Orthopaedic Trauma อ.ธีรชัย

1 Fracture Principles
2 Emergency Splinting and Casting
21
3 Fractures and Dislocations of Upper Extremity
35
4 Fractures and Dislocations of the Hand and Wrist
46
5 Fractures and Dislocations of Lower Extremity
58
6 Spinal Injuries
79
7 Fractures and Dislocations in Children
98
8 Open Fractures
110
9 Fractures and Dislocations for General Practitioner
120
10 Complications of fracture
134
Fracture Principles
1 Fracture Principles
__________________________________________________________________________________________
Terminology of Fractures

Anatomic location
proximal, middle distal thirds
epiphysis, metaphysis, diaphysis
Direction of fracture lines ( 1.1 )
Transverse :

Oblique :
30-60
Spiral :
Comminuted :
2
(segment) (butterfly
fracture)
Impacted :
2
(osteoporosis) cortex
metaphysis proximal humerus
1.1 fracture pattern
Fracture Principles
Relation of the fragment to each other

(displacement) (proximal
fragment) (distal fragment)
Stability
Stable fracture :
Unstable fracture :

transverse oblique fracture

spiral comminuted fracture
Associated soft tissue injury

Simple (closed) :

Compound (open) :
Eponym ( 1.2)
Colles fracture :
radius 1 1
dorsal
Smiths fracture :
radius volar
(Reverse Colles fracture)
Monteggia fracture : ulna 1/3 radial head
Galeazzi fracture : radius 1/3 distal radioulnar
joint (DRUJ)
1.2
( Eponym)
2
Fracture Principles
( 1.3)
Nightstick fracture : ulnar
Chauffeurs fracture : radial styloid
radial styloid
Boxers fracture :
metacarpal neck 4 5
March fracture :
metatarsal neck 2 3
!"#$%&%"'()*+,'%-+.
!"#$%&'()%*+,-%$
1.3
Joint Injuries
Sprain : 3
First degree :

Second degree :

Third degree :

Subluxation :
partial dislocation
Dislocation :
luxation
Fracture Principles
Fracture Healing

Cortical bone healing diaphysis long bone 3 ( 1.4)

1.! Inflammatory phase 10%
2.! Repairative phase 40%
3.! Remodeling phase 70%

1.4 Healing process

1.! Inflammatory phase (1.5)

hematoma osteocyte
inflammatory response
vasodilatation PMN ,
histiocyte osteoblast
2-4

2.! Reparative phase ( 1.6)
osteoblast new capillary bud
hematoma granulation
tissue cell collagen
calcium appatite
crystal callus
formation clinical
4
1.5 Inflammatory phase
1.6 Repairative phase
Fracture Principles
union callus

3.( Remodeling phase ( 1.7)

Wolff law stress
stress
1.7 Remodeling phase
Cancellous bone healing metaphysis long bone

cancellous bone cortical bone
cancellous bone
osteoblast
trabeculae cancellous bone healing cortical
bone healing metaphysis diaphysis bridging
external callus
2
external bridging callus
medullary internal callus
internal callus
Fracture Principles
1.! solid union

2.!

1.! Intra articular fractures anatomical reduction

(traumatic arthritis)
2.! Metaphyseal fractures (joint alignment)
3.! Diaphyseal fractures

1.(
- , , ,

- open
fracture 8 contamination
wound infected wound
- open fracture
-

open fracture
2.(

3
1.! life threatening condition, resuscitation
2.! (screening test)
3.!
Fracture Principles
Screening test

(compression test)
sternum 2

anterior superior iliac spine 2 2
pubic symphysis

(log rolling)

special test, nerve,

vessel

1.!
2.! (abnormal movement)
3.! (crepitus)
1.! (swelling) (ecchymosis)

2.! (tenderness, pain on motion)
3.! Pseudoparalysis
fracture clavicle pulled elbow
4.! Axial compression test

Fracture Principles
3.
1.!

2.! 2 anteroposterior lateral
3.!
4.! ossification center accessory
ossicle 2
5.!

6.!

C-spine open mouth
1 (atlas) 2
(axis, odontoid)
C-spine swimmer s view lower cervical spine, upper thoracic
Transcapular view
head humerus scapular
Lateral
Scaphoid view (PA) fracture scaphoid
Pelvis inlet, outlet

Judets acetabulum

Hip lateral cross table lateral proximal
femur
skyline view
vertical fracture patella
osteochondral fracture
Fracture Principles
ankle mortise
distal
tibiofibular joint
calcaneus
calcaneal axial
!

5
(5R)
1.( Recognition

2.( Reduction
3.( Retention
4.( Rehabilitation

5.( Reconstruction

5R 6R Refer
(Reduction)
(Retention)
Reduction
(displaced)
(non-displaced)

impacted fracture
displaced fracture
9
Fracture Principles
2
1. Closed reduction

1.1! (closed manipulation)

1.2! (continuous traction)

2. Open reduction

(internal fixation)
open reduction and internal fixation (ORIF)
Retention

Colles fracture
scaphoid
fracture

1.( (Casting)

closed manipulation
retention
2
Comminuted fracture of tibia
10
Fracture Principles
2.( (Continuous traction)

3.( (Internal fixation osteosynthesis)
plate and screw, intramedullary nail, wire

4.( (External fixation)
pin schanz screw
open fracture closed fracture
! Principle of Operative Fracture Treatment

rotation

hematoma, inflammation
pain reflex immobilization
fracture disease (LucasChampioniere 1907)
Pathogenesis of fracture disease pain,reflex immobilization bone muscle
complex physiologic load edema, intermuscular fibrosis muscle
atrophy chronic edema, soft tissue atrophy
patchy osteoporosis (disuse osteoporosis) physiologic load
11
Fracture Principles
fracture disease
active pain-free mobilization physiologic load bone muscle complex
joint stiffness muscle atrophy
early exercise
(intramedullary nail) (plate and screw)
(external fixation) open reduction internal fixation (ORIF)
early exercise ORIF external
immobilization
internal fixation
(bone healing mechanism)
internal fixation

(implant failure)
internal fixation
1.! anatomical reduction articular surface
post traumatic arthritis diaphysis
rotation
periosteum
(sequestrum)
2.! Stable internal fixation internal fixation
early exercise fracture disease
3.! Preservation of blood supply incision
handle soft tissue atraumatic surgical technique
bone healing
4.! Early active pain free mobilization bone muscle complex
physiologic load joint stiffness osteoporosis
12
Fracture Principles
Indications for Surgical Reduction and Stabilization

(internal fixation external fixation)
1.! Displace intrarticular fracture reduction closed method
open reduction anatomical reduction, promote
cartilage healing post-tramatic arthritis
2.! Unstable fractures close manipulation
3.! Major avulsion fracture disruption musculotendinous unit
ligament avulsion fracture olecranon, patella
4.! Displaced pathologic fracture ambulation

5.! Fracture femoral neck fracture,
Monteggia, Galeazzi fracture-dislocation
6.! Displaced epiphyseal fractures growth arrest
Salter Harris type III IV
7.! Nonunion close open method
8.! Fractures compartment syndrome fasciotomy
reduction stabilization
9.! Replantation
Relative Indications
improve function limb ambulation
1.! Multiple fractures unstable spinal injuries, unstable pelvic fractures,
polytraumatize head injury,chest injury improve nursing care
2.! Delayed union ORIF bone graft
3.! Impending pathologic fractures prophylaxis fixation
4.! Unstable open fractures complex soft tissue injury (Gustilo 3B)
5.! Fracture systemic complication hip
fracture
6.! Fracture vascular injury neurodeficit surgical repair
13
Fracture Principles
Contraindications to Surgical Reduction and Stabilization

internal fixation
1.! Osteoporotic bone
2.! soft tissue ORIF burn, dermatitis, scar
external fixation
3.! Active infection osteomyelitis ORIF infection
4.! General condition

acute
myocardial infarction
5.! Undisplaced fracture impacted fractures position fractures

6.!

exercise
1.!
internal fixation scar

muscle tendon unit scar
2.!
3.! local infection blood-born hepatitis,
AIDS.
4.! Metallic implant removal 2

Timing of Operative Treatment
factor
, associated injuries chest, abdominal trauma
Surgical procedures 3
1.( Emergency open fractures,
irreducible dislocation of major joint, unstable spinal injuries, unstable pelvic
14
Fracture Principles
fractures, fracture dislocation

2.( Urgent 24-72 evaluate resuscitation
re-debridement severe open fractures, long bone stabilization
polytrauma, hip fractures
3.( Elective 3-4 3-4 injury
2
4-6
tissue plane
autogenous bone graft
Types of Internal Fixation

Wire fixation
internal fixation
diaphyseal fracture
avulsion fracture olecranon, patella
Plate and Screw Fixation
Plate
plate screw 6-8 cortex (3-4 )
fracture
Intramedullary Nail Fixation
Nail medullary canal splint
fracture nail cortex
3-point fixation nail 2 unlocked nail
fracture transverse short oblique canal
fracture comminuted spiral nail 2
2 interlocking nail
15
Fracture Principles
External Fixation
wire, pin schanze screw

External Fixator
1.! open fracture open fracture type II,III
burn flap skin graft
2.! (limb lengthening)
3.! (arthrodesis)
4.! (infected fracture or nonunions)
5.!

6.!
7.! internal fixation
External Fixator
1.!
2.!

3.!
4.! (skin and bone graft)
5.! external fixator
6.!
External Fixator
1.! pin tract infection
2.! ring fixator
3.!
4.! pin
16
Fracture Principles
5.! pin (joint stiffness)

6.! pin
external fixator

Metal Removal
internal fixation implant
injury stress riser effect
bone implant titanium biological inert
implant elasticity stainless steel stress riser
effect
upper limb remove implant
inflammatory reaction plate shaft humerus proximal radius
injury radial nerve posterior interosseous nerve

plate lower limb implant screw stainless
, plate screw pelvis acetabulum titanium plate
Steinless implant
18-24
fracture healing
! (clinical union)
-( callus 2
callus
!
-( clinical union 6-8
3-4
! U-slab fracture humerus long arm cast fracture
forearm 6 clinical union long leg
cast fracture tibia clinical union PTB cast
17
Fracture Principles
-( humerus. forearm
tibia
weight bearing bone

PTB cast 8-12
intraarticular fracture fracture neck of femur
-( synovial fluid enzyme fibrinolysin blood clot
callus formation

-( internal medullary callus

external bridging callus
delayed union 3 6
-(

(non union)
-(
Pseudarthrosis fibrous union
1.! (osteosclerosis)
2.! (obliterate canal)
3.!
4.!
-(

(non-displaced fracture)
18
Fracture Principles
!
-(

bone graft
!
-( stainless steel
Titanium inert metal
!
-( upper extremity implant
acetabulum implant
lower extremity weight bearing bone
bone remodeling 18-24
Common pitfalls in diagnosis and treatment of fractures

1.! osteochondral fracture
2.! incomplete fracture, fracture tibia with
intact fibula, isolate fracture fibula
3.! accessory ossicles

4.! (no
fracture)
5.!
(osteoporosis)

1-2
6.! 2

7.! ossification center

19
Fracture Principles
8.! epiphyseal plate

ligament ligament injury
9.!

10.!

11.! isolate fracture fibula

1
12.! impact fracture neck of femur fracture
odontoid
13.! displacement
dislocation diaphysis
dislocation
14.! high
potency paracetamol 2 tab oral prn for pain
20
Emergency Splinting and Casting
2 Emergency Splinting and Casting

--------------------------------------------------------------------------------------------------------------------------------------
! Emergency splint of the spine

A.! ,
B.! 2

C.!
D.! neurogenic shock
venous return
! Upper extremity splinting

A.!
B.! splint
C.! arm sling
( 2.1)
D.! sling and swath arm sling

( 2.2)
E.! skin marceration
2.1 Arm sling
2.2 Sling and swath
21
! Lower extremity splinting

A.! Thomas splint splint half-ring splint
femur splint
thomas splint ring thomas splint
ischium tuberosity splint
B.! Jone compression splint acute knee trauma splint
1 2-3
elastic bandage elastic
bandage proximal distal
C.! Short leg or modified Jone compression splint acute ankle and
foot trauma ankle sprain, calcaneal fracture splint Jone
compression splint
tibial turbercle
circulation
! Splint ( 2.3)
A.! Pillow splint distal leg, ankle
B.! Board splint

2 lower extremity
fracture femur, tibia
! casting
2.3 Pillow splint

board splint

(CaSo4 )2 H2O + 3 H2O = 2 (CaSo4 . 2 H2O) + heat
2
1.!
2.! fiber glass

22

1.! slow, fast
extra fast setting
2.!
3.!

4.!

(webril) (stockinette)

(cast spreader)
Basic principle
A.!
1.! (immobilize)
2.! (early ambulation)
3.! (correct deformity)
4.! (prevent deformity)
B.!
soft tissue periosteum
three-point fixation
curved cast provide straight alignment ( 2.4)
2.4 three
point fixation

23
!
soft tissue splint
!

short arm cast Colles fracture
pronation ulna deviation 3-point fixation
PTB cast femoral condyle proximal
tibia
2.5 Three point fixation

Colles fracture
2.6 PTB cast

fracture tibia
C.!
1.!
2.!
4
6 6 3 webril
3 4 6
3.! (circular cast)
compartment syndrome slab
4.!
5.! (stockinette)
webril
webril webril
( 2.7)
24
2
webril 3-4
2.7 webril
6.!
( 2.8)

( 2.9)

2.8

2.9
7.!

4-6 mold

stockinette webril
webril

25
8.! (molding) mold

9.!

10.!

24-36
! splint (slab)
posterior splint
slab
slab

slab 8-10 4 slab
10-14 4 6
2.10 slab
2.11 slab
slab slab ( 2.10)

( 2.11) webril 2-3
elastic bandage
26
webril slab

1.!

2.!
3.!
4.! 2-3
5.!
6.!
7.!
.!
.!
.!
.!

.!
8.!
(cast windowing)

window

window
bandage

window
(window edema)
27
2.12
D.!

compartment syndrome
1.!
2.!
3.! bony prominence medial malleolus,

fibular head
(vibration)

1.!
2.!
2
(bivalve) ( 2.13 )
3.!
4.!
( 2.14 )
5.! webril stockinette
6.!
elastic bandage
exercise
28
2.13 2 (bivalve)
2.14
E.!
1.! U-slab sugar tong ( 2.15)
fracture shaft of humerus slab
6-8 distal end clavicle

1
2.15 U-slab sugar tong
internal rotation support
forearm arm sling
2.! Long arm cast ( 2.16) supracondylar
fracture humerus, fracture forearm
deltoid
distal palmar crease head
metacarpal 90
2.16 Long arm cast

3.! Short arm cast fracture distal radius
Colles fracture

long arm cast
2.17 Short arm cast

29
4.! Thumb spica cast fracture scaphoid,

Benettes fracture short arm cast
dorsiflexion wrist 15-20
IP joint
thumb
5.! Long leg cast ( 2.19) tibial fracture
1-2 5- 2.18 Thumb spica cast
10 neutral base
of toe
6.! Short leg cast ( 2.20) ankle fracture. ankle sprain, fracture
calcaneus tibial tuberosity hamstring
fibular neck common
peroneal nerve
7.! Cylinder cast ( 2.21) patella fracture, knee ligament injury
long leg cast medial malleolus 1
10 mold
femoral condyle proximal tibia
2.19 Long leg cast 2.20 Short leg cast
30
2.21 Cylinder cast
! Traction
traction
1.! maintain length alignment stability
2.! traction proximal tibia
traction Pearson attachment Thomas splint (Balanced traction)
3.! (muscle spasm)
Buck s traction hip injury
4.! traction
Skin traction
definite treatment

10 4

4-6
1.! tincture benzoin
2.!
fibular neck
3.! elastic bandage

elastic bandage
4.! spreader bar

10 .
Skeletal traction
Kirschner wire (K-wire) Steinmann pin
wire pin 2 (smooth) (threaded)
31
osteoporosis

pin wire
1.!
2.!

3.!
pin vital structure
olecranon pin medial lateral ulnar nerve
4.! infection
5.! subcutaneous
periosteum
pin
6.! pin
K-wire pin
pin
skin necrosis, pin tract infection
7.! pin metaphysis
cortical bone epiphyseal plate
tibial tubercle distal femoral epiphysis
8.! pin open fracture
9.! pin distal femur
Skeletal traction
1.! Metacarpals K-wire diaphysis 2nd 3rd metacarpal 1st
interosseous volar K-wire dorsal
2.! Olecranon distal olecranon process 1
90 medial lateral ulnar nerve
3.! Distal femur just proximal adductor tubercle
upper pole patella mid coronal distal femur
medial lateral popliteal vessel
32
4.! Proximal tibia distal

posterior tibial tubercle 1
lateral medial
common peroneal nerve
5.! Distal tibia and fibula
tip lateral malleolus 1 2.22
lateral medial fibular proximal tibial traction
distal tibia pin
fibula tibia
6.! Calcaneus tip lateral malleolus inferior
posterior 1 medial malleolus inferior posterior 1
Cervical spine traction

Head halter traction splint cervical spine
mandible occiput 10
head halter

temperomandibular joint
2.23 Head halter traction

Skull tong traction (Gardner-Wells tong) reduction fracture, dislocation
cervicle spine definite treatment Gardnerwells tongs ( 2.24)
(external auditory meatus) tip mastoid
process 1 (superficial
temporal artery) 0.5 . screw
2 indicator () 1 ..
33
screw outer table inner table

skull 2-3 indicator bone necrosis
screw screw
2.24 Gardner-Well skull traction

----------------------------------------------------------------------------------------------------------------------
34
Fractures and Dislocations of Upper Extremity
3 Fractures and Dislocations of Upper Extremity

__________________________________________________________________________________________
! Sternoclavicular (SC) joint injury

2
1.! Anterior dislocation medial end clavicle
arm sling closed reduction redislocate
skillful neglected ()
complication wound infection, mediastinitis
2. Posterior dislocation medial end clavicle
trechea esophagus
closed reduction general anesthesia towel clip
arm sling reduction
mediastinal structure
! Fracture middle third of clavicle

deformity
deformity
sternocleidomastoid proximal fragment posterosuperior

pectoralis major distal fragment
Fracture clavicle 80-90 % malunion

distal fragment
proximal fragment arm sling figure of eight
commercial clavicular strap figure of eight
figure of eight arm sling
figure of eight 3-5 cc.
2 figure of eight

nerve, vessel 4-6
35
1.! open fracture

2.! nonunion
3.! neurovascular injury
4.! pathological fracture
5.! impending open fracture
6.! floating shoulder
3.1 figure of eight
! Fracture distal third clavicle

acromioclavicular joint (A-C joint) dislocation
injury coraco clavicular ligament (CC ligament)
3 type( 3.2)
3.2 distal clavicle 3 type

1. Type I minimally displace CC ligament
clavicle coracoid clavicle
2 Type II displace fracture CC ligament proximal
fragment coracoid clavicle
3. Type III intraarticular fracture A-C joint
1.! Type I sling 1-2 exercise

2.! Type II K-wire
3.! Type III arm sling 1-2
exercise
36
! Acromioclavicular (AC) joint dislocation

ligament 2 acromioclavicular (AC) ligament
AC joint coracoclavicular (CC) ligament clavicle
coracoid process 3 type( 3.3)
3.3 Acromioclavicular joint dislocation 3 type
AC
dislocation
Type I
Type II
Type III
AC ligament CC ligament
Sprain
Tear
Intact
Sprain
Tear
Tear
Deformity
No
Slight AC
prominent
Gross AC
prominent
Treatment
Sling 7-10 day
Sling 1-2 weeks
ORIF
1.! Type I, II arm sling 1-2

2.! Type III K-wire
Type III

CC ligament ?
stress film 10-15 2 both
shoulder AP CC distance 50% 14 . complete
rupture CC ligament
37
! Anterior shoulder dislocation

indirect force abduction external rotation
hyperextension humerus coracoid process(subcoracoid type)
slightly abduction, external rotation

! Anterior fullness deltopectoral groove humerus
! Flatten deltoid acromion process lateral
epicondyle Hamilton ruler test
! Duga s test
! Axillary nerve sensation deltoid
insertion contraction deltoid muscle
! humeral head coracoid (subcoracoid type)
close reduction general anesthesia

2
1.! Zero position
abduction 165 forward flexion 45
medial epicondyle (
) traction humeral shaft abduction, flexion
zero position humeral head lateral
2.! Traction countertraction ( 3.4)
internal external rotate
Zero position

reduction
sling and swath 6
recurrent dislocation
sling and swath 13
abduction external rotation 6 strengthening
3.4 Traction-countertraction
exercise rotator cuff, scapulothoracic muscle
38
45 (stiffed shoulder) early

ROM exercise 1-2
! Fracture proximal humerus

2 high energy injury
displaced osteoporosis minor fall
impacted fracture non displaced fracture
Non displace, impacted fracture

AP, transcapular impacted fracture
proximal shaft
metaphysis ( 3.5) stable
non displaced

3.5 Impacted fracture

arm sling support
proximal humerus
2
early exercise
Displaced fracture ( 3.6)

displaced
1.! displaced 1 .
2.! Angulation 45
2, 3 4
displaced displaced
2 parts, 3 parts 4 parts fractures
ORIF plate,
3.6 Displaced fracture of
screw
proximal humerus
39
! Fracture shaft of humerus

radial nerve ( 3.7) spiral groove
distal humerus radial nerve palsy
wrist drop first web space
Holstein-Lewis fracture ( 3.8) spiral fracture distal humerus
reduction radial nerve
3.8 Holstein-Lewis fracture
3.7 radial nerve

humeral shaft
conservative 6-8
1.! Coaptation splint (Sugar tong, U-slab)
distraction splint 2 shaft ( U-slab)
4-6 2-3
functional brace
2.! Hanging cast 1

45

3.! Functional brace proximal shaft distal humerus

U-slab 2
40

1.! vascular injury
2.! multiple injury
3.! open fracture
4.! bilateral humeral fracture
5.! pathological fracture
6.! radial nerve palsy closed reduction
7.!
8.! non union
! Fracture of distal humerus ( 3.9)

! Supracondylar fracture distal humeral metaphysis joint
capsule (extraarticular)
non displaced fracture posterior splint 90 4

displaced fracture ORIF
! Trans condylar fracure osteoporosis variation
supracondylar fracture
joint capsule
closed reduction percutaneous pinning internal
fixation osteoporosis
! Intracondylar fracture medial lateral condyle
supracondylar
nondisplaced fracture long arm cast 4-6

displaced fracture ORIF early exercise
3.9 Fracture of distal

humerus
41
! Fracture Olecranon
2 direct injury comminuted fracture
triceps transverse fracture
Non displaced fracture 3
1.! 2 .
2.! 90
3.! gravity
posterior long arm slab 2-3
Displaced fracture K-wire plate screw
! Elbow Dislocation
90% posterior posterolateral
olecranon process
Heuters line medial
epicondyle,olcrenon,lateral epicondyle fracture radial
head, coronoid process, medial epicondyle dislocation radial artery
median, radial, ulnar nerve ulnar
nerve
closed reduction general regional anesthesia 2

1. proximal humerus traction forearm
medial lateral displacement 2
2 olecranon process
olecranon distal humerus
2. Parvin ( 3.10)

3-5 2-3 distal humerus

42
3.10 Parvins method of closed

reduction for elbow dislocation
reduction
! mechanical block
! 15-20
1 active
exercise
! Fracture shaft of radius and ulnar

fracture both bone of forearm radius, ulnar
proximal distal radius ulnar

pronation, supination
anatomical reduction
1.! Non displaced fracture
long arm cast 4-6
2.! Displaced fracture ( 3.11) ORIF plate screw
exercise
3.11 radius
ulnar ** **
43
! Monteggia fracture
Fracture proximal 1/3 ulnar radial head dislocation ( 3.12)
fracture ulnar radial head
fracture proximal ulnar radial head AP
lateral elbow radial head capitullum 2
capitullum radial head dislocation
3.12 Monteggia fracture ****
1.! closed reduction radial head traction supination radial

head reduce open reduction
2.! ORIF ulnar plate screw
posterior long arm slab full supination 2-4
! Galeazzi fracture (Reverse Monteggia fracture)

Fracture distal 1/3 radius distal radioulnar joint (DRUJ) dislocation (
3.13) Monteggia fracture fracture distal 1/3 radius DRUJ
distal ulnar
distal ulnar (piano key sign) AP DURJ
DRUJ injury
1.! closed reduction DRUJ supination forearm

2.! ORIF radius plate screw
posterior long arm slab supination 2-4
44
3.13 Fracture distal 1/3 radius

distal radioulnar joint dislocation
Galeazzi fracture
****
! Nightstick fracture
Isolate fracture ulnar shaft direct injury

1.! Non displaced fracture angulation 10

long arm cast 4
2.! Displaced fracture ORIF plate, screw
3.14 Nightstick fracture
45
Fractures and Dislocations of the Hand and Wrist
4 Fractures and Dislocations of the Hand and Wrist

----------------------------------------------------------------------------------------! Distal radius fractures
2 osteoporosis
minor fall high energy injury

Colles fractures
Abraham Colles ..1814
distal radius 2.5 ..
distal fragment dorsal radial (
4 . 1 )
osteoporosis
4.1 Dinner fork deformity
displaced fracture
Colles fracture
dinner-fork deformity nondisplaced minimally
displaced fracture deformity distal radius
median nerve proximal fragment
nondisplaced minimally displaced fracture

(closed reduction) short arm cast short arm
slab 4
displaced fracture

K-Wire ORIF 80-90

do not treat the x-ray but the patient
(closed reduction) 3
Colles fracture
1.! dorsal radial displacement
2.! shortening radius
46
3.! loss of normal 10 volar tilt lateral view
Anesthesia

1.! General anesthesia

2.! Regional anesthesia

3.! Local hematoma anesthesia ( 4.2)

simple
fracture

4.2 Local hematoma anesthesia

5 cc.

(reduction)

* pronation *
( 4.3)
Chinese finger trap
(degloving skin)
-! 1 Disimpaction
hyperextension soft tissue hinge ( 4.4)
-! 2 Traction distal fragment
extension dorsal cortex
volar flexion ( 4.5)
-! 3 Volar flexion dorsal cortex distal fragment
volar ulnar deviation ( 4.6)
volar flexion
15-20 , ulnar deviation pronation
3
47
webril short arm cast
just proximal metacarpophalangeal joint

slab
radial slab Charnley slab ( 4.7)
4.3 Diagram
Colles fracture
4.4 Disimpaction hyperextension
4.6 Volar flexion of distal fragment
4.5 Traction distal fragment
4.7 Radial slab Charnley slab
reduction fluoroscopy
closed reduction
osteoporosis volar tilt 0-10
48
radial height 5 .

arm sling

arm sling
arm sling
arm sling *
*
(Follow up)

1-2
24-48

1.!
2.!
3.! slab

(fluoroscopy) 10-14
49
?
non displaced fracture 1-2
6
displaced fracture 2-3
1-2
6
(clinical union)
-! skin complication compartment

syndrome median nerve
-
Malunion inadequate reduction redisplacement
radial dorsal displacement prominent ulnar styloid
Prolong stiffness

Colles fracture
re-manipulation osteoporosis
malunion

malunion
Smiths fracture (Reverse Colles fracture)

distal radius
volar displacement ( 4.8)
Colles fracture

Colles
fracture traction supination
distal fragment volar dorsal
50
4.8 Smiths fracture volar

displacement
long arm cast 90 supination dorsiflex wrist

volar volar buttress plate distal
fragment
Bartons fracture
fracture dislocation subluxation rim distal radius
dorsal rim Dorsal Bartons fracture ( 4.9) volar rim Volar Bartons
fracture ( 4.10) intraarticular fracture anatomical
reduction
4.10 Volar Bartons
4.9 Dorsal Bartons fracture

plate screw K-wire
Fracture of the radial styloid (Chauffeurs fracture)

radial styloid ( 4.11)

radial styloid
direct injury high energy trauma
radial styloid 4.11 Chauffeurs fracture
scaphoid fracture
anatomical snuff box
non displaced fracture short arm cast 4-5

displaced fracture closed reduction, percutaneous K-wire fixation
51
! Scaphoid fracture
carpal bone
dorsiflex
90 scaphoid
distal ( 4.12) proximal
avascular necrosis proximal
fragment chronic wrist pain
snuffbox dorsal 4.12 Vascular supply
scaphoid tubercle volar
scaphoid distal
PA ulnar deviation
scaphoid
non displaced fracture displacement 1 .

thumb spica 8-12
displaced fracture closed reduction
screw
thumb spica 2

bone scan CT scan
! Hand fracture

splint

safe position ( 4.13)
MCP joint 90
52
4.13 Safe position
* MCP joint splint extension*
Distal Phalangeal fracture

crush injury
( 4.14)
tuft fracture comminuted fracture
pulp septum
soft tissue, nail fracture

splint DIP joint aluminium splint
2-3 subungual hematoma paper clip
nail bed
Mallet finger
4.14
distal
phalange
DIP joint extensor

incontinuity tendon rupture bony avulsion extensor tendon
dorsal base distal phalange ( 4.15) DIP joint flexion
DIP joint Bone avulsion
dorsal base of distal phalange tendon rupture
tendon rupture avulsion fracture splint DIP joint

full extension 6 ( 4.16) avulsion 30% articular
surface K-wire
4.16 splint Mallet

finger extension
4.15 Mallet finger

avulsion fracture
53
Fracture of Proximal and Middle Phalanges

direct injury

(malrotation) ( 4.17) scaphoid
tubercle ( 4.18)
4.17 rotation
non displaced fracture buddy

splint ( 4.19)
4
displaced fracture closed
reduction
aluminium splint
K-wire, plate, screw
4.18 rotation
scaphoid tubercle
4.19 Buddy splint
Metacarpal Neck fracture

Boxers
fracture ( 4.20)
(dorsal angulation) interosseous
muscle volar axis metacarpal
54
4.20 Boxers fracture

dorsal angulation Volar
comminution
Closed reduction MP joint PIP joint 90 (Jahss Method)

apex of angulation dorsal AP Slab MP joint 90
accept angulation 40
angulation 40
Metacarpal Shaft fracture

direct injury 3 shortening, angulation malrotation
axial compression test
hand AP, oblique true lateral angulation
malrotation 5 shortening 5 .
angulation 20 closed reduction AP slab MP joint 90
PIP 10-15 DIP 0-10
comminuted fracture multiple fracture
K-wire, plate, screw
Bennetts fracture
intraarticular fracture dislocation
carpometacarpal joint (CMC)
stable adductor pollicis
abductor pollicis longus (APL) fracture
displacement ( 4.20)
fracture dislocation
closed reduction
fluoroscopy percutaneous K-wire fixation
thumb spica 6
55
4.20 Bennetts fracture
PIP Joint dislocation

most common ligamentous injuries in the hand dorsal dislocation
PIP joint hyperextension avulsion fracture volar
base middle phalange
simple dislocation closed reduction ( 4.21)

1.! hyperextension PIP joint traction
2.! base middle phalange flex PIP joint splint 1-2
4.21 closed reduction PIP joint
MP Joint dislocation
dorsal dislocation 2
simple complex simple dislocation
MP joint hyperextension 60-80
complex dislocation MP extension 20
( 4.22)
4.22 Complex MP joint

-! simple dislocation closed
dislocation
reduction
1.! flex wrist tension finger flexor
2.! hyperextension MP joint 80-90 proximal phalange
flex MP joint proximal phalange volar plate
complex dislocation ( 4.23)
AP slab flex MP joint 50-70 1-2
56
-! complex dislocation closed reduction

simple dislocation
4.23 Closed reduction dorsal MP joint dislocation
57
Fractures and Dislocations of Lower Extremity
5 Fractures and Dislocations of Lower Extremity

---------------------------------------------------------------------------------------------------------------------------------------
! Fracture of the pelvis

2
1.! Lower energy injury

1-2
2.! High energy injury

shock
1.! Antero-posterior (AP) compression

injury ( 5.1)

pubic symphysis anterior
sacroiliac (SI) joint open
book external rotation
pelvis
retroperitoneum
5.1 AP compression injury
shock
2. Lateral compression injury ( 5.2)
pelvis
fracture sarcrum, ilium
fracture pubic rami

58
5.2 Lateral compression

injury
3. Vertical shearing ( 5.3)

hemipelvis
(posterior and upward)
SI joint, pubic symphysis
pelvic floor, lumbar-sacral plexus

internal hemipelvectomy
5.3 Vertical shearing injury
pelvis AP lateral
compression test pubic symphysis pelvis
AP, inlet, outlet view
1.! Stable injury

1.1!Fracture pelvic ring fracture iliac wing
1.2!AP compression injury pubic symphysis 2.5 .
1.3! lateral compression injury rami fracture

1-2
4-6
2.! Unstable injury AP compression injury pubic symphysis
2.5 . vertical shearing 2
2.1!Vital sign stable
-! AP compression injury pelvic sling pelvis
ORIF pubic symphysis
-! Vertical shearing distal femoral traction definite
treatment ORIF
2.2!Vital sign unstable
(20-40%)
resuscitation, blood transfusion
59
diagnostic peritoneal lavage (DPL) supraumbilical

false positive ultrasound abdomen intraabdominal
bleeding close reduction
pelvis external fixator
(tamponade effect) laparotomy
external fixator elastic
bandage 6 pelvis internal rotation
femur elastic bandage 6
! Fracture Acetabulum
(dashboard injury)
greater trochanter
(post traumatic
arthritis) (recurrent dislocation)

pelvis AP Judet s view (internal, external oblique)
1.! posterior central dislocation

closed reduction
2
2.! 3-5 . non
displaced fracture skin traction 6
3.! 3-5 .
(ORIF)

1.! 3-5 .
2.! joint capsule
3.! posterior wall

60
! Hip dislocation

avascular necrosis
Anterior Dislocation of the hip

10-15% femur abduction, external
rotation

pathognomonic sign
flexion, abduction external rotation hip
joint femoral vessel nerve
dorsalis pedis posterior tibial
artery sensation femoral nerve
motor
quadriceps femoral
head acetabulum obturator
foramen( 5.4)
closed reduction
general anesthesia Alliss
maneuver( 5.5)
pelvis
adduction internal rotation
lateral traction

skin traction 1
2-4
61
5.4 Anterior dislocation

of the hip
5.5 Alliss maneuver for anterior

dislocation of the hip
Posterior Dislocation
80% ( 5.6)
(simple dislocation) (fracture-dislocation)
flexion, adduction
internal rotation posterior
dislocation sciatic nerve
( 5.7)
sensation common peroneal nerve
tibial nerve motor
common peroneal nerve

dorsiflexion tibial nerve 5. 6 Posterior dislocation of
the hip
plantar flexion

closed reduction general

anesthesia Alliss Maneuver
( anterior dislocation) ( 5.8)
pelvis
90
5.7 Sciatic nerve

1.! test stability fracture
posterior wall acetabulum
60-90 neural rotation

2.! both hip AP
joint space joint capsule

62
3.! test stability stable, joint space

2 simple
dislocation skin traction
5-7
2-4
4.! test stability
(unstable)
plate, screw
5.8 Alliss maneuver for
posterior dislocation of the hip
! Fracture of Proximal femur

3
1.! Fracture neck of the femur anatomical neck just proximal
intertrochanteric line intracapsular fracture
2.! Intertrochanteric fracture intertrochanteric line extracapsular
fracture
3.! Subtrochanteric fracture lesser trochanter
5
.
proximal femur
1.! Shentons line ( 5.9)
superior pubic rami
medial neck shaft femur
2.! lesser trochanter medial

neck, head, lateral neck, greater trochanter

3.! tip of greater trochanter
5.9 Shentons line
femoral head
63
! Fracture neck of femur

intracapsular fracture osteoporosis
minor trauma high energy trauma
2
1.! Non displaced impacted fracture (incomplete fracture) complete
fracture displaced groin pain
(antalgic gait) limitation of motion
2.! Displaced partially totally displaced
fracture neck
of femur midinguinal point
1.! Non displaced displacement

2-3 (multiple screw fixation)
2.! Displaced closed reduction multiple screw
fixation osteoporosis
(hemiarthroplasty) ( 5.10)
5.10 Femoral neck fracture multiple

screws fixation hemiarthroplasty
! Non union neck periosteum callus,

intracapsular fracture enzyme collagenase blood clot
! Avascular necrosis revascularization femoral head
64
! Intertrochanteric fracture
extracapsular fracture greater lesser trochanter
greater trochanter (ecchymosis)
external rotation fracture neck of femur
conservative treatment
traction 6
venous thrombosis, pressure sore, pneumonia, UTI
internal fixation( 5.11)

5.11 Intertrochanteric
fracture
! Subtrochanteric fracture
lesser trochanter 5 .
lesser trochanter 2

1.! high energy trauma
2.! pathologic condition metastatic cancer, metabolic bone

disease stress
fatigue fracture
65
high energy trauma internal

fixation metastatic cancer
internal fixation bone cement
! Fracture shaft of the femur

high energy trauma ipsilateral femoral neck fracture
ipsilateral knee ligament injuries 5%
fracture neck femur
hip knee joint 0.7-1.5
1.! traction balance suspension 6-8

femoral cast brace ischium
tuberosity
2.! implant
plate screw intramedullary nail
! Supracondylar fracture of femur

distal femoral metaphysis 9 . joint line
3 type ( 5.12)
A. extra articular
B. partial articular
C. complete articular

! articular fracture
! (knee axis)
1.! Non displaced fracture impacted fracture
osteoporosis long leg cast 2-3 knee
brace
66
2.! Displaced fracture ORIF plate, screw IM nail
5.12
A type -Extra-articular fracture
B type -Partial-articular fracture
C type -Complete-articular fracture
! Fracture of the patella

Patella sesamoid bone patella 2
comminuted fracture
quadriceps patella 2 transverse fracture ( 5.13)
5.13 patella fracture

(hemathrosis) patella
patella

! 2 .
! Extensor mechanism gravity
cylindrical cast 4-6 quadriceps
exercise
2.! Displaced fracture ORIF Kirschner wire wiring
partial patellectomy
67
! Knee dislocation
orthopaedic emergency injury
popliteal artery common peroneal nerve

tibia
anteior
dislocation ( 5.14) dorsalis pedis, posterior tibial artery common
peroneal tibial nerve reduction
closed
reduction traction tibia
distal femur

pulse angiography
,vascular repair

late
thrombosis popliteal artery 1
ligament injury

"#$%&'(&
)(*$%&'(&
+"$%&"+
5.14 knee dislocation

tibia
! Knee injury

knee injury
1.! dashboard injury PCL injury
(valgus) MCL injury
2.! ACL injury, meniscus injury patella
subluxation
68
3.! swelling
! Immediate hemathrosis rupture ACL, PCL meniscus
tear, intraarticular fracture, tear joint capsule
! Late effusion inflammation
4.! Instability
! Giving way ACL
laxity
5.! Locking
meniscus tear, loose body, ACL tear
6.! Pain, tenderness
! Joint line tenderness meniscus tear
! medial adductor tubercle proximal tibia MCL
injury
! lateral lateral epicondyle fibular head LCL injury
! Medial retinaculum patella dislocation
Meniscus injuries
Meniscus

! (click)
! meniscus
! joint line
! McMurrey test, Apley test positive
(arthroscopy)

partial menisectomy
meniscus repair arthroscopy
69
Anterior cruciate ligament (ACL) injuries

ACL proximal medial lateral femoral condyle
distal anterior tibial plateau tibia
ACL injury PCL injury 9
2-3 50-70%
pop Lachman test test sensitive anterior
drawer test arthroscopy MRI
ACL injury
! Associate ligament injury
!
!
!
3
1.! Conservative 3-4 knee brace
activity associate injury
2.! Surgical repair 50%
3.! Reconstruction
ACL
semitendinosus, bone patella tendon bone graft
Posterior Cruciate Ligament (PCL) injuries

PCL proximal lateral medial femoral condyle
distal, posterior PCL ACL 40-50%
tibia
posterior sagging, posterior
drawer test positive
isolate PCL injury

quadriceps tibia
reconstruction
70
Medial Collateral Ligament (MCL) injuries

MCL tibial collateral ligament medial femoral condyle
adductor tubercle distal 5-7 .
joint line valgus force

valgus stress test positive ligament
isolate MCL injury cylindrical cast

2 progressive range of motion exercise
strengthening exercise 3-4
Lateral Collateral Ligament (LCL) injuries

LCL fibular collateral ligament lateral femoral condyle fibular
head varus force ligament fibular
head
Isolate LCL injury ice pack 1-2 knee brace 2-4

varus stress
! Fracture of the tibial plateau

proximal 10 . tibia cancellous bone
axial loading varus vulgus femoral condyle
tibial plateau split
fracture osteoporosis compression
depression fracture

(fat globule)
1.! Minimally displace fracture

4 long leg cast 4
knee brace 8-12
2.! Displaced fracture plate screw
71
! Tibial fractures
tibia
open fracture infection
tibia
1.! initial displacement 50%
90%
2.! comminution
3.! soft tissue injury open fracture compartment
syndrome
4.! infection
1.! Conservative treatment non-displaced fracture

displaced transverse short oblique fracture closed
reduction long leg cast alignment
4-6 patella-tendon-bearing (PTB) cast
16-20
Criteria accept alignment tibia closed reduction
1.! varus vulgus 5 AP view
2.! anterior posterior angulation 10 lateral view
3.! abnormal rotation 10
ASIS patella second toe
4.! shortening 1 . distraction
5.! contact surface 50 %
2.! Operative treatment
1.! failed closed reduction accept alignment
2.! ipsilateral fracture femur, tibia (floating knee)
3.! multiple trauma
4.! fracture with compartment syndrome, vascualr injury
5.! open fracture
72
! Ankle Sprains
sport injury 85% lateral ligament injury
(inversion) plantarflexion anterior talofibular
ligament
lateral malleolus
anterior drawer test distal tibia
talus talus
ankle sprain 3 grade

Grade I : No laxity, minimal pain, mild swelling
Grade II : Mild to moderate laxity, soft tissue swelling

slight laxity on anterior drawer test
Grade III : Severe pain, swelling, gross laxity in anterior drawer test
Grade I, II
! ice pack 20 qid

! compression bandage, elevation 48-72
! nonsteroidal anti-inflammatory (NSAIDs)
!
! range of motion exercise

! strengthening exercise
! plantarflex, inversion ankle support
2-4
Grade III
grade I, II
short leg cast 2-3

exercise
grade I,II
73
! Ankle Fracture
talus ankle mortise injury

Denis-Weber fibular syndesmosis (
5.15)
Type A
syndesmosis
Type B syndesmosis
Type C syndesmosis talus unstable ankle

posterior tibial dorsalis pedis artery
bony structure
ligament
ankle AP, lateral
mortise view
5.15 Denis-Weber classification
splint skin necrosis

talus ankle mortise fibular
2 . short leg cast 6

plate, screw
! Talus Fracture
talus 60% cartilage
talus talar neck
hyperdorsiflexion talus neck anterior lip tibia
body talus
74
Hawkins talar neck fracture 4 type ( 5.16)

Type I
non displaced
Type II
displaced subtalar subluxation dislocation
Type III
displaced subtalar ankle subluxation
Type IV
type III talonavicular dislocation

short leg cast 6
2.! Displaced fracture

skin necrosis

Complication
avascular necrosis, skin
5.16 Hawkins classification
necrosis, infection
! Calcaneal Fracture
Calcaneus tarsal bone
talus posterior articular facet calcaneus
calcaneus ( 5.17) Bohlers tuber angle posterior
facet 25-40
5.17 calcaneus fracture

2
(squeeze test)

75
calcaneus lateral axial view subtalar joint

Broden s view
ice pack modified Jones compressive

dressing
1.! Non displaced fracture short leg cast 6
2.! Displaced fracture intraarticular fracture
subtalar joint plate, screw
! Injuries of the tarsometatarsal (Lisfrancs) joint

highenergy trauma
intrinsic stability Lisfrancs joint
base
second metatarsal
(recess) cuneiform
metatarsal 2,3 4 trapezoid
shape base 2nd 3rd 4th 5th
metatarsal Lisfrancs
5.18
ligament ligament 1st
Lisfrancs joint
2nd metatarsal weak
point ( 5.18)
AP oblique view normal foot medial second
metatarsal medial middle cuneiform AP oblique view
medial fourth metatarsal medial cuboid
oblique view angulation metatarsal lateral view
metatarsal tarsal bone base
second metatarsal Lisfrancs dislocation
76
non displaced 2 reduction toe traction

6 multiple
percutaneous K-wire fixation open reduction fixation
second metatarsal base key to reduction
! Fracture base of the fifth metatarsal

Jones fracture original Jones fracture
(1902) fifth metatarsal base
Classification
2 ( 5.19 )
1.! avulsion fracture
extraarticular
intraarticular
2.! Jones fracture transverse
fracture fifith metatarsal distal
tuberosity
Avulsion fracture
peroneus brevis
5.19 Jones fracture
Richi Rosenthal
avulsion fracture base of fifth
lateral cord plantar
aponeurosis base fifth metatarsal
base of fifth
metatarsal
AP, lateral oblique view base fifth
metatarsal os peroneus sesamoid peroneus
longus tendon os vesalianum sesamoid peroneus brevis
16 apophysis shaft sesamoid fracture
sesamoid sclerotic subchondral bone fracture line
sclerosis
77
Avulsion fracture
compression dressing 2-3
6-8
Jones fracture acute fracture short leg cast 6
non-union curettage bone graft
! Fracture of the metatarsal shaft

soft tissue injury
skin necrosis cold pack elevation

axial compression
toe metatarsal
AP, lateral oblique view plantar dorsal displacement
lateral film
non displaced minimal displaced fracture short leg walking

cast 2-4
displaced fracture 2nd,3rd, 4th metatarsal
nonunion malunion

displaced fracture first fifth metatarsal closed
reduction K-wire mini plate screw
! Fracture of the toe

subungual hematoma
deformity
2-3
5.20 buddy splint

(buddy splint)( 5.20) subungual hematoma paper clip
release pressure short leg cast
78
Spinal Injuries
6 Spinal Injuries
---------------------------------------------------------------------------------------------------------------------------------------
spinal injury 6 :1.! immobilization

transportation
2.! Medical management secondary damage
3.!
4.! anatomic alignment
5.! surgical decompression
6.! stabilization
prehospital phase

2
collar
cervical
spine injury C5

sacral sparing
vital sign
cervical spine injury

sympathectomy spinal cord injury
spinal cord injury
peritoneal lavage ultrasound abdomen
spinous process

log roll maneuver

79
Spinal Injuries

1.!
2.!
3.! spine
Three columns concepts

Denis spine 3 column (
6.1)
6.1 Three columns concepts of Denis

1.! Anterior column Anterior longitudinal ligament (ALL)
body disc
2.! Middle column Posterior longitudinal ligament (PLL)
body disc
3.! Posterior column Pedicle, facet, posterior ligament complex
Anatomy of spinal cord and spinal canal
Spinal cord medulla oblongata C1 (atlas) spinal canal
spinal cord 1/3 odontoid process 1/3 1/3
T4-T8 spinal cord spinal canal
C1-C2 spinal cord
midthoracic spinal cord injury
80
Spinal Injuries
Conus medullaris ( 6.2) spinal

cord disc L1-L2
conus medullaris spinal cord nerve root
cauda equina
injury L1 injury spinal cord nerve root
injury L2 injury nerve root
(Lower motor neurone lesion) prognosis spinal
cord injury
6.2 conus medullaris
cauda equina fracture spine
L2 spinal cord injury

Neurogenic shock
spinal cord injury hypotension sympathetic
outflow hypovolemic shock neurogenic shock bradycardia
hypovolemic shock tachycardia
replace fluid
systolic 100 . fluid
pulmonary edema
Spinal shock
spinal cord
physiologic structural disruption

spinal cord 24
reflex arc
bulbocavernosus reflex ( 6.3)
spinal shock
injury
complete structural disruption complete
spinal cord injury
81
6.3 Bulbocarvernosus reflex
Spinal Injuries
Bulbocavernosus reflex ( 6.3)

reflex arc S2-4 afferent fiber glans penis Foley
catheter spinal cord efferent fiber contraction anal sphinctor
reflex spinal shock
Complete spinal cord injury (SCI)
spinal cord injury motor sensory function injury
spinal cord
injury involuntary movement

recover 5%
Incomplete spinal cord injury
spinal cord injury motor sensory function injury
complete cord injury injury
SCI
Location
Functional impairment
Prognosis
Brown-Sequard
Hemicord
Ipsi. Motor weakness
Good
syndrome
Contra. Loss of pain, temp
Anterior cord
Anterior 2/3 Motor loss, loss of pain temp
Poor
syndrome
below injury level
Posterior cord
Posterior
Loss propioceptive, vibratory
Fair
syndrome
column
spare sensory, motor function
Central cord
Central area Motor weakness arm, hand >
Fair
syndrome
leg, sensation spare

1.! sensation dermatome
2.! muscle power nerve root
3.! reflex upper lower extremity
4.! sacral sparing perineal sensation, toe flexor sphinctor tone
82
Spinal Injuries
Sensory evaluation
pain,temperature
spinothalamic tract anterolateral
spinal cord position sense
posterior column C1 occipital
area C34 S234
dermatome ( 6.4)
sensation perineum
sacral sparing ( 6.5)
Motor evaluation
6.4 sensory level

dermatome
nerve
root C5 deltoid S1 toe
flexor ( 6.6) motor sacral
sparing voluntary sphinctor
contraction great toe flexor ( 6.5)
sacral sparing
spinal injury
sacral sparing functional
6.5 sacral sparing
recovery sacral sparing
sacral cord perianal
spinal cord
sensation great toe flexor

sacral sparing
spinal shock motor sensation
injury
complete cord lesion motor sensation

spinal cord injury
83
Spinal Injuries
6.6 motor power upper lower extremity

Reflex ( 6.7)
spinal cord injury reflex
lesion hypereflexia
response hyporeflexia reflex arc
hypereflexia spastic
6.7 reflex arc

Emergency medical treatment
spinal cord injury 8 injury high
dose methylprednisolone (Depo-medrol) 30 mg/kg IV bolus dose 15 IV
drip 5.4 mg/kg/hr 23 methylprednisolone secondary cord
damage inflammatory process , ischemia hemorrhage
lipid peroxidation
84
Spinal Injuries
Cervical Spine Injury
upper cervical spine (C1-C3)

Standard radiographic projection for c-spine injury
Projection
Anteroposterior
(AP)
Open - mouth
Lateral
Demonstration
! Fracture of the bodies of C3-C7
! Fracture of the lamina of C3-C7
! Abnormal rotation of spinous process
! Uncovertebral (Luschka) joint
! Fracture of lateral mass of C1
! Fracture of odontoid process, body of C2
! Jeffersons fracture
! Atlantoaxial rotatory subluxation
! Fracture of anterior, posterior arch C1
!
!
!
!
!
!
!
Oblique
Swimmers
Fracture of Odontoid process

Fracture of body of C2 to C7
Fracture of spinous process
Hangmans Fracture
Unilateral and bilateral facet locked
Abnormalities of disc space, Prevertebral soft tissue
atlantal-dens interval
! Intervertebral foramina
! Apophyseal joint
! Fracture, dislocation of C7, T1, T2
85
Spinal Injuries
-! C1 atlas anterior arch posterior arch

lateral mass 2 atlas body lateral mass 2
-! C2 axis body, pedicle, lamina odontoid process
body
anterior arch C1 odontoid process
atlantal dens interval (ADI) 3 .
8
4 .
-! C3-C7 body, posterior neural arch (pedicle, lamina
superior, inferior articular facet spinous process)

lateral view cassette
cross table AP open mouth
cervical spine
lateral view
1.! Lateral view ( 6.8)

vertebra
C1 C7

lower
cervical spine
2

Swimmers view
2.! curve cervical spine
lordotic
kyphotic
86
6.8 Lateral view of cervical spine
Spinal Injuries
3.! structure
3.1! prevetebral soft tissue shadow hematoma
C1 8-10 .
C3,4 3 . 5 . indirect evidence CSpine injury C4-7 10-15
3.2! vertebral body (anterior vertebral line)
compression fracture body, avulsion
fracture superior inferior rim body anterior
translation < 25% body unilateral facet locked
anterior translation > 50% body bilateral facet locked
3.3! vertebral body compression fracture burst fracture
bony spur cervical spondylosis
3.4! Disc space narrowing disc degeneration acute
cervical disc herniation
3.5! body (posterior vertebral line)
spinal canal (retropulsed
fragment)
3.6! Spinal canal funnel shape posterior vertebral line
spinolaminar line ( 6.8)
3.7! Facet joint inferior facet vertebra articulate
superior facet vertebra facet dislocation
inferior facet vertebra superior ferior
facet vertebra
3.8! Spinous process widening
interspinous ligament fracture spinous
process
4.! lateral view C1-C2
4.1! anterior arch odontoid process (ADI) ADI
atlantoaxial rotatory subluxation
rupture transverse ligament
87
Spinal Injuries
4.2! ring C1 Jeffersons fracture

4.3! odontoid process
4.4! pedicle C2 Hangmans fracture
5.! AP view
5.1! spinous process
rotatary dislocation (unilateral facet locked)
5.2! lamina body
5.3! Luschka joint narrowing joint space
spondylosis
6.! Open mouth ( 6.9)
6.1! lateral
mass C1
body C2
rupture transverse
ligament lateral mass C1

body C2 overhanging
6. 9 Open month view
edge overhanging edge 2
7 . rupture transverse ligament
6.2! odontoid process lateral mass
lateral mass 2 rotatory
subluxation C1-2
6.3! body C2 odontoid process isthmus
(Type II Fracture odontoid) body (Type III Fracture
odontoid)
88
Spinal Injuries
! Jefferson s Fracture ( 6.10)

Burst fracture C1 (atlas)
vertical loading occipital condyle
lateral mass C1
upper C-spine cord injury

6.10 Jeffersons fracture
AP
lateral view C1 ring open
mouth view C1
lateral C2 (overhanging edge) lateral skull film
immobilization skull traction 4-6

SOMI brace ( 6.11) (sterno-occipitomandibular-immobilization) 12
Halo cast
12
(posterior fusion) occiput
C2
6.11 SOMI brace
! Odontoid Fracture
spinal injury miss diagnosis
lateral view soft tissue abnormal curvature
odontoid process body C2 AP
open mouth
Anderson D Alonzo odontoid fracture 3 ( 6.12)
Type I apex of dens avulsion fracture
alar ligament type stable injury cervical collar 4-6
89
Spinal Injuries
Type II
base dens body
non union 10-67% 2
skull traction 6
SOMI brace 6 film
lateral flexion, extension
C1-C2
Type III body
C2 cancellous bone contact
surface
skull traction 4 SOMI
12
6.12 Odontoid fracture
Hangmans Fracture (Traumatic spondylolithesis C2)

extension
axial load
AP, open mouth
lateral view
body
6.13 Non-displaced fracture displaced fracture
pedicle C2
type
4 type non-displaced displaced ( 6.13)
1.! Non-displaced fracture 3 .
C2 C3 stable fracture SOMI brace
2.! Displaced fracture 3 . C2 C3
reduction skull traction
6 SOMI brace 6
reduction fusion C1 C3
90
Spinal Injuries
! Lower C-Spine (C3 C7) Injuries

Minor Compression, avulsion fracture
-! compression fracture 25%
posterior structure minor fracture
hard collar 6-8
-! fracture spinous process clay-shovelers fracture C6
C7 direct injury lateral flexion,
extension structure soft collar
Facet Dislocation
-! Unilateral facet dislocation facet 1
(torticollis) body
25% body nerve root compression 1
-! Bilateral facet dislocation facet 2
body 50% body
neural tissue injury
closed reduction skull traction

3-5
20
open reduction
(spinal fusion) pure ligamentous injury
posterior fusion
Compression Fracture
50% injury posterior structure
neural tissue
1.! neurological deficit skull traction reduction

6 SOMI brace 6-12
91
Spinal Injuries
2.! neurological deficit spinal cord, nerve root

(anterior decompression
and fusion)
Burst Fracture
axial load body spinal cord
body (anterior middle column)
1.! nerological deficit compression fracture

2.! neurological deficit body body
(vertebrectomy) bone graft
plate, screw
! Thoracolumbar Spine Injury

T-L junction injury transitional zone
thoracic spine rib cage lumbar spine
neural tissue injury spinal cord, conus medullaris cauda

equina injury injury disc L 1-2 cauda equina
peripheral nerve injury prognosis
general condition neurological evaluation

(log rolling) bowel ileus
retroperitoneum
IV fluid NG tube
decompression bowel 2-3
thoracolumbar spine injury T-L Spine
anteroposterior lateral
low back pain spondylosis, spondylolysis
spondylolisthesis LS-Spine AP, lateral oblique
92
Spinal Injuries
Thoracolumbar region
1.! AP view spine spinal column
(scoliosis) psoas shadow psoas abscess
kidney renal stone, ureteric tone rule out
urinary tract
2.! AP view vertebra structure
( 6.14)
2.1! vertebral body
2
upper end plate
lower end plate
body
compression fracture
burst fracture body
2.2! disc space body
6.14 AP view of lumbar spine
disc space
degeneration intervertebral disc lumbur spondylosis
irregularity end plate infection
(vertebral infective spondylitis)
2.3! Spinous process fracture-dislocation
rotation force spinous process body
2.4! Lamina spinous process

fracture lamina Chance Fracture
2.5! Pedicle 2 medial transverse process
interpedicular distance upper vertebra lower
vertebra burst fracture interpedicular distance
upper vertebra lower vertebra
93
Spinal Injuries
metastasis tumor spine body pedicle

involve pedicle dense osteolytic
body pedicle
2.6! Transverse process

transverse process
3.! lateral view lumbar spine lordotic curve spine
3.1! spine vertebra
vertebra (spondylolisthesis)
fracture dislocation
translation body
3.2! vertebral body
compression fracture body
burst fracture
body body spinal canal
(retropulse fragment)
! Compression Fracture
flexion injury
(anterior column) middle posterior
column ( 6.15)
motor vehicle accident
osteoporosis minor
injury

6 .15 Compression fracture
compression fracture stable injury

neural tissue progressive
deformity injury hyperextension postural
reduction 1-2 hyperextension brace (Jewette brace) 6.16
94
Spinal Injuries
12
3-5 body jacket
3 point fixation
Jewette
brace support
calcitonin osteoporosis

compression
fracture anterior column
50 % angulation 20
progressive deformity
6 .16 Jewette brace

(Thoraco lumbar brace)
! Burst Fracture
axial load body
anterior
middle column ( 6.17) middle column
retropulse-fragment
neural tissue
lateral view
anterior middle column AP view
pedicle (interpedicular distance)
body
6 .17 Burst fracture
pedicle
burst fracture
1.! Burst fracture neurological deficit posterior column intact

stable burst fracture body jacket extension
posterior column fail unstable fracture
distraction instrument Harrington rods
95
Spinal Injuries
2.! Burst fracture neurological deficit unstable fracture

Harrington rods retropulse fragment
decompression
! Chance Fracture
distraction injury spinal
column ligament
fracture lap seat belt
injury spinal column
failure 3 column
( 6.18)

stable fracture body jacket
ligament disc
space ligamentous injury
healing bone healing
progressive deformity
spinal fusion
6.18 Chance fracture
! Fracture Dislocation (Translational

injury)
injury
combination force
(6 .19) injury 3 column
neural tissue damage
AP, lateral
spinal column AP
view lateral traslation
lateral view AP
96
6 .19 Fracture - dislocation
Spinal Injuries
spondylolisthesis fracture dislocation
unstable fracture neurological deficit

(stabilization spinal fusion) ambulation
decompression neural tissue
97
Fractures and Dislocations in Children
7 Fractures and Dislocations in Children

---------------------------------------------------------------------------------------------------------------------------------------

,

1.! (elasticity)
greenstick fracture, torus fracture, plastic deformation
2.! periosteum splint
reduction
3.! cell active osteogenic potential
birth fracture clavicle
1-2
4.! epiphyseal plate
ligament, joint capsule epiphyseal plate injury dislocation
5.! conservative treatment

6.! growth arrest
epiphyseal plate injury nonunion
7.! ossification center
growth plate

8.! (remodeling) accept alignment
angulation joint motion
9.!
98
3
1.! Greenstick fracture ( 7.1) incomplete fracture

greenstick fracture
diaphysis cortex
7.1 Greenstick fracture cortex

2.! Torus Buckled fracture ( 7.2) incomplete fracture
metaphysis distal radius
7.2 Torus fracture

3.! Plastic deformation

(Elastic recoil)

(Plastic deformation)
(fracture)
! Epiphyseal plate or growth plate injuries

growth plate epiphyseal plate cartilagenous disk
epiphysis metaphysis long bone growth plate
epiphysis germinal layer cell growth plate
99
hypertrophic zone

Salter Harris epiphyseal plate injury 5 ( 7.3)

7.3 Epiphyseal plate injury Salter Harris

Type I epiphyseal plate epiphysis
metaphysis epiphysis
tenderness growth plate 3
(growth disturbance)
Type II distal radius distal
femur growth plate
metaphysis Thurston Hollands sign
periosteum Thurston
Hollands sign splint 3-4 growth disturbance
Type III growth plate growth

plate
closed open reduction anatomical reduction
growth disturbance growth plate
Type IV type III metaphysis
type III
100
Type V growth pate

growth plate
premature closure growth
arrest
premature closure growth plate
limb length discrepancy
(angular deformity)
Remodeling of fracture

Remodeling
1.! 2 12
14
2.! metaphysis remodeling diaphysis
3.! (Bayonet apposition)
4.! deformity plane joint motion flexion, extension
varus, valgus
Remodeling
1.! intraarticular fracture
2.!
3.! displaced epiphyseal plate fracture
4.! diaphyseal fracture

1.! Faild close reduction
2.! Displace intraarticular fracture
3.! Displaced epiphyseal plate injury Salter-Harris type III, IV
4.! Children with multiple fracture or head injury
101
(conservative)
! Fracture of Clavicle
(birth fracture)
middle third
(pseudoparalysis)
crepitation (callus)
brachial plexus injury birth palsy

1-2 callus

5-6
arm sling 2-3
figure of eight
! Supracondylar Fracture of the Humerus

5-10
cubitus varus
2
1.! Extension type 96%

2.! Flexion type

Gartland
3 ( 7.4)
Grade I non displaced fracture
Grade II partially displaced fracture

Grade III totally displaced fracture
102
7.4 Gartland classification

non displaced fracture
Grade III S shape
dimple sign radial artery
radial, median ulnar Grade III
neurovascular injury
Grade I
(fat pad sign) posterior grade II, III
1. Grade I posterior long arm slab 2-3

perfusion
slab
2. Grade II closed reduction distal fragment
periosteal hinge
posterior long arm slab 90 4
Grade I
3. Grade III ( 7.5)
K-wire (Percutaneous pinning)
posterior slab
4 compartment
syndrome, neurovascular injury
103
7.5 Supracondylar fracture
1.! radial median

2.! Compartment syndrome Grade III
reduction
circular cast
3.! Cubitus varus ()

! Fracture Lateral Condyle of Humerus

epiphyseal plate injury
radius radial head
lateral condyle extensor origin
supracondylar fracture
Milch s classification ( 7.6) 2
1. Type I capitellar - trochear
groove ossification center
lateral condyle Salter
Harris type IV
2. Type II trochear
ossification center lateral
7.6 Milchs classification
condyle Salter Harris type II
104
nondisplaced fracture
metaphysis lateral distal humerus long arm slab 4
displaced fracture metaphysis
lateral distal humerus displace intraarticular fracture
K-wire long arm slab 4-6
! Subluxation of the Radial Head

(Pulled elbow, Nursemaid s elbow)
subluxation radial head 2-3
7 radial head
radial head
annular ligament joint laxity
(pronation)
( 7.7) radial head
annular ligament
radial head

7.7 Pulled elbow

10-20

radial head
105

pulled elbow supracondylar fracture of
humerus

pulled elbow supracondylar fracture of humerus (SCFH)
pulled elbow
SCFH
1.

2.
2-3 7
4-5
12
3. radial head
lateral epicondyle
4.
pulled elbow

reduction forearm full supination full flexion

( )
radial head forearm full supination
( 7.8) resistance full flexion click
radial head 4-5

arm sling

radial head 2-3
annular ligament
reduction click
full supination full flexion elbow
reduction 7.8 radial head
106

2-3

! Fracture of the Forearm

radius ulnar ulnar radius
proximal radioulnar joint distal radioulnar joint (DRUJ)
displacement 2

1.! Torus Buckled fracture metaphysis distal radius
( 7.1)

cortex metaphysis distal
radius
deformity
immobilization short arm slab 1-2
elastic bandage
2. Greenstick fracture incomplete fracture diaphysis
radius ulnar ( 7.2)
cortex
2
long arm cast 4-6
over correction periosteum
long arm cast 4-6
3. Plastic deformation
closed reduction apex angulation

2 3-4
107
4. Complete fracture of radius and ulnar
closed reduction long arm cast 4-6

shortening bayonet apposition remodeling
5. Monteggia fracture ( 7.9) proximal 1/3 ulnar
radial head dislocation
radial head
fracture proximal ulnar radial
head dislocation radial
head capitellum AP lateral
view radial head capitellum
7.9 Monteggia fracture

radial head
closed reduction radial head

(longitudinal traction) full supination radial head
click long arm cast 90 forearm
full supination 4-6
6. Galeazzi fracture ( 7.10)
distal 1/3 radius
distal radioulnar joint (DRUJ) dislocation
ulnar styloid

7.10 Galeazzi fracture
DRUJ dorsal
dislocation distal ulnar
Monteggia fracture reduction DRUJ longitudinal

traction full supination DRUJ long arm cast
90 fore arm full supination 4-6
108
7. Distal radius fracture epiphyseal plate injury type I II

dinner fork deformity dorsal displacement
closed reduction periosteal hinge

dorsal longitudinal traction distal fragment volar short arm
cast 3 point fixation Colles Fracture 4-6
! Fracture Shaft of Femur

10 hip spica
6-8 1 .
overgrowth 10
plate screw intramedullary nail
injury growth plate
! Fracture Tibia and Fibular

Toddlers fracture
tibia fibular

Toddlers fracture hairline fracture spiral
fracture tibia intact fibular
Toddlers fracture short leg cast 2-3

closed reduction long leg cast 4-6
109
Open Fractures
8 Open Fractures
---------------------------------------------------------------------------------------------------------------------------------------
Open fractures
Open fractures
4
1.! Life preservation
2.! Limb preservation
3.! Avoidance of infection
4.! Functional preservation
.1878 Volkmann mortality rate 38.5% open fractures
1 open femoral fracture mortality rate 80%
open fractures
.1960 open fractures antibiotics ,
aggressive wound debridement , fracture stabilization delayed wound
closure
Definition
Open fracture compound fracture fracture
Objective of open fracture treatment

1.prevention and treatment of infection
2.solid bone healing
3.function of limb
open fracture
1.! cut wound, lacerated wound, burn
2.!
3.! (contamination)
4.! degree of soft tissue injury
5.!

Open Fracture classification (Gustilo and Anderson)
110
Open Fractures
Classification of open fracture (Gustilo and Anderson 1984)

open fractures prognosis
Type I 1 . puncture wound
(inside out) soft tissue
fracture transverse, short oblique minimal comminution
Type II 1 . 10 . extensive soft tissue damage
flaps avulsion
contamination
fracture transverse, short oblique moderate
comminution
Type III 10 . extensive soft tissue damage
skin, muscle, neurovascular bundles dead bone soft tissue damage
contamination type I,II
Conditions type III open fracture
1.! Open segmental fracture wound size
high energy trauma
2.! Farm injuries comtaminate ,
3.! Gunshot wound high velocity closed range shotgun injuries
4.! neurovascular injury
5.! traumatic amputation
6.! open fractures 8
7.!
Type III subtype prognosis
Type III A.
Adequate soft tissue bone fracture site
extensive soft tissue damage, laceration flap
type Infection rate
4%
Amputation rate 0 %
Type III B.
extensive soft tissue damage periosteal stripping
expose bone (inadequate soft tissue coverage) contamination
type Infection rate
52 %
Amputation rate 16 %
111
Open Fractures
Type III C. major arterial injury repair

type Infection rate
42 %
Amputation rate 42 %
open fracture
1.! open fracture emergency surgery
2.! Initial evaluation, diagnose other life-threatening injuries
3.! antibiotics
tetanus toxoid antitoxin
4.! Immediate debride the wound using copious irrigation open fracture
type II III repeat debridement 24 72
5.! Stabilize the fracture
6.! Leave the wound open for 5 to 7 days, secondary wound coverage
procedure
7.! Perform early autogenous cancellous bone graft
8.! Rehabilitate the involved extremity
Emergency Care of Open Fractures

open fracture
splint sterile dressing
20 infection rate 3.5 % refer
10 infection rate 22.2%
splint
, airway, fluid resuscitation of shock
condition stable open fracture
sterile environment irrigate sterile solution
foreign body sterile dressing
fracture
arterial bleeding
compression dressing major arterial bleeding
112
Open Fractures
skin, soft tissue, vascular, nerve injury

extension injury surgical debridement
injury open fracture 6 8
comtaminated wound infected wound high
energy trauma soft tissue bone injury low energy trauma
open fractures open fracture
Surgical debridement general condition

Antibiotic Treatment
antibiotics
antibiotics gram positive bacteria cephalosporin cloxacillin
aminoglycoside open fracture type III contamination
high dose penicillin antibiotic

infection hospital acquired organism

Gustilo recommened antiobiotics 3 wound
closure, internal fixation bone graft redebridement
antiobiotics
Debridement
open fractures
debridement procedure
1.! exploration of wound
2.! excision of devitalized tissue
3.! removal of foreign material and bacteria debridement
gentle handling of viable soft tissue
debridement superficial structure deep
structure
1. Skin puncture wound low velocity gunshot wounds
irrigation explore fracture
undisplaced fracture bone diameter
113
Open Fractures
bone fragment explore fracture contaminate

exploration
irrigation reduce
excision of devitalize structure layer by layer
spreading contamination structure
2. Fascia muscle tendon fascia contaminate trauma

muscle viability 4C
1.! Color beefy-red
2.! Consistency viable firm consistency
3.! Capacity of the muscle to bleed
4.! Contractibility forceps electrocautery

Tendon paratenon structure nutrition
tendon paratenon paratenon skin
soft tissue tendon
3. Periosteum structure bone healing process preserve
periosteum

4. Bone soft tissue attachment contaminate
soft tissue attachment 2
stability fix
autogenous bone graft soft tissue attachment
bone graft stimulate fracture healing
5.! Joint joint debridement exploration
remove foreign bodies osteochondral fragment arthroscope
debridement joint less invasive
6.! Nerves and vessels coagulation,
capillaries compression dressing major vessel
repair end to end anastomosis vein graft vascular repair
massive swelling distal prophylactic fasciotomy
114
Open Fractures
Stabilization of fractures
anatomic position
wound management early function
alignment circulation dead space hematoma
infection venous lymphatic return
Stabilization early motion early
mobilization joint stiffness, intra-articular adhesion, thromboembolic phonomena,
fat embolism syndrome
stabilization of fractures
1.! soft tissue
2.!
3.! alignment axis long bone anatomical reduction
intra-articular fractures

Plaster immobilization
open fracture
compartment syndrome type I
accept alignment
Pins and plaster
unstable open fractures tibia pin wire proximal
tibia distal tibia maintain length control rotation
stability external fixator
Skeletal traction and suspension
temporary stabilization definite stabilization open
fracture femur debridement proximal tibial traction
definite stabilization skeletal traction
1.! posterior
2.! maintain alignment
3.! stability wound healing, fracture healing
115
Open Fractures
External skeletal fixation (External fixator)

external fixation stabilization open fracture type III
tibia
external fixation devices
1.! modular system
2.! stability early mobilization
3.! reduction fracture fragments
4.! soft tissue trauma
1.! pin tract infection

2.! pin femur, humerus
3.! external fixator non weight bearing

delayed union nonunion
External fixator humerus femur
internal fixation open fracture humerus femur grade I, II
rate infection 2
open fracture type III soft tissue injury external fixator
sideswipe injury, open fracture pelvis, tibia
Internal fixation
internal fixation open fracture
Gustilo type I open fracture
debridement internal fixation open fracture infection
rate 0% internal fixation open fractures
1.! intra-articular fracture interfragmentary compression

cartilage healing anatomical reduction intra-articular fracture
minimal fixation intra-articular infection definite
internal fixation
116
Open Fractures
2.! Massively traumatized limbs soft tissue injury

internal fixation injury soft tissue internal fixation
non-reamed intramedullary nailing open fracture femur type III
muscle pedicle skin flap external fixation flap
internal fixation
3.! Vascular injuries vascular injury
internal fixation vascular repair

4.! Multiple injuries patients multiple fractures ARDS,
shock immediate internal fixations ARDS volume expansion
fracture pelvis
5.! Type I open fracture debridement
Definite wound management

1. Primary closure necrotic tissue
foreign material wound tension circulation type I open
fracture primary closure
secendary intention typeII, III
delayed primary closure secondary closure primary closure
clostidial myonecrosis gas gangrene
When in doubt, leave it open
2.! Delayed primary closure 3-10 injury
anaerobic infection local wound
defense mechanism
3.! Secondary closure skin graft flaps
Split-thickness viable muscle well-formed granulation
tissue bare tendon periosteum
extensive soft tissue loss skin grafts
flaps local fascial cutaneous flaps, local muscle pedicle flaps, remote
muscle pedical flaps free microvascularized muscle flaps
type I II open fracture partial closure open fracture
extension debridement
117
Open Fractures
proximal distal fracture

site releasing incision
type III second look debridement 24-48
3-7 exposed bone 3-7
flaps
Bone Grafting
open fracture soft tissue injury closed fracture bone
healing bone graft fill defect healing
autogenous cancellous bone graft bone graft open fracture
infection open fracture type I , type II intra-articular
fracture infection 6-8
bone graft soft tissue open
cancellous bone graft papineau technique
Rehabilitation
Elevation extermities
10 . arterial input distal
extremities compartment syndrome
Exercise involved limb
1.! muscle atrophy
2.! joint stiffness
3.! circulation, venous lymphatic return
Immediate or early amputation versus limb salvage

Immediate early amputation severe open fractures
limb salvage
1-2
painful limb reflex sympathetic dystrophy amputation
Helfet severity score
amputation limb salvage Mangled Extremity Severity Score (MESS)
118
Open Fractures
119
Fractures and Dislocations for General Practitioner
9 Fractures and Dislocations for General Practitioner

---------------------------------------------------------------------------------------------------------------------------------------

? ?
?

practical point
! Fractures and dislocations of upper extremity

1.! Sternoclavicular joint injury
anterior posterior dislocation arm sling
NSAIDs 1-2
refer -
2. Fracture middle third of clavicle
figure of eight
figure of eight 4

12
deformity malunion 90%
refer - open fracture impending open fracture

- (nonunion) ()
3. Fracture distal third clavicle
type I coracoclavicular (CC) distance
arm sling 1-2 NSAIDs 2
4-6
refer - type II distal clavicle
120
4. Acromio - clavicular joint dislocation (AC joint)

Type I, II arm sling distal clavicle type I Type III
arm sling
deformity
refer - type III
5. Anterior shoulder dislocation
closed reduction Zero position traction counter traction
15-35
arm sling abduction external rotation
greater tuberosity fracture reduction
greater tuberosity sling 2

refer - reduce greater tuberosity
- recurrent dislocation

6. Fracture proximal humerus
Non displaced impacted fracture arm sling 1-2
pendulum exercise arm sling
3 arm sling exercise ROM
impacted fracture reduction
arm sling distraction force
refer - displaced fracture refer arm sling
7.! Fracture shaft of humerus

transverse fracture reduction spiral comminuted
fracture U-slab
acromion process elastic
6
slab (clinical
union) U-slab exercise
121
refer - transverse fracture reduction

-! reduction radial nerve palsy
-! (nonunion)
8.! Fracture distal humerus
displaced fracture
refer -
9. Fracture olecranon
non displaced fracture criteria 3
posterior long arm slab slightly pronation 2
refer - displaced fracture
10. Elbow dislocation
reduction 3 reduction posterior long arm
* circular cast * exercise flexion, extension,
slab1-2
pronation supination limit fully extension 5-10
refer - reduce
- radial neck, radial head
- ulnar nerve palsy
11. Fracture shaft of radius and ulnar
Monteggia fracture, Galeazzi fracture
Displaced Night stick fracture
forearm reduction
alignment posterior long arm slab
refer
12. Non displaced Night stick fracture
long arm cast neutral 4
122
! Fractures and dislocations of the hand and wrist

1.! Distal radius fracture
Colles fracture 4
complication MP joint

Non displaced distal radius fracture, Chauffeurs fracture short
arm cast 4-6
refer - Smiths fracture ( displacement)
-!Bartons fracture dorsal volar ( subluxation radiocarpal
joint)
-!Displaced radial styloid fracture
-!Displaced intraarticular fracture lunate load fracture, comminuted
fracture
2.! Scaphoid fracture
non displaced fracture thumb spica cast 8
refer - Displaced fracture 1 .
- fracture displacement
-! fracture scaphoid fracture radial styloid
3.! Distal phalangeal fracture
aluminium splint 4 subungual hematoma
paper clip
4. Mallet finger
splint DIP joint 4-6
3-4 splint
deformity
refer - dorsal lip 30% articular surface volar
subluxation DIP joint
123
5.! Fracture of proximal and middle phalange

non displaced fracture plane malrotation
scaphoid tubercle () buddy splint 4
refer - displaced fracture reduce reduce deformity
6. Metacarpal neck fracture (Boxers fracture)
Boxers fracture neck 4th 5th metacarpal AP slab
angulation 40 accept AP slab slab
anterior MP joint MP joint slab posterior
dorsal PIP joint MP joint 70-90 dorsiflex 15-20
4
refer - angulation 40 AP slab
-! anatomical reduction cosmesis
7. Benetts fracture
refer reduction percutaneous K-wire fixation
8. PIP joint dislocation
simple dislocation reduce splint 1-2
refer - complex dislocation
9.! MP joint dislocation
simple dislocation reduce 4
simple complex dislocation splint 1-2
refer - complex dislocation volar plate
! Fracture and dislocation of lower extremity

1.! Fracture of the pelvis
conservative treatment
-! fracture pelvic ring fracture ischium, ilium
-! open book symphysis 2.5 .
-! pubic rami fracture 2 rami 4 rami
NSAIDs

walker
124
major injury fracture pelvis fluid

resuscitation elastic bandage 6 2 pelvis 1
pelvis
refer - fracture pelvis with vital sign unstable resuscitation
-! Open book injury symphysis 2.5 .
-! Vertical shear fracture
2.! Fracture acetabulum
non displaced fracture skin traction 3-4
2-4

3.! Hip dislocation
!Anterior dislocation
reduction Alliss Maneuver

skin traction 3-7
2-3 6
!Posterior dislocation
stable unstable
Alliss
Maneuver ( posterior dislocation) test stability

simple dislocation skin traction anterior dislocation
6
refer - (irreducible)
- test stability posterior wall fracture
- acetabular labrum
125
3. Fracture of proximal femur

fracture neck of femur, intertrochanteric fracture subtrochanteric
fracture
high energy trauma
refer
osteoporosis

non displaced displaced

4.! Fracture shaft of the femur
Supracondylar fracture
displace Thomas
splint, resuscitation refer
5.! Fracture of the patella
non displaced cylindrical cast
10-15 4
quadriceps
ROM exercise
refer - Displaced fracture ORIF
6. Knee dislocation
knee dislocation Orthopaedics emergency
reduction popliteal vessel injury longitudinal traction
splint refer
vascular injury
7. Fracture of the tibial plateau
non displaced fracture
long leg cast 6

refer - Displaced fracture
126
8. Fracture of the tibia

non displaced fracture, displaced transverse short
oblique fracture reduction accept alignment criteria long leg
cast 6 1-2 re-displacement 6
PTB cast refer
refer - irreducible unacceptable alignment
-!comminuted fracture, spiral fracture
-!compartment syndrome
-!open fracture
9.! Isolate fracture fibular shaft (not include distal 1/5)
displaced non displaced
1-2
6-8
10.!Ankle fracture
non displaced fracture medial / lateral malleolus short
leg walking cast 4-6
refer - displaced malleolar fracture 2
-!ankle fracture dislocation
11.!Calcaneus fracture
non displaced
displaced fracture lateral
calcaneus lateral malleolus displaced
fracture
non displaced fracture short leg cast 6
3-4
12.!Fracture base of 5th metatarsal
short leg cast 1-2
2-3 elastic
bandage 1-2
127
13.!Fracture of toe
buddy splint 2-3
subungual hematoma paper clip ()

2-4 hematoma release
pressure
! Spinal injury
spinal injury
(splint) secondary cord
damage spinal cord injury
spinal cord injury 8
high dose methyl prednisolone 30 mg./kg. IV bolus dose 15 IV drip 5.4
mg./kg. 23
spinal injury spinal brace
refer
compression fracture T-L spine
osteoporosis conservative treatment
1-2 Hormone calcitonin 50-100 IU 10
activity osteoclast bone pain compression
fracture Fowlers position
corset brace Jewette Chair back brace
3-4
128
! Fractures and dislocations in children

1.! Fracture of Clavicle
birth fracture
1-2 arm sling 1-2 figure of eight 4
refer - birth fracture brachial plexus injury

2.! Supracondylar fracture
non-displaced fracture posterior long arm slab 1-2
slab 2-3 periosteal new bone formation
partially displaced fracture reduction posterior long arm slab

distal fragment anterior 3-4
refer - Totally displaced fracture
-! compartment syndrome
-! nerve injury
long term complication
cubitus varus 5-10%
3.! Fracture lateral condyle of humerus
non-displaced fracture posterior long arm slab 4
non-displaced displaced fracture
displaced fracture
non-displaced fracture
refer - Displaced fracture
-!
4.! Subluxation of radial head (Pulled elbow)

supracondylar fracture ( 7)
rule out fracture
129
(full supination) (full flexion elbow)

5-10
5.! Fracture of the forearm
5.1! Torus fracture short arm slab 1
elastic bandage slab
5.2! Greenstick fracture complete fracture

displaced
long arm cast
(over correction) 4 1

refer - recurrent deformity
5.3! Plastic deformation
long arm cast over
correction recurrent deformity
5.4! Complete fracture of radius and ulnar closed reduction long
arm cast reduction longitudinal traction 90
mold
- radius ulnar
4-6
refer -
- compartment syndrome
5.5! Monteggia fracture, Galeazzi fracture reduction radial head
DRUJ forearm full supination long arm cast
radial head Galeazzi fracture

DRUJ supination 4-6
refer - irreducible radial head DRUJ
- radial head
130
6.! Fracture shaft of femur high energy injury

splint refer
7.! Fracture tibia and fibula
Toddlers fracture short leg cast posterior short leg slab 2-3

slab
closed reduction long leg cast
refer - irreducible unaccepted alignment
-! compartment syndrome
! Open fractures
high energy injury
vital sign resuscitation
open fracture
1.! Bleeding
compressive bandage major vascular injury
compressive bandage vascular injury
anterior tibial artery compressive bandage 5
tourniquet proximal control
open fracture pelvis
bleeding per vagina vaginal packing
definite treatment
2.! Infection open fracture

(wound irrigation) normal saline
normal saline sterile dressing
compressive bandage tetanus toxiod, antitoxin
tetanus cloxacillin first generation cephalosporin
aminoglycoside high
dose penicillin metronidazole anaerobic infection
131
3.! Fracture stabilization

compressive bandage splint
splint * *
splint elastic bandage splint
compression refer
Open fracture
1.! Fingertip injury 2
1.1! Non exposed bone 1
wet dressing silver sulfadiazine cream dressing 3-4
epithelium
(creeping epithelialization) 2-4
1 full thickness
skin graft
1.2! Exposed bone 2 skin flap
short bone to close

2.! Toe injury traumatic amputation severe open fracture toe

amputation, short bone to close primary closure

delayed primary wound closure
open fracture
1.! Wound irrigation contamination
2.! Compressive dressing ,
3.! Antibiotics prophylaxis and treatment
4.!
5.! NPO , film
132

Internet
e-mail consultation
digital attach file e-mail
(Teleradiology)
133
Complications of fracture
10 Complications of fracture
---------------------------------------------------------------------------------------------------------------------Complication
! Hemorrhagic (Hypovolemic) shock

multiple fracture, femoral fracture, unstable pelvic fracture
hypovolemic shock
unstable pelvic fracture temporary fixation
pelvic ring external fixator pelvic cavity temponade
effect
! Arterial injury
fracture-dislocation
arterial injury fracture-dislocation shoulder, supracondylar elbow
fracture, knee dislocation
arteriogram 6-8

! Nerve injury
arterial injury neurapraxia (physiologic
disruption) nerve injury cauda equina
compression (spinal fracture), axillary nerve (shoulder fracture-dislocation), radial nerve
(humerus fracture), ulnar nerve (medial epicondyle fracture), posterior interosseous
nerve (radial head, Monteggia fracture), sciatic nerve (posterior hip dislocation),
common peroneal nerve (lateral knee injury)
Nerve injury 3
1.! Neurapraxia physiologic disruption conduction block

134

2-6
2.! Axonotmesis axon endoneurium perineurium

motor end
plate 1
3.! Neurotmesis
nerve graft
! Cast syndrome
second part duodenum superior
mesenteric artery (body jacket) spinal fracture
hip spica cast femoral fracture small bowel
obstruction projectile vomiting
nasogastric tube
! Fat Embolism Syndrome (FES)

acute respiratory distress syndrome (ARDS)
multiple long bone fractures bone marrow fat
chylomicron stability free fatty acid
lung parenchyma
18-72
(restlessness) 39-40oc (tachypnea) 30 /
tachycardia 140 coma
long tract sign decerebrate rigidity 2-3
(patichiae) anterior chest, axilla, conjunctiva
135
FES Head injury

Sign, symptom
Lucid interval
Confusion
Pulse rate
Respiration rate
Onset of coma
Localizing sign
Decerebrate
FES
18-24
Severe
Rapid
Rapid
Rapid
Usually absent
Early
Head injury
6-10
Moderate
Slow
Slow
Slow
Usually present
Terminal
Arterial blood gas pO2 60 mmHg severe hypoxemia

CXR progressive snow-storm pulmonary infiltration specific
sputum urine fat
multiple long bone fractures

FES ARDS , pulmonary support
FES early stabilization of fracture FES
ambulation pulmonary ventilation
! Compartment syndromes
closed tissue compartment
microcirculation Volkmans ischemia,

Impending ischemic contracture
1.! compartment
2.! compartment
1.1!bleeding, vascular injury, bleeding disorder
2.2! capillary permeability post ischemic swelling, crush injury, burn
136
compartment syndrome bleb

capillary permeability
compartment syndrome 5P pain, paresthesia,
pallor, paralysis pulselessness 5 P

-! pain
passive stretching

-! paresthesia
-! paralysis motor function 6

-! pulselessness compartment pressure systolic blood
pressure pulse
compartment pressure compartment 0 .
compartment syndrome 40 .

10 .
arterial pressure
fasciotomy closed compartment
! Bone healing abnormalities

delayed union, nonunion, malunion avascular necrosis
high-energy injury 2
1.! Vascularity

open fracture
137
2.! Stability of fracture

!Delayed union nonunion
delayed union

nonunion obliteration of
medullary canal, persistent of fracture line 6-8
nonunion
nonunion 2 blood supply biologic reaction

1.! Hypervascular (hypertrophic)
(instability) blood supply

3
Elephants foot, Horses hoof Oligotrophic ( 10.1 )
2.! Avascular (atrophic) blood supply
4
Torsion wedge, Comminuted, Defect Atrophic ( 10.2 )
10.1 Hypertrophic nonunion
10.2 Atrophic nonunion

138
nonunion hypertrophic nonunion

plate screw intramedullary nail atrophic nonunion
bone graft
nonunion delayed union tibia, proximal scaphoid, talus,

femoral neck blood supply

!Malunion

malunion (post traumatic
arthritis)
shortening humerus
-
1.5 .
1.5-2.5 . 4 .
!Avascular necrosis

proximal scaphoid talus
mesenchymal cell
(resorption) remodeling
creeping substitution
(collapse)
relative
osteodensity disuse osteopenia
MRI
avascular necrosis
139

subchondral bone core decompression healing process
collapse
arthroplasty arthrodesis
Infection
open fracture open joint injury chronic
osteomyelitis septic arthritis open fracture open
joint injury debridement ( open
fracture)
(Tetanus) open fracture
5

0.5 cc. tetanus toxoid 5 0.5 cc.
tetanus toxoid 0.5 cc. tetanus toxoid 250 unit antitoxin
Fight bite human bite
anaerobic gram-negative rod
Eikenella corrodens Penicillin Ampicillin
Dog and Cat bites gram-negative coccobacillus Pasteurella
multocida Penicillin
Gas gangrene Clostridium perfringens anaerobes
toxin

12-24

subcutaneous emphysema
1.! shock
2.! high dose penicillin 3 4
3.!
140

Orthopaedic Trauma อ.ธีรชัย

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1 Fracture Principles

2 Emergency Splinting and Casting

3 Fractures and Dislocations of Upper Extremity

4 Fractures and Dislocations of the Hand and Wrist

5 Fractures and Dislocations of Lower Extremity

7 Fractures and Dislocations in Children

9 Fractures and Dislocations for General Practitioner

1.1 fracture pattern

Relation of the fragment to each other

Associated soft tissue injury

Cortical bone healing diaphysis long bone 3 ( 1.4)

1.4 Healing process

1.5 Inflammatory phase

1.6 Repairative phase

1.7 Remodeling phase

Cancellous bone healing metaphysis long bone

1.! solid union

1.! Intra articular fractures anatomical reduction

special test, nerve,

1.! (swelling) (ecchymosis)

1.2! (continuous traction)

2.( (Continuous traction)

! Principle of Operative Fracture Treatment

Indications for Surgical Reduction and Stabilization

Contraindications to Surgical Reduction and Stabilization

4.! General condition

internal fixation scar

fractures, fracture dislocation

Types of Internal Fixation

5.! pin (joint stiffness)

-( internal medullary callus

Common pitfalls in diagnosis and treatment of fractures

3.! accessory ossicles

8.! epiphyseal plate

11.! isolate fracture fibula

Emergency Splinting and Casting

2 Emergency Splinting and Casting

! Emergency splint of the spine

! Upper extremity splinting

2.1 Arm sling

2.2 Sling and swath

Emergency Splinting and Casting

! Lower extremity splinting

B.! Board splint

2.3 Pillow splint

Emergency Splinting and Casting

Emergency Splinting and Casting

2.5 Three point fixation

2.6 PTB cast

Emergency Splinting and Casting

Emergency Splinting and Casting

8.! (molding) mold

slab slab ( 2.10)

Emergency Splinting and Casting

Emergency Splinting and Casting

3.! bony prominence medial malleolus,

Emergency Splinting and Casting

2.17 Short arm cast

Emergency Splinting and Casting

4.! Thumb spica cast fracture scaphoid,

2.19 Long leg cast 2.20 Short leg cast

2.21 Cylinder cast

Emergency Splinting and Casting

1.! tincture benzoin