Orthopedic.pptx

Definition
• Orthopaedics is the art of correcting deformities in children by such
means as may easily be put in practice by parents and by themselves
and all such others as are employed in children department. It is
broadly classified into two:
• i) Cold Orthopaedics
• ii) Traumatology –the study of bone, articulars and soft tissue injuries

• TRAUMATOLOGY:
• Introduction
• Surgical history
• Clinical examination in orthopaedics
• Procedure for Local examination

• Fractures
• Classification of fractures
• Types of fractures
• Healing of fractures
• Principles of management of fractures
• Complications of fractures
• Application of Plaster of Paris

SPECIFIC FRACTURES AND INJURIES
• Clavicle
• Scapula
• Shoulder dislocation
• Humerus
• Radius & Ulna
• Femur + Dislocations
• Tibia and fibula
• Pelvis
• spine

ORTHOPAEDICS:
a) Bone infections
• Acute Osteomyelitis
• Pyogenic Arthritis
• Syphilitic arthritis
• Gonococcal arthritis
• Tuberculous Arthritis

b) Degenerative conditions
• Osteoarthritis
• Gouty Arthritis
• Ankylosing Spondilities
• Prolapse Intervertabral Disc
• Rheumatoid Arthritis

C) congenital abnormalities
• Congenital Talipes Equinovarus
• Congenital Mid tarsal varus
• Spina Bifida
• osteogenesis imperfecta

d) bone tumours:
• a) Malignant-
• b) Benign
OTHERS
• Perthes diseases
• Pagets disease
• Slipped upper femoral epiphysis (ostochondritis) of femur.

COLD ORTHOPAEDICS
i)Congenital deformities
• - Congenital tallipes equino-varus
• - Osteogenesis imperfecta
• - Congenital Dislocation of the Hip
• - Spina- Bifida
• - Cevical Rib
• - Torticolis

• ii) Acquired
• Infection of bones
• Osteomyeletis
• Pyogenic Arthritis
• Syphlitic Arthritis

Degenerative Conditions
• Oesteo Arthritis
• Ankylosing Spondilitis
• Rhematiod Arthritis

Biochemical diseases
• Gout Arthritis
• Osteo malacia
• Oestoporosis.

• Neoplasm
• Primary
• Osteo sarcoma
• Ostochondroma
• Ewings tumour
Mutiple mycloma

• Determinants of diagnosis in ortopaedics
• Diagnosis of bone conditions depends on the following factors.
• a) Good surgical history can diagnose about 85%
• b) Clinical examination
• c) Radiology
• d) Other specialized methods of investigations e.g. CT scan, MRI

SURGICAL HISTORY
• The surgical history is very important in making a diagnosis of an
orthopaedic problem. The problem can sometimes be diagnosed as from
the history alone.
• After picking the chief complains, the symptoms should be traced step by
step from the beginning up to the end. E.g. History of fall from height, –
pain at the knee joint, restrictions of movements.
• Patients own knowledge of the cause of the symptoms is very important.
The aggravating and relieving factors are also important.
• When symptoms of the local region have been exhausted, other symptoms
should be sought from the rest of the body in the review of the symptoms
and enquire whether general body health is affected.

CLINICAL EXAMINATION
• Before a clinician embarks on carrying out any clinical examination,
thorough explanation of the exact examination that is supposed to be
carried out.
• This should be followed by proper positioning of the patient and
adequate exposure of the area to be examined.

The clinical Examination should be done in 4 phases.
• I) examination of the general Examination of the features
• ii) Local Examination – Examination of the suspected source of
problem.
• iii) Examination of the suspected source of problem.
• iv) Systemic examination or the rest of the body.

• LOCAL EXAMINATION
i) Exposure – Expose he part to be examined as much as possible.
• - Ensure that there is good lighting and avoid use of colored bulbs.

ii) Inspection – Observe the:
• Bones for alignment.
• Any obvious shortening
• Any obvious abnormality
• Soft tissues – Observe the contours f the soft tissue

• Compare both limbs.
• Color and texture of the skin note any change or color.
• Scars and sinuses – If scars are present determine whether they are
surgical, therapeutic or cosmetic.

III)Palpations: Palpate for the following:
• Skin local temperature and compare both limbs
• Bones- general out line of the bone
• Soft tissues for any spasm, wasting thickening of synovial membrane
in joint, localized swelling e.g. tumors and cysts, increased synovial
fluid.
• Local tenderness – note the site of tenderness.
• Sensory –pain /temperature,position sense,crude touch,fine touch,
• Motor-muscle power,muscle tone,and muscle bulk

• iv) Measurements.
• The length of the limbs especially the lower limbs should be
measured with a tape measure cms).
• There are several point s of measurements in a human being
• A - The umbilicus
• B – Anterior superior iliac spine
• C – The knee
• D - Medial malleolus.
• There are two types of shortening:

• a) True shortening – This is where a limb is actually short due to
overlapping of the bones due to any other.
• b) Relative shortening – This where there is tilting of a part of the
body making a limb look shorter but its nit actually short.

VI) Movements
• Active movements – Patients moves on his own.
• Passive movements where the examiner moves apart of the patients
• Limb. While doing the movements note for:
• -tenderness
• - Crepitus – sounds produced by the two surfaces (rubbing each
Other).
• -Restrictions of joint movements.

• Power - note whether there is complete loss of power or general
weakness of the joint by doing straight leg raising test, the stability
depends on the integrity of the articular surfaces and the ligaments.
• Peripheral Circulation- The part distal to the affected site should be
examined for,
• a) Local temperature
• b) Color of the skin
• c) The capillarity feeting capacity in the nail beds.
• d) Arterial pulses – Anterior tibial pulse (tabes dorsally) or posterior
tibial pulse

FRACTURE
• A fracture is a complete or incomplete break or crack in the continuity
of a bone.

Definition of other terms
• Dislocation- Persistent loss of contact of two articular surfaces due to
a tear or ligaments.
• Sprain- Temporary loss of articular surfaces due to over stretching of
the ligaments.
• Epiphyseal separation – This is a fracture that occurs through
epiphyseal surfaces.
• Fracture dislocation- A fracture that involves an articular surface.

Classification of fractures
According to :
a)cause:
1.Traumatic fractures-Occurs when excessive force is applied to normal bone
either directly or indirectly
2.Fatigue/Stress fractures-This occurs if bones are subjected to chronic
repetitive forces-2nd & 3rd metatarsal heads
-Mid & Distal Tibia & Fibula fractures in long distance
runners & dancers
-Neck of femur
-Fractures of the pubic rami in severely osteoporotic or
osteomalacic patients
3.Pathological fractures-strength of bone is reduced by disease

4.Partial/Green-stick fractures-Longitudinal compression force
b)according to severity:
it can be; a)open/compound fracture
b)closed fracture

Open/Compound fractures
• Open/Compound fractures can communicate with the outside in 3
ways;
• i) Trauma directly damaging skin & breaks bone - outside-in injury
• ii) Bone breaks & pierces through skin - inside-out injury
• iii) Injury to skin which becomes necrotic & sloughs off exposing bone

Classification
A. Gustilo and Anderson Classification:
• Type 1 fracture is a low-energy injury with a wound <1 cm in length,
• Type 2 fracture involves a wound >1 cm long and significantly more injury,
caused by more energy absorption during the production of the fracture.
• Type 3 fracture has extensive wounds >10 cm in length, significant
fracture fragment comminution, and a great deal of soft tissue damage &
periosteal stripping. It is usually a high energy injury.
• This type of injury results typically from high-velocity gun shots, motorcycle
accidents, or injuries with contamination from outdoor sites such as with
tornado disasters or farming accidents.

Type 3A fractures do not require major reconstructive surgery to
provide skin coverage.
-Type 3B fractures, in contrast, usually require reconstructive
procedures because of soft tissue defects that provide either poor
coverage for bone or no coverage.
-Type 3C injuries involve vascular compromise requiring surgical repair
or reconstruction

Clinical presentation
Patient will give a history of –
• -Causative force (factor)
• -Severe pain
• -Swelling
• -Inability to use the limb.
• + Loss of bone contour.
• + Bleeding
• - Crepitus.
• - X-ray confirms

Mx of Open Fractures
Principles of Mx;
• - Wound debridement
• - Antibiotic prophylaxis
• - Stabilization of the fracture
• - Early wound cover

General management of fracture(5Rs)
1)Resuscitation
• i) primary survey:Airway with cervical spine control, Breathing, Circulation
& haemorrhage control, Disability & Exposure -
-30% of patients with an open fracture have other life threatening injuries
- Assess neurovascular status of the limb
- Relieve pain
- IV antibiotics - 70% of open fractures are contaminated with bacteria at the
time of injury
Give antibiotics for 48-72Hrs post injury & for 48-72Hrs each time a further
procedure is performed;
Cephalosporins (+ Aminoglycoside - Type II/III) (+ Penicillin - if a farmyard
injury to cover for Clostridium perfringens )

- Tetanus prophylaxis -
- Swab wound
- Photograph - to prevent reopening for examination
- Cover wound
- Splint
- Imaging-X-ray

Imaging
The rule of 2s is used in taking x-rays for fractures.
1.Two views: Obtain anteroposterior (AP) and lateral views of the injured
limb.
-2.Two joints: When an injury occurs to an extremity, obtaining radiographs
of the joints above and below the injury to rule out any potential associated
fracture or dislocation in a corresponding joint
3.Two limbs: obtaining radiographs of both the injured and noninjured limbs
to aid in analysis of the osseous anatomy and, ultimately, to aid in the
diagnosis. This is especially important to help determine limb length and
rotation in children with epiphyseal-plate injuries or in patients with severely
comminuted fractures.
4.Two times: obtaining 1 prereduction image and 1 postreduction or
postfixation image to assess the adequacy of the fracture reduction.

2)Reduction
• -The facture needs to be reduced so that healing can occur. Reduction of a fracture can be done in
two ways:
• 1. Closed reduction
• 2. Open reduction
-closed reduction-manual
-skin
Types
i) Gallows skin traction.
ii) Russell’s skin traction.
iii) Balanced skin traction .
iv)Thomas splint etc.

-skeleton
This involves use of Steinman pin through a bone. The selected sites
include the following:
• a) Skull
• b) Olecranon
• c) Supracodylar of femur
• d) Tibia tuberosity.
• e) Calcaneum.

Open reduction-ORIF
• a) Kuntcher nail, K- nail
• b) Plate –straight - angle
• c) Screws.(DHS-)
• D)intermedullary nails

Indication of ORIF
1. Failed conservative #
2. Segmental fracture
3. in elderly
4. Early mobilization is required
5. Multiple fractured patient

3.Restriction of movement:
The objectives are;
• o To prevent angulations or displacement of fragments
• o To prevent movements that interferes with union of a fracture
• o To relieve pain.
• This is usually achieved by use of splints such as;
a) Plaster of Paris- is anhydrous calcium sulphate
b) traction
- Skin
- Skeletal
c) Internal fixators
d) External fixators

4. Restoration of the function
• This is achieved through physiotherapy
• i) Exercise - Passive – Active
• ii) Massage
• iii) Heat treatment:

5. Rehabilitation
• Patient needs to back to his/ her normal duties after treatment of
fractures.
• This includes counseling and where applicable compensation by
insurance firms.
• Use of walk aids-name them??????

Amputation
Indications;
• Congenital anomalies especially of lower limbs so as to enable weight bearing
• Traumatic (Patient specific)
- A MESS score ≥7
- Massive loss of bone
- Extensive neurovascular damage
- Frost bite
• Vascular conditions e.g. Diabetes, Arteriosclerosis, Raynaud's Disease, SLE,
Berger's Disease
• Infective conditions e.g. Gas gangrene, Madura foot, Chronic osteomyelitis
• Neoplastic conditions

INVESTIGATION
I.FHG, ECG
II. Ischemic-Ankle Brachial Pressure Index - Use doppler pressure probe. Ratio
between pressure at
amputation level with SBP of brachial artery - Has to be >0.45 or no healing will
occur.
- Normal - 1
- Intermittent claudication - 0.6-0.9
- Resting pain - 0.3-0.6
- Impending gangrene - ≤0.3 or Ankle SBP <50mmHg
III.Angiography to check if there is an indication for reconstruction
IV. Transcutaneous oximetry - Determines the capacity of the vascular system to
deliver oxygen to level of proposed surgery (20-30mmHg)

Describing a fracture
i) Bone
ii) Segment - Proximal, Diaphyseal or Distal
iii) Type of fracture
• Proximal & Distal fractures may be extra-articular, peri-articular or
complete articular
• Diaphyseal fractures may be Simple, Wedge or Complex
iv) Displacement

Healing of various bones
• Humerus - 3-6wks
• Radius/Ulna;
* Children - 3-6wks
* Adults - 6-8wks
• Femur - 12wks (Older patients up to 16wks)
• Tibia/Fibula -16-18wks
• Spine - 4-6wks (Has good blood supply)
• Hand & Foot - 3wks

X-Ray changes in Bone Healing
• In young children, union is nearly always rapid, callus often being
visible radiologically within 2wks & the bone being consolidated in 4-
6wks.
• In adults, new bone visible within 4-6wks & consolidation is in 16-
24wks

Principles of # Mx
1)To obtain & hold fracture alignment
2)To limit soft-tissue damage & preserve skin cover
3) To prevent-or at least recognize-compartment
swelling
4)To start early weight bearing (loading promotes
healing)
5)To start joint movements as soon as possible

1)To obtain & hold fracture alignment
A).Reduction
• Reducing a fracture involves trying to return the bones to as near to
their original position as possible
• Acceptable reduction;
• Lateral shift of up to 50%
• 5° for varus or valgus angulation
• 10° for anterior or posterior angulation

Complications
Early complications (local) within few weeks
a) Fracture fever – due to normal tissue response to trauma.
b) Soft tissue injuries to blood vessels, muscles and nerves.
c) Bleeding –This may be revealed or concealed.
d) Crush syndrome(repurfusion injury) – When here is prolonged
compression of muscles, after release there is tendency release
myohaematin acid which is circulated in blood. When it reaches the
kidney it may block the renal tubules or cause renal artery spasm which
leads to renal tubular necrosis leading to renal failure

Early general.
a) Hemorrhage – If severe leads to hypovalaemic shock.
b) Neurogenic shock- This s due to involvement of the nerves # Ribs
(sympathetic nerves)

Intermediate local (24-48hrs).
a) Infections -if the wound is left uncovered or contaminated. It can
leadto the following;
• i) Local wound infection
• ii) Tetanus
• iii) Gangreen gas-gas
• iv) Osteomyelitits
• .

• b) Fat Embolism
• c) Pulmonary Embolism- far- gas
• d) Compartment syndrome
• e) Delayed union.

4. Intermediate general.
• • Hypostatic pneumonia due to inhalation of secretions
• • Bed sores due to prolonged bed rest.
• • Anuria due to renal failure

Late local complications.
• Mal union
• non- union
• Osteoarthritis – if fracture occurs through a joint.
• Disuse atrophy- due to lack of use of the limb.(Disuse atrophy)
• Contracture due to stiffness of the joins.

• BONE HEALING PROCESS ????????

Humerus
1.Anterior instability is the commonest cause;
• Lax capsule anteriorly
• Glenoid labrum is often torn
• The joint was designed for a wide range of movements

• Acute Dislocation
- The arm is forced into abduction, external rotation & extension
- Indentation on the posterolateral aspect of the humeral head (Hill-
Sachs lesion) - A compression fracture due to the humeral head being
forced against the anterior glenoid rim each time it dislocates.
• Recurrent sublaxation - Develops in ⅓ patients <30yrs & 20% older
patients;
- Patient describes a 'catching' sensation followed by 'numbness' or
'weakness' - Dead arm syndrome -whenever the shoulder is used with
the arm in the overhead position

2.Recurrent sublaxation - Develops in ⅓ patients <30yrs & 20% older
patients;
- Patient describes a 'catching' sensation followed by 'numbness' or
'weakness' - Dead arm syndrome -whenever the shoulder is used with
the arm in the overhead position

O/E;
Recurrent sublaxation;
• - Apprehension test - With the patient seated or lying, the examiner
cautiously lifts the arm into abduction, external rotation & then extension;
at the crucial moment the patient senses that the humeral head is about to
slip out anteriorly & his body tautens in apprehension.
• - Falcrum test - With the patient lying supine, arm abducted at 90°, the
examiner places one hand behind the patient's shoulder to act as a fulcrum
over which the humeral head is levered forward by extending & laterally
rotating the arm; the patient immediately becomes apprehensive.

Investigation
• Axillary view XR
• CT angiography for labral tears
• Recurrent sublaxation - The labrum & capsule are often detached
from the anterior rim of the glenoid (Bankart lesion)

Management
• • Closed reduction & immobilization for 3wks in a collar & cuff then
start physiotherapy & remove at 6wks
- Hanging method - Patient lies on the bed sedated with the arm
hanging on the edge of the bed
- Hypocritic method - Gentle traction & counter-traction
- Cock's manoeuvre

Surgery
- Indications;
• - Frequent dislocation, especially if this is painful
• - Recurrent sublaxation or a fear of dislocation sufficient to prevent
participation in everyday activities including sports
• Neglected shoulder dislocation;
• - Children - ORIF
• - Elderly - Physiotherapy to increase motion

Complications;
- Rotator cuff tear
- Axillary nerve & artery injury
- Shoulder stiffness

Shaft of Humerus
C/P
• # Above deltoid insertion - The proximal fragment is adducted by
pectoralis major
• # Lower down - The proximal fragment is abducted by the deltoid
• Injury to the radial nerve in the radial groove is common but recovery
is usual

mnx
• Closed Reduction - A hanging cast is applied from shoulder to wrist
with the elbow flexed at 90°, & the forearm section is suspended in a
sling around the patient's neck.
• This cast is replaced after 2-3wks by a short(shoulder to elbow) cast
or a functional brace for a further 6wks (union) after which only a
sling is needed until the fracture is consolidated.

Surgery
Indications for ORIF
- Fractures in the upper ⅓ or Muller's fractures
- Displaced intra-articular extension of the fracture
- Severe multiple injuries
- An open fracture
- Segmental fractures
- A pathological fracture
- A 'floating elbow' - simultaneous unstable humeral & forearm fractures
- Radial nerve palsy after manipulation
- Non-union

Fixation can be achieved by;
• a) A Dynamic compression plate & screws - 2 tubular plates at 90°
are used to control rotation
• b) An interlocking intramedullary nail
• c) flexible pins (Rash pins)

Complications
• Vascular injury - Brachial artery damage
• Nerve injury - Radial nerve palsy (wrist drop & paralysis of the MCP
extensors) may occur particularly displaced oblique fractures at the
junction of the middle & distal ⅓s of the bone.
Tested by active extension of the MCP joints; active extension of the
wrist can be misleading because extensor carpi radialis longus is
sometimes supplied by a branch arising proximal to the injury

Supracondylar #
• Most common fracture in childhood.
Mechanism of Injury
• Posterior angulation & displacement (95% cases) suggests hyperextension
injury, usually due to a fall on the outstretched hand. The humerus breaks
just above the condyles.
• The distal fragment is pushed backwards & (because the forearm is usually
in pronation) twisted inwards.
• The jagged end of the proximal fragment pokes into the soft tissues
anteriorly, sometimes injuring the brachial artery ± radial ± median nerve.
• Anterior displacement is due direct violence with the joint in flexion.

Classification - Gartland's classification
According to the severity & degree of displacement.
• Type I - Undisplaced fracture
• Type II - Angulated fracture with the posterior cortex still in continuity
A - Less severe & merely angulated
B - More severe & both angulated & malrotated
• Type III - Completely displaced fracture with no cortical contact
A - Posteromedial
B - Posterolateral

• Following a fall, the child is in pain & the elbow is swollen; with a
posteriorly displaced fracture the S-deformity of the elbow is obvious &
the bony landmarks are abnormal –
Differentiated from elbow injuries by the retention of the isosceles
triangle formed when the elbow is flexed between the medial + lateral
epicondyles & the olecranon process.
• It is essential to check the neurovascular status of the limb
• Passive extension of the flexor muscles should be pain free.

Investigation
• X-ray of Distal humerus - Jones view, AP & Lateral view;
• The elbow is gently splinted in 30° flexion to prevent movement &
possible neurovascular injury during the x-ray examination.
• Type I - 'Fat pad sign' - There is a triangular lucency in front of the
distal humerus, due to the fat pad being pushed forwards by a
haematoma.
• Posteriorly displaced fracture - the fracture line runs obliquely
downwards & forwards & the distal fragment is tilted &/or shifted
backwards

Management
• Dunlop's skin traction with the arm out to the side can be used;
• Severe oedema inhibiting reduction of the fracture
• If the fracture is severely displaced & cannot be reduced by
manipulation
• If, with the elbow flexed 100°, the pulse is obliterated & image
intensification is not available to allow pinning & then straightening of
the elbow.
• Severe open injuries or multiple injuries of the limb

Type I - The elbow is immobilised at 90° & neutral rotation in a
posterior slab up to the wrist & the arm is supported by a sling. It is
essential to obtain an x-ray 5-7days later to check that there has been
no displacement.
The splint is retained for 3wks then removed & then guided active
range of movements exercises are done while the patient still retains
the sling until full recovery - around 6wks.

Type IIA - If the posterior cortices are in continuity, the fracture can be
reduced under GA & the arm is held in a collar & cuff; the circulation
should be checked repeatedly during the first 24Hrs.
• An x-ray is obtained after 3-5days to confirm that the fracture has not
slipped. The splint is retained for 3wks, after which movements are
begun as above up to 6wks

Surgery
• Indications for ORIF - Percutaneous crossed Kirschner wires (take care not
to skewer the ulnar nerve!) -
Removed after 3wks;
• Type IIB & III
• Neurovascular compromise
• If the acutely flexed position cannot be maintained without disturbing the
circulation
• If the reduction is unstable
• Old injuries
• Open fractures
• Floating elbow

Anteriorly displaced Fractures - The fracture is reduced & a posterior
slab is bandaged on & retained for 3 weeks.
Thereafter the child is allowed to regain flexion gradually while still in a
sling as above.

Complications
• Vascular injury - Injury to the brachial artery ± compartment
syndrome ± Volkmann's ischemic contracture
• Nerve injury - All 3 nerves can be tested by the 'Thumb sign'
- Median nerve (Ask patient to snap fingers) particularly the anterior
interosseous branch; the patient is unable to abduct the thumb, &
sensation is lost over the palmar radial 3½ digits.
- In long standing cases, the thenar eminence is wasted & trophic
changes may be seen. Loss of function is usually temporary &
recovery can be expected in 6-8wks.

• Radial nerve - Pointing sign

Radial/ulna #
Mechanism of Injury
• Additional rotational deformity may be produced by the pull of
muscles attached to the radius;
• • # Upper ⅓ - Biceps & supinator muscles
• • # Middle ⅓ - Pronator teres
• • # Lower ⅓ - Pronator quadratus

Mnx
Children
• Closed treatment is usually successful because the tough periosteum
tends to guide & then control the reduction.
• The fragments are held in a well-moulded full-length cast, from axilla
to metacarpal shafts (to control rotation).
• The cast is applied with the elbow at 90°. If the fracture is proximal to
the pronator teres -The forearm is supinated;
• if it is distal to pronator teres, then the forearm is held in neutral.
• The position is checked by x-ray after a week &, if it is satisfactory,
splintage is retained until both fractures are united (usually 6-8wks)

ORIF
Indications for surgery;
• If the fracture cannot be reduced
• If the fragments are very unstable
• Fixation with a small plate,
• Kirschner wires or
• flexible intramedullary nails is then needed.

Adults
• ORIF - The fragments are held by interfragmentary compression with plates
& screws.
• Bone grafting is advisable if there is comminution of >⅓ of the
circumference.
• The deep fascia is left open to prevent buildup of pressure in the muscle
compartments, & only the skin & subcutaneous tissue are sutured.
• After the operation, the arm is kept elevated until the swelling subsides, &
during this period active exercises of the hand are encouraged.

• Immobilize with comminuted fractures or unreliable patients.
• It takes 8-12wks for the bones to unite.

Complications
• Nerve injury - Rarely caused by the fracture but may be caused by
the surgeon. Exposure of the radius in it's proximal ⅓ risks damage to
the posterior interosseous nerve where it is covered by the superficial
part of the supinator muscle. The patient complains of clumsiness &,
on testing, cannot extend the MCP joints of the hand. In the thumb
there is also weakness of abduction & IP extension.
• Vascular injury - Injury to the radial or ulnar artery seldom presents
any problem as the collateral circulation is excellent.
• Compartment syndrome - A distal pulse does not exclude
compartment syndrome.

Monteggia Fracture - Dislocation of the Ulna
• This is any fracture of the ulna associated with sublaxation or
dislocation of the radiocapitellar joint

Mechanism of Injury
• • Usually the cause is a fall on the hand; if at the moment of impact
the body is twisting, it's momentum may forcibly pronate the
forearm.
• The upper ⅓ of the ulnar fractures & bows forwards & the radial head
usually dislocates forwards.

Management
• ORIF with plates & screws of the ulnar; bone grafts may be added for
safety.
• The radial head usually reduces once the ulna has been fixed but if it fails -
ORIF.
• If the elbow is completely stable, then flexion/extension & rotation can be
started after 10 days.
• If there is doubt, then the arm should be immobilized in plaster with the
elbow flexed for 6wks.
• In children;
* Incomplete ulnar fractures can often be reduced closed. The arm is then
immobilized in a cast with the elbow in flexion & supination for 3wks.
* Complete fractures - ORIF

Complications
• Nerve Injury - The wrist & hand should be examined for signs of
injury to the radial nerve (Posterior interosseous branch), usually a
neuropraxia which will recover by itself.

Galeazzi Fracture
- Dislocation of the Radius
- Fracture of the Distal ⅓ of Radius & sublaxation or dislocation of the
Inferior Radioulnar joint
- More common than the Monteggia

• Prominence or tenderness over the lower end of the ulna
• Instability of the radioulnar joint demonstrateable by 'balloting' the
distal end of the ulna (the 'piano-key sign') or by rotating the wrist.
• Test for an ulnar nerve lesion which is common;
* Claw-hand deformity - with Hyperextension of the MCP (Paralysed
Lumbricals) & Flexion of the IP joints (Paralysed Interossei) of the ring &
little finger* Ask patient to cross fingers - PAD + DAB - Finger abduction
is weak + loss of thumb adduction= Pinch difficult
• * Hypothenar & interosseous wasting may be obvious.
• * Numbness of the ulnar 1½ fingers.

Management
• Children - Closed reduction
• Adults - ORIF with compression plating of the radius
• If the distal radioulnar joint remains unstable after reduction, the
forearm should be immobilized in the position of stability (usually
supination), supplemented if required by a transverse K-wire.
• The forearm is splinted in an above elbow cast for 6wks

Colles' Fracture
• Transverse fracture of the radius just above the wrist at the
corticocancellous junction, with extension, dorsal displacement,
radial tilt & shortening of the distal fragment. Often the ulnar styloid
process is broken off. C/P
• 'Dinner-fork' deformity - Prominence in the back of the wrist & a
depression in front

Management
• Undisplaced (or only very slightly displaced) - A dorsal splint is
applied for 1-2days until the swelling has resolved, then the cast is
completed & removed after 4wks to allow mobilization.
• Displaced - Closed reduction + a dorsal plaster slab extending from
just below the elbow to the metacarpal necks & ⅔ of the way round
the circumference of the wrist. It is held in position by a crepe bandage.
• Comminuted - Percutaneous K-wire fixation; If severe, External
fixation The fracture unites in about 6wks

Complications
• Nerve injury - Compression of the median nerve in the carpal tunnel -
wasting of the thenar eminence & diminished sensibility on the palmar
aspect of the radial 3½ fingers.
• Reflex sympathetic dystrophy/Algodystrophy
• Tendon rupture (of extensor pollicis longus)

Mechanism of Injury
• Fall on the dorsiflexed hand

Anatomical snuff box - Contains the radial artery
• Medially - Extensor pollicis longus
• Laterally - Extensor pollicis brevis & Abductor pollicis longus
• Base - Styloid process of the radius

Mx
• Fracture of the scaphoid tubercle needs no splintage & should be
treated as a wrist sprain; a crepe bandage is applied & movement is
encouraged.
• Undisplaced fractures - No reduction; Casting from the upper
forearm to just short of the MCP joints of the fingers, but incorporating
the proximal phalanx of the thumb. The wrist is held dorsiflexed & the
thumb forwards in the 'glass-holding' position (Position of Function) -
It is retained for 6wks.

• Displaced fractures - ORIF with a compression screw
Complications
• • Avascular necrosis - The proximal fragment may die especially with
proximal pole fractures.

LOWER LIMBS
• Dislocation of the Hip
• Often small fragments of bone are chipped off as the joint dislocates;
if there is a major fragment, or comminution, it is regarded as a
fracture-dislocation.

a) Posterior Dislocation
Mechanism of Injury
• Usually occurs when someone seated in a vehicle is thrown forwards,
striking the knee against the dashboard.
• The femur is thrust upwards & the femoral head is forced out of it's
socket; often a piece of bone at the back of the acetabulum (the
posterior wall of the socket) is sheared off making it a fracture-
dislocation.

• The leg is short
• lies adducted,
• internally rotated & slightly flexed

DDx for shortening
• Fracture femur
• Acetabular fracture

Mnx
• Reduction under GA - An assistant steadies the pelvis; the surgeon
starts by applying traction in the line of the femur as it lies (usually in
adduction & internal rotation) & then gradually flexes the patient's
hip & knee to 90°, maintaining traction throughout.
• At 90° flexion, traction is increased & sometimes a little rotation(both
internal & external) is required to accomplish reduction. A satisfying
'clunk' terminates the manoeuvre.
• Xrays are essential to confirm reduction & exclude a fracture.

Complications
Early;
• Sciatic nerve injury
• Vascular injury - the superior gluteal artery may be torn
• Associated fractured femoral shaft
Late;
• Avascular necrosis of the femoral head
• Myositis ossificans
• Unreduced dislocation
• 2° Osteoarthritis due to;* Cartilage damage at the time of the dislocation
* The presence of retained fragments in the joint
* Ischemic necrosis of the femoral head

Anterior Dislocation
• Mechanism of injury
• A posteriorly directed force on an abducted & externally rotated hip
will cause the neck to impinge on the acetabular rim & lever the
femoral head out in front.
• The femoral head will lie superiorly (Type I) or inferiorly (Type II)

• The leg lies externally rotated, abducted (occasionally almost to a
right angle) & slightly flexed. It is not short,because of the attachment
of the rectus femoris on the AIIS & superior aspect of the acetabulum
thus prevents the head from displacing upwards.
O/E
• The prominent head is easy to feel, either anteriorly (superior type)
or in the groin (inferior type)
• Hip movements are impossible

Mnx
• The manoeuvres employed are similar to those used to reduce
posterior dislocation, except that while the hip is gently flexed
upwards, it should be kept adducted; an assistant then helps by
applying lateral traction to the thigh

FEMUR
Anatomic Classification
• a) Intracapsular - Fracture of the femoral neck proper
i) Subcapital
ii) Transcervical
iii) Basal
• b) Extracapsular
i) Intertochanteric - Trochanteric fracture
ii) Subtrochanteric - Up to 5cm below the lesser
trochanter

Intracapsular Fractures - Fracture of the Neck of the Femur
• Common in women >60years in whom there is a tendency for the bone to
become increasingly fragile as a consequence of generalised osteoporosis
due to post-menopausal bone loss.
• Risk Factors
• Osteoporosis
• Bone-losing or bone-weakening disorders e.g. osteomalacia,
 diabetes,
stroke (disuse),
alcoholism &
chronic debilitating disease.

Garden's Classification
• This classification is based on the amount of displacement

• The femoral neck fracture may be missed in;
i) Stress fractures - The elderly patient with unexplained pain in the hip;
X-Ray is usually normal, but a bone scan will show the 'hot' lesion.
ii) Undisplaced fractures - Shows up on an MRI or Bone scan after a few
days.
iii) Painless fractures
iv) Multiple fractures e.g. Femoral shaft fracture

C/P
• Garden's Stage I - A typical history is that the elderly patient tripped &
fell & was able to pick herself up after falling & may have walked
perhaps with assistance & remained mobile despite pain. On
examination,there is no detectable abnormality & the patient is able
to move the hip through a moderate range without severe pain.

• Displaced fractures - the elderly patient tripped & fell, & was unable
to get up again unaided & she was subsequently unable to take weight
on the injured limb.
On examination, there was marked hip flexion, abduction & eternal
rotation of the limb because of gluteus medius & iliopsoas (inserted at
the greater & lesser trochanter respectively) causing shortening by 2-
3cm & movement of the hip causes severe pain.

• DDx - of external rotation;
• Congenital dislocation
• Intracapsular & Extracapsular & shaft of femur fractures
• Herpes osteoarthritis

mnx
Pre-op;
- Pain relief
- Splintage
• Conservative Mx - An 'old' Garden's I fracture where the diagnosis is
made only after the patient has been walking about for several weeks
without deleterious effect on the fracture position.
• Surgical Mx - Best if done within 12hrs.
• Reduction (Closed then Open)- Under GA.

Children - Closed reduction followed by immobilisation in plaster
Young patients
• - Garden's I - ORIF - Multiple parallel cannulated screws (usually 3)
• - Displaced - ORIF with a Dynamic Hip Screw

Elderly
• - Garden's I - ORIF with a Dynamic Hip Screw
- Displaced
- ORIF with a Dynamic Hip Screw
- Hemiarthroplasty - consists in removal of the head & neck of the femur &
replacement by a metal prosthesis;
* In very old patients with a limited lifespan ± comorbidity
* If ≥2 closed reduction attempts fail in an elderly patient
* Comminution of either fragment
* Pathological fractures

• Total Hip replacement;
• * If treatment has been delayed for some weeks & acetabular
damage is suspected(Garden I)
• * In patients with metastatic disease or Paget's disease.
Post-op;
• - Patient should sit-up in bed or in a chair
• - Breathing exercises
• - Active hip movements are encouraged
• - Early mobilisation - with crutches or a walker

• Complications
• a) Avascular necrosis
• Blood supply to the femoral head is through;
• (1) Vessels in ligamentum teres from the obturator artery - 15-20% supply
• (2) Retinacular vessels
• (3) Nutrient vessels from the femoral shaft
• (4) Trochanteric anastomosis in the trochanteric fossa;
• • Descending branch of superior gluteal artery
• • Ascending branches of medial & lateral femoral circumflex artery
• • Occasionally a branch of the inferior gluteal artery

• (5) Cruciate anastomosis at the level of the lesser trochanter;
• • Descending branch of inferior gluteal artery
• • Transverse branches of medial & lateral femoral circumflex artery
• • Ascending branch of 1st Perforator of the Profunda Femoris

Other Causes;
• i) Slipped upper femoral epiphysis
• ii) Perthe's Disease - painful disease of childhood characterized by avascular
necrosis of the femoral head; 4-8yrs old; M>F
• iii) Gaucher's disease
• iv) Infection
• v) Posterior dislocation of the hip - Most common
• vi) Fracture of the femoral neck
• vii) Sickle cell disease
• viii) Alcoholism
• ix) Radiation injuries

Non-Union:
• Avascular necrosis
• Incomplete immobilization
• • Flushing of the fracture haematoma by synovial fluid which also
contains angiogenic inhibiting factors
• • Lack of a periosteum
• • All healing must be endosteal

c) Late Osteoarthritis;
• • Mechanical damage to the articular cartilage at the time of injury or
operation
• • Impairment of the blood supply to the basal layers of the cartilage,
which are probably nourished largely from the vessels in the
underlying bone
• • From union in faulty alignment

Prognosis
• Garden I & II fractures, which are only slightly displaced, have a much
better prognosis for union & for viability of the femoral head than the
more severely displaced Garden III & IV fractures

Extracapsular Fractures
b) Intertrochanteric Fractures

c/p
• Patient old & unfit
• Following a fall she is unable to stand
• The leg is shorter & more externally rotated than fracture neck of
femur (because fracture is extracapsular)
• Patient cannot lift her leg

Subtrochanteric Fractures
• Occur up to 5cm below the lesser trochanter or between the lesser
trochanter & the isthmus - the narrowest part of the medullary canal.
• Seinsheimer classification of subtrochanteric fractures - Based on
number of fragments & location &configuration of fracture lines.

mnx
• Three important features are looked for on x-ray;
• An unusually long fracture line extending proximally towards the
greater trochanter & piriform fossa
• A large, displaced fragment which includes the lesser trochanter
• Lytic lesions in the femur

• ORIF - The posteromedial fragment (lesser trochanter) must be reduced &
fixed
• • Fractures extending to piriform fossa - 95° angle plate
• Lesser Trochanter - A compression (dynamic) hip screw & plate; A larger
medial fragment including part of the lesser trochanter may need separate
reduction & fixation to ensure stability
• Below lesser trochanter - Interlocking nail; if the fracture extends
proximally, the locking screws will need to grip the femoral head.
• If the medial cortex is comminuted or deficient, bone grafts should be
added.
• Pathological fracture - Full length nail as there may be tumour deposits in
the distal part of the femur

Femoral shaft fractures
Winquist's Classification

Epidemiology
• Essentially a fracture of the young adults;
• Diaphyseal fractures in elderly patients should be
considered'pathological' until proved otherwise.
• In children <4yrs of age, the possibility of physical abuse must be kept
in mind.

C/P
* Proximal shaft fractures - The proximal fragment flexes, abducts &
externally rotates because of gluteus medius & iliopsoas; the distal
fragment is frequently adducted.
• * Mid-shaft fractures - The proximal fragment abducts less but flexion
& external rotation by iliopsoas persists.

• * Lower ⅓ fractures - The proximal fragment adducts & the distal
fragment is flexed by gastrocnemius.
• Bleeding from the perforators of the profunda femoris may be severe;
>1ltr may be lost while within the femur, up to 3L

invx
X-ray;
• - Hip, Femur & Knee
• - CXR - Baseline is useful as there is a risk of PE & ARDS in those with
multiple injuries

mnx
• First-Aid;
• i) Treat shock
• ii) Splint fracture - Thomas splint - Helps to control pain, reduce
bleeding & make transfer easier.
• Definitive treatment;
• a) Indications for traction;
- Fractures in children - Skin traction
• - Contraindications to anaesthesia- Lack of suitable skill or facilities for
internal fixation

• Mid-shaft & Lower ⅓ - Traction & Bracing for 10-14wks.
▪ Children - Skin traction without a splint for 4-6wks
▪ Older children - Russell's traction
▪ Adults(& older adolescents) - Skeletal traction through a pin below
the tibial tubercle with an 8-10Kg traction applied over pulleys at the
foot of the bed & the limb supported on a Thomas' splint & a flexion
piece allows movement at the knee.
Also,Perkin's traction.

• Once the fracture is 'sticky' (6-8wks), traction can be discontinued &
the patient allowed up & partial weight bearing in a cast or functional
bracing is acceptable for the lower ⅓ or plaster spica for the Upper ½

ORIF;
i) Plating
• - The combination of shaft & femoral neck fractures
• - A shaft fracture with an associated vascular injury
ii) K-Nail
• - Fractures around the isthmus of the femur
iii) Interlocking nail;
• - Fractures near the middle of the shaft
• - Fractures prone to rotational forces
• - Fractures of bones with a wide medullary cavity

• c) Indications for external fixation
-Fractures in adolescents
- Severe open fractures
- Management of patients with multiple injuries where there is need to
reduce operating time
- Dealing with severe bone loss by the technique of bone transport

Complications
• Shock - 1-2L of blood can be lost even with a closed fracture
• Fat embolism & ARDS
• Thromboembolism
• Joint stiffness
• Refracture & implant failure
• DVT

Prognosis
• • In children, fracture union occurs within 2-4wks(depending on the
age of the child). Consolidation is usually complete by 6-12wks.
• • In adults, the fracture is usually 'sticky' in 6-8wks & consolidates in
16-24wks.

Supracondylar fractures of the femur
• The fracture line is just above the condyles but may extend between
them & up to the distal 9cm of the femur.
• When the lower fragment is intact, it may be markedly displaced by
the pull of the gastrocnemius, thus risking injury to the popliteal
artery –( Always palpate for the tibial pulses).

mnx
1. Traction through the proximal tibia; the limb cradled on a;- Thomas'
splint with a knee flexion piece & movements are encouraged
• - Braun's splint - To relax the gastrocnemius to prevent displacement
of the distal fragment

Indications;
• - Undisplaced or incomplete fractures
• - Impacted stable fractures in elderly osteoporotic patients
• - Spinal cord injury with fracture
• - Contaminated open fractures

2.ORIF;
a) 95° Angle plate
b) Locked intramedullary nail which is introduced retrograde through
the intercondylar notch

Complications
• Vessel injury - Popliteal artery - Posteriorly & Femoral Artery
anteromedially

# Patella
Mechanism of Injury
• Direct injury - Usually a fall onto the knee or a blow against the
dashboard of a car
- causes either an undisplaced crack or else a comminuted ('stellate')
fracture without severe damage to the extensor expansions.
• Indirect injury - Occurs when someone catches his/her foot against a
solid obstacle & to avoid falling,contracts the quadriceps muscle
forcefully. This is a transverse fracture with a gap between the
fragments

C/P
• Knee becomes painful & swollen
• The patella is tender & sometimes a gap can be felt
• Active knee extension should be tested - If the patient can lift the
straight leg, the quadriceps mechanism is still intact.
• If this movement is too painful, active extension can be tested with
the patient lying on his side.

Classification
• Displaced or Undisplaced
• Transverse
• Longitudinal
• Polar
• Comminuted (stellate)
• Separation of the fragments is significant if it is sufficient to create a
step on the articular surface of the patella or, in the case of a
transverse fracture, if the gap is >3cm

MNX
• If there is haemarthrosis it is aspirated.
• Undisplaced or minimally displaced fractures - The extensor mechanism is
intact & Mx is Conservative -
-A Plaster cylinder holding the knee straight is worn for 3-4wks, & during
this time quadriceps exercises are practised everyday.
• Comminuted (stellate) fracture - Extensor mechanisms are intact however,
the undersurface of the patella is irregular & there is a serious risk of damage
to the patellofemoral joint - Patellectomy or Back-slab is applied but
removed several times daily for exercises to mould the fragments into
position & to maintain mobility.
• Displaced transverse fractures - Lateral expansions are torn & the entire
extensor mechanism is disrupted.

• A plaster back-slab is worn until active extension of the knee is
regained;
• the back-slab may be removed everyday to permit active knee-flexion
exercises.

#Tibia & Fibula
Gustilo I & II
• a) Undisplaced or minimally displaced - A full-length cast from upper
thigh to metatarsal necks is applied with the knee slightly flexed (0-5°)
& the ankle at a right angle.
• b) Displaced - Closed reduction & casting as above
• The limb is elevated & the patient is kept under observation for 48-
72Hrs. If there is excessive swelling, the cast is split.
Patients are usually allowed up (& home) on the 2nd or 3rd day,
bearing minimal weight with the aid of crutches.

• After 2wks the position is checked by X-ray.
• The cast is retained until the fracture unites, which is around 8wks in
children but seldom under 16wks in adults.
• With stable fractures e.g. transverse fractures, the full-length cast
may be changed after 4-6wks to a functional below-knee cast/Patella
tendon bearing cast or brace which is carefully moulded to bear upon
the upper tibia & patella tendon.
• This liberates the knee & allows full weight-bearing

Skeletal fixation;
• Locked Intramedullary nailing - Used for unstable diaphyseal fractures e.g.
comminuted & segmental fractures -
• Plate fixation - Best for;
* Metaphyseal fractures that are unsuitable for nailing
* Tibial shaft fractures associated with displaced intra-articular fractures
of the knee & ankle
* Unstable low energy fractures in children.
• External fixation - This is the method of choice for open fractures & is an
excellent alternative to closed nailing; it avoids exposure of the fracture site
& it allows further adjustments to be made if this should be needed.

Tibial Plateau Fractures
Mechanism of injury
• Fractures of the tibial plateau are caused by varus or valgus force
combined with axial loading (a pure valgus force is more likely to
rupture the ligaments) usually following a car striking a pedestrian
(hence the term 'bumper fracture');
• more often it is due to a fall from a height in which the knee is forced
into valgus or varus.

• TYPE I-Vertical split of the lateral condyle - It may be virtually
undisplaced, or the wedge-shaped condylar fragment may be pushed
inferiorly & tilted; the damaged lateral meniscus may be trapped in
the crevice.
• The medial ligament is often intact; Anterior cruciate may also be
injured- Usually in young adults with dense cancellous bone

TYPE II-Vertical split of the lateral condyle combined with depression of
the adjacent central load-bearing part of the condyle - The wedge
fragment is displaced laterally; the joint is widened &, if the fracture is
not reduced, may later develop a valgus deformity - Usually in persons
>40yrs old with sparse cancellous bone

• TYPE III-Depression of the lateral articular surface with an intact
condylar rim - Commonest type of plateau fracture, occurs in
osteoporotic bone 2° to low-energy trauma - The joint is usually
stable - Usually in old people

• TYPE IV - Fracture of the medial tibial condyle;
• A - A depressed, crush fracture of osteoporotic bone in an elderly
person (a low-energy lesion)
• B - A high energy fracture resulting in a condylar split which runs
obliquely from the inter-condylar eminence to the medial cortex.
• The momentary varus angulation may be severe enough to cause a
rupture of the lateral collateral or cruciate ligaments & a traction
injury of the common peroneal nerve or peroneal vessels

• TYPE V - Fracture of both condyles
• TYPE VI - Combined condylar & subcondylar fractures - High-energy
injury. The tibial shaft is effectively disconnected from the tibial
condyles. Associated with compartment syndrome

C/P
• The knee is swollen & may be deformed.
• Bruising is usually extensive & the tissues feel 'doughy' because of
haemarthrosis

• X-rays - AP, Lateral & Oblique
• CT scan or Tomography - To show the amount of comminution or
plateau depression

MNX
• TYPE I-Undisplaced - Conservative - The haemarthrosis is aspirated &
a compression bandage is applied.
• As soon as acute pain & swelling have subsided (usually in a wk), a
hinged cast-brace is fitted & the patient is allowed up; however
weight bearing is not allowed for another 3wks & healing is in 8wks.
• * Displaced - ORIF with 1 or 2 lag screws

TYPE II
• Conservative - The haemarthrosis is aspirated & a compression bandage is
applied.
• Skeletal traction is applied via a threaded pin (Deinmann pin) passed
through the tibia 7cm below the fracture.
• An attempt is made to squeeze the condyle into shape; the knee is then
flexed & extended several times to 'mould‘ the upper tibia on the opposing
femoral condyle.
• The leg is cradled on pillows &, with 5Kg traction in place,active exercises
are carried out every day. As soon as the fracture is 'sticky' (usually at 3-
4wks), the traction pin is removed, a hinged cast-brace is applied & the
patient allowed up on crutches.
• Full weight bearing is deferred for another 6wks.

• Indications;
• Patient is old & frail or osteoporotic
• Slight depression(<5mm) + Stable knee

• IV - a) See IIb - The patient is likely to be left with some degree of
varus deformity
• b) * Undisplaced - See undisplaced Type I fractures
* Displaced - ORIF + Fix lateral ligament
• V - Carry an added risk of a compartment syndrome. See IIa
• VI - Carry an added risk of a compartment syndrome - ORIF with
screw fixation with a ring external fixator.

Pilon Fractures
Mechanism of Injury
• This injury to the ankle joint occurs when a large force drives the talus
upwards against the tibial plafond.
• There is considerable damage to the articular cartilage & the
subchondral bone may be broken into several pieces.
• Classification - Ruedi & Allgoner

Surgical Mx;
• • Type 1 fractures may be managed with ORIF with plates & screws
• • High energy pilon fractures - Type 2 & 3 carry a risk of wound breakdown
& infection if treated by wide open reduction & plating.
• Indirect reduction techniques (ligamentotaxis & percutaneous
manipulation of fragments) with minimal internal fixation with small
screws to hold the fragments together are better tolerated.
• Bone grafts are often added to the defects in the metaphysis & a circular
external fixation & tensioned wires is then applied to stabilize the tibial
plafond on the shaft. Reduction is maintained until union occurs usually
6wks & partial weight-bearing is permitted.
• Pilon fractures usually take 12-16wks to heal.

Compartment syndrome
• Definition: An increase in compartment pressure to the point where
tissue perfusion is impaired.
Causes
•Fracture (tibia, radius)
•Circumferential burns
•Tight dressings
•Crush injuries
•Bleeding (minor injury while anticoagulated)
•Reperfusion injury

c/p
• Early signs
•Tight
•Escalating pain
•Pain with passive stretch of the involved muscle
Late signs -6P
•Pain
•Pallor
•Pulselessness
•Paresthesia
•Paralysis
•Poikilothermia

mnx
Initial Management
•Remove all circumferential dressings/casts
•Ensure leg is at level of the heart - the affected part should not be
elevated above the level of the heart because this maneuver does not
improve venous outflow and reduces arterial inflow
•Remove any traction

Definitive management
• Compartment fasciotomy-2 incisions, 15 cm long
• Delay>12 hr. often results in irreversible muscle and nerve damage in
that compartment
Complications
• If left untreated: rhabdomyolysis and kidney failure

Shocks summary
• SPINAL SHOCK = temporary loss of spinal cord function and reflex
activity below the level of spinal cord injury, characterised by
bradycardia, hypotension (due to loss of sympathethic tone), and an
absent bulbocarvenosus reflex

c/p
• Hypotension
• Pulse Bradycardic
• Reflexes Absent
• Motor Flaccid paralysis
• Time 48-72hrs immediately after injury

mechanism
• Peripheral neurons become temporary unresponsive to brain stimuli

Treatment
• Immobilisation
• Neurological charting (until returnof bulbocarvenous reflex)
• Early surgical intervention

• Neurogenic Shock
• BP Hypotension
• Pulse Bradycardic
• Reflexes Variable
• Motor Variable Variable

• Time 48-72hrs immediately after injury
• Mechanism
• Loss of sympathetic tone and decrease systemic vascular resistance

• Treatment
• Swan-Ganz
• monitoring for
• careful fluid Mx
• Vasopressors

• Hypovolemic Shock
• BP Hypotension
• Pulse Tachycardic
• Reflexes Variable
• Motor Variable
• Time Following blood loss

• Mechanism
• Decreased preload= decreased cardiac output

Treatment
Fluid/blood resuscitation
Haemostasis

ACUTE OSTEOMYELITIS
• Invariably a disease of children.
Predisposing factors in adults;
• Diabetes
• Immunosuppression - acquired or induced
• Trauma - may cause a small haematoma or fluid collection in bone
• Sickle cell disease

Causal Organisms
• Staph. Aureus - most common
• Strep. Pyogenes & Strep. Pneumoniae
• Children <4yrs - H. influenza
• In Sickle Cell Disease - Salmonella

Pathogenesis
• The blood stream is invaded, perhaps from a minor skin abrasion, &
boil, a septic tooth or - in the newborn – from an infected umbilical
cord.
• In adults, the source of infection may be a urethral catheter, an
indwelling arterial line or a dirty needle & syringe.
• Organisms in children usually settle in the metaphysis, most often;
• * In the proximal tibia
• * The distal & proximal ends of the femur

• The predilection for the metaphysis has been attributed to the
peculiar arrangement of the blood vessels in that area:
• the non-anastomosing terminal branches of the nutrient artery twist
back in hair-pin loops before entering the large network of sinusoidal
veins; the relative vascular stasis favours bacterial colonization.
• In young infants, in whom there is still a free anastomosis between
metaphyseal & epiphyseal blood vessels,infection can just as easily
lodge in the epiphysis.

• In adults, haematogenous infection is more common in the
thoracolumbar vertebral bodies than in the long bones

Pathological Characteristics
a) Inflammation - The earliest change is an acute inflammatory
reaction with vascular congestion, exudation of fluid & infiltration
by polymorphonuclear leucocytes.
The interosseous pressure rises rapidly, causing intense
pain,obstruction to blood flow & intravascular thrombosis.
Even at an early stage the tissues are threatened by impending
ischemia.

b) Suppuration - By 2nd-3rd day, pus forms within the bone & forces its way
along the Volkmann canals to the surface where it produces a subperiosteal
abscess. From there the pus spreads along the shaft, to re-enter the bone at
another level or burst into the surrounding tissues.
* In infants, infection often extends through the growth plate to the
epiphysis & hence into the joint.
* In older children the growth plate acts as a barrier to direct spread but
where the metaphysis is partly intracapsular (e.g. at the hip, shoulder or
elbow), pus may discharge through the periosteum into the joint or even
when the joint is not infected, it may swell from an effusion of clear fluid
(Sympathetic effusion)

• * In adults, the abscess is more likely to spread within the medullary
cavity.
• Vertebral infection may spread through the end-plate & the
intervertebral disc into the adjacent vertebral body

c.)Necrosis - By the end of the week, there is microscopic evidence of bone death -
Sequestrum due to bacterial enzymes, leukocytic enzymes & increasing
compromise of the blood supply due to;
- Rising intraosseous pressure
- Vascular stasis
- Septic thrombosis
- Periosteal stripping
• In infants, the growth disc is often irreparably damaged & the epiphysis may
undergo avascular necrosis.
• There is gradual ingrowth of granulation tissue separating sequestra, from living
bone & macrophages & lymphocytes slowly remove the debris by a combination
of phagocytosis & osteoclastic resorption

d.)New bone formation - New bone - Involucrum, forms in the deep
layers of the stripped periosteum & is usually obvious by the end of the
2nd week & it grows to enclose the infected tissue & sequestra.
• If the infection persists, pus & tiny sequestrated spicules of bone may
continue to discharge through perforations in the involucrum
(cloacae) & track by sinuses to the skin surfaces - the condition is now
established as chronic osteomyelitis

e) Resolution - If infection is controlled & intraosseous pressure
released at an early stage, the bone around the zone of infection is first
osteoporotic (probably due to hyperaemia).
With healing, there is fibrosis & appositional new bone formation; this
together with periosteal reaction, results in sclerosis & thickening of
the bone.

c/p
hx
• Recent history of infection - a septic toe, a boil, a sore throat or a discharge from
the ear
• Pain
• Fever
• Raised pulse
• Acute tenderness near one of the larger joints (e.g. above or below the knee, in
the popliteal fossa or in the groin)
• Joint movement is restricted
• Lymphadenopathy
• Local redness, swelling, warmth & oedema are later signs & signify that pus has
escaped from the interior of the bone.

DDX
• Acute suppurative arthritis
• Acute rheumatism
• Cellulitis - diffuse & especially subcutaneous inflammation of
connective tissue characterised by widespread superficial redness &
lymphangitis
• Streptococcal necrotizing myositis
• Sickle-cell crisis
• Gaucher's disease

INVX
• Definitive diagnosis is made by Needle aspiration or bone biopsy for
bacterial culture (which is the "gold standard")
• FHG - ↑WBC, ESR, CRP
• Blood m/c/s - +ve in only 50%
• In SCD salmonella may be cultured from the faeces

IMAGING
X-RAY
* Normal during the first 10days
* By the end of the 2nd week there may be a faint extra-cortical outline due
to periosteal new bone formation - this is the classical x-ray sign of pyogenic
osteomyelitis
* Later, the periosteal thickening becomes more obvious & there is patchy
rarefaction (increase in porosity) of the metaphysis
* An important late sign is the combination of regional osteoporosis - a
feature of metabolically active, & thus living bone; with a localized segment
of apparently increased density - metabolically inactive & possibly dead.

• Ultrasound - May detect subperiosteal collection of fluid in the early
stages (? Haematoma or pus)
• Radioscintigraphy - Reveals increased activity in both the perfusion &
bone phases.
• MRI - can help differentiate soft tissue infection & osteomyelitis

MNX
• Supportive treatment for pain & dehydration
• Splintage of the affected part - for pain relief & to prevent joint
contractures. Simple skin traction may suffice &, if the hip is involved,
this also helps to prevent dislocation.
Also, plaster slab or half-cylinder
• Antibiotic therapy;
• Older children & previously fit adults (Staph. Aureus) - IV flucloxacillin
& Fusidic acid continuously until the condition begins to improve &
CRP return to normal levels - usually after 1-2wks.

• Thereafter, antibiotics are given orally for another 3-6wks
* Children <4yrs (H. Influenza) - Cefuroxime or Cefotaxime or
Augmentin
* SCD - Chloramphenicol or Septrin or Augmentin

Surgical drainage;
• Indications;
* If the clinical features do not improve within 36hrs of starting treatment
* Signs of deep pus (Local redness, swelling, warmth, oedema & fluctuation)
* If pus is aspirated
• If pus is found - & released - there is little to be gained by drilling into the
medullary cavity
• If there is no obvious abscess, it is reasonable to drill a few holes into the
bone in various directions or if there is an extensive intramedullary
abscess, drainage can be better achieved by cutting a small window in the
cortex.

• The wound is closed without a drain & the splint (or traction)
reapplied.
• Post-op - Once the signs of infection subside, physiotherapy is
instituted & full weight bearing is possible after 3-4wks

Complications
• Chronic abscess with discharging sinus.
• Suppurative arthritis
• Pathological Fractures
• Chronic ulcers - Non-healing with exposed bone
• Tumours - Osteosarcoma, skin tumours from chronically discharging
sinuses (SCC)
• Overgrowth of the limb due to hyperaemic stimulation

• Deformity or shortening due to growth plate damage
• Venous metastasis of infection to other areas - Brain abscess,
Empyema, Infections
• Liver problems due to persistent infections (Cirrhosis)
• Postoperative infection

Prognosis
• The prognosis is usually good even without surgery. Cure takes about
6-8 weeks.

Orthopedic.pptx

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