CMED 322 [ORTHOPEDICS: TRAUMA]

Lecturer Dr. Gatchalian Transcriber/s Liza Torrico II Date March 11, 2019

CONTENT
 Scope of Orthopedics
 Trauma Conditions in Orthopaedics
- Fractures/dislocations
 Long bone fractures
 Pelvis
 Pediatric
 Fracture Healing
 Rehabilitation

SCOPE OF ORTHOPEDICS
 Musculoskeletal Disorders  Displacement
- Orthopaedic (Greek)  Location within the Bone
 Orthos – straight  Bone involved
 Pais – child
 Nicolas Andry: “ to teach the different methods of preventing and A. Fracture Diagnosis
correcting deformities of children”  History
 Subject Matter: Injuries, diseases and deformities of bones and - Details of the injury/accident
joints and related structures – muscles, tendons, nerves, vessels. - Severity/ type of forces involved
 American Academy of Orthopedic Surgeons: “Orthopaedic - Age of patient
Surgery is the medical specialty that includes the investigation, - Time and place of injury
preservation, and restoration of the form and function of the - Pain and deformity
extremities, spine and associated structures by medical, surgical and
physical methods.”
 Pre-requisites
- Anatomy
- Physiology Figure 3.
- Biochemistry Severity/Type of
- Pharmacology Forces Involved.
- Biomechanics
- Physics
- Metallurgy
- Physical Therapy
- Neuroscience
- General Surgical Principles

FRACTURE
 Definition
 Physical Examination
 A fracture is a soft tissue injury complicated by a break in the
bone  Severely injured
 Respiratory difficulty
 Description
 Acute hemorrhage
 Open vs. Closed
 Shock
 Stable patient
 Detailed PE
 Open wounds
 Tenderness
 Sensory/Motor Testing
 Focused PE of injured area
 Basic extremity deformities
 Angulation
 Shortening
 Rotation
 Suspected fracture
 Evaluation of Vascular and Neurologic
Status of Extremity
 Complete vs. Incomplete  Compartment Syndrome
 Configuration  Imaging Techniques
 Transverse  Roentgenogram
 Oblique  Computed Tomography Scan
 Spiral  Magnetic Resonance Imaging
 Comminuted  Ultrasonography

*Legend: Additional notes – color RED “I can do all things through Christ who strengthens me”. Ph. 4:13 | Page 1 of 6
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Figure 7: Casting.
Figure 4&5. Basic Extremity Deformities.

B. Principles of Fracture Treatment

 PROPER DIAGNOSIS  PROPER TREATMENT
 Optimum treatment
 Patient’s general condition Figure 8: Traction pins.
 Associated injuries
 Open vs. Closed fracture
 Location and Displacement
 Basic Objectives
 Reduction  near anatomic
 Maintenance of reduction
 Preservation and restoration of function
 Reduction
 Anesthesia needed
 Because it is PAINFUL
 Need to counter-act strong muscle forces
 Manipulation
 Longitudinal traction
 Angulation
 Manual Pressure
 Traction
 Applied over a period of hours to days
 Open Surgery and MIS
 Conservative methods ineffective
 Contemplation of internal fixation
 Maintenance of Reduction
 After reduction, the corrected alignment must be
maintained until bone healing
 Common Methods
 Cast/Splints/Braces
 Traction Pins Figure 9: Fracture Treatment by Reduction.
 External Fixations
 Internal Fixations
 Wires
 Screws
 Plates
Figure 10: Internal Fixation.
 Nails
 Combinations

Figure 6: Splint.

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C. Clinical Example  FAST

 25/M  Radiographs: CXR, Cervical Spine, Pelvis, L thigh AP-L
 CC: L leg pain and deformity  Other Pertinent Info
 DOI: 2-28-2017  Patient is a call center agent
 TOI (Time of Injury): 10:30am  Breadwinner
 POI (Place of Injury): Nuvali Solenad, SR-Tag hiway  Married to a housewife
 MOI (Mode of Injury): Patient was on his motorcycle and lost  2 y.o. Child
control while navigating a curve in the road. L leg was pinned  Smoker: 10 sticks/day x 5yrs
under his motorcycle  Occl ROH drinker (2x/mo)
 Immediately brought to hospital  APE: E/N
 Physical Exam  No previous hospitalizations
 Awake, coherent, GCS 15  No FMHx: HPN, DM
 Stretcher borne  Results
 Not in cardiorespiratory distress  Hg 126
 BP 120/70 HR 90 RR 25  Hct 0.45
 Temp: 37.6 VAS 10/10  WBC: 11.0
 E/N systemic Physical Exam  Seg: 82
 Minor Abrasions on L torso, leg and Thigh  Lym: 18
 Gross deformity of L thigh  CXR: E/N (-) rib fractures
 Focused PE L lower extremity  Cervical Spine: (-) fx/disloc
 (+) Angular deformity of L thigh  Pelvis (-) fx/disloc
 (+) Externally rotated L leg/foot  FAST: (-) fluid
 (+) Hematoma and Swelling  L Thigh AP-Lat:
 (+) Direct tenderness and abnormal movement  two perpendicular views
 (+) LLD: 2cm shortening  proximal and distal joints
 (+) pulses: DP/PT (++) equal to contralateral extremity  Oblique fracture diaphysis of femur
 (-) Motor/Sensory deficits  2.5cm overriding
 Pertinent Negatives  15o Varus angulation
 (-) pelvic rock/pelvic pain  Slight external rotation
 (-) cervical/neck pain  No cortical contact
 (-) upper extremity findings
 (-) maxillofacial injuries SPECIAL CONDITIONS
 (-) back injuries A. Open Fractures
 (-) hematoma  What’s the Fuss?
 (-) contusions  They are contaminated.
 (-) tenderness  Infection  Osteomyelitis
 (-) chest/abdominal tenderness  Foreign material
 WORKING DIAGNOSIS: Fracture of the Femur  Dirt, grease, etc.
 Associated with more soft tissue damage
 Skin  periosteum
 Fracture edges may lacerate adjacent structures/
vessels
 Gustillo-Anderson Classification (Check Table 1&2 and
Figure 18)
 Cognitive Learning Theory
 Jean Piaget – cognitive development
 Sensorimotor stage- birth to 2 y/o
- Object permanence
 Preoperational – 2-7 y/o
- Symbolic thinking
 Concrete operations – 7-11 y/o
- Logical thinking; conservation of mass/weight/
number
 Formal operations – 11- end of adolescence
- Analytical thinking
 Patient put on NPO
 Venoclisis B. Fractures in Children
 1L D5 Lactated Ringers Solution  Why are they special AGAIN?
 40mg Parecoxib IV  Tendency for faster healing
 50mg Tamadol IV  Remodeling
 Thomas Splint Applied  Non-union is rare
 Laboratories  Epiphyseal plates still open
 CBC and Blood Typing  Salter Harris Classification
 Urinalysis  Greenstick and Torus fractures are peculiar to children

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 Incomplete fracture
 Angular/Compression deformity
 Periosteum
 THICK and ACTIVE
 Wolff’s Law: Remodeling
 Overgrowth sometimes occur

FRACTURE HEALING
 Stages of Fracture Healing
1. Hematoma Formation – inflammatory stage
2. Soft Callus Formation
A B
3. Hard callus / Osteogenesis
4. Remodeling
Figure 13-15.
A. Delayed Union.
B. Non-union.
C. Malunion.

C
Figure 12. Stages of Fracture Healing.
 Shortening
 Deviation from NORMAL COURSE: (Poor fracture healing)
 More a problem in lower limbs
a. Delayed Union
 Overriding or severe comminution
- Fx healing abnormally slow
 Accommodated by shoe lift
- Causes:
 Inaccurate reduction  Osteotomies and limb lengthening procedures
 Inadequate immobilization
 Severe local trauma
- Poor soft tissue coverage
- Vascular insufficiency
- Loss of bone substance
 Infection
 Distraction/separation of fracture ends
 Patient factors

b. Non-Union
- Fx does not unite
- Process of fracture healing ceased without fracture uniting
- Etiology
 Extensive Soft tissue damage  Rotation
 Impaired Blood supply  Distal fragment heals in external or internal rotation with
 Infection respect to the proximal fragment.
- Types:  Metacarpal rotational malunion
 Atrophic  Scissoring of fingers
 Hypertrophic  Hip fracture rotational malunion
 Pseudoarthrosis  Abnormal gait
 Forearm rotational malunion
c. Malunion  Restricted pronation/supination
- Fx heals in unsatisfactory alignment
- Union of fracture but in poor position.
- Etiology
 Poor reduction
 Poor immobilization
- Types
 Shortening
 Rotation
 Angulation

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 Angulation
- Abnormal stress on adjacent joints
- Vector change in pull of muscles
 Hip fracture in varus
- Valgus knee forces
 Elbow fracture
- Valgus or varus deformity
 Colles’ Fracture
- Silver-fork deformity
- Possible CTS
- Decrease grip strength

HOW TO NAME A LONG BONE FRACTURE

Figure 18. Gustillo-Anderson Classification.
 Open vs Closed
 Complete vs Incomplete
 Configuration
- Transverse
- Oblique
- Spiral
- Comminuted
- Segmental
- Greenstick/Torus (pediatric)
 Displacement
 Location within the bone
 Bone involved
 Laterality
 Example: Fracture: Closed, complete, transverse, displaced, distal
third, radius, Left

END

Table 2. Expanded version of Gustillo-Anderson Classification.

Table 1. Gustillo-Anderson Classification.

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Table 3&4. OTA/AO Classification (above) and Arbeitsgemeinschaft für Osteosynthesefragen (below)

*Legend: Additional notes – color RED “I can do all things through Christ who strengthens me”. Ph. 4:13 | Page 6 of 6