TRAUMATOLOGY – EXAM QUESTIONS

Camila Donadio, Heloisa Dias, Eloisa Gonçalves, Larissa Ferreira - Group 29

Sumário

1. The regeneration and repair of bone tissue (structure of bone tissue, types of bone
union, stages of fracture healing)............................................................................................. 5
2. The general principles of treatment of injuries in the muscular skeletal system (for
example, long bone fractures). ................................................................................................. 6
3. Conservative and operative method of treatment of orthopedic and traumatic
patients (general characteristics). ............................................................................................ 8
4. Clinical and radiological evidence of bone consolidation, delayed consolidation,
nonunion and pseudo arthrosis. ............................................................................................... 9
5. Diagnosis of bone fractures at the scene of incidence. General and specific signs
of bone fractures. Algorithm for formulation of diagnosis. .................................................. 10
6. Medical exercise therapy for rehabilitation after traumatic disease. (for example,
the treatment of fractures of the vertebrae). ......................................................................... 12
7. The algorithm of first aid in victims at the scene. Principles and means for
immobilization in injuries of the musculoskeletal system. .................................................. 13
8. Polytrauma. Classification. Strategy of diagnosis and treatment. ............................. 14
9. The etiology and pathogenesis of traumatic shock. Pathogenic principles of
intensive care treatment. ......................................................................................................... 17
10. Treatment and prevention of traumatic shock in the prehospital and hospital
stages. ........................................................................................................................................ 19
11. Principles of treatment of open fractures (prehospital and specialized medical
care). 22
13. Thoracoabdominal wounds. The pathophysiological disorders. Clinic,
diagnostics,................................................................................................................................ 26
15. Factors contributing to the development of wound infection.
Etiopathogenesis.clinics, diagnosis and treatment of purulent wound infection............. 29
16 Wound sepsis, Classification, Clinical and laboratory diagnosis. ......................... 31
17. Wound sepsis: the treatment of common symptoms and local complications. .. 34
18. Crush syndrome. Pathogenesis. Classification ....................................................... 34
19. Crush syndrome. Clinics, diagnostics, treatment of pre-hospital and hospital
stages. ........................................................................................................................................ 35
20. Moderns methods of medical immobilization: plaster casts, bandages, orthoses,
corsets (general characteristics, indications) ....................................................................... 37
21. Emergency care for open fractures of the bones of the limbs and bleeding ............ 39
22. Open and closed fractures of the metacarpals and phalanges (the mechanism of
injury, clinical features, treatment). ........................................................................................ 40
23. Diagnosis and treatment of tendon injuries in the wrist and hand. ....................... 42
24. Fractures of the wrist bone (mechanism of injury, clinical picture, treatment
scaphoid fractures). .................................................................................................................. 43
25. Fractures of the radial bone in a typical place (the mechanism of injury,
diagnosis and treatment). ........................................................................................................ 44
26. Fractures of the olecranon (mechanism of injury, clinical features, treatment). . 47
27. Diaphyseal fractures of the forearm bones (the mechanism of injury, diagnosis
and treatment)........................................................................................................................... 50
28. Traumatic dislocation of the forearm (the mechanism of injury, clinical features,
treatment). ................................................................................................................................. 53
29. Diaphyseal fractures of the arm (mechanism of injury, diagnosis, treatment). ... 55
30. Fractures of the surgical neck of the humerus (mechanism of injury, diagnosis,
treatment). ................................................................................................................................. 57
31. Traumatic shoulder dislocation (mechanism of injury, clinical features,
treatment). ................................................................................................................................. 59
32. Fractures of the distal humerus metaepiphysis (mechanism of injury, clinical
features, treatment). ................................................................................................................. 63
33. Damage to the acromioclavicular joint - dislocation of the acromial end of the
clavicle (mechanism of injury, clinical features, treatment). ............................................... 65
34. Fractures of the clavicle (mechanism of injury, diagnosis, treatment). ................ 66
35. Rib fractures (mechanism of trauma, diagnosis, treatment). ................................. 69
36. Rib fractures (unstable ribcage – Flail chest). The mechanism of injury,
diagnosis, first aid, treatment. ................................................................................................. 70
37. Diagnosis and treatment tactics for fractures of the ribs, complicated by closed
hemothorax................................................................................................................................ 71
38. Penetrating chest wounds, complicated by an open pneumothorax.
Characteristics and clinical picture. ....................................................................................... 72
39. Stable and unstable fractures of the vertebrae (the mechanism of injury,
diagnosis and treatment). ........................................................................................................ 72
40. The clinic, treatment of fractures of the pelvis. Methods of treatment of fractures
of pelvic bone with the damage of the pelvic ring. .............................................................. 73
41. Differential diagnosis of damage intra-pelvic organs in fractures of the pelvic
bone. 83
42. Traumatic dislocation of the hip (mechanism of injury, clinical features,
treatment). ................................................................................................................................. 84
43. Fractures of the femoral neck (mechanism of trauma, clinical features,
treatment). ................................................................................................................................. 88
44. Trochanteric fractures of the femur (the mechanism of injury, clinical features,
treatment). ................................................................................................................................. 92
45. Diaphyseal fractures of the femur (the mechanism of injury, clinical features,
treatment). ................................................................................................................................. 97
46. Damage to the ligaments of the knee (mechanism of injury, clinical features,
treatment). ............................................................................................................................... 102
47. Fractures of the patella (the mechanism of injury, clinical features, treatment).
105
48. Damage to the meniscus of the knee joint (mechanism of trauma, clinic,
treatment). ............................................................................................................................... 110
49. Intra-articular fractures of the knee (mechanism of injury, clinical features,
treatment). ............................................................................................................................... 114
50. Diaphyseal fractures of the bones of the leg (mechanism of trauma, clinical
features, treatment). ............................................................................................................... 119
51. Fractures of malleolus (mechanism of injury, clinical features, treatment). ...... 121
52. Fractures of the tarsal bones (the mechanism of injury, clinical, treatment of
fractures of the calcaneus bone). ......................................................................................... 124
53. The mechanism of injury, clinic, treatment of talus fractures. ............................. 125
54. Methods of temporary and final stop bleeding. Types of surgery. Prevention of
ischemic gangrene. ................................................................................................................ 127
55. Types of surgical debridement of wounds. Techniques and steps primary
surgical debridement of wounds, Indications and contraindications for primary suturing
of the wound. Types of suture. ............................................................................................. 128
56. Anaerobic infections. Types. Etiopathogenesis. Classification, and Prophylaxis.
129
57. Anaerobic infections. clinic, diagnostics, treatment. Indications and tactics of
amputation. .............................................................................................................................. 130
Diagnostics ...................................................................................................................... 131
Treatment......................................................................................................................... 131
58. Osteochondrosis of vertebrae. Etiology, pathogenesis. Basic clinical syndromes
132
59. Osteochondrosis of the lumbar segment of vertebrae (clinic, diagnostics,
treatment)................................................................................................................................. 134
60. Osteochondrosis of the cervical segment of vertebrae (clinic, diagnostics,
treatment). ............................................................................................................................... 136
61. Osteoarthrosis of large joints (etiology, pathogenesis and classification). ........ 138
62. Conservative complex treatment of osteoarthrosis of large joints. ..................... 140
63. Osteoarthrosis of the hip joint (coxarthrosis): clinical features, treatment. ........ 141
64. Osteoarthrosis of the knee (gonarthrosis): clinical features, treatment. ............ 143
65. Disorders of the posture.types, diagnosis, prevention.......................................... 144
66. Scoliotic disease (etiology,pathogenesis, classification). ..................................... 145
67. Scoliotic disease (diagnosis and treatment). .......................................................... 149
68. Flatfoot (etiology, types of flatfoot-classification, prevention). ............................. 150
69. Transverse-flatfoot (clinical features, treatment, prevention). ............................. 151
70. Longitudinal flatfoot (etiology, clinical features, treatment). ................................. 152
71. Valgus deformity of 1st toe (clinic, treatment). ....................................................... 153
72. Types of osteopenic states. Osteoporosis: etiology, classification, principles of
treatment .................................................................................................................................. 153
1. The regeneration and repair of bone tissue (structure of bone
tissue, types of bone union, stages of fracture healing).

Structure of bone tissue:

Compact and spongy boné:

1- Compact bone: consists of closely packed osteons or haversian systems. The osteon
consists of a central canal called the osteonic (haversian) canal, which is surrounded by
concentric rings (lamellae) of matrix. Between the rings of matrix, the bone cells
(osteocytes) are located in spaces called lacunae. Small channels (canaliculi) radiate
from the lacunae to the osteonic (haversian) canal to provide passageways through
the hard matrix. In compact boné haversian systems are packed tightly together to
form what appears to be a solid mass
2- Spongy (cancellous) bone : Lighter and less dense than compact bone. Spongy bone
consists of plates (trabeculae) and bars of bone adjacent to small, irregular cavities
that contain red bone marrow.
Types of bone callus:

1-Immature callus:

arises between direct contacting bony fragments, the space between which should be no more
than 0,1 mm, under the condition of maximal stability of fragments.

2-Periosteal callus

Arises as the result of rapid reproduction of cells of a cambial

layer of periosteum. Is situated around or produced external to bone

3-Central(Endoesteal) callus:

Formed on the internal surface of a intramedullar canal out of cells of endosteum

and marrow of both fragments.

4-Paraosseous callus:

Arise out of soft tissues (Tendon, ligaments) adjoining to a site of a fracture.

(Heterotopic ossification)

Stages of fracture healing of a bone

1. Hematoma. Mainly the blood and necrotic tissue are between fragments of a bone. ≈ 1 - 2
weeks.

2. Formation of a fibrous tissue. The stage is finished by commissure of fragments that exclude
theirs displacement on length and width. ≈ 2 - 6 weeks.

3. Formation of a bony callus. ≈ 6 - 12 weeks.

4. Consolidation of a fracture. The full load on a bone is possible. (bone units -> no crepitation,
no pathological movement.

5. Remodeling - Structural (architectonic) change of a bone. It is restoration of architectonics

of a bone tissue according to an orientation of a vector of a load, and of metabolic activity of
cells.

2. The general principles of treatment of injuries in the muscular

skeletal system (for example, long bone fractures).

GOALS OF FRACTURE TREATMENT

-Restoration of morphology of the damaged tissues
-Restoration of function of the damaged organs
-Prevention of complications
-Rehabilitation of a patient as early as possible

Principles of treatment of traumatized patients.

1. The principle of urgency,-

Remove influence of injury agent if still acting.
Diagnose and restorement of vital functions (ABC)/ First medical aid
of a pre-hospital stage. Transport to hospital
Stop bleeding if any, apply tourniquet (proximally/Upper to the
edge of the injury).
Immobilization of the limb, to avoid bone fragments displacement
(by Kramer and sling)

2. The principle of anaesthesia,

Medical aid and medical manipulations should begin with anesthesia
Narcotics(Morphine, Tramal), Non narcotics (Analgin),
NSAIDs (diclofenac, nimesulide)
local and regional anesthesia.
Analgesic usually given IM

3. The principle of reposition,

All displaced or disconnected tissue should be reduced or connected
Basic methods:
1- Conservative:
Single stage closed reposition:
Muscular retraction is surmounted at help of short-term
or prolonged traction;
Skeletal extension:
Reposition – until 3 days
Retention – until 3 weeks
Reparation – from 3-6 weeks
4. The principle of fixation,
everything that is reduced or connected, should be fixed during
accretion of the damaged tissue
1. Conservative
-external immobilization,
skeletal extension.
2. Operative
osteosynthesis,
devices of external fixing.
5. The principle of function,
in an ideal simultaneously with restoration of morphology of the
damaged tissues function of organs should be restored, With:
 Medical exercises, Functional splints, Electromechanical splints
6. The principle of complex treatment,
Treat not only the damage but of a patient with an optimum
combination of medical methods. Determine severity, concomitant
diseases, prognosis, complications, optimum combination of
essential methods of treatment and prophylaxis of complication.

7. The principle of rehabilitation.

Restoration of morphology of the damaged tissue and function of
musculoskeletal system, with Physiotherapy exercises, physiotherapy,
massages

3. Conservative and operative method of treatment of orthopedic and

traumatic patients (general characteristics).

Conservative:
Cast, plasters, braces, apparatus, Splints (Kramer wire), spinal supports
Medicines (analgesic, anesthesics), POP
Medical exercises – Gradual low dosed exercises
Physiotherapy – Ultra high frequency, magnetotherapy, laser
Massages
Closed reduction (fluoroscopy + skeletal traction + reduction)

Operative:
Repositioning - open reduction
 Fixation
Intramedullary blockaded nails
Extramedullary Osteosynthesis by plates and screws
External fixing devices (Illizarov device)

4. Clinical and radiological evidence of bone consolidation, delayed

consolidation, nonunion and pseudo arthrosis.

Clinical sign of consolidation:

No pathological mobility

No crepitation

No pain

No gap felt during palpation

Radiological sign of consolidation:

Disappearance of line of fracture

Normal/good Callus formation

Delayed consolidation:

Fracture, that until double average term of consolidation, still No clinical and radiological signs
of union.

Types:

Atrophic – minimal callus formation

Hypertrophic – ample callus formation, but fracture fails to heal

Etiology:

Compound fracture, severe crush injury, bone displacement,

Inadequate immobilization

Infection, Inadequate blood supply

Symptoms: Pain, tenderness at fracture after removal of splintae, after stipilated time. Patho
movement, crepitation

X-ray: Fracture line, evidence of union is lacking

Nonunion consolidation
Fracture that takes More than double average time of consolidation, still no clinical
radiological signs of consolidation.

Etiology:

Interposition, inadequate reduction, inadequate immobilization

Clinical Picture: Pain site of fracture even after stipulated time, abnormal mobility, gap ca be
felt at fracture site, not that tender as delayed union

X-ray: Fracture lines clearly visible, pseudoarthrosis, sclerosis at the bone ends may be present

Pseudo arthrosis.

Also known as False joint)

Marrow canals closed, egde of bone fragments with congruence ( cavity and head)

Signs: pathological mobility, deformation of limb, shortening

X-ray: Line of fracture, sclerosis, marrow channels closed,

Tx: Surgical – resection, decortication, bone grafting

5. Diagnosis of bone fractures at the scene of incidence. General and

specific signs of bone fractures. Algorithm for formulation of diagnosis.

Diagnosis of bone fractures:

General signs:

Pain, redness, swelling, Increased local temperature, loss of function

Specific signs:

Detection of Bony fragments, pathological movement, crepitation, deformation, shortening of

limb.

X-ray signs: Break at integrity of bone, callus formation (white shadows)

Algorithm for formulation of diagnosis:

1-Closed/Open

2- Type of fracture: Transverse, oblique, spiral, comminuted (multifragment), compression,

green-stick.

3-Localization: Proximal/Epishysis (Intra-articular)

Femur -> Subcapital, Transcervical, Basicervical

Proximal metaphysis (Extra-articular)

-Neck of radius

-Surgical neck of humerus

-Neck of femur -> Transtrochanteric, Intertrochanteric, Subtrochanteric

Diaphysis: Upper third

Middle third

Lower third

Distal metaphysis

Distal epiphysis (Intra-articular)

4-Bone name

5-Displacement -> by width, lenght, angle, rotation

6-Complication -> Nerve injury, artery rupture, shock

Ex: Closed oblique fracture of lower third of diaphysis of left humerus with displacement,
complicated with brachial artery rupture, traumatic shock 1st degree.
6. Medical exercise therapy for rehabilitation after traumatic disease.
(for example, the treatment of fractures of the vertebrae).

Medical exercises:

1-Isometric contraction of the muscles: Exercise involving muscular contractions without

movement of the involved parts of the body.

Passive exercises: Exercises done with movement of the body, usually of the limbs, without
effort by the patient, done by a physician.

Active exercises: Exercises done when the patient is able to voluntarily contract, control, and
coordinate a movement

Medical exercises for vertebrae:

3 groups:

1st group: from admission till 2-3 weeks. Exercises away from the place of injury, like
movements of hands, foot.

2nd group: From 3-6 weeks. Exercises closer to zone of injury, movements of shoulder joints,
hip

3rd group: After 6 weeks. Exercises focus on the zone of fracture. Like Extension for lumbar
compression ijury. Prone position at bed (abdomen touching the bed)

Strengthening-exercises: It is important to improve the lumbar stabilization by strengthening

the muscles of the lower back, strengthening the patient’s supportive axial musculature (in
particular the spinal extensors) but also the muscles of the trunk. Exercises should focus on
strengthening back extension and may include weighted or unweighted prone position
extension exercises, isometric contraction of the paraspinal muscles, and careful loading of the
upper extremities.

Medical exercises for

7. The algorithm of first aid in victims at the scene. Principles and
means for immobilization in injuries of the musculoskeletal system.

First aid and treatment of the victim should be urgent and begin on a place of incident

Algorithm of actions on a place of incidente:

1) To remove influence of injuring agent if it continues to act.

2) Diagnosis of functioning of life's ensuring organs and systems of an organism

3) Restoration of function of life's ensuring systems of an organism

4) Diagnosis of other damages

5) The first medical aid of a pre-hospital stage

6) Transportation to the hospital

The pre-hospital medical aid at fractures

1-close:

1. anaesthesia, usually narcotics

2. transport immobilization,

3. transportation to the hospital

2-open:
1. stopping bleeding,

2. anaesthesia,

3. aseptic bandage,

4. transport immobilization,

5. transportation to the specialized hospital

Principles of temporary immobilization

0. Analgesics = Non narcotics (Analgin, toradol), or Narcotics (Morphine, tramal) IM, or IV

1. At the damage of a segment of an extremity, it is necessary to immobilize two adjacente

healthy joints at least, Immobilization with Krammer-wire splint for emergency immobilization.

2. Middle physiological position is given to extremity  Upper limbs: Medial physiological

position with internal rotation, thumb to nose.

3. Splint is necessary be laid on clothes or on some pad

4. Cotton-gauze pad is necessary be placed under sites of bony prominences

5- Transport to hospital

8. Polytrauma. Classification. Strategy of diagnosis and treatment.

Polytrauma is defined as clinical state following injury to the body leading to profound
physiometabolic changes involving multisystem, or Patient with following combination of
injuries: 2 major system injury + 1 major limb injury;

1 major system injury + 2 major limb injury

1 major system injury + 2 open grade III skeletal injury

Unstable pelvis fracture with associated visceral injury

Classification:

Acc. Type/ quantity (?)

-Isolated:

Trauma to 1 segment or to internal organ

-Multiple:

Injuries to 2 or more segments or 2 or more segments or 2 or more internal orgains in

the same cavity.
-Combined:

Multiple trauma with internal organ or trauma to 2 or more internal organs with more
than 1 cavity

Acc. Stages:

-Moderate:

Shock Absent, or I degree shock,

Head concussion

Isolated rib fracture

Nonpenetrating abdominal injuries

Closed isolated fracture of long bones

Multiple trauma of short bones

No pelvic injury

Open fracture type 1A-2A

Wound up to 20 cm without massive bleeding

-High:

I-II degree shock

Edema and contusion of head, 1st degree and moderate high

Hemopneumothorax

Multiple trauma

Unstable pelvic fracture

Open fracture 2B-3C

Wound >20 cm without massive bleeding

-Critical:

Very bad condition, Fatal

Strategy diagnosis and treatment:

First diagnostic plan:

Correction of airway, with stabilizing the cervical region

Check for breathing

Check for bleeding and to stop it

Check for damage of Central Nervous system

Full check up

Management of polytrauma

The ABCDEF of polytrauma management are as follows :

A. Airway maintenance with cervical spine control

- cervical spin should be carefully protected at all times and not

to be hyperextended, hyperflexed or rotated to obtain a

patent airway

- a chin lift or jaw thrust maneuver, should be used to establish

the airway

B. Breathing with special emphasis on :

- tension pneumothorax

- open pneumothorax

- massive hemothorax

- flail chest with lung contusion

C. Circulation

Support blood circulation

Normalize quantity and quality of blood content,

Aggressive Infusion therapy – Correction of shock

D. Disability (neurological status) by Glasgow coma scale

E. Exposure and environment control, undress the patient but prevent hypothermia

F. Fracture splintage or fixation, as a rule the following steps

are to be followed :

- adequate immobilization of the cervical spine, proper handling of the patient in order to
prevent further damage to neurovascular elements

- immobilization does not need to be absolutely rigid

- the joint above and below the fractured site should be immobilized. Splints can be
improvized by pillows, clothing.

- overbleeding should be tamponaded with dressing and firm pressure

- tourniquet should be avoided, unless it is obvious that the patient's life is in danger

9. The etiology and pathogenesis of traumatic shock. Pathogenic

principles of intensive care treatment.

Traumatic shock is a response of the body to mechanical damage, manifested by a violation of

the functions of vital organs and systems: blood circulation, respiratory, nervous, endocrine
with metabolic metabolic disorder. The triggering mechanism is pain, blood loss, damage to
vital organs, and stress.

Etiology:
Severe tissue damage, such as

multiple fractures,

severe contusions, or

burns

Pathogenesis:

Pathophysiology results from tissue hypoxia due to hypoperfusion, which initiates the
inflammatory process, leading to multiple organ damage and dysfunction, as in hemorrhagic
shock; however, primary organ injuries aggravate systemic deterioration more seriously.

Pain (autonomic n. system affection) /bleeding  vital organs stress  shock

✓ Compensated traumatic shock - HR increase, vasoconstriction

✓ Decompensated traumatic shock- Hypoperfusion, multiple organ

dysfunction syndrome

✓ Acute Irreversible shock- Acidosis, coagulopathy

Pathogenic principles of intensive care treatment.

Treat pain and bleeding to decrease vital organs stress

There are four basic principles(Ravindu):

✓ Control of active hemorrhage

✓ Assessment of circulatory status

✓ Rapid intravascular access

✓ Aggressive fluid resuscitation

Principles of organisation in treatment of poly trauma: (LECTURE)

• Principle of domination (critical) trauma:

In any critical life situation, diagnose when admitted, should act very fast, up to

proceeding to the stage of the treatment.

• Principle of combination

 Principle of single trauma

Trauma triage:

-triage sieve:

to separate  the walking from the injured

-triage sort:

to categorise casualties according to local protocols.

Cat 1: critical & cannot wait.

Cat 2: urgent - can wait for 30 mins at most

Cat 3: less serious injuries.

Cat 4: expectant- survival not likely.

10. Treatment and prevention of traumatic shock in the prehospital and

hospital stages.

Prehospital:

Analgesics

Immobilization

Special transportation (? N tenho ctz)

Infusion (in ambulance)

Pre-hospital- primary survey: (Ravindu)

• A - assessment of Airway, protection of cervical spine by collar

• B - assessment of Breathing & 100% saturated oxygen administration

• C - establishment of blood Circulation - IV access and start normal

saline infusion (fluid bolus)

• D - check for disability and neurological status according to Glasgow

coma scale

• E - environment then,

✓ Apply pneumatic anti shock suit to prevent progression of shock.

✓ Patient keep on stretcher and immobilize by bandages in volcovich's pose.

 ✓ Immediate transfer of patient to hospital

Hospital- unit of hospital - intensive care unit (Ravindu)

• Anti-shock measures

• Patient connect to the cardiac monitor, pulse oximeter

• Close monitoring of the vital signs, distal pulse

• IV access - 2 large bore cannula

• Start fluid resuscitation - 2 normal saline bolus within 40 min

• Tranexamic acid - 1g over 10 min, followed by 1g over 8 hrs.

• Catheterization - manage input/output chart

• Start group specific blood transfusion

• Start further management according to laboratory and instrumental investigations.

HOSPITAL STAGE –Notes prof Sam.

1-Pain management

2-Operation

3-Post operation care  Infusion RBC, pO2.(Intubation)

Operative method (LECT -)

-1st group - Extraordinary emergency operation

Mainly operation is done to stop the patient from further progressing to shock Example:
intraabdominal and progress of intrapleural bleeding, hematoma in head with compression of
spinal cord

-2nd group – extraordinary operation with possibilities of methods for preventing from shock
before operation (up to 6 hrs)

Example: Injuries to intestine, urinary bladder, instable complication fracture of vertebra,

instable fracture of pelvis, open fracture of the long bones

-3rd group urgent operation, done within first 3 days before change in hemostasis

Factors influence: in which the stage progress to fat embolism, hypostatic and infection
complications

Example: fracture of long bones, intra capsular injuries, unstable fracture of pelvic,
uncomplicated of vertebra

-4th group – not urgent operation. 10 - 14 days after trauma in the steady compensation
period.

Example- reconstruction operation on the skeletal system

11. Principles of treatment of open fractures (prehospital and
specialized medical care).

The pre-hospital medical aid at open fractures:

1. stopping bleeding - apply pressure to stop bleeding, Tourniquet
2. anaesthesia,
3. Wound wash, aseptic bandage,
4. transport immobilization, Krammer wire splint
5. transportation to the specialized hospital

In emergency department
- wound care : aseptic dressing of wound
- analgesics
- splintage
- prophylactic antibiotics
- tetanus and gas gangrene prophylaxis
- X-ray to be taken to evaluate the fracture

a) Wound debridement
- small punctured wounds are left as it is
- clean lacerated wounds followed by primary closure
- doubtful lacerated wounds observed for 2-3 days
→ if there is no infection : delayed primary suturing
→ in presence of infection : secondary closure
- infected wound : healing by secondary intention

b) Definitive wound care

- decision regarding suturing is made as above

Fracture management:
- external skeletal fixation
- immobilization in plaster
- pins and plaster
- skeletal traction
- internal fixation

12. Bleeding: definition, classification, diagnosis. Symptoms of external

and internal bleeding.
Definition:

Hemorrhage is the escape of blood from vessels due to injury or increased permeability. It represents an
intravascular depletion through loss of plasma and RBC mass.

Classification:

i. According to source of bleeding –

a. Venous,
b. Arterial,
c. Mixed
d. Capillary
ii. According to area of bleeding –
a. Internal bleeding
b. External bleeding
iii. According to degree of blood loss – Mild(Class I), Moderate (Class II), Severe (Class III)
a. Class I – Blood pressure is maintained by peripheral vasoconstriction (PVC), pallor,
delayed capillary refill, increased pulse rate, mild oliguria.
b. Class II – Classic findings of hemorrhagic shock, obvious signs of mental status
alteration.
c. Class III- Obtundation, loss of consciousness, undetectable pulse and BP if blood loss
exceeds 50%.

• According to blood loss(Ravindu)

✓ Grade 1 - <750 ml

✓ Grade 2 – 750 – 1500 ml

✓ Grade 3 – 1500 – 2000 ml

✓ Grade 4 - >2000 ml

Diagnosis:

Clinical picture (RAVINDU)

✓ Bleeding and bruising

✓ Swelling
✓ Pain

✓ Absent pulse

✓ Pallor

✓ Paralysis, Paresthesia

• Laboratory investigation

✓ FBC – anemia

✓ Coagulation profile – Bleeding time, clotting time, PT/INR

✓ Liver function test

✓ Renal function test – s. electrolytes, blood urea nitrogen, s.

Creatinine

• Instrumental investigation

✓ USS

✓ Chest X-ray – hemothorax

✓ CT – bleeding in the brain

In Class I hemorrhage,

PR: 100-120/min

RR: 20-30/min

UO: 20-30 ml/hr

Mental status: Mildly anxious

CVP: Decreased

Hb: 120g/l

RBC:

Ht: > 35 ml/dl

Volume of blood loss:

<1500 ml (15-30%)

Class II hemorrhage:

PR: 120-140/min
RR: 30 – 40/min

UO: 5-15ml/hr

Mental status: anxious, confused

CVP: Decreased

Hb: 80 – 120g/l

RBC:

Ht: 25 – 35 ml/dl

Volume of blood loss: 1500 – 2 000 ml (30-40%)

Class III hemorrhage

PR >140/min

RR>35 /min

UO: Negligible

Mental status: Confused, lethargic .

CVP: Decreased.

Hb: >80g/l

RBC:

Ht: < 25 ml/dl

Volume of blood loss: > 2000ml (>40%)

Symptoms of external and internal bleeding.

External hemorrhage – Diagnosis is prompt and obvious. Differentiation of arterial (bright red, pulsating)
or venous blood (dark red) is required.

(Ravindu)

•Presence of a wound, bruising

• Discoloration of the skin

• Pale, cold, sweaty skin

• Pain

• Loss of function of injured area

Internal hemorrhage – Diagnosis is more difficult. General signs are: pale and clammy skin, fainting,
dizziness, tachycardia, drop of arterial blood pressure. More specific signs are when blood escapes through
original body openings and manifested as:

 Hemoptysis (bright red and foamy) – Pulmonary bleeding.

  Hematuria – Renal bleeding.
 Epistaxis – Nasal bleeding.

(Ravindu)

• Abdominal pain and swelling, bleeding from trauma of liver and spleen

• Light headed, dizziness, headache and fainting

• Ecchymosis, petechia or hematoma, bleeding in skin

• Swelling, tightness and pain in legs, bleeding due to fracture of thigh

• Hemothorax – pleural cavity

• Hemopericardium – pericardial cavity

• Tachycardia, hypotension

13. Thoracoabdominal wounds. The pathophysiological disorders.

Clinic, diagnostics,

Pathophysiological disorder

Blunt  fracture of ribs  damage to internal organs

Penetration  direct damage of internal organs (it has a inlet with/without outlet)

Thoracoabdominal trauma - traumatic injury with violation of the integrity of the diaphragm,
chest and abdominal cavities, due to a penetrating wound with a sharp object, a gunshot
wound , a blow or compression.

Clinics:

Respiratory disorders, hemo- or pneumothorax, hemoptysis, subcutaneous emphysema,

muscle tension of the anterior abdominal wall, abdominal pain, dysphagia, signs of massive
blood loss, and other symptoms of thoracic or abdominal trauma can be detected

Diagnostics:

Inspection – Open fracture, dyspnea, jugular distension, hemoptysis. signs that may indicate a
rupture of the diaphragm

Palpation - pain and pathological mobility at the sites of rib fractures, specific crepitus
("crunch of snow") in the area of subcutaneous emphysema.

Percussion - tympanic or box sound with pneumothorax, shortening of percussion sound or

dull sound with hemothorax.

Auscultation: Weakening or absence of breathing is noted on auscultation ,

Blood tests - signs of anemia, leukocytosis.

X-ray examination (plain chest and abdominal X-ray, also lateral views). High standing of the
diaphragm dome, gas in the abdominal cavity. Displacement of organs into the chest cavity is
possible. Fractures of the ribs, pneumothorax, hemothorax, hemoperitoneum are visible.

Ultrasound - hemopericardium, hemothorax, localize the latter and determine the optimal
point for therapeutic puncture of the pleural cavity.

14. Wounds. The phases of wound healing. Pathological anatomy of

gunshot wounds, the mechanism of formation zones. Primary and
secondary healing.
Phases wound healing:
-Hemostasis-inflammation:
vasoconstriction

fibrin clot formation

proinflammatory citokines and

growth factors releasing

vasodilatation

infiltration PMNs, macrophages

cytokines releasing

→ angiogensis

→ fibroblast activation

→ B- and T-cells activation

→ keratinocytes activation

→ wound contraction

-Granulation-proliferation:
fibroblast migration

collagen deposition

angiogensis

granulation tissue formation

epithelisation

contraction
-Remodelling:
regression of many capillaries

physical contraction – myofibroblasts

collagen degeneration and synthetisation

new epithelium

tensile strength – max. 80%

Gunshot wounds
Inlet – small

Outlet - wide

-3 areas:

1)wound canal (where bullet pass)

2)area of primary traumatic necrosis (in canal)

3)area of molecular concussion

Primary wound healing:

Occurs in the case of aseptic wounds or fresh injuries.The wound edges have smooth borders
and areclose vicinity. Primary wound healing occurs after a surgical incision in which the edges
of the wound are connected by a suture. In general, such wounds will heal within 6 – 8 days.

Secondary wound healing

The wound cannot be closed by a primary wound closure.The risk of infection is greatly
increased by the partially large-scale loss of tissue, or an infection has already occurred. The
healing of such wounds often leads to major scarring.

Secondary wound healing occurs in acute wounds with large tissue loss as in dog bites, when
primary closure is not possible, or in chronic wounds.

15. Factors contributing to the development of wound infection.

Etiopathogenesis.clinics, diagnosis and treatment of purulent wound
infection.
Factors contributing to the development of wound infection:
-Diseases: such as diabetes, cancer, or liver, kidney or lungs conditions
slow down healing
-Foreing objects: dead tissue and foreign objects, such as glass or metal,
stuck in the wound may delay wound healing
-Poor blood supply or low oxygen: blood flow may be decreased by high
BP, and blocked or narrowed blood vessels. Low oxygen may be caused by
certain blood heart and lung diseases
-Repeated trauma
-Weak immune system
-Age, obesity, malnutrition
-Endocrine and metabolic disorders
Ethiopathogenesis:

Clinics:
-High or low body temperature, low BP or a fast heart beat, dyspnea, chills
-Increased discharge or pus coming out of the wound
-Increased swelling that goes past the wound area and does not go away
after five days (red, painful, warm to touch) -> signs of inflammation

Diagnosis:
-Clinical picture
-General, biochemical, immunological blood analysis
-General analysis and bacteriological examination of urine
-US, CT, MRI in damage of internal organs, cavities and bone
-Smear microscopy
Treatment:
-Wound debridement (mechanical, physical or chemical debridement)
-Wound drainage (aspiration-washing, flow-washing, soft wound
tamponade by drapes)
-Cleasing
-Antibiotics of wide-spectrum of action
-Antiseptics
-Preteolytic enzymes (in inflammation stage)
-Detoxification

16 Wound sepsis, Classification, Clinical and laboratory diagnosis.

Sepsis is a phase of any infectious disease development, in the basis of which
there is organism reaction in the form of generalized (systemic) inflammation
with different localization of the primary focus on infection of bacterial, viral and
fungous origin.

Classification:
According to primary focus:

 Primary (cryptogenic when primary focus not found)

 Secondary (if purulent focus)

According to forms:

 Sepsis without metastases.

 Sepsis with purulent metastases.

By type of pathogen:

 Bacterial
‐ Aerobic (gram + and gram -) clostridial
‐ Anaerobic (non clostridial)
‐ Mixed (aerobic + anaerobic)
 Viral
  Micotic

According to the phase of metabolic disorders:

 Catabolic
 transitional
 anabolic

According to the phase of development:

 Septicemia
 torpid current sepsis

According to clinical course:

 Fulminant (1-3 days)

 Acute (4-14 days)
 Subacute (2-12 weeks)
 Chronic (> 3 months)

According to severity degree:

 Mild (SIRS + purulent inflammatory focus + multiple organ dysfunction on

1-2 systems).
 Moderate (SIRS + purulent-inflammatory focus + multiple organ
dysfunction on 3 systems and more).
 Severe (SIRS + purulent-inflammatory focus + multiple organ failure).
 Septic shock (all signs of sepsis + hypocirculation syndrome BP ↓
90mmHg)

By clinical affiliation:

 Surgical
 Therapeutic
 According to the localization of the septic focus, they distinguish:
 pleuro pulmonary sepsis
 peritoneal sepsis
 biliary sepsis
 intestinal sepsis
 gestational sepsis
 urosepsis
  skin sepsis
 phlegmonous (mesenchymal) sepsis with localization of septic foci
 in fatty tissue or connective tissue (fasciitis)
 angiogenic sepsis with or without a foreign body when the focus is
localized
 in the cardiovascular system.
 meningoencephalitic form of sepsis
 In obstetrics and gynecology, the most common 2 clinical forms of sepsis:
peritoneal and thrombophlebitis

Clinical and Laboratory Diagnosis:

Clinical:

 Signs of endogenous – fever, chills, diaphoresis, tachycardia, tachypnea

 Multiple organ dysfunction:
‐ CNS impairment – alterate mental status (disorientation, lethargy,
intoxication psychosis)
‐ Cardiovascular failure – hypotension
‐ Coagulopathy  DIC  petechiae, purpura
‐ Liver failure - jaundice
‐ Kidney failure – oliguria
‐ Respiratory failure – acute respiratory distress (ARDS)
 Features of primary infection
 Generalized edema
 Septic shock – hyportension (MAP <65mmHg/ systolic ↓90mmHg)

Laboratory:

 Serum lactate – may be elevated (reflects hypoperfusion)

 Blood culture
 CRP, procalcitonin – typically elevated
 CBC – variable findings
 Liver function – hyperbilirubinemia, ↑ INR, ↑ ALT, ↑AST
 Coagulogram - ↑ PT, ↑aPTT, ↑ D-dimer
 Blood gas – to identify possible acid-base disturbances and assess
oxygenation.
17. Wound sepsis: the treatment of common symptoms and local
complications.

Local treatment :

 All septic foci or sores should be subjected to surgical treatment of Ceska and
produced a thorough excision of nonviable tissue and extensive dissection of all
the streaks and pockets.
 After the operation, active drainage of the wound.
 Long-term continuous irrigation for 7-10 days with an antiseptic solution.
 Quickly close the wound.

General treatment:

 Broad spectrum antibiotics and modern antiseptics.

 Active and passive immunotherapy.
 Detoxification therapy - prolonged infusion-transfusion therapy aimed at
correcting the violations of all kinds of exchanges and vital functions.
 Correction coagulation and anticoagulation systems of blood.
 Parenteral food.
 Symptomatic treatment.

18. Crush syndrome. Pathogenesis. Classification

It is a clinical condition caused by compression of muscle with subsequente
rhabdomyolysis which can then cause the complications of electrolyte
disturbances, fluid sequestration and myoglobinuria.

Pathogenesis:
Crushing injury/ limb compression  soft tissue injury  ischemia  hypoxia
prevents mitochondria to produce ATP  no functioning Na/K pump  ↑
intracelular Na levels  water moves into cell by osmosis  intracelular edema
 cell death  rhabdomyolysis  myoglobulinemia and myoglobinuria  acute
renal failure

Classification:
According to severity:

 Mild (compensated endotoxicosis) : compression < 4h and oliguria 2-4

days
  Moderate (sub-compensated endotoxicosis): compression of 2 segments
5-6h and myoglobinuria
 Severe (decompensated endotoxicosis): compression of 1-2 extremities 4-
7h and acute renal failure
 Extremely severe: compression 2 lower extremities > 7h and death on
account of hemodynamic failure.

19. Crush syndrome. Clinics, diagnostics, treatment of pre-hospital and

hospital stages.

Clinics:
Compression period – No inflow and outflow (ischemia)
Tachycardia, hypotension, tachypnea, anemia

Decompression period – toxic substances in vascular channel

 I stage – Endogenous intoxication (1-3days):

‐ Shock
‐ Low urine output; hematúria
‐ Sour, reddish urine (coke)
‐ ↑ creatinina level 2-5x
‐ Electrolyte disbalance
‐ Hemoconcentration, hypercoagulation
‐ Hyperthermia, sluggishness
  II stage – Acute renal failure ( 2-3weeks):
Polyorgan pathology, rising intoxication level
‐ Oliguria
‐ Dark-brown urine (myoglobulinuria)
‐ Jaundice
‐ Hyperkalemia  bradycardia, arrhythmia
‐ Acute (stress) intestinal ulcers
‐ Necrosis and muscle tear
‐ Development of wound infectiond (including anaerobic)

 III stage – Uremia/Azotemia (3-5 weeks):

‐ Development of polyorgan pathology
‐ Hepato-renal insufficiency
‐ Uremic syndrome
‐ Elevation of urea and creatinine
‐ Contracture, thight mobility of joints

 IV stage – Recovery (from 5-6 weeks to a couple of years):

‐ Begins with a brief polyuria
‐ Refractory polyorgan patholoy with functional deficiency of organs
and systems
‐ Osteomyelitis, contractures, peripheral neuritis as sequele of
polynecrotic lesions

Diagnosis: Laboratory and instrumental

Treatment:
Pre-hospital:

 Tourniquet above área of compression  release victm and removal to

safe place  elastic bandage and release tourniquet
‐ Tourniquet is left in limb if:
‐ Destruction of limb
‐ Gangrene
‐ Sensitive and passive mobility absent
 Aseptic dressing to wound
 Stop external bleeding
 Remove shoes and cut clothes if edema
 Immobilization and transport
  Fluid replenishement

Hospital:

 Extracorporeal detoxification therapy and hemodialysis

 ICU:
‐ Correction of anemia – RBC transfusion suspension
‐ Replenishment of protein loss – frozen plasma, 10% albumin solution
‐ Metabolic acidosis – 4% sodium bicarbonate solution
‐ Hemostatic disorders – heparina
 Plasmapheresis (DIC)
 Faciotomy
‐ Severe progressive edema of limb
‐ Violation of tactile and pain sensitivity
‐ Lack of active movements in the limb
‐ Ineffectiveness of detoxication
‐ Purulent (anaerobic) infection
 Amputation
‐ Destruction of limbs
‐ Total ischemic necrosis (gangrene)
‐ Progressive wound and general infection with the failure of other
methods of treatment
‐ Repeated bleeding from the great vessels with extensive purulent

20. Moderns methods of medical immobilization: plaster casts, bandages,

orthoses, corsets (general characteristics, indications)

Plaster casts
Characteristics:
Plaster cast covers the whole of the circumference of the limb. Its thickness varies with
the type and location of the fracture
Fundamental principles to be remembered while applying a plaster cast:

 immobilize the joint above and below the fracture

 immobilize the joint in the functional position
 pad the limb adequately especially on the bony prominences
 mobilize the joints not included in the plaster

Indications:
 Fractures
 Severe sprains
 Dislocations
 Protection of post-operative repairs
 Gradual correction of a deformity with serial casting

Bandages
Characteristics:
Bandages are available in a wide range of types, from generic cloth strips to specialized
shaped bandages designed for a specific limb or part of the body. Bandages can often
be improvised as the situation demands, using clothing, blankets or other material.

Indications:

 Creating pressure
 Immobilizing a body part
 Reducing or preventing edema
 Securing a splint
 Securing dressings

Orthoses
Characteristics:
Brace, splint, or other artificial external device serving to support the limbs or spine or
to prevent or assist relative movement.

Indications:

 Pain relief
 Mechanical unloading
 Scoliosis managements
 Spinal immobilization after surgery
 Spinal immobilization after traumatic injury
 Compression fracture management
 Kinesthetic reminder to avoid certain movements

Corsets
Characteristics:
Corsets allow early mobilization of a patient, but they cause atrophy of the back’s
muscles. It is necessary regular kinesitherapy when fixation by corset

Indications:

 Acute attack accompanied by a strong painful syndrome as a result of pinching

nerve roots.
 Injuries that caused the displacement of vertebrate segments.
 Diseases resulting in violation of posture (scoliosis,).
 Prolonged static position of the vertebrae (seating, riding a car, a long pastime on
the legs).

21. Emergency care for open fractures of the bones of the limbs and
bleeding
At site of accident:

 Apply pressure to stop bleeding  by doing tourniquet proximally to the level

of fracture
 Wash the wound with tap water if it is dirty
 Fracture is splinted

Temporary stop of bleeding:

 Elevated position of the injuried extremity

 Direct pressure on the cut or wound (wound packing)
 Pressure bandage
 Pressure at pressure point
 Flexion of the limb in a joint
 Tourniquet

In emergency department wound care :

 Aseptic dressing of wound

 Analgesics
 Splintage
 Prophylactic antibiotics
 Tetanus and gas gangrene prophylaxis
 X-ray to be taken to evaluate the fracture
 22. Open and closed fractures of the metacarpals and phalanges (the
mechanism of injury, clinical features, treatment).

METACARPALS:

Mechanism:

The common causes are:

a fall on the hand

a blow on the knuckles (as in boxing)

crushing of the hand under a heavy object.

Common mechanisms of injury:

Direct trauma → transverse fracture

Torsional trauma → oblique or spiral fracture

Crush injury → comminuted fracture

Clinical features:

General signs: pain, swelling and tenderness ate site of affected metacarpal

Fracture signs: bone fragments, pathological mobility, creptation, deformity

Reduced range of motion at the carpometacarpal (CMC) and metacarpophalangeal joints

Palpable or visible bone and/or joint deformity:

 Angulation (mostly dorsal angulation → loss of the knuckle contour and/or pseudoclaw
deformity)
 Malrotation → digital overlap
 Shortening
 Displacement

Treatment:

 Conservative treatment
o Indication:
 Simple, closed, and stable metacarpal fractures
o Treatment options
 Closed reduction, if necessary
  Immobilization for approx. 4 weeks, depending on physical
examination findings
 1st metacarpal fractures: short-arm thumb spica splint
 2nd–4th metacarpal fractures: palmar wrist splint/cast
 5th metacarpal fractures: ulnar gutter splint/cast or twin taping to the ring
finger

 Surgical treatment
o Indication
 Open fractures
 Intraarticular fractures occupying > 25% of the articular surface
 Displaced fractures with a step-off of > 1 mm or subluxation/dislocation of
the CMC joint
 Deformities leading to functional impairment: severe angulation ,
shortening , or malrotation
o Treatment options: fracture fixation with K-wires, interfragmentary screws, or
mini plates

PHALANGES:

Mechanism:

fall of a heavy object on the finger or crushing of fingers.

Clinical Features:

General signs: pain, swelling and tenderness ate site of affected metacarpal

Fracture signs: bone fragments, pathological mobility, creptation, deformity

Reduced range of motion

Treatment:

Undisplaced fracture: finger strapping during 2 weeks

Displaced fracture: An attempt should be made to reduce the fracture by manipulation, and
immobilised in a simple malleable aluminium splint. Active exercises must be started not later
than 3 weeks after the injury. If displacement cannot be controlled by the above means, a
percutaneous fixation or open reduction and internal fixation using K-wire, may be necessary.
A comminuted fracture of the tip of the distal phalanx does not need any special treatment,
and attention should be directed solely to treatment of any soft tissue injury
23. Diagnosis and treatment of tendon injuries in the wrist and hand.
Diagnosis:
Testing for flexor tendons:
-Flexor carpi radialis injury: in palmar-flex of the wrist, hand goes toward the ulnar side
-Flexor digitorum profundus: ask patient to flex distal interphalangeal joint, it will not
be possible
-Flexor digitorum superficialis: hyperextension of other fingers and ask patient to flex
the finger being tested

Testing for extensor tendons:

-Metacarpo-phalangeal joint cannot be extended
X-ray and MRI
Treatment:
If your pain is affecting your ability to perform your daily activities, your doctor may
recommend a nonsurgical treatment such as:
-Avoiding using the injured area and pausing strenuous exercise is imperative during
rehabilitation.
-Putting a cold pack on the hand, wrist, or elbow tendon injury several times a day for
20 minutes at a time can help relieve pain and make movement easier.
-Physical therapy. Physical therapy is key, first to reduce pain and swelling and then to
increase strength and improve range of motion.
-Keep the injured hand, wrist, or elbow elevated when lying down.
-OTC medications. Over-the-counter pain relievers such as ibuprofen or naproxen can
relieve pain caused by hand, wrist, or elbow tendon injuries.
Surgical:
a) Primary repair, end-to-end, if it is a clean cut injury. In the finger if both flexor
tendons are cut, only the profundus tendon is repaired.
b) Delayed repair, reconstruction by tendon graft is performed if it is a crushed tendon.
The palmaris longus is the most commonly used tendon for grafting.
c) Tendon transfer: If a tendon cannot be reconstructed, or sometimes as a matter of
choice, another dispensable tendon can be transferred to its position, e.g., in rupture
of the extensor pollicis longus, the extensor indicis can be used.

24. Fractures of the wrist bone (mechanism of injury, clinical picture,

treatment scaphoid fractures).
SCAPHOID FRACTURES
Mechanism of injury:
Direct: fall onto outstretched hand or direct blow on palm
Indirect: punch or fall onto clinched fist

Clinical features:
-Slight edema and palpatory tenderness in region of radiocarpal articulation
-axial load along I and II fingers is painful
-movements in a joint are painful and limited, especially in dorsal and radial direction
-weakness of a catch of objects by the hand
-impossibility of complete compression hand to fist
Treatment:
First aid:
• Analgesic: non-narcotic (analgin) or narcotic analgesics (promedol) IM or IV
• Transport immobilization: thumb spica splint
• Transportation to the hospital
Without displacement:
-Immobilization 4-6 weeks (if tubercle fracture) with POP thumb cast
-Immobilization 10-12 weeks (fracture of body and distal 1/3 of navicular bone)
The hand is in position of slight flexion and radial deviation. The first finger
is fixated in position of moderate abduction
Surgical treatment:
Indications:
-fractures of the navicular bone with considerable displacement
-a delayed union
-a false joint
-aseptic necrosis
Operations:
-Autologous bone grafting by a bone nail
-Osteosynthesis by K-wires
Postoperative:
-Immobilization of a hand in mediumphysiological position during 6 – 8weeks
-exercise therapy
-physiotherapy
-laser therapy

25. Fractures of the radial bone in a typical place (the mechanism of

injury, diagnosis and treatment).

DISTAL RADIUS FRACTURES

Mechanism of injury:
-Fall on an outstretched hand (Colles fracture)
-Fall on a flexed wrist/direct blow to the back of the wrist (Smith fracture)
Fractures of the distal radius:
• Die-punch: A depressed fracture of the lunate fossa of the articular
surface of the distal radius
• Barton's: Fracture dislocation of radiocarpal joint with intra-articular
fracture involving the volar or dorsal lip (volar Barton or dorsal
Barton fracture)
• Chauffer's: Radial styloid fracture
• Colles‘: Low energy, dorsally displaced, extraarticular fracture
• Smith's: Low energy, volar displaced, extraarticular fracture

Clinical picture:
-Pain, tenderness and soft tissue swelling
-Reduced range of motion at wrist joint
-Wrist deformities:
Colles fracture: dorsally displaced and dorsally angulated fracture (bayonet or "dinner
fork" deformity
Smith fracture: “garden spade” deformity
Diagnosis:
-X-ray of the upper extremity
-CT – may be for intra-articular fractures
-Neurological examination can be performed to exclude conditions like carpal tunnel
syndrome
Treatment:
First aid:
1. Analgesic: non-narcotic (analgin) or narcotic analgesics (promedol)
IM or IV
2. Transport immobilization: Kramer's splint from upper 1/3 of arm to
the tip of the fingers
3. Transportation to the hospital

Conservative therapy
-Closed reduction while applying longitudinal traction through the fingers
-Dorsal forearm splint/casting and post-reduction x-rays
-Cast removal after 6 weeks
Extra-articular fractures:
• Colle’s fracture:

✓ Manipulation and casting with Colle’s cast

✓ If not enough; intra-focal wiring

• Smith’s fracture:

✓ Stability is difficult to achieve by casting and wiring; So,

plating is used
Intra-articular fractures –
• When there is significant articular displacement - formal open
reduction and fixation with plates and screws is beg performed
Surgical therapy
Indications:
-Open, significantly displaced, intra-articular, and/or unstable fractures
-Neurovascular damage
Procedures:
-Open reduction and internal fixation
-K-wire fixation
-Internal fixation with fixed-angle plates
-External fixation
Postoperative immobilization of the forearm and in a dorsal forearm splint

26. Fractures of the olecranon (mechanism of injury, clinical features,

treatment).
Mechanism of injury: usually the mechanism is direct (fall onto the point of the elbow)
Classification:
1.Mayo Classification:
Type I: Nondisplaced or minimally displaced, subclassified as either noncomminuted
(type 1A) or comminuted (type 1B). Treatment is nonoperative.
Type II: Displacement of the proximal fragment without elbow instability; these
fractures require operative treatment.
Type II A: Are noncomminuted, can be treated by tension band wire fixation.
Type II B: Comminuted and require plate fixation.
Type III: Instability of the ulnohumeral joint and require surgical treatment.
2.Colton classification:
A, Avulsion.
B, Oblique.
C, Transverse.
D, Oblique with comminution.
E, Comminuted.
F, Fracture–dislocation.
3.Schatzker classification:
Type A - Simple transverse fracture
Type B - Transverse impacted fracture
Type C - Oblique fracture
Type D - Comminuted fracture
Type E - More distal fracture, extra-articular
Type F - Fracture-dislocation

Clinical features:
Complaints: pain in the region of the olecranon, impossibility of movements in elbow
joint
General symptoms: arm is straightened; patient spares it, holding its healthy arm.
Edema and bruise. Palpatory tenderness. Passive movements is possible, but painful.
Active flexion is impossible
Authentic symptoms: at fracture with displacement is determined a fissure or a
retraction
First aid:
-Analgesic
-Transport immobilization: Kramer’s splint from the shoulder joint to the wrist joint
Treatment:
Conservative:
*only at fractures of the olecranon without displacement or with diastasis no more
than 2mm
-Plaster bandage
-Immobilization 4 week
-Exercise therapy on 2 day
-Xray control in 3-5 days and 4 week
Surgical treatment:
*fractures of the olecranon with diastasis between splinters more than 2mm
-Operation: open reposition, osteosynthesis by wires and tension-band wire
-Rehabilation: immobilization by cravat bandage during 4 weeks and exercise therapy

27. Diaphyseal fractures of the forearm bones (the mechanism of injury,

diagnosis and treatment).
Mechanism of injury:
Direct: blow to the forearm
Indirect: fall on the hand
Diagnostics:
Clinical picture:
The general symptoms: a pain, a swelling, a bruise (there can be a
fluctuation), increase of local temperature, lesion of function.
Authentic symptoms:
-deformation
-anatomical shortening of forearm,
-pathological mobility of splinters
-crepitation
-at open fractures it is possible a penetration of splinters in a wound
Classification:
Ulna fractures
• Monteggia fracture – fracture of upper 1/3 of the diaphysis of ulna
with dislocation of the head of the radius
1. flexion type – fracture angulation and radial head dislocation
anteriorly
2. extension type - fracture angulation and radial head dislocation
posteriorly
Radial fractures
• Galeazzi fracture – fracture of the distal 1/3 of diaphysis of radius
with dislocation of distal radio-ulnar joint

Treatment:

First aid:
1. Analgesic: non-narcotic (analgin) or narcotic analgesics (promedol)
IM or IV
2. Transport immobilization: Kramer's splint from the upper 1/3 of arm
to the metacarpophalangeal joints), elbow is flexed in 90’, in semipronated position of
the forearm
3. Transportation to the hospital
Conservative treatment:
-Closed reduction under general anesthesia and immobilization in an above-elbow
plaster cast
-Local anesthesia on the place of fracture
-If fracture segments are not displaced or displaced closed fracture– conservative
management with POP cast (from mid arm level to the tip of the fingers)

✓ Closed hand reposition if displaced

✓ Immobilization – 4 weeks

✓ X-ray control in 3 – 5 days and 4 weeks

✓ Exercise therapy on 2 days

Surgical treatment:
-Open reduction and internal fixation

✓ Immobilization during 4 weeks

✓ Exercise therapy

-Usually work-status is restored in 6 – 8 weeks in both conservative and surgical

management

28. Traumatic dislocation of the forearm (the mechanism of injury,

clinical features, treatment).
ELBOW DISLOCATION
Mechanism of injury:
Fall on an outstretched hand (most common) → posterior elbow dislocation
A posterior, direct trauma to a flexed elbow → anterior elbow dislocation
Medial/lateral trauma to the elbow → medial/lateral elbow dislocation
High impact trauma to the elbow → divergent elbow dislocation (radius and ulna
diverge from each other)
Classification:
Anatomical classification – based on the position of radius and ulna with respect to the
humerus:
-Posterior dislocation (most common)
-Anterior dislocation
-Medial dislocation
-Lateral dislocation
-Divergent dislocations (rare)
Presence of co-existent fractures
-Simple dislocation (no associated fractures)
-Complex dislocation (associated fracture)
Clinical features:
-Pain, swelling of elbow
-Limited range of motion: inability to flex or extend the elbow
-Elbow deformity
-Limb length discrepancy
-Nerve injury (up to 10% of cases)
Ulnar nerve palsy
Median nerve palsy
Radial nerve palsy or posterior interosseous neuropathy (depending on site of injury)
-Brachial artery injury (very rare)
Treatment:
Conservative:
Indication: simple elbow dislocation (no fracture)
Procedure: closed reduction and immobilization:
Position of the arm is abduction and semi-extension in the elbow joint,
• Traction is carried out along axis of the forearm by shoulder and hand,
• Reduction is carried out by pressure by thumbs on olecranon when
simultaneously shoulder is drawn back.

✓ Immobilization posterior plaster splint from proximal onethird of the shoulder to the
heads of the metacarpal bones at
flexion of forearm on the angle 90°

✓ Period of immobilization is 5 – 10 days

✓ Next rehabilitation: exercise therapy, physiotherapy

Surgical:
Indication: complex elbow dislocation (concomitant fracture); failed closed reduction;
joint instability post-reduction; vascular injury
Procedure:
-Closed reduction of elbow
-Open reduction and internal fixation of the fractured segments and repair of the torn
medial and/or lateral collateral ligaments of the elbow
-Immobilization of the elbow in a posterior splint or bracein pronation and 90° flexion
for 3 weeks
B) Monteggia fracture-dislocation:
This is a fracture of the upper-third of the ulna with dislocation of the head of the
radius. It is caused by a fall on an out-stretched hand.
Diagnosis - easily confirmed on X-rays.
Treatment
• This is a very unstable injury, frequently redisplacing even if it has been reduced
once. One attempt at reduction under general anaesthesia is justified. If reduction is
successful, a close watch is kept by weekly check X-rays for the initial 3-4 weeks.
• In case, the reduction is not possible or if redisplacement occurs, an open reduction
and internal fixation using a plate is performed. The radial head automatically falls into
position, once the ulna fracture is reduced.
C) Galeazzi fracture-dislocation
• This injury is the counterpart of the Monteggia fracture-dislocation. It commonly
results from a fall on an out stretched hand.
Diagnosis
• In an isolated fracture of the distal-half of the radius, the distal radioulnar joint must
be carefully evaluated for subluxation or dislocation.
Treatment
• Difficult to achieve and maintain perfect reduction by conservative methods (except
in children). Most adults require open reduction and internal fixation of the radius with
a plate.

29. Diaphyseal fractures of the arm (mechanism of injury, diagnosis,

treatment).
Mechanism of injury:
Direct: direct blow/injury
Indirect: twisting or bending force; fall on out-stretched hand
Diagnosis:
Clinical features: signs and symptoms of fracture; wrist drop may be present if the
radial nerve is injured
X-ray of whole arm including shoulder and elbow
Treatment:
Conservative:
-U-slab (plaster slab extending from base of neck, over the shoulder onto lateral aspect
of arm)
-Hanging cast
-Chest-arm bandage
Surgical treatment:
Indications: failure of closed treatment; associated articular injuries; vascular injuries;
pathological fractures; open fractures
-Plate osteosynthesis via a posterior or anterolateral approach
-Intramedullary nail
30. Fractures of the surgical neck of the humerus (mechanism of injury,
diagnosis, treatment).

Mechanism of injury:
Direct: direct blow and fall on shoulder
Indirect: fall with the hand

Classification – Neer:
4 main classifications: (1)head, (2)lesser tubercle, (3)greater tubercle, (4)fragment
below of fracture of a surgical neck
Diagnosis:
-Clinical picture (signs of fracture)
*can damage axillary nerve and posterior circumflex humeral artery
-X-ray

Treatment:
One-part fracture:
-treat by immobilization for 1-2 weeks
-rehabilitation: passive exercises; active exercises (including stretching); exercises with
resistance

Two-part fractures:
Surgical neck
-closed reduction can be attempted – axial traction, adduction and flexion, impact
-surgical treatment
Three-part fractures:
-non-operative (only for infirm patients)
-closed reduction and percutaneous pinning requires special technique
-operative: T-platestrong fixation in good bone only, hardware impingement; tension
band figure-of-eight (+intramedullary nail); immediate hemiarthroplasty

Four-part fractures:
-hemiarthroplasty

31. Traumatic shoulder dislocation (mechanism of injury, clinical

features, treatment).

Mechanism of injury:
Direct: direct force pushing the humerus head out of the glenoid cavity; direct blow on
the front of the shoulder
Indirect: fall on and out-stretched hand with the shoulder abducted and externally
rotated

Classification:
-By the time elapsed since injury: (a) fresh up to 3 days (b) stale from 3 days to 3 weeks
(c) chronic over 3 weeks
Anterior dislocations:
Head of humerus lies anterior to the glenoid fossa
Subtypes position of the humeral head:
-Subcoracoid (anterior to glenoid fossa but inferior to coracoid process)
-Subglenoid (anterior and inferior to glenoid fossa)
-Subclavicular (anterior to glenoid fossa and medial to coracoid process)
-Intrathoracic

Posterior dislocations:
Head of humerus lies posterior to the glenoid fossa
Subtypes position of the head:
-Subacromial (beneath acromion)
-Subglenoid
-Subspinous (medial to acromion and beneath the scapula)

Inferior dislocations (luxation erecta)

Head of humerus sits just beneath the glenoid fossa
Clinical features:
-Severe shoulder pain
-Inability to move shoulder
-Patient will be with his shoulder abducted and the elbow supported with the opposite
hand *book
-Normal round contour of the shoulder joint is lost and becomes flattened
-Empty glenoid fossa
In anterior dislocation:
-Humeral head can usually be palpated below the coracoid process
-Arm is held in external rotation and slight abduction
In posterior dislocation:
-Prominence of the posterior shoulder with anterior flattening
-Prominent coracoid process
-Arm is held in adduction and internal rotation
**can damage axillary nerve, brachial plexus, axillary artery
Treatment:
*reduction under sedation or general anesthesia, followed by immobilization of the
shoulder
Local anesthesia with novocaine
Reposition techniques:
1.Leverage techniques:
-Kocher’s
-Milch
-External rotation
2.Methods of traction:
-Hippocrate
-Stimsom
-Matsen’s Traction Counteraction
-Spaso
-Eskimo
-Manes
3.Scapular manifestations
Immobilization (plaster splint, headband desault, velpeau vandage, scarf bandage) -> 4
weeks
Rehabilitation – limiting the physical load up to 8 weeks, massage, physiotherapy

Indications to surgical treatment:

-irreducible dislocation
-damage to major blood vessels and nerve trunnks
-fracture of surgical neck of humerus
-recurrent dislocations

 Arthrotomy, open reduction of dislocation, chrezsustavnaya (?) fixing

spokes
32. Fractures of the distal humerus metaepiphysis (mechanism of
injury, clinical features, treatment).
Mechanism of injury:
Direct: direct blow
Indirect:
Lateral epicondyle: varus stress is applied to the extended elbow with the forearm
supinated; fall onto the extended hand leads to impaction of the radial head into the
condyle or vice-versa
Medial condyle: a fall on the palm of an outstretched arm, with the elbow forced into
valgus; a fall on the point of the elbow (apex of the flexed elbow), with the olecranon
driving the medial condyle proximally and medially; avulsion fracture due to violent
contraction of the flexor and pronator muscles that attach to the medial epicondyle,
such as that which occurs in arm wrestling
Medial epicondyle: pure avulsion injury produced by the flexor muscles of the forearm;
dislocation of the elbow

Clinical features:
-Elbow pain and swelling
-Instability of the elbow
-Pathological mobility
*brachial artery may be injured

Supracondylar fracture:
-Unusual posterior prominence of the point of the elbow because of the backward tilt
of the distal fragment
-three bony points relationship is maintained as in a normal elbow.
Lateral condyle fracture:
-Symptoms are not much
-There is mild swelling and pain over the outer aspect of elbow

Intercondylar fracture:
-There is generally severe pain, swelling, ecchymosis and crepitus around the elbow

Medial epicondyle:
-Commonly associate with posterior dislocation and may be associated with an ulnar
nerve injury

Treatment:
Supracondylar fractures:
Undisplaced fractures requires immobilization in and above-elbow plaster slab with
elbow in 90
Displaced fractures:
-closed reduction and percutaneous K-wire fixation
-open reduction and K-wire fixation
-continuous traction
-fixation of both condyles at a Y-turn
*injury to brachial artery; median nerve and radial nerve can be
Lateral condyle fracture:
Undisplaced fracture: support in above-elbow plaster slab for 2-3 weeks
Displaced fractures: open reduction and internal fixation using two K-wires

Intercondylar fracture:
Undisplaced fracture: support in an above-elbow plaster slab for 3-4 weeks, followed by
exercises
Diplaced fracture: open reduction and internal fixation

Medial epicondyle fracture:

Undisplaced fracture: support in an above-elbow plaster slab
Diplaced fracture: open reduction and internal fixation

33. Damage to the acromioclavicular joint - dislocation of the acromial

end of the clavicle (mechanism of injury, clinical features, treatment).

Mechanism of injury:
Direct: a traumatic strength in the acromioclavicular joint tha leads to a strength
reaction of the clavicle
Indirect: a traumatic strength of the humerus in the glenoid cavity (of the shoulder
joint) leading to a strength reaction of the clavicle

Clinical features:
General symptoms: pain, swelling, bruise, increase of local temperature, lesion of
function
Authentic symptoms: shortening of a shoulder girdle, deformation of shoulder girdle
(prominent acromial end of clavicle over acromion), pathological mobility of an
acromial end of clavicle
Diagnosis: X-ray -> luxation of an acromial end of a clavicle
Treatment:
-Analgesics
-Dressings (devices, splints) in which reduction of the clavicle is combined with lifting
of the shoulder girdle 2-3 weeks
-Surgical treatment is indicated if rupture of acromio-clavicular ligament, joint capsule
and coraco-clavicular ligaments

34. Fractures of the clavicle (mechanism of injury, diagnosis,

treatment).
Mechanism of trauma:
-Direct: blow on clavicle
-Indirect: fall on shoulder joint or outstretched hand
Birth trauma: clavicle compressed against maternal symphysis in a cephalic
presentation
Classification:
1.In relation to localization of fracture:
-acromial end
-distal third
-middle third
-proximal third
-sternal end

Diagnosis:
Clinical:
General symptoms: pain, swelling, bruise, increased of local temperature, lesion of
function
Authentic symptoms: appearance of bone’s fragment (in open fractures), pathological
mobility, crepitus, deformation and shortening
*usually there is displacement upwards because of the pull by sterno-cleidomastoid
muscle
*may injure subclavian vessels or brachial plexus
Imaging:
X-ray
First aid:
-Stop bleeding if present
-Analgesics
-Transport immobilization (Kramer’s splint from the healthy shoulder joint to the wrist
joint)
-Transportation to the specialized hospital
Treatment:
Without displacement:
-Analgesics
-Immobilization (3-4 weeks) – cravat bandage, Desault’s bandage; for young active
patients it’s necessary to apply Desault’s plaster bandage or plaster splint
-During immobilization carry out active and isometric exercise therapt, physiotherapy
-Rehabilitation after consolidation and removal of bandage: exercise therapy, massage,
physiotherapy 1-2 weeks
*X-ray control for 3-5th day and in 3-4 weeks after remove immobilization

With displacement:
-Anesthesia (novocaine block)
-Reposition – super abduction of the shoulder girdles and lifting shoulder
-Immobilization (4-6 weeks) – figure-of-eight bandage, Smirnov-Vanshtein’s bandage,
Delbe’s ring
-During immobilization carry out active and isometric exercise therapt, physiotherapy
-Rehabilitation after consolidation and removal of bandage: exercise therapy, massage,
physiotherapy 2-3 weeks
*X-ray control for 3-5th day and in 4-5 weeks after remove immobilization
Surgical treatment:
Indications:
-open fractures
-damage by bony splinter of big vessels and nerves
-damage by bony splinter of pleura
-danger of perforation of the skin
-displacement of the splinters (relative)
Options:
-Intramedullary osteosynthesis
-Extramedullary osteosynthesis
-Rod-shaped apparatus of extrinsic fixation

35. Rib fractures (mechanism of trauma, diagnosis, treatment).

Mechanism of injury:
Direct: blow from the front, side or back
Indirect: Fracture of clavicle that lead to ribs fracture, anteroposterior compression that
leads to fracture on the lateral or lateral compression that can lead to fracture on
anterior or posterior side

● Clinical features
○ Pain on inspiration
■ Respiratory distress
■ Tachypnea
■ Shallow breaths
○ Crepitus
○ Diagnostics
○ Chest x-ray (AP and lateral view)
■ Fracture lines
■ Displaced fractures
 ○ CT: if complications are suspected
● Treatment
○ Usually no surgery necessary
○ Analgesia
■ NSAIDs
■ Opiates
■ Local nerve block or epidural catheter
○ Intubation with positive pressure ventilation in severe flail chest
(bridge to surgery)
○ In case of pneumothorax or hemothorax: thoracic drainage and
thoracic surgical intervention
○ Indications for surgery
■ Significant chest wall deformity
■ Severe flail chest
■ Nonunion

36. Rib fractures (unstable ribcage – Flail chest). The mechanism of

injury, diagnosis, first aid, treatment.

○ Flail chest

■ Multiple (≥ 3) rib fractures in 2 or more places

■ Resulting in a floating section of ribs and soft tissue within

the chest wall
■ Paradoxical movement: the floating segment moves
inward during inspiration and outward during expiration
○ Focal chest wall tenderness
○ Chest wall deformity
37. Diagnosis and treatment tactics for fractures of the ribs,
complicated by closed hemothorax.

Traumatic hemothorax:

● Clinical features
○ Dyspnea and diminished/absent breath sounds
○ Decreased tactile fremitus, dullness on percussion
○ Chest pain
○ Flat neck veins, hemorrhagic shock and respiratory distress in severe
hemorrhage
○ Chest wall deformity
○ Paradoxical chest wall movement
○ Crepitus on palpation
● Diagnostics
○ Chest x-ray : similar appearance to pleural effusion
■ Opacity
■ Blunting of the costophrenic angle
■ Tracheal deviation (mediastinal shift)
○ Ultrasound: detection of smaller amounts of fluid/blood than on
chest x-ray possible
■ A hyperechogenic signal is first seen in the
costodiaphragmatic recess.
■ Commonly used in the FAST protocol for trauma
assessment
● Treatment
○ Chest tube insertion into the 5th intercostal space at the midaxillary
line
○ Thoracotomy indicated if
■ Chest tube output > 1500 mL immediately after placement
or 200 mL/hour for 2–4 hours [5]
■ Multiple transfusions required
38. Penetrating chest wounds, complicated by an open pneumothorax.
Characteristics and clinical picture.

Characteristics:

Open pneumothorax: air enters through a lesion in the chest

wall (e.g., following penetrating trauma)
 Air enters the pleural space on inspiration and leaks to
the exterior on expiration.
 Air shifts between the lungs  On inspiration, air from
the collapsed lung may enter the unaffected lung. On
expiration, air from the healthy lung returns to the
collapsed lung, causing it to re-expand.

Clinical Picture:

 Sudden, severe, and/or

stabbing, ipsilateral pleuritic chest pain and dyspnea
 Assymetrical chest, increased affected part of chest, smoothing intercostal
spaces, lagging of affected side of chest.
 Reduced or absent breath sounds, pathological metalic bronchial breathing
 Hyperresonant percussion
 Decreased fremitus on the ipsilateral side
 Subcutaneous emphysema

39. Stable and unstable fractures of the vertebrae (the mechanism of

injury, diagnosis and treatment).

Stable fractures:
injuries that have not tend to further displacement of the vertebrae
cuneiform compression of the vertebra until half of height of the corpus
avulsion of anterior-superior angle of the corpus of the vertebra
fracture spinous and transversal projections
Unstable fractures
injuries that have tend to further displacement of the vertebrae
fracture-dislocations with injury posterior supporting complex
cuneiform compression of the vertebra > ½ height of the corpus
“explosive” multifragmentation fracture

Treatment for stable injuries

Conservative:
Immobilization – hard surface of the bed (sheet)
Traction – extension on inclined plane
Reclination – reclinator (shaft) under place of the injury
medical exercises
physiotherapy
Massage

Treatment of unstable fractures

Surgery options: Open reposition and fixation by transpediculate spondylodesis

Mechanism of trauma

Usually is indirect
compressed
flexional
extensional
torsion
Combination

40. The clinic, treatment of fractures of the pelvis. Methods of treatment

of fractures of pelvic bone with the damage of the pelvic ring.
Pelvic ring is composed by: iliac bones, pubic bones, ischium and sacrum bones

Mechanism of injury:

Direct: a blow from the side – the fracture of wing of iliac bone or acetabulum a blow
from the front – the fracture of kind “butterfly”, rupture of pubic symphysis a blow from
behind – rupture of iliosacral syndesmosis, the fracture of sacrum
Indirect:

Young and Burgess system

Tile classification
Classification fractures of acetabulum

Complete – Incomplete
With displacement – Without displacement
With dislocation of thigh bone – Without dislocation of thigh bone

The judet letournel classification says there are 10 fracture patterns, 5 elementary and
5 associated based on degree of columnar damage
Clinical diagnosis of fracture of pelvis:

Complaints
Anamnesis
Appraisal of general condition of a patient including the clinic of traumatic shock, pseudo
abdominal syndrome
Local medical examination :
The general symptoms of damage: pain, swelling, bruise (may be a fluctuation),
increased local temperature, loss of function.
Significant symptoms of fractures: pathological mobility of fragments, crepitus,
appearance of bone’s fragments in a wound by open fractures, deformation.
First aid:
Analgesics: narcotics, if no close trauma of abdomen and (or) cerebral trauma,
analgetics, narcosis
Immobilization: on hard stretcher in the Volcovich’s pose (frog's)
Pneumatic antishock suit with clinic of shock (e.g. “PASG”, “Kashtan”)
Infusion therapy glucose, solution of Ringer, rheopolyglucin
Transportation in hospital

spital
41. Differential diagnosis of damage intra-pelvic organs in fractures of
the pelvic bone.
Bladder
Mechanism of trauma:
1) damage by splinters
2) damage as a result of strain of the ligaments of the urinary bladder
Types of damage:
1) bruise, hematocyst
2) partial rupture
3) full rupture a) intra-peritoneal b) extra-peritoneal ruptures.
Clinic: anuria, haematuria, symptom Zeldovich, peritonitis (by intraperitoneal ruptures).
Diagnostic: catheterization of bladder, urography, uroscopy

Ruptures and injuries of an urinary bladder are indicated to urgent surgical treatment
with a possibility of preoperative preparation and anti shock therapy during 1st 6 hours.
inspection urinary bladder, wound (defect) closure, draining of a pelvic cavity and
urinary bladder.
1 – cystostomy tube,
2 – paracystic tube,
3 - paracystic tube trans counteropening

Injuries of the urethra:

Isolated injuries (60%) More common in men More often as a result of traffic accident
or falling from high places: direct compression on perineum opposite of pubic arch

Diagnosis of injury to the urethra:

pain in perineum impossibility of an independent diuresis urethrorrhagia (blood in the

urine) hematoma of perineum, scrotum, internal surfaces of femurs retrograde
urethrography rectal digital inspection infusion urography
Urgent operation with possibility of preoperative preparation (during first 6 hours)
cystotomy, retrograde conduction of a permanent catheter primary urethroplasty
epicystostomy with further deferred urethroplasty

Injury to rectum or vagina- disruption of the perineum with damage to the rectum or
vagina.

• Injury to major vessels:- The common iliac artery or one of its branches may be
damaged by a spike of bone.

• Injury to nerves: paralysis, can be permanent, The damage may be caused by a

fragment pressing on the nerves, or by stretching.

• Rupture of the diaphragm- breathing trouble or pain in the upper abdomen, X-ray of
the chest

42. Traumatic dislocation of the hip (mechanism of injury, clinical

features, treatment).
DISLOCATION OF THE FEMUR
5% of all dislocation
Usually with athletic people 20 – 50 age
Usually the mechanism of trauma is indirect

Posterior dislocation of hip/ dash board injury

The head of femur is pushed out of the acetabulum posteriorly
Its usually associated with the chip fracture of the posterior tip of the acetabulum, which
is called fracture dislocation

Mechanism:
1.The injury is sustained by violence directed along the shaft of the femur with hip flexed
2.Moderate to severe force is required to cause this type of injury
3.Usually seen I road traffic accident
4.The occupants of the car are thrown forwards and his knee strikes against the dash,this
force is transmitted up to the shaft resulting in posterior dislocation of the hip, hence it
is called dashboard injury.

Clinical features:
1.History of trauma is present
2.Pain
3.Swelling
4.Deformity: flexion, adduction and internal rotation
5.Short limb
6.Head is felt in the gluteal region

Investigations: x ray
Femoral head is seen outside of the acetabulum
Thigh is internally rotated so that lesser trochanter becomes less prominent
Shenton’s line is broken: its an imaginary line which is semi circular joining the medial
cortex of the femoral neck to lower border of the superior pubic ramus

Treatment: it should be treated as an emergency, as greater the time the head of femur
is outside of the acetabulum greater the chance of avascular necrosis
1.Closed reduction under general anesthesia
2.Open reduction is done if: closed reduction fails, there is an extra-articular loose
fragment not allowing concentric reduction or the acetabular fragment is large and is
the weight bearing part
Types of the femur’s dislocations
a. iliac (posterior superior)
b. sciatic (posterior inferior)
c. pubic (anterior superior)
d. obturative (anterior inferior)
e. central

Thompson and Epstein classification of posterior hip dislocation

Type I- simple dislocation with or without an insignificant posterior wall fragment
Type II- dislocation associated with a single large posterior wall fragment
Type III- dislocation with a comminuted posterior wall fragment
Type IV- dislocation with fracture of the acetabular floor
Type V- dislocation with fracture of the femoral head

Epstein classification of anterior hip dislocation

Type I- superior dislocations, including pubic and subspinous
Type IA- no associated fractures
Type IB-associated fracture or impaction of the femoral head
Type IC- associated fracture of the acetabulum
Type II- inferior dislocations, including obturator and perineal
Type IIA- no associated fractures
Type IIB- associated fracture or impaction of the femoral head
Type IIC-associated fracture of the acetabulum

Clinica of anterior dislocation:

Pain
Impossibility of active and passive movement
Characteristic position of extremities (depending on type of dislocation)
Displacement of greater trochanter relatively of the line Rozer-Nelaton
Relative shortening limb (at superior dislocations)
The Treatment
Narcosis
Reduction
Prolonged unloading of a joint (skeleton extension, walking on crutches)

43. Fractures of the femoral neck (mechanism of trauma, clinical

features, treatment).
Mechanism of trauma:

Direct: low energy falls in the elderly

Indirect: usually in younger patients, after a substantial height or motor vehicle accidents
where the initial blow is usually on the knee
Classification:

1) Intracapsular - fracture of neck

2) Extracapsular - intertrochanteric fracture
Anatomical classification of fracture of the neck of femur:

1) Basicervical
2) Transcervical
3) subcapital

Pauwel’s classification:

Depends on Pauwel’s angle, which is the angle between fracture line and horizontal line

Grading:

1.Grade 1: 30 degree

2.Grade 2: 50 degree

3.Grade 3: 70 degree Greater the angle worst is the prognosis

Gardner’s classification:

This is based on displacement of the fracture

Degree of displacement is judged from change in direction of medial trabecular stream in
head, neck of the femur and acetabulum

Grading:

Grade 1: incomplete fracture of head tilt present postero medially

Grade 2: complete fracture but no displacement

Grade 3: complete fracture with partial displacement

Grade 4: complete fracture + full displacement

Pathanatomy:

Most of these fractures are displaced

Thigh comes to lie in the position of external rotation,adduction and proximal migration
Displacement is also seen in the case of intertrochanteric fracture and is more here because in
the case of intracapsular fracture, the joint capsule is attached to the distal fragment which
prevents displacement and vice versa

Investigations: x ray of both the hips are taken.

The following can be made out from x ray:

1.Break in the medial cortex of the neck

2.External rotation of the hip is evident- lesser trochanter becomes more prominent

3.Over riding of the greater trochanter so that it lies at the level of the head

4.Break in the trabecular stream

5.Break in the shenton’s line

Diagnosis

Characteristic history, unable to bear weight on affected limb

Limb shortened , externally rotated, painful syndrome, decreased range of motion of the hip

Obtain AP x-ray of pelvis and lateral of involved hip

If findings equivocal – bone scan and tomograms

Treatment: it is called unresolved fracture because of high incidence of complications

Treatment is difficult for several reasons: blood supply to the proximal fragment may be
impaired, difficult to achieve reduction and maintain the fracture because the proximal
fragment is too small usually

A.Impacted fracture neck of femur:

Treatment is by conservative line In children by using hip spica Immobilize using Thomas splint
Internal fixation

B. In displaced fractures or unimpacted ones:

Aim is to achieve union In elderly patients above 60 years old, usually requires internal
fixation. In younger patients presenting late, the following can be done:

a.Open reduction of fracture

b.Closed reduction under X ray guidance

c.McMurray’s osteotomy

d.Meyer’s osteotomy

e.Pauwels osteotomy

f.Hemiarthroplasty

g.Internal fixation

Surgical Indication and Choices

a) Femoral neck fractures reduced anatomically possibly to fix with 3 pins or screws.
b) b) Displaced femoral neck fractures are treated according to the age and functional
demands of the patient.
c) These fractures are at high risk for AVN (12% to 33%) and nonunion (15% to 33%).
d) In healthy, active patients the treatment of choice is anatomical reduction, which must
be achieved for a good result, with internal fixation
e) If a satisfactory closed reduction is not achieved, an open reduction is indicated
f) A prosthetic replacement may also be helpful in patients with hip arthritis and femoral
neck fractures.

Surgical Techniques

Femoral neck pinning. Placement of multiple screws across the fractured femoral neck is the
treatment of choice for femoral neck fractures, and may be performed following either closed
or open reduction using a standard lateral approach or a more limited percutaneous
technique.

44. Trochanteric fractures of the femur (the mechanism of injury,

clinical features, treatment).
Intertrochanteric fracture

Definition: fracture in the inter trochanteric region of the proximal femur, involving the greater
or lesser trochanter or both are grouped in this category

Mechanism: in elderly, it is due to fall or blow on the greater trochanter In young, it is due to
severe trauma as in RTA (road traffic accident)

Inter trochanteric fracture

Pathoanatomy: the distal fragment rides up so that the femoral neck shaft angle is
reduced(coxa vara) The fracture is usually comminuted and displaced.

Clinical features: patient has history of fall or trauma, pain in groin region, inability to move
the affected leg, swelling in hip region, leg is short and externally rotated, tenderness

Boyd & Griffin classification( intertrochanteric)

Type 1: nondisplaced intertrochanteric fractures

Type 2: communited intertrochanteric fractures

Type 3: communited intertrochanteric fractures with subtrochanteric extension

Type 4: reverse obliquity fracture

Evans classification( intertrochanteric)

Type 1: fracture line extends upwards and outwards from the lesser trochanter( stable). Can be
divided into:

Type 1a: undisplaced two fragment fracture

Type 1b: displaced two fragment fracture

Type 1c: 3 fragment fracture without medial support

Type 1e: 4 fragment fracture without postero-lateral and medial support

Type 2: fracture line extends downwards and outwards from the lesser trochanter( reversed
obliquity/ unstable
Russel-Taylor classification( subtrochanteric)

Type 1: no extension into piriformis fossa

Type 2: extension into greater trochanter with involvement of piriformis fossa

Diagnosis

Characteristic history, unable to bear weight on affected limb

Limb shortened, externally rotated, painful syndrome

X-ray AP of pelvis and lateral of involved hip If findings equivocal – bone scan and tomogRAM

treatment:

conservative:

russell's traction and skeletal traction with thomas splint

operative method:
fracture is reduced under x ray control and fixed with internal fixation devices, open
repositioning internal fixation osteosynthesis by dynamic hip screws and Ender's nails.

complications: malunion , osteoarthritis

Subthrochanteric fracture

Etiology:

1.Often traumatic

2.Pathological causes such as carcinomatous metastatic deposit, Paget’s disease in elderly,

bone cyst in youngsters
3.Clinical features: similar to fracture neck of femur, lower limb is externally rotated,
tenderness and crepitus below greater trochanter

Investigations: X ray. Fracture line below the trochanters Fracture line may be transverse or
oblique Upper end is often abducted by gluteal muscle and flexed by psoas Lower end shifts
medially and upwards

Treatment:

Conservative: if the general condition of the patient is good then use Thomas splint

Internal fixation, if general condition of patient is poor. In high subtrochanteric fracture use
McLaughlin nail. In low subtrochanteric fracture use Kuntscher intramedullary nail.

Complications:

Nonunion

Malunio

AVN

osteoarthritis

45. Diaphyseal fractures of the femur (the mechanism of injury, clinical

features, treatment).
pathoanatomy:

fracture shaft of femur is equal in all three regions: upper, middle and lower 1/3rd of femur it
can be transverse, oblique, spiral or comminuted fracture mechanism:

direct trauma: road accident

indirect injury: twisting force that is transmitted to shaft pathological fracture

Displacement:

common in adults than in children

in fracture upper 1/3rd of the shaft: proximal fragment is flexed, abducted, externally rotated.
distal fragment is adducted,externally rotated and proximally migrated

in fracture middle 1/3rd of the shaft: distal fragment is displaced backwards with backward
angulations.

clinical features:

history of trauma

pain

swelling

deformity

abnormal mobility

patient is usually in hemorrhagic shock

lower limb is short and externally rotated

tenderness and crepitus

Classification

Winquist and Hansen classification

Type 0: no comminution

Type 1: insignificant amount of comminution

Type 2: greater than 50% cortical contact

Type 3: less than 50% cortical contact

Type 4: segmental fracture with no contact between proximal and distal fragment
Clinical features:

General damage: pain, a swelling, a bruise (there can be a fluctuation), increase of local
temperature, lesion of function. Can be the clinic of the shock The bloodloss can be 500 – 1200
ml for open fractures and 2000 ml and more

Pathognomonic symptoms of fractures: appearance of bone’s fragments in a wound (only for

open penetrating fractures), pathological mobility of fragments, crepitus, deformation,
anatomic (true) shortening segment of extremity.

Diagnosis: X-ray in direct projection of upper and middle thirds and lateral projection of lower
and middle thirds

Pre-hospital medical aid on a place of incident

Anaesthesia – usually narcotic analgesics

Immobilization – Diterix’es splint

Infusion therapy – for clinic of shock or for the threat of development it

Transportation to the hospital

Possible algorithm of the hospital treatment for close fracture

Urgent hospitalization

Novocaine blockade of the place of the fracture (for blood pressure > 70 mmHg)

Infusion therapy as prophylactic or treatment of traumatic shock

Skeletal extension as temporary immobilization for preparation to operation

Optimal period of an operation

– the first three days

For grave shock or any complication

– operation at 12 – 14 days
investigations:

x-ray of whole femur and pelvis is to be taken. fracture can be transverse, oblique, spiral or
comminuted variety.

treatment:

conservative: traction with or without splints.( Thomas splint, skin traction for children, bone
traction for adult bone), hip spica( it is a plaster cast incorporating part of the trunk and the
limb)

operative: closed or open reduction with internal fixation is the operation of choice( closed
intramedullary nailing, interlocking nail, kuntscher clover leaf intramedullary nail, plating)
46. Damage to the ligaments of the knee (mechanism of injury, clinical
features, treatment).
Four principal ligaments play the basic part in ensuring of the stability of the knee: anterior
cruciate ligament (ACL), posterior cruciate ligament (PCL), lateral collateral ligament (LCL),
medial collateral ligament (MCL).

The mechanism of trauma is indirect

Fresh ruptures of the ligaments of the knee are difficult to diagnose because they are
accompanied by hemarthrosis, reflecting contraction of the muscles, forced position of the
limb. The mechanism of trauma when injury of the lateral ligament of the knee: combination
of the movements of abduction in extended position of the leg with it interior rotation.

Basic symptom of injury the lateral ligaments is deviation of the leg: abduction and adduction.
when rupture LCL – adduction; when rupture MCL – abduction

diagnosis
Examination of inter articulating space

Palpate meniscus and flex the leg •

Injuries of ligament will intensify the pain

Rotatory symptoms with stress test

Palpate meniscus and flex laterally(internal rotation) and medially (external rotation)

Lachman's test

Lachman's test most sensitive exam test grading

• A= firm endpoint, B= no endpoint

• Grade 1: < 5 mm translation

• Grade 2 A/B: 5-10mm translation

• Grade 3 A/B: > 10mm translation

ROM and Stability

valgus stress testing at 30 degrees knee flexion

• isolates the superficial MCL

• medial gapping as compared to opposite knee indicates grade of injury

1- 4 mm = grade I

5-9 mm = grade II

> or equal to 10 mm = grade III

valgus stressing at 0 degrees knee extension

• medial laxity with valgus stress indicates posteromedial capsule or cruciate ligament injury

Posterior Drawer Test (at 90° flexion)

• with the knee at 90° of flexion, a posteriorly-directed force is applied to the proximal tibia
and posterior tibial translation is quantified

isolated PCL injuries translate >10-12 mm in neutral rotation and 6-8 mm in internal rotation
combined ligamentous injuries translate >15 mm in neutral rotation and >10 mm in internal
rotation

• most accurate maneuver for diagnosing PCL injury

FIRST AID

Self-help treatment For the first 48-72 hours think of:

Paying the - Protect, Rest, Ice, Compression, Elevation; and

Do no - NO Heat, Alcohol, Running or Massage

Basic symptom of injury the cruciate ligament is symptom of “sliding box” - anterior sliding for
anterior cruciate and posterior sliding for posterior cruciate

Treatment when partial rupture of the ligaments is usually conservative

Puncture of the knee, aspiration of the blood

Immobilization about 3 weeks

Medical exercises: at first isometric and passive exercises, then active exercises

Physiotherapy

Massage

Treatment when complete rupture of the ligaments may be

non-operative or operative non-operative treatment is the same, bat immobilization is

continued about 6 weeks

operative treatment:

a) reinsertion,

b) suture of the ligaments,

c) transosseous fixation,

d) fixation of osseous plate by screw

Treatment when chronic instability of the knee is operative

a) flap plastic of injuring ligaments by local tissues

b) free autoplastic of injuring ligaments

c) alloplasty of injuring ligaments

47. Fractures of the patella (the mechanism of injury, clinical features,

treatment).
Anatomical peculiarities of the fractures of the patella

•Usually the fractures are intra articular (except the fracture of the lower pole)

•Usually there are damaged ligamentous apparatus (to various extent)

•Upper pole of the patella is displaced upwards (as a consequence of contraction of the
muscle quadriceps femur

Mechanism of injury:

Direct: the most common due to fall on the knee or hitting the wheel during a car accident

Inditect: seldom, excessive contraction of the muscle quadriceps femur

Basic symptoms of the fractures of the patella

Local signs: pain, swelling, hyperemia,increase temperature, loss of function

Specific sign

• Palpation designate the diastasis among splinters

• Pathological mobility of fragments

• Impossibility raising of straightening leg

• Hemarthrosis

• Unable to do extension

Diagnosis

Physical exam

• palpable patellar defect

• significant hemarthrosis

• unable to perform straight leg raise indicates failure of extensor mechanism

• retinaculum disrupted xray

first aid

Analgesics – Analgin (IM)

Immobilization by kremer splint

• From gluteal fold to foot posteriorly

Transport to hospital

The treatment for the fractures with diastasis between splinters more 2 mm

Urgent hospitalization

Urgent operation (optimal period is the first three days)

Osteosynthesis joining wire is the method of the choice

Immobilization is not required for stable osteosynthesis

Medical exercises: isometric contraction of the muscle quadriceps of the femur next day,
active movement in two week

Extra Articular: Avulsion

Lower pole avulsion fractures-nonarticular. a thin shell of bone may be avulsed from the distal
patella together with the patellar tendon (“sleeve” fracture).

require surgical fixation such as:

• Open reduction; salvage techniques

• Open reduction; sleeve fracture fixation

• Open reduction; krackow whip stitch - suture repair

Extra Articular: Isolated

Nonoperative treatment is often appropriate for minimally displaced fractures with no

compromise of the extensor function.

Long leg cast then hinged knee brace

48. Damage to the meniscus of the knee joint (mechanism of trauma,
clinic, treatment).
Mechanism of trauma: A common mechanism of injury is a varus or valgus force directed
to a flexed knee. When the foot is planted and the femur is internally rotated, a valgus
force applied to a flexed knee may cause a tear of the medial meniscus. A varus force
on a flexed knee with the femur externally rotated may lead to a lateral meniscus
lesion

Anatomical peculiarities of tears of the menisci:

Blood vessels are lacking in the menisci, except theirs of peripheral portion

The medial meniscus is torn much more often (80%) then the lateral

A tear is usually caused by rotational movement of the leg with the knee semi-flexed or flexed

Basic symptoms of tears of the menisci

• blockade of the knee

• Baikov’s symptom - pain appears when pressing on the joint slit during the extension of
the knee, bent at a right.
• loading deviation of extended leg

• rotary symptoms by Shaman-Buchard, McMurray

Types of menisci tear

1.longitudinal split

2.transverse tear

3.‘Bucket-handle’ tear

4.posterior horn tear

5.anterior horn tear

First aid

Analgesics –Analgin (IM)

Immobilization with bandage

Transport to hospital

At presence of blockade of a knee joint make its elimination

Puncture of a joint → evacuation of a contained joint (blood, synovial fluid) → injection

into a joint of 10 ml 1% procaine or another anesthetic

General principles of arthroscopic meniscectomy

A) partial meniscectomy is always preferable to subtotal or total meniscectomy

B) preservation of an intact, peripheral rim of meniscus promotes the stability of the joint
and defends articular surfaces against overload
C) excision of the major mobile fragments usually is preferable to morselization
49. Intra-articular fractures of the knee (mechanism of injury, clinical
features, treatment).
May involve the lower end of the femur, the patella and the upper ends of the tibial as
well
Distal femur fractures are traumatic injuries involving the region extending from the
distal metaphyseal-diaphyseal junction to the articular surface of the femoral condyles

● Mechanism
○ young patients
■ high energy with significant displacement
○ older patients
■ low energy, often fall from standing, in osteoporotic bone, usually
with lesser degree of displacement
Biomechanics
● hamstring and quadriceps
○ cause the femur to shorten
● adductor magnus
○ leads to distal femoral varus or valgus
■ direction of deformity is dependent on the location of
comminution and the relation of fracture lines to the adductor
tubercle
 ● gastrocnemius
○ extension at the fracture site (apex posterior)
○ rotation of condyles when an intercondylar split is present

● common symptoms
○ pain of distal femur that is made worse with knee movement
○ inability to weight-bear
Diagnostics:

X-RAY ap and lateral view

● traction views
○ AP, lateral, and oblique traction views can help characterize injury but are
painful for the patient
● adjacent joints
○ obtain imaging of entire femur to rule out associated injuries

Treatment

Nonoperative:hinged knee brace

■ indications (rare)
■ stable, nondisplaced fractures
■ nonambulatory patient
■ patient with significant comorbidities presenting
an unacceptably high degree of surgical/anesthetic
risk
○ Operative
■ external fixation
■ indications
■ temporizing measure to restore length, alignment,
and stability
■ unstable, polytrauma
■ soft tissues not amenable to surgical
incisions and internal fixation, or until the
patient is stable
■ contamination requiring multiple
debridements
■ definitive treatment
 ■ severe open and/or comminuted fractures
■ patients unstable for surgery
●
■ open reduction internal fixation (ORIF)
■ indications
■ displaced fracture
■ intra-articular fracture
■ traditional 95 degree devices
contraindicated in Hoffa fractures
■ periprosthetic fracture with osteoporotic bone
■ nonunion
■ fixed-angle plates required for metaphyseal
comminution
■ non-fixed angle plates are prone to varus
collapse

■ retrograde intramedullary nail

■ indications
■ extraarticular fractures
■ simple intraarticular fractures
■ periprosthetic fractures with implants with an
"open-box" design
■ distal femoral replacements do not allow
retrograde nail fixation
■ traditionally, 4 cm of intact distal femur needed
but newer implants with very distal interlocking
options may decrease this number
■ independent screw stabilization of
intraarticular components placed around
nail
■ arthroplasty and distal femoral replacement
■ indications
■ preexisting osteoarthritis with amenable
fracture pattern
■ distal femoral replacement
■ low demand patients
■ unreconstructable fracture
■ fracture around prior total knee
arthroplasty with loose component
 ■ osteoarthritis

DO ravindu pq nao tenho ctz se isso ta certo

Mechanism of injury
• The mechanism of trauma is indirect.
• The mechanism of trauma when injury of the lateral ligament of the knee: combination
of the movements of abduction in extended position of the leg with it interior rotation.

Clinical features
Basic symptom of injury the lateral ligaments is deviation of the leg: abduction and
adduction.
• when rupture LCL – adduction
• when rupture MCL – abduction.

Treatment
FIRST AID

• Self-help treatment
• For the first 48-72 hours think of: Paying the PRICE - Protect, Rest, Ice, Compression,
Elevation;
• and Do no HARM - NO Heat, Alcohol, Running or Massage.

Treatment Treatment when partial rupture of the ligaments is usually conservative.

• Puncture of the knee, aspiration of the blood.

• Immobilization about 3 weeks.

• Medical exercises: at first isometric and passive exercises, then active exercises.
• Physiotherapy
• Massage Treatment when complete rupture of the ligaments may be non-operative
or operative.
Non-operative treatment is the same, but immobilization is continued about 6 weeks.
Operative treatment: a) reinsertion, b) suture of the ligaments, c) transosseous fixation,
d) fixation of osseous plate by screw

50. Diaphyseal fractures of the bones of the leg (mechanism of trauma,

clinical features, treatment).

Mechanism of trauma:
Direct injury: Road traffic accidents are the commonest cause of these fractures,
mostly due to direct violence. The fracture occurs at about the same level in both
bones. Frequently the object causing the fracture lacerates the skin over it, resulting in
an open fracture.
Indirect injury: A bending or torsional force on the tibia may result in an oblique or
spiral fracture respectively. The sharp edge of the fracture fragment may pierce the
skin from within, resulting in an open fracture.

Clinical features:

 History of injury to the leg

 General signs: swelling, erythema, increased local temperature, pain and loss of
function
 Classic features of a fracture:
‐ Bony fragments
‐ Pathological mobility
‐ Creptations
‐ Deformation and shortening of limb
 There may be a wound communicating with the underlying bone.

Treatment:
Closed fracture:
Closed reduction: Under anaesthesia, the patient lies supine with his knees flexed over
the end of the table. The surgeon is seated on a stool, facing the injured leg. The leg is
kept in traction using a halter, made of ordinary bandage, around the ankle. The
fracture ends are manipulated and good alignment achieved.

Initially, a below-knee cast is applied over evenly applied cotton padding. Once this
part of the plaster sets, the cast is extended to above the knee  Above knee plaster –
during 6 weeks  After is above knee plaster is removed and below-knee cast is put.
(lecture - place in long leg cast and convert to functional brace at 4 weeks)
*outcome: risk of shortening w/ oblique fracture and riskk of varus malunion w/
midshaft tíbia fracture with intact fíbula

Surgical:
Intramedullary nail
Open reduction and internal fixation (ORIF)

Open fracture:

 Grade I: Wound dressing through a window in an above-knee plaster cast, and

antibiotics.
 Grade II: Wound debridement and primary closure (if less than 6 hours old),
and above-knee plaster cast. The wound may need dressings through a window
in the plaster cast.
 Grade III: Wound debridement, dressing and external fixator application. The
wound is left open.
51. Fractures of malleolus (mechanism of injury, clinical features,
treatment).

Mechanism of injury:

 Adduction injuries.
 Abduction injuries.
 Pronation-external rotation injuries.
 Supination-external rotation injuries.
 Vertical compression injuries.
Clinical features:

 History of a twisting injury to the ankle - often the patient is able to describe
exactly the way the ankle got twisted.
 General signs: swelling, erythema, increased local temperature, pain and loss of
function
 Classic features of a fracture:
‐ Bony fragments
‐ Pathological mobility
‐ Creptations
‐ Deformation (adducted or abducted, with or without rotation)

Treatment:
Fractures without displacement:

 It is usually sufficient to protect the ankle in a below-knee plaster for 3-6

weeks.
 Good, ready-made braces can be used in place of rather uncomfortable plaster
cast.

Fractures with displacement:

 Conservative treatment:
Manipulation (reduction) under general anaesthesia - restoring the alignment
of the foot to the leg. By doing so the fragments automatically fall into place.
Once reduced, a below-knee plaster cast is applied. If the check X-ray shows a
satisfactory position, the plaster cast is continued for 8-10 weeks. The patient is
not allowed to bear any weight on the leg during this period. Check X-rays are
taken frequently to make sure the fracture does not get displaced. If everything
goes well, the plaster is removed after 8-10 weeks and the patient taught
physiotherapy to regain movement at the ankle.

 Surgical method:

1) Internal fixation:

Medial Malleolus Fracture

‐ Transverse fracture – compression screw, tension-band wiring
‐ Oblique fracture – compression screws
‐ Avulsion fracture – tension-band wiring

Lateral Malleolus Fracture

‐ Transverse fracture – tension-band wiring
‐ Spiral fracture – compression screws
‐ Comminuted fracture – buttress* plating
‐ Fracture of the lower third of fibula – 4-hole plate

Posterior Malleolus
‐ Involving less than one-third of the articulating surface of the tibia – no
additional treatment
‐ Involving more than one-third of the articulating surface of the tibia –
internal fixation with compression screws
‐ Tibio-fibular syndesmosis disruption – needs to be stabilised by
inserting a long screw from the fibula into the tíbia
 2) External fixation:
May be necessary in cases of open fractures with bad crushing of the
muscles and tendons, with skin loss around the ankle.

52. Fractures of the tarsal bones (the mechanism of injury, clinical,

treatment of fractures of the calcaneus bone).

Mechanism of injury:
 Axial loading: Falls from a height are responsible for most intra-articular
fractures
 Twisting forces may be associated with extra-articular calcaneal fractures

Types of fractures:
 Undisplaced fracture resulting from a minimal trauma.
 Extra-articular fracture, where the articular surfaces remain intact, and the
force splits the calcaneal tuberosity vertically.
 Intra-articular fracture, where the articular surface of the calcaneum fails to
withstand the stress. It is shattered and is driven downwards into the body of
the bone, crushing the delicate trabeculae of the cancellous bone into powder.
This is the commonest type of fracture.

Clinical features:
 The patient often gives a history of a fall from height, landing on their heels.
 The patient is not able to bear weight on the affected foot.
 The general symptoms of damage: Pain, Swelling, Bruise (ecchymosis around
hell after a day or two), increase of local temperature, Lesion of function and
Flat-footed.
 Authentic symptoms of fractures: crepitus, deformation. Possible appearance
of bone’s fragments in a wound for open penetrating fractures.
Treatment:
Conservative:
 Supportive splint - allow dissipation of the initial fracture hematoma, followed
by conversion to a prefabricated fracture boot
 Non-weight-bearing restrictions - approximately during 10 to 12 weeks, until
radiographic union

Surgical:
Osteosynthesis by plate and screws (after: elevated position of limb during 72h;
sutures are removed every 3 weeks; immobilization by plaster until 6-9 months).

53. The mechanism of injury, clinic, treatment of talus fractures.

Mechanism of injury:
Hyperdorsiflexion – fracture of neck of talus

*Classification:
  Lateral process fractures
 Posterior process fractures
 Talar head fractures
 Talar body fractures
‐ Shear type I (A, B)
‐ Shear type II (C)
‐ Crush (D)
 Talar neck fractures
‐ Hawkins I - nondisplaced
‐ Hawkins II -subtalar dislocation
‐ Hawkins III - subtalar and tibiotalar dislocation
‐ Hawkins IV - subtalar, tibiotalar, and talonavicular dislocation

Clinical Features:

 Pain
 Range of foot and ankle motion is typically painful and may elicit crepitus.
 Diffuse swelling of the hindfoot withtenderness
 Associated fractures of the foot and ankle are commonly seen with fractures of
the talar neck and body.

Treatment:
Conservative treatment:
Short leg cast or boot for 8 to 12 weeks - patient should remain non-weight bearing for
6 weeks until radiographic evidence of fracture healing.
Indications: Nondisplaced Fractures (Hawkins Type I),talar body fracture,nondisplaced
fracture of the head of talus.

Surgical treatment:
Open reposition internal fixation osteosynthesis by plate and screw
Indications: all displaced fractures.

54. Methods of temporary and final stop bleeding. Types of surgery.

Prevention of ischemic gangrene.
Temporary stop of bleeding:

 Elevated position of the injuried extremity

 Direct pressure on the cut or wound (wound packing)
 Pressure bandage
 Pressure at pressure point
 Flexion of the limb in a joint
 Tourniquet

Final stop of bleeding:

 Mechanical (ligation of a vessel in a wound or along, suturing a vessel in a wound,

prolonged tamponade of wounds, vascular suture, vascular plastics)
 Physical (electrocoagulation, cryosurgery, laser scalpel)
 Chemical (calcium chloride, dicinone, adrenaline, pituitrin, epsilonaminocaproic acid,
hemostatic sponge, fibrin film, "alloplant", bioplant, fibrinogen, tachocomb, vicasol,
vitamin K, fresh frozen plasma, cryopreciptate)

Types of surgery:

 Ligation of the distal and proximal end of bleeding vessel

 Tying vessel with the surrounding tissue (figure of eight)
 Ligation along course of bleeding vessel
 Embolization
 Vasular anastomosis usign prosthetic graft or autovein

Prevention of ischemic gangrene:

 Timely diagnosis and treatment of diseases of the vascular system, the complication of
which is limb gangrene.
 Regular conservative protective therapy.
  Planned reconstruction of the main blood flow in the department of angiosurgery
according to indications.
 Timely urgent angiosurgical assistance.
 Prevention of surgical infection.
 Promotion of a healthy lifestyle (smoking cessation)

55. Types of surgical debridement of wounds. Techniques and steps

primary surgical debridement of wounds, Indications and
contraindications for primary suturing of the wound. Types of suture.

Types of surgical debridement of wounds.

 Primary – performed according to primary indications. Procedure is done in

first 24h after injury or within 48h if prophylatic antibiotic therapy is
performed.
 Secondary – performed with development of secondary changes in the wound.

Techniques and steps primary surgical debridement of wounds

‐ Preoperative examination: assessment of peripheral motor function, sensitivity
and blood circulation, depending on the situation. X-ray of soft tissues if a
foreign body is suspected. Tetanus immunization test.
‐ Specific risks, informed consent of the patient
‐ Pain relief. Local anesthesia, general anesthesia is possible in children.
‐ Patient position. Depends on the location of the wound.
‐ Excision of the skin and subcutaneous tissue around the wound (layer thickness
0.5-1 cm)
‐ Skin incision along the neurovascular bundle
‐ Dissection of the fascia and aponeurosis with a Z-shaped or arcuate incision.
‐ Removal of scraps of clothing, blood clots, foreign bodies
‐ Excision of crushed and contaminated tissue.
‐ Removal of small bone and biting off the ends of bone fragments with nippers.
‐ Stop bleeding.
‐ Closure of the wound (primary suture)

Indications and contraindications for primary suturing of the wound.

Indications:
Tidy wounds
scratches,
abrasions
shallow non-extensive wounds up to 1 cm,
multiple wounds (shallow),
simple puncture wounds
some cases of bullet wounds affecting only soft tissue.

Contraindications:
Contaminated wounds
Uncontrolable bleeding
Presence of necrotic or foreing materials that cannot be reemoved

Types of suture.

 Single seam
 Continuous seam
 Vertical mattress seam according to Donati
 Vertical mattress seam according to Algover
 Continuous subcutaneous suture
 Separate subcutaneous suture

56. Anaerobic infections. Types. Etiopathogenesis. Classification, and

Prophylaxis.
Types:

 Clostridium perfringens
 Vibrion septicus
 Clostridium oedematous
 Clostridium histoliticus
 Clostridium tetani

Etiopathogenesis
These microbes secrete exotoxins, causing severe intoxication, euphoria,
insomnia, etc. The development of anaerobic infection contributes to the
significant destruction of tissues, especially soft; it turned out that with
gunshot fractures, anaerobic infection develops 5 times more often. Also
facilitates the application of tourniquets, the mass arrival of the wounded,
the autumn-winter period, blood loss, overwork, the presence of shock,
soil contamination of the wound. Mortality in anaerobic infections is 15-
50%.

Classification:
1. By speed of spread: fast-spreading, slow-spreading.

2. According to clinical conditions: emphysematous forms, putrefactive forms,

edematous forms.

3. By depth of distribution: epifascial, subfascial.

Tetanus prophylaxis:
1. For unvaccinated previously introduced
a. 1 ml subcutaneous toxoid
b. After 0.5 hours, 0.1 ml of diluted tetanus toxoid is administered intradermally.
• After 20 minutes, they look at the papule. If it is more than 1 cm, then the reaction is
considered positive and further administration of serum should not be done. In case of
a negative reaction, 0.1 ml is injected subcutaneously. After 20 minutes, with a
negative reaction, the total administration of serum is brought to 3000 antitoxic units.

2. For vaccinated - 0.5 ml of toxoid is administered

57. Anaerobic infections. clinic, diagnostics, treatment. Indications and

tactics of amputation.
• Cardiac symptoms - the appearance of subcutaneous emphysema (subcutaneous crepitus),
yellowness of the skin, muscles in the wound acquire a brown-red color and do not bleed.

Skin symptoms:

● noticeable infection near the skin.

● smelly discharge.
● pus-filled abscess.
● tissue damage or gangrene.
 ● discoloration of the infected area

Diagnostics
● Leukocytosis
● Incisional SSI: wound swab for Gram stain and wound culture
● Organ/space SSI: imaging (e.g., CT, MRI)

Treatment
● Surgical therapy
○ Suture removal, incision and drainage, regular dressings, and
daily wound inspection
○ Debridement is indicated for devitalized tissue.
○ Delayed closure once the wound is no longer infected
○ See secondary wound closure for more details.
● Empiric antibiotic therapy for SSI
○ Indications
■ Erythema and induration extending > 5 cm from the
wound edge
■ Fever > 38.5° C
■ Heart rate > 110/min
■ WBC count > 12,000 cells/mm3
○ Antibiotic of choice
■ SSI in a clean wound over the trunk, head and neck,
or limb:
■ In low risk of MRSA: cefazolin
■ In high risk of MRSA and individuals with
beta-lactams allergy: vancomycin,
daptomycin, or linezolid
■ SSI in a clean-contaminated wound or in a clean
wound over the perineal region: cephalosporin PLUS
metronidazole, levofloxacin PLUS metronidazole, or
carbapenem
■ If group A Streptococcus or C. perfringens infection
is suspected: penicillin and clindamycin
 ● Targeted antibiotic therapy may be initiated once results of the
bacterial culture are available.
Indications and tactics of amputation:

● Complete amputation: the body part is totally severed

● Partial amputation: some soft tissue remains connected to the
affected body part and the rest of the body
● Surgical amputations: careful, controlled removal of a body part in
the operating room
○ Commonly due to poor blood flow, most often from peripheral
vascular disease (PVD)
○ Other reasons for amputation include severe burn or
accident, or cancer in a limb.
○ Management: see “Acute wound treatment”.
● Traumatic amputations: Most traumatic amputations are accidental,
and usually result from factory, farm, or power tool accidents. Motor
vehicle accidents may also cause traumatic amputations. The tips of
longer fingers tend to be injured more often because they are more
exposed to harm.

If the infection cant be stopped or the damage is irreparable, the amputation is indicated

58. Osteochondrosis of vertebrae. Etiology, pathogenesis. Basic

clinical syndromes
Osteochondrosis (OC) - degenerative disease of the spine, which is based on
degenerative changes of intervertebral discs, accompanied by their progressive
deformation, decrease in height and stratification followed by involvement of adjacent
vertebral bodies, intervertebral joints, ligaments, spinal cord and its roots and neuro
reflex mechanisms, and often, and vertebrobasilar blood supply structures.
Etiology
Main idea of etiology: disturbances of static (eg. lig. , capsule) and dynamic stabilizer (eg.
muscles, tendons) + autoimmune complex mechanism

 Acute and chronic infections

  Involutory theory
 Muscle theory
 Endocrine and exchange theory
 Anomalies of the spine
 Rheumatoid theory
 Traumatic theory
 The theory of heredity
 Autoimmune theory

Risk factor:
 Anomalies of the spine
 Lumbalization (separation of vertebrae from the sacrum and transforms to likeliess of
lumbar, as result 4 sacral vertebra, 6 lumbar veterbra)
 Sacralization (Malformation - L5 transforms into S1, as result: 6 sacral vertebra, 4
lumbar vertebra)
 The asymmetrical arrangement of the joint gaps intervertebral joints
 Congenital narrowness of the spinal canal
 Spondylogenic, somatic (radiatiing pain in diseases of the internal organs and blood
vessels) and muscle (radiating myofascial) pain
 Physical overstrain
 Vibrations, such as driving vehicles
 Psychosocial factors
 Physical inactivity
 Smoking
 Obesity

Pathogenesis
Exposure to endogenous and / or exogenous factor  violation microcirculation vertebral
segment  degenerative changes of the cartilage  autoimmune inflammation altered
cartilage and nucleus pulposus  atrophy, thinning, reducing the buffer properties of cartilage
 functional restructuring of overloaded bone to strengthen the bone (subchondral
osteosclerosis) and to reduce the load per unit of support surface - marginal bone growths
(osteophytes).

Basic clinical syndromes

 Reflex syndromes – causes reflex spasm of muscles and blood vessels of limbs and
trunk. Distinchish as muscle-tonic, neurodystrophic and neurovascular syndrome

 Compression syndromes – causes compression of neurovascular structures of

vertebral canal (spinal nerve roots, spinal cord and vertebral artery).
  Vertebral syndrome – feeling of pain, muscle tension of the trunk and limbs, limination
of range of motion, curvaturee of spine axis.

 Syndrome of instability of the vertebral motion segment – increased pain syndrome

after patient moves to upright position, with rotational movements of the trunk. Pain
relief – in horizontal position and with external immobilization of spine.

59. Osteochondrosis of the lumbar segment of vertebrae (clinic,

diagnostics, treatment)
Clinical features:
Exacerbation phase:
 Spontaneous pain
 Forced (antalgic) pose
 Expressed musculo-tonic responses (increase muscle tones)
 Function block of the affected spinal segment
 Expressed symptom root irritation
 Signs of loss of function of root

Progression phase:

 Provoked pain
 Static-dynamic disorders in walking and sitting
 Moderately expressed musculo-tonic disorders
 Block the affected segment of the spine often persists
 Root irritation symptoms are less pronounced
 Loss of root functions preserved

Remission phase:

 Pain may appear only in awkward positions (tilt, rotate the body, head, etc.) - changing
the position, pain usually disappear
 Root irritation symptoms are absent, but may be loss of its function.

Diagnostics
STUDY OF MEDICAL HISTORY- characteristic of pain syndrome

OBECTIVE EXAMINATION

 Examine configuration of spine at rest and during movement (lordosis, kyphosis

hyperlordosis)
 Palpation – determines myofascial pain points
 ‐ “cough point” and “call” –appearance of back pain during coughing or when
pressing with a hand in the area of intervertebral foramen. (lumbar root
compression)
‐ Lasegue symptom – patient lying on back raises his straight leg up angle of raising
reduced due to pain
‐ Neri’s symptom – pt lying on his back head is bent to his chest Radicular pain in the
leg increases

INSTRUMENTAL METHODS

 Spondylography –reduced height of intervertebral disc - subchondral sclerosis - post. &

ant. Marginal bony growths of the vertebral body - pathological mobility in the
vertebral segment - straightening of physiological lordosis, local kyphosis (“spacer”
symptom)
 Myelography with water-soluble contrast media - signs of deformation of
subarachnoid space - protrusion/ prolapses of discs - pathological changes in spinal
canal
 Discography – pathological changes in the disc
 CT & MRI- pathological changes in discs and vertebral bodies

Treatment:
Conservative
A) Orthopedic regime:
 Observance strict bed rest for 3-7 days (bed is hard, flat, under the mattress
which is enclosed shield
 Lumbar form - lie on your back (on the shield) in an easy position for the spine
kyphosis (gluteal region is enclosed by a small cushion)

B) CONSERVATIVE (symptomatic therapy)

 Medications:- anti-inflammatory, dehydrating, analgesics
 Reflex:- physiotherapy, acupuncture, laser therapy
 Vertebroneurological:- biochemical, traction, manual, surgical (bed rest,
external fixation devices)
 Local anesthetics:- steroids can be inected to most painful spot

C) PUNCTURE TX (For protrusions of discs)

 Punture of lumbar discs by posterior or lateral access (if cervical – ant.
approach) Aspirate content out
 Dereception of disc inject alcohol Novocain to painful intervertebral disc
 Papainization – introduce proteolytic enzyme papaine into disc selectively
dissolves parts of nucleus plposus fibrosis occurs forming ahesions of adj.
Vertebra
 Adhesive(glue) stabilization of discs

D) SURGICAL MX Indication failure to conservative mx, irreversible changes has occured

  partial laminectomy/ interlaminectomy
 anterior decompression and stabilization with titanium implant
 endoscopic disc protrusion removal

60. Osteochondrosis of the cervical segment of vertebrae (clinic,

diagnostics, treatment).

Clinical features:
Reflexory syndrome

 Cervicalgia – aching pain, radiation to back of head andr shoulder girdle.

Increase with neck movements and long monotonous position of head.
 Syndrome of lower oblique muscle of head – pain in cervico-occiptal region of a
constant nature, aggravated by rotation of head to the health side.
 Anterior scalene muscle syndrome – pain in the arm, hypalgesia and movement
disorders in the zone of innervation of ulnar nerve. Pain is worse when turning
and tilting head in opposite direction.
 Shoulder scapular periarthrosis syndrome - pain in the shoulder joint and
limited range of motion in it. Palpation: painful nodes in shoulder muscle
 Anterior chest wall syndrome (cardialgia syndrome) – pain in the muscles of the
chest on the left, with a return to the inerscapular region and the left arm.
Palpation: painful nodes. (Ddx with angina)
 Vertebral artery syndrome – headache spread from one side of cervico-
occipatal region to the temple and forehead (helmet-like pain). Cochleo-
vestibular disorder – noise in ear, dizzness – intensity varies depending on
position of the head.
 Anterior scalene muscle syndrome – instability of C6-7 or C5-6 (reflex muscle
tension and compression between the muscle and first rib of lower trunk of
brachial plexus, and in front, in the gap between the rib and clavicle, of the
subclavian vein)
Clinics: pain in arm, hypalgesia and movement disorder in zone of innervation
of ulnar nerve. Pain worse when turning or tilting the head in the opposite
direction.

Compression syndrome of neck:

 Syndrome of compression of spinal cord

‐ C6: pain and impaired sensitiviry on outer surface of the arm and forearm
up to 1st finger. Hypothorphy and weakness in bíceps mucle, reflex tendo
decrease
 ‐ C7: pain and sensory disorder along back-outer surface of the arm and
forearm up to II-III finger. Weakness and atrophy of tríceps muscle,
decrease reflex from its tendo.
 Compression syndrome of spinal cord and its vessels (vertebrogenic cervical
myelopathy) – slowly progressive spastic paresis of legs, weakness and atrophy
of arm muscles increase, slight delay or urgency to urinate.

Diagnosis:
Inspection: examine configuration of spine at rest and during movement (lordosis, kyphosis
hyperlordosis)

Palpation:

 Spurling test- with a load on head tilt on to the shoulder, same side limb pain /
paresthesias produced
 Berchi test – test of compression and stretching of cervical spine by hands of a doctor
Can cause increase or decrease of pain.

Instrumental Investigation:

Vertebral angiography – compression of vertebral artery by osteochondral growths of

cervical vertebra

Treatment:
E) CONSERVATIVE (symptomatic therapy)
 Observance strict bed rest for 3-7 days (bed is hard, flat, under the mattress
which is enclosed shield
 Medications:- anti-inflammatory, dehydrating, analgesics
 Reflex:- physiotherapy, acupuncture, laser therapy
 Vertebroneurological:- biochemical, traction, manual, surgical (bed rest,
external fixation devices)
 Local anesthetics:- steroids can be inected to most painful spot

F) PUNCTURE TX (For protrusions of discs)

 Punture of lumbar discs by posterior or lateral access (if cervical – ant.
approach) Aspirate content out
 Dereception of disc inject alcohol Novocain to painful intervertebral disc
 Papainization – introduce proteolytic enzyme papaine into disc selectively
dissolves parts of nucleus plposus fibrosis occurs forming ahesions of adj.
Vertebra
 Adhesive(glue) stabilization of discs

G) SURGICAL MX Indication failure to conservative mx, irreversible changes has occured

 partial laminectomy/ interlaminectomy
 anterior decompression and stabilization with titanium implant
  endoscopic disc protrusion removal

61. Osteoarthrosis of large joints (etiology, pathogenesis and

classification).

Etiology:
LECTURE

 Mechanical: acute and chronic overloading, dysplasia;

 Hormonal: post climacteric, endocrine diseases;
 Hereditary (39 – 65%);
 Inflammatory: specific, unspecific;
 Ischemic;
 Neurogenous;
 Idiopathic

AMBOSS

 Idiopathic OA

o No identifiable underlying cause

o Can be localized or generalized
o Genetic factors of causation have been implicated, but not definitively
proven.

 Secondary OA

o Hemochromatosis
o Wilson disease
o Ehlers-Danlos syndrome
o Diabetes
o Avascular necrosis
o Congenital disorders of joints
o Alkaptonuria
o Joint trauma

Risk factors:

 Modifiable risk factors

 o Obesity
o Excessive joint loading or overuse (mechanical stress)
 Nonmodifiable risk factors
o Age (> 55 years)
o Family history
o History of joint injury or trauma
o Anatomic factors causing asymmetrical joint stress
o Hemophilic hemarthroses and deposition diseases that stiffen cartilage
o Sex

Pathogenesis:
Chronic mechanical stress on the joints and age-related decrease in proteoglycans 
cartilage loses elasticity and becomes friable  degeneration and inflammation of
cartilage → joint space narrowing and thickening and sclerosis of the subchondral
bone

Classification:
According to clinical type:

 Compensated – fucntion is not disturbed (after conservative treatment pain is

absent)
  Subcompensated – function os disturbed not considerable
 Decompensated – Function is disturbed considerebly (no change after
conservative treatment)

Rontgenologic classification – Stages (Kellgren-Lorenz):

Stage I - Insignificant manifestation (marginal sharpening of joint surfaces, insignificant
osteophytes, constriction of joint space)
Stage II - Significant manifestation (evident osteophytes, significant constriction of
joint space, subchondral sclerosis, incongruent of joint surfaces)
Stage III - Sharply significant manifestation (evident osteophytes, sharply significant
constriction of joint space, subchondral sclerosis, significant incongruent of
joint surfaces. Disorder of biomechanical axis of a joint. Associated
osteoporosis. Possible chondromatosis)
Stage IV - X-ray pattern of fibrous ankylosis (Large osteophytes, subchondral
osteosclerosis in combination with cysts or cystoid remodeling of a bone,
evident incongruent and deformation articular surfaces; joint space is no
found partly or all along, evident change of biomechanical axis of a joint) –
absence of intra-articular space.

62. Conservative complex treatment of osteoarthrosis of large joints.

Conservative treatment – stage I and II

Surgical treatment – stage III and IV

Pharmacological:

 Chondroprotectors: alflutop, piascledin, structum priority to local therapy

 Implants of synovial fluid: ostenil, synvisc, noltrex
 NSAID: diclofenac, nimesil, nise, ambene, ortophen including ointments and gel
 Vascular drugs, angioprotectors: trental, curantyl, xantinol nicotinate
 Symptomatic therapy: analgesics, vitamins, nonsteroidal anabolic drugs,
sedative drugs, homeopathic drugs, drugs of folk medicine

Orthopedic comples:

 Unloading of a joint
 Immobilization
 Exercise therapy
  Massage, manual therapy
 Medicinal blockades

Non-pharmacological:

 Instruction of the patient

 Reduction of overweight
 Exercise therapy
 Limitation of static and inertial loads
 Using of a stick
 Using of bandages, insoles

63. Osteoarthrosis of the hip joint (coxarthrosis): clinical features,

treatment.

Clinical Features:

 Pain in the groin area and above the greater trochanter

 Increased contracture in the flexor, external rotation, and adduction position
 antalgic gait

 Early signs: limited and painful internal rotation of the hip joint
 Pain on palpation: greater trochanter, groin
 Positive Thomas test
o Function: test for hip flexion contracture
o Position: supine
o Procedure: Examiner passively flexes the hip joint opposite to the affected side to
a maximum to compensate lumbar lordosis.
 o Positive test: If flexion contracture is present, the ipsilateral leg will
simultaneously flex independently as a reflex.

Treatment:
Conservative:

 Frequent exercise, minimal load → Joint-friendly exercises are also

recommended after endoprosthesis implantation (swimming and cycling).
 Weight loss may be indicated.
 Physical therapy
 Pain medication
 Use of a forearm-supported crutch on the healthy, unaffected side when
walking
 Orthotic insoles - elp reduce the axial impact of the heel strike and can be used
in osteoarthritis of the ankle, knee, and hip.

Surgical:

 Total hip replacement

o Description: total hip joint replacement with replacement of the femoral head
and the acetabulum with a prosthesis
o Indications
 Primary arthritis with total joint destruction and exhausted conservative
measures
 Femoral neck fracture with concomitant hip osteoarthritis

 Hip hemiarthroplasty
 o Description: only femoral prosthesis is implanted, with preservation of the
native acetabulum
o Types:
 Fixed head prosthesis (unipolar head prosthesis): consists of a single,
undivided, femoral component with a fixed head, of a diameter that matches
that of the acetabulum; the head component articulates directly with
the acetabular articular cartilage.
 Dual-head prosthesis (bipolar head prosthesis): has a femoral head that swivels
during movement; this additional articulation in the prosthesis helps reduce
the amount of wear and tear on the new joint for longer-lasting results.
o Indications
 Femoral neck fractures in older patients without
concomitant hip osteoarthritis
 Primary arthritis with complete joint destruction in older patients
 Postoperative deep venous thrombosis prophylaxis is needed for hip
replacement and any surgery to correct a fracture close to the hip joint.
o Perioperative start
o For 28– 35 days postoperatively

64. Osteoarthrosis of the knee (gonarthrosis): clinical features,

treatment.

Clinical Features:

 Function-limiting knee pain

 Knee swelling which increases on activity
 Mechanical instability, locking, catching sensation
 In case of patello-femoral osteoarthritis: positive Patellar grind
test (pain on movement of the patella)
 Cartilage damage usually begins medially and may lead to genu
varum (bowing of legs)

Treatment:
Conservative:

 Frequent exercise, minimal load → Joint-friendly exercises are also

recommended after endoprosthesis implantation (swimming and cycling).
 Weight loss may be indicated.
 Physical therapy
  Pain medication
 Use of a forearm-supported crutch on the healthy, unaffected side when
walking
 Orthotic insoles - help reduce the axial impact of the heel strike and can be
used in osteoarthritis of the ankle, knee, and hip.

Surgical:
Knee joint replacement
Corrective osteotomy (unilateral osteoarthritis with correctable joint malformation)
Arthrodesis

65. Disorders of the posture.types, diagnosis, prevention.

Posture disorder is a persistent deviation of the trunk from a normal position. It is
accompanied by strengthening or smoothing of the physiological curves of the spine. It
is not a disease, unlike scoliosis and pathological kyphosis, however, in a certain sense,
it can be considered as a state of pre-disease, since it significantly increases the
likelihood of developing a number of diseases of the musculoskeletal system.
Types:

 Normal
‐ Feet should be parallel to the shoulder;
‐ legs straight;
‐ belly tucked up;
‐ the body upright, the angle of inclination of the pelvis - 45;
‐ shoulders back and lowered, shoulder blades close to the spine;
‐ arms hanging freely on the midline of the body;
‐ head straight, chin and forehead are on the same vertical line

 Bend spine
prevalence of lumbar lordosis in the background of normal or somewhat
increased thoracic kyphosis
 Stooped/Hunch spine
‐ Domination of thoracic kyphosis
‐ lordosis is less
‐ Often combined with curvatures in the frontal plane - scoliotic posture

 Flat spine
‐ curvature of the spine barely traceable
 ‐ vertical axis extends along the entire length of the spine
‐ flattened chest, abdomen retracted
‐ pterygopalatine blades are spaced from the chest
‐ elastic properties of the spine reduced. Spine easily damaged by
mechanical effects, is prone to lateral curvature

 Rounded/kyphotic spine
‐ Increase of physiological thoracic kyphosis
‐ Increase compensatory lordosis of the cervical and lumbar
‐ elasticity of the spine increased. Lateral curvature of the rare

Diagnosis:

 Bending test – to evaluate natural mobility of the spine and determine the
basic and compensatory arcs when S-shaped deformations.
 X-ray with lateral inclinations
 Functional spondylography in lateral projection
 Functional spondylography maximum flexion
 Stability Index (SI) - is the ratio of the curvature angle on radiographs, taken in
the child lying position (A) to the same angle in the position of the patient
standing (A1)
‐ IS ~ 1.0 – strengthening the fixation of curvature. Prognosis
favorable
‐ IS >1.0 - strengthening mobility curvature. Prognosis is poor

 MRI

Prevention:

 To prevent postural disorders in children, it is necessary to ensure that the child

evenly loads the spine when carrying weights (use a backpack instead of a
briefcase).
 Select furniture taking into account the child's height
 It is necessary to timely treat and correct hearing and vision impairments
 Choose comfortable shoes
 Correct flat feet
 Treat congenital anomalies

66. Scoliotic disease (etiology,pathogenesis, classification).

Etiology:
-Idiopathic scoliosis (70-90%): the cause is unknown
-Congenital scoliosis (dysonogenetic)
-Secondary (infection, trauma, sevre burns of the body, paresis, paralysis,
polio, neurofibromatosis, rheumatoid arthritis, tumor, etc)
Pathogenesis:

Classification:
According type and levels of deformation:
1.A single upper thoracic curve – C7, Th1 or Th2
2.A single rib arc – Th4, Th5 or Th6
3.A single thoracolumbar arc – Th8, Th9 or Th10
4.A single lumbar curve – L2 or L5
5.Thoracic arc with lumbar opposite side angulating:
-Thoracic arc -th8
-Lumbar opposite side angulating -L1-L2
6.Two primary arc – Thoracic Th7 or Th8 and lumbar L1 or L2
7.Two primary arc – Thoracic Th6 or Th7 and thoracolumbar Th12 – L1
8.Double thoracic arc – Thoracic curve Th3, Th4; Lower thoracic arc Th8,
Th9, Th10
9.Multiple arc

Classification of adolescent idiopathic scoliosis:

Type 1: an “S” shape deformity, in which both curves are structural and
cross the center sacral vertical line, with lumbar curve > thoracic one
Type 2: an “S” shape deformity, in which both curves are structural and
cross the center sacral vertical line, with thoracic curve >= lumbar one
Type 3: major thoracic curve in which only the thoracic curve is structural
and crosses the center sacral vertical line
Type 4: long “C” shape thoracic curve in which the L5 is centered over the
sacrum and the L4 is tilted into the thoracic curve
Type 5: double thoracic curve
67. Scoliotic disease (diagnosis and treatment).
Diagnosis:
Clinical picture:
-Complains of pain in the back, the lumbar and thoracic spine
-Increased pain when axial loads; decrease in the supine position
-Pain persists more than 2 weeks
-Asymmetry of the shoulder blades
-Asymmetry of triangle the waist and iliac crest
Adam forward bend test may show:
-Thoracic rotation (“rib hump”)
-Lumbar rotation (“lumbar hump”)
Scoliometry: placed on the back and measures the apex of the upper back
curve and angle of trunk rotation
Spondylography:
-Asess the state of the spine and identify its anatomical features
-Calculate the amount of deformation in the frontal and saggital planes
-Evaluate degree of torsion of vertebrae
-Determine the degree of maturity of the skeleton on the test Riesser
(degree of ossification of the apophyses iliac wings) and the vertebral
body apophyses
-Evaluate the size of spinal canal
68. Flatfoot (etiology, types of flatfoot-classification, prevention).
Definition: rare, complex foot deformity with a fixed vertical position of the talus and
luxation of the talocalcaneonavicular joint

Etiology:
o Hereditary
o Cranial luxation of the navicular bone
o (Sub)luxation of the talonavicular joint and the subtalar joint
o Short Achilles tendon
o Generalized ligament laxity
o Contracture of gastrocnemius-soleus muscle
o Secondary to posterior tibial tendon dysfunction
o Repetitive high impact activities (e.g., running, soccer) in adults with congenital
pes planus
o Posttraumatic
o Secondary to disorders such as Marfan syndrome, Ehlers Danos syndrome,
and Down syndrome

Classification:
I. Static deformations
1. Functional insufficiency
2. Longitudinal platypodia (planovalgus
deformity)
3. Transversal platypodia (broad foot)
4. Fibro-osseous excrescences in region of heads of I metatarsal bones
5. Hallux valgus
6. Hammer-shaped (or claw-shaped) and others deformity of toes

II. Paralytic deformations of feet

1. paralytic flat foot
2. paralytic short cavovarus deformity
3. paralytic heel foot
4. paralytic tip foot
5. talipes paralyticus
6. hypermobility of foot

III. Congenital deformities of feet

1. congenital flat foot
2. congenital clubfoot
3. congenital adducted foot
4. congenital deformity of toes

Prevention:
Insole, orthopedic shoe
Walk on the beach sand with bare foot

69. Transverse-flatfoot (clinical features, treatment, prevention).

Definition: spreading apart of the metatarsal bones with subsequent lowering of
the metatarsal heads (broad foot)

Etiology:
Muscular and connective tissue weakness (worsened by unsupportive footwear)

Clinical features:
Metatarsalgia: pain in the metatarsal bone joints II–IV → abnormal strain on
the metatarsal heads II–IV → painful callus (pt. gain weight due to pain because can’t
walk)
Hallux valgus and digitus quintus varus: malalignment of the first and fifth ray
Callus on foot

Prevention:
Insole, orthopedic shoe
Walk on the beach sand with bare foot

70. Longitudinal flatfoot (etiology, clinical features, treatment).

Etiology:

o paralytic
o traumatic
o rachitic
o static

Clinical Features:

o Pain, fatigue, edema

o Deformation: lengthening of the foot, widening of its middle part, descent of the
longitudinal arch, valgus deviation, prominence of the navicular bone on medial
aspect. (plano-valgum deformation)

Diagnosis:

o X-ray (AP and lateral view)

o Podometry index

Treatment:
Conservative:

o Massage,warm bath,medical exercise

o Insole supinator,Orthopedic shoe.
o Electromyostimulation of muscles of leg and foot
o Recommend patient to walk on the beach sand with bare foot

Operative treatment:
o Lengthening of the Achilles tendon
o Transplantation peroneous on the inside edge of the foot
o Arthodesis of three joint after full growth of foot.
71. Valgus deformity of 1st toe (clinic, treatment).

(Normal: <10º)

Clinical Picture:
Pain and inflammation
Secondary osteoarthritis in the first metatarsophalangeal joint
Can lead to deviation of the remaining digits resulting in hammer and claw toes
Fibrous osseous excrescenses (?)

X-ray: subluxation

Treatment:
Conservative therapy:
Special shoes and inlays
Orthoses (put between 1st and 2nd toe)
Pain management with NSAIDs and corticosteroid injections

Operative:
Indications: pain syndrome and cosmetic effect
Mac Bride operation – attach abductor on the base of metatarsal and adduct to
phalanx
Schede-Brandes surgery
Osteotomy

72. Types of osteopenic states. Osteoporosis: etiology, classification,

principles of treatment

Types of osteopenic states:

‐ Health/normal: 1 - -1
‐ Osteopenia: -1 - -2,5
 ‐ Osteoporosis: > -2,5
‐ Severe osteoporosis

Etiology :

 Primary osteoporosis (most common form)

o Type I (postmenopausal osteoporosis): postmenopausal women
 Estrogen stimulates osteoblasts and inhibits osteoclasts.
 The decreased estrogen levels following menopause lead to increased bone
resorption.
o Type II (senile osteoporosis): gradual loss of bone mass as patients age
(especially > 70 years)
o Idiopathic osteoporosis
 Idiopathic juvenile osteoporosis
 Idiopathic osteoporosis in young adults

 Secondary osteoporosis
o Drug-induced/iatrogenic
 Most commonly due to systemic long-term therapy with corticosteroids (e.g., in
patients with autoimmune disease)
 Long-term therapy involving:
 Anticonvulsants (e.g., phenytoin, carbamazepine)
 L-thyroxine
 Anticoagulants (e.g., heparin)
 Proton pump inhibitors
 Aromatase inhibitors (e.g., anastrozole, letrozole)
 Immunosuppressants (e.g., cyclosporine, tacrolimus)
o Endocrine/metabolic: hypercortisolism, hypogonadism, hyperthyroidism, hyperpa
rathyroidism, renal disease
o Multiple myeloma
o Excessive alcohol consumption
o Immobilization

Risk factors:
 Cigarette smoking
 Malabsorption, malnutrition (e.g., a vegan diet low in calcium and vitamin
D), anorexia
 Low body weight
  Family history of osteoporosis

Classification: (T-score)

Principles of treatment:
Drug of choice:

Bisphosphonates: aleanndronate, risedronate

Shoud be taken in the morning at leat 30 min before meal, with plenty of water and patient
should maintain na upright position for at least 30 min following intake to prevent esophagitis.

Alternative drugs:

Teriparatide (PTH analog)

Raloxifene (selective estrogen receptor modulator, SERM)

Denosumab (monoclonal Ab) – indicated for patient with impared renal function

Calcitonin – indicated for postmenopausal women

Hormonal replacement therapy – estrogen for women in menopause and testosterone for
men with hypogonadism.

 Calcium supplementation: diet or calcium bicarbonate (1000-1200mg/day)

 Vitamin D: 800-1000 IU/day – at least 30ng/mL
 Physical excercises