Orthopaedics Review

Mr. James Harty
A fracture is a break or
interruption in the
continuity of a bone
 Anatomical
• Bone involved
 Radius, femur
• Part of bone involved
 Diaphysis, metaphysis
 neck/shaft/head
 Direction
of Fracture
• Transverse
• Oblique
• Spiral
All fractures are
the deformity of the
All fractures are
A communication between the
fracture site and the skin surface
All fractures are
More than two fragments
(>1 fracture line)
fracture occurring in a
bone weakened by
 Often
refers to a fracture
occuring in a bony
fracture occurring in
immature bone
 Cortex
bends rather
than breaks
 Classified
 Types
by Salter-Harris
• Type II is commonest
 Type
II fracture distal radius
 “Look, Feel, Move”
 Pain, tenderness
 Swelling…
 Loss of function
 Crepitus
 Signs of blood loss
 Injury to other structures
 History
 Examination
 X-ray
 Isotope
Bone Scan
 Specialised Imaging
• C.T.
• M.R.I.
Two planes
Two joints
Two occasions
Two limbs
Two opinions
Two planes
Two joints
Two occasions
Two limbs
Two opinions
AP and Lateral
+/- special views e.g. scaphoid
Joint above and below for shaft fractures
Two planes
Two joints
Two occasions
Two limbs
Two opinions
Two planes
Two joints
Two occasions
Two limbs
Two opinions
Repeat X-rays after an interval may show
a fracture
e.g. scaphoid, hip
Two planes
Two joints
Two occasions
Two limbs
Two opinions
Comparative views of opposite limb e.g.
elbow injuries in children
Two planes
Two joints
Two occasions
Two limbs
Two opinions
Ask a radiologist or senior colleague!
inflammatory exudate
new blood vessels (2-3 days)
bone forming cells
bridge of callus (cartilage, bone, fibrous tissue)
framework for bridging the gap
replaced by woven bone
remodelling along lines of stress
 callus
is the response to movement
at fracture site
 callus does not develop if the
fracture is rigidly fixed with no
movement: primary bone healing
 Depends on many
• age
• bone
• type of fracture
• infection
• nutrition
• stimulation
Full assessment
Maintenance of reduction
 restoring “normal” anatomy
 not
always necessary
 open/closed
 anaesthesia
• local/regional/general
 general
rule: joint above and joint below
• for shaft fractures
 splints, plaster, braces
 internal
• plates, screws, wires, intramedullary rods
 external
 traction
 maintain
until united
 check x-rays
 clinical and radiological evidence of
 starts
 keep non-immobilised joints mobile
 avoid muscle wasting
 physiotherapy
problem: infection
prophylactic antibiotics appropriate to the injury
anti-tetanus cover
• “the solution to pollution is dilution”
debridement: remove all dead tissue
skin cover
 non-union/delayed
 multiple
 pathological fractures
 fractures likely to slip
 intra-articular fractures
 nursing difficulties
Initial treatment – splinting and analgesia.
Compound injuries – Antibiotic cover
(usually cephalosporin +/aminoglycoside if contaminated).
-Tetanus cover.
 Compound
injuries must be debrided
ASAP, should be within 6 hours.
 Bone should be covered with tissue to
prevent dessication.
 Delayed primary closure of the wound, or
“second look” procedure.
 Aims
– obtain union, maintain relative
positions of knee and ankle joints.
 Treatment options include:
 Conservative.
 Open Reduction and Internal Fixation.
 Intra medullary nailing.
 External fixation.
 Casting
may be considered if:
 Isolated tibial fracture (fibula not
 >50% cortical overlap at # site. Closed
reduction of displaced #’s and casting
leads to significant incidence of nonunion.
 Less than 2cm initial shortening.
 Usually
used for intra–articular #’s
involving knee or ankle rather than shaft
 Periosteal stripping required.
 Fracture site must be opened.
 May be useful in Rx of non-union +/bone grafting.
 Probably
preferred Rx of closed
displaced tibial shaft fractures.
 Union rates of near 100% for closed
 Fracture site not opened during the
procedure, reduced chance of infection.
 More difficult in proximal shaft fractures.
 Minimal
soft tissue trauma.
 Little foreign material in body, may be
preferred in compound fractures.
 Comminuted injuries.
 Uniplanar, circular or combination of
both (hybrid) fixators.
 Compartment
 Pressure in muscular compartments rises
above capillary pressure, ischaemia of
tissues in affected compartment.
 Patients complain of pain unrelieved by
splinting and analgesia.
 Pain
on passive stretching is classic
physical sign.
 Normal distal pulses and neurology DO
NOT exclude compartment syndrome.
 Incidence NOT reduced in compound
fractures (up to 9%).
 ? May complicate nailing of fracture.
 Union
• delayed union
• non-union
 atrophic
 hypertrophic
 infected
• mal-union
 skin
• compound wounds
• fracture blisters
• plaster sores
• pressure sores
 muscle/tendon
• disuse, wasting
• avulsion
• late rupture (e.g. EPL, Colles’ fracture)
 haemorrhage
• pelvis 6-8 units (hidden)
• femur 3-4 units
• hip 1-2 units
 thrombosis/embolism
• esp. pelvic and hip fractures
 infection
• local (compound or operated)
• respiratory
• urinary tract
 growth
• epiphyseal fractures
 stiffness
• keep non-injured joints mobile
 neighbouring
• nerves
• vessels
• internal organs
 Subcapital
Femoral Fracture.
 Over 100,000/year in the UK
Common in osteoporotic
Majority of blood supply to
head comes from the neck.
Almost 90% occur in >65
Almost 75% occur in females.
The fibres are reflected back
along the neck of the femur to
the articular margin of the
femoral head.
The reflected part constitutes the
retinacular fibres, which bind
down the nutrient arteries from
the trochanteric anastomosis,
along the neck to supply the
The head and intracapsular part of the neck receive
blood from the trochanteric anastomosis.
Formed by descending superior gluteal artery with
ascending branches of the medial and lateral
circumflex femoral arteries.
Branches pass along the femoral neck with the
retinacular fibres of the capsule.
 Traumatic
 Pathological fracture
Severe hip pain
associated with a fall.
Unable to weight-bear.
Shortened and
externally rotated leg
AP/Lateral hip required.
Older – co-morbidity.
RS Garden, Preston Royal Infirmary, JBJS 1961
 Blood
supply lost through thrombosis or
interrossoeus hypertension.
 Marrow of head is replaced by fat, bone dies.
 Zone of revascularisation, incomplete if large
avascular area.
 Zone of reossification – joint may collapse.
 May -> secondary arthritis.
X-rays – may appear
Radioisotope – dead
area of femoral head
surrounded by
hyperaemic area of
MRI – one or more
avascular areas.
ATLS principals of resuscitation
Work-up for theatre
Relevant Radiology - Diagnosis
Decide surgical/anaesthetic management
Informed Consent
Prophylactic Antibiotics
Early Mobilization
Discharge arrangements
Age and
Undisplaced (Garden 1 & 2):
1. Cannulated Hip Screws.
2. DHS.
3. Hemi-Arthroplasty
Displaced (Garden 3 & 4):
1. Hemi-Arthroplasty.
2. Total Hip Replacement occasionally if pre-existing
AO Screws to hold
femoral head in position
Indications for Closed Reduction and Fixation:
Physiologically young patient: age < 65, working
patient, good bone stock;
Demented elderly patient that requires total care;
Adequate closed reduction with no comminution
or femoral neck defects;
Patient should be aware that with an inadequate
closed reduction, then an open reduction or
hemiarthroplasty will be required
 Older
patients – Hemiarthroplasty
 Especially in Life Expectancy<5 years
 One definitive operation.
 Fractures may progressively displace.
Undisplaced Garden 1+2 – no vascular disruption
Lateral Approach
X-ray control
First part is a heavy plate fixed to lateral cortex of
femur with cortical screws.
Second part is a rod which passes into the
femoral head.
The threaded end crosses the fracture line to
engage and hold the fracture line.
As the patient weight bears on the healing
fracture the broken ends of the bone collapse into
each other and compress the fracture.
The sliding-rod mechanism allows this to happen
without the hip falling into varus.
Avascular Necrosis
 Non-Union
 Infection
 Ulcers
 Anaemia
 Femoral
Head survival unlikely.
 Under fifty – reduce and pin immediately.
 Older: <65 THR
>65 Hemiarthroplasty
Austin Talley Moore, MD
South Carolina 1899-1963
In September 1940, Austin Tally Moore and Harold Ray
Bohlman, replaced the proximal 12 inches of a femur destroyed
by a recurrent giant cell tumor with a custom-made prosthesis,
Dr. Moore was encouraged to develop a new femoral head with
a short stem for intramedullary fixation, and, the now
legendary Austin Moore Hip was introduced in 1950.
Frederick Roeck Thompson, MD
Texas 1907-1983
Son of the renowned reconstructive surgeon Dr. James E.
Thompson of the University of Texas Medical Branch, Frederick
R. Thompson, MD, designed - one of the first metal hips for use
in hip fractures and salvage arthroplasties. The first F.R.
Thompson Hip was implanted in January 1951, and is still in
worldwide use today.
Poor general health that would prevent a second operation;
pathologic hip fractures
Parkinson's disease, hemiplegia, or other neurological disease;
Physiologic age > 70 yrs;
Severe osteoporosis without loss of primary trabeclae in femoral head
Inadequate closed reduction;
Displaced fracture which is several days old;
Pre-existing hip disease (DJD, RA, AVN);
Pre-existing sepsis
Young patient
Failure of internal fixation devices;
Pre-existing disease of the acetabulum;
Even without normal preoperative cartilagenous space, many patients will become symptomatic at 5 years
due to metal induced degradation;
Mortality - mortality after hemiarthroplasty is 10 to 40%
Fracture of the Femur: 4.5%
 almost all fractures occur when surgeon attempts to reduce prosthesis;
 most are non displaced and involve either greater trochanter or neck;
 with femoral shaft fracture consider methy methacrylate combined with a long
stem prosthesis;
Post-op: sepsis: 2% to 20%
 more common w/ posterior surgical approach;
 infections may be superficial or deep
Loosening and migration
 presence of a radiolucent zone around the prosthesis;
 if clinical signs and symptoms are present and loosening or migration is
present, then consider revision to THR;erosion tends to occur in active pts with
cemented Thompson hemiarthroplasty;
 Dislocation
less than 10%.
more common with too much anteversion
or retroversion, posterior capuslectomy, &
excessive postoperative flexion or rotation
with hip adducted
 41% of elderly walk as well as pre-injury
(Koval, Clin Orthop 1995).
 3% to 27% in first 3 months.
 15-30% die within 1 year of fracture.
 The
goal of operative treatment is
 Strong ,stable fixation of the fracture
Dynamic Hip Screw:
Shorter plate (e.g
2-hole) can be used for some
undisplaced intra- capsular #s.
Varying angles to suit angle at femoral
Sliding compression screw device
allows collapse into position of stability.
 Dynamic
Screw (95 °):
Used in (paticularly) subtroch #s.
In certain inter-trochanteric
1. Femoral Shaft Fracture (intraoperative).
2. Respiratory, urinary tract
3. Wound haematoma/infection.
3. DVT/Pulmonary embolus.
1. Avascular necrosis.
2. Delayed/Non-Union.
3. Fixation Failure.
4. Post-traumatic arthritis.
5. Deep Infection
Other Complications:
 Pressure sores.
 Nerve palsies.
 Prosthesis Dislocation.
 Failure to mobilise &
 Mobility: 41% of elderly walk as well as pre-injury
(Koval, Clin Orthop 1995).
 Mortality: 3% to 27% in first 3 months.
15-20% die within 1 year of fracture.
Mortality risk  over age-matched controls for up to 1 year post injury.
Inter-trochanteric #s associated with greater morbidity & mortality.
 Hip
:Thomas test for fixed flexion deformity
 Hip
:Trendelenburg test
 May
be Primary due to intrnsic defect
(mechanical,immune, vascular, cartilage)
 Secondary
 Get
- trauma, infection, congenital
loss of the bearing surface, followed by
development of osteophytes and breakdown of
the osteochondral junction
 Subchondral
 Osteophyte
 Joint
cysts ( from microfractures)
space narrowing
 Sclerotic
bone formation
Joint space narrowing
Subchondral cysts
 Pain
is the main + best indication
 Degenerative
joint disease – OA 1o or 2o
 Rheumatoid Arthritis
 Intractable
 Stiffness
 Deteriorating

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