Fracture General PDF

Chapter 3: Principles of Fractures o angulation, rotation & axial compression #: consist of an oblique component caused by compression and a GENERAL PRINCI...

Chapter 3: Principles of Fractures o angulation, rotation & axial compression #: consist of an oblique component caused by compression and a GENERAL PRINCIPLES transverse component caused by angulation " oblique # History Metaphysial vs Diaphyseal Fractures Causes Metaphyseal o Healing: not by callus, but by ingrowth (as little Mechanism movement) Assessing injury o Movement: Little because usually compaction fracture Fracture Emergencies (stable) as lots of cancellous bone in metaphyses Metaphyseal vs Diaphyseal Fractures o Rapid repair: Consolidate within 3 weeks Joint Injuries o Management ! Minimal displacement, extra-articular: Simply cast Imaging and allow healing by ingrowth Radiographic Description of fractures ! Displacement, intra-articular: Once reduced will Stability of Fractures become unstable, hence must stabilize; might Healing even need to fill with bone graft to fill gaps from disimpaction (put in cast) ASSESSING COMPLICATIONS OF FRACTURE Diaphyseal MANAGEMENT o Healing: by callus Initial management o Movement: Lots of motion Definitive management Fracture Emergencies PRINCIPLES OF MX OF DISLOCATIONS Open fractures Compartment syndrome (tibia, forearm, femur, foot, hand – TABLE SUMMARY OF #S AND DISLOCATIONS areas with myocutaneous or myofascial compartments) GENERAL PRINCIPLES Neurovascular compromise History Very bad fractures with haemodynamic instability: Unstable Clinical Features pelvic fractures - Openbook pelvic fractures o Pain and tenderness Spine o Deformity & abnormal resting position Multiply injured o Swelling Fracture-dislocations – skin or soft tissue compromise (closed o Loss of function: inability to weight bear, abnormal FD can become open if not reduced) mobility and crepitus (avoid) Joint Injuries o Neurovascular compromise (impt to document) Ligament Injuries ! Concomitant injuries o Types High vs Low velocity ! Sprain: Painful twisting without actual tearing of o Indication of injury severity (concomitant injuries) ligaments or capsule o Pathological fractures ! Strain: May involve tearing of some fibers Mechanism of injury ! Tear/Ruptured ligament: Partial/ complete rupture Causes o Management Trauma: direct and indirect trauma ! Conservative: Splint " Physiotherapy " Replace Stress Fractures (repetitive mechanical loading): Normal bone; splint with functional brace abnormal stress ! Surgical reconstruction: Symptomatic instability or o Common sites avulsion of large enough bone fragment ! Metatarsal (esp 2nd) Articular Injuries ! Femoral Neck o Types ! Tibia ! Dislocation: Complete loss of articulation at joint ! Others: Shaft of humerus, Pars interarticularis of 5th Associated with lumbar vertebra, pubic rami, femoral shaft, patella, o Shaft #s often require open reduction calcaneum, navicular, fibula o Peri-articular fracture may increase Pathological Fractures: (OMIT) Abnormal bone; normal stress instability (eg. Hill-sachs lesion) o Osteopenia/osteoporosis Anatomy o Metabolic bone disease (hyperPTH, hyperthyroidism, Ligamentous laxity (especially for osteoporosis, osteogenesis imperfect, rickets) recurrent dislocations) o Infection Common: Shoulder (commonest), knee o Tumour (2nd commonest) – stability of knee Periprosthetic depends on ligaments, hip, elbow Mechanism ! Subluxation: Partial loss of articulation at joint Direct trauma o Management o Tapping fracture; occur when a force is applied over small ! Reduction as soon as possible (usually with area, usually transverse fracture line (eg nightstick fracture) anesthesia and muscle relaxant) o crush fracture: with extensive soft tissue damage, Imaging extensive comminution X-ray: rule of 2s o penetrating fracture: produced by projectiles, gunshot o 2 views (orthogonal views; AP and lateral) Indirect trauma o 2 joints (above and below site of injury) o avulsion or tension #: # line is perpendicular to line of force; o 2 sides (for paediatric cases) happen to the patella or olecranon when the knee or elbow o 2 times (before and after reduction) is forcibly flexed while extensor muscles are contracting o 2 opinions o angulation #: transverse #, may form butterfly fragment MRI: Soft tissue injury, Occult fractures o rotation fracture ; when a piece of chalk is twisted until it CT: Image bone surface (often for complicated fractures) breaks, a characteristic spiral fracture line is produced Bone scan (radioisotope scanning): only +ve abt a week after # o compression fracture ; T- or Y-shaped fracture (e.g. at the o Stress fractures lower end of the humerus or femur) o Undisplaced fractures ! 6! Description (on Xray) (ACS MAAD) Stability of Fractures Identify view + date + patient identification (“This is an AP X-ray Stable: When upon reduction, it remains reduced with simple view of the knee joint taken on 1/12/10 for Mdm Gee”) splintage and normal movement Anatomy o Inferred by x-rays and clinical examination (eg. can move o What – Which bone >50% of normal range) o Where – Diaphysis / Metaphysis / Epiphysis Types of fractures ! If diaphyseal, describe by thirds (prox/ middle/ distal) o Oblique/spiral – Unstable Complete vs Incomplete ! Translational/rotational displacement hence need Simple vs Comminuted complex splint to reduce and hold Fracture Morphology o Avulsion – Unstable ! Muscle pull keeps fragments apart o Complete transverse translation – Unstable ! Periosteal stripping circumferentially o Intra-articular Acceptable displacement – if deemed acceptable, can just immobilize in that position o Bone union requires >50% of bone contact o Angulation can accept up to 20 deg for long bones (in children) – but in adults may accept lower because of poorer remodeling capacity Healing Purpose of splinting o Alleviate pain o Ensure union takes place in good position o Permit early movement and return to function General stages in normal healing process o 0h: Haematoma formation o Transverse # o Within 8h: Inflammation and cellular proliferation under ! Mechanism: 3 point bend; direct force, high energy periosteum and within the medullary cana ! Stability: ! Macrophages, undifferentiated stem cells and Usually remain in place after reduction platelets surround fracture site But may be unstable in upper limb (due to ! Granulation tissue lateral motion as opposed to lower limb where ! Involve osteoclasts hence fracture gap accentuated axial loading stabilizes #) within first few weeks o Oblique # o 3-12 weeks: callus proliferation (formation & calcification) ! Mechanism: unequal force distribution of 3 point ! 3-6 weeks: osteoclasts remove sharp edges (thus # bend; angular and rotational force more visible on radiographs); fibrocartilage callus ! Stability: Tendency to slip/displace forms within hematoma o Spiral # (# line > 2x bone width) Soft callus - cartilage ! Mechanism: Torsion; rotational force, low energy ! 6-12 weeks: bone forms within the callus ! Stability: Tendency to slip/displace (endochondral calcification of cartilage), bridging o Comminuted # (>2 pieces) vs Simple # fragments; forming woven bone ! Mechanism: Often complicated; direct force, high Hard callus – calcified cartilage: # union energy o 6-12 months: Consolidation ! Stability: Often unstable ! Woven bone replaced by lamellar bone o Butterfly # (2 lines break out obliquely from point of contact o 1-2 years: normal architecture achieved thru remodeling of blow, producing a free-floating butterfly fragment) ! Takes years ! Mechanism: low velocity injuries due to 3 point bend 2 main ways o Avulsion #: strong muscle inserting into small bone o Callus formation ! Eg. quads to patella, triceps to olecranon, peroneus ! In response to movement tertius to 5th MT head ! Main advantage: Stronger o Compression # o Gap healing: In response to absolute immobilization Intra vs Extra Articular Shape of fracture affects rate of healing o Extra-articular: diaphysis or metaphysis o Spiral heal faster than transverse fracture due to larger o Intra-articular: salter-harris classification (for children) area of contact Associated structures (aka soft tissue): XR evaluation of healing: trabeculae cross # site, visible callus o Calcification, gas, foreign bodies bridging site Displacement (Type and plane): only comment w 2 views! Union vs Consolidation o Translation/ apposition (% displacement) Union Consolidation ! Shifting of fragments (sideways, forwards, Fracture line Fracture line visible Fracture line almost backwards etc) resulting in loss of contact between obliterated and crossed fragments " any shortening? (ie. Bayonet #) by bone trabeculae o Angulation/deformity ! With respect to apex (eg. volar apex angulation – State of callus Ensheathing callus Calcified callus ossified apex of angulation pointing volar) calcified ! Angle Tenderness Fracture site tender Fracture site non-tender o Rotation: Rotation on its longitudinal axis to palpation or o Altered length angulation stress ! Fragment distraction and separation Completion Incomplete repair: Complete repair ! Fragment overlap Unsafe to subject bone Open vs Closed to stress State of bone (any underlying pathology?) ! 7! ASSESSING COMPLICATIONS OF FRACTURES Local Early Soft Tissue Injury 1. Nerve injury: neuropraxia, axonometsis, neurotmesis (REFER to hand injuries) 2. Vascular Injury 3. Visceral Injury 4. Fracture blisters (refer to Cx of open #) Swelling related 1. Compartment syndrome (refer to Cx of open #) 2. Haemarthrosis Infection Gas gangrene, osteomyelitis Late Union-related Delayed union (refer to Cx of open #) Non-union: atrophic, hypertrophic, infected Malunion Avascular necrosis Common sites: Head of femur, proximal scaphoid, lunate, neck of talus (refer to Cx of open #) Growth disturbance Joint related Joint instability Osteoarthritis Joint stiffness Complex regional pain Chronic progressive disease characterized by severe pain, swelling, skin changes due to syndrome dysregulation of ANS post trauma Soft tissue related Heterotrophic ossification Muscle contracture Tendon rupture Nerve compression or entrapment Systemic Fat embolism syndrome (long bones) " refer to Cx of open # Hemorrhagic shock ARDS, MODS DVT/PE Sepsis MANAGEMENT Principles of management FRIAR: First aid " Reduction " Immobilisation " Active Rehabilitation Initial management: refer to “open fractures - emergency care” o General Mx of # ! ABCDE Assess neurovascular status, beware of compartment syndrome If hypovolemic " IV fluids, packed cells, whole blood ! Analgesics ! Preliminary skin traction " relieve pain, minimize further displacement ! How to determine if # is displaced or not: compare continuity of trabeculae lines Definitive Management – Steps: 1) reduce 2) stabilize 3) rehabilitate o Concepts: ! Operative vs Non-Operative Non-operative: Analgesia, splint/protect, restore function Operative: Reduction, fixation, others (arthroplasty, amputation) o Contraindications: severe osteoporosis, active infection or osteomyelitis, severe comminution that cannot be reduced, severe soft injury, poor general condition, nondisplaced fracture ! Broad principles: Reduce: Restore articular surface and normal alignment Stabilise: Allow healing and minimize pain o Indications for # fixation ! To save life or limb ! To reconstruct displaced articular fractures ! To prevent deformity ! To promote union when it is delayed ! Improved function following early motion Rehab: Restore function ! Objectives: Restore function, Prevent OA o Reduction ! Objective: adequate (not perfect) apposition and normal alignment (except for intra-articular #s where anatomic reduction is mandatory to restore joint congruency with absolute stability as irregularity will predispose to OA) Imperfect apposition may be acceptable while imperfect alignment is rarely acceptable Attempt closed reduction as much as possible o If successful: then stabilize o If unsuccessful: open reduction, then stabilize (usually internal fixation) ! Contraindications Little or no displacement (i.e reduce when amt of displacement is unacceptable) When displacement does not matter – eg. clavicle, fibula When reduction unlikely to succeed – eg. compression # of vertebrae ! 3 Methods: 1) Manipulation 2) Mechanical Traction 3) Open Reduction Closed Reduction o Principles: ! 8!  ! Minimse damage to BS ! Rely on soft tissue attachments ! Rarely adequate for intra-articular # ! Difficult in babies whose bones cannot be seen in XR o Manipulation ! Indications Minimally displaced # Most fractures in children Initial management for unstable fractures (prior to definitive mechanical fixation) ! Method Distal part of limb pulled in line of the bone Repositioning of disengaged fragments Alignment adjusted in each plane o Mechanical Traction: Indications: When manipulation difficult due to powerful muscle pull Open Reduction (Operation) o Indications: NO CAST ! N – Non-union ! O – Open fracture ! C – neurovascular Compromise (associated injuries) ! A – intra- Articular fractures (where there is large articular fragment that needs accurate positioning; require anatomic reduction) ! S – Salter-Harris 3, 4, 5 and/or special situations depending on Site Cannot cast or apply traction due to site (eg. hip fracture) ! T – polyTrauma ! Others: Failure of closed reduction (soft tissue interposition/difficulty controlling fragments) Avulsion fractures (fragments held apart by muscle pull) Pathological fractures When internal fixation needed (unstable fractures like fracture dislocations) Fracture in paraplegics for nursing access Potential for improved function w ORIF Infection New fracture thru screw holes Implant failure Stabilisation o Principle: Stabilize the fracture site but do not completely immobilize the limb if possible; maintain till united; jt above & below for shaft # o Principles of # fixation: Translational stability (3 point contact) + Rotational stability (engaging e metaphysis) + Axial stability (quality/strength of implant) External stabilization 1. splints/tape Non-rigid fixation – risk of loss of reduction 2. casts but stimulate rapid callus formation 3. traction 4. external fixator Internal fixation Rigid fixation – immediate 1. percutaneous pinning (Kirschner or K-wires) loading but does not 2. extramedullary fixation (screws, plates, wires) stimulate callus formation 3. intramedullary fixation (rods) - biomechanically advantageous o Sustained traction ! Principles Line of pull in alignment with long axis of bone Continuous traction maintained No interruption with line of pull Adequate counter traction ! Mechanism: Traction can be skin or skeletal Gravity Skin: Works by friction Skeletal: Works by tension o Skeletal traction can be with Thomas’s splint or pulley frame or both o Sites of Steinmenn pin insertion: tibia, distal femur, skull – as deep as inner table, calcaneum ! Types: Fixed, Balanced, Combined ! Complications: Circulatory embarrassment Nerve injury (Common peroneal palsy " weakness of dorsi flexion " foot drop) Skin: Pin-site infection, blisters, ulcers, pressure sores (Buttocks, Tendo Achilles, under heel) Problems with immobilization: DVT, pneumonia, bed sores, UTI Loosening of Steinmann pin Ring pressure (Thomas’s splint) ! Traction care ! Specific Examples (refer to traction slides) Straight leg traction (Buck’s traction): 10% of body weight Hamilton Russell: Vertical and horizontal line of pull to create a diagonal vector pull that is in line with the femur ! 9!  o Usually for proximal femur fractures Thomas Splint with Traction: Subtrochanteric/Femoral shaft fractures Bryant’s traction: position BrYant’s traction: Bent Y o Patient’s body is the stem of the Y lying on the bed, and legs are the ends of the Y up in the air Pearson knee piece: Distal femur or femoral shaft fractures where gastrocnemius needs to be relaxed o Cast splintage – Need to cover joint above and below ! Principles One joint above and below the # Cast is well molded with no pressure points Padding at bony prominences Backslab instead of full cast in acute setting as swelling likely to occur Always place a backslab/ U slab even if patient if just admitted for pain control Elevation to prevent swelling All hand fractures have a standard functional hand position cast ! Indications Fractures that can be reduced and stably maintained No major soft tissue injury No suspicion of compartment syndrome No vascular compromise ! Complications Immobility: Stiffness Pressure o Vascular compression (tight cast): Compartment syndrome o Pressure sores – if cast not applied smoothly o Skin abrasion or laceration (during removing plaster) Looseness: Delayed union (fracture not held due to loose cast) ! Types of plaster casting Forearm U slab: forearm # Shoulder U and O slab: proximal an midshaft humeral # Intrinsic plus hand slab: hand # Figure'1:'Air'Cast' Above knee cylinder slab: knee injuries Above knee slab: tibia/fibular # Below knee slab: ankle # Air cast - Advantages: can remove (more hygienic), can weight bear o Functional bracing ! Mechanism: Segments of a cast are applied only over the shafts of the bones leaving the joints free; cast segments connected by hinges allowing movements in one plane ! Use Usually used after 3-6 weeks of traction or conventional plaster Commonly used for humerus and tibia o Internal fixation ! Indications Fractures that cannot be reduced except by operation Inherently unstable #s – eg. dislocation fracture #s that unite poorly (NOF fracture) Pathological #s – where bone disease may prevent healing Multiple #s #s in patients with severe nursing difficulties ! Types Screws (have screw head and screw tract) o Reducing single fragments onto main shaft of tubular bone o Fitting together fragments of metaphyseal fracture Wires (Kirschner wires) – Used when fracture healing is predictably quick o Children fractures o Distal radius fractures o Tension band wiring for patellar fracutres Plates and Screws o Metaphyseal fractures of long bones o Diaphyseal fractures of radius and ulna o Intra-articular Intramedullary nail o Used for long bones: Femur, tibia, humerus o Have holes for interlocking screws ! Complications of Internal Fixation / Prosthesis Immediate o Surgery Related: Blood loss, Infection, Neurovascular compromise o GA Related: Cardiovascular, allergy, paralysis, AMI, stroke o Prosthesis related: Peri-prosthetic fracture Late o Systemic: DVT – for lower limb (thus importance of early mobilization!!!! " fixation construct is stable enough to allow postopersative functional care) ! 10!  o Local ! Peri-prosthetic fracture ! Implant failure – wear and tear ! Non-union ! Re-fracture o External fixation: Bone is transfixed above and below the fracture with screws or pins or tensioned wires and then connected to each other by rigid bars ! Rationale: Achieve immediate stability without traumatizing periosteum and endosteum further ! Role: Usually used as a temporary measure when difficult for definitive fixation initially; often replaced by other forms of fixation as soon as soft tissue lesions have healed ! Indications Fractures with severe soft tissue damage (where wound indicated to be left open for inspection) or swelling – need to wait for swelling to subside for definitive management Severely comminuted and unstable fractures Unstable joints Haemodynamically unstable patients Fractures of pelvis (which cannot be controlled by other method) Infected fractures – Internal fixation not suitable (external fixator can be easily removed in event when biofilm is formed) Severe multiple injuries/Poly trauma – Early stabilization reduces risk of serious complications ! Parts of external fixator: Schanz pins + Trans-fixation bar + Pin bar clamp ! Methods to increase stability of external fixator Multifixator: Fix in multiple planes More bars and more pins Position: 2 outer (as far apart) and 2 inner (as close as possible) ! Advantages and disadvantages Advantages o No foreign material in wound o Minimal further soft tissue damage o Provides easy access to wound o Can be removed easily (if infected or need further debridement) Disadvantages o Potential for pins to injure neurovascular structures o Pin loosening o Pin-track infections Rehabilitation o Prevention of edema: Elevation o Exercise: Active exercise + Assisted movement " avoid joint stiffness + regain strength and function ! Isometric exercises to avoid muscle atrophy ! ROM for adjacent joints ! Continuous passive motion (CPM) following rigid fixation of fracture allows joint motion to prevent stiffness for intra-articular fractures ! After cast/splint removed and # healed " resistive muscle strengthening ! Evaluate bone healing (clinical + XR) o Functional activity Alternative management: Arthroplasty, Amputation Principles of management of dislocations 5 main clinical presentations: o Pain + swelling + change of normal contour of joint (eg. flattening of deltoid in shoulder D/L) + loss of motion + postural change Always closed reduction is possible under general or local anesthesia / sedation o Indications for open reduction ! failed closed reduction due to interposition of soft tissue or bone fragment ! redislocation after closed reduction or impossible to maintain the ! reduction state ! neurologic deficit after closed reduction ! no improvement of circulation after closed reduction Emergently try to reduce as soon as possible Immobilization (cast, splint, traction) Associated injury of neurovascular structure (more often affected than in fractures) o Sciatic nerve injury in posterior D/L of of hip o Common peroneal nerve in medial D/L of knee o Axillary nerve or brachial plexus in shoulder D/L o Popliteal artery injury in knee dislocation Rehabilitation (early mobilization!) o starts A.S.A.P. o keep non-immobilised joints mobile o avoid muscle wasting o physiotherapy ! 11!  Table summary of fracture and dislocations Radial head trauma: MUA (supination, direct Monteggia #, PI Nerve Upper limb fractures dislocations by Lee Yizhi dislocation pressure), cast 6/52 inj Fracture Method Remarks Clavicle Sling 3/52 Malunion in adults Physio Excellent remodeling in children Pulled elbow Sling 3/7 or Pain, lateral Scapula body: Sling & physio Associated with 1)rib # Supinate + flex elbow tenderness, refusal to Scapula neck: ORIF if # dislocatn 2)lung contusion move arm 3)hemo/pneumothorax 9m-6yrs Body # by crushing No X-ray findings force Radial head slips out AC subluxatn: Sling ~1/52 & physio Partial dislocatn: AC of annular lig AC dislocatn: young and active : Arthrodesis, ligaments torn Radius and ulnar Compartment sx, PIN/ 3/52 rest, physio Complete dislocation: in adults: ORIF (plates/screws/rods) AIN inj, Inactive: Sling & physio CC ligaments torn in children: Long arm cast 6/52, check x-ray at delayed/non/mal- Late OA: excision outer 1/3 clavicle (conoid & trapezoid) 2/52 union, PIN Tenting of skin may cause necrosis Single forearm ORIF or long arm cast 12/52 Non-union! Sternoclavicular Anterior: conservative Post dislocatn: bone Cross-union dislocatn Posterior: ORIF Tracheal and vascular Monteggia’s: ORIF (ulnar plating, reduce radial Radial/ PIN palsy compressn head), long arm cast 90o flexion, (Mont), ECU & EDM Anterior dislocatn: Reduction under GA X-ray to exclude # partial supinatn inj (Gal) myositis Hippocrates/Kocher’s Axillary n often Galeazzi’s: ORIF (radial plating, reduce ulnar Ossificans, non-union, Sling 3/52 damaged head), long arm cast in supination missed dislocation Physio 95% of shoulder 6-8/52 # prox humerus: ORIF dislocatns Both in children: Reduction under GA, immobilisatn Recurrent: Surgery 6/52 Posterior GA Reductn Commonly missed! Colles’ Undisplaced: Splintage in plaster EPL rupture, malunion, dislocatn: Same as ant dislocatn 4% of shoulder slab median n dislocatns Displaced: MUA (Bier’s/ hematoma compression, Prox humerus: Neers 1: Sling 6/52 Usually seen in block), below elbow backslab 6/52 Sudeck’s atrophy, Neers 2: Collar cuff 6/52 osteoporotic pple >50y in neutral or slight flexion, xray @ DRUJ subluxatn, hand Neers 3: ORIF/HemiA Try to conserve head 2/52 shoulder stiffness Neers 4: HemiA in young pts even with Smith’s (reverse As for Colles’ but with wrist All followed by physio Neers 3/4 Colles’) extension Shaft of humerus U-slab 3-6/52 + sling Suspect mets in Barton’s ORIF with buttress plate If very unstable, plate/nail elderly! Radial styloid/ Percut K-wire/ lag screw A/w lunate dislocatn Chauffeur’s Supracondylar Closed reductn ASAP Cx: Shortening, Undisplaced Below elbow cast (exclude PIPJ) AVN, non-union, C&C 3/52 then sling 3/52 angular deformity scaphoid 10/52 scaphoid collapse, OA ORIF (dbl plating) in adult for early (gunstock), ↓ROM f(x) Acute: Brachial A inj, Displaced ORIF, cast 3/52 GENTLE physio compartment sx, scaphoid volkmann’s ischaemia Trans-scaphoid Chronic carpal Myositis ossificans perilunate instability Lateral condyle Undisplaced: C&C 3/52 Cubitus valgus, tardy dislocation Displaced: ORIF (Kwire) ulnar palsy: corrective osteotomy Peri-lunate Closed reduction, cast 6/52 Median n compression Proximal radius Mason 1: C&C 3/52, gentle physio dislocation If irreducible, OR with IF of Lunate AVN leading to in adults: Mason 2: ORIF plate & screw scaphoid # if present, CTR and OA Mason 3: Excision in 48hrs ligamental + capsular repair Mason 3 with Essex L: Prosthesis, Metacarpal Undisplaced: Crepe bandage 3/52 Rotational malunion, splint 2/52, physio and finger exercises stiffness 20o: MUA, if fail OR. If unstable, IF plaster slab 3/52, finger exercises In children: (K-wire) Displaced + unstable: ORIF with K- Olecranon Stable & undisplaced ( 5L screws & plates o Ruptured urethra, bladder o Bowel injury Hip, post. D o Muscle relaxant + Reduce, flex knee, hip 900, correct add Cxs -- Hip is flexed, add & int rot & int rot, lift fem head into acetabulum o Irreducible due to in-turned labrum o OR if irreducible or bony frags in acetabulum o ORIF if a/w #s elsewhere o # (fem head, NOF, patellar, fem Hip, ant. D shaft) -- Hip is abd, ext rot o Sciatic nerve palsy o Muscle relaxant + Reduce, flex knee, hip 900, correct abd o AVN due to tearing of capsule & ext rot, push down, convert to post. D, lift fem head into o 20 OA acetabulum o Recurrent D o Myositis Ossifcans (post exploration or D a/w head injury) Fem epiphysis, slipped o IF w screws + Manipulate if slip > 30% + epiphyseal o AVN -- fem shaft move up & ext rot on epiphysis closure o Involvement of Other Hip o Subtroch Osteotomy if epiphysis closed (chronic) Neck of Fem (intracap) # -- shortened, ext rot Tx principles -- 1. subcapital, 2. transcervical o Young (< 50 y.o.) ! CRIF o Undisplc --> CRIF -- osteoporosis impt factor o Elderly --> arthroplasty o Displc --> Arthroplasty Garden Classification o unfit for multiple Sx or badly displc, typ 4, avn & non-union o Typ 1: incomplete #, trabeculae angulated likely --> Hemiarthroplasty/ Total hip replacement w/o Cxs o Typ 2: complete #, trabeculae disrupted tryring CRIF o AVN " disruption of arterial ring but NOT angulated @ base of neck o Typ 3: complete #, fem head rotated, o Non-union " typ 3 & 4, bone trabeculae disturbed, displc graft (young), arthroplasty (elderly) o Typ 4: complete #, totally displc Neck of fem, basal (extracap) # o Displc/ Undisplc --> ORIF w DHS or Gamma Nail, fixation Cxs -- shortened, ext rot not removed unless pat < 45 y.o or pain o AVN & non-union NOT common Intertroch # o Stable, little frag " DHS w long plate -- shortened, ext rot o Unstable " DHS w long plate or Gamma Nail, then non- Cxs Types: weight bear crutches after 48 hrs to 16 weeks o Failure of fixation (cutting out of o Alt -->Traction +/- Thomas’s splint fixation device) " coxa vara* 1) # line thru mass of Great Troch, 2) (1) + separation of Less Troch, 3) separation of Great & Less Troch, *if early, bedrest & skeletal traction 4) 4. w a spiral # down prox fem shaft Fem shaft # o Traction to overcome pull of quads & hams -- leg is shortened, ext rot, abd " due to pull o Intramed Nail of quds & hams o Alt --> Traction, EF (Ilizarov), Plating Cxs o Fem & Tib # " Cx rate high, early mobilisation by o Hypovolemic shock Intramed Nail o Fat embolism o Metastatic # " Intramed Nail + packed cement to o Delayed Union, Non-union " relieve pain & give support esp. conservative o Fem shaft # w nerve palsy " exploration w repair + IF o Mal-union "lat. Angulation " Tx o Fem neck & prox shaft # "DHS + long Plate = osteotomy o Fem shaft & patellar # " close nailing for both, mobilise o Limb Shortening knee early o Knee stiffness " due to quads o Open # "deribement + IF tethering, knee jt invovlement or o Open #, IIIB,C "conservative or EF prolonged immobilisation Fem Supra, Uni, T & Y condylar # o Child supracondylar " plaster o Infection o Others " IF for good reduction & permit early mobilisation o If displc, grossly comminuted " conservative w traction ! 13! Patellar D o CR, plaster backslab x 3/52, knee exercise Remarks Patellar # o vertical # --> cylinder cast 6/52 w crutches during first Injuries to patellar & extensor apparatus of 2/52, physio after cast removal knee o horizontal, undisplc # --> as of above (patellar #, rupture of quads tendon, rupture o horizontal, displc # --> 1. sight communition: ORIF, 2. of patellar ligament, avulsion of tibial limited damage to patellar: partial patellectomy, 3. tubercle) due to: major damage: patellectomy, repair quads insertion & 1) direct force on knee lateral expansions 2) violent contraction of quads Every knee injury, exclude: Tibial tubercle, avulsion o CRIF (w screw) o ORIF (risk of premature epiphyseal fusion in child) o damage to extensor apparatus o lateral D of patellar w spontaneous Quads tendon, rupture o Tendon reattachment, plaster cast, quads exercises at reduction 2nd week, weight bear at 4th week, felxion at 6th week o torn ligaments Patellar ligament, rupture o As of above o torn mensici Tibial plateau, # o minimally displc --> aspirate hemarthrosis, compression o all involve articular surface bandage, CPM & active exercise, weight bear after 6/52 Cxs o key is to get knee f(x) vs pretty x-ray o comminuted--> aspirate, compression bandage, sk o Compartment syndrome o knee exercises ASAP traction, CPM & exercise crutches after 6/52 o Valgus deformity o “bumper #” o depressed # --> CR or ORIF, active exercises ASAP, o Joint stiffness o commonly lat. tibial condyle cast-brace after 2/52 Tibia & Fibula, # o closed, minimally displc --> full cast x 12/52 (upper thigh Cxs o Usu. # both, esp. adult to MT necks, knee slight flexion, ankle at 900), exercise foot, ankle, knee ASAP o Infection o commonly open o closed, displc --> MUA (IF when CR fails), full cast x o Vascular injury (prox # damage pop o usu. spiral # artery) 12/52, exercise ASAP o comminuted --> EF x 6/52 + partial weight-bear, then o Compartment Syndrome f(x)al brace o Delayed, Non-union --> Intramed Nail + o open --> Ab ASAP, debride, clean, leave open (above bone graft indicated grd II), EF to stabilise, WI, suture or graft when granulate o Malunion --> angulated --> osteotomy Ankle, ligament injury o partial --> crepe bandage, activity ASAP o partial/ complete tear of lateral o complete --> plaster immobilisation or operative repair ligament Cxs o bruising, swelling, tenderness o Adhesions o painful passive inversion o Recurrent subluxation o complete tear --> excessive movement Ankle # o 1 mall # --> reduce, cast x 6/52 (below knee), IF with Tx principles o normally talus seated in mortise screw if frag large o reduce to restore shape of mortise o one or both mall can be # o 2 mall #, below tibiofibular jt --> CR, +/- IF ,cast o plaster x 8/52 o eversion + ext rot = oblique # of lat o 2 mall #, above tibiofibular jt --> unstable, IF with screw mall (pushed off), transverse # of for frag & plate for fibula, +/- transverse screws between Cxs med mall (pulled off); vice-versa for tibia & fibula o Joint stiffness inversion o OA (not common) Distal tibial & fibular epiphyses, #- o Salter-Harris 1,2 --> MUA, full cast x 3/52, below knee Cxs separation cast x next 3/52 o Mal-union (valgus) o physeal injury o Salter-Harris 3,4 (undisplc) --> as above, re x-ray 5d o Asymmetrical growth (# thru epiphysis after to ensure good reduction may cause fusion of physis) o Salter-Harris 3,4 (displc) --> ORIF, below knee cast x o Shortening of leg 6/52 Calcaneum # o undisplc --> exercise ASAP, bandage after swell Tx principles o fall from height subside, nwb crutches x 6/52 o elevate leg + ice packs --> decrease o calcaneum driven up against talus o displc, avulsed tuberosity --> CRIF, immobilise in swelling o flattened Bohler’s angle equinus (relieve tension of tendon Ach), wb after 6/52 o x-rays, CT scans (better views) o check hip, pelvis, spine for # o displc, intra-art --> ORIF + bone grafts, splint & elevate, o extra-art --> involve posterior part, exercises ASAP, nwb crutches after 3/52, wb after 12/52 Cxs calcaneal processes o Broadening of foot o intra-art --> oblique # line, run to o Talocalcaneal stiffness --> subtalar superior articular surface arthrodesis or triple arthrodesis ! 14!