This document provides an overview of orthopedic and trauma topics taught by Dr. Nelly Maoga. It covers principles of fracture diagnosis and treatment including closed and open reduction techniques. Specific fracture types like open fractures and physeal injuries in pediatrics are addressed. Fracture healing stages and complications such as infection, delayed union, and non-union are also reviewed. The learning objectives focus on trauma management, pediatric and adult orthopedic disorders, and classifying and managing fractures and their issues.
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Orthopedic Trauma and Fracture Management
1. BCN 13: ORTHOPEDIC AND
TRAUMATOLOGY
Dr. Nelly Maoga
Trauma and Orthopedic Surgeon
2. LEARNING OBJECTIVES
• Describe concepts relating to first aid and transportation priorities in poly-trauma situations.
• Manage metabolic and pediatric orthopaedic disorders.
• Describe and manage emergency orthopaedic disorders among children and adults.
• Classify, diagnose and appropriately manage or refer fractures and their complications.
5. Introduction
• Fracture: Break in the structural continuity of a bone (complete and incomplete)
• Classification is subdivided according to:
(i) Based on aetiology: Pathological fracture, Fragility fracture, Stress fracture or Traumatic
(ii) Clinically: Open or Closed
(iii) Based on Pattern: transverse, wedge, comminuted, oblique, spiral, compression, greenstick
6.
7.
8. • When describing a fracture, include:
Radiographs Adequate
Anatomical Site
Articular Involvement
Configuration of displacement
Pattern of Fracture
Age: adult/pediatric
10. Diagnosis
• History: Pain, Mechanism of Injury, Associated Injury
• Physical examination: ATLS (primary and secondary survey)
• Investigations: Trauma Series ( AP, L, Open mouth C-spine, CXR, Pelvic
X-ray and FAST), X-ray of deformed limb.
11. Treatment
• Patient Evaluation and Stabilization (resuscitation) (ATLS)
• Definitive treatment: Reduction, Maintenance of reduction and
Rehabilitation
12. Advanced Trauma Life Support (ATLS)
• Primary Survey: ABCS
• Secondary Survey: Full physical exam, history and imaging.
• Tertiary Survey
13.
14.
15. • Adequate evaluation of resuscitation:
Serum lactate level: normal range <2.5mmol/L (<4.5 mg/dl)
Base deficit normal -2 to +2
Gastric mucosal pH
Urine output of 0.5-1 ml/kg/h (30cc/hr)
16. Reduction
• Restoration of fracture fragment to an acceptable position
• Its aim is –to restore the length
- to restore alignment and rotation
- to restore perfect joint surface in articular fracture
• Two methods: Conservative ( Closed) and Open Reduction ( Operative)
18. Skin Traction
• Maximum weight is 5kg
• Complications: Skin Sloughing, neurovascular compression and
compartment syndrome
• Contraindications: Abrasions, Impaired circulation (varicose veins,
gangrene), weight of more that 5kg
19. Skeletal Traction
• Types of Skeletal Traction: Balanced Skeletal traction and Skull Tong
Traction
• Indications: require weight of more than 5kgs
• 10% of body weight
• Complications: Pressure Ulcers, pin tract infection, neurovascular injury
20. Maintenance of Reduction
• The aim is to keep the fracture fragment in an acceptable position
• The methods:
Casting
Continuous Traction
External Fixation
Internal Fixation
21. CASTING
• Plaster of Paris (P.OP) is hemihydrate calcium sulphate which reacts with
water to form hydrated calcium
• It can be used as a splint (slab) or full-cast
• Indications:
As a first aid for the treatment of fracture
Corrective Deformity
Prevent pathological fracture
26. External Fixation
• Done by attaching pins above the fracture with a frame;
• Indications;
Fracture with severe soft tissue damage or contamination
Fracture around a joint that hinders initial joint fixation e.g. tibia plateau #
Damage control orthopaedic for poly-trauma patient
Infected fracture
27. • Types of EXFIX: Uni-planer and Mutli-
planer
• Complications:
Pin site infection/ loosening
Mal-union and Non-union
Neurovascular injury
Malalignment
Ankle Spanning EXFIX
28. Rehabilitation
• It aims to restore normal function
• The methods are:
Elevation
Active motion
Assisted motion
Functional activity
29. OPEN FRACTURE
• Defn: A break in the skin and soft tissue communicating with a fracture
• Classifying the fracture is essential for management.
• Gustilo Anderson Classification
30.
31.
32. Treatment for open fracture
• ATLS protocol
• Antibiotic prophylaxis and Tetanus toxoid vaccine
• Surgical Toilet (Surgical Debridement)
• Stabilisation of the fracture
• Early definitive wound care and fracture fixation
34. • Joint dislocation is the loss of congruity of a joint
• It may be associated with a peri-articular fracture.
• Cause: high energy injury (e.g. RTA, Fall from a height etc)
(must read: must know the following joint dislocations: shoulder, hip, knee and ankle)
35. • Symptoms: Pain, inability to use the limb, swelling.
• Sign: swelling, shortening, tenderness, +/- distal pulses and sensation.
• Imaging: radiographs ( rule of two)
36. Treatment:
• Joint reduction, either closed or open.
• Check neurovascular states
• Get post-reduction radiographs
• Immobilize the joint with a splint or cast, or brace.
39. Important features of Pediatric
• Growth plate (physis)
• Bone resilience (greenstick fractures)
• Thick periosteum
• Rapid healing
• Remodeling
• Catch-up growth
40.
41. • Phyeasl injury: injury and disruption of the physis, which might extend to the
metaphysis or the epiphysis.
• Physis is made of hyaline cartilage and is responsible for bone growth.
• Classification of the injury: Salter-Harris Classification
42.
43. • Most common Salter-Harris physeal injury: Type II (75%)> Type III and
Type IV (10%)> Type I (5%) > Type 5 (uncommon)
• Symptoms: pain, swelling, inability to use the limb and deformity
• Signs: tenderness, swelling, reduced range of motion
• Diagnosis: Radiographs
44. Treatment
• Type 1 and 2: closed reduction and immobilisation with a cast. If closed reduction fails, they
require ORPP. Patients require casting for 3-6 weeks.
• Type 3 and 4: usually managed surgically ORPP or ORIF. Patients require immobilisation for
4-8 weeks.
• Type 5: diagnosed retrospectively, leads to growth arrest.
• Physical activity (School P.E.) after 4-6 weeks of cast or implant removal
47. • The healing of bone is similar to other tissue. Start immediately after a
fracture.
• Macroscopic: cancellous bone and cortical bone
Cortical bone: heals by callus formation. Five stages of healing
Cancellous bone: heals without callous formation
48. I. Stage of Hematoma: ( 1 week)
Fracture, bleeding, ischemic necrosis of bone, stripping of periosteum and soft tissue, necrosis of osteocytes
II. Stage of Granulation Tissue: (week 2-3)
The proliferation of cells, organises to form osteoblasts and fibroblasts, soft granulation tissue.
III. Stage of Callus Formation: (week 4-12)
Granulation, osteoblasts, mineralisation of the granulation tissue- termed as woven bone.
49. I. Stage of Consolidation: (1-4 yrs)
Woven bone is replaced by lamellar bone
I. Stage of Remodeling
Gradual bone strengthening.
Prominent in pediatric fracture
Can never restore the joint line surface to its normal alignment.
51. Complications due to fracture
• Infection (Septic nonunion)
• Delayed Union
• Non-union
• Avascular Necrosis
• Malunion
• Shortening
Complications due to Injury
• Injury to blood vessel
• Injury to nerve
• Injury to viscera
• Injury to tendons
• Fat embolism
• Compartment Syndrome
52. Complications Due to Fracture
I. Infection:
-A wound infection that extends to the bone
and causes bone infection ( osteomyelitis)
• Acute Infection: < 2weeks
• Subacute infection: 2-6 weeks
• Chronic infection: > 6weeks
• Diagnosis: CBC, ESR, CRP, Xray,
tissue Cultures
• Treatment:
-Antibiotic for six weeks
-implant removal
-EXFIX
53. • II. Delayed Union
-Failure to reach union six months
post-injury
-Risk factors:
Metabolic disease- D.M, Osteoporosis
Smoking
Increase alcohol intake
• Treatment:
-Surgery and bone grafting
54. Non-union
• Due to lack of adequate fracture stabilisation, poor blood supply of both.
• Types of non-union:
Hypertrophic non-union
Oligotrophic non-union
Atrophic nonunion
Septic nonunion
58. • Septic Non-union:
- Caused by infection
- CRP is the most accurate predictor
of infection
• Treatment
-antibiotics
-EXFIX
-surgery once infections is controlled
59. • Must read fracture: ankle fractures, supracondylar fracture, femur
fracture, tibia fracture, forearm fracture, Fat embolism
• Assignment:
• Write an essay on Compartment Syndrome;
(i) definition
(ii) causes
(iii) pathophysiology
(iv) Diagnosis and treatment.
(v) Complications (including nerve injury)