The document discusses rural fracture care and provides examples of fractures that may be encountered. It begins with an overview of treating fractures in rural settings and driving between rural hospitals. It then covers principles of fracture management and casting. Specific fractures discussed include metacarpal fractures, scaphoid fractures, and distal radial fractures. Treatment options and criteria for referral are provided for each fracture type. Throughout, mnemonics and principles are presented to aid in learning fracture management.
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State of the art in Triangular FibroCartilage Complex lesion management. Current concepts in anatomy biomechanics and treatment with special focus in arthroscopic techniques. Detailed step by step description of the surgical technique with animations and video. See also https://www.youtube.com/watch?v=rgbemvKbtFk. Visit www.orthoinfo.gr
Συγχρονες τεχνικές αντιμετώπισης των βλαβών του Τρίφωνου Ινοχόνδρινου Συμπλέγματος στον Καρπό
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Achilles tendon repair at the Stone Clinic is often performed percutaneously following a torn achilles tendon injury. This method has proven to be as effective as an open surgical technique while reducing recovery time.
Dear all,
This ppt contains the cause, types, clinical and radiological features, treatment and complication of Femur shaft fracture. I hope this is useful to you.
Thank you
Achilles tendon repair at the Stone Clinic is often performed percutaneously following a torn achilles tendon injury. This method has proven to be as effective as an open surgical technique while reducing recovery time.
Dear all,
This ppt contains the cause, types, clinical and radiological features, treatment and complication of Femur shaft fracture. I hope this is useful to you.
Thank you
This is a short presentation on intraarticular knee injection. This presentation gives brief idea about hyaluronic acid injection used for management of osteoarthritic pain.
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This powepoint is aimed at undergraduate medical education. It gives information regarding the orhtopedic principles of management of closed and open fractures
Review of common fractures encountered in children and what makes them different from adult fractures. This presentation will best benefit undergraduate medical and paramedical students
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Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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4. I see this! (Albreda Mountain)I see this! (Albreda Mountain)
5. Romance of Rural MedicineRomance of Rural Medicine
• Driving
• I operate in 3 rural
hospitals and have
clinics in 5 other
smaller towns from
Hinton Alberta to
NakuspBC
• So far never a bad
day on the road
6. Romance of Rural MedicineRomance of Rural Medicine
• Rural canadian
SAFARI
• Be careful out there
8. Learning ObjectivesLearning Objectives
• By the end of this
session you should
be able to intelligently
discuss the
classification and
internal fixation
options for this
periprosthetic fracture
• NOT!!!!!!!!!!!!!
12. Digital X-rays allow easy consultDigital X-rays allow easy consult
• If in doubt, always call
your friendly local
orthopaedic surgeon
• Please don’t mention my name!
13. Variety of OpinionVariety of Opinion
• Orthopaedic surgeons
are like farmers
arguing over the best
farming methods
• THIS IS WHAT I DO
ON MY FARM
15. Regarding distal radial fracturesRegarding distal radial fractures
Which one is false?
1. Casting does not hold reduction
2. Locking plates can hold reduction
3. In elderly (60 plus), the outcome of these
is equal whether treated with cast or
plate.
4. These fractures can be treated by a rural
family doctor
16. How would you immobilize this?How would you immobilize this?
1. Thumb spica cast
2. Refer for surgery
3. Below elbow cast
4. Splint
17. Watson’s test is:Watson’s test is:
1. Clinical test for shoulder instability
2. A clinical test for Achilles tendon tear
3. A good way to test the scaphoid
4. Sherlock Holmes’ partner’s test
18. What is true of this FXWhat is true of this FX
• Monteggia fracture
DL
• Called fracture of
necessity
• Can be treated by
rural family physician
• Named after famous
British surgeon
19. Messing up on fracture can end upMessing up on fracture can end up
giving you a criminal chargegiving you a criminal charge
• Yes
• no
20. Comprehensive Fracture CareComprehensive Fracture Care
• Treat the Whole Patient
• Identify and prioritize other injuries ATLS
• Always check neurovascular status of the
fractured limb
• Then
21. Treat the FractureTreat the Fracture
• Decision to refer
• Or treat the patient at
your own location
• What is this injury?
• PRIZE QUESTION
23. FRACTURE SAFARIFRACTURE SAFARI
• SAFARI takes you on
a tour where you see
and learn about many
different animals
• Fractures are as
varied and interesting
as animals on a safari
• MNEMONIC
24. Principles of Fracture ManagementPrinciples of Fracture Management
SET the fracture
ARREST (immobilize)
FOLLOW-UP
ACTIVATE
REHABILITATE
INVESTIGATE
I
25. 1. Set (reduce) the Fracture1. Set (reduce) the Fracture
• Start with a straight
bone
• Alignment never
improves with follow-
up
26. What is acceptable angulationWhat is acceptable angulation
• Acceptable angulation
is where you END UP
• Most fractures wander
a bit in casts
• Patients have little
tolerance for acceptable
angulation
27. 2. Arrest (immobilize)2. Arrest (immobilize)
Surgeons arrest
(immobilize) with
internal fixation
1. In your rural
hospital you will
use a cast or splint
29. 3. Follow-up of Fractures3. Follow-up of Fractures
• In adults and
adolescents TAX
weekly for most
• In small children TAX
every 3 to 4 days
(they heal fast)
• Follow until healing
prevents
displacement
30. 3. Followup fractures3. Followup fractures
• Always check the X-
ray yourself or get a
verbal report
• Never rely on the
written report
31. 4. Activate the limb4. Activate the limb
• Start activation of the
limb on your first
follow-up visit
• Helps prevent CRP
syndrome
32. 4. Activation of the Limb4. Activation of the Limb
• Start immediate ROM of
restricted joints
• Weekly TAX sessions a
good opportunity to
monitor limb condition
and encourage ROM
and strengthening
33. 5. Rehabilitate5. Rehabilitate
• Healing comes from
within, therapist is
motivator but has
special techniques
that can help
• Always offer some
physio
• Be aware of third
party issues
34. 6. Investigate6. Investigate
• 6. Determine the
need for investigation
of the cause of the
fracture, i.e.
osteoporosis, child
abuse, balance
disorders, etc.
35. Principles of Paediatric fracturesPrinciples of Paediatric fractures
• Fractures In growing
bones
• From birth
36. Principles of Paediatric FracturesPrinciples of Paediatric Fractures
• Until the growth
plates close
• This patient has
almost mature bones,
but the rest of him…?
39. Children's Fractures NAIChildren's Fractures NAI
• Most commonly in
ages less than 3
• Most specific
fractures are
• 1. Metaphysial corner
or bucket handle
fractures
• (almost diagnostic for
NAI)
43. TAKE HOME MESSAGE NAITAKE HOME MESSAGE NAI
Have high index of
suspicion for non
accidental injuries
Get social worker
involved early
Treat parents with
dignity
Eg medicolegal case
50. Premature physial closurePremature physial closure
• Complication of
growth plate injuries
• Common in tibia and
femur (even in grade
1 and 2 injuries)
51. Premature physial closurePremature physial closure
• Distal radius fractures
• Less common than
lower limb
• Angular deformity
better tolerated in
upper limb
52. Premature physial closurePremature physial closure
• Reduction restores
alignment, but does
NOT change the
incidence of
premature physial
closure
• Journal Ped.
Orthopaedics 2013
53. TAKE HOME MESSAGETAKE HOME MESSAGE
• Treat as any other
fracture (SAFARI)
• Always mention
premature physial
closure to parents
• Follow-up for 6
months at least post
fracture
54. Principles of CastingPrinciples of Casting
• Good casting is an art
form
• You can use plaster
but fiberglass is
lighter and lasts
longer
• Plaster casts get wet
and soft and have to
be replaced
57. Principles of CastingPrinciples of Casting
• Cast is like a form for
hardening cement
• The form comes off
when the concrete
sets
58. How long for the castHow long for the cast
• Until fracture heals
enough to hold
alignment
• 2 yo 2 weeks
• Metaphyseal fractures
heal faster than
diaphysis
• Adult 6 plus weeks
59. Comprehensive Care of FracturesComprehensive Care of Fractures
• S
• A
• F
• A
• R
• I
63. Metacarpal Fractures: X-raysMetacarpal Fractures: X-rays
• True lateral
• Oblique view
increases apparent
saggital deformity
because the 5th
metacarpal is a
slightly curved bone
64. Acceptable AngulationAcceptable Angulation
of Metacarpal Fracturesof Metacarpal Fractures
• Up to 40 degrees metacarpal neck 5
• More proximal fracture creates more
deformity, accept less deformity
• Metacarpals 2 and 3 accept little, 5 to 10
degrees of deformity
• Rotational deformity not acceptable
65. Metacarpal # ReductionMetacarpal # Reduction
• Easy to straighten the
bone with Marcaine
block around fracture
• Use Marcaine with
epi and a long 25
needle
• Easier a few days
after injury
66. Metacarpal # ImmobilizationMetacarpal # Immobilization
• Ulnar gutter is
traditional
• Gives comfort to the
patient and comfort to
the doctor
• Doesn’t hold
alignment
67. Pedestal CastPedestal Cast
• Holds wrist in
GENTLE extension
with moulding under
metacarpal head
• Effective to displaced
fractures after
reduction
68. Metacarpal Fractures: RxMetacarpal Fractures: Rx
• Because the wrist
wants to fall into
relative flexion, there
is always pressure on
the metacarpal head
72. Metacarpal Fractures: FollowupMetacarpal Fractures: Followup
• Now just follow with
weekly X-rays for 4 to
5 weeks and take the
cast off and start
range of motion of the
MCP joint
• Results good if
patient compliant
73. Reasons for ReferralReasons for Referral
• Open injuries
• Rotational deformity
• Multiple unstable
fractures
• Patient demand
80. Scaphoid # XraysScaphoid # Xrays
• Wrist with scaphoid
view
• Negative X-ray
• Immobilize and
follow-up
81. Scaphoid # negative X-raysScaphoid # negative X-rays
• Immobilize and TAX
in about 2 weeks
• If still sore and
negative x-ray
-arrange a bone scan
• CT and MRI have
lower sensitivity rate
83. Casting scaphoid fractureCasting scaphoid fracture
• The new (Schramm
2007)
• The thumb can be left
free at the MCP joint
• Much more functional
cast
• Much happier patient
85. Scaphoid Fractures: RxScaphoid Fractures: Rx
• X-rays are not
conclusive to prove
healing
• Once you are fairly
sure it is healed, put
in a splint and
arrange a CT scan
86. Scaphoid Fractures: SurgeryScaphoid Fractures: Surgery
• Some subspecialty
papers point to the
advantage of fixing all
scaphoid fractures
• Same healing time,
but less time in a cast
and less time off work
87. Scaphoid SurgeryScaphoid Surgery
• However, most larger
reviews and
metanalyses show no
benefit of surgery for
undisplaced fractures
of the scaphoid
• Always some
complications with
surgery
88. Scaphoid FracturesScaphoid Fractures
• Indications for referral • 1. Displaced
fractures more than
1mm
• 2. Proximal fractures
• (60 to 70 % healing in
a cast)
• 3. Patient and
Surgeon preference
95. Distal Radial FracturesDistal Radial Fractures
• Usual deformity is
dorsal angulation and
radial shortening and
radial fall-off
• Talking about Dorsal
angulated fractures
96. Goal of ReductionGoal of Reduction
Poor outcome related to
1. Intra- articular step
deformity > 2mm
2. > 11 degrees of
dorsal angulation
3. >3 to 4 mm of radial
shortening
97. Goal of ReductionGoal of Reduction
• Younger adults should be restored to as
anatomical as possible
• Older adults should be reduced to at least
neutral on the lateral film and try to
minimize radial length loss
98. Cycling of Ortho opinionCycling of Ortho opinion
• 5 years ago ortho
trauma wrist
specialists were
saying these all
should be plated
99. Distal Radial FractureDistal Radial Fracture
• Arora 2009
• Dr. Geoff Johnstone in Saskatoon
followed 400 cases and found same
results 2014
• Anatomic plating gives no better function
and patient satisfaction than cast
treatment in older patients (over 70 years
of age)
• Regardless of the X-ray!
100. Distal Radial # ReductionDistal Radial # Reduction
• Anesthesia can be
achieved with a
hematoma block
• Or conscious
sedation
101. Distal Radial Fractures:Distal Radial Fractures:
ReductionReduction
• Reduction is achieved
by milking the
fragments with
traction on the thumb
and radial fingers
102. Distal Radial Fractures:Distal Radial Fractures:
ReductionReduction
• Patient laying on
stretcher
• Have plaster or
fiberglass with warm
water ready to go
103. Distal Radial # ImmobilizationDistal Radial # Immobilization
• Start below elbow
• Pad above elbow
• Mold as the cast
hardens
• CASTING IS SAFE
AND BETTER THAN
SPLINT
104. Distal Radial Fx: CastingDistal Radial Fx: Casting
• Cast is not too tight
• Just 3 point molding
• Below elbow
• Send home with
analgesics, elevation
and ice
105. Distal Radial Fx: CastingDistal Radial Fx: Casting
• Always leave the
fingers free at the
MCP joints
• Encourage ROM
• Elevation always
• Pain control
110. Goal of Severely displacedGoal of Severely displaced
fracturesfractures
• By improving the
position of the
fracture, you take the
neurovascular
structures out of risk
and reduce the need
for urgent surgery
111. Distal Radial Fx: Follow-upDistal Radial Fx: Follow-up
• TAX weekly
• Any fall off that is
significant for the age
should be referred
• Cast removal at 5
weeks and start
physio
112. Surgery Distal radial fracturesSurgery Distal radial fractures
• Indications
• 1. Unacceptable position for age and
activity level of patient
• 2. Smith’s fracture
• ALWAYS REFER EARLY ENOUGH FOR
SURGERY (2 WEEKS OR LESS)
114. Surgery distal radiusSurgery distal radius
• Locking plate
• Screws thread into
the plate
• Holds the fracture at
the set angle
115. Surgery Distal Radial #Surgery Distal Radial #
• Locking plate gives
early stability
• American surgeons
fix all of these
fractures
• Complication rate
20% in most studies
116. Answer Pre Test distal radiusAnswer Pre Test distal radius
• 1. Casting can hold fracture position
acceptable
• 2. Plating very good at holding reduction
• 3. In patients over 60 long term results
same in casting versus plating
• 4. Rural family doctors can treat many of
these fractures successfully
118. END SESSION ONEEND SESSION ONE
• FRACTURE SAFARI
ONLY HALF DONE!
• Questions about first
half?
119. Session two Fracture SafariSession two Fracture Safari
• Thankyou for
returning
120. Forearm # AssessmentForearm # Assessment
• This is the fracture
highly associated with
COMPARTMENT
SYNDROME
• Think of this in your
assessment
• Let pain be your
guide
121. Forearm # Acceptable anglesForearm # Acceptable angles
Age <6 ---10 degrees
Age 6 to 10--15 degrees
Age 10 to 12—10
degrees
Rotation 30 degrees
END UP HERE
Adult - anatomic
122. Forearm # ReductionForearm # Reduction
• Conscious sedation
• Reduce with thumb
pointing towards the
apex of the fracture
• ie. Pronate with volar
apex, supinate with
dorsal apex
125. Forearm # follow-upForearm # follow-up
• Forearm (diaphysial)
fractures heal slower
than metaphysial
fractures
• Continue casting, first
long arm then short
arm until solidly
healed 8 weeks
minimum
126. Forearm # internal fixationForearm # internal fixation
• Any displaced adult
fracture
• Proximal fractures in
children >6 years old
• Distal fractures when
less than 2 years of
growth left
134. Monteggia Fracture DLMonteggia Fracture DL
• Needs open reduction
internal fixation in
adults
• Closed reduction in
children
• Refer all
135. Paediatric Elbow #Paediatric Elbow #
• Radial head always
Lines up with the
Capitellum
Anterior humeral line
Passes through
Middle third of
capitellum
136. Elbow Fat pads: Prize QuestionElbow Fat pads: Prize Question
• Visualization of the
_____? pad can be
normal
• Visualization of the
______? pad is
always pathological
137. Paediatric Elbow FracturesPaediatric Elbow Fractures
• These fractures are
very unforgiving
• Recognize all
• Refer all
• Except the
undisplaced supra-
condylar fracture
139. Type 3 Supra-condylar #Type 3 Supra-condylar #
• Brachial artery may
be damaged or
blocked by the distal
humeral fracture
• Urgent referral
• Reducing in flexion
may bring back pulse
146. Radial head fracturesRadial head fractures
• There are several
degrees of
displacement
• Most minimally
displaced
147. Radial Head FracturesRadial Head Fractures
• Pass xrays by your
friendly local
orthopod
• Treat with early range
of motion
• See weekly, xray in 3
and 6 weeks
148. Radial Head FracturesRadial Head Fractures
• Orthopedic surgeon
may elect to fix or
replace more severe
fractures
149. Questions forearm and ElbowQuestions forearm and Elbow
fractures?fractures?
• S
• A
• F
• A
• R
• I
150. Humeral shaft FracturesHumeral shaft Fractures
• Torsional force
causes oblique
fracture
• Direct blow causes
transverse fracture
151. Humeral # assessmentHumeral # assessment
• Neurovascular Check
• Always check the
radial nerve!
• No wrist, finger or
thumb extension
153. Humeral Shaft # ImmobilizationHumeral Shaft # Immobilization
• Definitive care is best
with the Sarmiento
humeral fracture
brace.80 to 90% heal
with conservative
care
154. Humeral shaft # FollowupHumeral shaft # Followup
• X-ray every 2 weeks
• Average 8 to 10 week
healing time
155. Humeral Shaft # SurgeryHumeral Shaft # Surgery
From a rural point of
view refer if the
fracture doesn’t line
up reasonably well in
the Sarmiento splint
INDICATIONS
1. open fractures
• 2. upper limb injuries
secondary
• 3. bilateral radial
nerve palsy
• etc
157. Humeral shaft # surgeryHumeral shaft # surgery
• This one treated in a
Sarmiento splint for 3
months
• Smoker
• No callous
158. Humeral shaft # surgeryHumeral shaft # surgery
• Plate fixation is the
standard for fixing
these fractures
• IM nailing only for
pathological fractures
160. Clavicle # ImmobilizationClavicle # Immobilization
• Traditional figure of 8
• Like many of our
traditional practices
this has no proven
benefit . Let the
patient use what is
most comfortable eg.
sling
161. Clavicle Fracture Follow-upClavicle Fracture Follow-up
• X-ray every 2 weeks
• Don’t expect healing
for at least 6 weeks
• Refer for delayed and
non unions
164. Clavicle FracturesClavicle Fractures
• More recent review of
clavicle fractures
• Operative treatment
no benefit over non
operative treatment
• Cochrane review
2013
165. Clavicle FracturesClavicle Fractures
• McKee et al 2012
• ORIF can shorten
disability time and
reduce the incidence
of symptomatic non
union but little
evidence to show that
long term function
improved with ORIF
166. Clavicle fractures ? surgeryClavicle fractures ? surgery
• Cochrane 2013
• Limited evidence for
RCT’s to show
difference between
ORIF and
conservative care
• Younger, healthier
increased
displacement refer
175. Proximal Humeral X-raysProximal Humeral X-rays
• Axillary view
• X-ray techs can be
difficult to convince
but will comply if
instruction understood
• Legal liability to treat
without this view
176. Proximal Humeral Fractures:Proximal Humeral Fractures:
Displacement CriteriaDisplacement Criteria
• > 45 degrees of
angulation
• Displacement greater
than 1 cm of parts
(head, GT,LT and
shaft)
178. Proximal HumeralProximal Humeral
Fractures: RxFractures: Rx
• Undisplaced (80%)
need shoulder
immobilizer
• Weekly X-ray
• NO PHYSIO UNTIL
SIGNS OF HEALING
on X-ray
• Usually 4 to 5 weeks
182. Proximal Humeral FracturesProximal Humeral Fractures
• Hot off press
• In elderly, surgical vs
conservative care all
displaced 3 and 4 part
fractures had equal
outcome!
• Jawa et al AAOS
2014
184. Proximal Humeral surgeryProximal Humeral surgery
• Your reduce it and
now you have this
• 20% of dislocations
with greater tuberosity
fractures have
undisplaced surgical
neck fractures
185. Questions humerus and clavicleQuestions humerus and clavicle
fracturesfractures
• S
• A
• F
• A
• R
• I
187. Hip fracturesHip fractures
• The surgeon fixes the
fracture and sends
the patient back
ASAP
• This is a short gamma
nail
188. Subcapital Fracture HipSubcapital Fracture Hip
• These fractures are
the most important
ones for you because
the undisplaced ones
are , like a scaphoid
fracture, difficult to
diagnose
• Medico-legal issues
189. Subcapital Fracture HipSubcapital Fracture Hip
• Injury, followed by hip
pain and difficulty
bearing weight is a
fracture until proven
otherwise
• MRI best, CT second
best, bone scan not
great
• Keep patient non wt
bearing
190. Sub capital fracture hipSub capital fracture hip
• Undisplaced fractures
can be
percutaneously
pinned a 20 minute
operation
191. Displaced Subcapital Hip #Displaced Subcapital Hip #
• In patients under the
age of 55 or so this
should be pinned with
the hope to save the
hip. Risk of
avascular necrosis
• THIS IS THE ONLY
EMERGENCY HIP
FRACTURE
193. Hip Fractures FollowupHip Fractures Followup
• This is your job in a
rural community
• X-ray every 4 weeks
• The surgeon did the
SA
• You do the FARI
194. Hip Fracture Weight BearingHip Fracture Weight Bearing
Internally fixed fractures are
very variable, most with
good fixation can walk
weight of leg
Arthroplasty can weight
bear early just like a total
hip
Always ask surgeon!
195. Hip # AnticoagulationHip # Anticoagulation
• Most health care
organizations
recommend 28 days
average for chemical
anticoagulation
196. Hip # InvestigationHip # Investigation
• Over 80 % of older
hip fracture patients in
a Seattle study had
deficiency of VIT D
and Calcium
• You may need to do
densitometry
197. Femoral Shaft FracturesFemoral Shaft Fractures
• When the only tool
you have is a
hammer, then every
problem starts to look
like a nail
198. Femoral shaft fractureFemoral shaft fracture
• This is the standard of
care in the older child
and the adult patient
202. Patellar Fractures UndisplacedPatellar Fractures Undisplaced
Reduction not needed
Immobilization –
cylinder cast
Follow-up – weekly
Cast off and physio at 5
to 6 weeks
205. Tibial Shaft FracturesTibial Shaft Fractures
• Acceptable angulation
in both adults and
children
• Rotary or angular
deformity < 5 degrees
• < I cm of shortening
• 10 degrees anterior
angulation in children
207. Tibial Shaft# follow-upTibial Shaft# follow-up
• Weekly X-ray
• encourage non weight
bearing
• Patellar tendon
bearing cast as soon
as some healing on
X-ray
208. Tibial shaft # adult displacedTibial shaft # adult displaced
• Most of these are
nailed
209. Ankle FracturesAnkle Fractures
• Need an X-ray to
make diagnosis
• Ottawa’s rules help
Ottawa to save
money
• Lawyers’ rules are
different
210. Ankle fracture assessmentAnkle fracture assessment
• Routine history
• Physical should look
for pulses as
chronically ischemic
feet are a
contraindication for
surgery
• Always examine for
medial and lateral
tenderness
212. Ankle fracture undisplacedAnkle fracture undisplaced
• Lateral view helps
decide whether
operative or not
• Less than 3 to 4mm
displacement on the
lateral view
acceptable for cast or
roboboot
213. Ankle Fracture immobilizationAnkle Fracture immobilization
• Roboboot is much
better than a cast
• Should be in your
emergency rooms
cost about 100$
• Weight bearing
depends on fracture
214. Ankle Fracture followupAnkle Fracture followup
• X-ray weekly for 4 to
5 weeks
• Watch for talar shift
• Or fibular
displacement
215. Prize slidePrize slide
• What is the diagnosis
• Where is the patient
tender
• What is the treatment
216. Talar Shift: RxTalar Shift: Rx
• Tell the orthopod that
this patient needs a
syndesmosis screw
• Orthopods generally
don’t like being told
what to do so you
now really have
his/her attention
217. Ankle Fractures: DisplacedAnkle Fractures: Displaced
• Almost all of these
displaced fractures
need to be reduced
and fixed
226. Ankle fracture negative x raysAnkle fracture negative x rays
• Ankle X-ray can show
a lateral process talar
fracture
227. Lateral Process Fracture of theLateral Process Fracture of the
TalusTalus
• Snowboarder’s
fracture
• Easily missed
• Prognosis is not great
• Particularly with any
displacement
228. Foot FracturesFoot Fractures
• The foot is famous for hiding midtarsal
and tarsal fractures on X-rays
• Have a high clinical suspicion and a very
low threshold to order a CT scan and refer
the patient
229. Foot FracturesFoot Fractures
• Calcaneal Fractures
• Complex decisions if
displaced
• Treat undisplaced
with NWB and
monthly x rays
231. Foot fractures LisfrancsFoot fractures Lisfrancs
• Even minimal
displacement of the
midtarsal joints can
give permanent
disability
232. ALERT LISFRANCS INJURYALERT LISFRANCS INJURY
• Now most commonly
missed msk injury
• High medicolegal risk
• Clinical exam of foot
always
• If unsure put on
crutches and reasses
in a few days
• Weight bearing view
233. Foot fracturesFoot fractures
• Metatarsal fractures
• Treat with cast or
roboboot if well
aligned.
• Refer if significant
misalignment
234. Base of 5Base of 5thth
metatarsal fracturemetatarsal fracture
• Common
• Fix only those with
marked displacement
• SAFARI