th March 1 LO please insert relevant Learning objective reference here 2 Topics to be covered today Management of specific fractures lecture Injuries and management tutorial Childrens ID: 930505
Download Presentation The PPT/PDF document "Zain Ahmad BRS2: MSK 1 Thursday 10" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Zain Ahmad
BRS2: MSK 1
Thursday 10th March
1
Slide2LO: please insert relevant Learning objective reference here
2
Topics to be covered today
Management of specific fractures
(lecture)
Injuries and management
(tutorial)
Children’s
orthopaedics
(lecture)
Back pain
(lecture)
Back anatomy and management of slipped disc (tutorial)
How to treat common MSK conditions
(summary lecture)
Slide31. Management of specific fractures & injuries and management
3
Slide4Roles:
Support
Protection
Locomotion
Haematopoesis
Lipid and mineral storage
LO: please insert relevant Learning objective
4
Bone: function and types
Types:
Internal organ protection
- skull
- sternum
- scapula
Support/facilitate movement
- humerus
- radius
- ulna
Variable structure/shape - vertebrae - sacrum - pelvis
Stability/movement, width = length, diaphysis - carpals - metatarsals
Within tendons – stress/wear protection
- patella
Slide5Bone anatomy
LO: please insert relevant Learning objective reference here
5
E
M
D
Slide6Woven (primary) bone
First type of bone to be formed – embryonically and in fracture healing
Consists of osteoid, randomly arranged collagen fibres Temporary, unmineralised structure replaced by mature lamellar bone
Weaker and more flexible
Lamellar (secondary) bone
Bone of adult skeleton
Highly
organised
sheets of
mineralised
osteoid – hence stronger and less flexible than woven bone
Categorised
into compact (cortical) and spongy (cancellous) bone
LO: please insert relevant Learning objective
6
Microscopic bone structure
Slide7Location: periosteum,
diaphyses of long bones Structure:Structural unit of bone = osteon/Haversian system
(lamellae)Haversian/central canal runs vertically through osteon centreHaversian canals connected by perpendicular Volkmann’s canals
Osteocytes
located between lamellae within
lacunae –
interconnected by
canaliculi
LO: please insert relevant Learning objective
7
Macroscopic bone structure: cortical (compact) bone
Slide8Location: epiphysis
Structure:Osteocytes and lacunae found in trabeculae Irregular crosslinking of trabeculae forms porous yet strong bone – resistant against multidirectional lines of force
Honeycombed appearanceRed bone marrow – site of haematopoesis
LO: please insert relevant Learning objective
8
Macroscopic bone structure: spongy (cancellous) bone
Slide9LO: please insert relevant Learning objective reference here
9
Bone components I
Bone ECM (
osteoid
) provides biomechanical and structural support, containing:
Collagen – Types I (90%) and V: flexibility
Mineral salts – calcium hydroxyapatite: hardness and strength
Calcification – mineral salts interpose between collagen
fibres
Slide10Osteoblasts:
Synthesise uncalcified ECM (osteoid) Growing portions of bone: periosteum, endosteum Osteocytes:
Formed from osteoid mineralisation Regulation of bone mass Osteoclasts: Resorb cells: release H+ ions, lysosomal enzymes
Osteoprogenitor cells:
Undifferentiated stem cells
LO: please insert relevant Learning objective
10
Bone components II: cells
Slide11Formation of bone directly onto fibrous connective tissue
Involved in formation of flat bones of skull, mandible and clavicles
Provides width to bones
LO: please insert relevant Learning objective
11
Bone ossification: intramembranous
Slide12LO: please insert relevant Learning objective reference here
12
Bone ossification: endochondral
Formation of bone from temporary hyaline cartilage scaffold
Involved in formation of ALL bones (except for flat bones of skull, mandible, clavicles)
Provides length to bones
Slide13Bone removal = osteoclasts
Metabolism: removal of bone = increased Ca Bone production = osteoblastsReceptors from PTH, prostaglandins, vit D and cytokines – activate, allow for bone matrix synthesis
‘Drilling’ through old bone
LO: please insert relevant Learning objective reference here
13
Bone
remodelling
Slide14Decrease in bone density, reducing structural integrity
Osteoclast > osteoblast activity
Increased risk of fragility fracture Three types:Postmenopausal
Senile
Secondary
Diagnosis confirmed on DEXA scan
LO: please insert relevant Learning objective reference here
14
Clinical relevance: osteoporosis
Slide15Vit D/Ca deficiency
Osteoid mineralises poorly; remains flexible Adults =
osteomalacia – increased fracture risk Children = rickets – epiphyseal growth plates become distorted under body weight
LO: please insert relevant Learning objective reference here
15
Clinical relevance: rickets/
osteomalacia
Slide16Abnormal collagen synthesis
Symptoms:Increased fragility of boneBone deformitiesBlue sclera
Rare, autosomal dominant inheritance
LO: please insert relevant Learning objective reference here
16
Clinical relevance: osteogenesis imperfecta
Slide17Fractures are deformities of bone
Defining and classifying fractures
LO: please insert relevant Learning objective reference here
17
Slide18Intramembranous healing, occurs via Haversian
remodelling
Slow process Requires little (< 500 mm) or no gap between site of fracture, i.e., for undisplaced
, closed fractures
NO fracture callus formed
LO: please insert relevant Learning objective reference here
18
Primary (direct) bone healing
Slide19Secondary (indirect) bone healing
LO: please insert relevant Learning objective reference here
19
Endochondral healing with callus formation
Slide20LO: please insert relevant Learning objective reference here
20
Fracture healing: requirements and timeframe
Required for healing:
Minimal fracture gap
No movement if direct (primary) healing
Some movement if indirect (secondary) healing
Patient’s physiological state: nutrition, growth factors, age, smoking/ diabetes status
Fracture healing in circa 6 months, BUT:
Lower limb fractures = 2 x slower healing.
Paediatric
fractures = 2 x faster healing
Slide21Non-union: failure of bone healing within expected timeframe
Atrophic = healing stopped, minimal callus formation, vascular/lifestyle causes
Hypertrophic = too much movement, callus formation Malunion: bone healing occurs outside normal parameters of alignment
LO: please insert relevant Learning objective reference here
21
Fracture healing: complications
Slide22LO: please insert relevant Learning objective reference here
22
Principles of fracture management and techniques
Don’t forget the 4 Rs
Resuscitate, reduce, rest, rehabilitate (VTE prophylaxis)!
Slide23LO: please insert relevant Learning objective reference here
23
Systemic approach to
orthopaedic
X-ray interpretation
Projection
Patient details
Technical adequacy
Obvious abnormalities
Systematic X-ray review
Summarise
findings
Slide24What cell type is responsible for coordinating resorption and growth in bone?
A) Osteoblast
B) Osteon C) Osteocyte
D) Osteoblast
E) Osteoid
LO: please insert relevant Learning objective
24
SBA 1
Slide25What cell type is responsible for coordinating resorption and growth in bone?
A) Osteoblast
B) Osteon C) Osteocyte
D) Osteoblast
E) Osteoid
LO: please insert relevant Learning objective
25
SBA 1
Slide26Presentation
Variable Hx, often direct trauma Pain Restricted movement Loss of normal shoulder shape
Clinical examination Assess neurovascular status – axillary nerve (‘regimental badge’)
Types of dislocation
Anterior –
bimodal distribution
Posterior – seizures/shock association
Inferior – arm abducted above head
Management
Traction-counter traction +/- gentle internal rotation
or Stimson method if alone
Relax patient with Entonox/benzos
LO: please insert relevant Learning objective
26
Shoulder dislocations
Complications: neurovascular, damage to labrum/glenoid, humeral head or recurrent dislocations
Slide27Shoulder dislocation X-rays
LO: please insert relevant Learning objective reference here
27
Slide28Presentation
Fall onto outstretched hand Typically, in elderly/osteoporotic patients Investigations
Plain X-rays CT if concern over articular involvement/ highly comminuted Classification: surgical neck (2 parts), avulsion fracture of greater tuberosity (2 parts), comminuted (3 parts)
Management
Collar and cuff
2-part fracture, minimally displaced
High surgical risk
ORIF – plate and screws
Any fracture with displacement – 2+ parts but not highly comminuted
Arthroplasty
Humeral head fracture with large displacement; non-union risk
(Reverse arthroplasty – unrepairable rotator cuff, chronic dislocation,
prev
failed replacement)
LO: please insert relevant Learning objective
28
Proximal humerus fracture
Slide29LO: please insert relevant Learning objective reference here
29
Proximal humerus fracture X-rays
Slide30Presentation
Very common, bimodal distribution Present with clear mechanism of falling onto affected area, swelling and visible deformity Commonest presentation = dorsal displacement due to FOOSH
Investigations Plain X-rays – PA/lateral viewsThorough clinical exam to avoid concomitant injuries
Classification
Extra-articular (not within joint line) or intra-articular
Dorsal or volar angulation
Management
Cast/splint – temp treatment for ANY distal radius fracture, BUT definitive if minimally displaced, extra-articular
MUA + K-wire – extra-articular with instability
ORIF – for displaced, unstable fractures not for MUA/K-wire, OR intra-articular
LO: please insert relevant Learning objective
30
Distal radius fracture
Slide31LO: please insert relevant Learning objective reference here
31
Distal radius fracture X-rays
Slide328 carpal bones in wrist:
First row (lateral to medial)\
Scaphoid Lunate
Triquetrum
Pisiform
Second row (lateral to medial)
Trapezium
Trapezoid
Capitate
Hamate
LO: please insert relevant Learning objective reference here
32
Carpal bones
Slide33Presentation
Commonest carpal bone injury, usually young patients Typically, fall backwards onto hand
Clinical examination and investigations Suspect in anyone with FOOSH/distal radius fractureRequest scaphoid views on X-rayDelayed X-ray if normal but clinical suspicion Consider MRI/CT if still concerned
Management
Displaced fractures
Retrograde blood supply means high risk of non-union (compromised blood supply)
Most displaced fractures disrupt vascularity, therefore ORIF undertaken
Undisplaced
fracture
Treated conservatively in scaphoid cast
Long healing time - ? Surgical fixation
LO: please insert relevant Learning objective
33
Scaphoid fracture
Slide34Presentation
Usually, high energy trauma involved Unstable – lots of visceral organs/vasculature adherent to pelvis
Examination ABCDE – including perineal/urethral openingPV/PR exams – visceral damage/bleeding Investigations – plain X-rays, urethrogram, CT +/- angiography
Management
Manage
hypovolaemia
– IV access + resus
Consider pelvic binders as tamponade device; ongoing bleed –
embolisation
Restore pelvic ring and alignment of sacroiliac joints
Internal fixation with plate/screws
External fixation if unstable and unsuitable for surgery
LO: please insert relevant Learning objective
34
Pelvic fracture
Slide35LO: please insert relevant Learning objective
35
Pelvic fracture X-rays
Slide36History/presentation
Common in eldery – pathological fracture due to osteoporosis or minimal traumaRare in young – high energy major trauma
May report groin, thigh, buttock pain Preceding: ? MI, TIA/stroke, seizure Examination and investigations MSK – look, feel, move + top-toe exam for other injuries
X-rays, CT
Management
Pre op
Follow pre-op guidelines: rule out other pathology, pain relief,
catheterise
, bloods, ECG, fluids…
Post-op
Physiotherapy
OT/PT
MDT
LO: please insert relevant Learning objective
36
Proximal femur fracture aka hip/neck of femur fracture
Slide37LO: please insert relevant Learning objective
37
Proximal femur fractures: classification and management
Slide38During an intense game of football, Bill is tackled to the ground and falls awkwardly on his right hand, resulting in immediate pain and swelling.
On admission to ED, the following X-ray is obtained. What is best treatment here?
LO: please insert relevant Learning objective
38
VSAQ 1
Slide392. Children’s
orthopaedics
39
Slide40LO: please insert relevant Learning objective reference here
40
Child vs adult skeletons
Differing in:
Elasticity
Physes
Speed of healing
Remodelling
Slide41Children’s bones can bend – more elastic than in adults
Increased Haversian canal density in more metabolically active bone = increased vascularity
Implications: Plastic deformity – bone bends before breaking Buckle/torus fracture – in FOOSH, ‘buckling in’ on itself on ONE side
Greenstick – bone bends and cracks, instead of breaking into separate pieces
LO: please insert relevant Learning objective reference here
41
Elasticity
Slide42Physes
(physeal plate) in kids’ skeleton – sites of secondary ossification facilitating bone lengthening
Growth occurs at varying rates at different sites Growth ceases when physes closeClosure of physes dependent on puberty, menarche, parental height
Complete in girls at 15-16, boys 18-19
Traumatic
physes
injury (Salter Harris) – premature growth arrest – deformities
LO: please insert relevant Learning objective reference here
42
Physes
Slide43Younger children heal more quickly AND have greater
remodelling potentialUpper limb extremes – shoulder and wrist – have most potential
Lower limb – greatest healing around the knee (distal femur and proximal tibia)
LO: please insert relevant Learning objective reference here
43
Speed of healing and
remodelling
Slide44Definition: neonatal hip disorders where
head of femur is unstable/incongruous in relation to acetabulum Aetiology
:‘Packaging disorder’ – occurs in utero Normal development relies on concentric reduction and balanced forces through hip If hip sits outsides acetabulum both can’t develop properly Dyplasia
– subluxation – dislocation
Risk factors: female (6:1), first born, breech,
FHx
Examination: baby check screening
Limitation in hip abduction
Leg length discrepancy
Investigations measuring acetabular dysplasia/hip position:
Birth – 4 months = ultrasound
Post 4 months = X-ray
Treatment: reducible hip, < 6 months –
Pavlik harness;
failed Pavlik or 6-18 months – MUA + closed reduction + Spica
LO: please insert relevant Learning objective44Developmental dysplasia of hip
Slide45LO: please insert relevant Learning objective
45
Developmental dysplasia of hip
Slide46Definition: Congenital equinovarus deformity – feet are rotated inwards and downwards
Aetiology: genetic (PITX1 gene) – 25% familial
Risk factors: FHx, males (2:1), smoking pregnancy, lack of amniotic fluid
Presentation:
Top of foot twisted down and in, increasing arch and turning heel inwards
Shorter leg/foot and underdeveloped calves
Treatment:
Ponseti
Method
Gentle manipulation and stretching of foot followed by cast – repeated process
Minor surgery to loosen Achilles tendon
LO: please insert relevant Learning objective
46
Congenital talipes equinovarus aka clubfoot
Slide47Most common skeletal dysplasia!
Aetiology: autosomal dominant inheritance of gene mutation
Pathyphysiology: Inhibition of chondrocyte proliferation in proliferation zone of physis (secondary) Resulting defect in endochondral bone formation
Normal cognition; spinal issues arise
LO: please insert relevant Learning objective
47
Achondroplasia
Presentation:
Rhizomelic
dwarfism
Humerus
shorter than
foreaem
Femur shorter than tibia
Normal trunk
Adult height = 125 cm
Slide48LO: please insert relevant Learning objective
48
Fracture anatomy
Slide49Type 1-5:
Physeal separation
Traverses physis, exits metaphysisTraverses physis, exists epiphysis
Traverses epiphysis, metaphysis and physis
Crushing
physeal
injury
LO: please insert relevant Learning objective
49
Salter-Harris classification of
physeal
injuries
Slide50Physis injury can lead to growth arrest in kids
Location and timing key Whole physis affected – limb length discrepancyPartial injury – angulation as non affected side keeps growing
Treatment aims: correct deformity
Minimise
angular deformity
Minimise
limb length difference
LO: please insert relevant Learning objective
50
Growth arrest and its treatment
Slide51REDUCTION
Open – incision, realignment Closed – traction, manipulationRESTRICTION Stability
PlastersSplints
LO: please insert relevant Learning objective
51
Fracture management algorithm in kids
REHAB
Quick rehab
Encourage play – movement and strengthening
Slide52ALWAYS EXCLUDE
SEPTIC ARTHRITIS – EMERGENCY! Irreversible long-term joint problems Surgical washout of joint to clear infection
Kocher’s classification of probabilityHistory!
Transient synovitis
Joint inflammation post systemic illness
Supportive treatment with Abx
Perthes disease
Idiopathic necrosis of proximal femoral epiphysis
Supportive treatment
SUFE – slipped upper femoral epiphysis
Proximal epiphysis slips in relation to metaphysis
Treatment: operative fixation with screw
LO: please insert relevant Learning objective
52
Differentials for the limping child
Slide53The parents of Emily, a 5-month-old girl born via breech, have brought her to clinic as they notice her ‘left hip doesn’t move normally’.
What investigations would you like to order and what is first line treatment here?
LO: please insert relevant Learning objective
53
VSAQ 2
Slide543. Back pain
54
Slide55Non-specific low back pain:
Pain not due to any specific or underlying disease that can be found Mechanical low back pain: Pain after abnormal stress and strain on vertebral column E.g. car accident, poor-technique heavy lifting
Nerve root pain (sciatica)CSI case
Pain radiating to lower limbs with or without neuralgic symptoms
Irritation, compression, inflammation of sciatic nerve
LO: please insert relevant Learning objective
55
Some definitions
Slide56MECHANICAL
(90%) Disc degeneration – age Disc herniation Annular tearsFacet joint osteoarthritis
Instability
Tumours
, including myeloma, breast, prostate
Infection – e.g. TB of spine,
prev
ops
Spondyloarthropathy – e.g. ankylosing spondylitis
Pars interarticularis injury – repetitive action stress fracture
Compression fracture – elderly (osteoporosis) or trauma in youth
Visceral – referred from another region,
e.g
pancreatitis
LO: please insert relevant Learning objective
56
Causes of low back pain
Slide57TAKEAWAYS:
Don’t offer imaging generally with/without sciatica
ONLY image if will change management If doubt over treatment -> MRI
MRI is gold standard investigation
Secondary: X-rays, CT scans
LO: please insert relevant Learning objective
57
Back pain imaging
Slide58SIGNS
Can localize neurological deficit to one causative nerve root (sciatic nerve made of 5 nerve roots) Straight Leg Raise (SLR) test positive – Laseuge sign – more pain on straightening
SYMPTOMS
Unilateral leg, back pain
Pain may radiate to feet or toes
Numbness and
paraethsesia
in same distribution
Loss of bowel and bladder control (? cauda equina)
LO: please insert relevant Learning objective
58
Red flags signs and symptoms of sciatica
Slide59LOW BACK PAIN
Weight loss – ? CancerNight pain Under 19 years
– urgent MRI needed Fever - ? Infective process
LEG PAIN
Bowel or bladder dysfunction – incontinence
Saddle
anaethesia
Profound neurological deficit
CAUDA EQUINA SYNDROME – urgent MRI required
LO: please insert relevant Learning objective
59
Red flags for low back pain and leg pain
Slide60LO: please insert relevant Learning objective reference here
60
Treatments for low back pain
CONSERVATIVE
Analgesia
– regular paracetamol
Anti-inflammatory drugs
– e.g. ibuprofen
Manipulation
– chiropractors, osteopaths, physios (effective)
Acupuncture
– pain relief
Massage
Takes time!
Spontaneous recovery
Facet injections
Root block Epidural injectionsNeurostimulation SURGICAL Nerve root decompression, spinal stenosis decompression, disc replacement, fusion
Slide61James is a 23-year-old fast bowler who has presented at the end of the long season with lower back pain and stiffness that worsens while playing and improves with rest. He has been bowling fast for much of his life.
Given his history, what is the underlying cause of his back pain?
Pars interarticularis fracture
Compression fracture
Ankylosing spondylitis
Visceral
Tumour
LO: please insert relevant Learning objective
61
SBA 2
Slide62James is a 23-year-old fast bowler who has presented at the end of the long season with lower back pain and stiffness that worsens while playing and improves with rest. He has been bowling fast for much of his life.
Given his history, what is the underlying cause of his back pain?
Pars interarticularis fracture
Compression fracture
Ankylosing spondylitis
Visceral
Tumour
LO: please insert relevant Learning objective
62
SBA 2
Slide634. Common MSK conditions’ management
63
Slide64LO: please insert relevant Learning objective reference here
64
Bone fracture mechanisms
Slide65LO: please insert relevant Learning objective reference here
65
Final recap: fracture management pathway
Slide66LO: please insert relevant Learning objective reference here
66
Final recap: fracture management pathway
Slide67LO: please insert relevant Learning objective reference here
67
What are the clinical signs of a fracture?
Pain
Swelling
Crepitus – joint popping/clicking/crackling sound
Deformity
Adjacent structural injury: nerves, vessels, ligaments, tendons
Slide68LO: please insert relevant Learning objective reference here
68
Fracture complications
Visceral, nerve, vascular injuries
Prolonged immobility – UTI, chest infection, pressure sores
Fat embolus
DVT – prolonged bed rest
PE
Infection/sepsis
Delayed/mal/non-union
Slide69LO:
Distinguish the phases of the cardiac cycle, the corresponding pressure changes, valve openings and closures.
69
What we’ve covered today...
Fractures + management
Back pain
Children’s orthopaedics
Management of common MSK conditions
Slide70Any questions?
70
Slide7171
Next Tutorial
Pharmacology
Shehzar
(Pharmacology BSc)
Tuesday, 15
th
March, 6-8 pm
Microsoft Teams
Slide7272
Feedback
Please leave feedback by filling out this very short survey!
http://tiny.cc/tutorialfeedback