0 GENERAL ORTHOPEDIC 1. FRACTURE . A. UPPER LIMB ° i. PROXIMAL HUMERUS FRACTURE Q Fracture at or proximal to surgical neck of humerus. Common cause: © Fall from standing height: >60 years old e High energy trauma in younger individual. Signs and symptoms: e Localized shoulder pain e Reduced ROM from the affected extremity e Soft tissue swelling e Loss of normal convex contour of the shoulder e Open fracture are rare but should be ruled out Sensation over lateral aspect of proximal arm (regimental patch area) should be examined to rule out axillary nerve injury. Radial pulse and CRT of all fingers should be examined and COMPARED to the contralateral side. Imaging: AP Grashey view Neer view (Lateral Y) 15Classification: e Neer’s classification is based on 4 parts anatomy of proximal humerus e Humeral head, humeral neck, greater tuberosity and lesser tuberosity 3 part 4 part Anatomical neck Surgical neck Greater tuberosity Lesser tuberosity Fracture a Fractu: distocation posterior | — Fath Treatment: e Based on functional requirement of a patient © Non-operative: e Acceptable fracture is displacement of <1cm and angulation of <45 degree. e Immobilization for stable fracture can be done with collar and cuff sling. e Passive ROM shoulder exercise should start from 2 weeks; sling can be used during 1st 4-6 weeks after injury. *° Operative : - depends on fracture classification ° ORIF —with plate e Percutaneous pinHUMERAL SHAFT FRACTURE Men and women equally affected until the age of 60 e More frequent in women after the age of 60 - 80% e Commonest cause is a fall, followed by MVA injuries with humeral shaft fracture: = Radial nerve injury: inability to dorsiflex wrist and digits, along with numbness on dorsoradial aspect of hand. = Concomitant shoulder dislocation = Soft tissue injury: look for injury to rotator cuff or acromioclavicular joint * Vascular injury: Always palpate for distal pulses and circulation (brachial, ulnar and radial artery) = Floating elbow: Combination of both humeral shaft and radius/ulna fracture *always look for presence of wound communicating with fracture site, to rule out open fracture e Sign and symptoms: = Pain at fracture site * — Swelling and deformity around the fracture site = Reduced range of motion “findings from physical examination should be documented properly and completely e Treatment: Non operative: = Immobilization with U slab = Indication: 1) Acute, closed and simple fractures 2) <20° anterior angulation 3) <30°varus/valgus angulation 4) Less than 3 cm shortening 17Operative: es eecee je y | i Indications Inability to maintain satisfactory reduction by closed means Multiple injuries Bilateral fractures Floating elbow intra-articular fracture extension Progressive nerve palsy / nerve palsy after CMR Significant vascular injury Neurologic deficit after penetrating injury Nonunion Pathologic fracture Holstein-Lewis Fracture: Relative Indications Open fracture Segmental fracture Obesity / large breasts Periprosthetic fractures e Type A fracture in middle 3° of humerus « Long oblique fracture of proxhumerus | Noncompliant patient | | Spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve (22% incidence) HUMERUS LATERAL. INTER- MUSCULAR SEPTUM 18ER] —— SUPRACONDYLAR HUMERUS FRACTURE supRAcOrre————— errr Commonly associated with intraarticular fracture Signs and symptoms: Elbow pain and swelling Circulation to look for vascular injury Look for compartment syndrome Neurological examination: e Ulnar nerve injury: » Ulna claw hand = Paraethesia over ulnar half of palm, dorsum of hand, and medial 1 % digits. Classification: 1. Distal single column (condyle) fracture: Milch classification Lateral condyle > common Milch I: Lateral trochlear ridge is intact Milch II: Fracture through lateral trochlear ridge Distal two column (condyle) fracture:(Jupiter classification) High T: Transverse fracture proximal to or at upper olecranon fossa Low T: Transverse fracture just proximal to trochlea (common) Y: Oblique fracture line through both columns with distal vertical line H: trochlea is a free fragment (risk of AVN) Medial lambda: proximal fracture line exits medially Lateral lambda: proximal fracture line exits laterally 19‘Nodal Lambda Treatment: Non-operative treatment may be reserved for elderly patient with significant medical comorbidities Operative: ¢ ORIF: two plates applied to either column (double recon plate) = = Fractures can be protected with hanging cast while waiting for ORIF + Total elbow arthroplasty: useful for patients older than 65 years, particularly with osteoporosis or rheumatoid arthritis. iv. FRACTURE OF RADIUS AND ULNA Signs and symptoms: ° Pain and swelling and deformity. e Circulation - Radial and ulnar pulses * Assess Median, ulnar and radial nerve function = AIN & PIN injury Watch out for compartment syndrome - rare Treatment: e ORIF: DCP = Protect with above elbow backslab while waiting for ORIF. ° Severely displaced fragment can be reduced by CMR prior to ORIF, to prevent severe swelling and pain 20v. MONTEGGIA FRACTURE DISLOCATION Fracture of ulna with radial head dislocation. Bado’s classification: TYPE! Fracture of the proximal or middle third of the ulna lwith anterior dislocation of the radial head (most common in children and young adults) ~ Fracture of the proximal or middle third of the ulna lwith posterior dislocation of the radial head (70 to 180% of adult Monteggia fractures) Fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head TYPE IV |Eracture of the proximal or middle third of the ulna land radius with dislocation of the radial head in any ldirection Treatment: e All monteggia fracture in adult should be treated by ORIF. e Radial head will usually reduce after anatomical reduction of ulna. e If ulnar is anatomic, but radial head does not reduce, open reduction with separate approach for annular ligament repair is required. Complication: e Vascular injury: palpate for radial and ulnar artery ¢ Compartment syndrome e Posterior interosseous nerve injury: weakness of metacarpo- phalangeal joint extension (finger drop). 21Ta ul vi. GALEAZZI FRACTURES Fracture of radial shaft with distal radio-ulnar dislocation. Sub classified based on distance of radial fracture from articular surface: e Type 1: within 7.5cm from articular surface e Type 2: more proximal than type 1; lower rate of DRU4J instability Treatment: ° ORIF with DCP is the treatment of choice for adult. = Anatomic reduction of radius will usually reduce the DRUJ. = Unstable DRUJ should be pinned with K-wire with forearm in supination, and kept for 6 weeks A-C: Galeazi fracture after fixation with Small DCP D: Galeazzi fracture after fixation with smail DCP, lag screw and DRUJ k wire 22vii. DISTAL END RADIUS FRACTURE e Most common orthopedic injury with a bimodal distribution e younger patients - high energy e older patients - low energy / falls e 50% intra-articular e Associated i e DRU4J injuries must be evaluated e Radial styloid fracture - indication of higher energy Osteoporosis e High incidence of distal radius fractures in women >50 Distal radius fractures are a predictor of subsequent fractures o DEXA scan is recommended in woman with a distal radius fracture ( e Eponyms: A depressed fracture of the lunate fossa of the | articular surface of the distal radius Fracture dislocation of radiocarpal joint with intra- Barton's | articular fracture involving the volar or dorsal lip fracture (volar Barton or dorsal Barton fracture) Radial styloid fracture Low energy, dorsally displaced, extra-articular fracture Low energy, volar displaced, extra-articular fracture 23Management: e Intra — articular Locking Plate / bi Depend o ° Extra — articular Conservative ma Try CMR and AEPOp If not acceptable for ORIF CMR and above elbow cast Rarely nee fixation nagement Cast for 6/52 ONLY Wrist physiotherapy once off cast uttress plate " patient age and demand allt as Radial height Radial inclination Lateral tilt ( volar/radial tilt ) Ulna variance Joint stepping ( intra-articular) 11mm 22 degrees 11 degrees 0-2mm No stepping < 2mm shorthening <5 degrees loss Neutral ( no dorsal tilt ) No ulnar plus ( ulnar higher than radius ) <2 mm stenoffa = viii. CLAVICLE FRACTURE Common cause: Direct blow on the point of shoulder Check for brachial plexus injury and circulation e Especially when there is fracture over 1° rib Treated conservatively with sling immobilization e Gentle ROM exercise should begin in 2-4 weeks time. e Strengthening exercise can begin from 6 weeks onwards. e Union should be solid in 8-10 weeks. Indications for ORIF: e Symptomatic non-union e Neurovascular injury involvement e Skin tenting e Floating shoulder: fracture of clavicle with fracture or surgical neck of scapula/humerus Open fracture NO attempt at reduction should be made for clavicle fracture. ix. ACROMIOCLAVICULAR JOINT INJURIES ACJ: Located between the medial margin of acromion and lateral end of clavicle. Coracoctavicular [ Trapezoid ligament ligament Coracoacromial Normal y of the AC ont. Mechanism of injury - Direct blow to the shoulder or fall with arm in adducted position 25a —— —— Signs and symptoms: e Pain and deformity over ACJ 7 Clinical triad confirms the diagnosis of ACJ injury. 4. Point tenderness at AC joint 2. Pain exacerbation with cross arm adduction test Arm elevated to 90° and adducted across the chest with elbow flex in 90° 3. Relieve of symptoms by injection of LA Classifications: Graded according to amount of injury to ACJ and coracoclavicular joint (trapezoid and conoid ligament). 4 9 o a S 3 8 x = 3 ° a > ° s a 2 a ° 8 Es o $ Qa > o & a e. 9 3 Normal ACJ radiograph. Only minor strain to acromioclavicular ligament Lt | Lateral end of clavicle may be slightly elevated. When compared to unaffected side, ACJ appears to be widened. Coracoclavicular space remains similar to unaffected shoulder GJ is completely displaced and coracoclavicular is greater than the normal shoulder (by 25-100%) Posterior displacement of distal clavicle as seen from axillary lateral radiograph | Marked increased in coracoclavicular distance (100- than the normal shoulder 26Treatment: Type 1 and 2: Brief immobilization in arm sling, rest, and ice therapy for 1-2 weeks, followed by passive rom and strengthening exercise. Type 3: ° Controversial. Some advocated operative repair especially for heavy laborers Type 4, 5 and 6: Operative treatmentGUIDELINES FOR B. LOWER LIMB UR FRACTURE i. PROXIMAL FEM Types of proximal femoral fracture INTRACAPSULAR FRACTURE nearer TROCHANTER INTERTROCHANTERIC Tr onpaoaar eta wn vA rn 1. SUBCAPITAL -s pra interes ¢ine, 4 INTERTROCHANTERIC pee) EXTRACAPSULAR TROCHANTER ‘suBTROCANTERIC: sem FEMORAL SHAFT The fracture pattern will determine the management. Eg ; - Undisplaced intracapsular fracture (1 or 2) > screw fixation / conservative = Displaced intracapsular fracture (1 or 2) Hemiarthroplasty - Basal neck / Intertrochanteric fracture > DHS - Subtroctranteric fracture > DHS / DCS / PFN NECK OF FEMUR FRACTURE * Risk increasing with old, mainly due to osteoporosis * Healing potential is low dit lack of periosteal layer ¢ Higher risk of AVN d/t disruption of blood supply = Major blood supply - medial femoral circumflex artery * Cause: * Fallin elderly * High energy impact in young patient 28e Displaced fracture —leg in external rotation and abduction with shortening e Classification - Garden”s Classification PoP Type 1: Impacted fracture Type 2: Undisplaced fracture a ‘Type 3: Partial deplaced trecture Type 4: Displeced fracture Treatment Conservative e In previously non ambulators & ill patient Operative 1. Screw Fixation ¢ Non displaced transcervical fracture e Garden 1 and 2 fracture 2. Arthroplasty —hemi / total © Bipolar / Thompson hemiarthroplasty e Elderly with metabolic bone disease which previously active and ambulating Complication: e Osteonecrosis - AVN e Non Union ¢ Dislocation 29iii, INTERTROCHANTERI FRACTURE FEMUR (IT) * Cause by fall - from direct and indirect forces * Occurs along lines between greater and less trochanters e Extra capsular - has an excellent blood supply o Heals well ° Classification - Evan’s Classification | Type |_| Two fragment un: | Type lt Two fragment di: Z : : aera] Type ui | Three fragment iracture without RoweroTaveral SBP (oiepiaced Gt fragment) = mv | teres fnge aceaty withaur mealsT aver | Tee | (dupinced LY fragenere) 3 Tour Ragman fsciara without poataroTateral a | esi So serena | [Tree R | Reverse Oblique fracture I Management: 1. Non Operative Rx: Skin traction ° Even w/o treatment, fracture usually stabilizes w/in 8 weekS ¢ Allows wt bearing in 12 weeks * Marked varus of head & neck with external rotation deformity * Usually result in a short leg gait & limp 2. Operative * Dynamic Hip Screw ¢ Proximal Femur Intramedullary Nail 30iv. FEMORAL SHAFT FRACTURE High energy injuries in MVA (dashboard injuries) Associated with NOF fracture and knee injury Sign & symptom: e Tense swollen thigh -shortened leg ° Always asses for neurovascular Classification - Winquist and Hansen Classification TT Type 0 | No comminution Type | | Insignificant amount of comminution Type |_| Greater than 50% cortical contact, Type il! | Less than 50% cortical contact ‘Segmental fracture with no contact between promal and distal Type lv fragment Treatment e Conservative — POP = Only in babies and toddler e Operative e _ILN - Gold standard e Plating = Fracture at distal metaphyseal-diaphyseal junction = — Growing child Complication: e Pudendal Nerve Injury & Femoral Artery and Nerve injury * Shock and fat embolism syndrome * Delayed Union or Non Union 31v. DISTAL FEMUR FRACTURE Mechanism - Direct high energy force or axial loading Three types: Classification— AO ls Type A: Fractures do not | involve the joint surface; Type B: Fractures involve | the joint surface (one | condyle) but leave the | supracondylar region intact; ‘Type C: Fractures have supracondylar and condylar components A B ClL.. Li) td a Sign & Symptoms e Extreme pain e Knee effusion (hemarthrosis) * Shortened, externally rotated leg if displaced Treatment e ORIF * Retrograde nail = Locking plate / buttress plate = — Lag screw fixation * Early mobilization and strengthening Complications: e Popliteal arery tear — examine PTA & DPA Nerve injury e Soft tissue injury e Angulation deformities 32vi. TIBIAL PLATEAU FRACTURE Mechanism e Axial loading (e.g. fall from height) e Femoral condyles driven into proximal tibia e Can result from minor trauma in osteoporotics Classification - Schatzker Classification Treatment Temporary management: e Back slab e Circulation chart e Pain score ¢ Watch out for compartment syndrome Conservative management: e Full length cast (above knee cast) = Minimally displaced split or depressed fractures = Low energy fracture stable to varus/valgus alignment = Non ambulatory patients 33—= Operative management: ° Lag screw/ Plating and bone e Indications « Articular step off 3mm » — Condylar widening > 5mm * Varus/valgus instability = All medial plateau fracture = All bicondylar fracture graft Complication: e Ligamentous and meniscal injuries ° Fixed flexion deformity vii. TIBIAL SHAFT FRACTURE Mechanism ° MVA, falls, sport injuries Clinical Features ° Check for neurovascular injuries Always be on the alert for signs of an impending compartment syndrome. Treatment * CMR & Above Knee Cast = Cast x 3 months = Change to PTB cast — if delayed union e ORIF - IM nail / plate * Non - union fracture = Comminuted fracture * Failed CMR © Open fracture - external fixation Complications * High incidence of neurovascular injury and compartment syndrome * Poor soft tissue coverage in open fracture 34viii. ANKLE FRACTURE Injury patterns e Isolated medial malleolus fracture e Isolated lateral malleolus fracture e Bimalleolar and bimalleolar-equivalent fractures e Posterior malleolus fractures e Bosworth fracture-dislocations e Open ankle fractures e Associated syndesmotic injuries e Isolated syndesmosis injury Classification: i. Danis-Weber (location of fibular fracture) PTS aan LaJaie Pea Wi asais Fracture distalto Fractureatthe levelof Fracture proximalto syndesmosis (generally _-syndesmosis syndesmosis ankle stable} 35Lauge-Hansen Based on foot position and force of applied » — Supination Adduction (SA) = — Supination Ext Rotation (SER) = Pronation Abduction (PA) = Pronation Ext Rotation (PER) Supination adduction ‘Supination exorotation Treatment: Non-operative e Below knee cast/boot e Indications: * Isolated nondisplaced medial malleolus fracture or tip avulsions = Isolated lateral malleolus fracture with < 3mm displacement and no talar shift = Posterior malleolar fracture with < 25% joint involvement or < 2mm step-off 36Operative e Indications: = Talar displacement Displaced isolated medial malleolar fracture Displaced isolated lateral malleolar fracture Bimalleolar fracture and bimalleolar-equivalent fracture Posterior malleolar fracture with > 25% or >2mm step-off * Bosworth fracture-dislocations e ORIF = Medial malleolus - Lag Screw = Lateral malleolus - Plate (1/3rd tubular plate) « Posterior malleolus - Lag screw = Syndesmotic joint - Screw o Need to remove after 6/52 ix. TIBIA PLAFOND FRACTURE e Also known as PILON fracture e Mechanism = High energy axial load (mva, falls from height) © Characterized by Articular impaction and comminution Metaphyseal bone comminution Soft tissue injury (open or Tscherne II/III closed fractures) Associated musculoskeletal injuries 3 fragments typical with intact ankle ligaments © Medial malleolar (deltoid ligament) © Posterolateral/Volkmann fragment (posterior inferior tibiofibular ligament) Anterolateral/Chaput fragment (anterior inferior tibiofibular ligament) 37C. SALTER-HARIS FRACTURE Growth-Plate Fractures 15-20% of major long-bone fracture & 34% of hand fracture in childhood ¢ Majority fracture heal w/o any impairment of growth mechanism but some lead to clinically important shortening & angulation * May lead to growth disorders due to: © Destruction of epiphyseal circulation (inhibits physeal growth) © Formation of bone bridge across growth plate Fracture subtype SALTER — HARIS CLASSIFICATION OF PHYSEAL FRACTURES : | TY TYPE! TYPE IT TPE rev Srratairr Asove Lower Trrousn Ramen Leespiyss — | Actossensis | _ puvsis pass Pass puvsis aration racture racture fuined or scorn, [ccs tme | rocwe, [onus | munas 2 = PHysis physis, me portion of metaphysis, | Crushing type “GROWTH py Usually common ) | nysis and pysis and injury does MATE: through area pad down epiphysis not displace of through 3, through the {he ahyss but hypertrophic | Portion of epiphysis lamages it by Smerapnyss | and physis and direct, degenerating | that extends compression cartilage ca | through the columns metaphys —] 38SUPRACONDYLAR HUMERUS FRACTURE (CHILDREN) Typically remains extra-articular & involves thin bone between coronoid fossa & olecranon fossa of distal humerus Fracture line angles from anterior distal point to posterior prox site Fracture occurs most often around age 6-7 years Classification: = 2 types: extension type (95%) & flexion type Gartland classification for extension fractures = Non-displaced Displaced with Displaced with fracture Intact posterior no cortical Associated injuries: Distal radius fracture (occurs in 5-6%) Physical Examination: * Vascular Injuries — look for brachial artery injury o Examine radial pulse and CRT Neurologic Deficits - median, radial & ulna nerve Treatment: Initial — put on lateral traction if very swollen If pulse of affected arm is slightly decreased (i.e., vascular injury is a concern), then apply a continuous pulse oximeter Conservative for type | - AEPOP = Operative: o Percutaneous pin fixation © Open reduction and K-wire insertion 39Baumann’s angle (Ap View) Angle between longitudinal humeral shaft &physis of th condyle (Normal: 80 - 90 deg) | Carrying angle = Humeral-uina Angle axis of © lateray Line bisecting the shaft of the humerus with the shaft of the uina (Normal: 10-15 deg female, 5 deg male) Anterior humeral line Line dravn along anterior border of humerus should pass through middle 3” of capitulum Radiocapitular line Line drawn along the axis of radius should pass through the center of capitulum in all projections 402. JOINT DISLOCATION e Dislocation: Complete loss of contact between the articulating surfaces of a joint e Subluxation: Articulating surfaces of a joint are no longer congruous. Loss of contact is not complete e ALL DISLOCATION MUST BE REDUCED AS SOON AS POSSIBLE e CHECK XRAY MUST BE DONE AND REVIEW e IF REDUCTION UNDER SEDATION FAILED, PREPARE PATIENT FOR CMR UNDER GENERAL ANESTHESIA = Keep NBM » Inform medical officer = ECG &CXR in pt> 40 yrs A. SHOULDER DISLOCATION * 95% is anterior and 10% of ant dislocation a/w fracture = Humeral head in front of glenoid = Patient hold arm in hand-shake position * Posterior dislocation = — Light bulb sign = Empty anterior glenoid fossa Shoulder Dislocation Normal Anterior Posterior anatomy dislocation dislocation 41a @ Management: Close manipulation and reduction o Put arm sling and body strap for 2/52 Methods of reduction Figure 4. The taction-counter Se ee reduction Traction counter traction Stimson's Method Mitch method Hippocratic Method 42HIP DISLOCATION HIP DISLOCATION 90% posterior dislocation (limb internally rotated, adducted, flexed and shortened) » 10% have sciatic nv injury and may have acetabular fracture 10% anterior (limb externally rotated, abducted, slight flexed) Central- dislocated through acetabulum Reduction: Posterior Pt supine Gentle flexion of hip and knee to 90deg with slight adduction and internal rotation traction upwards whilst an assistant stabilizes the pelvic Rotation can be applied gently if required but forceful rotation should be avoided = Can cause femoral neck fracture Do telescopic test to check for the hip stability ° Anterior Pt supine Hip and knee flexed 90 deg Assistant stabilized pelvis Femur rotated to neutral and tract upwards | Check for Neurological status pre and post reduction Joint stability post reduction and * MUST DOCUMENT IN CASE NOTE 43 Sec +e— Se 3. DIABETIC FOOT e Thorough history and physical examination e Local examination — both lower limbs Evaluation Of The Musculoskeletal Status Attitude & posture Deformities - Hammertoes / Bunions / Pesplanus or cavus / Charcot deformities / amputations / prominent metatarsal heads Limited ROM — active and passive TA contractures / equines / foot drop Gait evaluation Muscle group strength testing Plantar pressure assessment Evaluation Of The Skin & Nails Of The Foot Skin appearance: color, texture, turgor, quality, and ary skin Calluses, heel fissures, cracking of skin due to reduced sweating in autonomic neuropathy Nail appearance: Onychomycosis, dystrophic, atrophy: hypertrophy, paronychia Presence of hair Ulceration, gangrene, infection Interdigital lesions Tineapedis Evaluation of Vascular Status ofthe Foot & Leg Pulses (DPA, PTA, popliteal, femoral) CRT (normal <3 seconds) Venous filling time (normal <20 seconds) Presence of edema Temperature gradient Colour changes: Cyanosis, dependent rubor, erythema Changes of ischemia: Skin atrophy; nail atrophy, abnormal wrinkling, diminished pedal hair 44Doppler segmental artery pressures, Ankle-brachial indices (ABI) - easy way to determine foot blood flow but may be misleading due to calcification of the arteries giving rise to higher pressures at the ankle. Normal value 1.1, <0.9 abnormal. Toe pressure measurements — Less calcification in digital vessels enable toe pressures to be measured more accurately and be more reliable in the assessment of healing potential. In general, 85%-100% of foot lesions will heal when toe pressures are >40mmHg and less than 10% will heal if<20mmHg. Transcutaneous oxygen tension (TcPO2) — <10mmHg correlates with non-healing, >30mmHg correlates with healing. Measurements require an experienced technician and may vary depending on measurement site Tnerpeatin of ABI any aMehnepromare a igor am pressure st-130 Nomad 04-090 Midiomodeate peripheral Len any isertt-ano pressure es ‘arteial doease Higher am pressure 00040 Sever gehen areal soase Righarm {yet systte presare f syste pressure rgttanie [OP OP] Lenane syste pres |p pr so pressureee Evaluation Of Neurological Status * Vibration perception: Tuning fork 128 Hz Pressure & Touch: Cotton wool (light), Monofitam, (5.07) 10gm (Semmes Weinstein) ~ Pain: Pinprick, using sharp and blunt tool Two-point discrimination Temperature perception: hot and cold Deep tendon reflexes: ankle, knee Clonus testing Babinski test Romberg’s test Ulcer Examination * Location * Colour * Size = Odour = Depth = Base = Margins = Discharge = Swelling vi. Evaluation of Patient's Footwear * Type and condition of shoes / sandals "Fit Shoe wear, pattern of wear, lining wear Foreign bodies Insoles, orthoses vii. Investigations: FBS (4.1-5.9 mmol/L) * ESR * RBS (44-78 mmol/L) * BUSE, Creat * HbAIC (<6.0mmou) " Swabcas = FBC . Urine biochemEE Classification: Wagner's Classification Pre-ulcer. No open lesion. May have deformities, erythematous areas of pressure or hyperkeratosis lead to “ Foot at risk “ Superficial ulcer. Disruption of skin without penetration of subcutaneous fat layer. Full thickness ulcer. Penetrates through fat to tendon or joint capsule without deep abscess or osteomyelitis. Deep ulcer with abscess, osteomyelitis or joint sepsis. It includes deep plantar space infections, abscesses, necrotizing fascitis and tendon sheath infections. Gangrene of a geographical portion of the foot such as toes, forefoot or heel. Gangrene or necrosis of large portion of the foot requiring major limb amputation. University of Texas Diabetic Wound Classification A | No infection or ischemia B | Infection present ic Ischemia present D | Infection and ischemia present eo cnag (The inclusion of stage capsule | Wound penetrates to bone or joint 0 | Epithelialized wound makes this 1_| Superficial wound | classification a better 2 | Wound penetrates to tendon or | predictor of outcome) 3 Stage A Grade 2 47Principle of treatment « Debridement of necrotic tissue&Wound care e Reduction of plantar pressure (off-loading) e Treatment of infection e Medical management of co morbidities e Surgical management to reduce or remove bony prominences and / or improve soft tissue cover e Reduce risk of recurrence 4. OSTEOMYELITIS Acute OM - common organism Staph Aureus Chronic OM 2 Sequel of acute OM ¢ Secondary to open fracture / operation Common pathogen e Staph aureus *° e.coli © proteus ° s. Pyogenes ¢ pseudomonas Presentations e Pain and fever ° Tender, inffammed and edema e — Sinus tract ( chr OM) Investigations: * Raise total white, ESR & CRP °) Xray: © Lytic lesion surrounded by area of sclerosis o Sequestrum: devitalized bone © Involucrum: new bone formation around area of bony necrosis 48Management: e Analgesic e 1V drip - septicemia and fever can cause dehydration e IV Antibiotic : start after sample for culture taken o Start based on most likely organism suspected o Older children/ adult = Likely staph aureus = — Start iv cloxacillin and fusidic acid o Antibiotic should then base on organism specific after culture available o Antibiotic should be continue for at least 6/52 e Surgical intervention o Sequestrectomy and sinusectomy e ESR & CRP monitoring 5. PRE-OPERATIVE & POST-OPERATIVE CARE A. ANTIBIOTIC PROTOCOL TO OT 1. ARTHROPLASTY (THR/TKR) a. IV Ceftriaxone (Rocephine) 2gm for induction b. WW Ampicillin/ Clavulinic Acid (Augmentin) 1.2gm for irrigation 2. SPINE SURGERY a. INV Cefoperazone (Cefobid) 2gm for induction 3. TRAUMA / ELECTIVE OP (PLATE/ NAIL/WIRE) a. I/V Cefuroxime (Zinacef) 1.5gm for induction 4, EMERGENCY SURGERY a. No need antibiotic to OT if patient already on antibiotic OR «s b. As ordered by specialist / MO if necessary 49B. ARTHROPLASTY (THR/TKR) Pre-operative preparation e Examine for hip or knee range of motion e Routine blood investigation e Urine FEME & urine C&S e Trace OOPD notes and make sure all x-ray films available o Make sure implant payment settled (self-paying / SOCSO; TBP etc) o Company and system of arthroplasty e Patient visited GA clinic and passed for op o Look for any special order by anesthetist = GXM, Blood Ix 1/7 prior op Patient referred to dental clinic for dental clearance © Antibiotic prophylaxis to OT ° Rocephine 2g — given to patient after induction o Augmentin 1.2g - for irrigation Post-operative management THR ° Do post —op review as soon as patient arrive in the ward Monitor all the vital sign — BP, pulse, pain score Circulation of operated limb — pulse & CRT Looked for any bleeding - radivac, wound bandage Post-op Hemoglobin DO NOT ALLOW ADDUCTION -~ keep abduction pillow © Others: © Removed radivac if less than 30mV/shift or as ordered by surgeon © Check x-ray once off epidural / PCA = PELVIC — AP VIEW = RIGHT / LEFT HIP — LATERAL VIEW © Encourage patient to sit up and walking frame ambulation © Wound inspection on day 3 © Antibiotic for 5 days 00000| summeeenemeniiaiiiaeee TKR Do post —op review as soon as patient arrive in the ward co Monitor all the vital sign - BP, pulse, pain score co Circulation of operated limb — pulse & CRT o Looked for any bleeding - radivac, wound bandage o Post-op Hemoglobin Others: o Removed radivac if less than 30m\/shift or as ordered by surgeon o Off CBD o Start ankle pump exercise o Check x-ray once off epidural / PCA = Knee AP and Lateral view o Atnight — keep knee in extension (pillow under ANKLE) o Encourage patient to sit up at bed side and allow active flexion and extension co Encourage walking frame ambulation Wound inspection on day 3 and off antibiotic Cc. ARTHROSCOPY Preoperative preparation e Examine the knee e Routine blood investigation e Trace OOPD notes and make sure all x-ray films available © Make sure payment settled (self-paying | SOCSO/ TBP etc.) — if required e Patient visited GA clinic and passed for op © Look for any special order by anesthetist = GXM, Blood Ix 1/7 prior op e Antibiotic prophylaxis: co IN Cefuroxime (Zinacef) 1.5gm for induction 51Post-Operative management Do post-op review as soon as patient arrive in the ward o Monitor all the vital sign — BP, pulse, pain score © Circulation of operated limb — pulse & CRT o Post-op Hemoglobin Keep knee brace (locked at 0 degree) Start strengthening exercise on bed Refer sport team Wound inspection day 3ORTHOPEDIC EMERGENCY 1, OPEN FRACTURE Definition - a fracture with direct communication to the external environment Basic Principles of management: Fracture management begins after initial trauma survey and resuscitation is complete Antibiotics o Early IV antibiotic * Zinacef 1.59 stat then 750mg tds « Flagyl 500mg stat the tds co Tetanus prophylaxis Control bleeding o Don't blindly clamp or place tourniquets on damaged extremities Assessment - soft tissue damage Neurovascular examination Wound irrigation — Minimum 10L water Splint fracture for temporary stabilization asic Principles of Management in the Operating Room ° Aggressive debridement and irrigation o Low pressure lavage > effective in reducing bacterial counts than high pressure lavage o Saline most effective irrigating agent = On average, 3L of saline are used for each Gustilo type = Type I: 3L = Type Il: 6L. «Type Ill: 9L Bony fragments without soft tissue attachment can be removed 53e Fracture stabilization o Can be with internal or external fixation, as indicated e Early soft t's coverage / wound closure is ideal e Antibiotic treatment: © Farm injuries or possible bowel contamination * Add penicillin for anaerobic coverage (clostridium) o Duration * Initiate ASAP = Continue for 24 hours after initial injury if wound is able to be closed primarily "Continue until 24 hours after final closure if wound is not closed during initial surgical debridement Open Fracture Classification: GUSTILO CLASSIFICATION Open fracture with clean wound , wound < 1cm length " Open fracture with wound > 1 cm length without extensive soft tissue damage , flap , avulsion Open fracture with extensive soft tissue laceration, | damage or loss or an open segmental fracture. This type also includes open fracture caused by farm injuries, gunshot fracture. ila | Type Ill fracture with adequate periosteal coverage despite extensive soft tissue damage Type III fracture with periosteal stripping and bone MB exposure. Usually associated with massive Contamination .Will often need further soft tissue coverage eg : flap tic | Type Ill fracture associated with arterial injury requiring repair , irrespective of degree of soft tissue injury 54