Transcript Surgery Orthopedics Dr Thurston 2012_compressed

LMCC Orthopedic Review Lecture
“Back to Basics”
April, 2012
Dr. P.R. Thurston
LMCC Orthopedic Review Lecture
There are 10 basic topics about which questions may be
framed for medical student examinations in Orthopedics.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Fractures.
Low Back Pain.
Child, Painless Limp.
Pulmonary Fat Embolus.
Compartment Syndrome.
Metabolic Bone Disease.
Metastatic Disease.
Septic Hip / Osteomyelitis – Children.
Dislocations.
Trivia.
Definitions
Fracture:A discontinuity in the structural
integrity of a bone.
Infraction:-
An incomplete fracture.
Dislocation:Complete loss of contact of the
articular surfaces of a
Subluxation:-
Non-concentric joint surfaces.
Reduction:Returning a fracture or dislocation to an
anatomical alignment.
Comminution:-
Multiple fragments.
joint.
Fractures
Definition :-
A discontinuity in the structural
integrity of a bone.
A fracture occurs because the force applied
exceeds the breaking strength of the bone so that the
Load can no longer be transferred across that zone
of the bone.
Fractures
Mechanical Properties of Bone
Bone is a two-phase material :-
Calcium HydroxyApatite
Osteoid
Ca10(PO4)6(OH)2
= mineral
Collagen type I and II = fibrous
Calcium is strong in compression, but weak in tension.
Osteoid is strong in tension, but weak in compression.
Fractures
(for adult bone)
BUT :-
Calcium is stronger in compression
than Osteoid is in tension
And therefore :-
Bone always fails first in tension
Fractures
A bone consists of three
areas :-
Each region has its own
fracture characteristics.
the Diaphysis
the Metaphysis
the Epiphysis.
Fractures
Diaphyseal
Bending
Torque
Oblique
Spiral
Direct
Metaphyseal
Traction
Transverse
Compression
Epiphyseal
Intra-articular
Pediatric
Mixed
Fracture Description
This fracture is angulated
laterally, since it points
laterally.
The distal fragment is tilted
medially
Fracture Description
1) The distal fragment is always described with
relation to the proximal segment.
2) Displacement = Translation of bone ends.
3) Angulation
= Orientation of bone ends.
4) Angulation identifies to where the fracture points.
5) For clarity, the tilt of the distal fragment is often
used to describe angulation.
Fractures
A fracture can occur in :Growing Bone.
=
Pediatric Deformities.
Normal bone subject to abnormal forces.
= Traumatic Fractures.
Abnormal bone subject to normal forces.
= Pathologic Fractures.
Normal bone subject to cyclic forces.
= Fatigue or Stress Fractures.
Fractures
I
IV
Salter-Harris Classification
II
III
V
Fractures
Salter-Harris Classification
1) Fractures interfering with growing bones.
2) Worse prognosis with increasing number.
3) Probability of surgery increases with
number.
Stress or Fatigue Fractures
Repeated loading below acute
failure threshold.
Eventual fatigue failure.
Military recruits, runners, aerobics.
Tibia, metatarsals, femoral neck.
Initial x-ray can be negative.
Bone tenderness – Bone scan.
Pathologic Fractures
Failure through abnormally
weakened bone
Minimal trauma – BEWARE
Osteoporosis
Metastasis
Tumours:- Benign,
Malignant
(Multiple Myeloma).
Metabolic Bone Disease
Pathologic Fractures
Metastases:
Lytic
Sclerotic
-
Lung
-
Colon
-
Thyroid
-
Renal
-
Breast
-
Prostate
Pathologic Fractures
Metastases:
- require fixation to prevent fracture if they are > 1/3.
- produce pain on weight bearing in the lower limb.
- survival > 3 months.
- cannot be managed by medical therapy.
- radiotherapy after fixation (2 weeks)
(radiotherapy induced osteonecrotic fractures)
Pathologic Fractures
Osteitis Deformans / Paget’s Disease
4% of pop. Over 40
yrs.
accelerated bone
turnover
often assymptomatic
monostotic >
polyostotic
loss of stature
AV shunting
pathologic bone
Gout
Urate crystalopathic arthritis
Crystals in periarticular tissues
Inconsistant elevated serum urate
Allopurinol and colchicine
Tophi in periarticular soft tissues
Deposits in non-articular cartilage
Juxta-articular erosions
Indications for Closed Reduction
There is significant displacement.
Reduction is possible.
The reduction, if gained, can be held.
The fracture has not been produced by a traction
force.
Indications for Open Reduction
1)
2)
3)
4)
5)
6)
7)
8)
There is a significant Displacement.
Open Fractures.
Intra-articular Fractures.
Un-reducible Fractures
Reductions that cannot be maintained in a cast.
Comminuted or Segmental Fractures.
Floating Joints.
Fractures with Neurovascular damage.
Open Fractures
Classification :1. < 1 cm., inside-out, little soft tissue damage.
= low potential for infection.
2. 1 cm. – 10 cms., outside-in, requires debridement, but
no flap or skin graft.
= moderate potential for infection.
3. > 10 cms., outside-in, high energy, devitalized muscle,
comminution or bone loss, soft tissue loss.
Open Fractures
Classification :3A.
No loss of soft tissue cover, no flap required.
3B.
Flap required due to soft tissue stripping.
3C.
Associated vascular injury.
Type 1. Open Fracture = 6 mm, extend & debride
Degloving Mechanism
Degloving Mechanism
Type III C Injuries – Vascular Injury
Note pallor of the ankle
No pulses
Fracture Complications
1. Pulmonary Fat Emboli
2. Compartment Syndromes
Pulmonary Fat Emboli :-
A.R.D.S.
- Long bone fractures, burns, contusions.
- Interstitial pneumonitis due to free fatty acids
- S.O.B. & confusion in young adults.
- Axillary & Subconjunctival Petechiae.
- Serum lipase elevated.
- pAO2 reduced – if < 50 – 20% mortality.
- Ventillatory support
- Dexamethazone.
- 5 day course.
Pulmonary Fat Emboli :-
A.R.D.S.
Since Pulmonary Fat Emboli occur as an on-going
process, involving either repeated showers of emboli or
an evolution of insults, the most effective treatment is:-
Early Fracture Fixation
for both prevention and management.
Compartment Syndromes
- increased interstitial tissue pressure.
- fractures, burns, tight dressings.
- normal pressure < 25 mm. Hg.
- when the tissue pressure > venous capillary pressure, but less
than the arteriolar pressure.
- 6 P’s
- pain.
- pallor.
- pulselessness.
- paresthesias.
- paralysis.
- poikylothermia.
Compartment Syndrome
Symptom: Pain out of proportion to that
expected for the injury.
Signs: 1. Loss of function of muscle due to
ischemia within the compartment.
2. Pain with passive stretch
3. Numbness etc. are LATE findings!
4. If neuro symptoms present, potential
for full neuro recovery is only 10 %.
Rx Compartment Syndrome
Release all compressive
dressings / plaster.
Elevate extremity to
heart level.
Fasciotomies.
4 compartment
fasciotomy
Compartment Syndrome
Careful monitoring.
Recognise it - 5 P’s
Call Orthopaedic Surgeon
Pressure measurements
Back Pain
Classification of MechanicalBack
Pain
Postural syndrome (MacKenzie)
normal tissues become painful by the application of
prolonged stresses (sitting, bending etc)
Dysfunction syndrome
soft tissues are shortened and stiff. Usually >30 year
old, poor posture, under exercised, reduced mobility
Derangement syndrome
Disc derangement (tears and herniation)
Causes and Classification of Back Pain: McNab
Viscerogenic
Vasculogenic
Neurogenic
Psychogenic
Spondylogenic
Spondylogenic
Osseus:
 Trauma
 Infection
 Neoplasms
 Inflammatory
 Metabolic (eg.Pagets)
 Deformities
Soft tissues:
 Muscles
 SI joints
 Disc
 Facets
Anatomy
Extension
Flexion
Three joint complex (Kirkaldy Willis)
Recurrent rotational strain
Synovial reaction facet joint
Disc circumferencial tears
Cartilage destruction
Osteophyte formation
radial tear
Disc herniation
Capsular laxity
Instability
Internal disc disruption
Subluxation
Lateral N. Ent
decrease disc height
Enlargement of articular process
Central Stenosis
osteophytes
Non operative Treatment of Back Pain
Do nothing
Activity modification
Medications
Exercise and physiotherapy
Braces
Manipulation
Massage therapy
Traction/inversion therapy
Vitamins/Supplements/Diets
Weight control
Disc herniation
Ms J.H. 25 y.o. female presented with cauda equina syndrome
Cauda Equina Syndrome
Sciatica associated with bowel or bladder dysfunction.
Perineal numbness.
Low or Sequestrated Lumbar Disc.
Pressure on S1, S2 and/or S3 nerve roots.
Requires immediate Decompression to
avoid permanent disability.
Spinal stenosis
Symptoms:
 unilateral radicular pain
 bilateral claudication
 better with forward flexion of trunk
 better walking uphill
 rare bowel/bladder involvement
Signs:
 usually no neuro signs
 look for pulses
 stress test
Investigations:
 XR
 CT
 Myelo-CT
 MRI
Developmental Dysplasia of the Hip
An in utero Anterior Subluxation of the hip.
Growth in this position produces excessive Anteversion /
Adduction.
Classification:
Positional
2/1000
Hereditary 2 x more likely if mother
Teratologic Arthrogryphosis
50% bilateral, F > M 8:1
Test ALL newborns at birth
Conservative Rx at birth – Pavlik, D.diaper
Surgical Rx if resistant
Legg-Perthe’s Disease
Osteochondrosis (avascular necrosis)
Proximal Femoral Epiphysis
Necrosis, revascularization, fragmentation, healing
3 – 11 yrs., M > F 4:1, 15% bilat.
Subluxation laterally, Coxa plana, Coxa magna
Osteoarthritis 50 yrs.
Slipped Capital Femoral Epiphysis
Weakness of the physis of the femoral head allows
medial and inferior slip during the last phase of
growth.
Shortening of the leg, adduction, painless limp and
external rotation contracture.
Observation if mild, fixation if severe
Surgery risks Avascular Necrosis of femoral head
Ages for Hip Disease
D.D.H.
Septic Hip
Legg-Perthes
Transient Synovitis
S.C.F.E.
Birth
Birth – 11
3 – 11
3 – 11
11 - 16
Osteomyelitis
Acute infection, metaphyseal
90% Staph., 20% mortality
100% growth abnormality
Periosteal elevation, osteolysis
Sequestrum, Involucrum
Dislocations
The articular surfaces are no longer in contact.
Commonly affects Shoulders > PIP joints > Elbows > Ankles.
Often associated with fractures.
Occasionally associated with neurologic injuries
Shoulder Dislocations
95 % anterior
1 % posterior
Luxatio erecta
Medial
Axillary nerve injury
Rapid reduction
Shoulder Dislocations
Conscious sedation.
Traction reduction.
Immobilization.
Recurrent.
Voluntary
Habitual.
Multiaxial instability.
Elbow Dislocation
Posterolateral.
Median nerve injury.
Ulnar nerve injury.
Rapid reduction.
Early mobilization.
Time for a 10 minute break!
1.
Talipes Equinovarus is the proper name for :-
a.
b.
c.
d.
e.
Flat feet
In-toeing
Club feet
Knock knees
Wry neck
Pes Planus
Metatarsus Adductus
Genu Valgus
Torticolis
Talipes Equinovarus
congenital deformity of the foot
Equinus, Inversion, Adduction, Supination
2 per 1000 live births
50% bilateral
M >F 2:1
Serial corrective casts at birth
Surgery if resistant
EARLY TREATMENT IS ESSENTIAL
2.
A Trendelenburg sign refers to :-
a.
b.
c.
d.
e.
f.
Leg length discrepancy
Gait abnormality
Knee recurvatum
Scoliosis
Hip Contracture
Abductor weakness
Trendelenberg Gait
3.
All of these are signs of D.D.H.
except :-
a.
b.
c.
d.
e.
Limited Abduction
Ortolani Sign
Asymmetric Skin Folds
Galeazzi’s Sign
McMurray Sign
Knee Meniscal Tear
Ortolani, Barlow & Galeazzi Signs
4.
a.
b.
c.
d.
e.
The most common congenital
spinal abnormality is :-
Scoliosis
Spina Bifida
Torticolis
Klippel – Feil Syndrome
Multiple Hereditary Osteochondroma
Spinal Bifida
defect of neural tube closure
Lumbar spine, commonly low
2 per 1000
myelodysplasia
Mild to complete paraplegia
Occulta, meningocoele, Myelomeningocoele
Bowel and bladder dysfunction
5.
?
5.
Polydactyly
6.
?
6.
Syndactyly
7.
?
7.
Sprengel’s Deformity
Omovertebral Bone
8. A 6 year old boy with delayed physical
development, convulsions, tetany,
weakness, blue sclera and bony deformities
is most likely suffering from :-
a.
b.
c.
d.
e.
Physical Abuse
Ehlers – Danlos Syndrome
Osteogenesis Imperfecta
Multiple Hereditary Exostoses
Myositis Ossificans
9.
A 6 year old boy with delayed physical
development, a rachitic rosary, weakness
and bony deformities is most likely
suffering from :a.
b.
c.
d.
e.
Physical Abuse
Rickets
Scurvy
Osteitis Deformans
Myositis Ossificans
9.
Rachitic Rosary
9.
Delayed Ossification
10. This is :a.
Osteomyelitis
b. Osteomalacia
c.
Osteoporosis
d.
Osteitis Deformans
e.
Leprosy
11. A child with knee pain has a ____
problem until proven otherwise.
a.
b.
c.
d.
e.
Knee
Femoral
Tibial
Hip
Patella
12. All of the following are part of the
differential of hip pain in a 6 year old,
except :a.
b.
c.
d.
e.
Femoral Osteomyelitis
Septic Hip
Transient Synovitis
Legg-Perthes Osteochondritis
Slipped Capital Femoral Epiphysis
13.
Osteomyelitis in children is
produced by what route of infection?
a.
b.
c.
d.
e.
Direct extension from another focus
Hematogenous spread
Perforating wounds
Lymphatic spread
Septic hip
14.
Paronychia
An infection of the base
of the nail plate
15.
Felon
A pulp space infection
16.
a.
b.
c.
d.
e.
All of these are findings of a
herniated L5-S1 disc, except :Absent Achilles reflex
Lateral foot numbness
S1 Nerve Root
Sciatica
Low back pain
Extensor Hallucis Longus weakness
L5 nerve root
17. Avascular necrosis of the femoral
head is associated with all of the
following except :a.
b.
c.
d.
e.
Steroid use
Alcohol
Deep sea diving
Lipid storage disease
Diabetes
18.
8 year old boy
What is the
Diagnosis?
Legg – Perthes
Osteochondosis
19.
Diagnosis?
Gout
20. What is this deformity?
A Diner Fork Deformity
21.
Probable Diagnosis?
A Colles Fracture
21. Colles
Fracture
21.
Colle’s Fracture
distal radial fracture
FOOSH
occurs at all ages
commonly 60 yrs. +
osteoporosis
intra-articular
CR & K-Wires
External vs Internal Fixation
22. Diagnosis? :-
22. Diagnosis? :- A Scaphoid Fracture
23. The common complication
of this fracture is :-
23. Proximal pole Avascular Necrosis
due to a Scaphoid Fracture
24. This is a :-
a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line
24.
This is a :a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line
25. Is this fracture treated by Closed or
Open Reduction?
25.
ORIF
25. Fractures of Necessity
26. What is the Diagnosis?
26. Posterolateral Dislocation of the Elbow
26. Reduction by traction.
TRACTION
27. What is the Diagnosis?
27. Anterior Dislocation of the Shoulder
27. Reduction by traction
Traction
28.
This is a :a. Supracondylar #
b. Olecranon #
c. Dislocation
d. Forearm #
e. Radial Head #
28. Supracondylar Fracture
29. The complications of a
Supracondylar fracture in children
include all of the following except :a. Malunion
b. Volkmann’s Ischemic Contracture
c. Compartment Syndrome
d. Cubitus Varus
e. Peripheral Nerve Injuries
f. Pulmonary Fat Embolus
30. The only sign of a Compartment
Syndrome that is always present
is :a. Pain
b. Pallor
c. Pulselessness
d. Paresthesias
e. Paralysis
31.
Compartment pressures
indicating the need for fasciotomy :-
a. 0 – 15 mms. Hg
b. 15 – 25 mms. Hg
c. > 25 mms. Hg
d. > 50 mms. Hg
e. > 75 mms. Hg
32. A 20 yr. old male with a fractured
femur has findings of confusion,
tachypnea and conjunctival
petechia.
The most likely diagnosis
is :- a. Pneumonia
b. Pulmonary Fat Emboli
c. Cerebral Contusion
d. Cardiac Contusion
e. Transient Stress Reaction
35. What fracture is this?
A Fracture of the Humerus
35. The commonest complication of this
fracture is :-
35. A Radial Nerve Palsy
36.
Does this fracture require surgery?
Yes, it is a Traction
Injury and cannot be
reduced and held
closed.
37. This patient
most likely has a
fracture of the
….?
Right Hip Fracture
External rotation
Shortening
Flexion
A Sub-capital Hip Fracture
38. All of the following are complications
of this fracture except :a. Malunion
b. Avascular
necrosis
c. Fat emboli
d. Non-union
e. Thrombophlebitis
38. Blood Supply of Femoral Head
38. Save Head versus Replacement
38. Subcapital Hip Fractures
Properties
1. Avascular Necrosis - 30%
2. Malunion - 30%
3. Non-union - 30%
4. Surgery required
5. Older population
6. Pathologic - Osteoporotic
Garden Classification
39. What’s the Diagnosis?
39.
Intertrochanteric Hip Fracture
39. Intertrochanteric Fractures
Properties
1. Varus deformity
2. Well - Healing
3. Traumatic + Osteoporosis
4. Surgery required
5. Mid-range Age population
40.
Surgery
or not?
Yes, Subluxation of
the Talus due to
rupture of the Distal
Tibio-fibular
Syndesmosis.
41.
Surgery or not?
Yes, Unstable
Bimalleolar
Ankle Fracture
42. What is the approach to this fracture?
23 y.o. male
Basketball injury
Open fracture
Numbness
dorsum of toes
42.
Reduce dislocation
Sterile dressing
Splint extremity
Re-check NV status
IV Antibiotics
Tetanus
Surgery
43.
A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back pain
and right sided sciatica to his foot, after chopping
wood at the cottage. Upon arising the following
morning, he notices numbness on the outer border
of his right foot and some weakness in the right leg. He
has no bowel or bladder problems.
The most likely diagnosis would be:-
Disc.
a.
Lumbar Muscular Strain.
b.
Herniated Lumbar Disc.
c.
Herniated Lumbosacral
d.
Cauda Equina Syndrome.
e.
Spinal Stenosis.
44. Your initial approach to this problem
would include some or all of the following:a.
Bedrest.
b.
Anti-inflammatories.
c.
Muscle Relaxants.
d.
Spinal X-rays.
e.
Physiotherapy.
f.
Orthopedic/Neurosurgical referral.
g.
CT-Myelogram or MRI
h.
Discectomy
45. During the work-up for this problem, the
patient complains that he has unaccountably soiled
his underwear, without knowing it. Your response to
this would be to:-
a.
Reassure the patient that this is not serious
b.
Order an urgent MRI
c.
Get an urgent referral to Neuro/Orthopedics
d.
Place the patient on immediate bedrest.
46.
Which of the following signs and
symptoms are consistent with a torn
medial meniscus of the knee:a.
Inability to squat
b.
Pain on descending stairs
c.
Locking
d.
Recurrent effusions
e.
All of the above.
47.
A 35 yr. old male falls jogging and sustains an
undisplaced lateral malleolar fracture of the ankle. He is
treated in a Below-knee Walking cast, but returns to the
ER 24 hrs. later complaining of increased, persistent,
burning pain at the ankle.
Your initial response to this situation would be :-
a.
Re-X-ray the ankle.
b.
Remove the cast.
c.
Measure the compartment pressures.
d.
Instruct the patient to elevate the limb and prescribe an
anti-inflamatory.
48. The most common dislocations of
the shoulder are:-
a.
Medial.
b.
Posterior.
c.
Luxatio Erecta.
d.
Anterior.
49.
Metastatic lesions to bone, of
the following tumours, usually
produce lytic defects except:a.
Thyroid.
b.
Pancreas.
c.
Prostate.
d.
Kidney.
e.
Lung.
Th - Tha – That’s all folks!