Mr Harry Krishnan MRCS MBBS BSc Hons Core Surgical Trainee St Marys Hospital London Classification of fractures Nature of injury Energy involved Universal communication Planning treatment ID: 1035769
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1. Orthopaedics for finals Part 1Mr Harry KrishnanMRCS, MBBS, BSc (Hons)Core Surgical TraineeSt Mary’s HospitalLondon
2. Classification of fracturesNature of injuryEnergy involvedUniversal communicationPlanning treatmentMonitor treatment modalities and outcomes
3. General classificationOpen or closed #Intra articular / extra articularDisplaced/ undisplacedTransverse # ( perpendicular to long axis of bone or oblique angle of < 30 degrees)Oblique # (oblique angle >30 degrees)Spiral # (line of # curves around the bone)Comminuted # (>2 fragments)Segmental #Pathological #Hairline/ avulsion #/ fatigue #
4. OTA Classification
5. Describing fracturesClinically : limb/ bone/ clinical deformity/ open or closedRadiographs: bone (right or left) location in bone (proximal/middle/distal third) pattern displaced/ undisplaced angulation/ tilt shortening intra/ extra articular
6. Description of fracturesDisplacement: cortical contact – is present if the ends of bone have shifted relative to one anotherDisplacement described in terms of distal fragment
7. DisplacementUndisplaced 50% displaced 100% displaced
8. Description of fracturesAngulation: described in terms of point of angle of the fracture (or the apex) classically.You will not fail finals for describing angulation of the distal fragmentTilt : direction of distal fragment
9. Angulation/ tiltMedial apex angulation Volar apex angulation/ Lateral tilt lateralmedialvolardorsalIt would be ok to say dorsal angulation of the distal fragmentIt would be ok to say lateral angulation of the distal fragment
10. Present this X ray
11. Summary of #Spiral # distal third left tibia50% lateral displacementLateral apex angulation of #Medial tilt of distal fragmentOrMedial angulation or varus angulation of distal fragmentShortMedialLateral
12. Treatment of fractures4 R ‘ sOpen fracture# NOFColles #Salter-Harris #
13. 4 RsResuscitate - ATLSReduce – Open / ClosedRestrict – Collar and cuff, braces, Plaster, Percutaneous k wires, internal fixation, external fixationRehabilitate – MDT (Physio/ OT/ Social services)
14. Restriction
15. RestrictionPlaster
16. RestrictionK wires
17. RestrictionInternal fixation – plates and screws
18. RestrictionInternal fixation – intramedullary nail
19. RestrictionExternal fixation
20. Complications of fracturesImmediate: Neurovascular injury Soft tissue injuryEarly: Compartment syndrome Fracture blisters Infection Embolus (fat/ DVT/ PE) Late: Delayed/ mal/ non union Post traumatic osteoarthritis Complex regional pain syndrome Growth arrest, Deformity, Joint stiffness, Myositis ossificans Chronic infection
21. Classification of hip fracturesIntracapsular – undisplaced displacedExtracapsular
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23. ManagementResuscitate appropriately (ATLS). Hx/ ExAssess neurovascular status of limbAnalgesiaiv access – fbc/ u+e/clotting/ group and saveECGAP pelvis/ lateral hip/ Chest X rayAdmitDVT prophylaxisInform seniorNot clear on X Ray – MRI pelvis
24. Intracapsular NOF#Main concern is risk of disruption of blood supply to the femoral head and subsequent avascular necrosis.Undisplaced: Blood supply okDisplaced: Blood supply potentially disrupted
25. Garden classification
26. Surgical managementOne - two screwThree – four Austin Moore
27. Surgical managementDisplaced NOF#< 55 Reduce and fix (screws/DHS)55-75 Total hip replacement75+ Hemiarthoplasty (walker - cemented Thompsons, non – mobiliser/serious co-morbidities uncemented Austin Moore)
28. Complications- Displaced NOF#Internal fixation – AVN 15 -33% Non-union 10 -30% Reoperation 10 -30%THR- Dislocation (10%).Hemiarthroplasty – Dislocation Anterior thigh pain (A-M uncemented prosthesis)
29. Quiz76 year old female. Hypertensive. Independent. Still exercises.
30. Quiz
31. QuizDiagnosisInitial managementDefinitive treatment
32. THR
33. Quiz36 year old female. Fall. Fit and well.
34. Quiz
35. QuizDiagnosisInitial managementDefinitive treatment
36. Cannulated screw fixation
37. Quiz93 years. Previous CVA. Arteriopath.
38. Quiz
39. QuizDiagnosisInitial managementDefinitive treatment.
40. DHS
41. Salter Harris classification#’s occurring in the skeletally immature around the growth plateSalter Harris classified I – VI: # through the physisII:# through physis and metaphysisIII: # through physis and epiphysisIV: # through metaphysis/ physis/ epiphysisV: Crush injury to the growth plate
42. Salter Harris classificationREFERENCE: E MEDICINE I II III IV V
43. Salter-Harris classificationSalter Harris IV
44. Salter-Harris classificationI-V indicates higher risk of growth plate injuryIII and IV require anatomic reductionV often diagnosed retrospectively – ie no obvious # initially seen and patient develops subsequent growth arrest in limb
45. Acute fracturesPeriarticular fracturesOpen fracturesSignificant soft tissue injuryBone lossPolytraumaOpen book pelvic fractures
46. ComplicationsNeurovascular injurySoft tissue injuryPin site infectionLoosening of pinsSeptic arthritis (if periarticular ex fix)OsteomyelitisPatient non-compliance
47. Colles fractureExtra articular # of the distal radius within 2.5 cm of the wrist joint with dorsal and radial displacementClinically dinner fork deformity
48. Colles fracture
49. Colles fracture X rayLoss of radial height (>5mm) Loss of radial inclination (Normal 20-25 degrees ) Dorsal tilt (Normal 10 degrees volar) Radial width Comminution Ulnar styloid fracture
50. Colles fractureReduction: haematoma block/ midazolam3 peopleCounter tractionIn line tractionDisimpact #Over exaggerate injuryUlnar + volar deviation
51. Colles fractureApply dorsal backslabAssess neurovascular status pre and post reductionRepeat x raySatisfactory position?No- ortho review – Consider MUA and K wiresYes- home c #clinic r/v next 48 hours for completion of POP.Review at 1 and 2/52 with X ray to ensure no displacement and POP for a total of 6/52 (follow up same for non-op and operative)
52. Smith’s fractureExtra-articular distal radius with volar displacementInherently unstable (v Colles)Closed reduction and POPHigh risk of displacement in plasterLower threshold for ORIF (open reduction and internal fixation) with volar plate.
53. Smith’s fracture- X Ray
54. Bartons fracturesDistal radial # intraarticularDorsal Barton’sVolar Bartons
55. Bartons fractures- X raysVolar Barton’s
56. Post ORIF Volar Barton’s
57. Ankle fracturesClassificationAnatomical – uni/ bi/ tri malleolarWeber – Relation of fibula # to joint line A: Below joint line B: Level of joint line C: Above level of joint line
58. Ankle fracturesRelevance of Weber B and C # is they represent possible injury to the syndesmotic ligaments between the tibia and fibula and thus potential instability
59. Ankle fractures – Uni malleolar
60. Ankle fractures – Weber C
61. Ankle fractures- Weber C
62. TreatmentResuscitateReduce RestrictRehabilitate
63. TreatmentWeber A: Non-operative. Boot or below knee POP 4-6/52 WeightbearingUndisplaced Weber B/C: Non-operative. Below knee POP 6/52 Non-weightbearing (NWB)Displaced Weber B/C: Non-operative – closed reduction and POP if anatomical reduction achievedOperative if closed reduction fails – ORIF( open reduction and internal fixation)Below knee POP 6/52 (NWB)
64. Scaphoid fracturesMajor source of medico-legal claimsAlways suspect scaphoid fracture following fall onto handLook for tenderness in anatomical snuffboxDocument presence/ absence of scaphoid tenderness
65. Scaphoid fracturesX rays: scaphoid viewsA normal x ray does not exclude a scaphoid #If clinically tender treat for scaphoid #Backslab and # clinic review next 48 hours for completion of cast.Re X ray at 2 weeks or urgent CT/MRI
66. Scaphoid fractures
67. Scaphoid fractures
68. TreatmentConcerned about non-union and avascular necrosis with displaced scaphoid fracturesUndisplaced – Colles/ Scaphoid POP 6-8/52Displaced – ORIF with screw.
69. Open fractures
70. Open fracturesATLS primary and secondary surveyAnalgesiaAssess NV status of limbAntibioticsAnti tetanusAn image (photo)Antiseptic dressingAn X rayAsk for helpTheatre – wound debridement and skeletal stabilisation
71. Indications for external fixationTemporary treatment of acute fractureDefinitive treatment of acute fractureComplications of fracturesDeformity correction (congenital/acquired)
72. Types of external fixatorMonolateralCircular
73. Compartment syndromeLimbs are divided into osteofascial compartments by thick fascial bandsA condition where the pressure within an enclosed anatomical compartment rises sufficiently to obstruct the micro-vascular circulation causing tissue ischemia and, if left untreated, necrosis
74. AetiologySevere trauma (>85%) usually associated with fractures, dislocations or crush injuries. Can occur in both open and closed injuries. Externally applied pressure (dressings, POP etc) Muscle trauma Vascular injury and reperfusion injury Prolonged increase in exercise intensity (e.g. military recruits)
75. DiagnosisClinical features Pain - most important. Especially pain out of proportion to the injury The 6 p’s of an acutely ischaemic limb appear very late and we should not wait for these (except pain)
76. SignsMost reliable signs are Pain on passive stretching of the involved compartmentPain on palpation of the involved compartment and Sensory deficit in the distribution of any sensory nerve traversing the involved compartment.
77. DiagnosisClinicalPressure monitoringIf clinically high suspicion of compartment syndrome don’t delay treatment to measure intracompartmental pressure.
78. TreatmentRelease external pressure – split plaster and underlying bandaging to skinElevate leg to level of heartDO NOT worry about losing the reduction, amputation would be a far worse complicationIf no rapid relief – ASK FOR HELPNeed fasciotomy in theatre
79. Septic arthritisInfected jointPresentation: Painful, hot swollen, joint. Unable to move. Unwell. Fevers.Recent history of concurrent infection, local traumaCo-morbidities: Diabetes. Drugs: Imunosuppressed.
80. Septic arthritisFBC/ CRP/ ESR/ Blood culturesCan aspirate joint if superficial landmarks (knee/ shoulder/ ankle)U/S guided hipSend for urgent gram stain as well as MC and SUltimately needs washout (open/ arthroscopic)
81. Septic arthritisAt washout send fluid/ tissue for MC+SDiscuss with microbiology
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90. Questions ?