Surgery

General Orthopedics, Open Fractures, Compartment Syndrome

Dr. Joe Bair Alonto, MD, FPOA
August 17, 2020

OUTLINE - Diagnostics
o XRAY
ORTHOPEDICS ................................................................................................ 1 o Special Views
History.............................................................................................................................. 1
Subspecialties ................................................................................................................. 1 o CT SCAN
Orthopedics ..................................................................................................................... 1 o MRI
Diagnosis ......................................................................................................................... 1
Treatment ........................................................................................................................ 2 o Bone Scan
- Treatment
FRACTURES .................................................................................................... 3
Classification ................................................................................................................... 3
o Nonoperative
Nomenclature .................................................................................................................. 3 o Operative
Treatment ........................................................................................................................ 4 o Goal:
OPEN FRACTURES ......................................................................................... 4 ▪ restore the normal anatomy
Treatment ........................................................................................................................ 4 ▪ stabilize fractures to allow early mobility and minimize
Gustilo-Anderson Classification .................................................................................... 5
complications related to multiple system trauma
COMPARTMENT SYNDROME ........................................................................ 5 ▪ repair/reconstruct these injuries to restore function
Treatment ........................................................................................................................ 5
Complications.................................................................................................................. 5
Diagnosis
- Radiographs
ORTHOPEDICS o Joint above and below
- Branch of medicine that focuses on the care of the musculoskeletal o 3D visualization
system o need to ask for two views
- Orthopedists use both surgical and nonsurgical approaches to the
▪ contralateral view
variety of musculoskeletal issues, such as sports injuries, joint pain,
• to compare both sides, especially in children
and back problems
- Part of a broader orthopedic team that may include physician ▪ special view
assistants, nurse practitioners, athletic trainers, and occupational or • stress views
physical therapists • skyline views
- Treat a wide of variety of musculoskeletal conditions
o fractures, arthritis, soft tissue injuries, overuse or sports
injuries, back problems, congenital conditions
- 4-5 years residency program, board certification,
fellowship/subspecialty

History
- Term coined in the 1700s by Nicholas Andry, a professor of medicine
at the University of Paris
- Orthopedia is a composite of 2 Greek words:
Figure 1. Contralateral view
o Orthos, meaning “straight and free from deformity”
o Paidios, meaning “child”
- Shoshone Indians, South Australian tribes, Ancient Egypt
o Splints of rawhide, clay
- Hippocrates (father of medicine)
o Principles of traction, countertraction
- Renaissance
o Surgical management of injuries
- Modern times
o Establishment of specialty 1800s

Subspecialties
- Trauma Figure 2. Stress view
- Spine
- Tumor/Oncology
- Sports
- Pediatrics
- Hand
- Foot and Ankle
- Reconstruction

Orthopedics
- History and PE Figure 3. Skyline view
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 Surgery | General Orthopedics, Open Fractures, Compartment Syndrome
- CT Scan
o particularly for pelvic fractures
o Check for fragments (better seen in 3D reconstruction)

Figure 8. Modern, water-proof type cast

- Splints, braces
o its difference from casts is that it’s not circumferential
o can take it off to take a bath, then put it back on

- Tractions
Figure 4. Examples of CT Scans o Balkan Frame
▪ has contraptions that can help pull a particular bone
- Magnetic Resonance Imaging (MRI) ▪ Figure 9 shows foot traction on the femur
o method of choice for the detection of radiographically occult,
clinically significant, acute fractures
o excellent resolution of soft tissue structures

Figure 9. Balkan Frame

Figure 5. Examples of MRI
- Injections
- Radionuclide Bone Scans o also used for diagnostics
o evaluate skeletal metabolic activity o steroid injections to the knee or to the joints
- Physical Therapy
- Rest and Observation

Surgical
- Excisions
- External fixation

Figure 6. Examples of Radionuclide Bone Scans

- Ultrasound
Figure 10. External fixation

- Internal fixation
o use of screws and pins, elastic nails, clip, intramedullary nail,
dynamic hip screw

Figure 7. Example of an Ultrasound

Treatment
Nonsurgical
- Casts
o water-proof type
o 3D printed
o Old type: plaster of Paris made of fiberglass
Figure 11. Internal fixation
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 Surgery | General Orthopedics, Open Fractures, Compartment Syndrome
- Joint Replacement - Lifetime fractures prevalence exceeds 50% in middle-aged men, and
40% in women over the age of 75 years

Classification
Causes
- Trauma
o Low energy - standing height or less
o High Energy - excessive force on the normal bone. It is most
commonly encountered (ex. road traffic accidents)
- Pathologic
o from low energy injuries which occur through an area of bone
weakened with a presenting abnormality

Figure 12. Total Hip and Knee replacement

- Spinal fusion
o use of screws to stabilize the unstable segment of the vertebrae

Figure 16. Pathologic cause

Type
- Open
- Closed

Figure 13. Spinal fusion Location

- Appendicular
- Megaprosthesis
- Axial
o in tumor oncology, where the bone is almost taken out, it is
used to replace almost the entirety of the whole bone
Nomenclature
- Fracture Nomenclature:
o Open or closed
o Complete or incomplete
o Configuration
o Displacement
o What part of the bone
o What bone
o Laterality

Figure 14. Megaprosthesis

- Limb Replacement
o in some cases, instead of taking out the whole limb, some
would use an exoskeleton

Figure 17. Incomplete (left), Complete (right) Fracture.

Figure 15. Exoskeleton

FRACTURES
- Soft tissue injury complicated by a break in the bone
- Calculated fracture incidence is 3.6 per 100 people per year
Figure 18. Configuration.
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 Surgery | General Orthopedics, Open Fractures, Compartment Syndrome
▪ Skin irritation

Figure 22. Splint and Cast

Figure 19. Non-displaced (left), displaced (right). - Traction

o Types:
Treatment ▪ Skin – wrap around limb and use it to put traction
Operative ▪ Skeletal – insert pin and directly put pressure on the
bone
- Internal fixation o Skin traction
o Plates and screws, intramedullary nails, wires ▪ Skin breakdown
o Advantages: ▪ Limited amount of weight
▪ more stable o Skeletal traction
▪ earlier return to function ▪ Reserve for the bigger bones and bigger patients
o Disadvantages:
▪ cost
▪ soft tissue trauma

Figure 20. Intermedullary nail. Figure 23. Splint.

Figure 21. Wires. Figure 24. Skeletal traction.

- External Fixation OPEN FRACTURES

o Percutaneous placement of wires or half pins connected to - Definition
rods or tubes o Fracture with communication to the external environment
o Advantages: o This is an emergency
▪ Minimal soft tissue trauma o Requires prompt assessment and treatment
▪ Avoidance of contamination - Gustilo-Anderson Classification
▪ Rapid application o Gustilo open fractures
o Disadvantages:
o Gustilo is a Filipino surgeon who trained in Minnesota
▪ Cumbersome
▪ The classification is based on his research of 1000 cases
▪ Pin tract infection
▪ Loosening of open fractures

Non-operative Treatment
- Splint & Casts - Immediate administration of antibiotics and irrigation and
o Splints don’t do the whole circumference of the extremity debridement of the wound
o Casts apply it to the whole circumference of the extremity - The goal of the treatment is to achieve fracture healing and to
o Support and immobilize prevent wound infections and osteomyelitis
o Complications:
▪ Pressure sores
▪ Burns
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 Surgery | General Orthopedics, Open Fractures, Compartment Syndrome
Gustilo-Anderson Classification
- Type 1: <1cm
- Type 2: 2-10 cm opening with moderate soft tissue damage and
wound contamination
- Type 3: Segmental fractures with extensive periosteal stripping, and
usually >10cm
o Has three basic classifications
▪ Type 3A: Adequate sufficient coverage
• After debridement of the wound, you can close it
primarily

Figure 28. Image showing compartment syndrome of the forearm.

Treatment
- Fasciotomy
o you open the compartment and just leave it open for the
structures to breathe

Figure 25. Example of type 3A.

▪ Type 3B: Requiring flap coverage or secondary closure

• Flipping a muscle and doing a skin graft to cover

Figure 29. Fasciotomy of the leg. Notice gaping of the wound and bulging.

Complications
- Irreversible necrosis and Volkmann's ischemic contractures which
Figure 26. Example of type 3B. could lead to severe loss of function or even in some cases,
amputation.
▪ Type 3C: Neurovascular injury requiring repair

Figure 27. (A) Gustilo-Anderson fracture type III open fracture. (B) Image of
external fixator of the tibia.

COMPARTMENT SYNDROME
- Significant swelling within a compartment of an injured extremity that
jeopardizes blood flow and microcirculation
- Patients they complain of pain that is greater than expected for the
injury of surgery
o Check for the movement of the toes, the patient acts as if the
limb is being cut
o pain that is out of proportion
- Early signs: pain, swelling, and pain with the passive stretch of the
compartment muscle
o Compartment syndrome could either be secondary to the
fracture itself or secondary to your surgical treatment
- Late signs: numbness, paralysis, and absence of cause
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