Final Med. Orthopaedics

1. Final Med. Orthopaedics Mr. James Harty

2. A fracture is a break or interruption in the continuity of a bone

3. Anatomical • Bone involved • Radius, femur • Part of bone involved • Diaphysis, metaphysis • neck/shaft/head

4. Direction of Fracture Line • Transverse • Oblique • Spiral

5. All fractures are eitherUNDISPLACED orDISPLACEDthe deformity of the fracture

6. A communication between the fracture site and the skin surface (Compound) All fractures are eitherCLOSED orOPEN

9. More than two fragments (>1 fracture line) All fractures are eitherSIMPLE orCOMMINUTED

12. A fracture occurring in a bone weakened by disease Often refers to a fracture occuring in a bony secondary

13. A fracture occurring in immature bone Cortex bends rather than breaks

14. Classified by Salter-Harris • Types I-V • Type II is commonest

15. Type II fracture distal radius

16. “Look, Feel, Move” Pain, tenderness Swelling… bruising Loss of function Crepitus Signs of blood loss Injury to other structures

17. History • Examination • X-ray • Isotope Bone Scan • Specialised Imaging • C.T. • M.R.I.

18. Two planes Two joints Two occasions Two limbs Two opinions

19. AP and Lateral +/- special views e.g. scaphoid Two planes Two joints Two occasions Two limbs Two opinions

20. Joint above and below for shaft fractures Two planes Two joints Two occasions Two limbs Two opinions

21. Repeat X-rays after an interval may show a fracture e.g. scaphoid, hip Two planes Two joints Two occasions Two limbs Two opinions

22. Comparative views of opposite limb e.g. elbow injuries in children Two planes Two joints Two occasions Two limbs Two opinions

23. Ask a radiologist or senior colleague! Two planes Two joints Two occasions Two limbs Two opinions

24. haematoma inflammatory exudate new blood vessels (2-3 days) bone forming cells bridge of callus (cartilage, bone, fibrous tissue) framework for bridging the gap replaced by woven bone remodelling along lines of stress

25. callus is the response to movement at fracture site callus does not develop if the fracture is rigidly fixed with no movement: primary bone healing

26. Depends on many factors • age • bone • type of fracture • infection • nutrition • stimulation

27. Full assessment Reduction Immobilisation Maintenance of reduction Rehabilitation

28. restoring “normal” anatomy • not always necessary • open/closed • anaesthesia • local/regional/general

29. general rule: joint above and joint below • for shaft fractures • splints, plaster, braces • internal fixation • plates, screws, wires, intramedullary rods • external fixation • traction

30. maintain until united check x-rays clinical and radiological evidence of union

31. starts A.S.A.P. keep non-immobilised joints mobile avoid muscle wasting physiotherapy

32. Open Fractures • problem: infection • prophylactic antibiotics appropriate to the injury • anti-tetanus cover • irrigation • “the solution to pollution is dilution” • debridement: remove all dead tissue • skin cover

33. non-union/delayed union multiple fractures pathological fractures fractures likely to slip intra-articular fractures nursing difficulties

34. Initial Treatment Initial treatment – splinting and analgesia. Compound injuries – Antibiotic cover (usually cephalosporin +/- aminoglycoside if contaminated). -Tetanus cover.

35. Further Treatment Compound injuries must be debrided ASAP, should be within 6 hours. Bone should be covered with tissue to prevent dessication. Delayed primary closure of the wound, or “second look” procedure.

36. Treatment Aims – obtain union, maintain relative positions of knee and ankle joints. Treatment options include: Conservative. Open Reduction and Internal Fixation. Intra medullary nailing. External fixation.

37. Conservative Treatment Casting may be considered if: Isolated tibial fracture (fibula not involved). >50% cortical overlap at # site. Closed reduction of displaced #’s and casting leads to significant incidence of non-union. Less than 2cm initial shortening.

38. ORIF Usually used for intra–articular #’s involving knee or ankle rather than shaft #’s. Periosteal stripping required. Fracture site must be opened. May be useful in Rx of non-union +/- bone grafting.

40. Nailing Probably preferred Rx of closed displaced tibial shaft fractures. Union rates of near 100% for closed injuries. Fracture site not opened during the procedure, reduced chance of infection. More difficult in proximal shaft fractures.

42. External Fixation Minimal soft tissue trauma. Little foreign material in body, may be preferred in compound fractures. Comminuted injuries. Uniplanar, circular or combination of both (hybrid) fixators.

45. Complications Compartment syndrome. Pressure in muscular compartments rises above capillary pressure, ischaemia of tissues in affected compartment. Patients complain of pain unrelieved by splinting and analgesia.

46. Compartment Syndrome Pain on passive stretching is classic physical sign. Normal distal pulses and neurology DO NOT exclude compartment syndrome. Incidence NOT reduced in compound fractures (up to 9%). ? May complicate nailing of fracture.

47. Union • delayed union • non-union • atrophic • hypertrophic • infected • mal-union

48. skin • compound wounds • fracture blisters • plaster sores • pressure sores

49. muscle/tendon • disuse, wasting • avulsion • late rupture (e.g. EPL, Colles’ fracture)

50. haemorrhage • pelvis 6-8 units (hidden) • femur 3-4 units • hip 1-2 units • thrombosis/embolism • esp. pelvic and hip fractures