Final Med. Orthopaedics

Final Med. OrthopaedicsMr. James HartyA fracture is a break or interruption in the continuity of a bone

AnatomicalBone involvedRadius, femurPart of bone involvedDiaphysis, metaphysisneck/shaft/head

Direction of Fracture LineTransverseObliqueSpiral

All fractures are

either UNDISPLACED or DISPLACED

the deformity of the fracture

A communication between the fracture site and the skin surface

All fractures are

either CLOSED or OPEN

(Compound)

More than two fragments(>1 fracture line)

All fractures are

either SIMPLE or COMMINUTED

A fracture occurring in a bone weakened by disease

Often refers to a fracture occuring in a bony secondary

A fracture occurring in immature bone

Cortex bends rather than breaks

Classified by Salter-HarrisTypes I-VType II is commonest

Type II fracture distal radius

Look, Feel, MovePain, tendernessSwelling bruisingLoss of functionCrepitusSigns of blood lossInjury to other structures

HistoryExaminationX-rayIsotope Bone ScanSpecialised ImagingC.T.M.R.I.

Two planesTwo jointsTwo occasionsTwo limbsTwo opinions

Two planesTwo jointsTwo occasionsTwo limbsTwo opinions

AP and Lateral+/- special views e.g. scaphoid

Two planesTwo jointsTwo occasionsTwo limbsTwo opinions

Joint above and below for shaft fractures

Two planesTwo jointsTwo occasionsTwo limbsTwo opinions

Repeat X-rays after an interval may show a fracturee.g. scaphoid, hipTwo planesTwo jointsTwo occasionsTwo limbsTwo opinions

Comparative views of opposite limb e.g. elbow injuries in childrenTwo planesTwo jointsTwo occasionsTwo limbsTwo opinions

Ask a radiologist or senior colleague!haematomainflammatory exudatenew blood vessels (2-3 days)bone forming cellsbridge of callus (cartilage, bone, fibrous tissue)framework for bridging the gapreplaced by woven boneremodelling along lines of stress

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

Depends on many factorsagebonetype of fracture infectionnutritionstimulation

Full assessment

ReductionImmobilisationMaintenance of reductionRehabilitationrestoring normal anatomynot always necessary open/closedanaesthesialocal/regional/general

general rule: joint above and joint belowfor shaft fracturessplints, plaster, bracesinternal fixationplates, screws, wires, intramedullary rodsexternal fixationtraction

maintain until unitedcheck x-raysclinical and radiological evidence of union

starts A.S.A.P.keep non-immobilised joints mobileavoid muscle wastingphysiotherapy

Open Fracturesproblem: infectionprophylactic antibiotics appropriate to the injuryanti-tetanus coverirrigationthe solution to pollution is dilutiondebridement: remove all dead tissueskin cover

non-union/delayed unionmultiple fracturespathological fracturesfractures likely to slipintra-articular fractures nursing difficulties

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

Further TreatmentCompound 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.TreatmentAims obtain union, maintain relative positions of knee and ankle joints.Treatment options include:Conservative.Open Reduction and Internal Fixation.Intra medullary nailing.External fixation.Conservative TreatmentCasting 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.ORIFUsually used for intraarticular #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.

NailingProbably 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.

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

ComplicationsCompartment syndrome.Pressure in muscular compartments rises above capillary pressure, ischaemia of tissues in affected compartment.Patients complain of pain unrelieved by splinting and analgesia.Compartment SyndromePain 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.Uniondelayed unionnon-unionatrophichypertrophicinfectedmal-union

skincompound woundsfracture blistersplaster sorespressure sores

muscle/tendondisuse, wastingavulsionlate rupture (e.g. EPL, Colles fracture)

haemorrhagepelvis 6-8 units (hidden)femur 3-4 unitship 1-2 unitsthrombosis/embolismesp. pelvic and hip fractures

infectionlocal (compound or operated)respiratoryurinary tractgrowth disturbanceepiphyseal fracturesstiffnesskeep non-injured joints mobile

neighbouring structuresnervesvesselsinternal organs

Fractured Neck of FemurSubcapital Femoral Fracture.Over 100,000/year in the UK

Key PointsCommon in osteoporotic bone.Majority of blood supply to head comes from the neck.Elderly.Almost 90% occur in >65 years.Almost 75% occur in females.

Hip Joint - AnatomyThe fibres are reflected back along the neck of the femur to the articular margin of the femoral head.The reflected part constitutes the retinacular fibres, which bind down the nutrient arteries from the trochanteric anastomosis, along the neck to supply the head.

About the blood supplyThe head and intracapsular part of the neck receive blood from the trochanteric anastomosis.Formed by descending superior gluteal artery with ascending branches of the medial and lateral circumflex femoral arteries.Branches pass along the femoral neck with the retinacular fibres of the capsule.

Anatomy Blood Supply

Fractures Traumatic fracturePathological fractureClinical FeaturesSevere hip pain associated with a fall.Unable to weight-bear.Shortened and externally rotated legAP/Lateral hip required.Older co-morbidity.

Garden 1 fractured neck femurRS Garden, Preston Royal Infirmary, JBJS 1961

Garden 2

Garden 3

Garden 4

Complications Avascular necrosis of femoral head

Blood supply lost through thrombosis or interrossoeus hypertension.Marrow of head is replaced by fat, bone dies.Zone of revascularisation, incomplete if large avascular area.Zone of reossification joint may collapse.May -> secondary arthritis.Complications Avascular necrosis of femoral head

X-rays may appear normal.Radioisotope dead area of femoral head surrounded by hyperaemic area of revascularisation.MRI one or more avascular areas.

Initial ManagementATLS principals of resuscitationCo-morbidityWork-up for theatre Relevant Radiology - DiagnosisDecide surgical/anaesthetic managementInformed ConsentProphylactic AntibioticsAnticoagulationEarly MobilizationDischarge arrangements

Surgical TreatmentAge and displacementCo-Morbidity

Undisplaced (Garden 1 & 2):

1. Cannulated Hip Screws.2. DHS.3. Hemi-Arthroplasty

Displaced (Garden 3 & 4): 1. Hemi-Arthroplasty. 2. Total Hip Replacement occasionally if pre-existing OA.

Garden 1 - TreatmentAO Screws to hold femoral head in position

Indications for Closed Reduction and Fixation: Physiologically young patient: age < 65, working patient, good bone stock; Demented elderly patient that requires total care; Adequate closed reduction with no comminution or femoral neck defects; Patient should be aware that with an inadequate closed reduction, then an open reduction or hemiarthroplasty will be required

Garden 2-3Older patients HemiarthroplastyEspecially in Life Expectancy