Orthopaedics & Trauma

Orthopaedics

Trauma All bones/joints except skull & face

Overview of Orthopaedics & Trauma

Paediatric Orthopaedics Spines Upper Limb Shoulder Elbow Hand

Sean Curry Consultant Orthopaedic Surgeon Barts & The London

Lower Limb Hip Knee Foot & Ankle

Paediatric Orthopaedics
• • • • • • • • Congenital Disorders Disorders of Growth Gait Disorders Cerebral Palsy Clubfoot DDH Perthe’s Disease SUFE
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Developmental Dysplasia of the Hip
• • • • • 1:1000 births First born Female Breech delivery Family History
Treatment: •Non-Operative •Operative

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QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.

Perthe’s Disease
• • • • Idiopathic avascular necrosis 4-10 years M>F 4:1 Containment
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Slipped Upper Femoral Epiphysis
• Commonest cause of hip pain adolescents • M:F 2:1 • Pin in situ • “What” test
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QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.

Final year medical student. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Principles of Fracture Management Student BMJ April 1999: Life Nicola Goodchild. Joint Instability • • • • Shoulder Knee Ankle Arthroscopic Surgery QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. •Disc (Cervical & Lumbar) •Shoulder •Elbow •Hip •Knee •Ankle •MCP MTP QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Deformity Correction/Bone Loss • Ilizarov Technique • Distraction Osteogenesis QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Orthopaedics: Joint Replacement QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.Spines • Scoliosis • Degenerative spine disorders: • Back Pain • Prolapsed disc • Spinal Stenosis QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Arthroscopic Surgery • • • • Stabilisation Ligament Reconstruction Microfracture ACI QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
Charing Cross and Westminster Medical School.
London . QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.

lesser risk FACTORS AFFECTING FRACTURE HEALING – The energy transfer of the injury – The tissue response • Two bone ends in opposition or compressed • Micro-movement or no movement • BS (scaphoid. QuickTime™ and a TIFF (Uncompressed) decompress are needed to see this picture.GOALS OF FRACTURE TREATMENT • Restore the patient to optimal functional state • Prevent fracture and soft-tissue complications • Get the fracture to heal. talus. LOW ENERGY INJURY . rehabilitation rapid. rehabilitation slow. femoral and humeral head) • NS • No infection HIGH-ENERGY INJURY – The patient – The method of treatment High Energy Injury QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. high risk With operative intervention (nailing or external fixation) • Healing by callus • Rapid process. rehabilitation rapid. low risk With operative intervention (reduction + compression) • Primary bone healing • Slow process. and in a position which will produce optimal functional recovery • Rehabilitate the patient as early as possible HOW FRACTURES HEAL In nature • Regeneration vs repair • Three phases of healing by callus • Rapid process.

pathological.DESCRIBING THE FRACTURE – Mechanism of injury (traumatic. stress) – Anatomical site (bone and location in bone) – Configuration /Displacement • three planes of angulation • translation • shortening – Articular involvement/epiphyseal injuries • fracture involving joint • dislocation • ligamentous avulsion – Soft tissue injury MINIMALLY DISPLACED DISTAL RADIUS FRACTURE • Life saving measures COMMINUTED PROXIMALTHIRD FEMORAL FRACTURE WITH SIGNIFICANT DISPLACEMENT – Life saving – Complication saving MANAGEMENT OF THE INJURED PATIENT • Diagnose and treat life threatening injuries • Emergency orthopaedic involvement – Emergency orthopaedic management (Day 1) – Monitoring of fracture (Days to weeks) – Rehabilitation + treatment of complications (weeks to months) LIFE SAVING MEASURES –A –B –C –D –E Airway and cervical spine immobilisation Breathing EMERGENCY ORTHOPAEDIC MANAGEMENT • Life saving measures • Reducing a pelvic fracture in haemodynamically unstable patient • Applying pressure to reduce haemorrhage from open fracture – Complication saving Circulation (treatment and diagnosis of cause) Disability (head injury) Exposure (musculo-skeletal injury) • Early and complete diagnosis of the extent of injuries • Diagnosing and treating soft-tissue injuries .

g. clavicle. degloving injuries and ischaemic necrosis • Muscles • Crush and compartment syndromes • Blood vessels • Vasospasm and arterial laceration • Nerves • Neurapraxias.g. ribs. MT’s) – “First-aid” reduction – Splintage and analgesia – Radiographs • Two planes including joints above and below area of injury – How accurate a reduction do we need? • alignment without angulation (closed reduction . wrist) • anatomic (open reduction .• Skin DIAGNOSING THE SOFT TISSUE INJURY • Open fractures. axonotmesis. neurotmesis • Ligaments • Joint instability and dislocation TREATING THE SOFT TISSUE INJURY • All severe soft tissue injuries………require urgent treatment – Open fractures – Vascular injuries – Nerve injuries – Compartment syndromes – Fracture/dislocations • After the treatment of the soft tissue injury the fracture requires rigid fixation SEVERE SOFT-TISSUE INJURY – A severe soft-tissue injury will delay fracture healing DIAGNOSING THE BONE INJURY – Clinical assessment • History • Co-morbidities • Exposure/systematic examination TREATING THE FRACTURE I – Does the fracture require reduction? • Is it displaced? • Does it need to be reduced? (e.e.g.e. adult forearm ) .

• Pathological #’s • Non-unions Displaced intra-articular fractures . Use of closed and minimally invasive methods Non-Operative Slow Present Present • Current absolute indications: • Polytrauma • Open #’s • #’s with vascular injury or compartment syndrome.TREATING THE FRACTURE II • How are we going to hold the reduction? • Semi-rigid (Plaster) • Rigid (Internal fixation) • What treatment plan will we follow? • When can the patient load the injured limb? • When can the patient be allowed to move the joints? • How long will we have to immobilise the fracture for? DIFFERENT TYPES OF RIGID FRACTURE FIXATION TREATING THE FRACTURE III Operative Rehabilitation Risk of joint stiffness Risk of malunion Risk of non-union Present Speed of healing Risk of infection Cost Rapid Low Low Present Slow Present ? Rapid Low ? INDICATIONS FOR OPERATIVE TREATMENT • General trend toward operative treatment last 30 yrs • Improved implants and antibiotic prophylaxis.

elderly patients COMPLICATIONS OF FRACTURES Early General Other injuries PE FES/ARDS Bone Infection Late Chest infection UTI Bed sores Non-union Malunion AVN • Approach needs to be:• Pragmatic with realistic targets • Multidisciplinary – Physiotherapist. District nurse. GP. Social worker Soft-tissues compression Plaster sores Wound Infection N/V injury Compartment syn Tendon rupture Nerve Volkmann contracture Colles’ Fracture Hip Fractures Intracapsu Displaced Undisplac (Garden I Garden III Extracapsu 1-4 Part .INDICATIONS FOR OPERATIVE TREATMENT • Current relative indications: • Loss of position with closed method • Poor functional result with non-anatomical reduction • Displaced fractures with poor blood supply • Economic and medical indications WHEN IS THE FRACTURE HEALED? • Clinically Upper limb Adult Child 6-8 weeks 3-4 weeks Lower limb 12-16 weeks 6-8 weeks • Radiologically • Bridging callus formation • Remodelling • Biomechanically REHABILITATION • Restoring the patient as close to pre-injury functional level as possible • May not be possible with:– Severe fractures or other injuries – Frail. Occupational therapist.

Intracapsular vs Extracapsular Spinal Fractures I Spinal Fractures II .

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