Orthopaedics & Trauma

Orthopaedics Trauma

Overview of Paediatric Orthopaedics All bones/joints except skull & face

Orthopaedics & Trauma Spines

Upper Limb

Shoulder
Elbow
Hand

Sean Curry Lower Limb

Consultant Orthopaedic Surgeon Hip

Knee
Barts & The London Foot & Ankle

Paediatric Orthopaedics Developmental Dysplasia of the Hip

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

• 1:1000 births
• Disorders of Growth
• First born
• Gait Disorders QuickTime™ and a
TIFF (Uncompressed) decompressor

• Cerebral Palsy • Female are needed to see this picture.

• Clubfoot • Breech delivery

• DDH • Family History
• Perthe’s Disease QuickTime™ and a
TIFF (Uncompressed) decompressor
• SUFE are needed to see this picture.
Treatment: QuickTime™ and a
TIFF (Uncompressed) decompressor
•Non-Operative are needed to see this picture.

•Operative

Perthe’s Disease Slipped Upper Femoral Epiphysis

QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
• Idiopathic avascular necrosis • Commonest cause
• 4-10 years of hip pain QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

• M>F 4:1 adolescents

• Containment
QuickTime™ and a
TIFF (Uncompressed) decompressor
• M:F 2:1
are needed to see this picture.

• Pin in situ
• “What” test
QuickTime™ and a
TIFF (Uncompressed) decompressor
QuickTime™ and a are needed to see this picture.
TIFF (Uncompressed) decompressor
are needed to see this picture.
 Spines Orthopaedics: Joint Replacement
• Scoliosis QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
•Disc (Cervical & Lumbar)
• Degenerative spine disorders: •Shoulder
• Back Pain •Elbow
• Prolapsed disc •Hip
•Knee
• Spinal Stenosis •Ankle
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture. •MCP
MTP
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

Joint Instability Arthroscopic Surgery

QuickTime™ and a
• Shoulder TIFF (Uncompressed) decompressor
are needed to see this picture. • Stabilisation
• Knee • Ligament Reconstruction
• Ankle • Microfracture
• Arthroscopic Surgery • ACI

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

Student BMJ April 1999: Life

Nicola Goodchild, Final year medical student,
Charing Cross and Westminster Medical
School,
London
 GOALS OF FRACTURE
HOW FRACTURES HEAL
TREATMENT In nature
• Regeneration vs repair
• Three phases of healing by callus
• Restore the patient to optimal functional state • Rapid process, rehabilitation slow, low risk
With operative intervention (reduction + compression)
• Prevent fracture and soft-tissue complications • Primary bone healing
• Slow process, rehabilitation rapid, high risk

• Get the fracture to heal, and in a position which will With operative intervention (nailing or external fixation)
produce optimal functional recovery • Healing by callus
• Rapid process, rehabilitation rapid, lesser risk

• Rehabilitate the patient as early as possible

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 HIGH-ENERGY
• BS (scaphoid, talus, femoral and humeral head) INJURY
• NS
• No infection
– The patient
– The method of treatment

High Energy Injury

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

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

LOW ENERGY INJURY

DESCRIBING THE FRACTURE
– Mechanism of injury (traumatic, pathological, 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

MANAGEMENT OF THE INJURED

PATIENT
• Life saving measures
• Diagnose and treat life threatening injuries
COMMINUTED • Emergency orthopaedic involvement
– Life saving
PROXIMAL- – Complication saving
THIRD
FEMORAL – Emergency orthopaedic management (Day 1)
FRACTURE
WITH – Monitoring of fracture (Days to weeks)
SIGNIFICANT
– Rehabilitation + treatment of complications (weeks to
DISPLACEMENT months)

EMERGENCY ORTHOPAEDIC
LIFE SAVING MEASURES
MANAGEMENT
• Life saving measures
–A Airway and cervical spine immobilisation • Reducing a pelvic fracture in haemodynamically unstable patient
• Applying pressure to reduce haemorrhage from open fracture
–B Breathing
– Complication saving
• Early and complete diagnosis of the extent of injuries
–C Circulation (treatment and diagnosis of cause)
• Diagnosing and treating soft-tissue injuries

–D Disability (head injury)

–E Exposure (musculo-skeletal injury)

 DIAGNOSING THE SOFT TISSUE
INJURY
• Skin
• Open fractures, degloving injuries and ischaemic necrosis

• Muscles
• Crush and compartment syndromes

• Blood vessels
• Vasospasm and arterial laceration

• Nerves
• Neurapraxias, 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 TREATING THE FRACTURE I

– Does the fracture require reduction?
– Clinical assessment
• Is it displaced?
• History
• Co-morbidities • Does it need to be reduced? (e.g. clavicle, ribs, MT’s)
• Exposure/systematic examination

– How accurate a reduction do we need?

– “First-aid” reduction
• alignment without angulation (closed reduction - e.g. wrist)
– Splintage and analgesia • anatomic (open reduction - e.g. adult forearm )

– Radiographs
• Two planes including joints above and below area of injury
 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

INDICATIONS FOR OPERATIVE

TREATING THE FRACTURE III
TREATMENT
• General trend toward operative treatment last 30 yrs
Operative Non-Operative
• Improved implants and antibiotic prophylaxis, Use of closed and minimally
invasive methods

Rehabilitation Rapid Slow

Risk of joint stiffness Low Present • Current absolute indications:
Risk of malunion Low Present • Polytrauma Displaced intra-articular fractures
• Open #’s
Risk of non-union Present
• #’s with vascular injury or compartment syndrome,
Present
• Pathological #’s
Speed of healing Slow Rapid • Non-unions
Risk of infection Present Low
Cost ? ?
 INDICATIONS FOR OPERATIVE WHEN IS THE FRACTURE
TREATMENT HEALED?
• Current relative indications: • Clinically
• Loss of position with closed method
Upper limb Lower limb
• Poor functional result with non-anatomical reduction
Adult 6-8 weeks 12-16 weeks
• Displaced fractures with poor blood supply
Child 3-4 weeks 6-8 weeks
• Economic and medical indications

• Radiologically
• Bridging callus formation
• Remodelling

• Biomechanically

COMPLICATIONS OF
REHABILITATION
FRACTURES
• Restoring the patient as close to pre-injury functional Early Late
level as possible General Other injuries Chest infection
PE UTI
• May not be possible with:-
– Severe fractures or other injuries FES/ARDS Bed sores
– Frail, elderly patients Bone Infection Non-union
• Approach needs to be:- Malunion
• Pragmatic with realistic targets AVN
• Multidisciplinary
Soft-tissues Plaster sores Tendon rupture
– Physiotherapist, Occupational therapist, District nurse, GP, Social worker
Wound Infection Nerve
compression
N/V injury Volkmann contracture
Compartment syn

Colles’ Fracture
Hip Fractures

Intracapsu Extracapsu

Displaced Undisplac 1-4 Part

(Garden I Garden III
Intracapsular vs Extracapsular Spinal Fractures I

Spinal Fractures II
Thank You.