Trauma & Orthopaedic Surgery
for the Intercollegiate MRCS


             Edward Gardner
       SpR Trauma and Orthopaedics...
What is the structure of bone?




                                 2
Microscopy

• Cortical bone
  – also “compact” and
    “lamellar” bone



• Cancellous bone
  – spongy bone, woven
    bon...
Bone Cells
• Osteoblasts
  make bone

• Osteoclasts
  multinucleated giant cells, resorb bone

• Osteocytes
  are osteobla...
Blood supply


• Blood vessels-
  nutrient artery
• Endosteal
• Periosteal
• Venous drainage


                    5
6
How do fractures heal?




                         7
Healing cascade: indirect healing
• Inflammation 0 – 5 days
   – Haematoma
   – Necrotic material
   – Phagocytosis

• Rep...
How do you treat a fracture?




                               9
TREATING A FRACTURE


• Reduce
• Hold
• Rehabilitate




                            10
TREATING A FRACTURE


• Reduce
  – Open
  – Closed




                           11
TREATING THE FRACTURE


• Hold
    • Operative / Non Operative
    • Internal / External
    • Intra / Extra medullary



...
TREATING THE FRACTURE


• Rehabilitate
     • Physio




                            13
FACTORS AFFECTING
          FRACTURE HEALING
• Injury Factors
   – Energy
   – Associated injuries
• Bone factors
   – Red...
ATLS
A - Airway and cervical spine immobilisation


B - Breathing


C - Circulation


D - Disability


E - Exposure
      ...
Pelvis Fracture and Ex-Fix




                             16
Soft Tissue Injuries
     Open




 I          Clean, <1cm
            Simple #
 II         Clean, >1cm
            Simple...
Soft Tissue Injuries
      Open



 I       Clean, <1cm
         Simple #
 II      Clean, >1cm
         Simple #
 III     ...
Soft Tissue Injuries
     Open


 I      Clean, <1cm
        Simple #
 II     Clean, >1cm
        Simple #
 III    Extensi...
Soft Tissue Injuries
  Open



 IIIa Soft tissue cover
 IIIb Soft tissue loss
      periosteal strip
 IIIc Vascular injury...
Soft Tissue Injuries
  Open



 IIIa Soft tissue cover
 IIIb No soft tissue cover
 IIIc Vascular injury
      -repair




...
Soft Tissue Injuries
  Open



 IIIa Soft tissue cover
 IIIb Soft tissue loss
      periosteal strip
 IIIc Vascular injury...
Diagnosis
• Clinical assessment
   – History - Co-morbidities
   – Exposure/systematic examination


• “First-aid” reducti...
Describe the Fracture
• Anatomical site
• Configuration Displacement
   – angulation
   – translation
   – shortening
• Ar...
25
26
27
What are the complications of
         fractures?




                                28
Complications of Fractures

               Early              Late
General        Other injuries     Chest infection
     ...
What is the definition of
compartment syndrome?




                             30
Compartment Syndrome

Increased Pressure
in a
closed tissue compartment
resulting in
local ischaemia



                  ...
Pain & spasm
                 Tissue      Compartment
  Muscle        swelling       pressure

                Ischaemia
 ...
Fasciotomy




             33
34
How do you classify hip
     fractures?




                          35
Fracture types
• Intracapsular
   Femoral neck


• Extracapsular
  Intertrochanteric


• Subtrochanteric
  Below lesser tr...
Gardens Classification
INTRACAPSULAR
   FRACTURES


 Undisplaced

  Displaced



                            37
38
39
40
Shoulder Dislocations




                        41
What is carpal tunnel
   syndrome?




                        42
Carpal Tunnel Syndrome

The entrapment of the median nerve at the
fibro osseous tunnel of the carpus




                 ...
CTS signs

• wasting of thener
  eminence
• numbness
• weakness
• Tinel sign
• Phalen sign



                            ...
CTS Treatment
• non operative
  – Splint
  – Steroid injection?


• surgical
  decompression
  – open




                ...
What is trigger finger?




                          46
Trigger Finger


 Stenosing tenovaginosis of the
flexor tendon sheath (A1 pulley)




                                   47
What is Dupuytren’s Disease




                              48
Dupuytren’s Contracture


nodular hypertrophy
    and contracture
of the palmar fascia




                              49
What is the pathology of
 rheumatoid arthritis?




                           50
Rheumatoid Arthritis
    Synovitis


    chronic infltrates, synovial hypertrophy, effusion

    Destruction


    prote...
Rheumatoid Arthritis
 early joint changes




                       52
Rheumatoid Arthritis
              Late Symptoms

    joint destruction


    pain


    deformity


    instability

...
Rheumatoid Arthritis
advanced joint changes




                         54
55
56
What is osteoarthritis?




                          57
Osteoarthritis

A chronic joint disorder in which there is
progressive softening and disintegration of
articular cartilage...
Osteoarthritis classification
    Primary or idiopathic





    Secondary -   infection


              -   dysplasia
 ...
60
Osteoarthritis X-ray changes




                               61
What is the treatment of
   osteoarthritis?




                           62
Non-surgical treatment

    analgesia


    altered activity


    walking aids


    physiotherapy





             ...
64
65
Joint Replacement
           Hip Complications

    dislocation - 1%


    loosening >90% 10y survival


    DVT / PE

...
Joint Replacement
          Knee complications

    limited ROM


    patellar instability 3-5%


    loosening > 90% 10...
What are the common bone
        tumours?




                           68
Metastatic bone tumours
•   Breast
•   Brostate
•   Bung
•   Bhyroid
•   Bidney
•   Multiple Myeloma



                  ...
Hot topics
•   # NOF
•   OA
•   CTS
•   Principles of # management
•   ATLS
•   Open #


                                 ...
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Mrc Sorthopaedicsandtraumalecture

  1. 1. Trauma & Orthopaedic Surgery for the Intercollegiate MRCS Edward Gardner SpR Trauma and Orthopaedics 1
  2. 2. What is the structure of bone? 2
  3. 3. Microscopy • Cortical bone – also “compact” and “lamellar” bone • Cancellous bone – spongy bone, woven bone. 3
  4. 4. Bone Cells • Osteoblasts make bone • Osteoclasts multinucleated giant cells, resorb bone • Osteocytes are osteoblasts in bone 4
  5. 5. Blood supply • Blood vessels- nutrient artery • Endosteal • Periosteal • Venous drainage 5
  6. 6. 6
  7. 7. How do fractures heal? 7
  8. 8. Healing cascade: indirect healing • Inflammation 0 – 5 days – Haematoma – Necrotic material – Phagocytosis • Repair: 5 – 42 days – Granulation tissue – Acid environment – Periosteum – osteogenic cells – Cortical osteoclasis • Remodelling – years 8
  9. 9. How do you treat a fracture? 9
  10. 10. TREATING A FRACTURE • Reduce • Hold • Rehabilitate 10
  11. 11. TREATING A FRACTURE • Reduce – Open – Closed 11
  12. 12. TREATING THE FRACTURE • Hold • Operative / Non Operative • Internal / External • Intra / Extra medullary 12
  13. 13. TREATING THE FRACTURE • Rehabilitate • Physio 13
  14. 14. FACTORS AFFECTING FRACTURE HEALING • Injury Factors – Energy – Associated injuries • Bone factors – Reduction, fixation – Blood Supply (scaphoid, talus, femoral and humeral head) – Infection • Patient factors – Smoking – Diabetes 14
  15. 15. ATLS A - Airway and cervical spine immobilisation B - Breathing C - Circulation D - Disability E - Exposure 15
  16. 16. Pelvis Fracture and Ex-Fix 16
  17. 17. Soft Tissue Injuries Open I Clean, <1cm Simple # II Clean, >1cm Simple # III Extensive High energy # 17 Gustilo & Anderson, 1976
  18. 18. Soft Tissue Injuries Open I Clean, <1cm Simple # II Clean, >1cm Simple # III Extensive High energy # 18 Gustilo & Anderson, 1976
  19. 19. Soft Tissue Injuries Open I Clean, <1cm Simple # II Clean, >1cm Simple # III Extensive High energy # 19 Gustilo & Anderson, 1976
  20. 20. Soft Tissue Injuries Open IIIa Soft tissue cover IIIb Soft tissue loss periosteal strip IIIc Vascular injury -repair 20 Gustilo, Mendoza & Williams, 1984
  21. 21. Soft Tissue Injuries Open IIIa Soft tissue cover IIIb No soft tissue cover IIIc Vascular injury -repair 21 Gustilo, Mendoza & Williams, 1984
  22. 22. Soft Tissue Injuries Open IIIa Soft tissue cover IIIb Soft tissue loss periosteal strip IIIc Vascular injury -repair 22 Gustilo, Mendoza & Williams, 1984
  23. 23. Diagnosis • Clinical assessment – History - Co-morbidities – Exposure/systematic examination • “First-aid” reduction • Splintage and analgesia • Radiographs – Two planes including joints above and below area of injury 23
  24. 24. Describe the Fracture • Anatomical site • Configuration Displacement – angulation – translation – shortening • Articular involvement/epiphyseal injuries – fracture involving joint – dislocation – ligamentous avulsion • Soft tissue injury 24
  25. 25. 25
  26. 26. 26
  27. 27. 27
  28. 28. What are the complications of fractures? 28
  29. 29. Complications of Fractures Early Late General Other injuries Chest infection PE UTI FES/ARDS Bed sores Bone Infection Non-union Malunion AVN Soft-tissues Plaster sores/WI Tendon rupture N/V injury Nerve compression Compartment syn. Volkmann contracture 29
  30. 30. What is the definition of compartment syndrome? 30
  31. 31. Compartment Syndrome Increased Pressure in a closed tissue compartment resulting in local ischaemia 31
  32. 32. Pain & spasm Tissue Compartment Muscle swelling pressure Ischaemia Ischaemia Venous Arteriolar Nerve stasis stasis Paraesthesia 32
  33. 33. Fasciotomy 33
  34. 34. 34
  35. 35. How do you classify hip fractures? 35
  36. 36. Fracture types • Intracapsular Femoral neck • Extracapsular Intertrochanteric • Subtrochanteric Below lesser troch 36
  37. 37. Gardens Classification INTRACAPSULAR FRACTURES Undisplaced Displaced 37
  38. 38. 38
  39. 39. 39
  40. 40. 40
  41. 41. Shoulder Dislocations 41
  42. 42. What is carpal tunnel syndrome? 42
  43. 43. Carpal Tunnel Syndrome The entrapment of the median nerve at the fibro osseous tunnel of the carpus 43
  44. 44. CTS signs • wasting of thener eminence • numbness • weakness • Tinel sign • Phalen sign 44
  45. 45. CTS Treatment • non operative – Splint – Steroid injection? • surgical decompression – open 45
  46. 46. What is trigger finger? 46
  47. 47. Trigger Finger Stenosing tenovaginosis of the flexor tendon sheath (A1 pulley) 47
  48. 48. What is Dupuytren’s Disease 48
  49. 49. Dupuytren’s Contracture nodular hypertrophy and contracture of the palmar fascia 49
  50. 50. What is the pathology of rheumatoid arthritis? 50
  51. 51. Rheumatoid Arthritis Synovitis  chronic infltrates, synovial hypertrophy, effusion Destruction  proteolytic enzymes, pannus Deformity  articular destruction, capsular stretching, tendon rupture 51
  52. 52. Rheumatoid Arthritis early joint changes 52
  53. 53. Rheumatoid Arthritis Late Symptoms joint destruction  pain  deformity  instability  53
  54. 54. Rheumatoid Arthritis advanced joint changes 54
  55. 55. 55
  56. 56. 56
  57. 57. What is osteoarthritis? 57
  58. 58. Osteoarthritis A chronic joint disorder in which there is progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margins (osteophytes) and capsular fibrosis 58
  59. 59. Osteoarthritis classification Primary or idiopathic  Secondary - infection  - dysplasia - Perthes’ - SUFE - trauma - AVN 59
  60. 60. 60
  61. 61. Osteoarthritis X-ray changes 61
  62. 62. What is the treatment of osteoarthritis? 62
  63. 63. Non-surgical treatment analgesia  altered activity  walking aids  physiotherapy  63
  64. 64. 64
  65. 65. 65
  66. 66. Joint Replacement Hip Complications dislocation - 1%  loosening >90% 10y survival  DVT / PE  infection - 1%  Death  66
  67. 67. Joint Replacement Knee complications limited ROM  patellar instability 3-5%  loosening > 90% 10y survival  DVT / PE  infection - 2%  67
  68. 68. What are the common bone tumours? 68
  69. 69. Metastatic bone tumours • Breast • Brostate • Bung • Bhyroid • Bidney • Multiple Myeloma 69
  70. 70. Hot topics • # NOF • OA • CTS • Principles of # management • ATLS • Open # 70

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