Orthopedic Surgery - Lecture notes 42 PDF

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ORT HOPEDI CSURGERY Me d i c a l s p e c i a l t yt h a t f o c u s e so nt h ei n j u r i e sa n dd i s e a s e so f t h emu s c u l o s k e l e t a l s y s t e m Bo n e s( e x t r e mi t i e sa n dt h es p i n e ) , j o i n t s , t e n d o n s , mu s c l e s

Subs pe c i a l t y : T r a u ma Sp o r t s Sp i n e J o i n t On c o l o g y

ORTHOPEDI CTRAUMA t h t h 5 l e a d i n gc a u s eo f d e a t h( US) i nt h efi r s t 5 d e c a d e so f l i f e

I n j u r i e sr e s u l t i n gt of r a c t u r eo f t h eb o n e s , d a ma g et oj o i n t sa n di n j u r i e st ot h es o f t t i s s u e s

FRACTURE Di s r u p t i o no f t h en o r ma l a r c h i t e c t u r eo f t h eb o n e

De fini t i o no f T e r ms Ac u t eF r a c t u r e  Sh a r p , we l l d e fi n e de d g e so f f r a g me n t s Chr on i cF r a c t u r e  Ro u n d e da n ds c l e r o t i ca p p e a r a n c ea f t e rr e s o r p t i o no f b o n eh a so c c u r r e do n f r a c t u r e de n d s I n c o mp l e t eF r a c t u r e

 Gr e e n s t i c k( c h i l d r e n ) o ri n f r a c t i o n s( a d u l t s ) St r e s sf r a c t u r e s  Ch r o n i cr e p e t i t i v et r a u mac a u s i n gmi c r o s c o p i cd i s r u p t i o n s( o v e r u s ei n j u r i e s ) Pa t h ol o g i cf r a c t u r e  F a i l u r eo f t h eb o n et h r o u g hawe a k e n e db o n eb yap r e e x i s t i n gd i s e a s e  Bo n et u mo r s , me t a s t a t i cl e s i o n s , i n f e c t i o n s Go a l so ft r e a t me nt :  Re s t o r en o r ma l a n a t o my  I mmo b i l i z ef o rp a i nr e l i e fa n da l l o wh e a l i n g  Re p a i r / r e c o n s t r u c t t or e s t o r ef u n c t i o n

F RACT URES Re s u l t f r o mh i g he n e r g yt r a u ma T y p e so fAc u t ef r a c t u r e :      

T r a n s v e r s e Ob l i q u e Sp i r a l –r o t a t i o n a l f o r c e Se g me n t a l Co mmi n u t e d–mu l t i p l ef r a g me n t s Di s p l a c e df r a c t u r e s

T r e a t me n t Re d u c t i o nu n d e ra n e s t h e s i a Sp l i n t i n go rc a s t i n g

CL OSEDv sOPENf r a c t ur e OPENF RACTURES Oc c u r swh e nt h eb o n eb r e a k st h r o u g ht h es k i n

Of t e na s s o c i a t e dwi t hd a ma g eo f t h es u r r o u n d i n gs o f t t i s s u e sa n dc o n t a mi n a t i o no f t h e wo u n d

T REATMENT i mme d i a t ed e b r i d e me n t a n da n t i b i o t i c s De fi n i t i v et r e a t me n t i sd e l a y e d( l i mbs a l v a g ev sa mp u t a t i o n )

Ho wt od e s c r i b eaf r a c t u r e 1 .Op e no r c l o s e , g r a d e 2 .T y p eo f f r a c t u r e( t r a n s v e r s e , o b l i q u e , e t c ) 3 .L a t e r a l i t y( r i g h t o rl e f t ) 4 .L o c a t i o ni nt h eb o n e( c o n d y l a r , s h a f t , e t c ) F r a c t u r e , o p e ng r a d eI I I , c o mmi n u t e d , l e f t f e mo r a l s h a f t

F I XATI ONPRI NCI PLES       

Ex t e r n a l fi x a t i o n Ex t e r n a l f r a me s( p i n s , c o n n e c t o r sa n dr o d s ) I n t e r n a l F i x a t i o n( ORI F ) Pi n sa n ds c r e ws T e n s i o nb a n d s Pl a t e s I n t e r me d u l l a r yn a i l

REDUCTI ONANDI MMOBI LI ZAT I ON  Sp l i n t i n g  Ca s t i n g  Sk e l e t a l t r a c t i o n

CLAVI CULARF RACT URES

 On eo f t h emo s t c o mmo nf r a c t u r e s r d  Us u a l l yi nt h emi d d l e3

T r e a t me n t :  Sl i n ga n dROMe x e r c i s e s  Op e nr e d u c t i o na n ds u r g i c a l r e p a i ro n l yf o rt h o s ewi t hs e v e r ed i s p l a c e me n t

F OREARMFRACT URES Re s u l t sf r o mh i g he n e r g yt r a u mao r f a l l so n t oo u t s t r e t c h e da r m T y pe s : Ni g h t s t i c kF xI s o l a t e du l n a r s h a f t f r a c t u r e Mo n t e gg i aF XUl n a rs h a f t f x+r a d i a l h e a dd i s l o c a t i o n Ga l e a z z i f xRa d i a l s h a f t f r a c t u r ewi t hd i s r u p t i o no f d i s t a l r a d i o u l n a r j o i n t

Ma na ge me n t : Pl a t ea n ds c r e wfi x a t i o n

F EMORALNECKF RACT URE Oc c u r swi t ht h ec a p s u l eo f t h eh i pj o i n t I n j u r yt ot h ev a s c u l a r s u p p l yc a nl e a dt oo s t e o n e c r o s i s Us u a l l yo c c u r si ne l d e r l yf e ma l ewi t hh i s t o r yo f f a l l

T x Su r g i c a l p l a c e me n t o f s c r e wsi f l o wr i s kf o rd i s r u p t i o no f b l o o ds u p p l y Hi pr e p l a c e me n t i f v a s c u l a r c o mp r o mi s e

I NT RAT HROCANT ERI CHI PF RACT URE F r a c t u r e si nb e t we e nt h eg r e a t e r a n dl e s s e r t r o c h a n t e r so f t h ep r o x i ma l f e mu r Ab u n d a n t b l o o ds u p p l y T x I n t e r n a l fi x a t i o nwi t hh i ps c r e w, c e p h a l o me d u l l a r yn a i l SUBTHROCANT ERI CHI PF RACT URE F r a c t u r e si nt h ep r o x i ma l f e mo r a l s h a f t j u s t d i s t a l t ot h el e s s e rt r o c h a n t e r Mu s c l e sa t t a c h e dt ot h el e s s e rt r o c h a n t e r d i s p l a c e st h eb o n ef r a g me n t s T xL o n gc e p h a l o me d u l l a r yn a i l wi t hs c r e ws

F EMORALSHAFTF RACT URES L o n gb o n ef r a c t u r e sa r eh i g h l ya s s o c i a t e dwi t ht h r o mb o e mb o l i ce v e n t s( f a t e mb o l i s y n d r o me ) a n dAc u t er e s p i r a t o r yd i s t r e s ss y n d r o me( ARDS) Ma n a g e me n t s h o u l dn o t b ed e l a y e db e y o n d2 4h o u r s T x I n t e r me d u l l a r yn a i l o re x t e r n a l fi x a t i o ni f h e mo d y n a mi c a l l yu n s t a b l e

PEL VI CF RACT URES I n d i c a t i v eo f h i g he n e r g yt r a u ma As s o c i a t e dwi t ho t h e r i n j u r i e st ot h eh e a d , c h e s t , a b d o me n L i f et h r e a t e n i n gh e mo r r h a g ec a no c c u r Bl e e d i n gi so f t e nd u et oi n j u r yt ot h ev e n o u sp l e x u si nt h ep o s t e r i o r p e l v i s F i r s tl i n et r e a t me nt :p e l v i cb i n d e r , e x t e r n a l fi x a t i o n

SPRAI N L i g a me n t o u si n j u r i e s Gr a d eI

 s t r e t c h i n go f t h el i g a me n t c o mp l e x , n oi n s t a b i l i t y Gr a d eI I  p a r t i a l r u p t u r eo f t h el i g a me n t swi t hc o n c o mmi t a n t i n s t a b i l i t yo f t h ej o i n t Gr a d eI I I  Co mp l e t er u p t u r e swi t hs i g n i fi c a n t i n s t a b i l i t yt ot h ej o i n t

I n j u r yt ot h emu s c l eo r t e n d o n Us u a l l yf r o mo v e r u s e T r e a t me n t :r e s t , c o l dc o mp r e s sa n de l e v a t i o no f e x t r e mi t y

COMP ART MENTSYNDROME  Ans u r g i c a l e me r g e n c y  Ca u s e db ys i g n i fi c a n t s we l l i n gwi t h i nac o mp a r t me n t o f a ni n j u r e de x t r e mi t yt h a t j e o p a r d i z e st h eb l o o ds u p p l yt ot h el i mb  Ed e map r e v e n t sv e n o u so u t fl o w( c o n g e s t i o n )  L e a d st oi s c h e mi aa n dn e c r o s i s Ca u s e s :  F r a c t u r e s , a r t e r i a l i n j u r y , g u n s h o t wo u n d , l i mbc o mp r e s s i o n , b u r n s , c o n s t r i c t i v e d r e s s i n g sa n dt i g h t c a s t s

Cl i n i c a l p r e s e n t a t i on :  p a i n , p a r e s t h e s i a , p u l s e l e s s n e s s  HI GHd e g r e eo f c l i n i c a l s u s p i c i o n

Sur gi c a l Ma n a ge me n t :F a s c i o t o my

DI SL OCATI ONS  Or t h o p e d i ce me r g e n c y

 Pr o l o n g e dd i s l o c a t i o nc a nl e a dt oc a r t i l a g ec e l l d e a t h , p o s t t r a u ma t i ca r t h r i t i s , n e u r o v a s c u l a r i n j u r ya n da v a s c u l a rn e c r o s i s Pr e s e n t a t i on : Gr o s sd e f o r mi t y( s h o r t e n e dl i mb , a d d u c t e dp o s i t i o n , e t c ) L i mi t e dr a n g eo f mo t i o n( mu s c l es p a s m)

Sho u l d e rdi s l o c a t i o n  Mo s t c o mmo n l yd i s p l a c e dj o i n t  Us u a l l yAn t e r i o rd i s l o c a t i o n s  As s o c i a t e dwi t hi n j u r i e st ot h el a b r u m, i mp r e s s i o nf r a c t u r e so f t h eh u me r a l h e a d a n dr o t a t o r c u fft e a r Po s t e r i o rd i s l o c a t i o ns  As s o c i a t e dwi t hs e i z u r e so r e l e c t r i c a l s h o c k  Ma n a g e me n t :  Re d u c t i o na n di mmo b i l i z a t i o nwi t has l i n g

El b o wDi s l o c a t i on  Al s of a i r l yc o mmo n  Us u a l l yPo s t e r i o r d i s l o c a t i o n  Re s u l t st oi n j u r yt ot h ej o i n t c a p s u l ea n dr u p t u r eo f t h el a t e r a l c o l l a t e r a l l i g a me n t Ma na ge me n t :  Re d u c t i o na n di mmo b i l i z a t i o n  Su r g e r yi sn e c e s s a r yi f wi t hc o n c o mi t a n t f r a c t u r e

Hi pd i s l o c a t i on  Re s u l t f r o mh i g he n e r g yt r a u ma  Us u a l l yp o s t e r i o rd i s l o c a t i o n  Ca nc a u s ei n j u r yt ot h es c i a t i cn e r v e Ma na ge me n t  URGENTr e d u c t i o n

 Wi t h i n6h o u r s  Pr e v e n t n e c r o s i so f t h ef e mo r a l h e a d( a v a s c u l a r n e c r o s i s )

Kne eDi s l o c a t i o n  Ra r eb u t d e v a s t a t i n gi n j u r yt h a t c a nb el i mb t h r e a t e n i n g  I n j u r i e st ot h eACL , PCL , L CL , MCL  I n j u r yt ot h ep o p l i t e a l a r t e r y

Ma na ge me n t : Mu l t i l i g a me n t o u sr e c o n s t r u c t i o n St i ff n e s sa n di n s t a b i l i t yi sac o mmo nc o mp l i c a t i o n

SPORT SMEDI CI NE De a l swi t ht h ep r e v e n t i o na n dt r e a t me n t o f i n j u r i e sr e l a t e dt os p o r t sa n de x e r c i s e Do e sn o t o n l yt r e a t t h ei n j u r yb u t a l s oh a st oc o n s i d e rr e t u r nt oa c t i v i t y( “ Ge t t i n gb a c ki n t h eg a me ” ) Sur gi c a l I n t e r v e n t i o n:a r t h r o s c o p i ca p p r o a c h

“ u n h a p p yt r i a d ” : MCL , me d i a l me n i s c u s , a n dA CLi n j u r y

Kne e Cr u c i a t eL i ga me n t s( ACL , PCL ) Si t u a t e dc e n t r a l l ywi t h i nt h ei n t e r c o n d y l a r n o t c ho f t h ek n e e ACLt e a r sa r emo r ec o mmo n( s o c c e r , b a s k e t b a l l ) Ma na ge me n t ACLt e a r swi l l n o t h e a l wi t h o u t s u r g e r y

Ma i n l ys u r g i c a l ma n a g e me n t

SPI NE Sp i n a l T r a u ma  J e ff e r s o nF r a c t u r e( C1 )  Od o n t o i dF r a c t u r e( C2 )  Ha n g ma n ’ sF r a c t u r eo f C2 Su d d e ne x t e n s i o nf o r c e so nt h en e c k

Di s cHe r n i a t i o n  Co mmo nb e t we e n2 0 5 0y e a r so l d  T e a r o f t h ea n n u l u sa l l o wi n gt h en u c l e u sp u l p o s u st oe x t r u d et h r o u g ht h ea n n u l u s a n de n t e rt h ec a n a l c a u s i n gc o mp r e s s i o no f t h en e r v er o o t s  Su r g e r yi si n d i c a t e di f s y mp t o msp e r s i s t b e y o n d6 8wk s Ma na ge me n t  An t e r i o rDe c o mp r e s s i o na n dl a mi n e c t o my

ORT HOPEDI CP ATHOL OGYANDONCOL OGY Or t h o p e di cOn c o l o g y  Ca r ea n dma n a g e me n t o f i n d i v i d u a l swi t hp r i ma r ya n ds e c o n d a r yn e o p l a s mso f t h emu s c u l o s k e l e t a l s y s t e m  I n v o l v e sa d e q u a t eo n c o l o g i cr e s e c t i o na n ds k e l e t a l r e c o n s t r u c t i o na n dr e s t o r a t i o n o f f u n c t i o n

ORT HOPEDI CP ATHOL OGYANDONCOL OGY  Ma l i g n a n t Bo n et u mo r s  Pr e s e n t swi t hah i s t o r yo f u n r e mi t t i n gp a i nu n r e l a t e dt oa c t i v i t yo r p a i nt h a t i n t e r f e r e swi t hs l e e ps u g g e s t sma l i g n a n c y  Ag e , l o c a t i o na n dg e n d e r c a nh e l pi nt h ed i ff e r e n t i a l d i a g n o s i s

MALI GNANTBONET UMORS OSTEOSARCOMA  Mo s t c o mmo np r i ma r yma l i g n a n t b o n et u mo r  Pr e s e n t sd u r i n g1 0 2 0y e a r so f a g e  Su r g i c a l wi t hma r g i n s

MALI GNANTBONET UMORS EWI NG’ SSARCOMA     

Se c o n dmo s t c o mmo np r i ma r yb o n et u mo r Ag eu n d e r3 0 Us u a l l yo c c u r si nt h ed i a p h y s i so f t h ef e mu r “ On i o nSk i n ” p e r i o s t e a l r e a c t i o no nx r a y Ch e mo t h e r a p ya n ds u r g e r yo r RT

CART I LAGEF ORMI NGT UMORS CHONDROSARCOMA    

T y p i c a l l yo c c u r si nma l ep a t i e n t so v e r 4 0y e a r so l d r d 3 mo s t c o mmo np r i ma r yb o n ema l i g n a n c y Pe l v i s , s h o u l d e ra n dr i b sa r ec o mmo nl o c a t i o n s “ p o p c o r nc a l c i fi c a t i o n s ”a r es e e no nx r a y

T r e a t me n t :wi d ee x c i s i o n No t s e n s i t i v et oc h e mo t h e r a p yo r r a d i a t i o n

PEDI ATRI CF RACT URES  Un o s s i fi e de p i p h y s e a l g r o wt hp l a t ei nc h i l d r e ni sa ni mp o r t a n t c o n s i d e r a t i o n  Re d u c t i o na n ds t a b i l i z a t i o ni si mp o r t a n t t omi n i mi z ep e r ma n e n t g r o wt h d i s t u r b a n c e sa n dd e f o r mi t y CLASSI F I CAT I ONOFGROWT HPLAT EI NJ URI ES Sa l t e ra n dHa r r i sCl a s s i fi c a t i on T y peI

 Si mp l et r a n s v e r s ef r a c t u r et h r o u g ht h ep h y s i s T y peI I  Co mp o n e n t f r a c t u r et h r o u g ht h eg r o wt hp l a t ei nc o n t i n u i t ywi t haf r a c t u r eo f t h e me t a p h y s i s T y peI I I  Oc c u r st h r o u g ht h ep h y s i sa n de x i t st h r o u g ht h eg r o wt hp l a t e T y peI V  F r a c t u r el i n ee x t e n d st h r o u g hf r o mme t a p h y s i si n t oe p i p h y s i s T y peV  Cr u s h i n go f t h ep h y s i s

PEDI ATRI CF RACT URES T r e a t me n t  An a t o mi cr e d u c t i o no f f r a c t u r e s  I n t e r n a l fi x a t i o na v o i d sp l a c i n gh a r d wa r ea c r o s st h eg r o wt hp l a t et omi n i mi z e p r e ma t u r eg r o wt hp l a t ec l o s u r e

DEVEL OPMENT ALDI SEASES De v e l o p me n t a l Dy s p l a s i ao f t h eHi p( DDH) Se e ni nfi r s t b o r nf e ma l e swi t hf a mi l yh i s t o r ya n db r e e c hb i r t h

Or t o l a n i ’ st e s t  Ge n t l ee l e v a t i o na n da b d u c t i o no f t h ef e mu r c a u s i n gap a l p a b l ec l i c ki nt h e r e l o c a t i o no f t h ed i s p l a c e dh i p Ba r l o w’ sT e s t  Ge n t l ea d d u c t i o na n dd e p r e s s i o no f t h ef e mu r wh i c hc a u s e sap a l p a b l ec l i c ka s h i ps l i p si n t oad i s l o c a t e dp o s i t i o n

DEVEL OPMENT ALDI SEASES De v e l o p me n t a l Dy s p l a s i ao ft h eHi p( DDH) T r e a t me n t    

Pa v l i c kh a r n e s st oma i n t a i n h i pi nfl e x i o na n da b d u c t i o n 6 1 2we e k sf o r mi l dDDH T xSe v e r eDDH–a d d u c t o rt e n o t o my

Con g e ni t a l T a l i pe sEq ui v a r u s “ Cl u bf o o t ” Co mmo np r o b l e m Co n t r a c t u r e so f t h eme d i a l t e n d o n so f t h ef o o t , t i g h t a c h i l l e st e n d o na n dc o n t r a c t u r e so f t h ea n k l e , h i n d f o o t a n dmi d f o o t T r e a t me n t :s e q u e n t i a l c o r r e c t i v ec a s t i n g

De s mo p l a s t i cfi b r o ma Ra d i o g r a p h ys h o ws' s o a pb u b b l e s '...