Orthopaedics lecture notes
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Ortho – fractures
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2 factors that lead to fracture, energy of the event and the strength of the bone. Energy can be low chronic leading to stress fractures, or acute high-energy. Bone strength is either normal or diminished from demineralisation or pathology. X rays should show joint above and below the fracture.
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On Examination:
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Pain and tenderness
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Deformity and swelling – haematoma, haemarthrosis. If deformity causes skin tenting then this will need to be reduced before XR for avoid skin necrosis. (Think of a fracture as a soft tissue injury with a break in the bone)
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Locally warm
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Abnormal mobility and crepitus
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Loss of function
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Always check distal neurovascular status.
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Definitions:
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Fracture = break in the continuity of a bone
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Comminuted fracture = >2 fragments
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Gross comminution = multiple fragments, often following severe high energy trauma, union often delayed or difficult.
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Types of #:
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Transvere – across bone
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Oblique – cut in an oblique down the bone, like fancy cucumber
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Spiral – spirals, result of a twisting motion
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Greenstick – in children, part of bone appears to buckle, other side may have a fracture
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Crush –
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Burst –
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Avulsion – soft tissue insertion into bone is ripped away pulling part of the bone with it.
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#dislocation / subluxation – dislocation or subluxation associate with a fracture.
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Open / compound – some communication with the external world with a much higher risk of infection. Gustilo-Anderson classification:
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Type I = wound <1cm, clean wound
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Type II = wound 1 - 10cm, clean wound
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Type IIIA = wound >10cm, high energy but adequate soft tissue coverage
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Type IIIB = would >10cm, high energy but with inadequate soft tissue coverage (plastic input)
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Type IIIC = all injuries with vascular injury (vascular input)
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Complicated – important soft tissue damage present, eg fracture opening body cavities or inner organs like the brain, lungs, viscera, spinal cord, concurrent neurovascular injury.
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Simple – no soft tissue injury
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Impacted – bone fragments forced together (usually stable)
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Unstable – displaced or have potential to displace, very relevant when important soft tissue structures at risk eg spinal column
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Hangman’s fracture – fracture of bilateral pedicle / lamina of the second cervical vertebra leading to immediate death due to damage to the spinal cord.
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Investigation:
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XR – at least 2 views, often more for relevant injuries suspected
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/ MRI / CT
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DEXA (Dual Energy X-ray Absorbed) scan for bone density in low energy injuries.
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Classification of fractures:
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Anatomical location:
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Epiphysis, diaphysis, metaphysis, intraarticular
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Proximal, middle, distal
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Head, neck, trochanter, shaft, supracondylar, condylar
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Degree:
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Complete
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Incomplete (children eg hairline, buckle, greenstick etc)
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Configuration:
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Transverse
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Oblique
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Spiral
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Longitudinal
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Number of fragments:
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Simple (linear)
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Comminuted
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Segmental
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Open / closed
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Stability
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Displacement (needs reduction)
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Shortening,
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Rotation
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Sideways shift or tilt
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Dislocation – loss of joint integrity
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Subluxation – partial loss of joint surface integrity
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Salter Harris Classification for epiphysial fractures:
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I – S = Straight across (through the growth plate, physis)
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II – A = Above (fracture divert into main shaft of bone, metaphysis) *most common
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III – L = Lower or BeLow (fracture diverts into growth plate, epiphysis)
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IV – T = Through or TWO (goes through both the epiphysis and metaphysis)
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V – ER = Everything Rammed (epiphysis crushed into the metaphysis, loss of physis)
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Fracture healing:
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Goals:
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Restore optimal functional state
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Prevent bony and soft tissue complications
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Prevent malunion, while preventing soft tissue wasting and contractures
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Immediate:
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Bleeding and fracture haematoma forms
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Inflammation
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2-3 days
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Phagocytosis. Capillary budding, granulation tissue
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Osteogenic cells invade and lay down osteoid.
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3 weeks
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Soft callus – cartilage and osteoid
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6-12 weeks
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Hard callus
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3-4 months
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Clinical union
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6-12 months
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Remodelling
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Potential ortho emergencies:
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Amputations
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Open fractures
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Penetrating injury / pelvic fracture / massive haemorrhage / vascular injury (>6h results in irreversible damage).
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Dislocated hip / knee
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Compartment syndrome
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Complex trauma
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Spinal injury or progressive neurology.
Management open #
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In ED = Examine wound 1X, sterile dressing, reduce to restore limb alignment, tetanus and antibiotics
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In OR = Debride to remove foreign material, dead tissue and any bacteria, clean thoroughly and irrigate. +/- antibiotic beads, stabilize.
Management closed #
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Reduction if appropriate – either manipulation or open
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Maintain reduction
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Intrinsic stability
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External fixation – splits, POP, cast braces, traction etc
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Internal fixation – screws, plates, grafts, intramedullary nails, wires and pins
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Frame fixators – maintain reduction and can extend to bridge a gap
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Fixation lasts:
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12 weeks for long bones, get cancellous ends of long bones and in short bones in 6-8 weeks)
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Children and elderly, or for pain relief only 2-3 weeks
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Complications of fractures:
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Soft tissue injuries:
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Skin – open #, degloving injuries, and ischaemic necrosis.
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Muscles – crush and compartment
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Blood vessels – vasospasms and arterial laceration
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Nerves:
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Neuropraxia – mild crush injury (sat night radial nerve injury)
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Axonotmesis – nerve damaged but axon sheath intact – nerve can regrow.
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Neuromesis – complex nerve damage.
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Ligaments – joint instability and dislocation
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Compartment Syndrome – Not only when fractures
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5P’s - Pain (out of proportion to injury or clinical situation), Pallor, Paraesthesia, pulselessness, paralysis
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Fasciotomy when:
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Worsening clinical state
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Tissue pressure rising from 30mmHg below diastolic, as it approaches 20mmHg below diastolic.
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Significant tissue injury
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History of 6 hours total ischaemia when perfusion restored.
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Complications at time of injury:
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Haemorrhage, damaged to important structures and skin loss
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Complications medium term:
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Local:
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Tissue necrosis,
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Infection,
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Loss of alignment
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General:
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DVT, PE, fat embolism
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Pneumonia
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Late complications:
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Delayed and non union, malunion
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Late wound infection
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Joint stiffness and contracture
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Sudeks atrophy - ?sympathetic malfunction
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OA
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Chest infections, bed sores, UTI
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AVN
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Tendon contracture, nerve compression,
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Volkmann contracture (necrosis of muscles in forearm following # in children causes arm to contract in.
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