Tips for Orthopedics Exam

(Unit 9)
By Kareem Hamimy
6th year medical student
Unit 9 – Kasr Al Ainy Medical School
 Fracture Humerus
• Fracture Shaft
– Injury to Radial Nerve is common
• So you Must Document this Injury before reduction
(Medicolegally)
• Will lead to Finger Drop, Wrist Drop
– Management
• U shaped Cast
• Collar and cuff sling
• N.B. Edge of cast have to be 2 cm above fracture
• Plain X-ray, Antero
posterior view of
a humerus of an
adult, showing
Mid shaft Spiral
Fracture, With
angulation varus
( Apex is lateral )
 Open Reduction
• Indications :
– Associated with vascular injury
– Bilateral
– Multiple
– Compound Fracture (Haematoma communicating to
outside)
– Floating Elbow ( Fracture in humerus + Fracture radius
and ulna )
– Pathological (due to tumour/osteoporosis)
– Comminuted
• Supracondylar Fracture
– Types ( Flexion, Extension 90%in children)
– Risk of injury to brachial Artery very high
• Why ? After its bifurcation, its branches become
attached by fibrous tissue, being fixed makes it more
liable to injury
– Median nerve injury
– Radial nerve is least prone to injury because it is
protected between the brachialis and
brachioradialis
• Supracondylar fracture
– Management :
– First : Check The pulse
pulse‫اللجنة بتخلص عند ال‬ –
– If no pulse, Document, then reduce it ( to
decrease compression on artery
– If no pulse after reduction, Do open exploration
and Vascular Surgery
• Plain X-ray,
Lateral view, of
and adult elbow
joint, Showing
Supracondylar
Fracture, with
posterior
displacement of
distal segment
 Compartment Syndrome
• Bleeding and edema inside fascial
Compartments, Increases the pressure, leading
to compression of veins then arteries, and lately
Nerves leading to a limb threatening condition
• Treatment: By Fasciotomy
• N.B. it is not only due to fracture but also
maybe due to soft tissue injury inside a
compartment
 Complications Of Fractures
• General
– Shock
– DVT
– Pulmonary Embolism
– Fat Embolism
– Tetanus
– Psycological depression
– Constipation
– Renal Infection
– Bed sores
 Complications Of Fractures
• Local
– Early
• Vascular Injury
• Nerve Injury
• Infection
• Tendon Injury
• Avascular necrosis of bones
– Late
• Delayed Union
• Malunion
• Nonunion
• Volkman’s Ischemic Contracture
• Myositis ossificans
 Shock (Tissue Hypoperfusion)
• Hypovolemic
– Fracture Femur 500cc blood loss
– Fracture Pelvis 1000cc
– C.P.
• Pulse Rapid due to sympathetic response, Temp low, Respiratory rate Rapid
• B.P. According to Severity of blood loss ( Mild decreased systolic, Moderate
Decreased Pulse pressure, Severe Decreased Diastolic)
– Management
– 2 cannulas, Urinary catheterization (to asses perfusion)
– Crystalloid infusion increasing volume
– or Colloid (Contains Protein) infusion increase blood pressure by keeping
fluid inside vessels
– >1000 cc lost  Blood transfusion
 Shock (Tissue Hypoperfusion)
• Neurogenic
– Females, Old
– How to differentiate from Hypovolemic ? 
Bradycardia, and skin flushed
– Why bradycardia ? Due to parasympathetic response
– Ttt: by analgesics
• Septic
– As in compound fracture
– Antibiotics, Antitetanus
 DVT
• Virchow's Triad
– Stasis
– Hypercoagulability
– Endothelial Injury
• Early fixation, Proper Hydration
• Anticoagulants
– Parenteral ( Heparin)
– Oral (warfarin)
• How to avoid Pulmonary Embolism
– Conservative ( Prevent DVT)
– Vena caval Filter (Green Field Filter)
 Fat Embolism
• Due to yellow Bone marrow in Medulla of
Bones
• Difference between Fat Embolism and
Pulmonary embolism ( Onset )
– Fat onset is acute, immediately after trauma
– Pulmonary, 1 week after trauma
 Bed Sores
• How to Prevent ?
– Early Mobilization (by early reduction and fixation)
– Frequent Mobilization (by changing his position in
bed )
– Proper Hydration
 Local complications
• Vascular injury
– Causes :
• Direct Injury by the blow
• Fractured (serrated) end of bone
• Compartment Syndrome
• Nerve Injury
– N.B. Sites
• Ulnar Nerve : Behind Medial Epicondyle
• Median Nerve : Cubital fossa
• Radial Nerve between brachialis and brachioradialis
• Sciatic Nerve : Behind hip Joint
 Compound fracture
• Fracture Hematoma Connected with the
External
• Significance :
– potentially Infected
– Delayed Union ( Because the first step of healing is
the organization of the hematoma and its
resolution )
 Union
• Malunited ( abnormal positioned)
• Delayed ( more than expected time)
• Ununited ( Not united at all)

• Causes
– Improper reduction
– Poor Blood Supply
– Gapping
– Infection
– Soft tissue between fractured bone
 Internal Fixators
• Humerus and radius ( forearm)  Plates and
Screws
• Spine  Pedicular Screws
• Tibia ( Shaft )  Intramedullary Nail
• Tibia ( Pott’s)  K wire or Plate and Screws
• Colles Fracture  Closed reducation + K wires
• Fracture Shaft femur  Tomas Tractor till
open reduction and internal fixation
• Plates and
Screws In
humerus
• K wires in Colles
Fracture
D.H.S.
• Intra
medullary
Nail In Tibia
Thomas Skin tractor
 External Fixators
• Below elbow slap ( fractures below elbow)
• Above elbow slap ( near elbow joint )
• Humerus : U-shaped slap
• Clavicle : arm to chest sling
• Neck : Collar
• Lumbosacral : Lumbosacral brace
• Below knee slap
• Above Knee Slap
• Tomas Splint ( for femur ) Skin traction
 Illizarov External Fixator
• Used in compound fractures
• Also in comminuted potentially infected
 N.B.
• In a displaced fracture, Shortening occurs
because the muscle is shorter than the
distance between the origin and insertion,
pulling the bone with it
 N.B.
• Any poly trauma pt
• ABC
• Immobilization of back
• Inspection
• Palpation of bones and checking if there is any
fracture
• X-ray at site of fracture
• Routine X-ray on Cervical spine, Lumbosacral, Pelvis
 X-ray
• One joint above and one joint below the
fracture site
• Anteroposterior view and lateral view
• In children, X-ray the other limb for
comparison ( Epiphyseal lines )
 Emergencies in Orthopedics
1. Fracture Neck Femur
– Avascular Necrosis of head can occur
– We fix by Dynamic head Screw
2. Fracture Neck talus
3. Compound Fracture
4. Dislocation ( May cause Arthritis Forever)
5. Slipped Physis (Epiphyseal Plate) in Children
– Arrest of Growth, Growth Deformities may occur
6. Fracture with Vascular Injury
• N.B.
• Infection in Bone is very Serious ( if
osteomyelitis occurred, we excise it as
tumour)
 N.B
• Range of Acceptance ( range at which fracture
can be left not reduced and heals well )
• Range of Angulation “According to each bone”
• Range of Overriding “According to each bone”
• But Rotation is not accepted at all, No range
of acceptance, reduction must be done
• Range of acceptance increases in pediatrics
due to their remodelling ability
 Comment On X-ray
• X-ray
• Anteroposterior or lateral view
• Of (Anatomy)
• Adult or child ( By Checking Epiphyseal plates)
• Showing Fracture with
– Angulation (Varus or vulgus) /
– Shortening ….. Cm (With anterior or posterior or
medial or lateral displacement, of the distal segment )
– Rotation
• Epiphysis means Part of bone connected to
Joint
• Arterial supply of neck of femur is very
important
• Why Fracture Neck femur occur ?
– Junction between cancellous and cortical bone
• Subcapital and midcervical  Intracapsular
• BasiCervical - Extracapsular
 Management of fracture neck femur
• Depends on Physiological activity And Age
• Extracapsular  DHS
• Intracapsular
• If Young, with high activity urgent fixation  DHS
• If old >60-70 years old Hemiarthroplasty
• Complications of hemiarthroplasty
– Infection
– Dislocation
– Periprosthetic Fracture
– Loosening which is painful
 Dynamic head Screw
• Used in fracture neck femur
• It uses body weigt, leading to compression
and rapid healing
• 135 degrees
• And also used in trochanteric fracture
• In Subtrochanteric fracture we use dynamic
condylar screw DCS, which is 95 degrees
 N.B.
• How to know the bone is osteoporotic
• By comparison to the color of the cortex of
shaft
• What is the difference between Intracapsular
and Extracapsular Neck femur fracture ?
• Intracapsular Is an Emergency due to avasucalr
necrosis and high mortality rate
 Thank you

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