Orthopedic Surgery Notes: Dr. Roel S. Cobarde Fracture Healing

 

ORTHOPEDIC SURGERY NOTES

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Comminuted (high intensity, several communicating fracture lines)

Dr. Roel S. Cobarde FRACTURE HEALING Stage 1 – 1 – Inflammation  Inflammation and hematoma (Day 1) Stage 2 – 2 – Hematoma  Hematoma organization (Day 2-7) Stage 3 – 3 – Callus  Callus formation (Day 8-90) - Soft Callus -> fibrous tissue - Hard Callus -> Calcification Stage 4 – 4 – Remodeling  Remodeling -Longest part (years) -Remodeling will stop when the bone has reconfigured

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Closed (simple)

itself

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Open (compound)

WOLFF’S LAW 

COMPARTMENT SYNDROME

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Julius Wolff 1892

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The bone will adapt to the degree of o f mechanical loading, such

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According to outside communication

 

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Emergency situation Increased

that an increase in loading will cause the architecture of the

intracompartment pressure

internal, spongy bone to strengthen, followed by the

swelling within the

strengthening of the cortical layer

compartment that affects

Every change in form and function of bones will determine their

blood flow of the limb

due to the

definite changes in accordance to mathematical law

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Treatment: emergency fasciotomy

Stage of remodeling (resorption and deposition)

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Complications: irreversible necrosis and contractures resulting to

TRAUMA

loss of function

Goals of treatment of MSK (musculoskeletal) injuries 1. 

Restore normal anatomy – anatomy – manipulation,  manipulation, traction, open surgery

FRACTURES IN CHILDREN

2. 

Immobilization – Immobilization  – pain  pain relief and healing

Factors:

a. 

External fixation – fixation – cast,  cast, splint, ext. fixator device

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Rapid healing

b. 

Traction – Traction  – skin  skin (children), skeletal (adults), cast, brace,

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Spontaneous correction, mild to moderate degrees of angulation

crutch field tongs c. 

and overriding

Internal Fixation – Fixation – screw,  screw, bone, plate, pins, intramedullary nails

*hardware: stable construct to allow fracture to heal and 3. 

align Repair and reconstruct – reconstruct – to  to restore function

DEFINITION OF TERMS Fracture – Fracture  – break  break in bone continuity Dislocation – Dislocation  – displacement  displacement of joint articulation Subluxation – Subluxation  – slight  slight displacement of joint Sprain – Sprain  – ligamentous  ligamentous injury Strain – Strain  – muscular  muscular injury DIAGNOSIS

*When there is rotation, it cannot be corrected by remodeling Greenstick Fracture - 

Incomplete fracture where only 1 bone cortex is broken

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Treatment: break the intact cortex and proceed with fracture

History

principles -Thorough and include mechanism of injury

Torus Fracture (Buckle’s Fracture)  Fracture) 

- NOI (Name of Injury)

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Incomplete fracture at 1 side of the metaphysis

-POI (Place of Injury)

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Treatment: immobilization

-TOI (Time of Injury) -DOI (Date of Injury) Physical exam -ABC’s ABC’s   -thorough and include neurovascular status -deformity, muscular pull -asymmetry Roentgenography -Films (large Xray), perpendicular (AP,L), evaluate adjacent joints PRINCIPLES OF SPLINTING -immobilization of the joint above and below -example: Thomas joint

SALTER AND HARRIS CLASSIFICATION OF EPIPHYSEAL FRACTURE Type 1 – 1 – only  only the cartilage plate Type 2 – 2 – cartilage  cartilage plate and a triangular segment of the

FRACTURE CLASSIFICATION  CLASSIFICATION 

metaphysis

According to configuration:

Type 3 – 3 – transverses  transverses the epiphysis and the cartilage plate

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Transverse (perpendicular to long axis)

Type 4 – 4 – transverse  transverse the metaphysis, cartilage plate and epiphysis Type 5 - crushing the growth plate

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Oblique (axial and bending force)

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Spiral (force and twisting, S-formed fracture)

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Segment (no sup. and inf. communication)

 

OPEN FRACTURES (Outside communication) - 

R. Gustilo and Anderson

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Type 1 - 2cm, clean, moderate periosteal stripping, low to

medial malleolus and distal posterior aspect of the tibia)

moderate energy

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Pott’s Disease (tuberculosis of the spine)  spine)  

Type 3 - >10cm wound, grossly contaminated, severe periosteal stripping, comminuted, high energy, high velocity (GSW, ( GSW, farm injury, casualty situations, >golden hour/6 hrs, war) 3A-Adequate soft tissue coverage

SPINAL CORD SYNDROMES - 

Complete – Complete  – total  total loss below the level of lesion

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Incomplete

 

3B-Bad, massive soft tissue loss, bony exposure

o

& proprioception, contra: nociception & thermo

3C-Circulation, major repairable blood vessel injury

 

o

COMPLICATIONS OF OPEN FRACTURES  FRACTURES 

  o  o

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Hematogenous spread (endogenous) Direct inoculation (exogenous)

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Direct spread

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Ex. Kabahong – Kabahong – long  long staying skin sore, chronic skin wounds, could

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Indications

  o  o  o  o  o

-Acute – -Acute  – 1-7  1-7 days, (+) inflammation local l ocal and systemic, (-) radiograph -Subacute – -Subacute  – 8-14  8-14 days, (+/-) inflammation, (+) - 

  o  o  o  o  o  o

involucrum, sequestrum, epidermoid cancer Late Bony Complication of Fracture Healing Delayed union – union  – slow  slow healing  healing 

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Nonunion – Nonunion  – healing  healing stops short of firm union  union  

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Malunion – Malunion  – healing  healing takes unsatisfactory alignment

Fractures of the long bone

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M.C. fractured long bone – bone – radius/tibia  radius/tibia

o

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M.C. dislocated joint – joint – shoulder  shoulder M.C. sprained joint – joint – ankle  ankle

o

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M.C. site of nonunion – nonunion – middle  middle distal tibia and talus

o

  

  o  o  o  o  o  o

Humerus – Humerus  – surgical  surgical neck, shaft, supracondylar area, radial groove

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Radius and ulna – ulna –  distal 1/3, colle’s fracture, smith’s fracture,

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Hand – Hand  – phalanges,  phalanges, metacarpals – metacarpals – cast/surgery  cast/surgery for multiple

proximal and middle thirds fracture fractures, carpals – carpals  – navicular  navicular common nonunion - 

Lower extremity - 

  o  o  o  o  o 

Femur – Femur  – Pedia:  Pedia: cast immobilization

o

Tibia and Fibula – Fibula – plateau:  plateau: joint congruence Plafond: joint congruence Bimalleolar: ankle joint Shaft: cast/surgical

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Congenital abnormalities Forequarter amputation Shoulder disarticulation Above elbow amputation AEA Elbow disarticulation Below elbow amputation BEA Wrist disarticulation Transmetacarpal amputation Phalangeal amputation DIP/PIP disarticulation Hemipelvectomy Hip disarticulation Above knee amputation AKA Knee disarticulation Below knee amputation BKA Ankle disarticulation Syme amputation, Boyd amputation Chopart amputation Lisfran amputation Transmetatarsal amputation Phalangeal amputation DIP/PIP joint articulation

Foot – Foot  – phalanges:  phalanges: Metatarsals: cast/surgical for multiple fractures

SPINAL COLUMN INJURY

Tarsals: talus, m.c. non union Calcaneus: restore the calcaneal angle (spring ligament)

Disc Herniation -  M.C. 20-50 yo with Hx of heavy lifting objects

Fractures of Spine  Spine   - 

Tumor

Foot

Adult: surgical, femoral neck -> pins/prosthesis - 

Peripheral vascular disease

Lower extremity

Upper extremity - 

Infection

Hand

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Trauma – Trauma  – type  type 3C fx

Upper extremity

-Chronic - >14 days, (-) inflammation, draining sinus,

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Central Cord Syndrome: gray matter, upper extremity

AMPUTATIONS

Classifications:

radiograph – radiograph  –  periosteal reaction (codman’s triangle)  triangle)  

Post. Cord syndrome: dorsal half, proprioception weakness

spread the infection to the bones - 

Ant. Cord syndrome: ventral half, bilateral: motor, pain, temperature

Osteomyelitis - 

Brown-Sequard syndrome: half of the cord, ipsi: motor

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Annulus tear with extension of nucleus pulposus compressing the spinal cord/nerve root

Cervical spine – spine –  Jefferson fx, hangman’s fx (isthmus), whiplash injury (odontoid)

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Thoracolumbar – Thoracolumbar  – chance  chance fx, compression fx, burst fx (2 or 3 columns)

Spinal Stenosis - 

DISLOCATIONS   DISLOCATIONS

Loss of hydration of the disc resulting to loss of disc height and increased bulging of annulus and the ligamentum flavum f lavum causing

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Shoulders

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Elbow

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Facet osteophytes can also cause spinal foramen stenosis

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Hip

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Sx:

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Knee

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Tx: reversal of the mechanism of injury

narrowing of the spinal canal

 

o

Cervical stenosis – stenosis – may  may result to hyperreflexia, ataxia, balance issues, weakness and pain

 

FRACTURE SYNONYMS

o

Lumbar stenosis – stenosis – neurogenic  neurogenic claudication, progressive

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Colle’s fx (complete fx (complete fx of the radius r adius bone close to the wrist) wrist)  

pain, weakness and numbness of the legs assoc. w/

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Smith’s fx (end fx (end of radius)  radius)  

walking and standing but relieved by bending forward fo rward

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Monteggias fx (proximal radioulnar joint in assoc w/ forearm

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  o  o 

fracture)  fracture)  - 

Tx: o

Galeazzi’s fx Galeazzi’s  fx ( fracture of the middle to distal third of the radius associated with dislocation or subluxation of the distal radioulnar

Epidural stenosis PT Surgical decompression and stabilization

 joint), piedmont fx (a fracture of the radius at the middle and distal third with associated disruption of the distal radioulnar - 

Degenerative Disc Disease

 joint)

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M.C. cause of absence of work, Resolves 1-2 weeks

Night stick fx (An isolated fracture of the ulnar shaft)  shaft) 

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Unremitting chronic back pain – pain  – infection,  infection, malignancy, metastasis

 

 

Scoliosis Lateral curvature of spine

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Classification:

  o  o  o  o  o  o

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diaphysis  diaphysis 

  o 

Congenital Metabolic – Metabolic  – mucopolysaccharides  mucopolysaccharides

PEDIATRIC ORTHOPEDICS

Neurogenic

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Brachial plexus injury – during birth  birth 

Myogenic – Myogenic  – muscular  muscular dystrophy

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Cerebral palsy – from injury in the brain  brain  

  o  o 

Idiopathic – Idiopathic  – m.c  m.c 80%

o

Structural – Structural  – the  the curve of the spine is rigid and can’ can’t be reversed

Arthritis – Arthritis  – could  could lead to articulating cartilage thinning and loss  loss   Age and obesity  obesity 

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Conservative Mngt:

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Tx: tendon lengthening, contracture release,

Developmental dysplasia of the hip (DDH)

  o  o  o 

JOINT RECONSTRUCTION - 

Increased muscle tone  tone 

Developmental disease - 

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Classifications: spastic, athetotic, ataxic  ataxic 

maintenance of motion and function  function 

the scoliosis (limb length, muscle spasm)

  o 

Tx: Chemo, radio, stem cell  cell 

Degenerative

Non-structural – Non-structural  – due  due to referred effects of the surrounding

o

M protein in serum and urine – urine  – bence  bence jones protein  protein 

o

tissues or structures, correcting the underlying cause will correct - 

Punch out lesions of radiograph esp. skull bone

o

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o

Seen in first born female + history  history  Breech birth  birth  Ortolani’s Test – abduction – abduction test  test   Barlow’s test – adduction – adduction test  test  -Palpable clicking in the relocation of the femoral head

Weight loss, activity modification  modification   rest bracing, PT, pain management, assistive devices devices  

in the acetabulum

 

Pharmacologic Mngt: steroid, lidocaine injection,

Tx: Pavlik harness for early treatment (froglet position),

o

surgical for delayed  delayed 

viscosupplementation  viscosupplementation  - 

Surgical Mngt:

    o  o

Arthrodesis

o

Arthroplasty Computer aided joint arthroplasty

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Legg-Calve-Perthes disease

 

o

in flattening of femoral head - 

Slipped capital femoral epiphysis (SCFE) Slipped 

  o  o

ONCOLOGY  ONCOLOGY  - 

Diagnosis: Hx, P.E.

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Labs: LDH, Ca, Alk Phos, PSA

o

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Imaging: Xray, US, CT, MRI

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Biopsy: FNAB, FNAC, Open

10-20 yo

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Around the knee

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Classified according to predominant cell type

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Tx: wide resection w/ or w/o chemo

Tx: minimal screw fixation to prevent slip Mild degree of in toeing/out toeing toei ng in normal and will correct at age 8

 

o

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Osteosarcoma -  M.C. primary malignant bone tumor - 

In obese boys

Lower extremity rotational abnormalities

 

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Osteonecrosis of proximal femoral epiphysis resulting

Tx: Rotational femoral osteotomy by age 10-11

Clubfoot / Congenital talipes equino varus o

 

Contracture of medial tendons of the foot, tight Achilles Tendon, contracture of the ankle, hindfoot and midfoot

  o  o

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2nd m.c. primary bone tumor  tumor  

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