Overview of Orthopaedic Trauma PDF

Overview of orthopaedic trauma Prepared by Mr Georgios Arealis, MD, PhD, FRCS Email: [email protected] Fractures Fracture Description Fracture Definition – Disruption in continuity of bone – Break, crack, hairline crack Fracture Type (Suggests mechanism of injury) – Transverse – Linear –...

Overview of orthopaedic trauma Prepared by Mr Georgios Arealis, MD, PhD, FRCS Email: [email protected] Fractures Fracture Description Fracture Definition – Disruption in continuity of bone – Break, crack, hairline crack Fracture Type (Suggests mechanism of injury) – Transverse – Linear – Oblique – Spiral – Avulsion – Special types in children Torus, greenstick, lead-pipe deformity Avulsion Which bone is injured Site of bone injured – E.g. metaphysis, diaphysis, epiphysis – Diaphysis divided into thirds Displaced or undisplaced – Direction and amount of displacement Angulated or nonangulated – Direction and angle of angulation Rotated or not? Fracture Description Comminution – More than 2 pieces of bone Open or closed – Is there a skin breach? – If open extent of wound? – Open fractures graded Type 1 Type 2 Type 3 Joint Injuries Joints – Located (normal) – Subluxed / subluxated – Dislocated Fracture dislocation – Fracture plus dislocation Fracture Management Reduce If displaced and if needed e.g. intraarticular Open or closed Hold Internally or externally Treat the soft tissues Elevation Monitor compartments (specific fractures) Mobilize joints Maintain muscle bulk Physiotherapy Conservative or Surgical NB: Open fractures need Conservative special consideration – Plaster of Paris – Removable Splint e.g. futura splint – Brace e.g. knee range of motion brace – Nothing! Surgical – Internal Fixation Extramedullary – Plate and screws, tension band Intramedullary - Nail – External Fixation Fracture Complications General Local Immediate Cardiorespiratory Fat embolism Bleeding Nerve Injury Early PE (DVT) Fat embolism If open sepsis If bleeding shock Haematoma Wound infection Wound dehiscence Implant issues – loss of reduction, dislocation Late Delayed union, non-union, malunion Avascular necrosis Chronic infection Implant failure Secondary osteoarthritis Paediatric versus Adult Fractures Children not just small adults! Larger cartilaginous component to bones Cortical bone more porous than adults Injury pattern differs Periosteum much thicker Different types of fractures Bones have growth plates (physis) Remodelling or worsening deformity with growth Overgrowth after long bone fracture Remodelling in Paediatric Fractures 2 days after injury 6 weeks after injury 12 weeks after injury Growth Plate Fractures Involve the growth plate (physis) Specific Paediatric Fractures Torus Greenstick Plastic deformation Specific Paediatric Fractures Supracondylar humeral fracture Lateral humeral condyle fracture Upper limb trauma Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint AC Joint: Contains intra-articular disk of variable size. Thin capsule stabilized by ligaments on all sides: AC ligaments control horizontal (anteroposterior ) displacement Coracoclavicular ligaments “Suspensory ligaments of the upper extremity” Two components: Trapezoid Conoid Stronger than AC ligaments Provide vertical stability to AC joint Classification of Clavicle Fractures Group I : Middle third – Most common (80% of clavicle fractures) Group II: Distal third – 10-15% of clavicle injuries Group III: Medial third – Least common (approx. 5%) Nonoperative Treatment “Standard of Care” for most clavicle fractures. It is difficult to reduce clavicle fractures by closed means. Most clavicle fractures unite rapidly despite displacement. Significantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion Scapula Fractures the injury that is really threatening this patient is not his broken scapula it’s the very bad lung injury. Proximal Humerus fractures Third most common fracture in patients > 65 yrs hip fxs > “colles” fxs > proximal humerus fxs Treatment considerations: (patient + fracture) x surgeon = treatment Hemiarthroplasy Fixation options: nail Proximal humeral nail – Less invasive – Proximal stability àIncreases with fixed angle screws Used for: Surgical neck – +/- proximal comminution – Shaft extension – Ipsilateral shaft Possibly 3–4 part Fixation options: plates Proximal humerus Standard clover leaf plate 3.5 Proximal humeral locking plate 3.5 Revision to RSA 23 Fractures of the Humeral Shaft Mechanism of InjuryDirect (fracture at site of impact) or indirect forces (compression or torsion between elbow and shoulder) Violent muscle contraction (e.g. arm wrestling) Nonsurgical Treatment Many humeral fractures are amenable to closed, nonsurgical treatment rigid immobilization is not necessary for healing perfect alignment is not essential for an acceptable result* 98% union rate with good functional restoration and minimal angular deformity Nearly full ROM of the extremity were restored and complications were minimal Surgical treatment Failed closed treatment Loss of reduction Poor patient tolerance/compliance Failure of union Complex injuries Open fractures Vascular injury Floating elbow Radial Nerve Injury Transverse fractures of the middle 1/3 are most commonly associated with neuropraxia Spiral fractures of the distal 1/3, the HolsteinLewis fracture, present a higher risk of laceration or entrapment of the radial nerve Spontaneous recovery of nerve function is found in >70% of reported cases Even secondary palsies, those associated with fracture manipulation, have a high rate of spontaneous recovery 90% will resolve in 3 to 4 months EMG and nerve conduction studies can help to determine the degree of nerve injury and monitor the rate of nerve regeneration Fractures of the Distal Humerus Anatomic articular reduction Stable internal fixation of the articular surface Restoration of articular axial alignment Stable internal fixation of the articular segment to the metaphysis and diaphysis Early range of motion of the elbow Elbow fractures Contoured dorsal plate Fixation of coronoid Bridge fragmention Forearm Fractures Most require surgery, Indicated - All Unstable Forearm Fractures and All Open Forearm Fractures ORIF with Plates Distal Radius Fractures Casting Long arm vs. short arm Futuro Splint External Fixation Joint-spanning Non bridging Percutaneous pinning Internal Fixation Dorsal plating Volar plating Fractures of the Hand and Digits Power Grip: – ulnar digits – intrinsics Dexterity/ Fine Manipulation: – median innervated – radial sided digits Malrotation Lower limb trauma Lower Limb Fractures Pubic ramus fractures Left neck of femur fracture Lower Limb Fractures Epidemiology Overall M:F = 2:1 Femur and tibia make up over 80% – fibula, pelvis, patella, foot remainder RTC or other high energy trauma in younger group Low energy fall in older group Dementia carries higher risk of neck of femur (NOF) fracture Lower Limb Fractures Pathophysiology High energy in traumatic fractures – RTC, fall from height, sporting activity Low energy in osteoporotic fractures – Neck of femur – Pubic rami – Distal femur – Tibial plateau in elderly – Distal tibia in elderly – Metatarsal neck in elderly Pelvic Fractures High velocity trauma in young people Often a result of serious RTC Those associated with high velocity trauma often associated with massive blood loss and multiorgan injuries Urethral injuries in male in 20% Goal is to save life by stopping haemorrhage by stabilizing pelvis with external fixator Pelvic Fractures In elderly with osteoporosis with minimal trauma Commonest site is the pubic ramus, often multiple sites Neck of Femur Fractures About 76,000 annually in UK 25% admitted from institutionalized care 1—20% admitted from home are discharged to institutionalized care 30 day mortality of about 6.5% 12 month mortality is about 33% Neck of Femur Fractures Usually a result of low energy fall Severe pain Unable to weight bear Unable to straight leg raise Lower limb will adopt an externally rotated and shortened position Diagnosis on plain xrays (2 views) IF unclear on plain films, but clinically fractured then do CT Management is multidisciplinary – Health Care of Older Person Physician – Nursing Staff – Physiotherapist – Occupational Therapist – Orthopaedic Surgeon Patella Fractures Usually a result of a direct blow onto the knee May be displaced or undisplaced Inability to SLR is clinical sign Treatment depends on displacement and ability to SLR Conservative (splint or cast) Surgical – open reduction and internal fixation Tibial Shaft Fractures Usually a result of a direct blow (e.g. football) or a twisting injury (e.g. foot planted and body twists) Often compound due to the proximity of the tibia to the skin surface Much more common than femoral shaft fractures Conservative or Surgical Treatment POP – long time, above knee, no risk of infection Surgery – intramedullary nail or external fixator, risk of infection, compartment syndrome Rotation important Ankle Fractures Usually a result of a twisting injury Unimalleolar, bimalleolar, trimalleolar Stability of ankle mortise is critical – Dependent on bony and soft tissue structures Diagnosis on plain xrays – At least two orthogonal views – Do not forget Maisonneuve injury pattern – Talar shift or not? Depends on fracture pattern and ankle stability If ankle mortise intact and stable then conservative management in walking boot or cast If ankle mortise disrupted then reduce and hold usually with ORIF Foot Fractures Usually a result of a twisting injury Avulsion fracture of base of 5th metatarsal from pull of fibularis brevis (peroneus brevis) Most of these can be treated conservatively unless there is intra-articular disruption or they are in the avascular watershed area - Jones type Foot Fractures – Lisfranc Injury Tarsometatarsal fracture dislocation Traumatic disruption between medial cuneiform and base of second metatarsal RTC, fall from height, sporting injury Xrays show widening of interval between 1st and 2nd ray Treatment generally operative with ORIF or arthrodesis Other significant injuries Non-Accidental Injury Injury that results from deliberate actions against a child Second commonest cause of death in children 50% of fractures in those < 1 year of age are NAI Non-Accidental Injury Epidemiology 90% of fractures due to abuse occur in children < 5 years of age 50% of fractures in children < 1 year of age 30% of fractures in children < 3 years of age Most common cause of femur fractures in the nonambulatory infant is nonaccidental trauma Frequency of fractures: humerus > tibia > femur Diaphyseal fractures 4 times more common than metaphyseal Non-Accidental Injury Red Flags Non-Accidental Injury Social Risk Factors Child – first-born – unplanned pregnancy Parent – premature – single-parent home – disabilities – recent social stressor (cerebral palsy) (move, job loss) – step-children – unemployment – drug use – personal history of abuse as a child – lower socioeconomic status – lack of support system Delayed presentation No history of injury or inconsistent story High specificity fractures – long bone fractures in nonambulatory child – classic metaphyseal lesion – corner fractures – bucket handle fractures – transphyseal separation of the distal humerus – rib fractures, especially posteromedial – scapula fractures – sternal fractures – spinous process fractures Moderate specificity fractures – multiple fractures in various stages of healing – vertebral body fractures and subluxations – digital fractures – complex skull fractures Other injuries concerning for abuse – multiple bruises – burns especially if on soles of feet, palms of hand or buttocks – human bite marks – thumb prints or finger prints Non-Accidental Injury Associated Injuries Retinal hemorrhage Torn frenulum Bruises around buttocks, genitals, ears, Burns – electric, water, cigarette Bite marks Multiple fractures Non-Accidental Injury Management Be aware of red flags Admit the child Involve paediatric team Fractures generally treated conservatively Beware those with bone disease who can present with similar fracture patterns e.g. Osteogenesis Imperfecta Non-Accidental Injury Prognosis If unreported: – 30-50% chance of repeat abuse – 5-10% chance of death from abuse Compartment Syndrome Compartment Syndrome Definition Increased pressure in limb osseofascial compartment to a level that results in insufficient perfusion to the limb that may lead to irreversible muscle and neurovascular damage Volkmann's Contracture Compartment Syndrome Epidemiology May occur anywhere that muscle is surrounded by fascia Most commonly – leg, forearm and hand, thigh and buttock and foot Two main types: acute and chronic Most commonly an acute phenomenon after trauma Compartment Syndrome Pathophysiology Trauma and soft tissue injury → bleeding and tissue swelling → increase interstitial pressure → venous obstruction → increased interstitial pressure → myoneural ischaemia Causes: – Trauma - fractures, gunshot wounds, crush injury – Tight casts, bandages, dressings – Extravasation of IV infusion – Burns – Bleeding disorders – Arterial injury Compartment Syndrome Symptoms and Signs PAIN out of proportion to injury PAIN increasing despite immobilization of fracture PAIN intensified on passive stretch Pallor Palpable swelling (woody hard) Paraesthesia THIS IS A CLINICAL DIAGNOSIS Paralysis Pulseless (TOO LATE) In selected special situations e.g. unconscious patient Compartment Syndrome Investigation Intra-compartment pressure monitoring may have a role If compartment pressures are measured, they should at least 30mmHg below diastolic BP Compartment Syndrome Management URGENT FASCIOTOMY SURGICAL EMERGENCY – Complete full-length incisions – All compartments must be decompressed – Leave skin and compartments open – Remove necrotic tissue (late diagnosis) – Plan further EUA and secondary closure – May require extensive skin grafting Late diagnosis = no surgery as exposes necrotic tissue to superadded infection Compartment Syndrome in Forearm Compartment Syndrome in Leg Compartment Syndrome Complications Tissue necrosis Muscle necrosis Renal failure and sepsis (rhabdomyolysis) Volkmanns ischaemic contracture Left thigh after compartment syndrome with a split skin graft applied to the fasciotomy incision Necrotising Fasciitis Life-threatening subcutaneous soft-tissue infection Spreads along soft tissue plans rapidly Caused by a number of different bacteria, often multiple organisms usually including group A Streptococcus Common in those who are immunocompromised (e.g diabetes) Within 24 hours – Intense and severe pain out of proportion to any external signs of infection on the skin – Small but painful cut or scratch on the skin – Fever and other flu-like symptoms 3-4 days – Swelling of the painful area, accompanied by a rash – Diarrhoea and vomiting – Large dark blotches, that will turn into blisters and fill up with fluid (subcutaneous bullae) Critical symptoms (usually within 4 to 5 days) include: – Severe fall in blood pressure – Toxic shock from the poisons released by the bacteria – Unconsciousness as the body weakens Necrotising Fasciitis Management Progresses rapidly and can result in death Early diagnosis is key Exploratory surgery urgently High dose, appropriate broad spectrum intravenous antibiotics Drugs that raise the blood pressure (if needed) Amputation may be necessary to stop infection spreading LRINEC – Laboratory Risk Indicator for Necrotising Fasciitis can aid prediction BUT clinical suspicion outweighs any score Necrotising Fasciitis Surgery Radical debridement (removal of any affected tissue) “Dirty dishwater” fluid with grey coloured tissues Necrosis of fascia and underlying tissues Time to surgical debridement most important factor for survival Repeated surgical debridement may be necessary Surgical debridement of right lower limb for necrotising fasciitis Debrided area covered with a paraffin impregnated weaved gauze (jelonet) Necrotising Fasciitis Complications Sepsis and death (up to 25%) Chronic Infection Functional impairment Amputation may be necessary to save life Limb Threatening Injuries Open fractures/ dislocations Traumatic amputation (an injury that results in loss of the extremity distal to the wound) Crush injuries Severe soft tissue injuries - degloving