Lecture Notes in Orthopaedics-1
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Eugene Sherry, MD, MPH, FRACS.
Dept. of Orthopaedic Surgery,
University of Sydney, Australia.
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Run over by a truck
There are many ways to describe a fracture. A thorough understanding of the basics is necessary before addressing specific fractures. Fractures can be classified based upon location (e.g., proximal, middle and distal thirds), direction (transverse, spiral, oblique, comminuted, segmental), alignment (angulation [apex], displacement [of distal fragment], articular involvement), and associated factors (open fractures, dislocations, etc.), and classified by a variety of schemes. Many factors come into play in the description and ultimate management of fractures. The mechanism of injury provides important clues to the nature of the injury and may even be used in the classification schemes for those injuries (e.g., ankle and spine fractures). For example, traction injuries result in avulsion fractures, compression forces yield angulated or T-type fractures, and rotational forces cause spiral fractures.
Death on the ski fields
|Open Fractures (See POT)|
Open fractures, whether obvious or subtle, always communicate with the environment. Special consideration should be given to these injuries. Infection and poor healing are frequently the consequences of open fractures (although less so with hand injuries because of an excellent blood supply). Formal careful debridement and irrigation (ideally within 4-8 hours of the injury), IV antibiotics (consisting of a first - or second-generation cephalosposrin and an aminogly-coside [and penicillin for barnyard or clostridium infections]) for 48 hours and after each subsequent procedure, appropriate immobilisation and fixation, and careful wound management will reduce these risks. Early flap coverage (48 hours to 1 week after injury) has also been shown to reduce risk of chronic infections.
Classification - Based on the size of the wound and amount of soft tissue injury (Gustilo): I (< 1cm), II (> 1cm), III (extensive soft tissue with nerve and blood vessel injury).
Gunshot Wounds (GSWs) - Often result in open fractures.
Debridement with lavage in the operating room is essential
General Treatment Principles
Treatment of orthopaedic injuries must follow adequate stabilisation of the patient (life before limb). An adequate airway should be secured before checking for pulses and bleeding. Nasotracheal intubation is recommended in breathing patients with cervical spine injuries; oral endotracheal intubation with in line traction is favored for all nonbreathing patients. A chest x-ray should be checked for mediastinal widening and pneumo - or hemothorax, and the C-spine must be evaluated prior to proceeding to the secondary survey. The Trauma Score (based on respiratory, cardiovascular, and neurological parameters) is predictive of injury severity and prognosis. The most common abdominal injuries include rupture of the spleen followed by liver injuries (10-20% mortality rate). Diagnostic peritoneal lavage is favored over CT for abdominal assessment. Pericardial tamponade should be suspected with a narrow pulse pressure and an elevated diastolic blood pressure. IVP studies are indicated for gross hematuria only. Head injuries are the most common cause of early death with trauma (Glasgow Coma Scale score <8 being severe). Haemorrhage can occur from ruptured viscera and is also commonly seen with pelvic fractures (see page Manual Sports Medicine). The orthopaedic surgeon plays a key role in these latter injuries with early application of external fixation to select pelvic fractures. Once stabilised, the patients should be carefully assessed for extremity injuries which should be reduced and stabilised. Determining the mechanism of injury, careful physical exam, and obtaining appropriate radiographs should be done in every trauma patient.
Reduce - Generally, less than anatomic reduction is better than angulation in reduction of fractures. Joint surface involvement demands near-anatomic reduction. Age and function of the patient is important in considering the goals in reduction. Reduction can be closed (manipulation or traction) or open (usually combined with internal fixation). Manipulative reduction usually involves exaggeration of the mechanism of injury followed by reversal of these forces. Traction, often applied to the femur or cervical spine through weights and skeletal fixation, may be temporary or prolonged. Open reduction, either primarily or after failure of other methods, should restore the fracture to as near anatomic alignment as possible. See 3 minute fracture talk.
Debridement with lavage in the operating room is essential
Hold (immobization) - Used to prevent displacement or angulation, to decrease movement at the fracture site, or to relieve pain. Immobilisation can be through casting, splinting orthotics, traction, external fixation, or internal fixation. Internal fixation is indicated when closed methods have failed.
Restoration of Function - Rehabilitation during and after fracture treatment is essential for good results.
Fracture Healing is by formation of haematoma (within minutes) granulation tissue (hours) immature callus ( 4 to 6 weeks) mature callus (months) and re-modelling (years).
Standard AP and lateral radiographs, to include the joint above and below the fracture level, are the minimal requirement for most fractures. Special fractures require special x-rays but best to train yourself to get most of your information from AP + lat. views).
Complications occur commonly following trauma, and can be a direct result of the injury (intrinsic) or can be associated with other organ systems (extrinsic). General complications are discussed in this section;
Bone Healing Problems - Include delayed union, nonunion, malunion, and avascular necrosis. More common with high-energy injuries and in bones with limited blood supply/healing potential. (eg. scaphoid, head of femur).
Delayed Union/Nonunion - Although the distinction is not always clear, fractures that still allow free movement of the bone ends at 3-4 months after injury demonstrate delayed union, and if this persists (usually for more than 6 months) then a diagnosis of nonunion can be made. Too much or too little motion at the fracture site, excessive space between fracture fragments, inadequate fixation, infection, soft tissue interposition, inadequate blood supply, and many other factors can lead to delay in bone healing. Nonunions are classified as hypervascular (hypertrophic) or avascular (atrophic) based upon their capability of biologic reaction (vitality of the bone ends).
Malunion - Union in a clinically significant imperfect position. Initial fracture care is critical to help avoid this result, but it often cannot be avoided.
Avascular Necrosis - Caused by disruption of the blood supply and can lead to nonunion, osteoarthritis, collapse, and other problems. It is more common with intra-articular fractures, especially of the femoral head/neck, femoral cordyles, proximal and talar neck.
To learn more see case 3 in the cases section.
Click to see pot from Case 3
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Debridemant of open fracture by pulsatile irrigation
Usually is a complication of open fractures and can lead to osteomyelitis (often chronic involvement of joints leads to persistent pain, stiffness, and progressive concentric joint space narrowing. Soft tissue infections may produce soft tissue air on radiographs from gangrene (Clostridium - a gram-positive anaerobe) and gas-producing gram-negative organisms. The most critical factor in avoiding infection in open injuries is adequate debridement. Prophylactic antibiotics for grade III open fractures should include a first-generation cephalosporin, penicillin, and an aminoglycoside. Tetanus (caused by Clostridium tetani) can lead to devastating systemic complications and requires early treatment with boosters and toxoid for susceptible injuries.
Soft Tissue Injuries
Include direct injuries to vessels, nerves, and soft tissues as well as indirect compromise of these tissues.
Increased pressure within enclosed soft tissue compartments of the extremities can lead to serious sequelae. Elevated compartment pressures commonly follow significant injuries to the forearm and leg and should be diagnosed early with careful patient monitoring. Pain (especially with passive flexion of the digits) is the earliest and most reliable indicator, but pallor, paralysis, paraesthesia, and pulselessness are also indicative of elevated pressures.
Nerve Injuries. (See fig. Man. Sports Medicine)
Compartment syndrome fasciotomy
Adult Respiratory Distress Syndrome (ARDS) - Pulmonary edema and decreased function commonly follow severe trauma. ARDS can be a result of direct (aspiration, inhalation, etc.) insults.
Fat Emboli Syndrome (FES) - A form of ARDS that follows major long bone fractures (0.5-2% of patients with multiple fractures).
Pulmonary Embolism - Thromboembolic disease is the most on complication following surgery on the extremities.
Bleeding Disorders - (DIC).
GI Complications - Can be a result of the trauma itself (the spleen is the most commonly injured organ with blunt trauma.)
Reflex Sympathetic Dystrophy (RSD) - Pain, swelling, discoloration, and stiffness of the affected extremity.
Late Complications - Can be systemic or involve local soft tissue, bones, and joints. Myosotis ossificans can follow injuries. Posttraumatic osteoarthritis. Immobilisation hypercalcemia.
Pathologic fractures occur through abnormal bone. Most of these fractures involve the elderly (osteoporosis is the most common cause), but should be suspected in any patient when minimal trauma causes a major fracture. Repeated fractures, a history of prior malignancies, increased pain, and patients with metabolic disorders.
(See case 8 in the cases section for more information about pathological fracture in malignancy).
Click to see pot from Case 8
Systemic Skeletal Disease.
Benign Local Lesion - Generally should be removed after fracture healing if it caused a pathologic fracture (except in the hand).
Malignant Primary Bone Disease.
Metastatic Disease - The second most common cause of pathologic fractures. The most common primary tumours involved are breast, lung, thyroid, prostate, and kidney.
Stress Fractures - Stress fractures are the result of repetitive loading below the yield strength and are in elderly women (insufficiency fractures), athletes, and military recruits (fatigue fractures), steroid use.
Soft Tissue Trauma
High-Pressure Injection Injuries.
| || [Lecture 1 - Trauma ] [Lecture 2 - Arthritis ] [Lecture 3 - Low back pain ] [Lecture 4 - Infections ]|
[Lecture 5 - Bone and Soft Tissue Tumours ] [Lecture 6 - Fractures ]