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LMCC Orthopedic Review Lecture April, 2009 “Back to Basics” Dr. P.R. Thurston Fractures & Dislocations Definitions Fracture:- A discontinuity in the structural integrity of a bone. Infraction:- An incomplete fracture. Dislocation:- Complete loss of contact of the articular surfaces of a joint. Subluxation:- Non-concentric joint surfaces. Reduction:- Returning a fracture or dislocation to an anatomical alignment. Comminution:- Multiple fragments. Fractures Definition :- A discontinuity in the structural integrity of a bone. A fracture occurs because the force applied exceeds the breaking strength of the bone so that the Load can no longer be transferred across that zone of the bone. Fractures All fractures ultimately begin with kinetic energy, released by misadventure and applied to the human body. Some of that energy is absorbed and some is transmitted to the surroundings. Absorbed energy must be dissipated, ie. distributed, through the soft tissues and bones. Fractures occur when the bone can not dissipate all of the energy absorbed. Fractures Mechanical Properties of Bone Bone is a two-phase material :Calcium HydroxyApatite Osteoid Ca10(PO4)6(OH)2 Collagen type I and III = mineral = fibrous Calcium is strong in compression, but weak in tension. Osteoid is strong in tension, but weak in compression. Fractures BUT :- (for adult bone) Calcium is stronger in compression than Osteoid is in tension And therefore :Bone always fails first in tension Fractures A bone consists of three areas :the Diaphysis the Metaphysis the Epiphysis. Each region has its own fracture characteristics. Fractures Diaphyseal Metaphyseal Epiphyseal Bending Torque Direct Traction Compression Intra-articular Pediatric Oblique Spiral Transverse Mixed Fractures Salter-Harris Classification I IV II III V Fractures Salter-Harris Classification 1) Fractures interfering with growing bones. 2) Worse prognosis with increasing number. 3) Probability of surgery increases with number. Fractures A fracture can occur in :normal bone subject to abnormal forces. = Traumatic Fractures. abnormal bone subject to normal forces. = Pathologic Fractures. normal bone subject to cyclic forces. = Fatigue or Stress Fractures. Fracture Description This fracture is angulated laterally, since it points laterally. The distal fragment is tilted medially Description Medially Displaced Closed Comminuted Short Oblique Fracture of the Proximal Humerus Caused by a direct fall Fracture Description 1) The distal fragment is always described with relation to the proximal segment. 2) Displacement = Translation of bone ends. 3) Angulation = Orientation of bone ends. 4) Angulation identifies to where the fracture points. 5) For clarity, the tilt of the distal fragment is often used to describe angulation. Indications for Closed Reduction There is significant displacement. Reduction is possible. The reduction, if gained, can be held. The fracture has not been produced by a traction force. The Periosteal Bridge The Periosteal Bridge is intact on the concave side of the fracture. Reversal of the mechanism of the fracture tightens the bridge and stabilizes the fracture. The Periosteal Bridge Tightening the periosteal bridge locks the fracture together. Holding the bridge tight requires three point fixation. “It takes a bent cast to produce a straight bone” J. Charnley Indications for Open Reduction 1) 2) 3) 4) 5) 6) 7) 8) There is a significant Displacement. Open Fractures. Intra-articular Fractures. Un-reducible Fractures Reductions that cannot be maintained in a cast. Comminuted or Segmental Fractures. Floating Joints. Fractures with Neurovascular damage. Open Fractures Classification :1. < 1 cm., inside-out, little soft tissue damage. = low potential for infection. 2. 1 cm. – 10 cms., outside-in, requires debridement, but no flap or skin graft. = moderate potential for infection. 3. > 10 cms., outside-in, high energy, devitalized muscle, comminution or bone loss, soft tissue loss. Open Fractures Classification :3A. No loss of soft tissue cover, no flap required. 3B. Flap required due to soft tissue stripping. 3C. Associated vascular injury. Type 1. Open Fracture = 6 mm, extend & debride Degloving Mechanism Degloving Mechanism Type III C Injuries – Vascular Injury Note pallor of the ankle No pulses Fracture Complications 1. 2. 3. 4. Pulmonary Fat Emboli Compartment Syndromes Stress Fractures Pathologic Fractures Pulmonary Fat Emboli :- A.R.D.S. - Long bone fractures, burns, contusions. - Interstitial pneumonitis due to free fatty acids - S.O.B. & confusion in young adults. - Axillary & Subconjunctival Petechiae. - Serum lipase elevated. - pAO2 reduced – if < 50 – 20% mortality. - Ventillatory support - Dexamethazone. - 5 day course. Compartment Syndromes - increased interstitial tissue pressure. - fractures, burns, tight dressings. - normal pressure < 25 mm. Hg. - when the tissue pressure > venous capillary pressure, but less than the arteriolar pressure. - 5 P’s - pain. - pallor. - pulselessness. - paresthesias. - paralysis. Compartment Syndrome Symptom: Pain out of proportion to that expected for the injury. Signs: 1. Loss of function of muscle due to ischemia within the compartment. 2. Pain with passive stretch 3. Numbness etc. are LATE findings! 4. If neuro symptoms present, potential for full neuro recovery is only 10 % Rx Compartment Syndrome Release all compressive dressings / plaster. Elevate extremity to heart level. Fasciotomies. 4 compartment fasciotomy Compartment Syndrome Careful monitoring. Recognise it - 5 P’s Call Orthopaedic Surgeon Pressure measurements Stress or Fatigue Fracture Repeated loading below acute failure threshold. Eventual fatigue failure. Military recruits, runners, aerobics. Tibia, metatarsals, femoral neck. Initial x-ray can be negative. Bone tenderness – Bone scan. Pathologic Fractures Failure through abnormally weakened bone Minimal trauma – BEWARE Osteoporosis Metastasis Tumour:- Benign, Malignant (Myeloma). Metabolic Bone Disease Pathologic Fractures Metastases: Lytic - Lung Colon Thyroid Renal Breast Blastic - Prostate Pathologic Fractures Metastases: - require fixation to prevent fracture if they are > 1/3. - produce pain on weight bearing in the lower limb. - survival > 3 months. - cannot be managed by medical therapy. - radiotherapy after fixation (2 weeks) (radiotherapy induced osteonecrotic fractures) Pathologic Fractures Dislocations The articular surfaces are no longer in contact. Commonly affects Shoulders > PIP joints > Elbows > Ankles. Often associated with fractures. Often associated with neurologic injuries Shoulder Dislocations 95 % anterior 1 % posterior Luxatio erecta Medial Axillary nerve injury Rapid reduction Shoulder Dislocations Conscious sedation. Traction reduction. Immobilization. Recurrent. Voluntary Habitual. Multiaxial instability. Elbow Dislocation Posterolateral. Median nerve injury. Ulnar nerve injury. Rapid reduction. Early mobilization. Back Pain Classification: Mechanical (MacKenzie) Postural syndrome • normal tissues become painful by the application of prolonged stresses (sitting, bending etc) Dysfunction syndrome • soft tissues are shortened and stiff. Usually >30 year old, poor posture, under exercised, reduced mobility Derangement syndrome • Disc derangement (tears and herniation) Causes and Classification of Back Pain: McNab Viscerogenic Vasculogenic Neurogenic Psychogenic Spondylogenic Spondylogenic Osseus: • • • • • • Trauma Infection Neoplasms Inflammatory Metabolic (eg.Pagets) Deformities Soft tissues: • • • • Muscles SI joints Disc Facets Non operative Treatment of Back Pain Do nothing Activity modification Medications Exercise and physiotherapy Braces Manipulation Massage therapy Traction/inversion therapy Vitamins/Supplements/Diets Weight control Every Suzanne Summers sponsored abs exerciser Anatomy Extension Flexion Three joint complex (Kirkaldy Willis, Farfan) Recurrent rotational strain Synovial reaction facet joint Disc circumferencial tears Cartilage destruction Osteophyte formation Capsular laxity Subluxation Enlargement of articular process radial tear Disc herniation Instability Lateral n. ent Central stenosis Internal disc disruption decrease disc height osteophytes Disc herniation Ms J.H. 25 y.o. female presented with cauda equina syndrome Spinal stenosis Symptoms: unilateral radicular pain bilateral claudication better with forward flexion of trunk better walking uphill rare bowel/bladder involvement Signs: usually no neuro signs look for pulses stress test Investigations: XR CT Myelo-CT MRI Cauda Equina Syndrome Sciatica associated with bowel or bladder dysfunction. Perineal numbness. Low or Sequestrated Lumbar Disc. Pressure on S1, S2 and/or S3 nerve roots. Requires immediate Decompression to avoid permanent disability. Time for a 10 minute break! 1. Talipes Equinovarus is the proper name for :a. b. c. d. e. Flat feet In-toeing Club feet Knock knees Wry neck 1. Talipes Equinovarus is the proper name for :c. Club feet 1. Talipes Equinovarus is the proper name for :a. b. c. d. e. Flat feet In-toeing Club feet Knock knees Wry neck Pes Planus Metatarsus Adductus Genu Valgus Torticolis Talipes Equinovarus congenital deformity of the foot Equinus, Inversion, Adduction, Supination 2 per 1000 live births 50% bilateral M >F 2:1 Serial corrective casts at birth Surgery if resistant EARLY TREATMENT IS ESSENTIAL 2. Trendelenburg refers to :a. b. c. d. e. Leg length discrepancy Gait abnormality Knee recurvatum Scoliosis Hip Contracture 2. Trendelenburg refers to :- b. Gait abnormality 3. All of these are signs of D.D.H. except :a. b. c. d. e. Limited Abduction Ortolani Sign Asymmetric Skin Folds Galeazzi’s Sign McMurray Sign 3. All of these are signs of D.D.H. except :- e. McMurray Sign 3. All of these are signs of D.D.H. except :a. b. c. d. e. Limited Abduction Ortolani Sign Asymmetric Skin Folds Galeazzi’s Sign McMurray Sign Dislocated Reducible Dislocated Knee height Torn Meniscus Developmental Dysplasia of the Hip Acetabular dysplasia Femoral anteversion Adduction Contracture 50% bilateral, F > M 8:1 Test ALL newborns at birth Conservative Rx at birth – Pavlik, D.diaper Surgical Rx if resistant 4. The most common congenital Spinal abnormality is :a. b. c. d. e. Scoliosis Spina Bifida Torticolis Klippel – Feil Syndrome Multiple Hereditary Osteochondroma 4. The most common congenital Spinal abnormality is :- b. Spina Bifida Spinal Bifida defect of neural tube closure Lumbar spine, commonly low 2 per 1000 myelodysplasia Mild to complete paraplegia Occulta, meningocoele, Myelomeningocoele Bowel and bladder dysfunction 5. Polydactyly 6. Syndactyly 7. Sprengel’s Deformity Omovertebral Bone 8. A 6 year old boy with delayed physical development, convulsions, tetany, weakness, blue sclera and bony deformities is most likely suffering from :a. b. c. d. e. Physical Abuse Ehlers – Danlos Syndrome Osteogenesis Imperfecta Multiple Hereditary Exostoses Myositis Ossificans 8. A 6 year old boy with delayed physical development, convulsions, tetany, weakness, blue sclera and bony deformities is most likely suffering from :- c. Osteogenesis Imperfecta 9. A 6 year old boy with delayed physical development, a rachitic rosary, weakness and bony deformities is most likely suffering from :a. b. c. d. e. Physical Abuse Rickets Scurvy Osteitis Deformans Myositis Ossificans 9. A 6 year old boy with delayed physical development, a rachitic rosary, weakness and bony deformities is most likely suffering from :- b. Rickets 9. 9. Etiology Alkaline Phosphatase Calcium Phosphate Normal Urea Vitamin D Deficiency Rickets Up Down Normal Renal Insufficiency (Renal Rickets) Up Down Up Up Renal Tubular Insufficiency (HypoPhosphatemia) Up Down Down Normal 10. This is :- a. b. c. d. e. Osteomyelitis Osteomalacia Osteoporosis Osteitis Deformans Leprosy 10. This is :- d. Osteitis Deformans Osteitis Deformans Paget’s Disease 4% of pop. Over 40 yrs. accelerated bone turnover often assymptomatic monostotic > polyostotic loss of stature AV shunting pathologic bone 11. A child with knee pain has a ____ problem until proven otherwise. a. b. c. d. e. Knee Femoral Tibial Hip Patella 11. A child with knee pain has a ____ problem until proven otherwise. d. Hip Obdurator Nerve 11. All of the following are part of the differential of hip pain in a 6 year old, except :a. b. c. d. e. Femoral Osteomyelitis Septic Hip Transient Synovitis Legg-Perthes Osteochondritis Slipped Capital Femoral Epiphysis 11. All of the following are part of the differential of hip pain in a 6 year old, except :- e. Slipped Capital Femoral Epiphysis Ages for Hip Disease D.D.H. Septic Hip Legg-Perthes Transient Synovitis S.C.F.E. Birth Birth – 11 3 – 11 3 – 11 11 - 16 12. Osteomyelitis in children is produced by what route of infection? a. b. c. d. e. Direct extension from another focus Hematogenous spread Perforating wounds Lymphatic spread Septic hip 12. Osteomyelitis in children is produced by what route of infection? b. Hematogenous spread Osteomyelitis Acute infection,metaphyseal 90% Staph.,20% mortality 100% growth abnormality Periosteal elevation, osteolysis Sequestrum, Involucrum 13. 13. Paronychia 14. 14. Felon 15. All of these are findings of a Herniated L5-S1 disc, except :a. b. c. d. e. Absent Achilles reflex Lateral foot numbness Sciatica Low back pain Extensor Hallucis Longus weakness 15. All of these are findings of a Herniated L5-S1 disc, except :- e. Extensor Hallucis Longus weakness 15. All of these are findings of a Herniated L5-S1 disc, except :a. b. c. d. e. f. Absent Achilles reflex Lateral foot numbness Sciatica Low back pain Extensor Hallucis Longus weakness Knee jerk S1 S1 S1 L5 L4 16. Avascular necrosis of the femoral head is associated with all of the following except :a. b. c. d. e. Steroid use Alcohol Deep sea diving Lipid storage disease Diabetes 16. Avascular necrosis of the femoral head is associated with all of the following except :- e. Diabetes 17. 8 year old boy What is the Diagnosis? 17. 8 year old boy Legg – Perthes Osteochondosis Legg-Perthe’s Disease Osteochondrosis (avascular necrosis) Proximal Femoral Epiphysis Necrosis, revascularization, fragmentation, healing 3 – 11 yrs., M > F 4:1, 15% bilat. Subluxation laterally, Coxa plana, Coxa magna Osteoarthritis 50 yrs. 19. Diagnosis? 19. Gout Gout Urate crystalopathic arthritis Crystals in periarticular tissues Inconsistant elevated serum urate Allopurinol and colchicine Tophi in periarticular soft tissues Deposits in non-articular cartilage Juxta-articular erosions 20. L4 L5 Spondylolytic Spondylolisthesis Spondylolisthesis Lumbosacral junction defect Spondylolysis of Pars Interarticularis Traumatic or congenital Acute – immobilize Chronic - surgery 21. The Salter- Harris Classification is used to assess the severity of :a. b. c. d. e. Epiphyseal Fractures Developmental Dysplasia of the Hip Legg – Perthe’s Disease Club Foot Osteomyelitis 21. The Salter- Harris Classification is used to assess the severity of :a. Epiphyseal Fractures 22. What is this deformity? 22. A Diner Fork Deformity Probable Diagnosis? 22. Colles Fracture 22. Colle’s Fracture distal radial fracture FOOSH occurs at all ages commonly 60 yrs. + osteoporosis intra-articular CR & K-Wires External vs Internal Fixation 23. The common complication of this fracture is :- 23. Proximal pole Avascular Necrosis 24. This is a :- a. Buckle Fracture b. Greenstick Fracture c. Stress Fracture d. Pathologic Fracture e. Growth Arrest line 24. This is a :- a. Buckle Fracture 24. This is a :a. Buckle Fracture b. Greenstick Fracture c. Stress Fracture d. Pathologic Fracture e. Growth Arrest line 24. Greenstick Fractures 25. Is this fracture treated by Closed or Open Reduction? 25. ORIF 25. Fractures of Necessity 26. What is the Diagnosis? 26. Posterolateral Dislocation of the Elbow 26. Reduction by traction. TRACTION 27. What is the Diagnosis? 27. Anterior Dislocation of the Shoulder 27. Reduction by traction 28. This is a :a. Supracondylar # b. Olecranon # c. Dislocation d. Forearm # e. Radial Head # 28. This is a :a. Supracondylar # 28. Supracondylar Fracture 29. The complications of a Supracondylar fracture in children include all of the following except :a. Malunion b. Volkmann’s Ischemic Contracture c. Compartment Syndrome d. Cubitus Varus e. Peripheral Nerve Injuries f. Pulmonary Fat Embolus 29. The complications of a Supracondylar fracture in children include all of the following except :- f. Pulmonary Fat Embolus 30. The only sign of a Compartment Syndrome that is always present is :a. Pain b. Pallor c. Pulselessness d. Paresthesias e. Paralysis 30. The only sign of a Compartment Syndrome that is always present is :a. Pain 31. Compartment pressures indicating the need for fasciotomy :a. 0 – 15 mms. Hg b. 15 – 25 mms. Hg c. > 25 mms. Hg d. > 50 mms. Hg e. > 75 mms. Hg 31. Compartment pressures indicating the need for fasciotomy :- c. > 25 mms. Hg 32. A 20 yr. old male with a fractured femur has findings of confusion, tachypnea and conjunctival petechia. The most likely diagnosis is :a. Pneumonia b. Pulmonary Fat Emboli c. Cerebral Contusion d. Cardiac Contusion e. Transient Stress Reaction 32. A 20 yr. old male with a fractured femur has findings of confusion, tachypnea and conjunctival petechia. The most likely diagnosis is :b. Pulmonary Fat Emboli 35. The commonest complication of this fracture is :- 35. A Radial Nerve Palsy 36. Does this fracture require surgery? 36. Does this fracture require surgery? Yes 37. Does this fracture require surgery? 37. Does this fracture require surgery? No 38. This patient most likely has a fracture of the --------. 38. This patient most likely has a fracture of the --------. Hip 38. This patient most likely has a fracture of the hip. External Rotation Shortening Hip Flexion 38. 39. What’s the Diagnosis? 39. Sub-Capital Hip Fracture. 40. All of the following are complications of this fracture except :a. Malunion b. Avascular necrosis c. Fat emboli d. Non-union e. Thrombophlebitis 40. All of the following are complications of this fracture except :- c. Fat emboli 40. Blood Supply of Femoral Head 40. Save Head versus Replacement 40. Subcapital Hip Fractures Properties 1. Avascular Necrosis - 30% 2. Malunion - 30% 3. Non-union - 30% 4. Surgery required 5. Older population 6. Pathologic - Osteoporotic 41. What’s the Diagnosis? 41. Intertrochanteric Hip Fracture 41. Intertrochanteric Fractures Properties 1. Varus deformity 2. Well - Healing 3. Traumatic + Osteoporosis 4. Surgery required 5. Mid-range Age population 43. Surgery or not? 43. Surgery or not? Yes 44. Surgery or not? 44. Surgery or not? Yes 45. What is the approach to this fracture? 23 y.o. male Basketball injury Open fracture Numbness dorsum toes 45. Reduce dislocation Sterile dressing Splint extremity Re-check NV status IV Antibiotics Tetanus Surgery 48. A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices numbness on the outer border of his right foot and some weakness in the right leg. He has no bowel or bladder problems. The most likely diagnosis would be:a. b. c. d. e. Lumbar Muscular Strain. Herniated Lumbar Disc. Herniated Lumbosacral Disc. Cauda Equina Syndrome. Spinal Stenosis. 48. A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices numbness on the outer border of his right foot and some weakness in the right leg. He has no bowel or bladder problems. The most likely diagnosis would be:- c. Herniated Lumbosacral Disc. 49. Your initial approach to this problem would include some or all of the following:- a. b. c. d. e. f. g. h. Bedrest. Anti-inflammatories. Muscle Relaxants. Spinal X-rays. Physiotherapy. Orthopedic/Neurosurgical referral. CT-Myelogram or MRI Discectomy 49. Your initial approach to this problem would include some or all of the following:- a. ? b. c. d. e. f. g. h. Bedrest. Anti-inflammatories. Muscle Relaxants. Spinal X-rays. Physiotherapy. Orthopedic/Neurosurgical referral. CT-Myelogram or MRI Discectomy 50. During the work-up for this problem, the patient complains that he has unaccountably soiled his underwear, without knowing it. Your response to this would be to:- a. b. c. d. Reassure the patient that this is not serious Order an urgent MRI Get an urgent referral to Neuro/Orthopedics Place the patient on immediate bedrest. 50. During the work-up for this problem, the patient complains that he has unaccountably soiled his underwear, without knowing it. Your response to this would be to:- c. Get an urgent referral to Neuro/Orthopedics 51. A lumberjack felling a tree is unfortunately struck on the back by the tree, knocking him to the ground and injuring his left lower extremity. In the ER, his left hip is in flexion, adduction and internal rotation. The most likely diagnosis is:- a. b. c. d. e. Fracture of the Hip. Fracture of the Femur. Anterior Hip Dislocation. Posterior Hip Dislocation. Fracture of Pelvis. 51. A lumberjack felling a tree is unfortunately struck on the back by the tree, knocking him to the ground and injuring his left lower extremity. In the ER, his left hip is in flexion, adduction and internal rotation. The most likely diagnosis is:- d. Posterior Hip Dislocation. 52. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:- a. b. c. d. e. Inability to squat Pain on descending stairs Locking Recurrent effusions All of the above. 52. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:- a. b. c. d. e. Inability to squat Pain on descending stairs Locking Recurrent effusions All of the above. 53. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle. Your response to this situation would be to:- a. b. c. d. Re-X-ray the ankle. Remove the cast. Measure the compartment pressures. Instruct the patient to elevate the limb and prescribe an anti-inflamatory. 53.. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle. Your response to this situation would be to:- b. Remove the cast. 54. The most common dislocations of the shoulder are:- a. b. c. d. Medial. Posterior. Luxatio Erecta. Anterior. 54. The most common dislocations of the shoulder are:- d. Anterior. 55. Metastatic lesions to bone, of the following tumours, usually produce lytic defects except:a. b. c. d. e. Thyroid. Pancreas. Prostate. Kidney. Lung. 55. Metastatic lesions to bone, of the following tumours, usually produce lytic defects except:- c. Prostate. Th - Tha – That’s all folks!