SURGERY

September 3, 2014
Dr. Abogado
Ortho Trauma



Eva and Pagaddu Doctor of Medicine - III Page 1 of 8

Mechanism of Injury
Fracture Care and Management

Open Fracture
- Bone breaks through the skin
- Penetrating injury
o Sharp object
o Gun shot

Classifications of Open Fractures
OPEN TYPE 1 Wound is 1cm
OPEN TYPE 2 Wound is >1cm
OPEN TYPE 3 Wound is >10cm
OPEN TYPE 3A Intact periosteum,
minimal comminution
OPEN TYPE 3B Stripped periosteum,
comminuted
OPEN TYPE 3C With nerve or vascular
injury
OPEN TYPE 3 SPECIAL Grossly contaminated with
soil, feces, high velocity
GSW



Compartment Syndrome
- Severe swelling
- Ischemia/necrosis
- 4 Ps:
o Pain
o Paresthesia
o Paralysis
o Pulselessness
- Treatment: Fasciotomy



Clavicle Fracture
- Due to direct injury
- Most common: middle third
- Non surgical treatment: armsling
- Surgical treatment is done if:
o Displaced
o Shortened
o Skin penetration
- Surgical treatment: plate/pin

Fracture of the Middle Third

- Other fractures and Injuries in the clavicle:
o Distal Third
o Acromio-clavicular joint injury
o Sterno-clavicular joint injury
If anterior: management is
close reduction
If posterior: watch out for
pulmonary or neurovascular
injury

Fracture of the Distal Third

Coraco-clavicular screw
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Lateral Clavicular Plate

Scapular Fracture
- With associated injury
- Non-surgical
- Glenoid/articular

Shoulder Dislocation
- ANTERIOR
o Labrum (bankart)
o Impression fracture on humeral shaft
(hill-sachs)
o Rotator cuff tear
- POSTERIOR
o Seizure
o Electric shock

Proximal Humerus Fracture
- Elderly due to fall
- Young due to high energy trauma
- NEER 4 Part Classification:
o Humeral Head
o Greater Tuberosity
o Lesser Tuberosity
o Humeral Shaft
- CT Scan: intraarticular
- It can be:
o Non-displaced
o Displaced: may lead to osteonecrosis
- Management:
o Young: fix the injury
o Elderly: prosthetic replacement





Risk of Avascular Necrosis (AVN)
- 3 part fracture
o 12-25%
- 4 part fracture
o 21-75%
- Valgus 4 part fracture
o 8-26%



Eva and Pagaddu Doctor of Medicine - III Page 3 of 8


2- and 3- part fracture in young patients showing
pinning/nailing


3-part fracture in elderly patients showing
hemiarthroplasty

Humeral Shaft Fracture
- Due to direct trauma
- Or due to fall
- Risk of radial nerve injury
- Treatment:
o Nonsurgical if nondisplaced or with
minimal displacement
o Surgical if angulated or displaced
- Safe zone for diaphyseal fracture
o Anterior approach



Anterior Approach

Distal Humerus Fracture
- Due to fall
- Supracondylar fracture
- Treatment:
o Nonsurgical if minimal displacement
o Surgical if there is articular
involvement
o Prosthetic replacement
- If there is joint stiffness early range of motion
excercises


41 y/o, RHD, Security Officer

Elbow Dislocation
- Posterior
- Lateral collateral ligament
- Fracture of radial head, coronoid, epicondyles
- Close reduction
- Elbow stiffness
- Terrible triad
o Elbow dislocation
o Radial Head Fracture
o Coronoid Fracture


Eva and Pagaddu Doctor of Medicine - III Page 4 of 8



Elbow Dislocation
- Lateral Soft Tissue Complex
o Common extensors
o LUCL
o Annular Ligament
- Medial Soft Tissue Complex
o Common flexors
o MUCL

Radial Head Fracture
- Most commonly treated non-operatively
- If displaced:
o Fix
o Prosthetic replacement
- Do excision if:
o Elderly
o Elbow instability
o Wrist symptoms




Olecranon fracture
- Fall directly on a flexed elbow
- Non-displaced: cast
- Displaced:
o Tension band wire
o Plate and screws

Transolecranon Fracture Dislocation
- Fracture through olecranon
- Coronoid fracture
- Radial Head fracture
- PRUJ (Proximal Radio-ulnar Joint) and Collateral
ligaments are intact

Classification


Forearm Fractures
- High energy trauma
- Fall
- Radial Bow
- Plates and screw
- Nightstick fracture isolated ulna fracture
- Monteggia fracture ulnar shaft fracture with
radial head dislocation
- Galeazzi fracture radial shaft fracture with
disruption of DRUJ

Pelvic Fracture
- High energy trauma
- Associated injuries to pelvic organs:
o Urethra
o Prostate
o Rectum
o Vagina
o Sphincter
- Hemorrhage venous plexus at post pelvis,
gluteal artery
- Pelvic binder/external fixator
- Injuries on the bladder and urethra
- Pelvic ring (sacrum and 2 innominate bones)
Eva and Pagaddu Doctor of Medicine - III Page 5 of 8

o Bounded by strong ligaments
o Integrity of the pelvic ring is essential
for stability
- Three fracture patterns:
o Antero-posterior
o Lateral compression
o Vertical shear
- Stable nondisplaced non surgical
- Open book/ unstable surgical

Open book



Pelvic Clamp



Hip dislocation
- High energy trauma
- Posterior most common
- Sciatic nerve
- Associated with fracture of acetabulum or
femoral head
- Emergent reduction
- Osteonecrosis of femoral head
- Post traumatic arthritis




Bed sheet
Vacuum splint
Pelvic Binder
Coronal # line: column
Saggital # line: transverse
Oblique # line: wall-type
- Intraarticular
loose
fragment
- Impacted
fragments
- Dome
comminution
Eva and Pagaddu Doctor of Medicine - III Page 6 of 8

Hip Fractures
- Elderly/oseoporotic patients fall
- Young patients high energy trauma
- At risk of:
o Deep vein thrombosis
o Pulmonary embolism
o Pneumonia
o Pressure sores
o Death
- Goals of Surgery
o Minimize pain
o Restore function
o Allow early mobilization

Femoral Neck Fracture
- Intracapsular fracture
- Osteonecrosis
- Non-displaced: screw fixation
- Displaced: partial prosthetic replacement
- Displaced arthritic: total hip replacement

Intertrochanteric Fracture
- Extracapsular
- Osteonecrosis is uncommon
- Surgical fixation
o Sliding hip screw fixation
o Cephalomedullary nail


Subtrochanteric Fracture
- High energy trauma
- Significantly displaced due to muscle forces
- Cephalomedullary nail
- Palte and screws
- Fileding classification of subtrochanteric
fracture
- Classification:
Type I Fracture at the level of the lesser
trochanter
Type II Fracture < 2.5 cm below the lesser
trochanter
Type III Fracture between 2.5 and 5 cm below
the lesser trochanter

Deforming Forces

Femoral Shaft Fracture
- High energy trauma
- ARDS/PE
- Intramedullary nail

Distal Femur Fracture
- Non-displaced fracture : hinged knee brace
- Plate and Screws
- Intraarticular fracture

Extraarticular Fracture
Eva and Pagaddu Doctor of Medicine - III Page 7 of 8

Knee Dislocation
- ACL/PCL/LCL/MCL
- Popliteal artery
- Neurovascular exam
- Angiogram, MRI
- Emergent reduction
- Ligamentous injury
- Stiffness, instability

Extensor Mechanism
- Quadriceps tendon
- Patella, Patellar ligament
- Knee extension
- Repair of patellar fracture
- Repair of tendon tears
- Patellar dislocation

Tibial Shaft Fracture
- Most common long bone fracture
- Cast/immobilization
- Intramedullary nail
- Plate and Screws
- External Fixation

Tibial Plafond
- Articular fracture
- External fixation
- Fibula is fixed with plate to maintain height of
the tibia
- Complications:
o Stiffness
o Wound healing
o Infection
Goals of Surgery
- Stage 1 Goals
o Restoration of skeletal length and
ligament
o Span joint and allow soft tissues to
stabilize
o Distraction across ankle joint
o Align talus beneath tibia
- Stage 2 Goals
o Anatomic restoration of joint
o Stable fixation to allow motion
o Fracture heal in anatomically aligned
limb
Ankle Dislocation
- Ankle joint hinge joint
o Tibial plafond
o Medial malleolus
o Lateral malleolus
o Talus
o Severe twisting injury
o Prompt reduction

Ankle Fracture
- Twisting injury
- Pattern of injury depends on direction of force
- Goals of Surgery
o Restore anatomy
o Restore length
o Restore rotation of fibula
- Swelling
- Classification
o Simple:
Unimalleolar
Bimalleolar
o Complex:
Trimalleolar
Dislocations

Lateral Malleolus
- Isolated fracture: anatomic reduction
- 1mm Talar shift: 40% reduction in contact
- Traumatic arthritis

Medial Malleolus
- Avulsion injury
- Minimimal displacement: cast
- Displaced: screw fixation

Bimalleolar fracture
- Unstable
- ORIF
- Triamlleolar fracture
o Posterior malleolus
o >25% of articular surface: surgery

Calcaneal Fracture
- Fall from a height
- Lumbar fracture
- Intraarticular
Eva and Pagaddu Doctor of Medicine - III Page 8 of 8

- CT scan
- Displaced articular plate/screws
- Hell pain, arthritis


Mechanism of Injury
Axial compression: fall from a height
- The force is axially directed through the talus
into the tibial plafond, causing impaction of the
articular surface;

Shear: skiing accident
- Mechanism is primarily torsion combined with a
varus or valgus stress.

Tallar Fracture
- Forced dorsiflexion
- Osteonecrosis
- Undisplaced: cast
- Displaced: screw fixation (25%)
- Osteonecrosis, arthritis

FOOT
- LISFRANC LIGAMENT
o 2
nd
metatarsal head to medial
cuneiform
o Stabilizer of midfoot
o Torsional forces
o Surgery
- Joint fracture: base of 5
th
Metatarsal, Nonunion
- Metatarsal/Phalangeal Fracture


Lisfranc Injuries