal segment. 2) Displacement = Translation of bone ends. 3) Angulation = Orientation of bone ends. 4) Angulation identifies to where the fracture points. 5) For clarity, the tilt of the distal fragment is often used to describe angulation.

  16. Indications for Closed Reduction There is significant displacement. Reduction is possible. The reduction, if gained, can be held. The fracture has not been produced by a traction force.

  17. The Periosteal Bridge The Periosteal Bridge is intact on the concave side of the fracture. Reversal of the mechanism of the fracture tightens the bridge and stabilizes the fracture.

  18. The Periosteal Bridge Tightening the periosteal bridge locks the fracture together. Holding the bridge tight requires three point fixation. “It takes a bent cast to produce a straight bone” J. Charnley

  19. Indications for Open Reduction 1 ) There is a significant Displacement. 2 ) Open Fractures. 3 ) Intra-articular Fractures. 4 ) Un-reducible Fractures 5 ) Reductions that cannot be maintained in a cast. 6 ) Comminuted or Segmental Fractures. 7 ) Floating Joints. 8 ) Fractures with Neurovascular damage.

  20. Open Fractures Classification :- 1. < 1 cm., inside-out, little soft tissue damage. = low potential for infection. 2. 1 cm. – 10 cms., outside-in, requires debridement, but no flap or skin graft. = moderate potential for infection. 3. > 10 cms., outside-in, high energy, devitalized muscle, comminution or bone loss, soft tissue loss.

  21. Open Fractures Classification :- 3A. No loss of soft tissue cover, no flap required. 3B. Flap required due to soft tissue stripping. 3C. Associated vascular injury.

  22. Type 1. Open Fracture =6 mm, extend & debride

  23. Degloving Mechanism Degloving Mechanism

  24. Type III C Injuries – Vascular Injury Note pallor of the ankle No pulses

  25. Fracture Complications 1. Pulmonary Fat Emboli 2. Compartment Syndromes 3. Stress Fractures 4. Pathologic Fractures

  26. Pulmonary Fat Emboli :- A.R.D.S. - Long bone fractures, burns, contusions. - Interstitial pneumonitis due to free fatty acids - S.O.B. & confusion in young adults. - Axillary & Subconjunctival Petechiae. - Serum lipase elevated. - pAO2 reduced – if < 50 – 20% mortality. - Ventillatory support - Dexamethazone. - 5 day course.

  27. Compartment Syndromes - increased interstitial tissue pressure. - fractures, burns, tight dressings. • normal pressure < 25 mm. Hg. • when the tissue pressure > venous capillary pressure, but less than the arteriolar pressure. • 5 P’s - pain. - pallor. - pulselessness. - paresthesias. - paralysis.

  28. Compartment Syndrome • Symptom: Pain out of proportion to that • expected for the injury. • Signs: 1. Loss of function of muscle due to • ischemia within the compartment. • 2. Pain with passive stretch • 3. Numbness etc. are LATE findings! • 4. If neuro symptoms present, potential • for full neuro recovery is only 10 %

  29. Rx Compartment Syndrome Release all compressive dressings / plaster. Elevate extremity to heart level. Fasciotomies.

  30. 4 compartment fasciotomy

  31. Compartment Syndrome Careful monitoring. Recognise it - 5 P’s Call Orthopaedic Surgeon Pressure measurements

  32. Stress or Fatigue Fracture Repeated loading below acute failure threshold. Eventual fatigue failure. Military recruits, runners, aerobics. Tibia, metatarsals, femoral neck. Initial x-ray can be negative. Bone tenderness – Bone scan.

  33. Pathologic Fractures Failure through abnormally weakened bone Minimal trauma – BEWARE Osteoporosis Metastasis Tumour:- Benign, Malignant (Myeloma). Metabolic Bone Disease

  34. Pathologic Fractures Metastases: Lytic - Lung Colon Thyroid Renal Breast Blastic - Prostate

  35. Pathologic Fractures Metastases: - require fixation to prevent fracture if they are > 1/3. - produce pain on weight bearing in the lower limb. - survival > 3 months. - cannot be managed by medical therapy. - radiotherapy after fixation (2 weeks) (radiotherapy induced osteonecrotic fractures)

  36. Pathologic Fractures

  37. Dislocations The articular surfaces are no longer in contact. Commonly affects - Shoulders > PIP joints > Elbows > Ankles. Often associated with fractures. Often associated with neurologic injuries

  38. Shoulder Dislocations 95 % anterior 1 % posterior Luxatio erecta Medial Axillary nerve injury Rapid reduction

  39. Shoulder Dislocations Conscious sedation. Traction reduction. Immobilization. Recurrent. Voluntary Habitual. Multiaxial instability.

  40. Elbow Dislocation Posterolateral. Median nerve injury. Ulnar nerve injury. Rapid reduction. Early mobilization.

  41. Back Pain

  42. Classification: Mechanical (MacKenzie) • Postural syndrome • normal tissues become painful by the application of prolonged stresses (sitting, bending etc) • Dysfunction syndrome • soft tissues are shortened and stiff. Usually >30 year old, poor posture, under exercised, reduced mobility • Derangement syndrome • Disc derangement (tears and herniation)

  43. Viscerogenic Vasculogenic Neurogenic Psychogenic Spondylogenic Spondylogenic Osseus: Trauma Infection Neoplasms Inflammatory Metabolic (eg.Pagets) Deformities Soft tissues: Muscles SI joints Disc Facets Causes and Classification of Back Pain: McNab

  44. Non operative Treatment of Back Pain Do nothing Activity modification Medications Exercise and physiotherapy Braces Manipulation Massage therapy Traction/inversion therapy Vitamins/Supplements/Diets Weight control Every Suzanne Summers sponsored abs exerciser

  45. Anatomy Extension Flexion

  46. Three joint complex(Kirkaldy Willis, Farfan) Instability Lateral n. ent Central stenosis

  47. Disc herniation Ms J.H. 25 y.o. female presented with cauda equina syndrome

  48. Cauda Equina Syndrome Sciatica associated with bowel or bladder dysfunction. Perineal numbness. Low or Sequestrated Lumbar Disc. Pressure on S1, S2 and/or S3 nerve roots. Requires immediate Decompression to avoid permanent disability.

  49. Symptoms: unilateral radicular pain bilateral claudication better with forward flexion of trunk better walking uphill rare bowel/bladder involvement Signs: usually no neuro signs look for pulses stress test Investigations: XR CT Myelo-CT MRI Spinal stenosis

  50. Time for a 10 minute break!

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