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Principles of Principles of MusculoskeletalMusculoskeletalInjuriesInjuriesWiroon Laupattarakasem, M.D.Wiroon Laupattarakasem, M.D.Professor in OrthopaedicsProfessor in Orthopaedics

Faculty of MedicineFaculty of Medicine

Khon Kaen UniversityKhon Kaen University

13/12/06 Prof.Wiroon Laupattarakasem 2

Contents: Contents: Fractures and DislocationsFractures and Dislocations

■ Mechanisms of injuries■ Description or terminology■ Diagnosis■ Treatment■ Fracture healing


DefinitionsDefinitions■ Fracture

◆ Displacement of fracture fragment■ Joint injuries

◆ Dislocation (luxation) --} loss of congruency◆ Subluxation (sub+luxation)◆ Instability◆ Sprain

■ Muscle and tendon injuries◆ Tear or rupture◆ Strain


Transverse Oblique Spiral Comminuted

FractureFracture


Subluxation Dislocation


ข�อเคล!"อน (subluxation)

ข�อหล&ด (dislocation)

ข�อค("งเล!อด (haemarthrosis

)


Rupture of Meniscus


StrainStrain


Muscle & tendon rupture


Mechanisms of FractureMechanisms of Fracture

ForceForce● Direct● Indirect

FractureFracture

(failure)(failure)

● Brittle● Fatigue● Plastic

LoadLoad

● Tension (tensile)● Compression● Shear

StressStress

ConcentrationConcentration● (Stress> Strength)


Fracture MechanismFracture Mechanism

by direct forces:

‘‘ ForceForce’ vs. ‘’ vs. ‘AreaArea’’ ■ Tapping fracture■ Crushed fracture■ Penetrating fracture


Fracture MechanismFracture Mechanism

by indirect forces■ Avulsion (tension)■ Angulation (bending)■ Rotation (torsion)■ Axial compression■ Angulation + compression■ Angulation + compression + rotation


Avulsion FractureAvulsion Fracturee.g., olecranon process

Triceps


Angulation FractureAngulation Fracture

Transverse fracture Buckled fractureBuckled fractureGreen-stick fractureGreen-stick fracture


Rotation FractureRotation Fracture

Spiral fracture

ลองบ�ดแทงชอล�ก แล�วส�งเกตด�รอยห�ก


Long bone

Oblique fracture

Axial CompressionAxial Compression


Axial CompressionAxial Compression

Short bone

Burst fracture


Angulation + CompressionAngulation + Compression

Butterfly

fracture


Angulation+ Angulation+ Compression+ Compression+ RotationRotation

Short

spiral

fracture


Common Fracture DeformitiesCommon Fracture Deformities

CompressionDistraction

RotationAngulationOverriding

Malapposition


Description of a Description of a Fracture DeformityFracture Deformity■ Global agreements:

◆ Always indicating deformity of the distal fragment in relation with the proximal one

◆ e.g., anterior displacement = anterior displacement “of the distal fragment”

Distal

Anterior

Not ‘anteriordislocation’ !

Proximal


Description of FracturesDescription of Fractures■ Fracture■ Fracture of the right femur■ Fracture of the right femoral shaft■ Oblique fracture of the right femoral shaft with

anteromedial displacement■ Type II open oblique fracture of the right

femoral shaft with anteromedial displacement

Which one tells you more definitely ?


Styles:Description of FracturesDescription of Fractures

➾ Fracture of the femur➾ Femoral fracture ➾ Fractured femur➾ Fracture, femur➽ Fracture femur

ใช�บอยในภาษาพ�ดแตไมถ�กหล�กตามภาษาเข"ยน


Description of Bone and Joint Description of Bone and Joint InjuriesInjuries■ “Fracture” / “dislocation, etc.”

◆ Adding adjective, conjunction, preposition◆ Usually describing acute conditions

● Define otherwise old fracturemal-united fractureun-united fracturerecurrent dislocation


Description of Bone and Joint Description of Bone and Joint InjuriesInjuries■ Described by telling

◆ Anatomy, site (e.g., side, bone, part)◆ Type, extent (e.g., open, incomplete)◆ Configuration (e.g., transverse, comminuted)◆ Deformity, ‘direction’ (e.g., displacement,

‘anterior’)◆ Eponym (Colles, Monteggia, Galeazzi)◆ Complication, cause (e.g., infected, fatigue,

pathological)


Hair-line fractureTea-cup fracture

Green-stick fracture

Buckled fractureลองเอา

ก�#งไม�สดมาห�กด�

Incomplete Fractures


Segmental

T-shaped Y-shaped

H-shaped

Comminuted Fractures

Double

segmental


Description of Fractures

Example:Try your own!


Description of FracturesDescription of Fractures

✎ Closed, segmental fracture of the right femoral diaphysis and type IIIB open comminuted fractures of the ipsilateral tibial shaft with bone loss

Example:

ลองประเม�นต�วเองด�วาเข�าใจ

ท'กค)าหร*อไม


■ Closed, segmental fracture of the right femoral diaphysis

■ Type IIIB open comminuted fractures of the ipsilateral tibial shaft with bone loss


Open fracturesOpen fractures

■ Open fracture = fracture + contamination

■ Classifications ---} prognosis◆ Type I: inside - out◆ Type II: outside - in◆ Type III: Type II + destruction

of other functional unit(s)

ไมใช Openedfracture

Type IIIA, B, C


Type III Open FracturesType III Open Fractures■ Shotgun fracture■ High velocity gunshot fracture■ Displaced segmental fracture■ Diaphyseal segmental bone loss■ Farm yard / highly contaminated (wound) ■ Crushed fracture from high speed vehicle■ Associated major vascular injury


DescribeDescribe



DiagnosisDiagnosis■ Common errors—missing and

misdiagnosing (incorrect diagnosis)?■ Tools?

◆ History taking◆ Screening test◆ Physical examination◆ Radiological examination◆ Laboratory investigation


DiagnosisDiagnosis

■ History taking◆ Where, when and how did it happen?◆ Which part (s) of the body is (are)

involved?◆ What treatments have been given

prior to the arrival?

ถ�าม"ป+ญหาการส*#อภาษาก�บผ��ป.วย ควรขอร�องให�ผ��น)าสง

ชวยอย�ให�ประว�ต�ด�วย


Screening TestsScreening Tests■ Upper extremities

◆ Active movements, shaking hands■ Ribs & sternum

◆ Chest compression – AP, bilateral◆ Cough, deep inspiration

■ Pelvis ◆ Compression – both ilia, pubis

■ Lower extremities◆ Active movements, sign-of-4

■ Spines◆ Active movements, palpation

Functional tests to detect

the evidence of injuries


Physical ExaminationsPhysical Examinations

■ Fracture/dislocation◆ Definite signs

● Deformity● Abnormal motion● Crepitus

เจ/บปวดเพ�#มข01นอาจเพ�#มการบาดเจ/บ


Physical ExaminationsPhysical Examinations■ Fracture/dislocation

◆ Relative signs● Similar to soft tissue contusion

tenderness, swelling, ecchymosis● Circumferential involvement● Osteophony test● Axial compression test

เคาะกระด�กแล�วฟ+งเส"ยง


Osteophony test


Axial Compression (Loading) TestAxial Compression (Loading) Test

Tenderness on direct palpation:

fracture or contusion?


Radiographic ExaminationsRadiographic Examinations■ Plain film

◆ AP, lateral, (2 obliques)◆ Special views, e.g., swimmer’s, axial

■ Computerized tomography (CT scan)■ Magnetic resonance imaging (MRI)■ Special techniques

◆ e.g., tomography, angiography, MRA


Roentgenographic Roentgenographic ViewsViews■ 2 views: AP, lateral; two oblique■ 2 joints: parallel bones, one displaced

fracture, e.g., Monteggia■ 2 sides: growing ossification centers■ 2 occasions: non-displaced scaphoid

fracture■ 2 media: contrast media



Axial view Axial view for the for the calcaneuscalcaneus


Ultimate Goals of Treatment in Orthopaedics

to restore....... FORMFORM ..........and FUNCTIONSFUNCTIONS


Priority Setting for Priority Setting for Trauma PatientsTrauma Patients■ To save

◆ Life◆ Limb◆ Function◆ Aesthetics


TreatmentTreatment■ Immediate cares

(at the injury site) for◆ A irway obstruction◆ B reathing◆ C irculatory failure: shock◆ D islocation/ fracture

SplintSplint the injured the injured parts:parts:

● Involved joints: Involved joints: one joint above one joint above and below and below

● Different types of Different types of splintsplint

● Thomas splint Thomas splint (best for LE)(best for LE)


Thomas Thomas SplintSplint


TreatmentTreatment■ Transportation

◆ In suspicion of head injury, splint the neck

◆ Move the victim only when necessary◆ Move unconscious or back-injured

patient as a log (by 3 rescuers)◆ Drive carefully to the hospital


TransportationTransportation


TreatmentTreatment

■ Emergency cares (at ER/AE room) for◆ A irway obstruction◆ B reathing (bleeding)◆ C irculatory failure◆ D islocation/ fracture

● IntubationIntubation

● HaemostasisHaemostasis

● Fluid / blood Fluid / blood replacementreplacement

● SplintageSplintage


General principles of treatmentGeneral principles of treatment

■ Firstly do no harm■ Base treatment on an accurate diagnosis and

prognosis■ Select treatment for specific problems■ Cooperate with the laws of nature■ Be realistic and practical in treatment■ Select treatment for individual patient


■ Definitive treatments of fracture / dislocation◆ Reduction (manipulation)◆ Immobilization

TreatmentTreatment

Retention of reduction


Closed Closed VsVs Open Treatment Open Treatment

■ Joint immobilization■ Skin problems■ Socioeconomic problems■ Risks of surgery

◆ Anaesthesia◆ Blood transfusion◆ Infection


Definitive TreatmentsDefinitive Treatments■ Reduction

▼Closed manipulation ▼with or without fluoroscopy --} image intensifier or C-arm

▼Open (under direct vision)


Image Intensifier (C-arm)Image Intensifier (C-arm)


■ Alignment◆ how parallel is the longitudinal axes?

Overriding Angulation Rotation

Reduction -- goalsReduction -- goalsFracture deformities to be corrected :


■ Apposition◆ end-to-end contact◆ (side-to-side contact: bayonet)

OverridingTranslationCompression

Fracture deformities to be corrected :Reduction -- goalsReduction -- goals


■ Rotation: around an axis

Rotation



■ Length: shortening / lengthening of an axis


Overriding Distraction Bone loss


ReductionReduction

3-point effect

of deforming &

reduction forces

‘Curved’ cast

to maintain

reduction

‘Straight’ cast

results in

re-displacement

or


ReductionReduction

Increase

deformity

2

Apply

Traction

1

Reduce 1cortex

3

Reverse

deformity

4


ReductionReduction

Increase

deformity

Reduce 1

cortex

Reverse

deformity

Apply

Traction


ImmobilizationImmobilization■ Direct

◆ e.g., plating, nailing,applying external fixator

■ Indirect ◆ e.g., casting,

bracing, splinting, traction


External Fixators


Internal FixationsInternal Fixations■ Plate■ Screw■ Nail, rod■ Pin, wire

◆ Kirschner ◆ Steinmann

■ Wire ◆ cerclage


Plate

Screw

Cerclage wire

Nail, rod

Pin, wire -Kirschner -Steinmann

Implants


Treatment of Open Fractures


Treatment of Open FracturesTreatment of Open Fractures■ Aims

◆ Preventing wound infection▼ Remove devitalized tissues▼ Preserve survived tissues▼ Apply appropriate antibiotics

◆ Fracture reduction and stabilization ---> mostly using external fixator

DebridementDebridement

อานเพ�#มเต�ม


TreatmentTreatment Early rehabilitation......Early rehabilitation......

CContiontinuousnuous PPassiassiveve MMotiootionn


■ Conclusions◗ Recognition◗ Relief of pain◗ Reduction of fracture◗ Retention of reduction◗ Rehabilitation◗ Reconstruction

TreatmentTreatment

Specific Methods Specific Methods of Treatment for of Treatment for Closed FracturesClosed Fractures


■ No reduction and immobilization■ Non-weight bearing, arm sling, leave alone■ Non- or minimally displaced, stable fracture

◆ fibular # alone, rib #◆ metacarpal #, metatarsal #◆ clavicular # in small children◆ impacted # of humeral neck◆ compression # of vertebra without neuro. deficit

■ Needs close follow-up

Protection aloneProtection alone


No reduction--} external splintingNo reduction--} external splinting

■ Partially displaced, stable under axial load ■ Other deforming forces (angulation, rotation)

can be neutralized (stabilized) by cast molding or splinting

◆ tibia and/or fibula (cast)◆ radius and/or ulna (cast)◆ humerus (sugar tong slab)◆ small bones of hand and foot (buddy splint)


Closed reduction --} external imm.Closed reduction --} external imm.

■ Displaced fractures, but reduction can be obtained and maintained by closed methods

■ Fractures that do not require rigid immobilization

■ Closed reduction by◆ manipulation◆ gravity or positioning

e.g., flexion compression # of the spines◆ traction: temporary, continuous


Chinese finger trap


Closed reduction --} external imm.Closed reduction --} external imm.

■ External immobilizations: cast, splint, brace, cast-brace

◆ most stable # in adults● Colles # (short arm cast)● # tibia and fibula (long leg or PTB cast)● # radius and ulna (long arm cast)

◆ most complete # in children ● type I&II epiphyseal injuries (cast)


Closed reduction --} direct fixationClosed reduction --} direct fixation

■ Closed reduction: ◆ manipulation, traction + image intensifier

■ Closed internal fixation:◆ pin, wire (supracondylar humeral #) ◆ canulated screw (femoral neck)◆ nail, rod + locking screw (tibia, femur)

■ ‘External fixator’ application


Open reduction --} direct fixationOpen reduction --} direct fixation■ A closed fracture that closed reduction cannot be

obtained and/or subsequently maintained■ Open fracture, after sufficient debridement■ Stable or rigid fixation can be obtained by internal

fixation (osteosynthesis) ◆ plate, screws ◆ intramedullary nail or rod (other modified designs)◆ tension band wiring

■ ‘External fixator’ application


Excision of a fracture fragment --} Excision of a fracture fragment --} + endoprosthesis replacement+ endoprosthesis replacement

■ Excisional arthroplasty■ High incidence of avascular necrosis, nonunion,

posttraumatic osteoarthritis ◆ femoral neck # in an elderly or being osteoporotic◆ comminuted radial head # in young adults◆ comminuted humeral head # (4-part #)◆ severe comminuted # of the patella


LigamentotaxisLigamentotaxis■ Severe comminuted fractures of the joint not

feasible for open reduction and fixation ◆ severe comminuted # of distal radius

■ Distraction of the ligaments and capsule to hold the fracture fragments together as reduction

◆ using external fixator and encourage early motion


Ligamentotaxis


Bag-of-bone technique

■ Severely comminuted fractures of cancellous bone not feasible for open reduction and fixation

◆ severely comminuted calcaneal #■ Manipulative molding of the fragments as an

reduction■ Encourage non-weight bearing ambulation /

motion


If the only tool you have is If the only tool you have is

a a hammerhammer, you tend to see , you tend to see

every problem as a every problem as a nailnailAbraham MaslowAbraham Maslow


Fracture HealingFracture Healing■ Regeneration, no scar■ Form Vs function: Wolff’s law■ 3 major phases:

◆ Inflammation◆ Repair: bone / cartilage /

fibrosis● External bridging callus● Medullary callus

◆ Remodeling● Creeping substitution

■ Clinical union◆ Motion◆ Tenderness / pain

■ Roentgenographic union

◆ No fracture line◆ Fully remodeled


Result:Result:◆ Restoration of Restoration of

original tissueoriginal tissue◆ Scar tissueScar tissue◆ Excessive repairExcessive repair◆ Failure of healingFailure of healing

Healing:Healing:◆ InflammationInflammation◆ RepairRepair◆ RemodelingRemodeling

Cell Cell matrix matrix damagedamage

TraumaTrauma

InjuryInjury◆ TypeType◆ IntensityIntensity◆ ExtentExtent◆ DurationDuration

PatientPatient◆ AgeAge◆ MetabolicMetabolic◆ Disease Disease ◆ MedicationMedication

TreatmentTreatment◆ AppositionApposition◆ StabilizationStabilization◆ LoadingLoading◆ MotionMotion

Tissue typeTissue type◆ BoneBone◆ CartilageCartilage◆ Fibrous tissueFibrous tissue◆ MuscleMuscle


InflammationInflammation

10%10%

RepairRepair

40%40%

RemodelingRemodeling

70%70%

Time

Inte

nsity

of r

espo

nse


Subperiostealcallus

Cartilage

Dead bone end

Organizedhaematoma


Externalbridging

callus

Medullarycallus


Thank you Thank you for your for your

attentionattention