Project 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.

3. • TRAUMA
• PEDIATRIC ORTHOPEDICS
• ADULT ORTHOPEDICS

4. TRAUMA
Basic Principles of Fracture

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

8. • When describing a fracture, include:
 Radiographs Adequate
 Anatomical Site
 Articular Involvement
 Configuration of displacement
 Pattern of Fracture
 Age: adult/pediatric

9. Paul Kibet
5years
24/2/2023

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

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)

17. • Conservative ( Closed Reduction)
 Closed Reduction by Manipulation
Continuous traction: Skin traction
: Skeletal Traction
• 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

22. • Complications of Casting:
 Compartment Syndrome
 Joint Stiffness
 Re-displacement
 Pressure Sores
 Disuse Osteoporosis

23. Continuous
Traction
Traction is able to exert a
continuous pull in the long axis of
the bone.
Types:
Fixed
Balanced
Combined

24. Internal Fixation
• Fixing fractures with plates, screws, intramedullary nails or wires
• Indications:
 Unstable fracture
 Pathological fracture (except active infections)
 Poly-trauma patient
 Delayed Union
 Non-union

25. • Complications of internal fixation:
 Infection
 Non-union
 Implant failure
 Re-facture

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

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

33. JOINT DISLOCATION

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.

37. • Complications of Joint dislocation
• Acute complications:- Neurovascular Injury
• Chronic Complications:
 Post-traumatic arthritis
 Joint stiffens
 Avascular necrosis
 Myositis ossificans

38. PEDIATRIC
FRACTURES

39. Important features of Pediatric
• Growth plate (physis)
• Bone resilience (greenstick fractures)
• Thick periosteum
• Rapid healing
• Remodeling
• Catch-up growth

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

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

45. • Complications of physeal injury:
 Growth arrest
 Growth acceleration
 Secondary osteoarthritis

46. FRACTURE
HEALING

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.

50. Complications of Fracture
Non- Unions

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

55. • Hypertrophic Non-union:
-Due to inadequate fracture
stabilisation
Treatment:
-Surgical

56. • Oligotrophic non-union:
-inadequate fracture reduction and
displacement of fracture fragments
• Treatment:
-Surgical/ revision surgery

57. • Atrophic Non-union:
-inadequate mobilisation and poor
blood supply
• Treatment
- Surgical with bone graft.

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)

60. Thank-you