Introduction

Orthopaedics is
concerned with bones,
joints, muscles, tendons
and nerves – the
skeletal system and all
that makes it move
Introduction
Scope : Subdivision :
• Congenital & developmental • Traumatology
abnormalities
• Infection & inflammation • Orthopaedi :
• Arthritis & rheumatic 1. Adult Reconstruction
disorders 2. Oncology Orthopaedic
• Metabolic & endocrine
disorders 3. Pediatric Orthopaedic
• Tumours 4. Spine
• Sensory disturbance & 5. Hand & Microsurgery
muscle weakness
6. Sport Injury
• Injury & mechanical
derangement 7. Foot and Ankle
Introduction
Steps in orthopaedic diagnosis:
1. History taking
2. Physical Examination
* Posture
* Gait
1. Inspection
2. Palpation
3. Examination of movements
4. Conduction of special tests
3. Further investigations
1. Examination of radiographs
2. Examination of blood, sinovial fluid, etc
Inspection
• Is there swelling?
• Is there bruising?
• Is there any discoloration, or edema?
• Is there muscle wasting?
• Is there any alteration in shape or posture,
or is there evidence of shortening?
Inspection
Palpation
• Is the joint warm?
• Is there tenderness?
• How is the artery
pulse?
Movements
• Active ROM
• Passive ROM
• Fixed deformities
• Restriction of ROM
• Movements in abnormal plane
• Crepitus
• Strength of muscle contraction
• Gait
Movements
Conduction of Special Test
• Integrity of certain
joint ligaments
• Examination of
structures associated
with the joint
• Appropriate
neurological
examination
Examination of Radiographs
• Soft tissue
• Bone : shape, size, contour
• Alignment
Examination of Radiographs
• Comparison films
• Oblique projections
• Localized views
• Stress films
Arranging Further Investigations
• ESR, CRP
• Full blood count with differential
• Estimation of RF
• Serum calcium, phosphate & AP
• Serum Uric Acid
• Chest X-Ray
Equipment Requirements
• A tape measure
• A goniometer
• A tendon hammer
• A disposable sharp point
WHAT IS POLYTRAUMA ?
 Objectives
Establish the principles for assessing the
patient with musculoskeletal injuries.
Establish treatment priorities.
Identify the importance of musculoskeletal
injuries in the multiply injured patient.
Emergency in Orthopaedic
• Emergency : trauma cases
- Life threatening
- Limb treatening
• 85 % of blunt trauma affect
musculoskeletal system
• Life saving before limb
saving
Key Questions
• How do musculoskeletal injuries
impact on the primary survey?
• What are my priorities?
• What are my management principles?
Assessment of the Polytrauma Patient
Primary Survey
– A irway with cervical spine control
– B reathing
– C irculation with control of hemorrage
– D isability (neurological state)
– E xposure (take the patient clothes off)
 Primary survey management

The 3 S’s
Stop the bleeding!
Splint the extremity
Stabilize the pelvis
Primary Survey & Resuscitation

 Recognize and control hemorrhage

• Direct pressure
• Splint fractures
• Fluid resuscitation
BE AWARE OF REPERFUSION
INJURY!
Primary Survey & Resuscitation

Adjuncts : Fracture immobilization

 Goals

• Hemorrhage control
• Pain relief
• Prevent further soft tissue injury
 Apply splint early, but avoid delay in

resuscitation.
 Be careful in dislocation
Primary Survey & Resuscitation
Adjuncts : X-Rays
 Determinited by patient’s condition

 Obtain AP pelvis early if hemodynamically

abnormal and no obvious source of

bleeding
Secondary Survey
• History
AMPLE

• From Head to toe examination

• Every orifice must be examined
• Don’t forget the back!
Secondary Survey

Look
Feel
Listen
For What?
 For What?
Look Feel
 Deformity  Crepitus
 Pain  Skin flaps
 Tenderness  Neurologic
 Wound(s) deficit
 Pulses

Listen
Doppler signals
Bruit
Life- Threatening Injuries
 Major pelvic disruption with hemorrhage
 Major arterial hemorrhage
 Crush syndrome (rhabdomyolysis)
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
• Posterior pelvic structures disrupted
• Pelvis open : vessels, nerves,rectum, skin
• Mechanism of injury
– Motorcycle
– Pedestrian
– Crush
– Falls > 12 feet (3.6 meters)
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
Life Threatening
Musculoskeletal Trauma
Pelvic Trauma with Massive Bleeding
 Pelvic
Wrapping
Life Threatening
Musculoskeletal Trauma
Main Arterial Rupture
1. Trauma
- sharp, blunt
2 Examination
- Artery pulse, Doppler
- Ankle / brachial index
3. Management
- Pneumatic tourniquet
- Vascular clamp?
- Traction, Splint
Life Threatening
Musculoskeletal Trauma
Crush Syndrome
 Myoglobinuria
 Metabolic acidosis, ↑K,
↓Ca and coagulopathy
 Compartment syndrome
 IV fluids, alkalization of
urine
Limb- Threatening Injuries
 Open fracture and joint injuries
 Vascular injuries
 Compartment syndrome
 Neurologic injury
 What are my early concerns?

Vascular compromise
Open fractures
Limb Threatening
Musculoskeletal Trauma
Open Fractures

Apply appropriate splint

Cleanse / debride (now or later)
Consider time factor
Obtain orthopaedic consult
Limb Threatening
Musculoskeletal Trauma
Open Fractures

Classifying the injury

Gustilo’s classification (Gustilo et al, 1990)
Open Fracture grade 1
Open Fracture grade 2
Open Fracture grade 3A
Open Fracture grade 3B
Open Fracture
grade 3C
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
• Objectives :
- Prevention of infection
(sepsis/osteomyelitis)
- Promote bone healing
- Restoration of function
Limb Threatening
Musculoskeletal Trauma
Open Fractures
Principles of treatment
• 4 essentials are :
1. Wound irrigation & debridement
2. Antibiotic prophylaxis
3. Stabilization of the fractures
4. Early wound coverage
Open Fracture
Complicated case
Not proper initial management
Limb Threatening
Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

Reduce fracture(s)
Splint fracture(s)
Assess by Doppler
Obtain consult (time
is critical)
Consider
angiography
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation
Limb Threatening Musculoskeletal Trauma
Vascular Trauma & Traumatic Amputation

Management
• Muscle necrosis : 6 h
• Warm & Cold Ischemic
• Reimplatantation &
Revascularization
• Proper amputee
management!
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
• Fractures of the arm or leg  ischemia
• Infarcted muscles  fibrous tissue
(Volkmann’s ischemic contracture)
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome
Clinical features
• Elbow, forearm bones, 1/3
prox. of tibiae, multiple
fractures of the foot or
hand, crush injuries &
circumferential burns
• Five Ps
• The presence of a pulse
does not exclude the
diagnosis
• Be careful in unconscious
patient !
Limb Threatening
Musculoskeletal Trauma
Compartement Syndrome

Treatment
• Decompression
• Open fasciotomi
Limb Threatening
Musculoskeletal Trauma
Dislocations
• Displacement of bone from normal joint

• Location : hip, shoulder, elbow, finger,

patella, knee, ankle, acromioclavicular

• Sign : loss of normal shape &

loss of movement
Posterior Hip Dislocation
Neurologic Injury
 Due to fracture /dislocation
• Posterior shoulder : Axillary nerve
• Posterior hip : Sciatic nerve
 Recognize injury and immobilize
 Early orthopaedic consult
 Careful reduction, if possible →
reassess and splint
Limb Threatening
Musculoskeletal Trauma
Massive skin avulsion
Abdominal flap following
skin avulsion of the hand
Limb Threatening Musculoskeletal Trauma
Massive skin avulsion
‘Kelirumologi’ in Fracture
Management
Pitfalls

 Occult injuries
 Occult blood loss
 Compartment syndrome
Case 1 : Male, 40 y.o
ICD 9-CM 79.63, 93.44
Question
Summary
 Primary Survey : Identify life-threatening
Injuries
 Secondary Survey : Identify limb-
threatening injuries
 Mechanism of Injuries : History important
 Orthopaedic consult
 Early immobilization