Tips for Orthopedics Exam(Unit 9)

By Kareem Hamimy6th year medical student

Unit 9 – Kasr Al Ainy Medical School

Fracture Humerus

• Fracture Shaft– Injury to Radial Nerve is common• So you Must Document this Injury before reduction

(Medicolegally)• Will lead to Finger Drop, Wrist Drop

– Management• U shaped Cast• Collar and cuff sling• N.B. Edge of cast have to be 2 cm above fracture

• Plain X-ray, Antero posterior view of a humerus of an adult, showing Mid shaft Spiral Fracture, With angulation varus ( Apex is lateral )

Open Reduction

• Indications :– Associated with vascular injury– Bilateral– Multiple– Compound Fracture (Haematoma communicating to

outside)– Floating Elbow ( Fracture in humerus + Fracture

radius and ulna )– Pathological (due to tumour/osteoporosis)– Comminuted

• Supracondylar Fracture– Types ( Flexion, Extension 90%in children)– Risk of injury to brachial Artery very high• Why ? After its bifurcation, its branches become

attached by fibrous tissue, being fixed makes it more liable to injury

– Median nerve injury– Radial nerve is least prone to injury because it is

protected between the brachialis and brachioradialis

• Supracondylar fracture– Management :– First : Check The pulse

بتخلصعند – اللجنةpulseال

– If no pulse, Document, then reduce it ( to decrease compression on artery

– If no pulse after reduction, Do open exploration and Vascular Surgery

• Plain X-ray, Lateral view, of and adult elbow joint, Showing Supracondylar Fracture, with posterior displacement of distal segment

Compartment Syndrome

• Bleeding and edema inside fascial Compartments, Increases the pressure, leading to compression of veins then arteries, and lately Nerves leading to a limb threatening condition

• Treatment: By Fasciotomy• N.B. it is not only due to fracture but also

maybe due to soft tissue injury inside a compartment

Complications Of Fractures

• General– Shock– DVT– Pulmonary Embolism– Fat Embolism– Tetanus– Psycological depression– Constipation– Renal Infection– Bed sores

Complications Of Fractures

• Local – Early

• Vascular Injury• Nerve Injury• Infection• Tendon Injury• Avascular necrosis of bones

– Late• Delayed Union• Malunion• Nonunion• Volkman’s Ischemic Contracture• Myositis ossificans

Shock (Tissue Hypoperfusion)

• Hypovolemic– Fracture Femur 500cc blood loss– Fracture Pelvis 1000cc– C.P.

• Pulse Rapid due to sympathetic response, Temp low, Respiratory rate Rapid• B.P. According to Severity of blood loss ( Mild decreased systolic, Moderate

Decreased Pulse pressure, Severe Decreased Diastolic)

– Management– 2 cannulas, Urinary catheterization (to asses perfusion)– Crystalloid infusion increasing volume – or Colloid (Contains Protein) infusion increase blood pressure by

keeping fluid inside vessels– >1000 cc lost Blood transfusion

Shock (Tissue Hypoperfusion)

• Neurogenic– Females, Old– How to differentiate from Hypovolemic ?

Bradycardia, and skin flushed – Why bradycardia ? Due to parasympathetic response– Ttt: by analgesics

• Septic– As in compound fracture– Antibiotics, Antitetanus

DVT

• Virchow's Triad– Stasis– Hypercoagulability– Endothelial Injury

• Early fixation, Proper Hydration• Anticoagulants

– Parenteral ( Heparin)– Oral (warfarin)

• How to avoid Pulmonary Embolism– Conservative ( Prevent DVT)– Vena caval Filter (Green Field Filter)

Fat Embolism

• Due to yellow Bone marrow in Medulla of Bones

• Difference between Fat Embolism and Pulmonary embolism ( Onset )– Fat onset is acute, immediately after trauma– Pulmonary, 1 week after trauma

Bed Sores

• How to Prevent ?– Early Mobilization (by early reduction and fixation)– Frequent Mobilization (by changing his position in

bed )– Proper Hydration

Local complications

• Vascular injury– Causes :

• Direct Injury by the blow• Fractured (serrated) end of bone• Compartment Syndrome

• Nerve Injury– N.B. Sites

• Ulnar Nerve : Behind Medial Epicondyle• Median Nerve : Cubital fossa• Radial Nerve between brachialis and brachioradialis• Sciatic Nerve : Behind hip Joint

Compound fracture

• Fracture Hematoma Connected with the External

• Significance : – potentially Infected– Delayed Union ( Because the first step of healing is

the organization of the hematoma and its resolution )

Union

• Malunited ( abnormal positioned)• Delayed ( more than expected time)• Ununited ( Not united at all)

• Causes– Improper reduction– Poor Blood Supply– Gapping– Infection– Soft tissue between fractured bone

Internal Fixators

• Humerus and radius ( forearm) Plates and Screws

• Spine Pedicular Screws• Tibia ( Shaft ) Intramedullary Nail• Tibia ( Pott’s) K wire or Plate and Screws• Colles Fracture Closed reducation + K wires• Fracture Shaft femur Tomas Tractor till open

reduction and internal fixation

• Plates and Screws In humerus

• K wires in Colles Fracture

D.H.S.

• Intra medullary Nail In Tibia

Thomas Skin tractor

External Fixators

• Below elbow slap ( fractures below elbow)• Above elbow slap ( near elbow joint )• Humerus : U-shaped slap• Clavicle : arm to chest sling• Neck : Collar• Lumbosacral : Lumbosacral brace• Below knee slap• Above Knee Slap• Tomas Splint ( for femur ) Skin traction

Illizarov External Fixator

• Used in compound fractures• Also in comminuted potentially infected

N.B.

• In a displaced fracture, Shortening occurs because the muscle is shorter than the distance between the origin and insertion, pulling the bone with it

N.B.

• Any poly trauma pt• ABC• Immobilization of back• Inspection• Palpation of bones and checking if there is any

fracture• X-ray at site of fracture• Routine X-ray on Cervical spine, Lumbosacral,

Pelvis

X-ray

• One joint above and one joint below the fracture site

• Anteroposterior view and lateral view• In children, X-ray the other limb for

comparison ( Epiphyseal lines )

Emergencies in Orthopedics

1. Fracture Neck Femur – Avascular Necrosis of head can occur– We fix by Dynamic head Screw

2. Fracture Neck talus3. Compound Fracture4. Dislocation ( May cause Arthritis Forever)5. Slipped Physis (Epiphyseal Plate) in Children– Arrest of Growth, Growth Deformities may occur

6. Fracture with Vascular Injury

• N.B.• Infection in Bone is very Serious ( if

osteomyelitis occurred, we excise it as tumour)

N.B

• Range of Acceptance ( range at which fracture can be left not reduced and heals well )

• Range of Angulation “According to each bone”• Range of Overriding “According to each bone”• But Rotation is not accepted at all, No range

of acceptance, reduction must be done• Range of acceptance increases in pediatrics

due to their remodelling ability

Comment On X-ray

• X-ray• Anteroposterior or lateral view• Of (Anatomy)• Adult or child ( By Checking Epiphyseal plates)• Showing Fracture with – Angulation (Varus or vulgus) / – Shortening ….. Cm (With anterior or posterior or

medial or lateral displacement, of the distal segment )– Rotation

• Epiphysis means Part of bone connected to Joint

• Arterial supply of neck of femur is very important

• Why Fracture Neck femur occur ?– Junction between cancellous and cortical bone

• Subcapital and midcervical Intracapsular• BasiCervical - Extracapsular

Management of fracture neck femur

• Depends on Physiological activity And Age• Extracapsular DHS• Intracapsular• If Young, with high activity urgent fixation DHS• If old >60-70 years old Hemiarthroplasty• Complications of hemiarthroplasty– Infection– Dislocation– Periprosthetic Fracture– Loosening which is painful

Dynamic head Screw

• Used in fracture neck femur• It uses body weigt, leading to compression

and rapid healing• 135 degrees• And also used in trochanteric fracture• In Subtrochanteric fracture we use dynamic

condylar screw DCS, which is 95 degrees

N.B.

• How to know the bone is osteoporotic• By comparison to the color of the cortex of

shaft• What is the difference between Intracapsular

and Extracapsular Neck femur fracture ?• Intracapsular Is an Emergency due to avasucalr

necrosis and high mortality rate

Thank you

And if there is anything wrong in the ppt. check with Unit professor,

then Send meKareemhamimy89@yahoo.co.uk