Tips for orthopedics exam

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  • 1. Tips for Orthopedics Exam(Unit 9) By Kareem Hamimy6th year medical studentUnit 9 Kasr Al Ainy Medical School

2. Fracture Humerus Fracture Shaft Injury to Radial Nerve is common So you Must Document this Injury before reduction (Medicolegally) Will lead to Finger Drop, Wrist Drop Management U shaped Cast Collar and cuff sling N.B. Edge of cast have to be 2 cm above fracture 3. Plain X-ray, Anteroposterior view ofa humerus of anadult, showingMid shaft SpiralFracture, Withangulation varus( Apex is lateral ) 4. Open Reduction Indications : Associated with vascular injury Bilateral Multiple Compound Fracture (Haematoma communicating to outside) Floating Elbow ( Fracture in humerus + Fracture radius and ulna ) Pathological (due to tumour/osteoporosis) Comminuted 5. Supracondylar Fracture Types ( Flexion, Extension 90%in children) Risk of injury to brachial Artery very high Why ? After its bifurcation, its branches become attached by fibrous tissue, being fixed makes it more liable to injury Median nerve injury Radial nerve is least prone to injury because it isprotected between the brachialis andbrachioradialis 6. Supracondylar fracture Management : First : Check The pulsepulse If no pulse, Document, then reduce it ( todecrease compression on artery If no pulse after reduction, Do open explorationand Vascular Surgery 7. Plain X-ray, Lateralview, of andadult elbowjoint, ShowingSupracondylarFracture, withposteriordisplacement ofdistal segment 8. Compartment Syndrome Bleeding and edema inside fascialCompartments, Increases thepressure, leading to compression of veins thenarteries, and lately Nerves leading to a limbthreatening condition Treatment: By Fasciotomy N.B. it is not only due to fracture but alsomaybe due to soft tissue injury inside acompartment 9. Complications Of Fractures General Shock DVT Pulmonary Embolism Fat Embolism Tetanus Psycological depression Constipation Renal Infection Bed sores 10. Complications Of Fractures Local Early Vascular Injury Nerve Injury Infection Tendon Injury Avascular necrosis of bones Late Delayed Union Malunion Nonunion Volkmans Ischemic Contracture Myositis ossificans 11. Shock (Tissue Hypoperfusion) Hypovolemic Fracture Femur 500cc blood loss Fracture Pelvis 1000cc C.P. Pulse Rapid due to sympathetic response, Temp low, Respiratory rate Rapid B.P. According to Severity of blood loss ( Mild decreased systolic, Moderate Decreased Pulse pressure, Severe Decreased Diastolic) Management 2 cannulas, Urinary catheterization (to asses perfusion) Crystalloid infusion increasing volume or Colloid (Contains Protein) infusion increase blood pressure bykeeping fluid inside vessels >1000 cc lost Blood transfusion 12. Shock (Tissue Hypoperfusion) Neurogenic Females, Old How to differentiate from Hypovolemic ? Bradycardia, and skin flushed Why bradycardia ? Due to parasympathetic response Ttt: by analgesics Septic As in compound fracture Antibiotics, Antitetanus 13. DVT Virchows Triad Stasis Hypercoagulability Endothelial Injury Early fixation, Proper Hydration Anticoagulants Parenteral ( Heparin) Oral (warfarin) How to avoid Pulmonary Embolism Conservative ( Prevent DVT) Vena caval Filter (Green Field Filter) 14. Fat Embolism Due to yellow Bone marrow in Medulla ofBones Difference between Fat Embolism andPulmonary embolism ( Onset ) Fat onset is acute, immediately after trauma Pulmonary, 1 week after trauma 15. Bed Sores How to Prevent ? Early Mobilization (by early reduction and fixation) Frequent Mobilization (by changing his position inbed ) Proper Hydration 16. Local complications Vascular injury Causes : Direct Injury by the blow Fractured (serrated) end of bone Compartment Syndrome Nerve Injury N.B. Sites Ulnar Nerve : Behind Medial Epicondyle Median Nerve : Cubital fossa Radial Nerve between brachialis and brachioradialis Sciatic Nerve : Behind hip Joint 17. Compound fracture Fracture Hematoma Connected with theExternal Significance : potentially Infected Delayed Union ( Because the first step of healing isthe organization of the hematoma and itsresolution ) 18. Union Malunited ( abnormal positioned) Delayed ( more than expected time) Ununited ( Not united at all) Causes Improper reduction Poor Blood Supply Gapping Infection Soft tissue between fractured bone 19. Internal Fixators Humerus and radius ( forearm) Plates andScrews Spine Pedicular Screws Tibia ( Shaft ) Intramedullary Nail Tibia ( Potts) K wire or Plate and Screws Colles Fracture Closed reducation + K wires Fracture Shaft femur Tomas Tractor tillopen reduction and internal fixation 20. Plates andScrews Inhumerus 21. K wires in CollesFracture 22. D.H.S. 23. IntramedullaryNail In Tibia 24. Thomas Skin tractor 25. External Fixators Below elbow slap ( fractures below elbow) Above elbow slap ( near elbow joint ) Humerus : U-shaped slap Clavicle : arm to chest sling Neck : Collar Lumbosacral : Lumbosacral brace Below knee slap Above Knee Slap Tomas Splint ( for femur ) Skin traction 26. Illizarov External Fixator Used in compound fractures Also in comminuted potentially infected 27. N.B. In a displaced fracture, Shortening occursbecause the muscle is shorter than thedistance between the origin andinsertion, pulling the bone with it 28. N.B. Any poly trauma pt ABC Immobilization of back Inspection Palpation of bones and checking if there is anyfracture X-ray at site of fracture Routine X-ray on Cervicalspine, Lumbosacral, Pelvis 29. X-ray One joint above and one joint below thefracture site Anteroposterior view and lateral view In children, X-ray the other limb forcomparison ( Epiphyseal lines ) 30. Emergencies in Orthopedics1. Fracture Neck Femur Avascular Necrosis of head can occur We fix by Dynamic head Screw2. Fracture Neck talus3. Compound Fracture4. Dislocation ( May cause Arthritis Forever)5. Slipped Physis (Epiphyseal Plate) in Children Arrest of Growth, Growth Deformities may occur6. Fracture with Vascular Injury 31. N.B. Infection in Bone is very Serious ( ifosteomyelitis occurred, we excise it astumour) 32. N.B Range of Acceptance ( range at which fracturecan be left not reduced and heals well ) Range of Angulation According to each bone Range of Overriding According to each bone But Rotation is not accepted at all, No rangeof acceptance, reduction must be done Range of acceptance increases in pediatricsdue to their remodelling ability 33. Comment On X-ray X-ray Anteroposterior or lateral view Of (Anatomy) Adult or child ( By Checking Epiphyseal plates) Showing Fracture with Angulation (Varus or vulgus) / Shortening .. Cm (With anterior or posterior ormedial or lateral displacement, of the distal segment ) Rotation 34. Epiphysis means Part of bone connected toJoint Arterial supply of neck of femur is veryimportant Why Fracture Neck femur occur ? Junction between cancellous and cortical bone Subcapital and midcervical Intracapsular BasiCervical - Extracapsular 35. Management of fracture neck femur Depends on Physiological activity And Age Extracapsular DHS Intracapsular If Young, with high activity urgent fixation DHS If old >60-70 years old Hemiarthroplasty Complications of hemiarthroplasty Infection Dislocation Periprosthetic Fracture Loosening which is painful 36. Dynamic head Screw Used in fracture neck femur It uses body weigt, leading to compressionand rapid healing 135 degrees And also used in trochanteric fracture In Subtrochanteric fracture we use dynamiccondylar screw DCS, which is 95 degrees 37. N.B. How to know the bone is osteoporotic By comparison to the color of the cortex ofshaft What is the difference between Intracapsularand Extracapsular Neck femur fracture ? Intracapsular Is an Emergency due toavasucalr necrosis and high mortality rate 38. Thank youAnd if there is anything wrong in theppt. check with Unit professor,then Send me