Dr. Rami Abo Ali

1. ORTHOPEDIC SURGERY
Dr. Rami Abo Ali
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
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2. COMPLICATIONS OF FRACTURES
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
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3. GUSTILO CLASSIFICATION OF OPEN FRACTURES
 Type I
 wound ≤1 cm, minimal contamination or muscle damage
 Type II
 wound 1-10 cm, moderate soft tissue injury
 Type IIIA
 wound usually >10 cm, high energy, extensive soft-tissue damage,
contaminated
 adequate tissue for flap coverage
 farm injuries are automatically at least Gustillo IIIA
 Type IIIB
 extensive periosteal stripping, wound requires soft tissue coverage
(rotational or free flap)
 Type IIIC
 vascular injury requiring vascular repair, regardless of degree of soft
tissue injury
 Most accurate way to grade open fractures is by intra-operative
examination
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Dr.
Rami
Abo
Ali

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IIIA
IIIB
IIIC
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5. GUN SHOT WOUNDS
 Gun shot wounds represent the second-leading cause of death for
youth in United States.
 wounding capability of a bullet directly related to its kinetic energy
 damage caused by
 passage of missile
 secondary shock wave
 cavitation
 A gunshot wound is different; it must never be closed and
debridement must be very thorough, taking special care to remove
fragments of clothing, soil and wadding from the wound.
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Orthopedic
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Dr.
Rami
Abo
Ali

6. GUN SHOT WOUNDS
 Classification
 Low velocity
 muzzle velocity <350 meters per second
 wounds comparable to Gustillo Type I or II
 Intermediate velocity
 muzzle velocity 350-650 meters per second
 highly variable depending on distance from target
 wound contamination/infection with close range injuries due to shotgun
wadding
 High velocity
 muzzle velocity >600 meters per second
 military (assault) and hunting rifles
 wounds comparable to Gustillo Type III regardless of size
 high risk of infection
 Physical exam
 perform careful neurovascular exam (clinical suspicion for compartment
syndrome secondary to increased muscle edema from higher velocity
wounds
 examine and document all associated wounds
 Radiology (x-rays , CT )
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Orthopedic
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Dr.
Rami
Abo
Ali

7. GUN SHOT WOUNDS
 Treatment General
 Non-operative
 local wound care, anti tetanus +/- short course of oral or IV antibiotics
 low-velocity injury with no bone involvement or non-operative
fractures
 primary closure contraindicated
 antibiotic use controversial but currently recommended if wound
appears contaminated
 Operative
 Open reduction internal fixation (ORIF) /external fixation
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Orthopedic
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Dr.
Rami
Abo
Ali

8. BONE GRAFTING
 A material with either osteoconductive, osteoinductive,
and/or osteogenic properties
 Autografts – From patient (Cancellous, Cortical, Vascularized
bone graft)
 Allografts – From another individual (Fresh, Fresh frozen)
 Xenografts (Heterograft) - From another species
 demineralized bone matrix (DBM)
 synthetics
 bone morphogenetic protein (BMP)
 stem cells
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Orthopedic
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Dr.
Rami
Abo
Ali

9. BONE GRAFTING
 Bone graft has aspects of one or more of these three properties
 osteoconductive
 material acts as a structural framework for bone growth
 demineralized bone matrices (DBMs)
 osteoinductive
 material contains factors that stimulate bone growth and induction of stem
cells down a bone-forming lineage
 bone morphogenetic protein (BMP) is most common from the transforming growth
factor beta (TGF-B) superfamily
 osteogenic
 material directly provides cells that will produce bone including
primitive mesenchymal stem cells, osteoblasts, and osteocytes
 mesenchymal stem cells can potentially differentiate down any cell line
 osteoprogenitor cells differentiate to osteoblasts and then osteocytes
 cancellous bone has a greater ability than cortical bone to form new bone
due to its larger surface area
 autologous bone graft (fresh autograft and bone marrow aspirate) is the
only bone graft material that contains live mensenchymal precursor cells
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Orthopedic
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Dr.
Rami
Abo
Ali

10. INDICATIONS OF BONE GRAFTS
 Bone gaps in trauma or communiated fractures
 Delayed or nonunion of fractures
 Bony defects after benign or malignant lesion resection
 Reconstruction of functional and contour deficits in craniofacial
skeleton
 Arthrodesis
 Limb lengthening procedures
 Spinal fusion
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Dr.
Rami
Abo
Ali

11. COMPLICATIONS OF FRACTURES
 Immediate complications
 Early complications
 Late complications
 Immediate complications
 Haemorrhage.
 Damage to arteries.
 Damage to surrounding soft tissues.
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Ali

12.  The normal blood volume is about 5 litres , and serious problems
occur if more than one third of the blood volume is lost from the
circulation
 From this, it follows that patients with two fractured femurs or a
fractured pelvis can go into hypovolemic shock or exsanguinate
unless prompt action is taken.
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Dr.
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Abo
Ali
HEMORRHAGE

13. DAMAGE TO ARTERIES
 The arteries most commonly damaged at the moment of
injury are:
 The middle meningeal artery in temporoparietal skull
fractures.
 The brachial artery in supracondylar fractures of the humerus
in children.
 The popliteal artery in fractures and dislocations at the knee.
 The aorta in fractures of the 4th and 5th thoracic vertebrae.
 The femoral artery in fractures of the femur
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Dr.
Rami
Abo
Ali

14. DAMAGE TO SURROUNDING STRUCTURES
 Serious problems can also arise from damage to
neighbouring structures:
 Broken rib – perforated lung – pneumothorax.
 Fractured sternum – ruptured aorta - exsanguination.
 Broken ribs – ruptured liver – exsanguination.
 Broken neck – paraplegia with paralysis of phrenic nerve (C3,
4, 5) – asphyxia.
 Broken skull – brain damage.
 Fractured face or mandible – obstructed airway
– suffocation.
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Dr.
Rami
Abo
Ali

15. EARLY COMPLICATIONS
 Wound infection.
 Fat embolism.
 Shock lung.
 Chest infection.
 Disseminated intravascular coagulation.
 Exacerbation of generalized illness.
 Compartment syndrome
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Dr.
Rami
Abo
Ali

16. WOUND INFECTION
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Ali
Wound infection from open fractures can lead to septicemia and
tetanus or gas gangrene from anaerobic infection.

17. FAT EMBOLISM
 Fat embolism is an uncommon complication which leads to
hypoxia from pulmonary insufficiency.
 Major cause of morbidity and mortality after fractures in the
patient with multiple injuries.
 It is a type of embolism in which the embolus consists of fatty
material
 Fat embolism occurs in up to 90% of all trauma patients.
 Fat embolism syndrome (FES) accounts for only 2-5% of
patients who have long-bone fractures
 The likelihood of developing fat embolism syndrome is not
proportional to the severity of the injury
 At postmortem examination, the alveoli are found to be
crammed with small fat globules
 Fat embolism syndrome (FES) typically manifests 24 to 72
hours after the initial insult
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Orthopedic
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Dr.
Rami
Abo
Ali

18. FAT EMBOLISM
 Pathophysiology
 Two theories regarding the causes of fat embolism include
 mechanical theory
 embolism is caused by droplets of bone marrow fat released into
venous system
 metabolic theory
 stress from trauma causes changes in chylomicrons which result in
formation of fat emboli
 Triad of FES
Hypoxia
Neurological abnormalities
Petechial rash 18
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

19. DIAGNOSIS CRITERIA
Orthopedic
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Dr.
Rami
Abo
Ali
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 Major (1)
 hypoxemia (PaO2 <
60 mmHg)
 CNS depression
(changes in mental
status)
 petechial rash
 pulmonary edema
 Minor (4)
 tachycardia
 pyrexia
 retinal emboli
 fat in urine or sputum
 thrombocytopenia
 decreased HCT
Additional
PCO2 > 55
pH < 7.3
RR > 35
dyspnea
anxiety
Management : supportive
Nonoperative
mechanical ventilation with high levels of PEEP (positive end
expiratory pressure)
Prevention
early fracture stabilization

20. SHOCK LUNG
 Shock lung, also known as wet lung or
acute respiratory distress syndrome (ARDS), can follow
slight fluid overload and is made worse if there is any
damage to the lungs, aspiration into the lung or over
transfusion.
 Edema and electrolyte retention secondary to the trauma
also contribute to the adult respiratory distress syndrome.
 Treatment is by oxygen and ventilation.
 Do not over transfuse with crystalloids!
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

21. CHEST INFECTION
 Chest infection can be fatal in the elderly patient
or patients with shock lung.
 Early mobilization and vigorous chest physiotherapy are
the best prophylaxis.
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
Diffuse intravascular coagulation (DIC)
Diffuse intravascular coagulation (DIC) can follow any injury
and is due to a disturbance of the clotting mechanism.
The help of the hematologist is needed in treatment, which
may require fresh frozen plasma or platelets, and heparin.

22.  Exacerbation of generalized illness in unfit patients
 Diabetes, chest disease, coronary insufficiency and
any other pre-existing problem can be exacerbated
by a fracture.
 Infection
 Orthopedic textbooks of the 19th century describe
infections of closed fractures, presumably from a
bacteraemia, with the patients dying of septicemia.
 This complication is, thankfully, rarely seen in modern
times.
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

23. COMPARTMENT SYNDROME
 What is a compartment?
 Muscle are arranged in different compartments and surrounded by
one fascia, this arrangement is called osteofascial compartment.
 Normal compartment pressure: 5 – 15 mmHg
 Compartment syndrome is an increased pressure within
enclosed osteofascial space that reduces capillary perfusion
below level necessary for tissue viability;
 The underlying mechanism is:
 Decreased Compartment Size
 Increased Compartment Content
 Combination of both
 Compartment pressures over 30 mm Hg or within 30 mm Hg
of the diastolic pressure are indicative of compartment
syndrome.
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

24.  Decreased Compartment Size
 Tight dressing; Bandage/Cast
 Localized external pressure; lying on limb
 Closure of fascial defects
 Increased Compartment Content
 Bleeding; Fractures, vascular injury, bleeding disorders
 Increased Capillary Permeability: Ischemia / Trauma / Burns /
Exercise / Snake Bite / Drug Injection / IVF
 Fractures are the most common cause
 Tissue survival:
 Muscle
 3-4 hours - reversible changes
 6 hours - variable damage
 8 hours - irreversible changes
 Nerve
 2 hours - looses nerve conduction
 4 hours - neuropraxia
 8 hours - irreversible changes
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Dr.
Rami
Abo
Ali

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Abo
Ali

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Ali

27. COMPARTMENT SYNDROME
 The classic features of ischaemia are the five Ps:
• Pain
• Paraesthesia
• Pallor
• Paralysis
• Pulselessness
 Treatment
 Non-operative
 Observation (diastolic differential pressure is > 30)
 bi-valving the cast and loosening circumferential dressings
 Operative
 emergent fasciotomy of all affected compartments
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Orthopedic
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Dr.
Rami
Abo
Ali

28. LATE COMPLICATIONS
 Deformity.
 Osteoarthritis of adjacent or distant joints.
 Aseptic necrosis.
 Traumatic chondromalacia.
 Complex Regional Pain Syndrome (CRPS)
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Orthopedic
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Dr.
Rami
Abo
Ali

29. DEFORMITY
 Deformity due to malunion may require late correction.
 Angular deformities greater than 5° can cause degenerative
arthritic changes in the joints above and below the fracture.
 When treating a broken bone it is important, therefore, not to
accept an angular deformity unless there is a real possibility
that the fracture will remodel.
 Patients less than 9 years of age with a deformity close to the
growth plate and in the axis of joint movement may remodel
the fracture over a period of 1–2 years but remodelling in
other planes, and in older patients, is much less satisfactory.
 Deformities can be corrected by an osteotomy with fixation of
the bone or by angular corrections using external fixators and
bone lengthening techniques .
 These limb-lengthening techniques can also be used to correct
shortening as a result of bone loss, etc.
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Orthopedic
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Dr.
Rami
Abo
Ali

30. OSTEOARTHRITIS OF ADJACENT JOINTS
 Joint surfaces broken at the time of the fracture are much
more likely to develop osteoarthritis than is ban intact joint
because of abnormal mechanical wear on the rough joint
surfaces
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Dr.
Rami
Abo
Ali

31. OSTEOARTHRITIS OF DISTANT JOINTS
 The joint surface does not have to be broken for osteoarthritis to develop
.
 Ex : If there is a malunion of the tibia, excessive load will be taken by
both the knee and the ankle, and this causes early degenerative change.
 If the leg is short after a fracture, the patient will walk with a tilt to one
side, compensated for by a curve in the spine.
 This causes excessive wear on the facet joints on the side opposite the
fracture and degenerative osteoarthritis will follow
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Orthopedic
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Dr.
Rami
Abo
Ali

32. ASEPTIC NECROSIS (AVASCULAR NECROSIS)
 If the fracture interrupts the blood supply to bone the
affected bone dies, the bone collapses, the joint is
destroyed and the patient develops a stiff and painful
joint.
 Aseptic necrosis often takes 2 years to develop. This is
important if the injury is the subject of litigation.
 If a patient with an excellent result 12 months after injury
is reassured that there has been a perfect recovery and
settles the claim on this basis, he or she will be very
disappointed if aseptic necrosis develops 12 months later.
 Aseptic necrosis is common in bones that derive most of
their blood supply from the medullary cavity rather than
the surrounding soft tissues or periosteum
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Dr.
Rami
Abo
Ali

33. ASEPTIC NECROSIS (AVASCULAR NECROSIS)
 Three bones are particularly susceptible :
 The femoral head following a femoral neck fracture.
 The scaphoid – the proximal pole of the scaphoid, because the blood supply
of the scaphoid often enters through the distal pole.
 The head of the talus, because the blood supply enters through the sinus
tarsi and the neck of the talus.
 If the neck of the talus is broken, aseptic necrosis of the body will occur.
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Orthopedic
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Dr.
Rami
Abo
Ali

34. TRAUMATIC CHONDROMALACIA
 Articular cartilage may be damaged by a blow that leaves the bone
intact. The articular cartilage softens and eventually disintegrates.
 The patient is aware of pain and crepitus, which may take as long as 2
years to develop.
 Once established, traumatic chondromalacia is likely to be followed
by osteoarthritis.
 Injuries to the patella are the most common cause of traumatic
chondromalacia
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Orthopedic
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Dr.
Rami
Abo
Ali

35. COMPLEX REGIONAL PAIN SYNDROME (CRPS)
 complex regional pain syndrome is defined as sustained
sympathetic activity in a perpetuated reflex arc characterized
by pain out of proportion to physical exam findings.
 It affects bone and can follow any injury, particularly a fracture.
 Cardinal signs includes : exaggerated pain , swelling , stiffness
and skin discoloration
 The patient cannot move the limb normally and in severe cases
the skin is thin and shiny.
 Radiologically, there is patchy osteoporosis .
 The mechanism of reflex sympathetic dystrophy is unclear but it
is probably due to a perversion of the sensory fibres which
interpret temperature change as a painful stimulus.
 This over activity of the sympathetic nerves at the wrist is called
Sudeck’s atrophy
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Orthopedic
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Dr.
Rami
Abo
Ali

36. COMPLEX REGIONAL PAIN SYNDROME (CRPS)
 Treatment
 Nonoperative
 physical therapy and pharmacologic treatment (first line of treatment)
 nerve stimulation
 nerve blockade
 chemical sympathectomy
 Operative
 surgical sympathectomy
 surgical decompression
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Dr.
Rami
Abo
Ali

37. INJURIES TO JOINTS
 Three grades of joint injury occur
 Subluxation (partial dislocation).
 Dislocation.
 Fracture dislocation.
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Orthopedic
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Dr.
Rami
Abo
Ali

38. INJURIES TO LIGAMENTS
 Three grades of ligament injury are
recognized :
 Sprain, in which stability is maintained.
 Partial rupture, in which there is some loss of stability but
some fibres remain intact.
 Complete rupture, with loss of both stability and
continuity of the ligament.
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Orthopedic
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Dr.
Rami
Abo
Ali

39. BLOOD VESSELS
 Blood vessels can be damaged in four
ways :
 Division.
 Stretching.
 Spasm.
 Crushing
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Orthopedic
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Dr.
Rami
Abo
Ali

40. NERVES
 Injuries to nerves
 Neurapraxia – transient loss of function caused by local myelin damage
usually secondary to compression. Early recovery.
 Axonotmesis – loss of function due to more severe compression but
without loss of continuity of the neurone. Recovery in weeks or
months.
 Neurotmesis – division of the nerve, no neuralcontinuity. No recovery
unless repaired
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Orthopedic
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Dr.
Rami
Abo
Ali

41. MUSCLE
 Muscle can be damaged in four ways:
 Crushing.
 Laceration.
 Ischaemia.
 Ectopic ossification
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Dr.
Rami
Abo
Ali

42. SKIN
 Skin can be damaged by:
• Direct trauma.
• Stretching.
• Degloving.
• Undermining at operation
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Dr.
Rami
Abo
Ali

43. COMPLICATIONS OF TRACTION
 Over-distraction.
 Loss of position.
 Pressure sores.
 Pin track infection.
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Orthopedic
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Dr.
Rami
Abo
Ali

44. COMPLICATIONS OF CASTS
 Circulatory embarrassment.
 Pressure sores.
 Undiagnosed wound infection.
 Joint stiffness.
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Dr.
Rami
Abo
Ali

45. COMPLICATIONS OF INTERNAL FIXATION
 Infection. (most common cause for implant failure)
 Skin necrosis.
 Neurovascular damage
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