Principles of Musculoskeletal Injuries Wiroon Laupattarakasem, M.D. Professor in Orthopaedics Faculty of Medicine Khon Kaen University
Contents: Fractures and Dislocations Mechanisms of injuries Description or terminology Diagnosis Treatment Fracture healing 2
Definitions Fracture Displacement of fracture fragment Joint injuries Dislocation (luxation) --} loss of congruency Subluxation (sub+luxation) Instability Sprain Muscle and tendon injuries Tear or rupture Strain 3
Fracture Transverse Oblique Spiral Comminuted 4
Subluxation Dislocation 5
ขอเคล!"อน (subluxation) ขอค(ง" เล!อด (haemarthrosis ) ขอหล&ด (dislocation) 6
Rupture of Meniscus 7
Strain 8
Muscle & tendon rupture 9
Mechanisms of Fracture Force Direct Indirect Load Tension (tensile) Compression Shear Stress (Stress> Strength) Concentration Fracture (failure) Brittle Fatigue Plastic 10
Fracture Mechanism by direct forces: Force vs. Area Tapping fracture Crushed fracture Penetrating fracture 11
Fracture Mechanism by indirect forces Avulsion (tension) Angulation (bending) Rotation (torsion) Axial compression Angulation + compression Angulation + compression + rotation 12
Avulsion Fracture e.g., olecranon process Triceps 13
Angulation Fracture Green-stick fracture Transverse fracture Buckled fracture 14
Rotation Fracture ลองบดแทงชอลก แลวสงเกตดรอยหก Spiral fracture 15
Axial Compression Long bone Oblique fracture 16
Axial Compression Short bone Burst fracture 17
Angulation + Compression Butterfly fracture 18
Angulation+ Compression+ Rotation Short spiral fracture 19
Common Fracture Deformities Overriding Angulation Rotation Distraction Compression Malapposition 20
Description of a Fracture Deformity Global agreements: Proximal Always indicating deformity of the distal fragment in relation with the proximal one e.g., anterior displacement = anterior displacement of the distal fragment Anterio r Dista l Not anterior dislocation! 21
Description of Fractures Which one Fracture tells you more Fracture of the right femur definitely? Fracture of the right femoral shaft Oblique fracture of the right femoral shaft with anteromedial displacement Type II open oblique fracture of the right femoral shaft with anteromedial displacement 22
Description of Fractures Styles: Fracture of the femur Femoral fracture Fractured femur Fracture, femur Fracture femur ใชบอยในภาษาพด แตไมถกหลก ตามภาษาเข"ยน 23
Description of Bone and Joint Injuries Fracture / dislocation, etc. Adding adjective, conjunction, preposition Usually describing acute conditions Define otherwise old fracture mal-united fracture un-united fracture recurrent dislocation 24
Description of Bone and Joint Injuries Described by telling Anatomy, site (e.g., side, bone, part) Type, extent (e.g., open, incomplete) Configuration (e.g., transverse, comminuted) Deformity, direction (e.g., displacement, anterior ) Eponym (Colles, Monteggia, Galeazzi) Complication, cause (e.g., infected, fatigue, pathological) 25
Incomplete Fractures Hair-line fracture Tea-cup fracture Green-stick fracture ลองเอา ก#งไมสดมาหกด Buckled fracture 26
Comminuted Fractures T-shaped Y-shaped Segmental Double H-shaped segmental 27
Description of Fractures Example: Try your own! 28
Description of Fractures Example: Closed, segmental fracture of the right femoral diaphysis and type IIIB open comminuted fractures of the ipsilateral tibial ลองประเมน shaft with bone loss ตวเองดวาเขาใจ ท'กค)าหร*อไม 29
Closed, segmental fracture of the right femoral diaphysis Type IIIB open comminuted fractures of the ipsilateral tibial shaft with bone loss 30
Open fractures ไมใช Opened fracture Open fracture = fracture + contamination Classifications ---} prognosis Type I: inside - out Type II: outside - in Type III: Type II + destruction of other functional unit(s) Type III A, B, C 31
Type III Open Fractures Shotgun fracture High velocity gunshot fracture Displaced segmental fracture Diaphyseal segmental bone loss Farm yard / highly contaminated (wound) Crushed fracture from high speed vehicle Associated major vascular injury 32
Describe 33
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Diagnosis Common errors missing and misdiagnosing (incorrect diagnosis)? Tools? History taking Screening test Physical examination Radiological examination Laboratory investigation 35
Diagnosis ถาม"ปญ + หาการส*#อภาษากบ ผป.วย ควรขอรองใหผน)าสง ชวยอยใหประวตดวย History taking Where, when and how did it happen? Which part (s) of the body is (are) involved? What treatments have been given prior to the arrival? 36
Screening Tests Upper extremities Ribs & sternum Active movements, sign-of-4 Spines Compression both ilia, pubis Lower extremities Chest compression AP, bilateral Cough, deep inspiration Pelvis Active movements, shaking hands Functional tests to detect the evidence of injuries Active movements, palpation 37
Physical Examinations Fracture/dislocation Definite signs Deformity Abnormal motion Crepitus เจ/บปวดเพ#มข01น อาจเพ#มการบาดเจ/บ 38
Physical Examinations Fracture/dislocation Relative signs Similar to soft tissue contusion tenderness, swelling, ecchymosis Circumferential involvement Osteophony test เคาะกระดก แลวฟ+งเส"ยง Axial compression test 39
Osteophony test 40
Axial Compression (Loading) Test Tenderness on direct palpation: fracture or contusion? 41
Radiographic Examinations Plain film Computerized tomography (CT scan) Magnetic resonance imaging (MRI) Special techniques AP, lateral, (2 obliques) Special views, e.g., swimmer s, axial e.g., tomography, angiography, MRA 42
Roentgenographic Views 2 views: AP, lateral; two oblique 2 joints: parallel bones, one displaced fracture, e.g., Monteggia 2 sides: growing ossification centers 2 occasions: non-displaced scaphoid fracture 2 media: contrast media 43
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Axial view for the calcaneus 45
Ultimate Goals of Treatment in Orthopaedics to restore... FORM...and FUNCTIONS 46
Priority Setting for Trauma Patients To save Life Limb Function Aesthetics 47
Splint the injured parts: Treatment Immediate cares (at the injury site) for Involved joints: one joint above and below Different types of splint Thomas splint (best for LE) A irway obstruction B reathing C irculatory failure: shock D islocation/ fracture 48
Thomas Splint 49
Treatment Transportation In suspicion of head injury, splint the neck Move the victim only when necessary Move unconscious or back-injured patient as a log (by 3 rescuers) Drive carefully to the hospital 50
Transportation 51
Treatment Emergency cares (at ER/AE room) for A irway obstruction B reathing (bleeding) C irculatory failure D islocation/ fracture Intubation Haemostasis Fluid / blood replacement Splintage 52
General principles of treatment Firstly do no harm Base treatment on an accurate diagnosis and prognosis Select treatment for specific problems Cooperate with the laws of nature Be realistic and practical in treatment Select treatment for individual patient 53
Treatment Definitive treatments of fracture / dislocation Reduction (manipulation) Immobilization Retention of reduction 54
Closed Vs Open Treatment Joint immobilization Skin problems Socioeconomic problems Risks of surgery Anaesthesia Blood transfusion Infection 55
Definitive Treatments Reduction Closed manipulation with or without fluoroscopy --} image intensifier or C-arm Open (under direct vision) 56
Image Intensifier (C-arm) 57
Reduction -- goals Fracture deformities to be corrected : Alignment how parallel is the longitudinal axes? Overriding Angulation Rotation 58
Reduction -- goals Fracture deformities to be corrected : Apposition end-to-end contact (side-to-side contact: bayonet) Compression Translation Overriding 59
Reduction -- goals Fracture deformities to be corrected : Rotation: around an axis Rotation 60
Reduction -- goals Fracture deformities to be corrected : Length: shortening / lengthening of an axis Overriding Distraction Bone loss 61
Reduction or 3-point effect of deforming & reduction forces Curved cast to maintain reduction Straight cast results in re-displacement 62
Reduction Apply Traction Increase deformity Reduce 1 cortex Reverse deformity 1 2 3 4 63
Reduction Apply Traction Increase deformity Reduce 1 cortex Reverse deformity 64
Immobilization Direct Indirect e.g., plating, nailing, applying external fixator e.g., casting, bracing, splinting, traction 65
External Fixators 66
Internal Fixations Plate Screw Nail, rod Pin, wire Kirschner Steinmann Wire cerclage 67
Implants Plate Screw Nail, rod Pin, wire -Kirschner Cerclage wire -Steinmann 68
Treatment of Open Fractures 69
Treatment of Open Fractures Aims Preventing wound infection Debridement Remove devitalized tissues Preserve survived tissues Apply appropriate antibiotics อาน เพ#มเตม Fracture reduction and stabilization ---> mostly using external fixator 70
Treatment Early rehabilitation... Continuous Passive Motion 71
Treatment Conclusions Recognition Relief of pain Reduction of fracture Retention of reduction Rehabilitation Reconstruction 72
Specific Methods of Treatment for Closed Fractures
Protection alone No reduction and immobilization Non-weight bearing, arm sling, leave alone Non- or minimally displaced, stable fracture fibular # alone, rib # metacarpal #, metatarsal # clavicular # in small children impacted # of humeral neck compression # of vertebra without neuro. deficit Needs close follow-up 74
No reduction--} external splinting Partially displaced, stable under axial load Other deforming forces (angulation, rotation) can be neutralized (stabilized) by cast molding or splinting tibia and/or fibula (cast) radius and/or ulna (cast) humerus (sugar tong slab) small bones of hand and foot (buddy splint) 75
Closed reduction --} external imm. Displaced fractures, but reduction can be obtained and maintained by closed methods Fractures that do not require rigid immobilization Closed reduction by manipulation gravity or positioning e.g., flexion compression # of the spines traction: temporary, continuous 76
Chinese finger trap 77
Closed reduction --} external imm. External immobilizations: cast, splint, brace, cast-brace most stable # in adults Colles # (short arm cast) # tibia and fibula (long leg or PTB cast) # radius and ulna (long arm cast) most complete # in children type I&II epiphyseal injuries (cast) 78
Closed reduction --} direct fixation Closed reduction: manipulation, traction + image intensifier Closed internal fixation: pin, wire (supracondylar humeral #) canulated screw (femoral neck) nail, rod + locking screw (tibia, femur) External fixator application 79
Open reduction --} direct fixation A closed fracture that closed reduction cannot be obtained and/or subsequently maintained Open fracture, after sufficient debridement Stable or rigid fixation can be obtained by internal fixation (osteosynthesis) plate, screws intramedullary nail or rod (other modified designs) tension band wiring External fixator application 80
Excision of a fracture fragment --} + endoprosthesis replacement Excisional arthroplasty High incidence of avascular necrosis, nonunion, posttraumatic osteoarthritis femoral neck # in an elderly or being osteoporotic comminuted radial head # in young adults comminuted humeral head # (4-part #) severe comminuted # of the patella 81
Ligamentotaxis Severe comminuted fractures of the joint not feasible for open reduction and fixation Distraction of the ligaments and capsule to hold the fracture fragments together as reduction severe comminuted # of distal radius using external fixator and encourage early motion 82
Ligamentotaxis 83
Bag-of-bone technique Severely comminuted fractures of cancellous bone not feasible for open reduction and fixation severely comminuted calcaneal # Manipulative molding of the fragments as an reduction Encourage non-weight bearing ambulation / motion 84
If the only tool you have is a hammer, you tend to see every problem as a nail Abraham Maslow 85
Fracture Healing Regeneration, no scar Form Vs function: Wolff s law 3 major phases: Clinical union Inflammation Repair: bone / cartilage / fibrosis External bridging callus Medullary callus Remodeling Motion Tenderness / pain Roentgenographic union No fracture line Fully remodeled Creeping substitution 86
Treatment Apposition Stabilization Loading Motion Trauma Cell matrix damage Healing: Inflammation Repair Remodeling Injury Type Intensity Extent Duration Tissue type Bone Cartilage Fibrous tissue Muscle Result: Restoration of original tissue Scar tissue Excessive repair Failure of healing Patient Age Metabolic Disease Medication 87
Repair Remodeling 10% 40% 70% Intensity of response Inflammation Time 88
Organized haematoma Cartilage Subperiosteal callus Dead bone end 89
Medullary callus External bridging callus 90
Thank you for your attention 91