ORTHOPEDIC SURGERY NOTES - Comminuted (high intensity, several communicating fracture

Dr. Roel S. Cobarde lines)

FRACTURE HEALING
Stage 1 – Inflammation and hematoma (Day 1)
Stage 2 – Hematoma organization (Day 2-7)
Stage 3 – Callus formation (Day 8-90)
- Soft Callus -> fibrous tissue
- Hard Callus -> Calcification
Stage 4 – Remodeling
-Longest part (years) According to outside communication
-Remodeling will stop when the bone has reconfigured - Closed (simple)
itself - Open (compound)

WOLFF’S LAW COMPARTMENT SYNDROME

- Julius Wolff 1892 - Emergency situation
- The bone will adapt to the degree of mechanical loading, such - Increased
that an increase in loading will cause the architecture of the intracompartment pressure due to
internal, spongy bone to strengthen, followed by the swelling within the
strengthening of the cortical layer compartment that affects the
- Every change in form and function of bones will determine their blood flow of the limb
definite changes in accordance to mathematical law - Treatment: emergency fasciotomy
- Stage of remodeling (resorption and deposition) - Complications: irreversible necrosis and contractures resulting to
TRAUMA loss of function
Goals of treatment of MSK (musculoskeletal) injuries
1. Restore normal anatomy – manipulation, traction, open surgery FRACTURES IN CHILDREN
2. Immobilization – pain relief and healing Factors:
a. External fixation – cast, splint, ext. fixator device - Rapid healing
b. Traction – skin (children), skeletal (adults), cast, brace, - Spontaneous correction, mild to moderate degrees of angulation
crutch field tongs and overriding
c. Internal Fixation – screw, bone, plate, pins,
intramedullary nails
*hardware: stable construct to allow fracture to heal and
align
3. Repair and reconstruct – to restore function

DEFINITION OF TERMS
Fracture – break in bone continuity
Dislocation – displacement of joint articulation
Subluxation – slight displacement of joint
Sprain – ligamentous injury *When there is rotation, it cannot be corrected by remodeling
Strain – muscular injury Greenstick Fracture
- Incomplete fracture where only 1 bone cortex is broken
DIAGNOSIS - Treatment: break the intact cortex and proceed with fracture
History principles
-Thorough and include mechanism of injury Torus Fracture (Buckle’s Fracture)
- NOI (Name of Injury) - Incomplete fracture at 1 side of the metaphysis
-POI (Place of Injury) - Treatment: immobilization
-TOI (Time of Injury)
-DOI (Date of Injury)
Physical exam
-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
FRACTURE CLASSIFICATION
According to configuration:
- Transverse (perpendicular to long axis)
- Oblique (axial and bending force)
- Spiral (force and twisting, S-formed fracture)
- Segment (no sup. and inf. communication)
SALTER AND HARRIS CLASSIFICATION OF EPIPHYSEAL FRACTURE
Type 1 – only the cartilage plate
Type 2 – cartilage plate and a triangular segment of the
metaphysis
Type 3 – transverses the epiphysis and the cartilage plate
Type 4 – transverse the metaphysis, cartilage plate and epiphysis
Type 5 - crushing the growth plate
OPEN FRACTURES (Outside communication) - Chauffer’s fx (intra-articular fractures of the radial styloid
- R. Gustilo and Anderson process)
- Type 1 - <1cm wound, clean, minimal periosteal stripping, low - Pott’s fx (a fracture affecting one or both of the malleoli),
energy cotton’s fx (a fracture of the ankle involving the lateral malleolus,
Type 2 - >2cm, clean, moderate periosteal stripping, low to medial malleolus and distal posterior aspect of the tibia)
moderate energy - Pott’s Disease (tuberculosis of the spine)
Type 3 - >10cm wound, grossly contaminated, severe periosteal
stripping, comminuted, high energy, high velocity (GSW, farm SPINAL CORD SYNDROMES
injury, casualty situations, >golden hour/6 hrs, war) - Complete – total loss below the level of lesion
3A-Adequate soft tissue coverage - Incomplete
3B-Bad, massive soft tissue loss, bony exposure o Brown-Sequard syndrome: half of the cord, ipsi: motor
3C-Circulation, major repairable blood vessel injury & proprioception, contra: nociception & thermo
o Ant. Cord syndrome: ventral half, bilateral: motor, pain,
COMPLICATIONS OF OPEN FRACTURES temperature
Osteomyelitis o Post. Cord syndrome: dorsal half, proprioception
- Hematogenous spread (endogenous) o Central Cord Syndrome: gray matter, upper extremity
- Direct inoculation (exogenous) weakness
- Direct spread AMPUTATIONS
- Ex. Kabahong – long staying skin sore, chronic skin wounds, could - Indications
spread the infection to the bones o Trauma – type 3C fx
- Classifications: o Infection
-Acute – 1-7 days, (+) inflammation local and systemic, o Peripheral vascular disease
(-) radiograph o Tumor
-Subacute – 8-14 days, (+/-) inflammation, (+) o Congenital abnormalities
radiograph – periosteal reaction (codman’s triangle) - Upper extremity
-Chronic - >14 days, (-) inflammation, draining sinus, o Forequarter amputation
involucrum, sequestrum, epidermoid cancer o Shoulder disarticulation
Late Bony Complication of Fracture Healing o Above elbow amputation AEA
- Delayed union – slow healing o Elbow disarticulation
- Nonunion – healing stops short of firm union o Below elbow amputation BEA
- Malunion – healing takes unsatisfactory alignment o Wrist disarticulation
Fractures of the long bone - Hand
- M.C. fractured long bone – radius/tibia o Transmetacarpal amputation
- M.C. dislocated joint – shoulder o Phalangeal amputation
- M.C. sprained joint – ankle o DIP/PIP disarticulation
- M.C. site of nonunion – middle distal tibia and talus - Lower extremity
Upper extremity o Hemipelvectomy
- Humerus – surgical neck, shaft, supracondylar area, radial groove o Hip disarticulation
- Radius and ulna – distal 1/3, colle’s fracture, smith’s fracture, o Above knee amputation AKA
proximal and middle thirds fracture o Knee disarticulation
- Hand – phalanges, metacarpals – cast/surgery for multiple o Below knee amputation BKA
fractures, carpals – navicular common nonunion o Ankle disarticulation
Lower extremity - Foot
- Femur – Pedia: cast immobilization o Syme amputation, Boyd amputation
Adult: surgical, femoral neck -> pins/prosthesis o Chopart amputation
- Tibia and Fibula – plateau: joint congruence o Lisfran amputation
Plafond: joint congruence o Transmetatarsal amputation
Bimalleolar: ankle joint o Phalangeal amputation
Shaft: cast/surgical o DIP/PIP joint articulation
- Foot – phalanges:
Metatarsals: cast/surgical for multiple fractures SPINAL COLUMN INJURY
Tarsals: talus, m.c. non union Disc Herniation
Calcaneus: restore the calcaneal angle (spring ligament) - M.C. 20-50 yo with Hx of heavy lifting objects
Fractures of Spine - Annulus tear with extension of nucleus pulposus compressing the
- Cervical spine – Jefferson fx, hangman’s fx (isthmus), whiplash spinal cord/nerve root
injury (odontoid)
- Thoracolumbar – chance fx, compression fx, burst fx (2 or 3 Spinal Stenosis
columns) - Loss of hydration of the disc resulting to loss of disc height and
DISLOCATIONS increased bulging of annulus and the ligamentum flavum causing
- Shoulders narrowing of the spinal canal
- Elbow - Facet osteophytes can also cause spinal foramen stenosis
- Hip - Sx:
- Knee o Cervical stenosis – may result to hyperreflexia, ataxia,
- Tx: reversal of the mechanism of injury balance issues, weakness and pain
FRACTURE SYNONYMS o Lumbar stenosis – neurogenic claudication, progressive
- Colle’s fx (complete fx of the radius bone close to the wrist) pain, weakness and numbness of the legs assoc. w/
- Smith’s fx (end of radius) walking and standing but relieved by bending forward
- Monteggias fx (proximal radioulnar joint in assoc w/ forearm - Tx:
fracture) o Epidural stenosis
- Galeazzi’s fx ( fracture of the middle to distal third of the radius o PT
associated with dislocation or subluxation of the distal radioulnar o 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) - M.C. cause of absence of work, Resolves 1-2 weeks
- Night stick fx (An isolated fracture of the ulnar shaft) - Unremitting chronic back pain – infection, malignancy, metastasis
Scoliosis o Punch out lesions of radiograph esp. skull bone
- Lateral curvature of spine diaphysis
- Classification: o M protein in serum and urine – bence jones protein
o Congenital o Tx: Chemo, radio, stem cell
o Degenerative
o Metabolic – mucopolysaccharides PEDIATRIC ORTHOPEDICS
o Neurogenic - Brachial plexus injury – during birth
o Myogenic – muscular dystrophy - Cerebral palsy – from injury in the brain
o Idiopathic – m.c 80% o Classifications: spastic, athetotic, ataxic
- Non-structural – due to referred effects of the surrounding o Increased muscle tone
tissues or structures, correcting the underlying cause will correct o Tx: tendon lengthening, contracture release,
the scoliosis (limb length, muscle spasm) maintenance of motion and function
- Structural – the curve of the spine is rigid and can’t be reversed Developmental disease
- Developmental dysplasia of the hip (DDH)
JOINT RECONSTRUCTION o Seen in first born female + history
- Arthritis – could lead to articulating cartilage thinning and loss o Breech birth
- Age and obesity o Ortolani’s Test – abduction test
- Conservative Mngt: o Barlow’s test – adduction test
o Weight loss, activity modification -Palpable clicking in the relocation of the femoral head
o rest bracing, PT, pain management, assistive devices in the acetabulum
- Pharmacologic Mngt: steroid, lidocaine injection, o Tx: Pavlik harness for early treatment (froglet position),
viscosupplementation surgical for delayed
- Surgical Mngt: - Legg-Calve-Perthes disease
o Arthrodesis o Osteonecrosis of proximal femoral epiphysis resulting
o Arthroplasty in flattening of femoral head
o Computer aided joint arthroplasty - Slipped capital femoral epiphysis (SCFE)
o In obese boys
ONCOLOGY o Tx: minimal screw fixation to prevent slip
Diagnosis: - Lower extremity rotational abnormalities
- Hx, P.E. o Mild degree of in toeing/out toeing in normal and will
- Labs: LDH, Ca, Alk Phos, PSA correct at age 8
- Imaging: Xray, US, CT, MRI o Tx: Rotational femoral osteotomy by age 10-11
- Biopsy: FNAB, FNAC, Open - Clubfoot / Congenital talipes equino varus
Osteosarcoma o Contracture of medial tendons of the foot, tight
- M.C. primary malignant bone tumor Achilles Tendon, contracture of the ankle, hindfoot and
- 10-20 yo midfoot
- Around the knee o Tx: sequential corrective casting
- Classified according to predominant cell type o Surgical Tx: severe cases or delayed diagnosis
- Tx: wide resection w/ or w/o chemo - Osgood-Schlatter Disease – often in athletically active adolescent
Ewing’s sarcoma o Calcified ossicles at Tibial tuberosity
- 2nd m.c. primary bone tumor o Present as local pain and tenderness in the tibial
- <30 yo tubercle
- Clinical Presentation: onion skin periosteum (xray), small round, o Tx: active restriction or surgical treatment
blue cell tumor
- Tx: chemo, radiotherapy, surgery
Cartilage Forming Tumors TRAUMATOLOGY
- Chondrosarcoma
- Tx: Surgery (cells are not radio or chemo sensitive) Gadgets
Fibrous Lesions of Bone - Neck Brace
- Desmoplastic fibroma - Stretcher
- Malignant fibrous histiocytoma of bone - Air cast
- Malignant vascular tumors
o Hemangioendothelioma
o Hemangiopericytoma
o Angiosarcoma of bone
Miscellaneous Tumors
- Giant cell tumors (bone)
o Female, 20-40 yo
o Knee, distal radius, proximal humerus, pelvis
o Eccentric epimetaphyseal lytic lesions eroding to
subchondral bone
o Mets: Lungs
o High recurrence rate
- Ossifying fibroma
o Ant. Cortex of tibial diaphysis of young males w/ soap
bubble appearance on Xray
o Precursor to adamantinoma
- Adamantinoma
o May metastasize
o Tubular, basaloid, squamoid or spindle pattern
o Tx: Wide surgical resection
- Primary Lymphoma of Bone
- Chordoma
- Multiple Myeloma
o M.c. primary bone malignancy