Handbook Of Orthopaedic Traumatology

HANDBOOK OF ORTHOPAEDIC TRAUMATOLOGY DEPARTMENT OF ORTHOPAEDICS AND TRAUMATOLOGY QUEEN MARY HOSPITAL

Content Trauma Fracture Principles of management of fractures----------------1 Comprehensive classification of long bone fractures 2 Principles of management of multiple trauma 6 patients Acromioclavicular joint dislocation-------------------9 Fracture of clavicle--------------------------------------19 Fracture of scapula--------------------------------------31 Fracture of proximal humerus-------------------------41 Fracture of humeral shaft-------------------------------47 Supracondylar fracture of humerus--------------------- 49 Fracture of distal humerus------------------------------- 57 Fracture of capitellum------------------------------------ 63 Fracture of radial head----------------------------------67 Olecranon fracture--------------------------------------71 Fracture of shaft of radius and 77 ulna--------------------Galeazzi fracture------------------------------------------ 78 Monteggia fracture--------------------------------------79 Fracture of pelvis----------------------------------------81 Fracture of acetabulum---------------------------------- 101 Fracture of proximal femur------------------------------ 113 i

Fracture of femoral neck--------------------------------- 116 Intertrochanteric fracture of femur--------------------- 121 Subtrochanteric fracture of femur---------------------Fracture of femoral shaft--------------------------------Supracondylar fracture of femur-----------------------Fracture of patella---------------------------------------Fracture of tibial plateau--------------------------------Fracture of proximal and distal tibia-------------------Fracture of tibial shaft-----------------------------------Pilon fracture---------------------------------------------Malleolar fracture---------------------------------------Fracture calcaneum--------------------------------------Dislocation Principle of management of dislocation--------------Shoulder dislocation------------------------------------Hip dislocation--------------------------------------------

ii

125 129 131 137 145 161 165 169 173 181 191 193 201

Surgical site infection (SSI) ----------------------------

Hand Guidelines for hand

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cases-------------------------------Compound hand fractures------------------------------Phalangeal fractures-------------------------------------Fracture of distal radius---------------------------------Acute tendon injuries-------------------------------------

223 225 227 239

Others Compartment syndrome--------------------------------Necrotizing fasciitis--------------------------------------

250 253

Procedure Principles of closed reduction--------------------------Principles of plaster technique-------------------------Intravenous regional block-----------------------------Tourniquet usage----------------------------------------Halo traction----------------------------------------------

255 256 259 261 263

Some useful classification Gustilo and Anderson classification for open fracture Tscherne and Gotzen classification for soft tissue injury------------------------------------------------------Injury Severity Score------------------------------------Hospital Trauma Index (Extremity Injury)-----------Mangled extremity severity score (MESS) ----------iii

Drugs Recommended pre-operative antibiotic prophylaxisUse of methypredinisolone in traumatic acute spinal cord compression----------------------------------------Drugs for CR under sedation---------------------------Telephone directory------------------------------------

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269 271 272 273 iv

277 281 281 282

PRINCIPLES OF MANAGEMENT OF FRACTURES • Closed vs open # • Assessment • site of # (e.g. humerus, radius; intra-articular vs extra-articular) • Type of fracture (e.g. spiral vs transverse; simple vs comminuted) • Associated neurovascular injury • Other concommitant injury • Treatment 1. Reduction if necessary 2. Immobilization if necessary 3. Rehabilitation always

Principle of fracture management

1

COMPREHENSIVE CLASSIFICATION OF LONG BONE FRACTURE (Muller, 1990)

Diaphyseal Fracture Type

Metaphyseal / Diaphyseal segment

A: B: C:

Comprehensive classification of fracture

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3

Simple Wedge (2 main fragments still in direct contact) Comminuted (no direct contact between 2 main fragments)

Comprehensive classification of fracture

Metaphyseal Fracture

A: B: C:

Comprehensive classification of fracture

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5

Extra-articular Partial articular (part of the articular surface is still in continuity with the metaphysis) Complete articular (no continuity between metaphysis and articular surface)

Comprehensive classification of fracture

PRINCIPLES OF MANAGEMENT OF PATIENTS WITH SEVERE AND MULTIPLE TRAUMA Triage • sort patients with acute life threatening injuries and complications from those whose life are not in danger 1. level of consciousness 2. Abnormal breathing / breathing difficulties 3. Signs of shock Priorities 1. Support life (eg. CPR, fluid resuscitation) 2. Locate and control bleeding 3. Prevent brainstem compression and spinal cord damage 4. Diagnose, evaluate and treat all other injuries and complications Basic Management Principles 1. Emergency assessment A--Airway obstruction (eg. noisy breathing, respiratory distress) B--Breathing difficulty (eg. tachypnoea, mental confusion, cyanosis, abnormal pattern of breathing) C--Circulatory shock (eg. cold periphery, delayed capillary refill, low BP, rapid weak pulse) 2. Fluid resuscitation • If necessary, 2 or 3 large 14- or 16-gauge intravenous cannula inserted 3. Oxygen therapy

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Principle of management of multiple trauma

• 4. 5. 6. •

High flow oxygen by mask ventilatory support Cross-match blood Analgesia Urine output monitoring Foley unless suspected rupture urethra(eg. blood at urinary meatus, severe fractured pelvis) 7. Evaluation of other injuries Evaluation of injuries 1. Head Injury • Glascow Coma scale and Neuro-observation q1h • Inspect for presence of CSF and/or blood in ears and nose • SXR (3 views) +/- CT Brain 2. Facial Injury • Exclude bleeding into airway and severe oro-pharyngeal edema (eg. from caustic burn), which may lead to airway obstruction • SMV and OMV view 3. Suspected spinal injury • Immobilize until exclusion • signs of spinal cord injury (eg. paralysis, diaphragmatic breathing, loss of vasomotor tone, lax anal tone) • Cervical spine fracture or dislocation need to be excluded in all patients with head injury (Xray cervical spine AP and lateral; lateral Xray must include C7 / T1 junction)

Principle of management of multiple trauma

7

4. Chest • Look for haemothorax, pneumothorax, lung contusion, flail chest • Clinical signs + CXR 5. Abdomen • Rupture viscera (eg. spleen, liver, mensenteries) haemoperitoneum and peritoneal sign for rupture bowel • Retroperitoneal haemorrhage (eg,. in # pelvis) • Renal injury with retroperitoneal haemorrhage, leading to haematuria and loin pain • Clinical signs + AXR (E & S) 6. Pelvis # • Stability of Pelvis • Look for suspected ruptured bladder and urethral bleeding • Clinical signs + XR pelvis (AP + inlet view + outlet view) 7. Extremities • eg. long bone fracture, associated nerve or arterial damage

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Principle of management of multiple trauma

ACROMIOCLAVICULAR JONT DISLOCATION (C. Rockwook, Fractures in Adults, 4th ed., 1342-1413, 1996) Anatomy

Mechanism of Injury

1. Direct force—patient falling onto the point of shoulder with the arm at the side in an adducted position 2. Indirect force—fall on outstretched hand Classification (Rockwood) Type I

• • • •

Sprain of AC ligament ACJ intact CC ligament intact Deltoid and trapezoid muscle intact

•

Stabilizer 1. Acromioclavicular ligament 2. Coracoclavicular ligament–conoid part and trapezoid part 3. Dynamic stabilizer—deltoid (anterior part) and trapezius (upper portion)

•

Coracoclavicular interspace—1.1 to 1.3cm (Bearden, 1973)

•

Acromioclavicular ligament—horizontal (anteroposterior) stability of ACJ

•

Coracoclavicular ligament—vertical stability of ACJ

Acromioclavicular joint dislocation

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Acromioclavicular joint dislocation

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Type III Type II

• • • • •

ACJ disrupted ACJ wider: may be a slight vertical separation when compared with the normal shoulder Sprain of CC ligament CC interspace might be slightly increased

• • • • •

Deltoid and trapezius muscles intact

AC ligaments disrupted ACJ dislocated and the shoulder complex displaced infreriorly CC ligaments disrupted CC interspace 25% to 100% greater than the normal shoulder Deltoid nad trapezius muscles usually detached from the distal end of the clavicle

Type II Variants 1. “Pseudodislocation” through intact periosteal sleeve 2. Physeal injury 3. Coracoid process fracture

Acromioclavicular joint dislocation

17

Acromioclavicular joint dislocation

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Type IV • AC ligaments disrupted • ACJ dislocated and clavicle anatomically displaced posteriorly into or through the trapezius muscle • CC ligaments completely disrupted • CC space may be displaced, but may appear same as the normal shoulder • Deltoid an trapezius muscles detached from the distal clavicle

Acromioclavicular joint dislocation

17

Type V • AC ligaments disrupted • CC ligaments disrupted • ACJ dislocated and grossly disparity between the clavicle and the scapula (i.e. 100% to 300% greater than the normal shoulder) • Deltoid and trapezius muscles detached from the distal half of the clavicle

Acromioclavicular joint dislocation

18

• • • •

•

Type VI AC ligaments disrupted CC ligaments disrupted in subcoracoid type and intact in subacromial type ACJ dislocated and clavicle displaced inferior to the acromion or coracoid process CC interspace reversed in the subcoracoid type (i.e. clavicle inferior to the coracoid), or decreased in the subacromial type (i.e. clavicle inferior to the acromion) Deltoid and trapezius muscles detached from the distal clavicle

Acromioclavicular joint dislocation

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Radiographical Assessment 1. Xray both ACJ (AP) 2. Zanca view—100 to 150 cephalic tilt

Acromioclavicular joint dislocation

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•

• •

3. Axillary lateral view 4. AP stress film To 15 pounds are suspended from each arm with wrist wrap

Treatment 1. Non-operative treatment • Rockwood 1 and 2 (minimally displaced) • Arm sling x2./52; then, early and gradual rehabilitation • Heavy lifting or contact sports avoided for 8 to 12 weeks 2. Operative treatment • Rockwood 3 to 6 • ACJ debridement • 6MM transacromial K-wires • repair of CC ligament + Tevedek reinforcement o Rehabilitation—pendulum exercise x 6/52; then, r/o K-wires at 6/52

5. Lateral stress film (Alexander view) Patient is positioned as if a true scapulolateral radiograph is taken Patient is asked to thrust both shoulder forward

Acromioclavicular joint dislocation

6. Stryker notch view • demonstrate fracture base of coracoid

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Acromioclavicular joint dislocation

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FRACTURE CLAVICLE Anatomy

Fracture clavicle

ALLAM CLASSIFICATION GROUP 1 • middle third clavicular fracture • 80/5 of all clavicular fracture • Proximal fragment: pulled superiorly and posteriorly by sternocleidomastoid • Distal fragment: drops forward as a result of gravity and pull of pectoralis

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Fracture clavicle

GROUUP II • distal third clavicular fracture • 12% to 15 % of clavicular fracture • sub classified according to the location of coracoclavicular ligaments relative to the fracture fragments Neers Classification (Type I to Type III) Type I • most common • Interligamentous fracture • occurring between the conoid and trapezoid / the coracoclavicular and acromioclavicular ligament • minimal displacement

Type II Coracoclavicular ligaments are detached from the medial/proximal segment Proximal fragment: no ligamentous attachment Distal fragment: retained ligamentous attachment Type IIA • Both conoid and trapezoid remain intact on the distal fragment • Proximal fragment: no ligamentous attachment

Type IIB • Conoid ligament ruptured while trapezoid ligament remains attached to the distal fragment (i.e. Distal fragment: partial ligamentous attachment) • Proximal fragment: no ligamentous attachment • Thus, displacement is similar to Allam Group I fracture

Fracture clavicle

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Fracture clavicle

• •

i.e. proximal fragment: pulled superiorly and posteriorly distal fragment: droops forward

Type IV (Craig) • Occur in children <16 years old • “pseudodislocation” of ACJ • Proximal fragment: ruptures through the thin periosteum, may be displaced upward by muscular forces • Coracoclavicular ligaments remain attached to the periosteum or are avulsed with a small piece of bone • Clinically and radiologically not distinguishable from Grade III ACJ separation and Type II# distal clavicle

Type III Involve the articular surface of ACJ • No ligamentous injury • No displacement • Present with late degenerative arthrosis of ACJ •

Fracture clavicle

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Fracture clavicle

Type V (Craig) • Comminution • Neither the proximal nor distal fragments has functional coracoclavicular ligament • Coracoclavicular ligament are intact and remain attached to a small, third comminuted intermediate segment • Displacement same as Group 1 # and Type II # distal clavicle • More unstable than type II # distal clavicle GROUP III # medial third of clavicle • 5 % to 6% of clavicular fracture • Craig: subdivided according to the integrity of ligamentous structures • Type I: minimal displacement • Type II: significant displacement (ligaments ruptured) • Type III: intra-articular (sterno-clavicular joint) • Type IV: epiphyseal separation (children and young adult) • Type V: comminuted •

Mechanism of Injury 1. Direct blow to shoulder 2. Fall on outstretched hand

5Fracture clavicle

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Associated Injury 1. Associated skeletal injuries • Fracture dislocations of sternoclavicular or acromioclavicular joints • Head and neck injuries • Fractures of first rib (ipsilateral and contralateral) • Floating shoulder (fracture of the clavicle and scapula) • Rockwood • Treatment directed primarily at stabilization of clavicle • For # scapula, conservative treatment unless grossly displaced intra-articular or fracture of glenoid fossae 2. Pneumothorax 3. Brachial plexus injury • Considerable trauma • Force usually come from above downward or from the front downward • Traction injury • Direct injury ( with lesion directly by bone fragments)(in direct injury, ulnar nerve is usually involved) 4. Vascular injury • Unusual • Major trauma required • Potential vascular injury: laceration, occlusion, spasm, acute compression Most common vessels injured: subclavian artery subclavian vein, internal jugular vein

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Fracture clavicle

On admission, House Officer must examine 1. significant skin impingement 2. neurological deficit 3. vascular status (e.g. radial pulse, capillary refill) 4. whether breath sound is symmetrical bilaterally

Treatment Conservative Treatment 1. Figure of eight bandage

X-ray 1. X-ray clavicle (AP) 2. X-ray clavicle: 450 cephalic view Treatment • Conservative vs operative • Non-union: failure to show clinical or radiographic progression of healing at 4 –6 months • Conservative treatment: non-union: 0.1% • Operative treatment: non-union: 4.4% Predisposing factors to non-union 1. Inadequate immobilization 2. Severity of trauma (with associated soft tissue damage) 3. Re-fracture 4. Distal third fracture 5. Marked displacement 6. Primary open reduction

5Fracture clavicle

Principles of non-operative treatment 1. Brace the shoulder girdle to raise the outer fragment upward, outward and backward 2. Depress the inner fragment 3. Maintain reduction 4. Enable ipsilateral elbow and hands to be used

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2. • •

Arm sling (if patient cannot tolerated figure of eight bandage) Immobilization should be continued until union is complete Usual healing period of # of middle third of clavicle (Rowe) Infants: 2 weeks Children: 3 weeks Young adults: 4 to 6 weeks Old adults: >6 weeks

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Fracture clavicle

Operative Treatment (if) 1. skin impingement 2. open # 3. neurovascular compromise 4. bilateral fracture clavicle 5. floating shoulder 6. multiple fracture 7. non-union 8. cosmesis Treatment – ORIF (PC Fix/3.5mm reconstruction plate)

5Fracture clavicle

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Fracture clavicle

Posterior surface of scapula

FRACTURE OF SCAPULA (K.P. Butters, Fractures in Adults, 4th ed., 1996) Anatomy Anterior surface of scapula

Fracture scapula

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Fracture scapula

Fractures 1. Body and spine 2. Glenoid neck 3. Intra-articular glenoid 4. Coracoid 5. Acromion Mechanism of Injury 1. Indirect injury • through axial loading on outstretched arm (fracture scapula neck) 2. Direct injury • From a blow or fall (# body) (often high energy trauma) • Direct trauma to the point of shoulder (# acromion and coracoid) 3. Shoulder dislocation • # glenoid 4. Traction injury • avulsion # Associated Injury ( occur in 35% to 98% of patients with scapular #) 1. Pneumothorax (11% - 38%) (Delayed in onset from 1 to 3 days) 2. Ipsilateral fractured ribs (27% to 54%) 3. Pulmonary contusion (11% to 54%) 4. # clavicle (23% to 39%) (associated with # glenoid or glenoid neck)

Fracture scapula

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Fracture scapula

5. Brachial plexus injury (5% to 13%) (usually supraclavicular type) 6. Arterial injury (11%) 7. Skull # (24%) 8. Closed head injuries (20%) 9. Fracture of thoracic spine, cervical spine, lumbar spine

Glenoid Neck # (extra-articular) 1. Stable # • isolated glenoid neck # • conservative treatment

Xray Assessment 1. True AP view of shoulder 2. Transcapular view 3. Axillary lateral view　how acromial and glenoid rim # 4. Stryker notch view or cephalic tilt view--show coracoid fracture

2. Unstable # • # glenoid neck associated with # clavicle or disruption of coracoclavicular ligament • ORIF of # clavicle

Scapular body and spine # • examine for associated injury • conservative treatmenty with arm sling for comfort and early mobilization exercise

Fracture scapula

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Fracture scapula

Type I # • fracture of glenoid rim • > 25 % of intra-articular involvement • If displaced, predispose to instability of gleno-humeral joint 1. Type IA • anterior type • ORIF 2. Type IB • posterior type • uncommon

Intra-articular Glenoid Fracture Ideberg Classification (Ideberg, Acta Orthop. Scand., 58:191-192, 1987)

Type II # • transverse or oblique fracture through the glenoid with inferior glenoid as a free fragment • humeral head may subluxate inferiorly • If humeral subluxate ORIF Type III # • upper third of glenoid and includes coracoid process • often accompanied by # acromion or clavicle or acromioclavicular separation • (Gross, 1995) If intra-articular step > 5mm, ORIF

Fracture scapula

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Fracture scapula

radiologically (AP shoulder) a normal and symmetric coracoclavicular distance suspect # coracoid (base or through an epiphyseal line) • Stryker notch view • if # coracoid process + ACJ separation ORIF

Type IV # • horizontal glenoid # extending all the way through the body to the vertebral border • if displaced, ORIF Type V # • type II + type IV • If humeral head is well centred conservative treatment Type VI # • badly comminuted # • conservative treatment with early motion Acromion # • usually minimal displacement • DDx--os acromiale 1. If undisplaced • conservative treatment 2. If displaced with subacromial space and upward movement of humeral head • investigate rotator cuff lesion Coracoid # • may occur with acromioclavicular dislocation with coracoclavicular ligaments intact • clinical evidence of third degree acromioclavicular separation with a high-riding clavicle BUT

Fracture scapula

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Fracture scapula

FRACTURE OF PROXIMAL HUMERUS (J. Schatzker, The Rationale of Operative Fracture Care, 2nd ed., 1995, 51-82) Anatomy Four major fragments 1. Humeral head superior to anatomical neck 2. Lesser tuberosity 3. Greater tuberosity 4. Shaft of humerus

Unstable Fracture • movement between the shaft and head fragments • resulted from tension or shear force

Stable vs Unstable Fracture Stable Fracture • Impacted fracture • Shaft and head moves as one piece • resulted from compression force

Fracture proximal humerus

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Fracture proximal humerus

CLASSIFICATION OF FRACTURE TYPE 1. Stable Fracture 2. Unstable Fracture A. Minimally displaced (i. No segment displaced > 10 mm) (ii.No segment angulated > 45 ) B Displaced (C.S. Neer, JBJS, 52A: 1077-1089) 1. Two-part a. Lesser tuberosity b. Greater tuberosity c. Surgical neck d. Anatomical neck 2. Three-part--Surgical Neck a. Plus Lesser tuberosity b. Plus Greater tuberosity 3. Four-part--Anatomical Neck Plus tuberosities 4. Fracture-dislocation a. Two-part--with greater tuberosity b. Three-part--Anterior, with greater tuberosity Posterior, with lesser tuberosity c. Four-part—Anterior & Posterior 3. Articular a. Head impaction—(Hill Sachs) b. Articular fractures 1. Humeral head split 2. Glenoid rim

Fracture proximal humerus

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Fracture proximal humerus

TREATMENT 1. Stable Fracture • Early motion 2. Unstable, Minimally displaced Fracture • Collar and cuff x 3 weeks • then mobilization 3. 2-Part # (Displaced Unstable Fracture Surgical Neck, Displaced Greater Tuberoisty) & 3-Part # • CR + Percutaneous K-wire • If fail, OR + suture / wire 4. Fracture Anatomical Neck / Head Split / 4-Part # • Neer’s Hemiarthroplasty

Fracture proximal humerus

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Fracture proximal humerus

FRACTURE OF THE HUMERAL SHAFT • most fractures can be treated successfully by closed method Acceptable alignment 1. < 20 angulation 2. > 50% bony overlap To assess • Neurological function (esp. radial nerve) • Vascular condition FRACTURES WITH ACCEPTABLE ALIGNMENT • U-slab x 3 weeks; then, functional brace • Check Xray humerus (AP + lat) after application of U-stab FRACTURES WITH UNACCEPTABLE ALIGNMENT • Attempt CR under sedation • U-slab x 3 weeks • Check for function of radial nerve after CR • Post-reduction Xray humerus to confirm alignment

Fracture shaft of humerus

47

FRACTURES REQUIRING OPERATIVE INTERVENTION 1. Fracture with unacceptable alignment despite repeated CR (either due to failure to obtain a satisfactory reduction or failure to maintain reduction) 2. Open fracture 3. Comminuted / unstable fracture 4. Multiple fractures 5. Pathological fracture 6. Nerve palsy after manipulation 7. Humeral fracture with asssociated vascular lesion METHOD OF FIXATION 1. Proximal and Middle 1/3 • Retrograde AO unreamed humeral nail 2. Distal 1/3 • ORIF (plating) 3. Open # • AO nail / External fixator

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Fracture shaft of humerus

SUPRACONDYLAR FRACTURE OF HUMERUS (J. Schaztker, The Rationale of Operative Fracture Treatment, 2nd ed., 1995, 103-111) Anatomy

Supracondylar fracture of humerus

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1. Articular Surface • Capitellum • covered by articular cartilage on its anterior and inferior surface (not posterior) • articulate with radial head • Elbow in flexion: radial head articulate with anterior surface of capitellum • Elbow in extension: radial head articulates with inferior surface of capitellum • Trochlea • covered completely with articular cartilage • articulates with the trochlear notch of ulna • Elbow in Flexion • trochlear notch of ulna articulate with the anterior aspect of trochlea • coronoid process of ulna rests in coronoid fossa of humerus • radial head rests in radial fossa of humerus • Elbow in Extension • ulna articulates with inferior and posterior aspect of trochlea • tip of olecranon lodges within the olecranon fossa of humerus • Trochlea: corresponds the physiological valgus tendency of elbow in full extension (ie. Carrying angle, 170 )

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Supracondylar fracture of humerus

2. At the level of olecranon fossa, the two columns of bone on either side of the fossa bone for fixation of implants 3. Longitudinal axis of lateral condyle makes a 60 angle with the longitudinal axis of the shaft reconstruction plate applied to the level of lateral condyle must be bend to angle forward • Otherwise, extension deformity of distal fragment will result CLASSIFICATION Riseborough and Radin Classification (E.J. Riseborough and EL Radin, JBJS, 51A:130-141) Type I Non-displaced fracture between capitellum and trochlea

Type III Separation of the fragments with rotational deformity

Type IV Severe comminution of the articular surface with wide separation of the humeral condyles

Type II Separation of capitellum and trochlea without appreciable rotation of the fragments in frontal plane

Supracondylar fracture of humerus

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Supracondylar fracture of humerus

Comprehensive Classification

Mechanism of Injury • fall on the point of elbow P/E 1. Closed vs Open 2. Associated vascular injury (Feel for radial pulse) 3. Associated compartment syndrome 4. Associated neurological complications 5. Associated fracture of humerus or radius and ulna 6. Concomitant injury Aim of treatment 1. Accurate anatomical reduction of joint surfaces 2. Stable internal fixation 3. Early active motion Recommended Treatment 1. Undisplaced Conservative 2. Displaced and intra-articular ORIF (+ olecranon osteotomy if intraarticular)

Supracondylar fracture of humerus

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Supracondylar fracture of humerus

Immediate management 1. Exclude need for emergency operation (eg. open #, associated vascular injury) 2. Long arm backslab for temporary immobilization 3. Elevation Factors which influence success of surgical treatment 1. Patient’s age and degree of osteoporosis 2. Type of # 3. Degree of displacement 4. Degree of joint comminution 5. Whether trochlea can be reconstructed 6. If trochlea can be reconstructed ORIF 7. If trochlea is beyond surgical reconstruction conservative treatment (traction with early mobilization); or total elbow replacement (in active elderly patients) Rehabilitation 1. CPM 2. Indomethacin x 1/12 3. Hinged elbow brace

Supracondylar fracture of humerus

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Supracondylar fracture of humerus

FRACTURE OF DISTAL END OF HUMERUS Anatomy

FRACTURE OF EPICONDYLE (J. Schaztker, The Rationale of Operative Fracture Treatment, 2nd ed., 1995, 95-97) Fracture of Lateral Epicondyle • avulsion # • Adult • Rare • associated with posterolateral or posterior dislocation of elbow(may be associated with # medial epiconyle) • Children • lateral epicondyle is avulsed with varying portion of capitellum • may turn no itself by 180 • risk of non-union and deformity • When elbow is reduced, epicondylar fragment reduces and heals in place • Prognosis: good

Fracture distal humerus

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Fracture of Medial Epiconyle • most common in children • may be seen in adult 1. Direct injury 2. Avulsion Treatment 1. Small and undisplaced • conservative treatment 2. Displaced • ORIF to prevent ulnar nerve palsy • ORIF {4.0mm cancellous screw {medial approach {ulnar nerve protected +/- anterior transposition • Prognosis: good

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Fracture distal humerus

Fracture of Lateral Condyle

FRACTURE OF CONDYLES (R.N. Hotchkiss, Fracture in Adults, 4th ed., 1996, 953-958)

•

capitellotrochlear sulcus divides the capitellar and trochlear articular surfaces • lateral trochlear ridge: key to analyse humeral condyle # Milch Classification (H. Milch, JAMA, 160: 529-539, 1956) 1. Type I # • lateral trochlear ridge remains with the intact condyle elbow stable (medial to lateral) 2. Type II # • lateral trochlear ridge is involved in the fractured condyle elbow unstable (medial to lateral)

Fracture distal humerus

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1. Type I # • lateral trochlear ridge remains intact preventing dislocation of radius and ulna 2. Type II # • lateral trochlear ridge is a part of the fractured lateral condyle • If + medial capsuloligamentous disruption radius and ulna may dislocate • always extends medially and involve part of the trochlea Treatment • ORIF, then early mobilization • Lateral approach, 2 x 3.5mm cancellous screws Prognosis • good

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Fracture distal humerus

Fracture of Medial Condyle

1. Type I # • Lateral trochlear ridge intact elbow stable 2. Type II # • lateral trochlear ridge is a part of fractured medial condyle • If + lateral capsuloligamentous disruption radius and ulna may dislocate medially on humerus Treatment • ORIF, then early mobilization

Fracture distal humerus

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Fracture distal humerus

FRACTURE OF CAPITELLUM (J. Schatzker, The Rationale of Operative Fracture Care, 2nd ed., 1995, 97-102) Anatomy • smooth, rounded, knob-like portion of lateral condyle of humerus • covered with articular surface only on anterior and inferior surface (but not on posterior surface) • Elbow in Flexion Head of radius articulated with the anterior surface of capitellum (radial fossa, a depression on anterior humerus just above the capitellum, accomodates the margin of radial head when the elbow is acutely flexed. Thus, radial fossa must be cleared of all # fragments for the elbow to regain a FROM) • Elbow in Extension Radial head articulates with the inferior surface of capitellum

• •

Always displaced antero-superiorly into the radial fossa limit elbow flexion Occasionally, displaced posteriorly limit elbow extension

Classification Type I (Hahn-Steinthal) Capitellar #

Type II (Kocher-Lorenz) Capitellar #

1. Isolated injury 2. Part of comminuted supracondylar fracture Isolated Injury Mechanism 1. As the head of radius is forcibly driven against the capitellum with the elbow in flexion 2. Direct blow to elbow when it is fully flexed •

Becomes a free intra-articular osteochondral body

Fracture capitellum

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Fracture capitellum

Recommended Treatment • closed manipulation always fail • attempts at internal fixation five poor results • If the fragment is small excision • If the fragment is sufficient large to allow stable fixation ORIF 1. Lateral approach • posterior fixation • capitellum held in place with a small hook; then, provisionally fixed with K-wire; then, 3.5 mm cancellous screw from back to front

2. Fix the capitellum transarticularly • (head of screw must be countersunk below the level of articular cartilage)

Fracture capitellum

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Fracture capitellum

FRACTURE OF RADIAL HEAD (J. Schtazker, The Rationale of Operative Fracture Care, 2nd ed., 121-125) Aim • preservation of elbow flexion and extension, pronation and supination of forearm Mechanism of injury • Fall on outstretched hand(majority) (may be associated with # capitellum) • Valgus force to elbow(occasionally) (may be associated with fracture olecranon and torn medial collateral ligament of elbow elbow instability)

Treatment Early active mobilization as pain allow Otherwise, 1. OR + Bone wedge elevation + mini-screw; or 2. Radial head excision and spacer (if elbow is unstable) Type I # • simple split wedge # • displaced vs undisplaced Treatment • OR + lag screw

Permanent loss of motion 1. Bony block(due to displaced piece of bone) • Treatment: removal of block • confirm bony block by infiltration of the joint with 2% lignocaine and test motion 2. Capsular and pericapsular scarring • Prevention: early mobilization Conservative treatment 1. Displacement < 2mm 2. Fragment < 1/3 of radial head 3. In comminuted #, no associated elbow dislocation 4. No bony block

Fracture radial head

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Type II # • impaction # • part of the head and neck remain intact

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Fracture radial head

• •

(usually the medial portion is intact because the injury is usually the result of a valgus force with forearm in supination) variable comminution Treatment OR + Bone wedge elevation + mini-screws

Fracture radial head

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Type III # • severely comminuted # • no portion of head and neck is in continuity • severe comminution • may be associated with torn medial collateral ligament of elbow and fracture olecranon 1. If possible(esp. young patient) • OR + Bone wedge elevation + mini-screws 2. If irreconstructable, • excision of radial head (except with elbow dislocation) • excision + prosthetic replacement (if elbow is unstable)

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Fracture radial head

OLECRANON FRACTURE (J. Schaztker, The Rationale of Operative Fracture Treatment, 2nd ed., 1995, 113-119) Fracture of olecranon with displacement disruption of triceps mechanism loss of active extension of elbow

CLASSIFICATION • Intra-articular Fracture 1. Simple Transverse Fracture

Assesment and Initial Management 1. Xray • Simple # vs comminuted # • Undisplaced vs displaced 2. For undisplaced fracture • test for ability to actively extend elbow against gravity 3. Long arm backslab for displaced fracture or with loss of extensor mechanism 4. Elevation

Mechanism of injury avulsion fracture and results from a sudden pull of both the triceps and brachialis muscle • Direct fall on olecranon Treatment • OR + TBW + K-wires 2. Complex Transverse # •

Recommended Treatment 1. Minimally displaced with intact extensor mechanism Free mobilization 2. Displaced # +/- Ipsilateral elbow dislocation ORIF • • •

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Mechanism of injury Direct force, such as a fall comminution and depression of articular surface Treatment TBW + K-wire / Plate (in severe comminution) +/bone grafting

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Olecranon fracture

3. Oblique #

Mechanism of injury • hyperextension injury of elbow • begins at the mid-point of trochlear notch and runs distally Treatment • OR + Lag screw(at right angle to the # line) + TBW +/- K-wire 4. Comminuted # with associated injury Mechanism of injury • high velocity direct injury to elbow, eg. with a considerable fall directing on elbow • # lines are variable Treatment • OR + Plate (3.5mm DCP) +/- bone grafting • certain features needed to be distinguished a. Fracture involving coronoid process Small fragment unimportant If the fragment is large instability of elbow in extension

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Treatment OR + Lag screw(to coronoid process) + plate +/- BG b. Distal extent of fracture if fracture extends distally past the midpoint of the trochlear notch disruption of triceps mechanism compromise the stability of elbow in withstanding varus or valgus force

Treatment OR + lag screw + plate (3.5 mm DCP)

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Olecranon fracture

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c. Fracture or Dislocation of Radial head associated with disruption of medial collateral ligament

Treatment • ORIF of # (TBW + K-wires) • Repair of ligament • Radial head is reduced and fixed or replaced by a prosthesis

Olecranon fracture

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Olecranon fracture

Type III # • lateral or anterolateral dislocation of radial head + fracture of ulnar metaphysis

MONTEGGIA FRACTURE (R.R. Richards, Fracture in Adults, 4th ed., 1996, 914-925) • Fracture shaft of ulna + dislocation of radial head • < 5% of an forearm fracture Bado’s Classification (J.L. Bado, Clin. Orthop., 50: 71-86, 1967) Type I (most common) • anterior dislocation of radial head + anterior angulated fracture of ulna shaft

Type IV # (rare) • anterior dislocation of radial head + fracture of proximal one third of both radius and ulna

Type II # • posterior dislocation of radial head + posterior angulated fracture of ulna shaft

For Monteggia #, must look for neurological injury, esp. radial nerve (PIN), ulnar nerve injury has also been reported

Monteggia fracture

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Monteggia fracture

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FRACTURE OF SHAFTS OF RADIUS AND ULNA Aim of Treatment 1. Anatomical reduction 2. Stable fixation

fracture of radius (junction of middle third and distal third) + Dislocation / Subluxation of distal radio-ulnar joint • Dislocation of DRUJ may occur at 1. initial injury 2. progressively during conservative treatment • Treatment must include reduction of DRUJ

Patients requiring operative treatment 1. All displaced # 2. Monteggia fracture and Galeazzi # with persistent subluxed / dislocated proximal / distal radio-ulnar joint On admission 1. make sure Xray whole forearm(including both elbow and wrist joint) is well taken(to rule out Monteggia and Galeazzi #) 2. For undisplaced # long arm pop 3. For displaced # long arm backslab for temporary immobilization; and work-up for OT Operative Choice 1. Closed # • ORIF (PC Fix / LCDCP) 2. Open # • ORIF vs External Fixator GALEAZZI FRACTURE

Fracture shaft of radius and ulna

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Galezzi fracture

PELVIC FRACTURE On admission 1. Follow principle of management of patients with severe trauma 2. Assessment • Haemodynamic condition • Associated potential life threatening injuries (esp. in high enery trauma, eg. severe RTA, fell from height, etc) • eg. Head injuries • Cervical spine injuries • Chest injuries (eg. haemothorax, pneumothorax) • Abdominal injuries (eg. haemoperitoneum, torn abdominal viscera) • Torn vessels 3. Other associated injuries • eg. ruptured bladder • ruptured urethra • ruptured pelvic organ (eg. vagina, rectum) • peripheral nerve injuries 4. Fracture pelvis • Type and stability • Close vs open 5. Other associated muscoloskeletal injuries

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Haemodynamic instability due to 1. Bleeding from fracture site • Pelvis fracture: 1500 - 2000 ml • Fracture femur: 1000 ml 2. Torn pelvic vessels (arterial or veins), with retroperitoneal haemorrhage 3. Other injuries(eg. rupture abdominal viscera, haemothorax, etc) For patients with haemodynamic instability / Associated life threatening condition 1. NPO 2. Start Fluid resuscitation, as indicated 3. Start oxygen therapy (high flow oxygen +/intubation) 4. Insert 2 large bore iv line +/- CVP 5. Foley to BSB (uless suspect urethral injury) 6. Blood x cross-match 7. Routine blood test 8. Must examine patient’s neurology(to r/o severe head injury and spinal injury), chest (for pneumothorax, haemothorax) and abdomen (for haemoperitoneum ) 9. Analgesics

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Fracture pelvis

PELVIC FRACTURE (M. Tiles, The Rationale of Operative Fracture Care, 2nd ed., 1995, 221-270) Anatomy • Pelvic ring • 3 bones • Sacrum + 2 inominate bones (each consists of ilium, ischium and pubis) • Stability • ability of pelvis to withstand physiological force without significant displacement • depends mainly on surrounding soft tissues 1. Symphysis pubis 2. Posterior sacroiliac complex 3. Pelvic floor

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Fracture pelvis

SACROILIAC COMPLEX Posterior sacroiliac complex(work like a suspension bridge) • transfer weight bearing forces from the spine to the lower extremities 1. Posterior sacroiliac interosseous ligaments (strongest ligament in the whole body) (maintain sacrum in position with pelvic ring) 2. Iliolumbar ligament (from transverse process of L5 to iliac crest) 3. Interosseous ligament

PELVIC FLOOR • muscular layer covered by investing fascia • contains 2 major ligaments: sacrospinous ligament and sacrotuberous ligament 1. Sacrospinous ligament • resists external rotation of the pelvis 2. Sacrotuber ous ligament • resists vertical shearing force

Anterior sacroiliac ligament • resists external rotation and shearing force

Fracture pelvis

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Fracture pelvis

TYPES OF INJURIES FORCE 1. External rotation force 2. Internal rotation force (lateral compression force) 3. Vertical shearing force 4. Complex force (as in high energy trauma)

External rotation force ( open book injury) symphysis pubis disrupts sacrospinous ligament and anterior sacroiliac ligament open impingement of the posterior ilium on sacrum

External Rotation Force 1. Direct blow to the PSIS

Internal Rotation Force (Lateral Compression) 1. Direct blow to iliac crest upward rotation of the hemipelvis (bucket handle injury)

2. Forced external rotation through hip joints unilaterally or bilaterally

1. Through the femoral head, by a direct force against the greater trochanter, often causing an ipsilateral injury Internal rotation force / lateral compression

Fracture pelvis

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Fracture pelvis

anterior structures, usually the rami, break and then hemipelvis rotates internally If the posterior ligament remain intact anterior sacrum will compress If the posterior ligament is torn, stability is maintained by pelvic floor

1. External rotation and Vertical Shear force Tearing of viscera and arteries Traction injuries to nerves 2. Internal rotation puncture viscera compress nerve

Vertical Shearing Force Vertical shearing force marked displacement of bone gross disruption of soft tissue structures unstable pelvic ring with major anterior and posterior displacement

CLASSIFICATION Type A • Stable # • pelvic ring not displaced Type B • Partially stable • retain posterior stability • cannot translate vertically ie. stable in vertical plane 1. Open book injury (external rotation force) • (Unstable in external rotation) 2. Lateral compression injury(internal rotation) • either unstable in internal rotation; or • rigidly impacted Type C • Unstable • complete disruption of posterior arch, pelvic floor and usually the anterior arch • •

Type A + B : 70 % Type C : 30 %

Effects of Force on Soft Tissue

Fracture pelvis

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Fracture pelvis

TYPE A--STABLE FRACTURES • pelvic ring is stable and cannot be disrupted by physiological force Type A1 • avulsion # of innominate bone • not involve pelvic ring • usually in adolescent Type A2 • involve the iliac ring; or • anterir arch • no posterior injury • rare Type A3 • transverse # sacrum and coccyx

CLASSIFICATION OF PELVIC RING DISRUPTION Type A: Stable pelvic ring injury A1: Avulsion of the innominate bone A2: Stable iliac wing fracture or stable minimally displaced ring fracture A3: Transverse fractures of the sacrum and coccyx Type B: Partially stable B1: Open book injury B2: Lateral compression injury B2.1: Ipsilateral type B2.2: Contralateral type (buckethandle) B3: Bilateral B injuries

TYPE B--PARTIALLY STABLE FRACTURE Open Book Fracture (External Rotation) First stage • disruption of symphysis pubis(< 2.5cm opening of symphysis pubis)

Type C: Unstable (vertical shear) C1: Unilateral C1.1: Ilium C1.2: Sacroiliac dislocation or fracture dislocation C1.3: Sacrum C2: Bilateral, one side B, one side C C3: Bilateral C lesions

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Fracture pelvis

Second stage • continuation of external rotation force will tear the sacrospinous ligament and anterior sacroiliac ligament Signified by 1. Opening of pubis symphysis > 2.5cm 2. Avulsion fracture fo ischial spine

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Lateral Compression Fracture (Internal Rotation) Ipsilateral Injury • anterior and posterior lesion on the same side • direct blow to greater trochanter • superior and inferior pubic rami break + crush at anterior part of SIJ • posterior ligamentous structures are intact • possible rupture of bladder +/- blood vessels • elastic recoil

strong posterior sacroiliac ligament remain intact( stable in vertical force)

Third stage • external rotation force go beyond the yield point of posterior ligament posterior complex ruptures unstable Type C # now (avulsion fracture of L 5 transverse process)

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Fracture pelvis

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Contralateral Injury (Bucket-handle injury) • anterior fracture on the opposite side of posterior lesion • (or all four rami may fracture anteriorly but the anterior displacement is on the side opposite the posterior lesion) • usually has major leg length discrepency (shortening of the side of posterior lesion because of marked internal rotation of hemipelvis) • posterior structures are firmly impacted • reduction require derotation of hemipelvis rather than pure vertical traction

complete disruption of posterior sacroiliac arch + rupture of pelvic floor(including the sacrospinous and sacrotuberous ligaments)

Radiographic signs of Instability 1. Avulsion fracture of the transverse process of L5 vertebrae • (indicating rupture of ilio-lumbar ligament) 2. Avulsion fracture of ischial spine or avulsion of sacral attachment of sacrospinous ligament (indicating rupture of ischiospinous ligament) 3. > 1cm posterior or vertical translation MANAGEMENT FO PELVIC # Depends on 1. “Personality” of injury 2. Associated injuries Management • Assessment • Resuscitation • Provisional stabilization • Definite stabilization

TYPE C--UNSTABLE FRACTURE

Fracture pelvis

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Fracture pelvis

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ASSESSMENT General assessment • general assessment and management of a polytraumatised patient Specific Musculoskeletal assessment • Aim: Determine the stability of pelvic ring Clinical Assessment 1. History • High-energy injury(eg.RTA, fell from height) vs low-energy injury 2. P/E • Major bruising or bleeding from urethral meatus, vagina, rectum (may signify an open fracture) • Rotatory deformity or limb shortening (may imply unstable pelvic injury) • Test pelvic stability • apply both hands to ASIS and move the affected hemi-pelvis (external rotation vs internal rotation) • apply one hand to the pelvic iliac crest and using the other to apply traction to the leg (displacement in vertical plane) Radiological Assessment • Plain Xray • Xray pelvis (AP) • Xray Pelvis (inlet view) • direct Xray beam 60 from head to midpelvis • demonstrate posterior displacement • Xray pelvis (outlet view)

Fracture pelvis

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Xray beam from the foot of patient to the symphysis at an angle of 45 • demonstrate superior or inferior migration CT scan

Diagnosis of Pelvic Stability 1. Type C (Completely unstable) • Clinically, lack of a firm end-point in rotation or traction • Radiologically, • displacement / gap (vertical displacement or antero-posterior displacement)on Xray or CT > 1cm • Avulsion # of ischial spine or sacrum 2. Type B (Partially stable) • Clinically, firm end-point on palpation

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Fracture pelvis

RESUSCITATION • Pelvic # hamorrhage (arterial, venous, bony) • Risk in unstable # > stable # 1. Massive fluid replacement, as indicated 2. Pneumatic antishock garment 3. Application of anterior external frame / Pelvic C Clamp • in hypotensive patients / unstable # • pelvic volume tamponade effect • help to stop venous and bony bleeding 4. Embolization of pelvic vessels • usually only help to control bleeding from a small-bore artery • Small-bore artery bleeding may be asssumed if, although the patient can be well controlled using the above methods of fluid replacement, PASG, an fracture stabilization, he or she goes into a shocked state each time the fluid is slow down 5. Direct surgical control • rarely indicated and usually unsuccessful PROVISIONAL STABILIZATION Provisional stabilization by Anterior External Fixator / Pelvic C Clamp Indications • those fractures with potential increase in pelvic volume and patients with unstable haemodyname condition • Wide open book injury (B1, B3) • Unstable pelvic fracture C • rarely required for lateral compression injuries (B2) Fracture pelvis

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Anterior External Fixator • 2 pins percutaneously place in each ilium, at approximately 45 to each other • one pin in ASIS • one in iliac tubercle • joined by an anterior rectangular configuration Pelvic C Clamp • point of entry • 4 finger breadth from PSIS on a line joining ASIS and PSIS Provisional stabilization with Skeletal traction • for patient with no haemodynamic instability • temporary skeletal traction pin in distal femur • 5 - 20 kg of traction to prevent hemipelvis from shortening

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Fracture pelvis

ACETABULAR FRACTURE (M. Tile, The Rationale of Operative Fracture Treatment, 2nd ed., 1995, 271-324) Aim of Treatment • anatomical reduction of hip joint without operative complication Major factors affecting prognosis 1. Degree of initial displacement 2. Damage to superior weight bearing surface of acetabulum or femoral head 3. Degree of joint instability caused by posterior wall fracture 4. Adequacy of reduction, either open or closed 5. Late complications • AVN of femoral head • Heterotropic ossification • Chondrolysis • Sciatic or femoral nerve injury Anatomy

Fracture acetabulum

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Mechanism of injury • pathological anatomy of the fracture depends on the position of the femoral head at the moment of impact 1. External rotation of hip • anterior column # 2. Internal rotation of hip • posterior column # 3. Abduction of hip • Low transverse # 4. Adduction of hip • high transverse # 1. Direct blow on the acetabulum / upon the greater trochanter usually a transverse acetabular # 2. Dashboard injury (Flexed knee joint strikes the dashboard of a motor vehicle, driving the femur posteriorly on the acetabulum) posterior wall or posterior column fracture or fracture dislocation of hip joint

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Fracture acetabulum

ASSESSMENT • Follow principles of assessment of polytrauma patient • Specific assessment of # acetabulum Xray pelvis (AP) Important landmarks 1. iliopectineal line • denoting limit of anterior column 2. ilioischial line • denoting limit of posterior column 3. Anterior lip of acetabulum 4. Posterior lip of acetabulum 5. Tear drop 6. Superior dome

Fracture acetabulum

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Iliac oblique view • 45 external rotation of the affected pelvis • by elevating the uninjuried side on a wedge foam • Landmarks 1. best depicits the extent of posterior column 2. anterior lip of acetabulum 3. entire iliac crest

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Fracture acetabulum

Obturator Oblique View • 45 internal rotation of the affected hemipelvis • by placing a foam wedge under the affected hip • Landmarks 1. best shows the anterior column 2. posterior lip of acetabulum 3. best show displacement of iliac wing in the coronal plane (because iliac crest is seen perpendicular to its normal plane)

Classification • acetabulum consists of 4 basic anatomical areas 1. Anterior column 2. Posterior column 3. Anterior wall of lip 4. Posterior wall of lip

Fracture Types 1. Isolated Anterior Column fractures 2. Isolated Posterior Column fractures 3. Combined anterior column and anterior lip fracture 4. Combined posterior column and posterior lip fracture 5. Transverse fracture • both anterior and posterior columns are broken

Fracture acetabulum

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Fracture acetabulum

surface of the acetabulum remain attached to the acetabulum

6. T Fracture • both columns are broken and separated from each other • both transverse or T fracture may be associated with an anterior or posterior lip # • Transverse / T fracture, a portion of acetabular dome is always attached to the intact ilium 7. Both Column Fractures • both anterior and posterior columns are fractured and separated from each other • but the fracture in the columns is proximal to the acetabulum in the ilium • true floating acetabulum • no portion of the weight-bearing

Fracture acetabulum

Management (Depends on) 1. Fracture factor 2. Patient’s factor (age and bone quality, general medical status, associated injuries) Fracture factor Non-operative management if Hip stable and Congrous Undisplaced fractures (all types) require no skeletal traction Minimally displaced # (displacement < 2mm) Low anterior column # (# not involve major weight bearing area) Low transverse # • through the acetabular fossa area (infratectal) • skeletal traction • Low transverse # (infratectal) • main portion of the weight bearing dome is intact

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Fracture acetabulum

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medial portion of the dome act as a buttress to the femoral head, preventing redisplacement

c.f. High transverse # (Supratectal, tanstectal) divides the mid-portion of the superior weight-bearing dome medial fragment remains displaced and the femoral head is congrous with that portion rather than the dome portion Both column fractures without major posterior column displacement • true floating acetabulum • no portion of the weight bearing dome attached to the axial skeleton • exhibit secondary congruence (Letournel, 1980) • skeletal traction

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Operative management • indicated for unstable and/or incongruous hip joint Instability • hip dislocation associated with 1. Posterior wall or column displacement (posterior instability) 2. Anterior wall or column displacement (anterior instability) Incongruity 1. Fractures through the roof of the dome • displaced dome fragement • High transverse or T types # (transtectal) • Both-column types with incongruity (displaced posterior column) 2. Retained bone fragments 3. Displaced fractures of femoral head 4. Soft tissue interposition (usually posterior capsule) Other operative indications 1. development of a sciatic or femoral nerve palsy after reduction of the acetabular # (possible entrapment of the nerve) 2. Presence of a femoral artery injury associated with an anterior column fracture of the acetabulum

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Fracture acetabulum

3. Fracture of the ipsilateral femur / disruption of ipsilateral knee, which makes closed treatment of acetabulum virtually impossible

Fracture acetabulum

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Fracture acetabulum

FRACTURE OF PROXIMAL FEMUR *For patients < 60 years old presenting with acute intracapsular fracture neck of femur (both displaced and undisplaced), need EOT x CR + IF (AO screw) (J. Schaztker, The Rationale of Operative Fracture Care, 2nd ed., 1995, 323-340) Anatomy

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Neck shaft angle: 125 - 135

Blood Supply of Femoral Head 1. Via retinacular vessels in the posterior capsule of hip joint • Common femoral artery medial circumflex femoral artery posterior superior retinacular vessels and posterior inferior retinacular vessels posterior superior retinacular artery gives rise to lateral superior epiphyseal vessels Femoral artery (Lateral femoral circumflex artery anterior retinacular vessels not contribute to blood supply of head

Fracture proximal part of femur

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Fracture proximal part of femur

2. Via ligamentous teres (supply a small portion of head close to their site of entry) 3. Intraosseous blood supply Attachment of capsule of hip joint 1. Front • along the intertrochanteric line 2. Back • attach to the neck only halfway to the intertrochanteric crest

Fracture proximal part of femur

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Fracture Proximal Part of Femur 1. Intracapsular • Subcapital # neck of femur • Transcervical # neck of femur • In these fractures, capsule may be torn blood supply of femoral head is at risk 2. Extracapsular • Fracture basal neck of femur • Intertrochanteric fracture of femur • Subtrochanteric fracture of femur • In these fractures, capsule is intact Femoral head is not at risk of AVN Intracapsular Fracture Neck of Femur Garden Classification (1964) • use the relationship of medial trabeculae (compression trabeculae) in the head and pelvis as an index of displacement • undisplaced # (Garden I and II) vs displaced # (Garden III and IV) 1. Undisplaced Fracture • capsule is less likely to be injuried lower incidence of AVN 2. Displaced Fracture • capsule is likely to be torn higher incidence of AVN and higher incidence of failure of fixation and nonunion

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Fracture neck of femur

Garden I • head impacted in valgus

Garden IV • completely displaced #

Garden II • undisplaced #

History • simple fall with pain over groin +/- inability to walk P/E • R/O concomittant injury (eg. head injury, # distal radius) • Affected leg shortened and externally rotated • Pain on manipulation of the affected leg

Garden III • partially displaced #

Fracture neck of femur

Treatment 1. For all young patients (< 60 years) with intracapsular fracture neck of femur (both displaced and undisplaced #) need EOT x CR + IF 2. For patients > 60 years • for elective OT uless medically unfit • Undisplaced intracapsular Fracture (Garden I and II) AO screws +/- AMA

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Fracture neck of femur

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Displaced intracapsular fracture (Garden III and IV) AMA / Cemented Thompson

CR of intracapsular fracture neck of femur • Femoral head usually displaces into varus and retroversion • femoral shaft externally rotates Methods of CR (under Image Intensifier) 1. Longitudinal traction (bring the head out of varus position) 2. Gentle internal rotation of the limb (correct retroversion) Acceptable alignment(Schatzker) 1. Anatomical reduction or one with the head in slight valgus position 2. Head in neutral version or minimally anteverted • repeated attempts of CR increase risk of AVN

Fracture neck of femur

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Fracture neck of femur

INTERTROCHANTERIC FRACTURE OF FEMUR (J. Schaztker, The Rationale of Operative Fracture Care, 2nd ed., 1995, 340-348) • Fracture of proximal femur in the region joining the greater and lesser trochanter • extra-capsular • Calcar (Postero-medial fragment in the bone around lesser trochanter) • important to the weight bearing capacity of femur

• calcar is involved Kyle’s I • stable non-displaced fracture without comminution

Kyle’s II • stable with minimal comminution

Kyle’s Classification (1979) 1. Stable fracture (Kyle’s I and Kyle’s II) • calcar is not involved 2. Unstable fracture (Kyle’s III and Kyle’s IV)

Intertrochanteric fracture of femur

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Intertrochanteric fracture of femur

Kyle’s III • unstable and has a large postero-medial comminuted area

Treatment • all #TOF require elective OT for internal fixation with DHS (dynamic hip screw) • look for assicated injuries (eg. head injury, fracture distal radius) • work-up for OT

Kyle’s IV • fracture with subtrochanteric extension • highly unstable

Intertrochanteric fracture of femur

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Intertrochanteric fracture of femur

SUBTROCHANTERIC FRACTURE (J. Schaztker, The Rationale of Operative Fracture Care, 2nd ed., 1995, 349-366) • Subtrochanteric segment--extends from lesser trochanter to the junction of proximal and middle third of the diaphysis

Factors important for stability (in order of importance) 1. Degree of comminution 2. Level of fracture 3. Pattern of fracture Degree of comminution 1. irreconstructable medial cortex comminution (shattered medial cortex) 2. irreconstructable segmental comminution

Biomechanical consideration • subtrochanteric region is subjected to: 1. axial load 2. bending force because of eccentric load application to the femoral head • medial cortex--loaded in compression • lateral cortex--loaded in tension

Level of fracture 1. Closer the fracture to the lesser trochanter shorter the lever arm and the lower the bending moment 2. Involvement of greater trochanter • difficult to keep the intramedullary nail within the proximal fragment • better to fix the fracture with an angled device (eg. angled blade plate) 3. Involvement of lesser trochanter • lock proximally within the femoral neck and head (eg. AO unreamed femoral nail + spiral blade locking) Pattern of fracture • determine the mode of internal fixation

Subtrochanteric fracture of femur

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Subtrochanteric fracture of femur

Comprehensive Classification of Fractures (Muller, 1990) Type A # • simple • transverse / oblique / spiral

Type B # • wedge # • can still be reconstructed to yield a stable structure lateral wedge medial wedge

Type C # • comminution to a degree that a stable unit cannot be achieved

Indications for surgery • all subtrochanteric fracture of femur needs operative treatment On admission 1. r/o associated injury 2. skeletal traction 3. work-up for OT Surgery • AO unreamed intramedullary nail with spiral blade locking

Subtrochanteric fracture of femur

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Subtrochanteric fracture of femur

FRACTURE SHAFT OF FEMUR • result of high energy trauma • rule out associated injury • follow management of polytrauma patient

Type C • complex # • C1--spiral • C2--segmental • C3--irregular

Comprehensive Classification of Fracture (Muller, 1990) Type A • simple # • A1--long oblique • A2--short oblique • A3--transverse

Treatment • All adult femoral fracture • Closed # O unreamed femoral nail • Open # xternal fixator On admission • Follow management of polytrauma patient (if applicable) • Skeletal traction • work-up for operation

Type B • wedge fracture

Fracture shaft of femur

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Fracture shaft of femur

SUPRACONDYLAR FRACTURE OF FEMUR (J. Schaztker, The Rationale of Operative Fracture Care, 2nd ed., 1995, 387-413) 1. Younger patient • high energy trauma • severe fracture with greater intra-articular disruption or segmental comminution • possible association with open wound, multiple fractures, ligamentous injury 2. Older patients • low energy trauma (eg. slip an fell) • associated with severe osteoporosis Aim of treatment 1. accurate anatomical reduction of Joint surface 2. Stable internal fixation of the articular surface 3. Restoration of normal axial alignment and length 4. Buttressing of metaphysis 5. Early mobilization 6. thus, operaive treatment for all patients On admission • Follow management of polytrauma patient (if applicable) • Skeletal traction • work-up for OT

Supracondylar fracture of femur

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Comprehensive Classification of Fractures (Muller, 1990) Type A • extra-articular • A1--extra-articular, simple • A2--extra-articular, metaphyseal wedge • A3--extra-articular, metaphyseal complex

Type B • partial articular • part of the articular surface intact and in contact with the diaphysis • B1--partial articular, lateral condyle, sagittal • B2--partial articular, medial condyle, sagittal • B3--partial articualr, frontal

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Supracondylar fracture of femur

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Type C • complete articular • articular surfaces are fractured and have lost continuity with the diaphysis • C1--cmplete articular #, articular simple, metaphyseal simple • C2--complete articular #, articular simple, metaphyseal multifragmentary • C3--complete articular #, multifragmentary

ORIF (May plate +/- Bone grafting +/- Cement augmentation)

Surgical Anatomy 1. Anatomical axis: • in valgus • with sagittal plane • (79 to 82 ) with the knee joint axis (parallel to ground) 2. Mechanical axis: • line projected through the centre of femoral head, knee joint an ankle joint • with sagittal plane • with anatomical axis of femur

Treatment

Supracondylar fracture of femur

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Supracondylar fracture of femur

Lateral view • when posterior cortex of the shaft is projected distally, it divides the epiphysis into an anterior and posterior half • Anterior position of condyles appear as a continuation of shaft • thus, blade of a condylar plate / screw of a DCS should be placed into the anterior part of condyle; or the plate will not fit the femur

Supracondylar fracture of femur

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Cross Section • distal femur appear as a trapezoid • anterior and posterior surfaces are not parallel • medial and lateral walls are inclined (medial wall inclined at 25 to the vertical) • important in selecting the length of compression screw

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Supracondylar fracture of femur

FRACTURE PATELLA (J. Schaztker, The Rationale of Operative Fracture Care, 2nd ed., 1995, 415-418) Anatomy • seasmoid bone within the tendon of quadriceps muscle • displacement with disruption of quadriceps mechanism loss of active extension of knee and loss of ability to lock the knee in extension • Patella is bound 1. proximally to quadriceps tendon 2. distally to infrapatellar tendon 3. on either side to retinacular expansion which are adherent to the capsule

Classification Transverse fracture

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Fracture patella

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result from sudden, violent contraction of the quadriceps (eg. when a person tries to stop a fall) may disrupt quadriceps mechanism may result in avulsion of quadriceps tendon, or infrapatellar tendon, or transverse fracture of patella associated with a tear into retinacular expansion If undisplaced # with intact extensor mechanism long leg cylinder x 6 weeks and FWB walking For all displaced fracture open reduction + TBW / Cerclage wiring

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Fracture patella

Stellate fractures / Vertical fractures • result from a direct blow to patella • quadriceps mechanism is undisturbed and retinacula is not torn • Fracture is stable and will not displace under normal physiological stress of active motion • surgery is not necessary

On admission 1. Test for integrity of extensor mechanism--inability to maintain the knee in extension against gravity 2. For undisplaced # with intact extensor mechanism long leg cylinder 3. For all displaced # long leg backslab for temporary immobilization and work-up for OT Surgical Option Tension Band Wiring

Osteochondral fracture • result of lateral dislocation of patella • usually involve portion of medial facet and subjacent bone • # is visualized in “skyline” view • Surgery is required 1. remove the intra-articular loose body 1. repair quadriceps mechanism to prevent recurrences of the dislocation

Fracture patella

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Fracture patella

Dynamic compression (by TBW) • TBW applied to the anterior surface of patella absorbs the distracting force • In flexion, patella is pulled against the

K-wire • provide rotational and lateral stability • must be inserted parallel (otherwise, block the interfragmental compression by TBW) Lag screws • provide interfragmental compression • must be protected by TBW Cerclage Wiring • unable to neutralize the pull of quadriceps and infrapatellar tendon • under load, such as flexion of knee, the fracture gaps anteriorly and stability of the fracture and congruity of the patella are lost

intercondylar groove Fracture closes with the fragments under axial compression

Fracture patella

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Fracture patella

Partial patellectomy

Fracture patella

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Fracture patella

TIBIAL PLATEAU FRACTURE (J. Schaztker, The Rationale of Operative Fracture Care, 2nd ed., 1995, 419-438) History • Mechanism of injury(S/F, RTA, Fell from height) • High velocity injury vs Low velocity injury • Direction of force • Patient’s expectation and level of function required P/E • Soft tissue condition (open wound, swelling, bruising, etc) • Site of Local tenderness (may indicate possible disruption of collateral ligament) • Neurological deficit • Vascular deficit • Compartment syndrome Management 1. Rule out concomitant injury 2. Rule out patients requiring EOT (eg. open fracture, vascular injury, acute compartment syndrome) 3. Long leg backslab for temporary immobilization

Fracture tibial plateau

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Tibial Plateau Fracture • about 50 % patients get satisfactory results (both closed and open treatment) Causes of failure of treatment 1. Residual pain 2. Stiffness 3. Instability of knee joint 4. Deformity 5. Recurrent effusions 6. Giving way Mechanism of Injury • usually a combination of vertical thrust and bending Aims of Treatment 1. Stable Joint 2. Congruent articular surface 3. Correct axial alignment 4. Satisfactory range of movement

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Fracture tibial plateau

TREATMENT 1. Undisplaced Fracture (< 5mm depression, no splaying of condyles) hinged knee brace x 6 weeks + protected weight bearing (NWB walking x 6/52 PWB walking x 6/52 FWB walking) 2. All others / Open Fracture / Fracture associated with acute compartment syndrome / Fracture associated with vascular or neurological injury (vascular injury is most often associated with type IV tibial plateau injury) i. OR + Buttress Plate + Bone Graft ii. CR + Ilizarov +/- Mini-open technique + bone graft

Schatzker Classification of Tibial Plateau Fracture

Rehabilitation • early mobilization

Fracture tibial plateau

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Fracture tibial plateau

1. Undisplaced • Hinged knee brace x 6/52; protected weight bearing 2. Displaced • ORIF +/- bone graft (Young people: lag screw Old people : lag screw + buttress plate) 3. Minor displacement • may need arthroscopy to make sure that the meniscus is not trapped in the fracture

Type I Fracture

Prognosis • excellent if the joint is carefully reconstructed • 1. 2. • • •

wedge fracture of lateral tibial plateau Undisplaced Displaced with lateral wedge fragment spread apart from the metaphysis broadening of joint surface Depressed Both spread and depressed

•

(For fracture with significant displacement, lateral meniscus may be trapped in the #) Mechanism • result of bending and shearing force Age • usually young people < 30 years (because of dense cancellous bone of lateral tibial plateau) Treatment

Fracture tibial plateau

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Fracture tibial plateau

1. • • 2. • 3.

Type II Fracture

•

• •

wedge fracture + depression adjacent weight bearing portion of lateral tibial plateau Depressed fragment may be anterior, central, posterior, or a combination of all three

Undisplaced and Depression < 5mm Hinged knee brace x 6/52 Protected weight bearing Displaced fracture ORIF (buttress plate) + Bone graft Displaced Fracture with contraindication to surgery CR + Hinged knee brace x 6/52 + Protected weight bearing

Prognosis 1. Poor results if residual joint depression, incongruity, joint instability 2. Significant knee stiffness if prolonged immobilization

Mechanism • result of bending and shearing force Age • > 50 years

Treatment

Fracture tibial plateau

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Fracture tibial plateau

Treatment 1. Depression < 5mm and No knee instability • Hinged knee brace x 6/52 + Protected weight bearing 2. Depression > 5mm • ORIF (Buttress plate + Lag screw below the elevated portion of tibial plateau + Bone graft)

Type III Fracture

Prognosis • excellent

• •

most common but least serious tibial plateau fracture Depression of articular surface of the lateral tibial plateau without an associated lateral wedge fracture

Mechanism • result of smaller force exerting its effect on weaker bone Age • > 55 years

Fracture tibial plateau

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Fracture tibial plateau

Type IV Fracture • • • •

• •

fracture medial tibial plateau carry worst prognosis

1. High velocity injury • Younger individual • medial plateau splits as a simple wedge with an associated fracture of the intercondylar eminence and adjacent bone with the attached cruciate ligament • may be associated with a posterior split wedge of medial plateau femoral condyle subluxate posteroirly on flexion • frequently a concomitant disruption of the lateral collateral ligament complex (tear through the

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substance of ligament or avulsion of bone, such as the proximal fibula) possible stretching or rupture of the peroneal nerve (as a result of traction) occasionally, damage to popliteal vessels represents a subluxation or a dislocation of knee which has been reduced Poor prognosis--because of associated soft tissue injury and other complications, such as compartment syndrome, Volkmans’ contracture, footdrop

2. Trivial Low Velocity Injury • elderly with marked osteoporotic bone • medial tibial plateau crumbles into an irreconstructable mass of fragments • Poor prognosis--because of joint incongruity and instability

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Fracture tibial plateau

Treatment 1. Undisplaced with No significant soft tissue injury • Hinged knee brace x 6/52 + Protected weight bearing 2. Displaced and/or associated ligamentous or neurovascular lesion • Open repair of ligamentous injury • ORIF--buttress plate to medial plateau + BG Avulsed intercondylar #: Fixed with lag screw or wire loop Posterior split wedge fracture 2nd buttress plate posterio-meduially • CR + Ilizarov External Fixator +/- Mini-open technique + bone grafting

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Type V Fracture

•

bicondylar fracture, which consists of a wedge fracture of the medial and lateral tibial plateau • No assiciated depression of the articular surface • Intra-articular vs Extra-articular (when the fracture lines begins in the intercondylar eminence) • associated with limb shortening Mechanism • equal axial thrust on both plateaux Treatment • ORIF (buttress plate on both sides) Prognosis • depends whether # is intra- or extra-articular

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Fracture tibial plateau

Type VI Fracture Treatment • ORIF + BG (Two buttress plates, one strong narrow 4.5mm DCP to bridge the diaphysis and act as neutralization or compression plate) • CR + Ilizarov External Fixator +/- Mini-open technique + Bone grafting Prognosis • 80% with satisfactory result (Schatzker, 1979)

• • • • •

most complex type of tibial plateau # Fracture which separates the metaphysis from the diaphysis Fracture pattern of the articular surface is variable can involve one or both tibial condyles and articular surfaces associated with marked displacement and depression of the articular fragments

Mechanism • High velocity injury

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Fracture tibial plateau

FRACTURE OF PROXIMAL AND DISTAL TIBIA (JUXTA-ARTICULAR) • in the region of metaphysis and transition between metaphysis and diaphysis Mechanism of Injury 1. Compressive force • # are crushed and axially malaligned • closed reduction of this type often leave a gap at the site of crush, with a tendency for the fracture to redisplace into it • disimpaction of the # changes it from a stable to an unstable one 2. Shear forces (tensile force) • may be direct trauma or indirect trauma (torsional force) • markedly unstable • For young patient, usually result of high energy trauma

For closed # 1. Undisplaced # without significant soft tissue injury nor swelling • long leg pop x 6/52; then, Sarmiento brace x 6/52 • NWB walking x 6/52; then, PWB walking x 6/52; then, FWB walking 2. Undisplaced # with significant soft tissue injury or swelling • long leg backslab for temporary immobilization • change to long leg pop once soft tissue condition allow 3. Displaced # • Ilizarov external fixator For open # • Follow principle of management of open # • Book EOT x Debridement +/- # stabilization (if necessary)

On admission • Closed vs open • Degree of soft tissue injury • exclude compartment syndrome • exclude associated vascular injury

Treatment

Fracture proximal and distal tibia

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Fracture proximal and distal tibia

“Safe Corridor” for insertion of Ilizarov K-wires in tibia

FRACTURE SHAFT OF TIBIA On admission 1. Closed vs Open (Gustilo classification for open #) 2. Determine degree of soft tissue injury (Tscherene classification for closed #) 3. Must r/o compartment syndrome 4. Measure compartment pressure if any doubt 5. Look for associated vascular injury Treatment For closed # 1. Undisplaced # without significant soft tissue injury nor swelling long leg pop x 6/52; then, Sarmiento brace x 6/52 NWB walking x 6/52; then, PWB walking x 6/52; then, FWB walking 2. Undisplaced # with significant soft tissue injury or swelling long leg backslab for temporary immobilization elevate the fracture limb For long leg pop after soft tissue condition improve 3. Displaced fracture / multiple # elective OT for AO unreamed intramedullary nailing work-up for OT long leg backslab for temporary immobilization

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For open # • Follow principle of management of open fracture • Book EOT x Debridement + # Fixation (if necessary) • # Fixation 1. AO unreamed intramedullary nailing 2. External fixator (Gustilo IIIC) For confirmed compartment syndrome • Book EOT x Fasciotomy +/- # stabilization High Energy Trauma (e.g. RTA) • transverse # / comminuted # / marked displacement • significant soft tissue injury Low Energy Trauma • spiral # with minimal displacement and minimal comminution • mild soft tissue damage

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Fracture shaft of tibia

External Fixator ”Safe Corridors” for inserting Schanz screw in tibia

Fracture shaft of tibia

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Fracture shaft of tibia

PILON FRACTURE (M. Tile, The Rationale of Operative Fracture Care, 2nd., 1995, 491-521) • metaphyseal injury of distal tibia, extending into ankle joint Mechanism of Injury Compressive Injury (e.g. fell from height) Tibia 1. Articular cartilage • impaction of articular surface • marked comminution 2. Metaphysis • severe impaction of metaphyseal bone • axial malalignment • when reduced by closed reduction extremely large peri-articular gap is formed thus, redisplacement possible Fibula • may remain intact • With an intact fibula, ankle is often driven into varus with severe impaction of medial part of tibial plafond Shear (Tension) Force (e.g. skiing injury, RTA) Tibia 1. Articular cartilage • may spare articular surface / minor cracks at joint surface • severe impaction is rare

Pilon fracture

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2. Metaphysis • unstable injury with disrupted soft tissue envelop Fibula • always fractured • usually transverse / short oblique with a butterfly fragment • occasionally comminuted Combined Axial compressive force and Shearing force (e.g. severe high energy trauma) On admission • Closed vs open # • State of soft tissue injury • Elevate the injuried limb always Treatment 1. For undisplaced fracture with minimal swelling • short leg pop x 6/52 • NWB walking x 6/52; then, PWB walking x 6/52; then, FWB walking 2. For displaced fracture • Short leg backslab x temporary immobilization • elevate injuried limb • Ilizarov + mini-open technique + Bone grafting

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Pilon fracture

Type B • partial articular • B1--pure split • B2--split depression • B3--multifragmentary depression

Aim of treatment 1. Anatomical reduction of articular surface 2. Correct axial alignment 3. Bone grafting Classification Type A • extra-articular • A1--metaphyseal simple • A2--metaphyseal wedge • A3--metaphyseal complex

Type C • complete articular • C1--articular simple, metaphyseal simple • C2--articular simple, metaphyseal multifragmentary • C3--complete articular #, multifragmentary

Pilon fracture

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Pilon fracture

MALLEOLAR FRACTURE (W.B. Geissler, Fractures in Adults, 4th ed., 1996, 2201-2266) Anatomy • Tibia and fibula forms a mortise, providing a constrained articulation for the talus

Stability of ankle joint depends on 1. Bony architecture (mortise formed by tibia and fibula) 2. Joint capsule 3. Ligaments Syndesmotic ligament maintains integrity between distal tibia and fibula • resists axial, rotational and translational forces that attempt to separate these two bones • consists of • anterior tibiofibular ligament • posterior tibiofibular ligament • transverse tibiofibular ligament • interosseous ligament

Malleolar fracture

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Malleolar fracture

Medial Collateral Ligament • superficial deltoid ligament • deep deltoid ligament

Lauge-Hausen Classification Basic mechanism of injury

Lateral Collateral Ligament • anterior talofibular ligament • posterior talofibular ligament • calcaneofibular ligament

Malleolar fracture

Supination-adduction injury pattern

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Malleolar fracture

Pronation-external rotation injury pattern

Supination-external rotation injury pattern

Vertical loading injury pattern

Pronation-abduction injury pattern

Malleolar fracture

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Malleolar fracture

Treatment 1. Undisplaced # • short leg pop x 6/52; • NWB walking x 6/52; then, PWB walking x 6/52; then, FWB walking 2. Displaced # • short leg backslab for temporary immobilization • elective OT x ORIF 3. Fracture with Dislocation / Subluxation of ankle joint • immediate CR under sedation to improve alignment • short leg backslab for temporary immobilization • elevate involved limb

Weber Classification • Weber A--infra-syndesmotic lesion • Weber B--trans-syndesmotic lesion • Weber C--supra-syndesmotic lesion

• •

the higher the fibular #, the more extensive the damage to the tibiofibular ligaments the greater the damage, the greater the danger of ankle mortise insufficiency

Malleolar fracture

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Malleolar fracture

FRACTURE CALCANEUM (M. Tile, The Rationale of Operative Fracture Care, 2nd ed., 1995, 589-603)

• •

fracture through sustentaculum tali is a constant feature of all os calcis fracture If not anatomically restored, will interfere with medial arch

Mechanism of Injury • direct axial load 1. Fell from height 2. Motor vehicle injury

1. Superior surface of calcaneum has 3 articular surfaces: • Posterior facet • articulates with talus • middle one third of calcaneum supports the posterior facet • Middle facet • Anterior facet • Both articulates with cuboid • supported by anterior one third of calcaneum 2. Sustentaculum tali • articulates with talus • supported by the complex medial arch structures, including insertion of tibialis posterior tendon and spring ligament (key soft tissue of medial arch)

Fracture calcaneum

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Primary Fracture Line • constant medial fragment containing the sustentaculum tali • rotation of heel into varus

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Fracture calcaneum

Secondary Fracture Line 1. may involve the joint itself in a single or in multiple fragments (Joint Depression Type Fracture) 2. may be a single horizontal fracture line, resulting in Tongue-Type Fracture

2. Three-part fracture • Tongue-type fracture • Joint depression type fracture

On admission • Closed # vs open # • R/O other injuries (eg. burst # lumbar spine) • short leg backslab for temporary immobilization) • Elevate injuried limb • XR calcaneum (lateral + axial) • Book CT calcaneum (axial cut) Classification (Sanders Classification) • CT classification 1. Two-part fracture • Primary fracture line through sustentaculum tali

Fracture calcaneum

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Fracture calcaneum

3. • • •

Four-part fracture may involve more than four parts additional fracture of lateral wall of calcaneum fracture line often extend forward into the cuboid articulation

Assessment Xray • lateral and axial view • determine number of primary and secondary fracture line • Bohler angle: 25 to 40 • Crucial angle of Gissane--135

Fracture calcaneum

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CT • axial cut • 3-D reconstruction Conservative Treatment • walking with calcaneal brace (NWB walking) x 6/52; then, PWB walking x 6/52; then, FWB walking Operative Treatment If # is constructable • ORIF + BG • lateral approach (Hockey stick or wavy) +/medial approach • Timing: 5 - 14 days pot-injury • time for revascularization of subcutaneous skin and allow fracture blisters to resolve • lateral approach

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Fracture calcaneum

•

medial approach

1. 2. 3. 4. 5.

Application of traction Elevation of depressed intra-articular fragment Bone grafting Lag screw fixation (3.5mm cancellous screw) Buttress plate to lateral cortex (1/3 tubular or 3.5mm reconstruction plate)

Fracture calcaneum

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Fracture calcaneum

If fragments within the posterior facet of os calcis is too comminuted and irreducible • Primary subtalar fusion

Prognosis • poor for those fractures with multi-fragmentation of joint surface, widening of heel an poor soft tissue Indications for surgery 1. Displaced fracture, which deforms and widens the os calcis, esp. with the lateral fragment impinging on the lateral malleoli 2. Depressed and altered articular surface of the posterior facet

Causes of long term pain 1. secondary arthritis 2. residual deformity, causing lack of a plantigrade foot 3. widening of heel, causing impingement at the lateral malleolus to all soft tissues, esp. the peroneal tendon 4. injury to heel pad

Fracture calcaneum

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Fracture calcaneum

DISLOCATION 1. All acute dislocations require urgent reduction 2. Assessment before reduction • site of dislocation (e.g. shoulder, elbow, hip, knee, etc) • direction of dislocation (e.g. anterior, posterior, inferior,etc) • associated fractures (e.g. fracture greater tuberosity in anterior dislocation of shoulder) • associated neurological injury • e.g. shoulder joint--axillary nerve • posterior dislocation of hip joint--sciatic nerve • associated vascular injury • look for signs of vascular insufficiency (e.g. pallor, prolonged capillary refill, absent pulse, etc.) • look for signs of compartment syndrome (esp. for knee dislocation) • Other committant injury 3. Reduction • attempt closed reduction in ward under sedation immediately (valium 10 mg iv, pethidine 50 mg iv) preferably under image intensifier guide • (Patient must be fully sedated. CR under sedation must be gently performed If any difficulty encountered during CR under sedation, for CR under GA) •

Inform MO and book EOT x CR under GA +/OR 4. After Reduction • must reassess neurovascular status • If there is deterioration in neurovascular condition, may need EOT x urgent exploration • Must take post-reduction Xray to confirm alignment • Test for post-reduction stability Dislocation 1. Acute dislocation 2. Chronic dislocation 3. Recurrent dislocation

For failed CR under sedation

Dislocation

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Dislocation

SHOULDER DISLOCATION (C. Rockwood, Fractures in Adults, 4th ed., 1996, 1193-1302) 1. Anterior dislocation (common) 2. Posterior dislocation 3. Inferior dislocation 4. Superior dislocation ANTERIOR DISLOCATION Mechanism of Injury 1. Direct trauma—e.g. a blow directed at the proximal humerus 2. Indirect force (most common) –combination of abduction, extension and external rotation forces applied to the arm • • • • • • •

Xray • AP Thorax vs True AP view of shoulder

P/E very painful (acute dislocation) muscle spasm humeral head palpated anteriorly hollow beneath acromion arm is held in slight abduction and external rotation shoulder incapable of complete IR and abduction associted nerve injury esp. axillary nerve

Shoulder dislocation

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Shoulder dislocation

•

Transcapular view (True lateral view of shoulder)

Hippocratic technique

Method of Closed Reduction Modified Stimson Technique

•

Shoulder dislocation

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196

note that heel of physician is not in patient’s axilla

Shoulder dislocation

Modified Hippocrates Method

POSTERIOR DISLOCATION Mechanism of Injury 1. Violent muscle contraction by electrical shock or convulsive seizures 2. Direct force applied to anterior shoulder

Post-reduction Care 1. Shoulder immobiliser x 3/52 2. Check for neurovascular status 3. Check Xray for post-reduction alignment (AP + transcapular view) 4. Test for stability

Shoulder dislocation

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3. Indirect posterior force applied through the arm up to the shoulder

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Shoulder dislocation

P/E 1. severe pain and muscle spasm limited ER of shoulder (< 0 3. limited elevation of arm (< 90 ) 4. posterior prominence and rounding of the shoulder compared with the normal side 5. flattening of the anterior aspect of shoulder 6. prominence of coracoid process on the dislocated side Treatment 1. Adequate muscle relaxation (preferably GA with muscle relaxant) 2. patient supine • axial traction supplied to the adducted arm in the line of deformity • gentle lifting of the head back into the glenoid fossa • NOT to force the arm into external rotation 3. If locked posterior dislocation (Pre-reduction Xray head is locked on the posterior glenoid) • distal traction of arm + lateral traction of upper arm

Shoulder dislocation

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Shoulder dislocation

HIP DISLOCATION (J.C. DeLee, Fractures in Adults, 4th ed., 1996,1756-1825) • usually result from high energy trauma • thus, follow principle of management of multitrauma patient (r/o life threatening injuries) • need urgent CR under sedation • if fail, for CR under GA as EOT Hip Dislocation 1. Anterior dislocation 2. Posterior dislocation ANTERIOR DISLOCATION • 10 % to 15 % of traumatic dislocation of hip

Superior dislocation (Pubic type)--femoral head is palpable in the groin region Inferior dislocation--fullness in the region of obturator foramen 4. Circulatory status--damage to femoral artery and vein 5. Neurologial status--damage to femoral nerve Epstein Classification (H.C. Epstein, Clin. Orthop., 92:116-142, 1973) Type I—Superior dislocation (including pubic and subspinous dislocations) Type IA • no associated # (simple dislocation)

Mechanism of injury • RTA (when the knee strikes the dashboard with the thigh abducted) • Falls from height • Secondary to a blow to the back of patient while in a squatted position P/E 1. involved limb slightly shorten 2. Superior dislocation--hip is extended and ER Inferior dislocation--hip is abducted, ER and in varying degree of flexion 3. Superior dislocation (Subspinous type)--femoral head is palpable in vicinity of ASIS

Hip dislocation dislocation

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Hip

Type IB • associated # of the head (transchondral or indentation type) and/or neck of femur

Type II--inferior dislocation (includes obturator, thyroid, and perineal dislocations) Type IIA • no associated # (simple dislocation)

Type IC • associated # of the acetabulum

Hip dislocation

Type IIB • associated # of the head (transchondral or indentation type) and/or neck of femur

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204

Hip dislocation

Type IIC • assocated fracture of the acetabulum

Allis Maneuver • patient supine • knee flexed (relax hamstring) • assistant stabilize pelvis and apply a lateral traction force to the side of thigh • longitudinal traction is applied in line with the axis of femur • Hip is slightly flexed • surgeons gently abducts and IR the femur to achieve reduction

Treatment • Closed Reduction--preferably under GA / SA Gravity method of Stimson

Hip dislocation

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Hip dislocation

Reversed Bigelow Maneuver • patient supine • hip partially flexed and abducted • Lifting method • firm jerk applied to the flexed thigh • Traction method (if lifting method fail) • traction in the line of deformity • hip is then adducted, sharply IR and extend • gentle reduction due to risk of #NOF

POSTERIOR DISLOCATION • common Mechanism of injury • force applied to the flexed knee with the hip in varying degree of flexion P/E • Involved limb shortened, IR and adducted • associated sciatic nerve injury (10 % to 14 %)

Post-reduction care 1. Check for neurovascular status 2. Check for post-reduction Xray 3. Skin traction with hip in slight flexion and IR

Hip dislocation

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Hip dislocation

Thompson and Epstein Classification (V.P. Thompson and H.C. Epstein, JBJS, 33A:746) Type I • with or without minor fracture

Type II with a large single # of posterior acetabular rim

Hip dislocation

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Type III • with comminution of the rim of acetabulum with or without a major fragment

Type IV • with fracture of acetabular floor

210

Hip dislocation

Type II • posterior dislocation of hip + # of the femoral head cephalad to fovea centralis

Type V • with fracture of femoral head

Pipkin Subclassification of Epistein type V (G. Pipkin, JBJS, 39:1027-1042, 1957) Posterior dislocation of Hip (with # femoral head) Type I • posteror dislocation of hip + # of femoral head caudal to the fovea centralis

Hip dislocation

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Type III • type I and type II with associated # of femoral neck

212

Hip dislocation

Type IV • Type I, II, III with acetabular fracture

Type I (Posterior dislocation without fracture) • urgent CR within 12 hours Gravity method of Stimson

Treatment • reduction (closed vs open) within 12 hours of 0injury • Immediate CR • Open reduction is reserved for • failed CR unstable reduction • Fracture fragments are trapped between the joint • neurovascular injury after reduction

Hip dislocation

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Allis maneuver 1. patient supine 2. pelvis stabilized 3. axial traction in line of deformity 4. gentle hip flexion to 90 5. Hip is gently rotated internally and externally with continued longitudinal reduction is achieved

214

Hip dislocation

Allis maneuver

Hip dislocation

Bigelow maneuver • supine • pelvis stabilized • longitudinal traction along line of deformity • adducted and IR thigh is then flexed 90 or more on the abdomen • While traction is maintained, femoral head is levered into acetabulum by abduction, external rotation and extension of hip risk of #

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216

Hip dislocation

Post-reduction • Check for neurovascular injury (e.g. sciatic nerve) • Check post-reduction Xray • Skin traction / Skeletal traction with hip in abduction, extension and external rotation

Hip dislocation

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Hip dislocation

GUIDELINES FOR HAND CASES Basic Operative Technique 1. Anaesthetic • Metacarpal blocks (No digital ring block) • Intravenous regional anaesthesia 2. Antibiotics • Ampicillin and Cloxacillin (po/iv if necessary and not contraindicated eg. allergy) 3. Tourniquet • Cotton wool should be wrapped around the limb before its application 4. Skin grafts • Donor site for split skin grafts should have xylocaine jelly applied after graft taking 5. Skin closure • Tourniquet must be released and haemostasis checked before closure 6. Drain • If in doubt, put in a drain 7. Suture material • Silk and catgut has no place in hand surgery • For tendons, atraumatic prolene • For nerves, 8/0 atraumatic prolene or 8/0 atraumatic fine nylon

Guideline to hand cases

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Post-operative 1. Dressing • Everyone should know how to put a boxing-glove dressing +/- a volar pop slab 2. Elevation • for all cases 3. Check circulation • of finger tips hourly x 8 hours for doubtful cases 4. If patient complains of excessive pain, must remove all dressing and examine the wound 5. Rheomacrodex • To improve micro-circulation: • 500 ml q8h/q6h at most 1 bottle per day, for at most 3 days Open Hand Injuries 1. Aim is to achieve skin healing by the end of 2 weeks 2. Physical examination: • If necessary, give pethidine 50mg 1ml 30 min. prior P/E • Done in treatment room • In detail (both you and the patient sit down. Use a trolley to support the hand) 3. X-Rays • Should be available for all crush injury cases 4. Surgical toilet • If operation delayed for some reasons, preliminary toilet can be done in the treatment room under pethidine coverage

220

Guideline to hand cases

•

Irrigation with plenty of normal saline (3-6 bottles) can be done in the treatment room under pethidine coverage • And sterile swabs soaked with hibiscrub instead of peviscrub • Nails should be cleaned with a brush • This most important procedure may take up to half of the operating time 5. Debridement • Done with tourniquet inflated and then again after deflated • Wound closed after tourniquet is released and haemostasis secured 6. Dressing • Sufratulle • Then a layer of wet normal saline gauze swab • Then outter dressing 7. Nerves • All digital nerves to be repaired if possible, unless the wound is heavily contaminated 8. Bone 9. Tendons • For extensor tendons : Primary repair • For flexor tendons : Primary repair if possible 10. Finger-Tip Injury • No skin grafting • All treated by bone shortening and open method • For thumb tip loss proximal to middle of proximal phalanx, consult your senior

Guideline to hand cases

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11. All amputated finger or hands for replantation should be wrapped in sterile cloth or gauze and then put in a well sealed plastic bag which should then be put in a basin with ice and water Others 1. Amputation • No primary emergency ray amputation 2. Infection • Generous incision • Squeeze all pus out during I & D until fresh blood appear • Hand is then immobilised with boxing glove dressing + elevation + iv antibiotics • If in doubt, institute close-irrigation system for frank tendon sheath infections 3. Mallet fingers • Closed Mallet fingers should be referred to Occupational Therapist for a mallet finger splint after wound has healed up • For open mallet fingers, Primary repair + axial K-wire

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Guideline to hand cases

COMPOUND HAND FRACTURES Suggested emergency management 1. Management of soft tissue • wound debridement and lavage • approximate skin edges • raw area covered with acriflavine gauze 2. Management of fracture • debridement of contaminated fragment • reduce fracture to improve alignment • subcutaneous K-wire to splint fracture • immobilize in boxing glove for phalangeal or metacarpal fracture • immobilize in short arm pop for carpal fracture • definitive fixation if soft tissues allows or in cases with neurovascular bundle injury Definitive treatment 1. Stable fracture • active mobilization programme 2. Unstable fracture / unacceptable alignment • definitive fixation within 7 days if the plan is operative or • splintage / pop as definitive treatment

Compound hand fractures

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Compound hand fractures

PHALANGEAL FRACTURE(D/P, M/P, P/P) AIM 1. Early active mobilization 2. Convert fracture alignment to acceptable configuration by CR or OR, if indicated 3. Convert unstable # to stable # by ORIF / External Fixator 4. Avoid unnecessary immobilization DEFINITIONS 1. Stable Fracture • The fracture is stable enough for mobilization programme • The range of active movement of adjacent joints > 30% of normal range • Flexion and extension views of Xrays required 2. Acceptable Alignment Determined by Xrays • AP view : angulation < 10 • True lateral: angulation < 10 at shaft angulation < 20 at base and proximal end angulation < 45 at neck of 4th and 5th metacarpals • Area of contact > 50% • No obvious visible rotation 3. Significant soft tissue injuries • simple skin laceration is not counted as significant soft tissue injury

Phalangeal fractures

225

•

defined as flexor tendon, extensor tendon, digital nerve injuries or a large skin defect that requires reconstructive procedures eg. skin graft or flaps 4. Splintage • Intra-articular # D/P with mallet finger deformity: short mallet splint for 6 weeks • # proximal half of P/P, stable on flexion, unstable on extension: MP block splint for 3 weeks • Condylar fracture of M/P, P/P with acceptable alignment: IPT extension splint for 6 weeks CLOSED FRACTURE 1. Stable fracture with acceptable alignment free active mobilization 2. Fracture with acceptable alignment and stable on spints under study splintage 3. Fracture with unacceptable alignment CR 4. Unstable fracture / Fracture with failed CR / Re-displaced fracture Operative fixation (ORIF, CR + ext. fix., CR + percutaneous absorable K-wires, Ext. fix. + limited ORIF)

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Phalangeal fractures

FRACTURE OF DISTAL RADIUS (W.P. Cooney, Fractures in Adults, 4th ed., 1996, 769-791) 1. Colles’ # 2. Smith’s # 3. Barton’s # COLLES’ # • most common • involves distal metaphysis of the radius, which is dorsally displaced and angulated • within 2 cm of the articular surface • may extend into distal radiocarpal joint or DRUJ • Dorsal angulation (silver fork deformity) Dorsal displacement Radial angulation Radial shortening • may have an accompanying fracture of ulnar styloid • may signify avulsion of TFC insertion • Classification 1. Frykman classification 2. Melone’s classification 3. Mayo classification

Fracture of distal radius

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Frykman Classification of Colles’ Fracture

Fractures Extra-articular Intra-articular involving radiocarpal joint Intra-articular involving distal radioulnar joint Intra-articular involving both radiocarpal and distal radioulnar joint

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Distal Ulnar Extension Absent Present I II III IV

V

VI

VII

VIII

Fracture of distal radius

Type III • additional fracture component from the shaft of radius that can project into the flexor compartment

Melone’s Classification • four basic components 1. Shaft 2. Radial styloid 3. Dorsal medial 4. Palmar medial Type I • Non-displaced and minimally comminuted

Type IV • transverse split of the articular surfaces with rotational displacement

Type II (Die punch fracture) • moderate to severe displacement • comminution of anterior cortex unstable 1. anterior displacement 2. posterior displacement

Fracture of distal radius

229

230

Fracture of distal radius

Mayo Classification for intra-articular fractures of distal radius Type I • intra-articular, undisplaced

Type IV • displaced • involving both the radioscaphoid and lunate joints and the sigmoid fossa of distal radius • comminuted • always includes a fracture component into the DRUJ

Type II • displaced • involving radioscaphoid joint • associated with scaphoid lunate ligament tears • significant dorsal angulation and radial shortening

Fracture of distal radius

Type III • displaced • involving radiolunate joint • die-punch or lunate load fracture • often irreducible by traction alone

231

232

Fracture of distal radius

SMITH’S FRACTURE • reversed Colles’ fracture • volar angulated fracture of the distal radius • “garden spade” deformity • Hand and wrist displaced forward or volarly with respect to the forearm

BARTON’S FRACTURE • fracture-dislocation or subluxation in which the rim of distal radius is displaced dorsally or volarly 1. Dorsal Barton fracture 2. Volar Barton fracture

Modified Thomas Classification Type I : Extra-articular Type II : Intra-articular, cross into the dorsal surface Type III: Enters the radiocarpal joint (equivalent to volar Barton's fracture-dislocation)

Fracture of distal radius

233

234

Fracture of distal radius

FRACTURE WITH ACCEPTABLE ALIGNMENT 1. No reduction required 2. Apply pop • Age < 60 years: complete long arm pop x 3 weeks; then, short arm pop x 3 weeks • Age > 70 years: short arm backslab x 4 - 6 weeks 3. Check XRay wrist to confirm alignment (AP + Lat)

NORMAL ALIGNMENT 1. Coronal plane (XRay AP) • ulnar inclination 22 22

FRACTURE WITH UNACCEPTABLE ALIGNMENT 1. CR under sedation 2. Apply pop 3. Check XRay wrist (AP + Lat)

2. Saggital plane (XRay lateral) • volar tilt 14 14

4. Failed CR x 2 times

ACCEPTABLE ALIGNMENT 1. Coronal plane (XRay AP) • Intra-articular gap < 2 mm • Intra-articular step < 2 mm • Radial shortening < 2 mm (compared with normal side) 2. Sagittal plane (XRay lateral) • dorsal angulation < 10 to ventral angulation < 20

Fracture of distal radius

235

ORIF

*For patient with severe swelling Backslab for temporary immobilization Elevate the involved limb Definite treatment after swelling subside

236

Fracture of distal radius

emergency operation without waiting for 3D CT

POSITION OF IMMOBILIZATION OF FRACTURE 1. Colles’ fracture wrist in palmar-flexion and slight ulnar deviation 2. Smith’s fracture wrist in dorsi-flexion 3. Volar Barton fracture wrist in palmar-flexion 4. Dorsal Barton fracture wrist in dorsi-flexion STUDY PROTOCOL Inclusion criteria 1. Age 16 - 60 years 2. Type C3 intra-articular fracture (complex articular and metaphyseal facture) Protocol 1. CR under Fluroscan on day of admission to improve alignment +/- second CR under Fluroscab when edema subsides 2. 3D CT scan of wrist within one week (CT booking form attention to Dr. W Peh) 3. If alignment acceptable, long arm pop for 3 weeks then, short arm pop for 3 weeks 4. If alignment not acceptable / redisplacement within 3 weeks post-injury ORIF 5. For compound #, compartment syndrome, vascular surgery

Fracture of distal radius

237

238

Fracture of distal radius

FLEXOR TENDON INJURY (J.P. Leddy, Operative Hand Surgery, 2nd ed., 1988, 1935-1968) ZONES 1. • • 2. •

Zone I Distal to FDS insertion in M/P FDP only Zone II From distal palmar skin crease to insertion of FDS • synovial sheath • FDP + FDS 3. Zone III • From distal to carpal tunnel to distal palmar crease • where lumbrical arise 4. Zone IV • Within carpal tunnel 5. Zone V • From distal one third of forearm (at musculo-tendinous junction) to just proximal to carpal tunnel

Acute tendon injury

239

SYNOVIAL SHEATHS

240

Acute tendon injury

PULLEYS

PULLEYS ON THUMB

•

1. • 2. • • 3. •

A1 pulley located at MPJ Oblique pulley located on P/P insertion of adductor pollicis A2 pulley near insertion of FPL

•

A1 and oblique pulley are more important

thickened areas within flexor tendon sheath 1. A pulley: Annular pulley • prevent bowstringing of flexor tendon during finger flexion • A2: arise from P/P A4: arise from M/P • A1: arise from MCPJ A3: arise from PIPJ A5: arise from DIPJ • A2 and A4 most important 2. C pulley: Cruciate pulley • thinner than A pulley • concertina on flexion • entry point of blood vessels

Acute tendon injury

241

242

Acute tendon injury

ARRANGEMENT OF FDS AND FDP IN FINGERS

WOUND EXTENSION

TEST FOR FDP

TEST FOR FDS

Acute tendon injury

243

244

Acute tendon injury

• • 1. • • 2. 3. • • 4. 5.

SUTURE METHOD 1. Core suture • Modified Kessler (4/0 prolene) 2. Epitendinous suture • running stitch (6/0 prolene)

systematic one step by one step Passive positioning Distal joints (first) Proximal joints (then) “Milking” technique Tendon retriever used only if you can see the cut end of the tendon gentle handling of the tendon Proximal skin incision Infant feeding tube technique (Find the tendons in the proximal incision first) • side-by-side • end-to-end • If step 1 - 3 fails, proximal stump of tendon may retract to • In fingers, around / proximal to A1 pulley never to the wrist because of the attachment of lumbricals • In thumb, Vincula intact: around / proximal to A1 Vincula rupture: can retract to carpal tunnel or even to the wrist

PARTIAL TEAR • no need for repair if < 50% cut without any impingement TECHNIQUE OF TENDON RETRIVAL

Acute tendon injury

245

246

Acute tendon injury

EXTENSOR TENDON SIX COMPARTMENTS OVER WRIST 1ST: APL + EPB 2nd: ECRL + ECRB 3rd: EPL 4th: EDC + EI 5th: EDM 6th: ECU

POST-OPERATIVE CARE • follow flexor tendon programme

Acute tendon injury

247

248

Acute tendon injury

ZONES OF EXTENSOR TENDON INJURIES Zone Finger Thumb DIPJ IPJ I M/P P/P II PIPJ MPJ III P/P MC IV MPJ CMCJ V MC -VI Dorsal wrist -VII retinaculum Distal forearm -VIII -Middle and IX proximal forearm

ARRANGEMENT OF EXTENSOR EXPANSION

Acute tendon injury

250

249

Acute tendon injury

•

COMPARTMENT SYNDROME Causes 1. Crush injury 2. Tibial fracture 3. Vascular comprimise, eg. after dislocation of knee 4. Compression within a complete pop Signs 1. Exaggerated pain on passive stretching of the muscle group involved 2. Parathesia 3. Paralysis 4. Pulseless 5. Perishing cold 6. Pallor

All confirmed compartment syndrome require urgent fasciotomy

1. 2. 3. 4. 5.

NPO IVF as appropriate Elevate involved limb Inform MO Book EOT x Fasciotomy, Debridement +/- Fracture fixation 6. Consent 7. Pre-op. Antibiotic, if indicated 8. May require urgent bedside fasciotomy if situation is critical

Compartment pressure • < 40 mmHg within all compartments

Compartment syndrome

251

252

Compartment syndrome

NECROTIZING FASCIITIS Risk Factors 1. Elderly patients 2. Liver cirrhosis 3. DM 4. Immunocomprimised, eg. steriod taking 5. Marine organism injury/contact Organisms 1. Vibrio 2. Group A haemolytic Streptococcus 3. Others, mixed organisms Diagnosis 1. +/- septic patients 2. Rapidly progressing cellulitis in hours (which spread proximally in an abnormal rapid manner) 3. (Thus, need frequent assessment) 4. Clinical signs • Bullae or blisters • Patchy cyanosis of skin • Initially painful, but later become painless or numb (despite ongoing cellulitis) • Superficial venous thrombosis 5. Aspirate subcutaneous plane with an angiocatheter and send the tip of angiocatheter for urgent Gm smear

Necrotizing fasciitis

253

Management 1. NPO 2. IVF +/- Fluid resuscitation 3. Close monitoring (BP/P q1h, u/o q1h, T , +/CVP, +/- H’stix) 4. Urgent inform MO 5. Urgent consult microbiologist 6. iv antibiotics (Penicillin G + Ciprofloxacillin) 7. Book EOT x Debridement +/- Amputation 8. Consent major +/- minor 9. Routine pre-op. work-up 10. T & S; blood products(FFP, Platelet concentrate) if indicated 11. Blood culture

254

Necrotizing fasciitis

PRINCIPLE OF CLOSED REDUCTION identify the direction of force leading to the fracture identify the intact periosteum, which can act as soft tissue hinge

Technique 1. Traction: to disimpact the fracture Exaggerate initial fracture configuration(if necessary): to get clear of any jamming periosteum or bone spike Reduction by reversing the direction of forces which initially leading to the fracture and maintain the fracture in a slightly over-corrected position (to put the intact soft tissue hinge in tension)

PRINCIPLE OF PLASTER TECHNIQUE Plaster of Paris a layer of cotton wool is interposed between the skin and plaster the wet plaster bandage is rolled around the limb To immobilize a fracture satisfactory, one joint above and one joint below the fracture are included. Molding: plaster bandage is pressed and pushed round the limb by the pressure of the thenar eminence of the surgeon Principle of Three-point fixation: 1. Identify soft tissue hinge 2. Two of the three points are those where the surgeon’ hands molded the plaster while setting; one is applied to the proximal fragment while the other is applied to the distal fragment 3. The third point extends over a diffuse area at the proximal part of the cast

If a fracture slips in a well padded plaster, then the fracture was mechanically unsuitable for treatment by plaster and another mechanical principle should have been chosen WEDGING Opening wedge vs closing wedge Correct angulation of #

Intravenous regional block / Bier’ block (Stewart, Traction and Orthopaedic Appliances, 1983Ed.) For operations < 2 hours in the region of hand / forearm Dilute lignocaine without adrenaline to 0.5% Apply double pneumatic cuff: For operations in hand- forearm cuff For operations in forearm- cuff over region of arm Insert a small intravenous cannula (22G) into a superficial vein, preferably over dorsum of hand Exsanguinate the limb by elevation for four minutes or applying Esmarch bandage Inflate the distal cuff to a pressure of 250 mmHg and maintain this pressure during the duration of operation Inject the required dose of 0.5% lignocaine slowly Cuff over forearm: 25 ml Cuff over arm : 35 ml (Maximum dose: < 3 mg lignocaine per kg body weight) Wait for analgesia to work. About 4 - 6 minutes. Remove the cannula On completion of the operation, deflate the cuff. The cuff should be kept inflated for at least 30 minutes after injecting the local anaesthetic agent Sensation will usually return within 8 minutes Allow patient to recover under supervision ’

Complications of tourniquet: refer to chapter on tourniquet Complications of overdose of LA: Mild: palpitation, dizziness, blurred vision, nausea, vomiting, tinnitus, peri-oral numbness Severe: arrhythmia, tremor, convulsion, cardiac arrest

’

TOURNIQUET(Stewart, Traction and Orthopaedic Appliances, 1983Ed.) • It is used to provide a bloodless field after exsanguinating blood from the limb Contra-indications to the use of tourniquet: 1. Peripheral vascular disease 2. Severe crushing injuries 3. Sickle cell disease Contra-indications to expressive exsanguination: 1. Infections and tumor 2. Proven or suspected deep vein thrombosis Methods of exsanguination: 1. Elevate the limb as vertically as possible for four minutes 2. Apply Esmarch bandage Tourniquet pressures: 1. Upper limb-250 mmHg } At least twice the systolic blood Lower limb-300 mmHg } pressure Tourniquet time: < 2 hours Dangers of tourniquet: 1. Dangers from exsanguination by applying Esmarch bandage a. Skin damage b. Embolisation of deep vein thrombosis, malignant tumor and infection c. The heart may be overloaded 2. Dangers from the pressure in the tourniquet cuff

Tourniquet paralysis syndrome (Tourniquet palsy)(Moldaver, Archieves of Surgery, 1954) - caused by pressure Motor paralysis with hypotonia or atonia but without appreciable atrophy Sensory dissociation--Touch, pressure, vibration and positional sense: absent Pain sensibility is rarely lost. Hyperalgesia. Heat and cold sensation: preserved The colour and temperature of skin are normal. Peripheral pulses are normal Recovery from full paralysis takes more than three months 3. Dangers from ischaemia - The tissues distal to the cuff become anoxic, acidotic and loaded with metabolites Post-tourniquet syndrome (Bruner, JBJS, 1951) - due to ischaemia and its duration Puffiness of the hand and fingers Stiffness of the joints in hand to a degree not otherwise explained Colour changes in the hand which is pale when elevated and congested when dependent Subjective sensations of numbness without true anaesthesia Objective evidence of weakness of muscles in the hand and forearm without real paralysis 4. Dangers from bleeding after closure of the wound 5. Dangers from failing to remove the tourniquet

HALO-TRACTION Indications 1. Reduce a dislocation or fracture dislocation of cervical spine 2. Immobilize an unstable cervical spine fracture or dislocation 3. Maintain position of cervical spine before and after operative fusion, if indicated

4. Shave the scalp 5 cm around each pin site 5. Slip the halo ring over the skull and ask an assistant to hold it in correct position 6. Advance the positioning pins (about 3) so that the halo ring lies evenly around the skull 7. Infiltrate the site of insertion of fixing pins with 2 - 3 ml lignocaine 8. Ask the patients to close his eyes 9. Advance the four fixing pins until finger tight

Procedure 1. Choose a halo ring of appropriate size

2. Patient lie supine 3. Identify sites of the four fixing pins • 1 cm above the lateral one third of eyebows in the shallow grooves on the forehead between the supra-orbital ridges and frontal protuberances • 1 cm above the tops of the ear in the line with the mastoid process

Halo traction

263

10. Using torque-limiting screw-drivers, further advance the pins in diagonally opposite pairs at the same time (avoid side to side drifting of the halo ring) 11. Torque limit: • Adult 6 lb/inch • Children < 4 lb/inch (use 6 pins in children) 12. Remove the positioning screws 13. Apply traction, if indicated 14. Start with 2 kgf 15. Elevate the head of bed to provide counter traction

264

Halo traction

Management of Skull Traction 1. Apply minimum traction weight Recommended tracton weights (Crutchfield, 1954) Level Minimum Maximum weight weight C1 5 lb 10 lb (2.3 kg) (4.5 kg) C2 6 lb 10 - 12 lb (2.7 kg) (4.5 -5.4 kg) C3 8 lb 10 - 15 lb (3.6 kg) (4.5 - 6.7 kg) C4 10 lb 15 - 20 lb (4.5 kg) (6.7 - 9.1 kg) C5 12 lb 20 -25 lb (5.4 kg) (9.0 - 11.3 kg) C6 15 lb 20 - 30 lb (6.7 kg) (9.0 - 13.5 kg) C7 18 lb 25 - 35 lb (8.2 kg) (11.3 - 15.8 kg) 2. Check alignment with X-Ray / mini-C arm 3. For trauma cases, if reduction has not been obtained, gradually increase traction weight 4. Repeated clinical and radiological assessment. Make sure that the reduction can be achieved within a few hours 5. Stop increasing traction weight if there is increase in neurological symptoms or if X ray reveal over-distraction 6. For OR if closed reduction with traction fail

Important: Check daily that 1. Neurological examination of patient has not been changed 2. Check the tightness of fixing screw by using a torque limiting driver • 1st week : daily st • after 1 week: twice each week 3. Watch out for pin tract infection

Halo traction

266

265

Halo traction

GUSTILO (& ANDERSON) CLASSIFICATION (for open fracture) (R.B. Gustilo and J.T. Anderson, JBJS, 58A:453-458, 1976) Type I : Open fracture with a clean wound < 1cm long Type II : Open fracture with a laceration more than 1 cm long (1-10cm), without extensive soft tissue damage, flaps or avulsion Type III : Open fracture with extensive soft tissue damage (laceration > 10 cm) III A : Adequate coverage of the fracture bone despite extensive soft tissue lacerations, flaps; or high energy trauma regardless of the size of the wound III B : Extensive soft-tissue injury with periosteal stripping and bony exposure, usually associated with massive contamination III C : Open fracture with associated vascular damage requiring repair

Gustilo and Anderson classification

267

268

TSCHERNE AND GOTZEN CLASSIFICATION (1984) • classification of soft tissue conditions in closed fractures Grade 0 little or no soft tissue injury

Grade III extensive contusion or crushing of skin or destruction of muscle; also subcutaneous avulsions, decompensated compartemnt syndrome, or rupture of a major blood vessel

Grade I significant abrasion or contusion

Grade II deep contaminated abrasion with local contusional damage to skin or muscle

Tscherne Classification

269

270

Tscherne Classification

INJURY SEVERITY SCORE (ISS) (S. Baker, J. Trauma, 14:187-196, 1974) • for evaluation of multiple trauma patient • evaluate 6 body system • Abbreviated Injury Scale Defined Body Area 1. Soft tissue 2. Head and neck 3. Chest 4. Abdomen 5. Extremity and/or pelvis 6. Cardiovascular • • 1. 2. 3. 4. 5. •

• • •

non-fatal injury based on a rating system 0 (no injury) to 5 (critical) Severity Code Minor Moderate Severe (non-life threatening) Severe (life threatening) Critical (survival uncertain) Overall mortality in the presence of associated injury to a second or third body system, but injury to a forth system has little effect on survival (Baker, 1974) ISS = A2 + B2 + C2 (i.e. Sum of the squares of the three highest Abbreviated Injury Scale Grades) Minimum ISS = 0 Maximum ISS = 75

Injury Severity Score

271

HOSPITAL TRAUMA INDEX EXTREMITY INJURY (Am. Coll. Surg., 65:31-33, 1980) Injury No injury Minor sprains and fractures--no long bones Simple fractures: humerus, clavicle, radius, ulna, tibia, fibula, single nerve Fractures: multiple moderate, compound moderate, femur(simple), pelvic(stable), dislocation major, major nerve Fractures: two major, compound femur, limb crush or amputation, unstable pelvis Fractures: two severe, multiple major

Class No injury Minor

Index 0 1

Moderate

2

major

3

Severe

4

Critical

5

272

Hospital Trauma Index

MANGLED EXTREMITY SEVERITY SCORE (MESS) (K. Johansen, J. Trauma, 30:568-573, 1990) Skeletal / soft tissue injury Low energy (stab, simple fracture, 1 low-velocity gunshot wound) Medium energy (open or multiple 2 fractures, dislocation) 3 High-energy (close-range shotgun or high-velocity gunshot wound, crush injury Very high energy (above plus gross 4 contamination, soft tissue avulsion) Limb ischaemia Pulse reduced or absent but perfusion 1 normal Pulseless; paresthesias, diminished 2 capillary refill 3 Cool, paralysed, insensate *score doubled for ischaemia > 6 hours Shock Systolic blood pressure always > 90 1 mmHg Hypotension transiently 2 Persistent hypotension 3 Age < 30 years 1 30 - 50 years 2 > 50 years 3 • Score < 7 points: limb salvage MESS

273

274

SURGICAL SITE INFECTION (SSI) Risk Factors 1. ASA (American Society of Anaesthesiology) 3, 4, 5 2. Dirty-infected wound and contaminated wound 3. Prolonged duration of operation Risk index 0 : no risk factor present 1 : any one of the above risk factors present 2 : any two of the above risk factors present 3 : all of the above three risk factors present

*( ): Figure reported in National Nosocomial Infections Surveillance System (Jan 1987 - Dec 1990)(Am Journal of Med. 91 3B: 152S-157S) American Society of Anaesthesiology (ASA) 1. Healthy 2. History of medical disease, no disabling 3. Major medical disease, high risk if not well controlled 4. High risk to operation, not contraindicated for life saving procedure 5. Pending death within 24 hours

SSI Rates in UOU QMH Jan 96 - Dec 96 Classification of wound Risk Index Limb Amputation Spinal Fusion Open reduct-i on of # Hip prosthesis Others

0

1

2

3

0% (3.9%)

0% (4.6%)

5.9% (5.5%)

8.3% (7%)

6.3% (0.7%) 0.3% (1.0%)

6.3% (1.9%) 2.3% (1.8%)

10% (4%) 0% (3.5%)

-(50%) -(3.7%)

1.4%

7.1%

4.2%

--

0% (0.4%)

3% (0.7%)

9.3% (2.3%)

-(0%)

Surgical site infection

275

Clean wound Clean-contaminated wound Contaminated wound Dirty-infected wound

276

Infection Rate 2.1 % 3.3 % 6.4 % 7.1 %

Surgical site infection

RECOMMENDATIONS ON USE OF ANTIBIOTIC PROPHYLAXIS IN ORTHOPAEDIC SURGERY 1a

1b

2

Non-traumati c No foreign body Excluding: immunocom promised open intra-articula r procedure spine surgery with grafting Non-traumati c No foreign body immunocom promised open intra-articula r procedure spine surgery with grafting Non-traumati c implants

Antibiotics

eg. Arthroscopy Tendon transfer Posterior diskectomy

eg. Arthrotomy ASF

3

Non-traumati c prosthesis

eg. Total joint replacement

4

Close Traumatic No FB

5

Close Traumatic Implants Close Traumatic Prosthesis Soft tissue wound No #

eg. Repair of tendo Achilles eg. Malleolar # DHS eg. AMA

No Antibiotics

Cefazolin 1g iv on induction In cefazolin sensitivity, use gentamycin 1.5 mg/kg

6 7

8 eg. Osteotomy Spinal instrumentation

Cefazolin 1g iv on induction In cefazolin sensitivity, use gentamycin 1.5 mg/kg

277

278

Gustilo I & II compound #

eg. Laceration of Tendo Achilles

Cefazolin 1g iv on induction In cefazolin sensitivity, 1g slow iv vancomycin infusion on induction Cefazolin 1g iv on induction In cefazolin sensitivity, use gentamycin 1.5 mg/kg Cefazolin 1g iv on induction Cloxacillin 1g q6h iv Gentamycin 1.5mg/kg q8h for 3 days For farm injury, add Flagyl 500mg q8h

Antibiotics

9

Gustilo III compound #

10

Diabetic foot

Antibiotics

As above for 3 days and individualized thereafter according to sensitivity Augmentin 375 mg tds po or 1.2g iv on induction Duration individualized

279

280

Antibiotics

ACUTE SPINAL CORD COMPRESSION (2 to acute trauma) • high dose of iv methylprednisolone • start within 8 hours of injury • loading dose : 30 mg/kg iv within 1 hour • maintenance dose : 5 mg/kg/hour x 23 hours and then stop • covered with Zantac 50 mg iv q8h DRUGS FOR CR UNDER SEDATION • valium 10 mg iv • pethidine 50 mg iv • decrease dose in elderly patients, paediatric patients • watch out for respiratory depression

Drugs

281