A/1. Fractures in general. Pathological fractures. Compartment syndrome.

Fracture refers to the breaking of a bone in the body, either with or without major soft tissue damage
Fracture Classification
Simple / Compound: ancient classification, used by military surgeons, infected wounds were amputated
Simple: No open wound
Compound: Open wound with soft tissue damage

Open / Closed: describes if the skin is intact or not

+Compound from within: the skin is penetrated by the fractured bone

Shape
Transverse: horizontal break relative to the bone long axis, by direct hit on the spot; easier to put back together
Oblique / Spiral: by twist along the bone long axis, thus indirect to the fracture point; harder to put back, and
cause more soft tissue damage
Butterfly fragments: when the tip of the spikes produced break into free triangular fragments
Comminuted: when the fracture produce more than 2 fragments; by direct trauma
Crush: seen in Lumbar vertebra, Tibial plateau (condyle) & Calcaneum
Greenstick: seen in children, when the bone transversely break, but not the whole way, where one cortex remain
attached
Avulsion fracture: ligament or tendon is ripped off the bone as a result of trauma
Other
Undisplaced: the bones are still in correct position
Impacted: Compression along the long axis
Segmental: when long bone breaks at 2 points, creating a free middle segment
Complicated: when vascular injury or infection is present
Epiphysial injury

Injury Mechanism:
Direct
Indirect: no direct violence to the site of fracture. Usually a twist of the limb
Pathological fracture: occurs due to an abnormally weak bone structure, by tumor, cyst, osteoporosis; commonly at
humerus (metastasis), and tibia (osteoporosis)
Fatigue fracture: by repeated small bending stresses on the same bone; e.g. 2nd metatarsal fracture by walking
excessive distance

Clinical signs: tenderness, inability to use the limb/walk, Cracking sound! When your try to move the 2 fragments

Compartment syndrome: any tissue injury will cause inflammation and swelling, for that a space is required for the tissue
to expand.
In limb open skin injury, when the skin is tightly stitched, increased pressure will cause decreased blood perfusion,
and soft tissue death (keep limb elevated to decrease swelling)
Groups of muscles nerves and vessels are contained within facial compartment, In muscle injury the pressure will
increase due to the facia limiting expansion, causing decreased blood perfusion, muscle tissue death and fibrosis, and
nerve cells death causing disability
Symptoms: Pain, Pallor, Cool limb, Absent pulse & extreme pain in Active/Passive movement
Treatment: Elevate the limb, Keep the Skin and Facial compartment open until the swelling decrease
A/2. Classification of open fractures. Basic principles of treatment.

Gustilo-Andersen open fracture classification

Type I: Wound <1cm with minimal soft tissue injury
With intramedullary nailing, the average time to heal is 21-28weeks
Type II: Wound >1cm with moderate soft tissue injury
With intramedullary nailing, the average time to heal is 26-28weeks
Type III: Extensive damage to the soft tissues, including muscle, skin, nerves & vessels
IIIA: Adequate soft tissue coverage
IIIB: Extensive soft tissue loss with periosteum stripping, and bone exposure (The soft tissue is inadequate and
requires regional or free flap)
IIIC: Fracture in which there is a major arterial injury requiring repair for rescuing the limb.
Special patterns classified as Type III:
Open segmental fracture, regardless of the wound size
Gun shot wounds
Farm injuries, with soil contamination, regardless of the wound size
Traumatic amputations
Open fractures over 8 hours old
Mass casualties, e.g.war and tornado victims

Open fracture management

1. Deal with open wounds: cleaning & debridement of possible contamination site
2. Deal with Fracture
Reduce the fracture & Immobilize
Cover the bone with well vascularized tissue/flap
Topical/Systemic antibiotic treatment
3. Mobilize the joints and rehabilitate the limb ASAP

Muller AO classification (Association for Osteosynthesis) - NOT open fractures

Assign a number to the bone fractured
1. humerus
2. radius and ulna (considered one)
3. Femur
4. tibia and fibula
5. for the vertebrae
Assign another number to the segment involved
1. Proximal segment
2. Diaphysis
3. Distal segment.
Assign A, B or C (could have different meaning in different bones)
A. Simple fractures (1 break point)
B. Wedged fractures (2 break points)
C. Complex fractures (multiple, with many fragments)
Assign another number next to the letter
1. Spiral
2. Oblique
3. Transverse
A/3. Biomechanical conditions for fracture healing.

Rule of thumb: Most bone healing require about 8 weeks, +Doubled in Lower limb, and Halved in Children
Immobilization and surgery facilitate the healing
The healing process is mainly determined by the periosteum (the connective tissue membrane covering the bone). The
periosteum is one source of precursor cells which develop into chondroblasts and osteoblasts that are essential to the
healing of bone.
The bone marrow (when present), endosteum, small blood vessels, and fibroblasts are other sources of precursor cells.
Primary/Direct bone healing
Occurs without callus formation.
Involves a direct attempt by the cortex to re-establish itself after interruption. Bone on one side of the cortex must
unite with bone on the other side of the cortex to re- establish mechanical continuity. This process occurs only
when theres an anatomic restoration of the fracture fragments, by rigid internal fixation, and when the stability of
fracture reduction is ensured by a substantial decrease in inter-fragmentary strain. Under these conditions, bone-
resorbing cells on one side of the fracture show a tunneling resorptive response, and they re-establish new
Haversian systems by providing pathways for the penetration of blood vessels.

Secondary/Indirect healing of bones

Occurs with a callus precursor stage.
Involves the classical stages of fracture healing
Impaction stage: The surviving local cells are sensitized, enabling them to respond better to local and systemic
messages and stimuli, and second, local biochemical and biophysical messengers are released to stimulate the
surviving cells.
This biological sensitization lasts for up to 7 days.
Inflammation stage: hematoma and hemorrhage formation results from the disruption of periosteal and
endosteal blood vessels at the site of injury. The open ends of these vessels undergo thrombosis. Lysosomal
enzymes are then released and acidic pH follows. Macrophages, leukocytes and other inflammatory cells invade
the area.
Clinically, this stage is associated with pain, swelling and heat.
Primary soft callus formation stage: the cells that are stimulated and sensitized begin to produce new vessels,
fibroblasts, intracellular material and supporting cells. They form granulation tissue in the space between the
fracture fragments. After that, macrophages, giant cells and other wandering cells arise in granulation tissue to
invade and remove it.
This stage lasts for about two weeks and clinically corresponds to the time when clinical union is established
by fibrous or cartilaginous tissue.
Callus mineralization stage: the mineralization of soft callus begins about 1 week later, after the formation of new
soft callus. The increased oxygen tension leads to the production of osteoid by deposition of radiopaque calcium
hydroxyapatite, which makes it radiologically visible. The presence of osteoid provides rigidity within the callus.
The more motion there is at a fracture site, the larger callus is needed to prevent this motion. From here the
patient may resume limited activity.
The creation and mineralization of callus may take anything from 4 to 16 weeks and is a quicker process in
children and in spongy bone.
Callus remodeling stage: callus is replaced with new bone. Osteoclasts act to remodel the external surface of
bone and decrease the size of the callus. Local vascular supply, oxygenation and pH all revert to normal. The
mineralized cartilage is initially replaced by woven bone to form a primary spongiosa. This is further replaced by
new lamellar bone.
A/4. Delayed bone healing and pseudoarthrosis

Malunion: when the fractured bone has united sufficiently, but in the wrong position, resulting in malfunction of the
involved limb
May be not important, e.g. In clavicle shortening/overlap without affecting the function
Cross-union: when 2 adjacent bones, originally unlinked, become linked by a new bone. e.g. In the forearm
(radius&ulna) blocks pronation and supination

Non-union: When the healing process fails. The bone ends do not unite and remain seperate
Hypertrophic: when the bone is trying but fails to heal properly, it forms a cuff/elephant foot-shaped ends on the
fracture bone ends
This type may be helped by better movement prevention via intra/extramedullary stabilization
Atrophic: shows rounding of the bone ends, and closure of the medullary cavity, usually a sign of poor blood supply
May require bone grafting to stimulate the healing
Pseudoarthrosis: a not-true joint, may develop in atrophic non-union. It enables an abnormal movement in a limb
that is usually not possible, imitating a presence of an actual joint (which isnt there)

Delayed union: Simply union that takes longer time to heal, so it requires a longer time, attention, and proper
immobilization
A/5. Basic principles of conservative fracture treatment.

Fracture management
1. Reduction, preferably closed-reduction, unless indicated otherwise (verify alignment with X-ray), methods:
Traction
External splint/braces
External fixation
Internal fixation
2. Immobilization of fracture fragments until union
3. Rehabilitation of soft tissue and joints

Traction: the injured limb muscles are expected to shorten the limb due to a missing resistance (the fractured bone),
thus we need to pull the limb enough to overcome the muscle power
Skeletal traction: pins inserted through the skin and bone, preferably threaded (screwed in the bone), and maintains
the required position
Skin traction: adhesive strapping/band is applied on the limb skin, and that will be pulled, causing traction through soft
tissue, indirectly to the bones
Not preferred, rashes under the strapping are common, and underlying tissue can be damaged
Maximal weight applied is 5kg
Suitable for kids

External splints/slings/cast braces

Splint: any device that holds a fracture steady
Cast: a hard material that holds the limb straight, usually requires covering of both joints proximal and distal to the
fracture. Best cast: Plaster of Paris
One should be careful that the cast is not too tight to stop circulation to the limb, check for pain, cold, or loss of
sensation
Cast cannot be applied directly after fracture, because the swollen limb will unswell and loosen the limb
Sling: a piece of fabric used to support the injured/casted limb (tied to the neck)
Cast braces: cast is divided into 2 pieces, connected by a hinge at the joint, to allow movement (important for
articular cartilage nutrition)
A/6. Basic principles of stable osteosynthesis. Role of the ASIF (AO).

Osteosynthesis: the reduction and fixation of a bone fracture with implantable devices that are usually made of metal.
Used when conservative treatment is inadequate
It is a surgical procedure with an open or percutaneous approach to the fractured bone. Osteosynthesis brings the
bone ends together and immobilizes the fracture while healing takes place

External fixation
Percutaneously, threaded pins are inserted to bone fragments and externally linked to a metal bar
Used in long bone, maxillofacial fractures and spinal surgery
If rigidly fixing the fragments, it might delay union. Thus it should allow a minimal movement (dynamization)
Advantages: can be used in patients where the skin is lost, or an infection is present, and the fragments position is
easily adjusted
Recent models: Ring fixators

Internal fixation
Indications:
Cannot be fixed in another way
Multiple bones are involved
Limb blood supply is disrupted, and vessels should be protected
Intra-articular fractures
Disadvantages: risk of infections, and additional trauma of operation (large exposure is required to apply screws and
plates)
Screws
Cortical screws: a hole is first drilled at the chosen angle, and tapped, to enable the screw to fit. The screw is
threaded its whole length
Self-tapping screws: the tip is not threaded. Usually cut less precise thread
Cancellous screws: have a wider thread (thicker), to grip the soft cancellous bone. Proximally unthreaded (a lag
screw)
Screws are used to press the bone to the plate, or bone fragments to each other. In that case, one bone should
be gripped by the screw, and the other not, but simply pushed towards it. This is achieved by the lag screw.
Plates
Hold the bones in correct position, and also compress the two bone ends together
Applied on the tension side, i.e. The side the puts the soft tissue under pressure, (help push bones together
rather than apart)
Disadvantages
Wide exposure surgery is required
Increased stress on the bone, and high rigidity can cause osteoporotic effect later on, thus sometimes it
better to remove it later, which exposes the patient to another surgery, and risk of another fracture.
Intra-medullary nails
Long nails, inserted along the whole length of the bone, in the medulla, after a cavity has been reamed inside the
shaft.
Preferably inserted in a closed technique, to avoid exposing and devitalizing the bone
Locking nails can be used along the shaft, proximal and distal to the long IM nail (going through it), to allow
better rotation of the bone

ASIF(AO): association for the study of internal fixation. Non-profit organization of surgeons doing research,
development and education in the field of trauma and corrective orthopedic surgery
A/7. Intramedullary osteosynthesis.

These nails operate like an internal splint that shares the load with the bone
can be flexible or rigid, locked or unlocked, and reamed or unreamed.
IM nails become the standard for femoral shaft fixation and for the tibia. Nowadays, specially designed nails exist for each
bone.
IM nails allow for stable fixation of diaphyseal fractures with early mobilization of joints, early movement, and weight
bearing of extremities. They have advantages over plates and external fixation because the intramedullary location allows
for axial alignment and load sharing.
Since the femur has a good soft tissue envelope, femoral shaft fractures are more often closed than open

A non-locking cloverleaf Kntscher nail is an example of a centromedullary nail, which is inserted in line with the femoral
canal and relies on longitudinal interference with bone-to-nail contact at multiple points to maintain axial and rotational
stability of the fracture.
Condylocephalic nails such as Ender pins are commonly used for fixation of intertrochanteric fractures. These solid
devices are small in diameter and are inserted in the condyles or the metaphyseal region, advanced across the fracture
either antegrade or retrograde, and embedded in the opposite metaphysis for stability. This procedure decreases the
operative time, the blood loss and the fixation rate. These nails are usually inserted in clusters of 2 to 4 for bending
stability but have limitations with rotational and axial forces.
Interlocking screws increase the working length of the nail from a simple interference fit to semi-rigid fixation at the
ends of the nail, which is capable of resisting axial and rotational forces.
Reconstruction-type nails and gamma-style nails with a reinforced proximal section that allow for fixation into the
femoral head and neck region are cephalomedullary nails. These nails increase the fixation options for proximal femoral
fractures.
Locking configurations
Statically locked nail implies the presence of proximal and distal screws in a non-slotted hole, allowing for control of
axial translation and allowing for rotation, with the nail performing more as a load-bearing implant. This application is
appropriate for unstable fracture patterns or locations and is certainly a consideration if immediate, full weight-
bearing is needed, as is sometimes the case in patients with multiple traumatic injuries.
Dynamic locking allows the shaft to axially translate several millimeters while rotational control is maintained.

Cross-sectional geometry: Nails may be solid, cannulated and in various shapes: cylindrical, square, triangular..
Solid nail: for smaller-diameter devices, but they do not allow for insertion over a guidewire, and they are difficult to
extract if broken.
A channel along the length of the nail potentially allows for revascularization
Torsion and bending resistance in a cylindrical structure is proportional to the fourth power of its radius. By increasing
the radius away from the load axis by a thicker wall or greater diameter, the rigidity increases.
Increasing the diameter of an IM nail by 1 mm increases its rigidity by 30-45%, but this would require additional reaming
of the canal. Excessive reaming may weaken the diaphyseal bone and increase the possibility of thermal necrosis.

Reaming of the medullary canal increases the working length of an IM implant by increasing the implant-to-bone
contact, this allows for a larger-diameter and stronger nail to be inserted than with an unreamed nail
Reaming of the medullary canal damages the medullary vascular system and increases the IM pressure and
temperature, with devitalization and necrosis of the diaphyseal cortical bone, also it weakens the bone
The recommendation is that the cortex should not be reamed to less than half of its original thickness.
Any instrumentation of the medullary canal, including placement of a guidewire and reaming, embolizes marrow
contents to various organs, including the pulmonary system.
A/8. Basic principles of recognition and treatment of peripheral vessel and nerve injuries.

Nerves
Median N.
Compression before wrist: sensory symptoms at the thumb, index, middle, and half of ring fingers (palmar and
dorsal sides)
Compression at wrist: patient presents with persistance hand parasthesia
Compression in carpal tunnel: weakness and wasting in the thenar eminence, but the palm is spared (branch
before the carpal tunnel)
Ulnar N.
Irritated at the elbow, behind the medial epicondyle
Parasthesia in the little finger, and the lateral half of the ring finger, with weakness in the hand
Radial N.
Vulnerable at the upper proximal arm (prolonged pressure at axilla)
Drop wrist (paralysis of the wrist extensors), but almost normal sensation in the hands
Sciatic N.
Posterior hip dislocation causes damage to the lateral half of the N. (L4,L5,S1,S2)
Common peroneal N.
Pass behind the fibular neck
Similar clinical picture.
Treatments:
Decompression: e.g. Decompression of median N. At carpal tunnel syndrome
Immediate primary suture: suitable for clean cut injury, performed under the microscope
Secondary suture: postponed, where initially the nerve ends are tagged by a suture and the wound is closed, and
after 2 weeks, reopened, the nerve ends are cut (refreshened), and then sutured through the epineurium
Cable grafting: less important nerves are taken as graft to replace the original (saphenous or sural N. In the calf)

Vessels
Signs
Absent pulse, active hemorrhage, pulsating hematoma
Signs of ischemia: pain, pallor, cold, paralysis, parasthesia
Treatment:
Cut arteries can be re-sutured
If crushed, it should be clean cut, and possibly grafted to fill the empty segment
Rerouting is another way
Veins are more difficult to fix, because of thinner wall, usually just ligated, if necessary
A/9. The financial significance of modern traumatological treatment.

Trauma is the leading cause of death for people age 1 to 34 years

The 3rd leading cause of death for all age groups.
Injuries create a substantial burden on society in terms of medical resources used for treating and rehabilitating injured
persons, productivity losses caused by morbidity and premature mortality, and pain and suffering of injured persons and
their caregivers.
Injury-attributable medical expenditures cost as much as $117 billion in 2000, approximately 10% of total U.S. medical
expenditures.
In 2001, the death rates for motor vehicle-related injuries were 15.3 per 100,000 people, totally 43,987.
Crash injuries result in about 500,000 hospitalizations and four million emergency-department visits annually.
Motor vehicle-related deaths and injuries, is also enormous ($150 billion/year)
Musculoskeletal injuries have a tremendous effect on the patient, the family, and the society in general because of the:
Physical and psychological effects of pain, limitation of daily activities, loss of independence, and reduced quality of life
Direct: expenditures for diagnosis and treatment
Indirect: economic costs associated with lost labor and diminished productivity.
For example, the cost of hip fracture is estimated at $8.7 billion, or 43% of the total cost of all fractures.
Direct costs are about 80% of the total, of which inpatient hospital care amounts to $3.1 billion and nursing home
care $1.6 billion.
More recent estimates show an increasing effect on the U.S. economy, including over $150 billion per year in direct
and indirect cost from lost labor productivity due to trauma.
A/10. Joint dislocations in general.

Joint injury
Subluxation: partial dislocation, with partial contact between joint surfaces. Usually heals spontaneously
Fracture dislocation: dislocation due to fracture at the joint, require more urgent mostly operative treatment, but
outcome is better, because bone heals better than ligament tears
Dislocation
Dislocation: complete, no contact between joint surfaces. Need to be reduced ASAP, and immobilized until healing
occurs
Congenital: e.g. CHD (congenital hip dislocation)
Traumatic
Acute: commonly at the shoulder, hip, or elbow. Can be subclassified according to its direction (Ant./Post./Inf.),
one should look for vascular and nerve injury
Old unreduced: when the patient comes after weeks/months of dislocation
Recurrent: when dislocation keep recurring after the first time.
Pathological: common in hip, when theres a destruction of the femur head, as in tuberculosis of the hip, septic
arthritis, or avascular hip necrosis
Habitual: recurrent form, occurs due to loose joint capsule. Common in shoulder, and the patient can fix it easlity
A/12. Medical first aid and patient transport. Organization of treatment of injured masses.

Primary survey (according to ATLS - advanced trauma life support course)

Before anything, and before resuscitation: ABC, with making sure to preserve the spinal column from damage
Airway: check the airway, obstruction can be due to objects, teeth, blood, vomit, facial fractures, or neck/larynx
injuries.
Respiratory failure can also be due to chest injuries, pneumothorax, hemothorax, cervical fracture above C3
(phrenic N. C3-C5 diaphragm)
Management: Endotrachial or Nasotrachial intubation, or tracheostomy
Keep track of the respiratory rate and chest movement
Bleeding: stop the bleeding
Apply external pressure on the bleeding site
In limb bleeding: apply tourniquet, but make sure to release it at least every hour, before fixing the hemorrhage,
to avoid gangrene
In venous bleeding, elevating the limb will stop the bleeding
Circulation: restore blood volume.
The heart! - CPR..
Set an IV line ASAP (after AB), either peripheral or central (usually hard to find the collapsed veins in shock
patients)
If needed, isotonic 0.9% NaCl Saline
Before transport (if needed), cervical spine should ALWAYS be protected, and if possible spinal injury is present, the
patient must stay log rolled until X-ray results are out
+DE
Disability:
Perform brief neurologic examination:
Determine level of responsiveness (GCS)
Check sensory and motor function briefly (leg movement)
Check pupils (diameter, and light response)
Exposure
Expose the patient to uncover hidden injuries
Look for inhaled foreign bodies, lacerations, and open fractures
Log roll each patient to inspect the back for injury Cover the patient with warm blanket to stop hypothermia

Secondary survey
Full systematic review of all the body parts and systems
Set a chart, and evaluate each system separately
Examine the whole body, Deal with all the wounds, ECG, Neurological examination & grading, Check the whole
body for any fractures (every bone)
Check the patient again :)

Alone at the seen - first aid

Check for danger in the environment before approaching the patient
Call for help
ABC

Organizing the treatment in injured masses - the Triage

A system developed by french military surgeons during napoleonic war :), that put patients into groups
1. Those requiring immediate & energetic treatment
2. Those with minor injury, or none at all
3. Those with serious, but not urgent injuries, who doesnt fit in either of the first 2 groups
A/13. Monotrauma, multiplex trauma and polytrauma. Trauma mortality. Trauma scales.

The Abbreviated Injury Scale (AIS): an anatomical-based coding system created to classify and describe the severity of
specific individual injuries
AIS-Code is on a scale of one to six, one being a minor injury and six being life-threatening

The Revised Trauma Score (RTS) is a physiologic scoring system, designed for use in based on the initial vital signs of a
patient.A lower score indicates a higher severity of injury.
score range is 0-12. In START triage, a patient with an RTS score of 12 is labeled delayed, 11 is urgent , and 10-3 is
immediate. Those who have an RTS below 3 are declared dead and should not receive certain care because they are
highly unlikely to survive without a significant amount of resources
Revised Trauma Score is made up of a three categories: (each score range of these correspond to points number on the
RTS, 0-4)
Glasgow Coma Scale
The Glasgow Coma Scale or GCS is a neurological scale for recording the conscious state of a person
The scale is composed of three tests: eye, verbal and motor responses. The three values separately as well as
their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15
(fully awake person)
Systolic blood pressure
respiratory rate

Trauma mortality
11,5/10000 in Hungary
1st cause of death in age 1-35, 3rd in all ages

Polytrauma or multiple trauma is a medical term describing the condition of a person who has been subjected to
multiple traumatic injuries, such as a serious head injury in addition to a serious burn. It is defined via an Injury Severity
Score ISS >=16 (correlates to AIS, somehow!)
In civilian life, polytraumas are often associated with motor vehicle accidents. This is because car accidents often
occur at a high velocities causing multiple injuries. On admission to hospital any trauma patient should immediately
undergo x-ray diagnosis of their cervical spine, chest and their pelvis, commonly known as a 'trauma series', to
ascertain possible life threatening injuries
A/15. Wounds, types of wounds, rules of wounds treatment. Decollement.

Wound: an injury in which skin is torn.

Blunt shear: This is the most common mechanism of injury, resulting in laceration (deep cut) of tissues.
Crush: wounds are often stellate, are at high risk for complications, debridement should be done.
Burns
Penetrating
Knife stab: wounds are low velocity, and result in minimal tissue damage.
Gunshot wounds: bad prognosis, with high incidence of gangrene and anaerobic infections
Low velocity injury: done by heavy bullets, cause little soft tissue damage
High velocity injury: e.g. Rifle bullet, an effect like a small explosion within the tissue. Larger soft tissue damage,
and larger risk of infection/contamination, with more un-clean penetration of the body
Shotgun injury: cause a widespread soft tissue damage (by pellets - small particles from the shot), proper
debridement is required, to remove as many pellets as possible
Bites and Stings:
Human bite wounds are contaminated, anaerobic bacteria
Cat bite and scratch wounds that penetrate should be considered heavily contaminated
Dog bite wounds are associated with soft tissue damage because of the enormous force. Infection is less
common than in human and cat bites
Snake/spider bite management: immobilization, neutral positioning and light dressing

Threats to wound healing

Ischemia and necrosis, Hemorrhage
Inadequate hemostasis can result in wound hematomas. Hematomas are excellent culture media

Treatment
General examination: Skin should be assessed by color, capillary refill, dermal bleeding, and sensory examination.
Subcutaneous tissues are difficult to assess, as the viability of fat can be difficult to determine. Muscle is difficult to
assess, and examined for color, bleeding, and contractile response
Tetanus prophylaxis: Assess the need for and type! (active vs passive)
Anesthesia: Local - lidocaine
Antibiotic prophylaxis: not indicated in simple wounds. used in:
Open fractures and joint spaces
Wounds with heavy contamination or requiring extensive debridement
Patients with immunocompromise, peripheral vascular disease, or valvular disease
Closure:
Primary closure: appropriate for simple, no contamination or devitalized tissue and wounds, as long as it is closed
within 8 hours of injury.
Secondary closure: the wound heals by granulation and contraction.
Delayed primary closure (aka. tertiary closure): is used for contaminated (infected) wounds. Wound edges are
left open for up to 5 days, and packed with damp to dry sterile paraffin gauze. then, the wound is sutured close
Vacuum-assisted wound closure: used to facilitate complex wound closure or to prepare a wound bed for skin
grafting
Skin grafting

Decollement: Rarely used term for surgical separation of tissues/organs which are adherent, either normally/
pathologically
A/16. Bleeding and stoppage of bleeding. Hemorrhagic shock in trauma.

Traumatic wounds bleeding

Abrasion: caused by friction of an object against the skin, and usually does not penetrate below the epidermis
Excoriation: abrasion caused by scratching of itchy skin
Hematoma: damage to a blood vessel that causes blood to collect under the skin.
Laceration: a tear/cut in the skin, resulting from injury
Incision: A cut into a body tissue or organ, such as by a scalpel, made during surgery.
Puncture Wound: object penetration into the skin and underlying layers, by needle or knife..
Contusion: aka bruise, a blunt trauma damaging tissue under the skin
Blunt trauma may cause internal organ injury, where any organ might be affected, causing internal bleeding, which
could be silent
Crushing Injuries: Caused by a great or extreme amount of force applied over a period of time.
Ballistic Trauma: Caused by a projectile (gun) weapon, this may include two external wounds (entry and exit)
Venous bleeding can be stopped with a general pressure over the bleeding area or a "pressure" type dressing.
Arterial bleeding requires more specific pressure on the bleeding vessel (higher pressure in the arterial system)

External bleed
Get the person to lie down. Decreased chance of shock if the head is lower than the trunk
Elevate a wounded limb above the level of the heart. (If you suspect a broken bone do not elevate)
Remove dirt, any visible foreign body, and debris.
If the foreign object is large however (large piece of glass, knife..) do not remove it. It is most likely stopping a lot of
the bleeding itself.
Apply firm pressure directly to the wound until the bleeding stops. Use gauze or dressing.
Apply a tourniquet at the main artery in limb bleeding
Internal bleed
Call ambulance
Keep victim calm & comfortable
Monitor airway, breathing and circulation
Maintain normal body temp

Shock
Circulatory shock is defined as an inadequate perfusion of tissues,
insufficient to meet cellular metabolic needs.
Types: Hypovoleamic, Cardiogenic, Distributive (sepsis, anaphylaxis),
Obstructive (tamponade, tension PTX, massive PE)
Initial symptoms
Tachycardia. Pallor (especially the lips)
If pressure is applied to a fingernail or earlobe it wont regain its color immediately.
Sweating, and cold, clammy skin (sweat does not evaporate).
Later symptoms
Weakness, Nausea, Vomiting,Thirst.
Rapid, shallow breathing, Weak pulse.
When the wrist pulse disappears, fluid loss may equal half the blood volume.
When severe brain hypoxia: Yawning and hunger for air, Conciseness loss, Finally, the heart will stop.
Treatment:
Localize site of bleeding, try to fix
IV fluids, blood, plasma, osmotically active fluids + ionotropic drugs (dopamine, adrenaline)
100% O2
A/17. Inactivity atrophy. Fracture illness. Reflex dystrophy.

Inactivity atrophy
Loss of bone and muscle mass because of loss of stimulation, and resistance, which is needed to maintain muscle
mass and function. Seen in patients lying for long periods of time, and astronauts!

Fracture illness
Occurs after a long period of casting which leads to osteoporosis and muscular atrophy.
To avoid you may mobilize the patient.
Joints as well can start ossifying after long immobilization.
Symptoms:
Atrophy (due to inactivity)
The limb may be cold & wet
X-ray: diffuse osteoporosis

Reflex sympathetic dystrophy - RSD (aka complex regional pain syndrome - CRPS)
An incompletely understood response of the body to an external stimulus, resulting in pain that is usually non-
anatomic and disproportionate to the causative event or expected healing response.
Definition: an excessive/exaggerated response to an injury of an extremity, manifested by 4 constant characteristics:
1. Intense/excessive prolonged pain
2. Vasomotor disturbances
3. Delayed functional recovery
4. Various associated trophic changes (changes from interruption of nerve supply)
Pain ("burning"), tenderness, and swelling of an extremity associated with varying degrees of sweating, warmth and/or
coolness, flushing, discoloration, and shiny skin.
A/18. Joint fractures. Joint capsule and ligament injuries.

Joint fractures are classified according to how the bone was broken.
Greenstick, Transverse fracture, Impacted fracture, Spiral fracture, Comminuted fracture, Avulsion fracture
For hairline or stress fractures, the best recommended type of treatment is for the patient to stop doing the activity
which has caused the injury for a couple of weeks.
Use of casts or crutches (stick).
For more serious cases of fractures, immobilization of the bone/joint may be required.
External fixation requires the use of splints, braces, and casts while internal fixation need screws, pins, and metal plates.
Internal fixations method is also needed when there is damage to soft tissues, an avulsion or a ripped ligament or
tendon.

Elbow fractures
Olecranon fracture: the olecranon is the proximal tip of the ulna bone, which can be felt directly under the elbow. It
is only covered by a thin layer of tissue so it can be easily broken when hit. Most fractured elbows are classified as
olecranon fractures. It can be treated with non-invasive therapy but some cases with severely displaced ligaments
may need surgery.
Displaced supracondylar: most common in children and elderly. It is caused by a displaced humerus bone which
affects the neighboring arteries and nerves causing severe pains. Most cases need immediate surgery except for few
cases when there is no injury in the arteries or nerves.
The ulna is the part of the elbow which is most sensitive to fractures because it does not have enough soft tissues
and muscle protection. This makes the elbow bone easily breakable especially if the person experiences an accident
or blow directly to the elbow area.
The use of slings and casts, on the other hand, are prescribed for those who need to stretch their joints. Slings can
also help severely displaced bones to be realigned on their proper positions. Surgery, on the other hand, is mostly
done on displaced fractures and open skin fractures

Hip fractures
Femoral neck fracture: This occurs at the neck of the femoral bone about one to two inches away from the hip
joint. Common among older people (in osteoporosis). The critical point of this fracture is when the break in the
bones cuts off the blood supply of the leg.
Intertrochanteric hip fracture: This fracture occurs three to four inches far from the joint on the hipbone. It is two
inches away from the neck it does not interrupt blood supply to the bone
Stress fracture of the hip: Harder to diagnose because it could only be caused by a hairline crack and may not also
involve the whole femur. Caused by repetitive motion or the overuse of the femur.

Ankle fractures
Among joint injuries, ankle fractures are one of the most common.
The joint of the ankle is composed of 3 bones that are joined together by
ligaments. (tibia, fibula and the talus)
Type A ankle fracture: occurs between the joints of tibia, the fibula, and the ankle
joint. Because all three joints are affected, the fracture may not be severe so
some doctors consider this as a sprain (ligament twist) issue. However, since it
still might have a hidden fracture because the x-ray is unable to reveal, the ankle
can be subjected to casting. (fracture at the malleoluli)
Type B fracture. This is the fracture where the fibula that is joined by the
connective tissues of the ankle is affected the most, reconstructive surgery may
be the only procedure needed to correct the damage.
Type C ankle fracture is considered a very unstable case of foot fracture. The breakage occurs at the fibula, surgery
may be required.
 Torsion of ligaments and capsule damage
A joint is distorted beyond its normal anatomical limits (as when an ankle is inverted or a shoulder is dislocated and
reduced). The patient may complain of a snapping or popping noise at the time of injury, immediate swelling, and loss
of function, or he may come in hours to days following the injury, complaining of gradually increasing swelling and
resulting pain and stiffness.
Ligamentous injuries are classified as:
First-degree, (minimal stretching)
Second-degree Subluxation (a partial tear with functional loss and bleeding but still holding)
Third-degree Dislocation (complete tear with ligamentous instability, often requiring a cast).
A tense joint effusion will limit the physical examination (and is one reason to require re-evaluation after the swelling
has decreased) but also suggests less than a third degree ligamentous injury, which is normally accompanied by a tear
of the joint capsule.
A/19. Fractures in children and injuries to the epiphysis. Classification of injuries to the
epiphysis.

Childrens bones are more flexable, and tend to bend more without breaking. This explains the reason for finding both
greenstick and torus fractures almost exclusively in the pediatric population.
Fracture of bones in children can cause damage to the growth plate (epiphysis). Growth plate injuries can cause long-
term problems if not appropriately treated..

Treatment of fractures in children

Bones that are not out of position, or minimally displaced, can often be treated with a cast alone (a simple cast).
When a growth plate has displaced, or is no longer properly aligned, your doctor may realign the broken bones by
applying pressure to the injured area.
Often the bones can be realigned without surgery, but may need added stabilization during the healing process. In
these cases, pins may be placed through the skin to hold the broken bones in alignment, like in supracondylar
humerus fractures. Open reduction can be done by making an incision and realign the bones, and if needed using
screws, plates or rods.
Epiphyseodesis: A growth arrest procedure performed most commonly in the non-injured extremity. A scenario
would be if the growth plate were injured in the left shin bone causing the growth plate to close too soon, the right
shin bone may undergo a procedure to stop growth in the right shin bone.
Bar resection: If a portion of the growth plate has prematurely closed because of growth plate injury, but the
remainder of the growth plate is healthy, the area that is prematurely closing can be removed. This procedure
removes the closed portion of the growth plate, allowing the limb to continue growing.
If growth plate damage has caused the extremity to become angled, or if there is significant growth remaining, a
procedure may be recommended to correct the angulation (osteotomy) or lengthen the extremity.

The Salter-Harris classification of children's fractures:

Type I: fracture along the epiphysial line. The epiphysis is completely separated from
the metaphysis. The vital portions of the growth plate remain attached to the
epiphysis.
All type I injuries generally require a cast to keep the fracture in place as it heals.
Unless there is damage to the blood supply, the likelihood that the bone will
grow normally is excellent.
Type II: seperation of epiphysis with triangular fragment of shaft attached. This is the
most common type of growth plate fracture.
type II fractures typically have to be put back into place and immobilized for
normal growth to continue. Because these fractures usually return to their
normal shape during growth, sometimes the doctor does not have to manipulate
this fracture back into position.
Type III: part of the epiphysis is broken, the rest is still attached to the shaft. This
fracture occurs only rarely, usually at the lower end of the tibia.
Surgery is sometimes necessary to restore the joint surface to normal. The outlook or prognosis for growth is
good if the blood supply to the separated portion of the epiphysis is still intact, if the fracture is not displaced,
and if a bridge of new bone has not formed at the site of the fracture.
Type IV: fracture line passing through both epiphysis and metaphysis.
Surgery is needed to restore the joint surface to normal and to perfectly align the growth plate. Unless perfect
alignment is achieved and maintained during healing, prognosis for growth is poor. This injury occurs most
commonly at the end of the humerus (the upper arm bone) near the elbow.
Type V: This uncommon injury occurs when the end of the bone is crushed and the growth plate is compressed.
Most commonly occur at knee/ankle. Poor prognosis, premature stunting of growth is almost inevitable.
A/20. Post-traumatic and post-operative connective tissue and bone infections.

Microorganisms may infect bone through one or more of three basic methods: via the bloodstream, contiguously from
local areas of infection, or penetrating trauma, including iatrogenic causes such as joint replacements or internal fixation
of fractures.

After sterile orthopedic surgery and closed fx 1-5%

After open fx septic complications occur in 2.11-25.31%
Treated acute osteomyelitis turns into chronic form in 15-31%

There is always a possibility for cellulitis. It can be caused by normal skin flora or by exogenous bacteria, and often
occurs where the skin has previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical wounds, or
sites of intravenous catheter insertion.
Most commonly caused by group A Streptococci and Staphylococci

In rare cases, the infection can spread to the deep layer of tissue called the fascial lining.
Necrotizing fasciitis ("flesh-eating bacteria"), most commenly caused by group A streptococci, is an example of a
deep-layer infection. It represents an extreme medical emergency.

OM: A big problem after orthopedic and trauma surgeries is osteomyelitis (infection of bone/bone marrow). This is
usually caused by Staphylococcus aureus, Enterobacter or Haemophilus influenzae. Pseudomonas aeruginosa and
Echerichia coli are also common in adults.
Possible persistence and development into chronic osteomyelitis
Treatment: antibiotics (combination of amoxicillin 500mg & flucloxacillin 500mg x4/day) and surgical debridement.

Risk factors for postoperative infections: Obesity, Diabetes, Old age, Emergency operations, Obvious contamination
(dirt, pus, stool), Immunocompromised
B/4. Fractures of the proximal end of the humerus.

Avulsion of greater tuberosity

The supraspinatus M. Is attached to the greater tuberosity
Can be avulsed (break off) in a fall on the shoulder in eldery
Usually heals properly in correct place. Though the fragment might get stuck
between humerus head and the acromion, limiting shoulder movement
Treatment: support shoulder until the pain resolves. Then physiotherapy
Surgical neck fracture
Occurs when the patient fall on the outstretched arm
Treatment: sling for 4-6 weeks
Impacted fractures (more common): mobilize after 2 weeks
Undisplaced/Minimally displaced: usually unite smoothly
Displaced/Severely displaced (less common, but more severe): might need internal fixation
Proximal epiphyseal separation
Common in children
Treatment: rest and sling
Fracture dislocation of the shoulder
Dislocation is seen when multiple fragments results from humeral head fracture
Complications:
Fragments obstruct reduction, and might require open reduction
Reduction will be unstable
Soft tissue damage will cause limited joint movement, and stiffness
Avascular necrosis of the humeral head might develop after anatomic neck fracture!
Treatment: open reduction. Prosthetic treatment of humeral head in severe cases
B/10. Fracture of the radius in typical location. Joint fractures of the distal forearm.

Fractures at the lower end of the radius

Colles fracture
The commonest of all fractures that are seen in clinics
Caused by fall on outstretched arm & extended hand. in patients over
50, mostly women
Characteristics
1. Within 2.5cm from the wrist
2. Dorsal angulation of the distal fragment
3. Dorsal displacement of the fragment
4. Associated with fracture of ulnar styloid
Clinically presents as Dinner fork deformity with 5 elements (referring to the fractured fragment):
1. Backward angulation: fragment is turned & displaced backward
2. Backward displacement
3. Radial deviation: fragment is moved radially (laterally)
4. Supination
5. Proximal impaction: fragment is pressed proximally against the radius
Complications
Sudecks atrophy: stiff, blue and cold hand, (reflex sympathetic dystrophy), caused by
distrubances in sensory and autonomic supply of the bone and blood vessels
Avoided by continuing finger movement
Median N. Damage
Rupture of extensor pollicis longus tendon
Malunion
Treatment:
Reduce by manipulation to good position, with plaster from the elbow until the metacarpophalangeal joint.
With fingers left free to enable movement - 4 weeks

Smiths fracture & Bartons fracture

Smiths: fall on a flexed hand, the reverse colles fracture
Bartons: when the fracture line enters the joint
Treatment: forearm cast with hand in supinated and wrist in full extension
If good position cannot be achieved: open reduction with small buttress plate

Fracture of radial styloid

Commoner in firm bone of young adults rather than soft bone of eldery
Treatment: usually doesnt require reduction, cast for 4 weeks (if large fragment, open
reduction and internal fixation)
C/3. Fractures of the femur neck.
C/4. Complications of femur neck fractures.

Clinical features
More frequent in women in post-menopause due to osteoporotic changes. Or due to high impact injury
The patient presents with a shortened and Externally rotated leg

Types
Intracapsular fracture
Most severe. Fracture line inside the cavity
May interrupt the blood supply to the femoral head (supplied by 3:
synovium&joint capsule, medullary cavity, and the ligamentum teres)
This may lead to aseptic necrosis of femoral head, or non-union
The capsule is filled with blood, which increases intracapsular pressure. But
also prevent visible bruising!
Femoral head is very mobile, making the reduction very had
Extracapsular & Basal fractures
Less severe because
Blood supply is mildly affected
Union is better (larger surface area)
Femoral head is less mobile
Yet, nonunion and avascular necrosis is possible
Undisplaced & Impacted fractures
Dangerous because they might go unnoticed, and the patient might be able to keep walking
Displacement might occurs days after the injury

Treatment
Depends on the type, the age, the fitness, and the degree of displacement
Undisplaced: Rest and protected weight bearing. Or internal fixation to avoid displacement
Displaced: internal fixation or prosthetic replacement
In complicated cases, nonunion or aseptic necrosis: prosthetic hip replacement
Internal fixation is prefered in younger patients (usually <65, fix it). Slow rehabilitation
Prosthesis in older. But faster weight-bearing activity
Prosthetic replacement of the head (only): hemiarthroplasty (e.g. Thompson or Austin Moore prosthesis)
If it fails: Total hip replacement
Early mobilization
For younger patients with need of prosthesis: Bipolar prosthesis (a ball and a socket)
C/5. Pertrochanteric and subtrochanteric fractures of the femur.

Trochanteric fractures
Pertrochanteric (between and through both trochanters)
Intertrochanteric (between trochanters)
Subtrochanteris (below the trochanters)
Avulsion of trochanter (muscle force pulling trochanter out)

Pertrochanteric fractures
Both trochanters are separated, and another fracture at the
intertrochanteric line
Occurs by sharp twisting injury
Because the fractures occur through cancellous bone and are
surrounded by muscles, they usually unite. But are very unstable,
and malunion is inevitable, unless internally fixed
Treatment: reduction to good position with dynamic hip screw
or intramedullary hip screw
These will not give full functionality weight support, but will only help keep everything in position untill the bones
unite again (8 weeks)

Subtrochanteric fractures
More rare, and often pathological. Associated with pagets disease or metastasis
Treatment: usually require internal fixation using nail-plate with long femoral plate or intramedullary implant
C/11. Fractures of the ankle.
C/12. Injuries of the ankle ligaments. Injuries of the Achilles tendon.

Ankle bones may be broken at

1. Tibia medial malleolus
2. Lower of of fibula, including lateral malleolus
3. Posterior margin of tibia posterior malleolus
Ligament tears
1. Inferior tibiofibular
2. Medial
3. Lateral collateral
Forces causing the injury
1. Abduction
2. Adduction
3. External rotation
4. Vertical compression
Grades of severity
1. Ligament injury, alone
2. Ligament injury + 1 malleolus fracture
3. Ligament injury + 2 malleoli
4. Ligament injury + 3 malleoli
5. Ligament injury + seperation at inferior tibiofibular joint + fracture
Management
Basically should reverse the movement that caused the fracture. Then hold the
ankle in good position.
Can be done only by manipulation, or internal fixation if the fracture is
unstable. The choice is based on the severity of injury, stability, and patient age
Conservative: cast for 4-8 weeks followed by physiotherapy
Internal fixation: with purpose to reconstitute the joint surface and create a stable joint
Complications: malunion, and secondary osteoarthritis

Webber classification
Type A: transverse fracture of the lateral malleolus, or below the level of the
ankle joint
Type B: the fracture involves the joint line
Type C: the fracture above the joint line

Abduction injuries
Tear in the Deltoid ligament, or avulsion of the medial malleolus
Severe swelling occurs
Treatment: casts are not good because of swelling (will loosen up later), internal fixation is preffered
Adduction injuries
Sprained ankle
Commonest ankle injury.
A partial tear of the anterior inferior talofibular ligament
Tenderness over the ligament, with possible haemarthroses
Treatment: firm elastic support. If severe, then below-knee cast.
Lateral collateral ligament rupture
Can occur without rupture
Treatment: protected mobilization for 4-6 weeks
Complications: recurrent instability. May require reconstructive procedure
 Avulsion of lateral malleolus
by the strong lateral collateral ligament when it doesnt tear.
Fracture of both malleoli: also possible
External rotation injuries
The movement pushes the talus against the lateral malleolus
Deltoid ligament rupture, medial malleolus avulsion, and fibula fracture (at/above the ankle) are all possible
Treatment: these are very unstable. Internal fixation is needed
Vertical compression / Hyperextension
Can cause a comminuted crush fracture at the tibia
Treatment: internal fixation with plate.

Achilles tendon rupture

By forward lunge movement (sport injury)
The patient feels a kick on the achilles tendon from behind
Swelling around the tendon, and the defect can be felt
The squeeze test is positive: squeeze the calf, and the leg wont move if the tendon is ruptured
Treatment: operative is usually the preferred method. Conservative treatment is possible.
After either, cast immobilization for 4 weeks (below the knee cast) in full flexion . Then changed to bring the the
foot half way up for 2 weeks. Then a walking cast for 2 weeks
After that, intensive physiotherapy
C/15. Craniocerebral injuries. Displacement-causing intracranial bleeding.

Head injuries
Severity depends on brain damage, and not the skull
The skull can be crushed between 2 fixed objects and cause little/no brain damage. While a rapid deceleration
causing very mild/undisplaced skull fracture can be associated with severe brain damage
Primary brain damage
Contusion / Laceration: caused by violent impact of the brain against the skull. either at the point of injury or the
one directly opposite to it.
Penetration of skull, with direct brain damage
Secondary brain damage
Edema of the brain
Extradural hemorrhage
Subdural hemorrhage
Clinically
Concussion: a transient loss of consciousness following a blow to the head. Recovery is usual, and duration is
proportional to the severity of injury
Contusion: theres damage to the cerebral tissue from localized bleeding or edema. Recovery is slower, and may
be incomplete (leaving neurological deficit)
Compression: caused by bleeding into the skull. The more it bleeds the worse it gets. Decompression and
stopping the bleeding can be life saving. Recovery is tricky, the patient regain consciousness, but keep bleeding
slowly
Management
Level of consciousness
Evaluated as alert&oriented / drowsy / reacts to movement / reacts to painful stimulus / and unarousable
Glasgow coma scale (1-5, 5 is fully conscious and alert)
Evaluated by: eye opening, verbal response, and motor response
Eye signs: increased ICP will impair iris function. The light reflex is used as a sign to intracranial bleeding
Temperature: thermoregulatory control centers might be damaged. Deal with it (/)
Open skull fractures
Penetrating skull injuries should be treated by neurosurgeon. Dead bone and dead brain tissues should be
removed
Cerebral edema
Follows any severe head injury
Reduced by diuretics (mannitol infusion), or controlled by hyperventilation in intubated patients
Extradural hematoma
The patient will typically have a small head injury, but after some time the bleeding will start to increase,
compressing the brain more, followed by loss of consciousness and death
Bleeding from the middle meningeal artery.
The head MUST be checked by CT scan to exclude damage/bleeding
Treatment: burr hole at the pterion point where the MMA cross. And ligation of the MMA
Pterion: 2 finger above the zygoma and 3 fingers behind the orbit
Subdural hemorrhage
Cause more gradual and slower loss of consciousness than extradural.
Chronic subdural hematoma is not an emergency
Any patient with decreasing in the level of consciousness in the WEEKS after head injury,
should have a CT scan
Post-traumatic amnesia (forgetting what happened)
As a general rule: <24h amnesia patient can expect complete recovery. >1week, permanent impairment is
expected
C/16. Injuries of the spine. Diagnosis, conservative treatment.
C/17. Injuries of the spine. Injuries leading to neurological symptoms. Operative treatment.

Cervical spine
Flexion injuries: the commonest and most severe, more often at the lower cervical part
Crush fractures
The result of flexion + vertical compression
Usually stable, but may cause severe neck pain
Treatment: symptomatic. four-post Collar or a cast, with analgesics for 6 weeks
Supraspinous ligament rupture (the one linking the posterior processes)
By violent flexion, the ligament can tear, or avulse the spinous process
The posterior part of the spine can be unstable
Neurological damage can happen if the movement is repeated
Treatment: collar to hold the neck in extension
Dislocation
Flexion with rotation can result in one/both of the posterior facet joints to jump over and dislocate
Usually without neurological signs
Treatment: traction or professional manipulative reduction
Fracture dislocation
Vertebral bodies and the facet joints are disrupted
Paraplegia often occurs (impairment of sensory/motor function of the lower limb)
Typically caused by a fall on the head
Treatment
Traction. External (connected to halo vest traction)/Internal fixation. Cast immobilization (not used)
Extension injuries: More often at the upper cervical spine, and usually less serious
Fracture of the odontoid process (dens)
Difficult to diagnose. The patient feel unsteadiness in the neck and pain at the
base of the skull
Types: I (tip of the process), II (middle), III (close to the base)
Type II have 50% chance of non-union, requiring fusion to stabilize the neck
Treatment: halo vest for 4 months!
Hangmans fracture
A neck-hanging-like injury. As in slipping under a seatbelt, or a fall
Fracture is usually through the pedicles of C2
Treatment: hold the head with MINIMUM traction. High traction will cause
neurological damage (thats how hanging kills)
Anterior spinal artery syndrome
ASA can be compressed by posterior longitudinal ligament (after
hyperextension in elderly)
This leads to weakness and sensory symptoms in the upper limbs (sparing
the lower limbs). Can be accompanied by poor bladder control
Treatment: immobilization in a collar
Fracture of the vertebra with disc prolapse
Might cause permanent damage to spinal cord!
Treatment: after confirmation with CT, urgent decompression and stabilization is required
Vertical compression:
Fracture of the atlas (C1): treated by immobilization with halo-vest for 6 weeks, then a collar for 2 weeks
Burst fracture: causes crush fracture , usually at the atlas or axis (C2). Treated with halo-vest for 6 weeks. And if
neurological signs are present paraplegia should also be treated, and rehabilitation begun ASAP
Rotational injuries: usually combined with the others (extension/flexion/compression..)
 Typically treated with halo-vest for 6 weeks. And if neurological signs are present, start rehabilitation ASAP for
paraplegia
Whiplash (combined flexion extension) injury
Seen in road traffic accident
In severe cases, anterior longitudinal ligament might tear, causing bleeding in the retropharyngeal space, causing
dysphagia hours after injury
Clinically
Might be asymptomatic for 6-12 hours after injury
Leading symptoms are neck pain and stiffness, with ache across the shoulders and arms. Possibly dysphagia.
And possible neurological signs, like parasthesia, but its usually transient
Prognosis is unpredictable. But 90% of the patients are symptomless after 2 years
Treatment: supporting collar and analgesics for few days, but then start physiotherapy ASAP to avoid permanent
neck stiffness and pain

Thoracic spine injuries: Generally severe, and often cause paraplegia

Compression fracture
Occurs at the Thoraco-lumbar joint!
An old person who slips and land on his ass. Or a young one who fall from a height on his heels (+calcaneum)
A crush fracture at the anterior lip of vertebral body.
Treatment: if <50% of the anterior vertebra height is lost, mobilize rapidly. If >50%, distraction and internal
fixation might be needed, and pain may persist for >2years
Burst fracture
More severe crushing to the vertebral body (fragmentation even).
Caused by pure axial force
Neurological damage is often seen, from backward displacement of the vertebra or its fragments
Treatment: if stable, mobilize ASAP. If not, 6 weeks bed rest, brace mobilization or operative fixation
Seat-belt fracture
Rapid deceleration by seatbelt in car accidents can cause vertebral body splitting! with severe displacement
Treatment: usually managed conservatively. 6 weeks bed rest, then plaster jacket.
Fracture dislocations
When a combination of flexion compression and rotational forces are present. As in a fall from a height
Vertebral body can split, Pedicles may fracture, and the Facet joints can dislocate
Paraplegia is expected
Treatment: either operative (fixation) or conservative (immobilization) treatment. If paraplegic, start rehabilitation
ASAP.

Lumbar spine injuries: cervical and lumbar spine (unlike thoracic spine) have somett mobility, which makes them more
susceptible to injuries
Avulsion of transverse process
By violent twisting/flexing movements, or by violent muscle spasm, as in epilepsy
Usually not serious, but causes pain and muscle spasm for 6-8 weeks
Treatment: nothing. Just analgesics and mobilization
Compression fractures: at thoracolumbar joint (as in thoracic spine injuries)
Flexion-rotation fractures
Twisting and rotational forces damages the vertebrae in the lumbar spine, causing neurologic damage, but the
thoracic spine is less sensitive to such movements
The spinal cord does not extend below L1, thus only the motor neurons and sensory nerves are involved in the
injury, giving a different clinical picture
Treatment: conservative treatment is preferred, as in the cauda equina the nerve roots are stronger than in
spinal cord. Thus giving better prognosis than more rostral spinal injury. Operative fixation may be required in
unstable fractures
C/18. Diagnosis and treatment of abdominal injuries.
C/19. Injuries to organs in the retroperitoneal space.

Ruptured spleen
The spleen is a very vascular, capsulated organ. Its main problem is only upon rupture
Injury can be as mild as a blow with the edge of the desk to the left hypochodrum, or a strong blunt trauma.
The spleen has no sensory fibers, so the patient doesnt feel any pain
The spleen can start bleeding into the peritoneal space, or into the capsule which can rupture hours after injury. In
either case, the patient can die from internal hemorrhage
The patient can present with signs of blood loss, with HR, BP, and pallor. Abdomen can be normal, but usually with
bowel sounds
Detecting a small amount of intraperitoneal blood is critical. Done by abdominal paracentesis (needle into the
abdomen) infusing some warm saline and draining it out.
Treatment: urgent laparatomy and splenectomy are life saving.
Ruptured liver
Also a vascular organ, causing an intraperitoneal bleeding.
Injury usually by rapid deceleration and blunt trauma, as in road traffic accidents
The liver cannot be removed as the spleen. Thus more problematic
Treatment: laparatomy to control the bleeding, suturing and ligating individual vessels, and removing dead tissue
Ruptured gut
Bowel and stomach can be ruptured by direct trauma, but great force is needed
X-ray show gas in the peritoneal cavity on sitting and standing film, accumulated under the diaphragm (gas rises)
Treatment: laparatomy and repair/resection of affected part
Stab wounds
Stab wounds between the nipple and the pubis
Treatment: most wounds need proper exploration
Retroperitoneal hematoma
Retroperitoneal space contains aorta, vena cava, adrenals, kidney, ureters, bladder, psoas muscles, and part of the
autonomic nervous system
Damage to any of these can be followed by hemorrhage into this space. Also seen after lumbar vertebra fracture, or
avulsion of transverse processes
Hematoma can cause painful restriction to lumbar movement and interrupts the ANS, causing paralytic ileus!
Treatment: no treatment. But the patient should not eat or drink until bowel function has returned
Kidneys
Trauma to the lumbar region
Accumulation of urine and blood in the retroperitoneal space
Hematuria. Can be a sign for upper UT injury. Call a urologist.
Excretion urogram (IV pyelography)
Treatment: suture, partial nephrectomy, or total nephrectomy might be needed.
C/20. Chest injuries.

Rib fractures
Isolated fractures
In direct injury, or violent cough in elderly. Sudden pain in the chest followed by pain upon deep inspiration
Tenderness on localized pain over the affected site
X-ray usually doesnt show the fracture (before 2 weeks, after you can see it). And diagnosis should be clinical
Treatment: no treatment is needed. Analgesics in the first few days.
Strapping the chest: a bandage covering the chest. Not needed. Might be used though
Multiple fractures
Flail chest (waving ribs): occurs after direct blow to the chest. The flail ribs are moving improperly. On inspiration
they are sucked in and on expiration, out (paradoxical respiration). This interferes with normal breathing function
of the ribs. And decrease tidal volume
Crushed chest: fractured ribs on both sides. Do not have paradoxical respiration, but painful movement will
interfere with breathing. Causing respiratory failure
Treatment:
Stable and no flail segments: same as isolated fracture. But stronger analgesics
Unstable flail segments: positive pressure ventilation for 2-3 weeks.
Pathological fractures: ribs are common sites for metastatic deposits
Costal cartilage injury: similar presentation as isolated rib fracture, but less severe. Possible need to hydrocortisone
injection
Pleural cavity injuries: seen in lung or pleura injuries
Closed pneumothorax
Seen on x-ray in standing/upright position, above the clavicle
Treatment: if it occupied >25% of the hemithorax (one side of the chest) it will cause respiratory difficulties.
Draining may be needed by catheter attached to an underwater seal. Otherwise, it might be reabsorbed
spontaneously
Open pneumothorax
When the skin and the parietal pleura are broken, leaving a pleura space communication to the outside air
The air from outside will flow in and out of the open pleural cavity
Respiratory deterioration might follow if the opening is not closed
Treatment: as first aid, a pad can be placed over the opening, or the patient lay with the wound downward,
followed by insertion of a chest drain. Then u may close the wonud
Tension pneumothorax
The same as open, but the wound works as a flap, letting air in, but close when it tries to come out. Thus the air
accumulates in the pleural cavity, the lung will collapse, and the mediastinum will shift to the other side
Unless treated directly, the patient may die within minutes.
Treatment: chest drain
Short skin incision in 4th intercostal space at the midaxillary line, (lower part, on the side of pneumothorax)
Dissect through the intercostal muscles and pleura with scissors. And open the scissor widely to release the
air! . It should be heard. And the patient will improve
Insert a chest drain
Secure the drain and connect to an underwater seal/valve
Haemothorax
Bleeding in the pleural cavity cause a more gradual deterioration
Can be seen on x-ray. HR and BP. Chest is dull on percussion
Treatment: drainage.
Chylothorax (lymphatic fluid)
By damage to the thoracic duct
Treatment: might heal spontaneously after drainage. Or might require thoracic surgery to close the thoracic
duct!. The patient should not take anything by mouth during healing time!, Only parenteral nutrition
B/1. Scapula and clavicle fractures. Acromioclavicular and sternoclavicular dislocations.

Clavicular fractures: one of the commonest of all fractures

Clavicle is firmly attached to the sternum medially, and acromion and coracoid laterally by ligaments which are
stronger than the bone, thus the bone breaks rather than allow movement when impacted with a force
The clavicle helps hold the arms at a distance from the body, thus, when broken, the arm kind of stick to the body,
and its weight makes the clavicle fragments overlap and form malunion
Fractured clavicle require 3 weeks to return to function, but 6 weeks to become solid (half in children)
Midshaft fractures
Occurs on force pushing upward and backward (e.g. Falling of a horse, with extended arms)
Complications:
Malunion: internal fixation with a curved plate can be performed
Damage to the great vessels (brachial A.), or lung
Non-union: rare, and non-symptomatic. Requires internal fixation and grafting
Deformity: when malunioned, giving unwanted appearance
Lump formed by the callus, interferes with bra and back bags :)
Treatment
Sling to support the arm, for 10 days
Figure 8 bandage, pulls the shoulders backward
Internal fixation: rarely used
Acromioclavicular separation
The joint contain a fibrocartillaginous disk, and its easily disrubted by a fall on the shoulder.
Injury can result either in separation of the two bones, or a part of the clavicle remain attached to the acromion
Clinically: tenderness of the joint, and a visible step at the joint location which disappears when lifting the arm
Grading
1. Sprain (ligament twist) without displacement: analgesics and symptomatic treatment
2. Subluxation: analgesics, and sling to support the arm
3. Dislocation (complete seperation): internal fixation
4. Dislocation with perforation of the upper deltotrapezius facia: open reduction & internal fixation
5. 4+posterior dislocation: same treatment
6. Subcoracoid dislocation: same
Sternoclavicular dislocation
Normally, elevating the lateral side of the clavicle (elevate the shoulder) is accompanied by downward
movement of the medial side at this joint
Treatment: the joint may be repaired if detected early, but otherwise left without treatment, where recurrent
subluxation is expected
Scapula fractures
Acromion fracture
Occurs in direct trauma or violent shoulder abduction
Treatment: Sling and rest is usually all thats needed. Internal fixation in severe injury
Blade of scapula
Functions as a point for muscle attachment, injured by direct trauma
Treatment: sling and rest, with early mobilization
The glenoid
Fracture by direct hit to the shoulder from the lateral side
Treatment: rest and early mobilization
B/2. Connective tissue injures of the shoulder (rotator cuff, lesion of the long head of the
biceps). Post-traumatic immobility of the shoulder.

Acute Tears Of The Rotator Cuff (muscles that hold the shoulder in place, supra- & infra-spinatus, teres minor, and
subscapularis muscles
Seen younger patients after a violent injury, or in older ones with degenerative tendons!
The patient presents with bruising and tenderness around the affected muscle with abduction weakness
X-ray: Damage to the glenohumeral joint, including the greater tuberosity, is best assessed on an anteroposterior
view, obtained with the arm in 30 degrees of external rotation.
Young individuals who are suspected of having a rotator cuff tear on history or examination should undergo an MRI
scan or an ultrasound evaluation to assess the status of their rotator cuff.
Treatment
In young or active patients with a true acute rotator cuff tear, early (within 3 months) operative repair is
indicated.
Early repair is also indicated in those cases associated with a displaced avulsion fracture of the greater
tuberosity. Displacement of a greater tuberosity fragment by more than 1 cm correlates highly with an acute
rotator cuff tear.

Non acute lesion of the rotator cuff

Any anatomic influences that narrow the subacromial space have the potential to
compromise, in particularly, the superspinatus tendon and irritate the SA bursa. Thickening
of the bursa, instability of the glenohumeral joint, or changes in the shape of the acromion
are the most common reasons for rotator cuff compromise.
Clearly visible atrophy of the posterior shoulder in the region of the supraspinatus and/or
infraspinatus muscle belly is an indicator of a large rotator cuff tear. Plain X-ray in patients
with a history of acute trauma or in those who do not improve with standard nonoperative
treatment.
Treatment
Bursitis/tendinopathy:The focus of treatment for chronic shoulder disorders is physical therapy (PT). Injections
provide another important component in the treatment of nonacute shoulder problems . The most common is
an SA injection .
Operative treatment is indicated in individuals who fail a minimum 6-month course of nonoperative treatment.
The goal of surgery is to open the SA space. This is typically accomplished by excision of the thickened and
scarred bursa, recession of the coracoacromial ligament, and an anterior acromioplasty. opening of the SA space
is termed a decompression. A decompression may be completed through either open or arthroscopic
techniques.

Ruptures of the long head of the biceps

Injuries of the long head of the biceps (LHB) tendon may occur with forceful elbow flexion or hand supination.
Eighty percent of the cases are associated with ongoing rotator cuff problems.
Steroid use for body conditioning is an increasingly common etiology.
A visible asymmetry of the injured compared to the noninjured upper arm is evident when the patient is asked to
contract biceps muscle. This deformity is called a Popeye sign.
Treatment
Ruptures of the LHB tendon are treated nonoperatively. The indications for repair are mainly cosmetic in nature
because little functional disability results.

Adhesive capsulitis (frozen shoulder)

Capsular fibrosis after a traumatic or surgical event, or idiopathic fibrosis
The patient complains of a deep, achy pain in the shoulder that is present at rest as well as with activities. Complaints
of loss of motion follow the onset of the pain by several weeks.
 A global loss of active and passive range of motion is noted. Internal and external rotation are typically affected first.
Nonspecific tenderness is usually present early in the disease process. Rotator cuff strength is often normal but may
be difficult to assess secondary to the limited and painful range of motion. X-ray is normal
Treatment
Nonoperative management with a home-based stretching program as well as pain medication if necessary is
successful in 90% of patients. Symptoms may take up to 18 months to resolve.
Occasionally, an injection of the glenohumeral joint with corticosteroid is necessary to control pain.
Operative treatment is directed at releasing the contracted capsule in a sequential fashion to improve range of
motion. This may be accomplished either closed or arthroscopically.
B/3. Dislocations of the shoulder joint.

The shoulder is mechanically unstable

The humerus head is pushed and held against the glenoid surface by a cowl (hat-like) of muscles from all directions,
except inferiorly in the axilla
Anterior dislocation
Most common, the humerus head pops off the glenoid inferiomedially, giving the shoulder a flat appearance
Occurs in shoulder abduction and external rotation at the same time
Hamiltons ruler test: if the tip of the acromion and the lateral epicondyle (of the humerus) can be joined by straight
line, the shoulder is dislocated
Complications:
Axillary circumflex N. Injury (runs around the humerus neck): causing deltoid M. Paralysis
Axillary artery: check radial pulse
Irreduciblity: when the head pops out over the subscapularis M. . Requires open reduction
Joint stiffness, Recurrent dislocations
Treatment
X-ray to confirm negative humerus head fracture
Check axillary circumflex N. Functionality (sensory/motor) before and after reduction
Reduce:
MUA: manipulate under general anasthesia
Hanging-arm technique: the patient lie, face down, and the arm is hanged freely in the air, where its weight
will reduce the joint by itself. Muscle relaxant is needed
Hippocratic method: patient lies on the flood, elevate and pull the arm, and manipulate and push-in the
humerus head with your foot to its place
Kochers method: slow external rotation of the arms, when fully achieved, the head can be easily put back
Bandaged the arm close the shoulder for 3 weeks (enabling mobility of the shoulder)
Posterior dislocation
Occurs in shoulder injury when the joint is in internal rotation, or in ligamentous laxity
Often missed, but seen as light-bulb on X-ray
Treatment: pull the arm forwards and externally rotate, bandage for 3 weeks
Luxatio erecta
True inferior dislocation. The humerus head slips over and is stuck under the glenoid, with the arm pointing upward !
Treatment: Reduce
Fracture dislocation: fracture of the humerus head
Rupture of supraspinatus tendon
Clinically: tenderness at the supraspinatus M., and weakness in abduction
Treatment: surgical repair
B/5. Fractures of the humerus shaft.

Segmented fractures
Spiral fractures: by twisting movement of the arm
Transverse fractures: direct injury/fall
Pathological fracture: humerus is a common site for metastases

Complication
Neurovascular damage: spike shaped fractures may damage radial N., vessels, or surrounding muscles (check
brachioradialis M. As a guide to neurological damage)
Malunion: might happen because of the deltoid M. Pulling the upper fragment away
Non-union: when soft tissue (radial N. Or triceps M.) is stuck between the 2 fragments
Treatment
Conservative treatment, with a hanging cast (with flexed forearm), and supported by a collar
If malalignment is present, or in pathological fracture: internal fixation
B/6. Fractures of the distal end of the humerus (supracondylar, condyle of humerus,
epicondyle).

Supracondylar fracture
Occurs in children when falling with outstretched arm. Fracture has severe complications:
Vascular damage: brachial artery
Cause 5 Ps: pulseless, pallor, pain, paraesthesia, paralysis.
The skin will be cool, with loss of passive finger extension due to edema in flexor compartment!
If these signs are present before/after reduction:
Remove any splint/dressing/cast
Extend the elbow
If circulation is still not present, administer papaverine to relax the smooth muscle of arterial wall
If nothing work, you need to open the artery and fix any intemal tears
Compartment syndrome: edema in the anterior compartment, causing median N. Compression, and loss of
finger extension. Require fasciotomy
Volkmanns ischemic contracture: end result of muscle ischemic necrosis, masses of fibrous tissue replace patches
of muscle in flexor compartment, where these contract and pull the fingers into flexion and hand into pronation
Median N. Damage
Malunion
Myositis ossificans
Treatment:
If undisplaced: Backslab (cast cut in half, one part is used) with flexed elbow for 3 weeks
Reduction: longitudinal pull with forearm in midprone position. Then Dunlop traction is applied (forarm is hanged
up)
Percutaneous K wiring if needed for fixation
Medial epicondyle
In children, Medial epicondyle and its growth plate can be pulled off the humerus by a strong injury. The fragment
might get into the joint space, limiting injury
Complication
Ulnar N. Palsy
Growth arrest
Treatment: accurate reduction (closed/open), with Kirschner wire for extra stability (later removed)
Lateral condyle
Commonest between age 3-5
If the fragment is small, involving only the capitulum, itll make closed reduction impossible
Complications: tardy ulnar palsy (first dorsal interosseos M. Atrophy), and non-union
Treatment: accurate reduction (open/closed), with Kirschner wire
B/7. Fractures of the proximal end of the radius. Olecranon fractures.

Proximal: B/4
Olecranon fractures
Olecranon: a part of the ulna extending to articulate with the distal end of humerus
Fractures upon direct fall on the elbow
The humerus presses the ulna to break it at the narrowest place
Also can break due to avulsion injury: due to pull of triceps
Treatment:
Usually displaced, and requires internal fixation with screw or tension band wiring
If comminuted fracture: excision of the olecranon (especially in elderly)
B/8. Dislocations of the elbow. Monteggia and Galeazzi fractures.

Elbow dislocation
By fall on an outstretched arm
The lower humerus end will slide forward, over the coronoid process
Complications:
Stiff joint: loss of 15-20 degrees of motion. full range of movement
restoration is usually impossible!
Ectopic ossification: occurs around the soft tissue involved
Recurrent dislocation
Treatment: reduce by pulling movement in slight flexion. Then rest in a collar for
2 weeks.

Monteggia fractures: dislocation of radial head after ulna fracture (proximal

radioulnar joint dislocation)

Treatment: the importance is not to fix one and miss the other
Internal fexation of the ulna (ulna fracture is very unstable)
Reduction of radial dislocation

Galeazzi fractures: radius fracture with distal radioulnar joint dislocation

A mirror image of Monteggia
Occurs after fall on and outstretched hand
Complications:
Malunion: due to high instability of the distal fragment, thus keep slipping
Treatment: Internal fixation of the radius, and ulnar reduction
B/9. Forearm fractures in children and adults.

Fracture of proximal radial head and neck

Types:
1. vertical split
2. tilt (the head will bend in an angle)
3. shear fracture (a fragment will fall)
4. crush (compressed)
Treatment:
Undisplaced: joint blood aspiration, supporting bandage, and early mobilization
Displaced: correct displacement (open/closed reduction)
Comminuted: radial head excision and early mobilization (possible prosthetic head replacement)

Radius & Ulna fractures

Occurs on twisting injury
Complications
Malunion: if not corrected. Limiting pronation & supination
Compartment syndrome and vascular damage
Non-union: if not corrected/controlled
Cross-union: impossible pronation & supination
Treatment
Operative: Treatment of choice, with internal fixation of both bones. (external fixation in wound contamination)
Conservative: cast that include the upper arm & the hand, with forearm in supination (high possibility of slipping)

Ulna fracture
Easily fractured, close to the surface of skin, without soft tissue protection
By direct injury/ protecting the face from a hit (e.g. Ball, object)
Treatment
Non-displaced: full arm cast immobilization.
Displaced: the rotational element makes it impossible to immobilize, thus Internal fixation with plate

Radius fracture
By direct trauma
Treatment: like ulnar fracture

Monteggia fracture
Galeazzi fracture
B/11. Fractures and pseudoarthrosis of the scaphoid bone. Perilunar dislocations.

Fractures in the hand, as in other places follows the same rule. Stable fractures
should be mobilized, and unstable fractures should be stabilized and then mobilized

Scaphoid waist fracture

By violent wrist hyperextension
Problems:
Hard to see on x-ray (even in multiple angle views): 4 views needed of
different angles
Non-union if immobilized
Aseptic necrosis of the scaphoid and osteoarthritis of the wrist: because blood supply to proximal pole of
scaphoid enters by the distal pole (backward, from distal to proximal direction), thus proximal fragment
devitalization
Few clinical signs: only tenderness in the anatomical snuff-box. With swelling, weakness of pinch, and pain on
hyperextension (these are not always present though)
Treatment
Cast to immobilize the joint, covering the joints above and below (wrist, carpometacarpal, and first
metacarpophalageal joints) for 6 weeks
Thumb should not be in abduction

Tubercle of scaphoid fracture

Less common, and usually benign
treatment: Immobilization of scaphoid is advisable for pain relief

Carpal dislocations
Perlunate dislocation
Violent hyperextension pushes the carpus (carpal bones) off the radius end. But the lunate bone remain
attached to it
Lunate bone dislocation: the same, but when followed by flexion movement, the bone is pushed forward,
separating from the other carpal bones
Treatment: reduce and hold for 4 weeks. Open reduction might be needed
B/12. Fractures of the metacarpal and phalangeal bones.

Metacarpal injuries
Fifth metacarpal bone is the most frequently broken
5th metacarpal Neck fracture
Injury to the hand with flexed fingers (fist punch)
Treatment: simple holding of the little finger to the ring finger by elastic strapping
5th metacarpal Oblique fracture of the shaft
By little finger being held and twisted
Treatment: correct rotation, with the same treatment as before
5th metacarpal Comminuted transverse fractures
By sideway direct hit to the hand edge
Treatment: Reduce the fracture, and hold the little finger to the middle one. Protect the fracture site
1st metacarpal - Bennetts fracture
By punching movement, often in boxers
Fracture line extending to the carpometacarpal joint
Treatment: reduce, and possible need for percutaneous screw/pin
1st metacarpal - Rolando fracture
A comminuted intra-articular fracture (at proximal 1st metacarpal head)
Multiple metacarpal fractures
By crushing injury
Treatment: fix alignment, with using Kirschner wires, or small plate

Phalanges
Fractured by twisting / angular forces
Angulation of bones is easily corrected by manipulation. But harder in spiral fractures
Re-union is usually smooth :)
Treatment: hold the damaged finger against its neighbor, lightly, with elastic strapping to allow swelling, with a smal
layer of absorbable material between the 2 fingers, to absorb sweat and avoid irritation. Mobilize ASAP
Unstable fractures might need internal fixation
Special cases:
Juxta-epiphyseal fractures: since phalanges are long bone, epiphysis injury is possible (just like in femur and tibia)
Intra-articular fractures: break through the condyles, producing very unstable fracture. Treat with percutaneous
wire fixation
B/13. Examination of sensation and movement of the hand. Moberg scheme. Innervations of
the hand.

Primary examination
Rested hand
Flexed fingers: damage to extensor tendon
Extended fingers: damage t flexor tendon
Skin color/Sweating abnormality: Digital N. Injury
Press the finger tips: no re-reddening in 2 seconds: Microvascular damage
No discrimination of 2 points, 5mm apart: Neurological damage
Pain/Parasthesias/Loss of sensation: Dermatomes

Secondary examination
Flexor digitorum superficialis: flexion at the Poximal IP joint (hold the other
fingers, and the patient flex one at PIP)
Flexor digitorum profundus: flexion at the Distal IP joint (hold the proximal part,
while the patient flex the DIP)
Extensor digitorum: flexion at DIP joint (can also be a sign for distal phalange fracture)
Carpal bones trauma: tendernes over the affected area

Moberg scheme: Moberg pick-up test

Tactile gnosis is the fine sensibility of the fingers pulp to recognize objects without the vision
The test examines both sensibility and motion of the hand-fingers
First with the unaffected hand, and eyes open, the patient is asked to pick up 9 small objects (screw, chalk, key,
nut) and put it in a container
then, with the second hand
The test is the repeated with closed eyes for both hands
The time is recorded and compared between both hands
When the patient is examined with closed eyes, and has a defect in median N., he wont use the low
sensibility areas, thus he will pick the objects with the thumb and ring fingers (instead of thumb and index)
The test can be made harder, if the patient is asked to identify the object, with closed eyes
Normal time to finish the picking up process of 9 objects is <10 seconds
B/14. Possibilities of treatment for injuries of the radial, ulnar and median nerves.

Topic A8
B/15. Injuries of flexor tendons in the hand.

Anatomy
Tendons run part of their way, from distal interphalgeal (DIP) joint till distal palmar
skin crease, inside a fibrous sheath, lined by synovium
The thumb and little finger sheaths continue further through the carpal tunnel
The other fingers joint the proximal common flexor sheath at the palm, and reach
the proximal wrist end
Tendons repaired inside the fibrous sheath do not slide smoothly, and suture line
must lie outside the sheath. If not, tendon should be replaced with graft, running
from distal phalanx to the palm so that theres no suture line within the synovial
sheath.
If its a must, it can be done (inside..), but very sophisticatedly
2 tendons involved - differentiation
Tendon profundus (x4): extend to the end (movement is possible at DIP joint)
Tendon superficialis (x4): only reach the middle phalanx. Tested by holding all fingers, and moving the one in test
at the PIP joint (proximal IP)

Zone I: distal to the tendon sheath

Injury distal to DIP
Treatment
Tendon advancement: detach tendon from insertion point, and reattach at an advanced
location
Arthrodesis of DIP: stick the joints together
Early movement is important
Thumb advancement can be done in the forearm, because flexor pollicis longus has
no connection with the other flexors tendons (?)
Zone II: at the fingers
Treatment - depending on the associated tendon
Superficialis: either ignore the lesion, or excise the redundant (unneeded) portion, and profundus will do the
flexion job
Superficialis & Profundus: primary repair or graft
Profundus: advancement to the distal phalanx
Zone III: in the palm
Outside to fibrous sheath, so repair is easier.
Early mobilization
Zone IV: in the carpal tunnel
11 flexor tendons + 1 median nerve. If all are cut, 24 pieces to reattach together
Risk of adhesion between repaired tendons
Treatment: only fix the essential ones. Thus u may sacrifice the flexor superficialis tendons
Zone V: in the forearm
Outside any sheath. Easily reattached. Early mobilization
B/16. Injuries of extensor tendons in the hand.

Anatomy
Synovial sheath only at the wrist, thus easier repair. Fingers can be mobilized after
3-4 weeks
If the tendons are divided/cut they cannot really contract much, because they are
connected fibrous bands.
Treatment: reattach tendons and repair the damage. Then the finger should be
splinted in extension for 3 weeks
Mallet finger
Violent flexion injury can divide the extensor digitorum (longus) at the DIP
Causes droop (hang down) of distal phalanx
Treatment: small splint at DIP joint, that allows PIP joint flexion. For 6 weeks
Boutonniere lesion
by violent muscle contraction or injury
Extensor is detached from its central insertion at the base of middle phalanx
Tendon is either injured or partial cut, not the whole way through
PIP will protrude out, giving a characteristic shape
Treatment: Splint with a straight finger
B/17. Paronychia (panaritium) acute purulent infections of tissues of the fingers.

Paronchia: a tender bacterial or fungal hand infection or foot infection where the nail and skin meet at the side or the
base of a finger or toenail.
Caused by superficial trauma (nail biting, artificial nails, excessive hand washing)
Can be divided as acute/chronic, or as candidal (candida albicans)/pyogenic (bacterial)
Mostly by S. Aureus / Streptococcus
Pus accumulation is often present
Treatment
Warm soaks can be used 3 or 4 times a day for acute paronychia to promote
drainage and relieve some of the pain. Most cases of acute paronychia benefit from
being treated with antibiotics such as cephalexin or dicloxacillin. Topical antibiotics or
anti-bacterial ointments do not effectively treat paronychia. If there is pus or an
abscess involved, the infection may need to be incised and drained. Rarely, a portion
of the nail may need to be removed.
Chronic paronychia is treated with topical antibacterial medication such as Mupirocin
ointment. A mild topical steroid like hydrocortisone may be added to the antibacterial
medication to help reduce inflammation. Steroids should never be used alone on a
chronic paronychia.
Fleon: a closed space infection of the finger pulp
The distal palmar phalanx is compartmentalized by vertically oriented fibrous septa. These septa result in a closed
compartment at the distal phalanx, which helps prevent the proximal spread of infection.
Cause: Direct inoculation of bacteria by penetrating trauma Hematogenous spread Local spread from an untreated
paronychia.
Infecting agent: Staphylococcus aureus, Streptococcus species
Symptoms: Painful, tense, and erythematous finger pad, abscess. Signs typically limited to area distal to the distal
interphalangeal joint because of anatomic constraints Evidence of penetrating trauma
Treatment: Incision and drainage. to avoid penetration of the tendon sheath, the incision should not extend to the
distal interphalangeal crease. Tetanus booster
Herpatic withlow
Cause: Herpes simplex virus infection of the distal finger. Direct inoculation of the virus
into broken skin
Infecting agent: HSV-1, HSV-2
Symptoms: Clear vesicles on an erythematous border localized to one finger. Pain,
typically out of proportion to findings. Edema. Turbid or cloudy fluid in vesicles, possibly
suggesting a superimposed pyogenic infection In later stages, coalescence of vesicles to
form an ulcer Distal finger pulp that remains soft, which may help distinguish HSV infections from bacterial felons
Treatmet: Dry gauze dressing to the affected finger to prevent further spread of the lesion
Infectious tenosynovitis
Infection within a flexor tendon sheath
Cause: direct inoculation of bacteria from penetrating trauma (fight bite). Hematogenous spread with N.
Gonorrhoeae
Infectious agent: S. aureus, Streptococcus species N. Gonorrhea
The 4 cardinal signs (Kanavel signs):
Tenderness along the course of the flexor tendon, Symmetric edema of the involved finger, Pain on passive
extension, and Flexed resting posture of finger
Treatment: Pain relief, Initiating antibiotic therapy Elevating and immobilizing the hand, Surgery by an expert!
Deep fascial space infection:
by Penetrating trauma, spread from other compartment or hematogenous seeding. (S. aureus, Streptococcus
species)
Symptoms: Lymphangitis, lymphadenopathy, fever
B/18. Basic rules of amputation of the hand. Immobilization of the injured hand.

Amputations: the removal of extremities that are severely diseased, injured, or no longer functional.
The aim should be a mobile finger/hand with innervated skin. If the sensibility is abscent or the part is extremely painful,
its better to amputate the finger for example.
Vascular Disease and Diabetes
Ischemia resulting from peripheral vascular disease remains the most frequent reason for amputation in the United
States.
Where to amputate?
Activity level, ambulatory potential, cognitive skills, and overall medical condition must be evaluated to determine if
the distal-most level of amputation is really appropriate for the patient.
For patients who are likely to keep & need to walk/move & use the limb, the goals are to achieve healing at the
distal-most level that can be fit with a prosthesis and to make successful rehabilitation possible.
Surgical Definitions & Techniques
Terminology for amputation level now uses an accepted international nomenclature.
Transtibial should be used instead of below knee, and transfemoral instead of above knee.
In the upper extremity, the terms transradial and transhumeral replace the older terms below elbow and above
elbow.
The tissues are often traumatized or poorly vascularized, and the risk of wound failure is high, particularly if close
attention is not paid to soft-tissue technique.
Flaps should be kept thick, avoiding unnecessary dissection between the skin and subcutaneous, fascial, and muscle
planes.
In adults, periosteum should not be stripped proximal to the level of transection. In children, however, removing 0.5 cm
of the distal periosteum may help prevent terminal overgrowth.
Stabilizing the distal insertion of muscle can improve residual limb function by preventing muscle atrophy, providing
counterbalance to the deforming forces resulting from amputation, and providing stable padding over the end of the
bone.
Myodesis is the direct suturing of muscle or tendon to the bone or the periosteum.
The transection of nerves always results in neuroma formation, but not all neuromas are symptomatic. No technique is
more effective than careful and meticulous isolation, retraction, and clean transection of the nerve.
Amputations
Finger tips: vertical through the nail/oblique through the pulp/vertical through the nail and distal phalanx
Fingers: possible need to shorten the finger. If neuroma forms after cutting the digital nerve, causing severe
tenderness, apply a protective finger glove, or resect the digital nerve.
Thumb: if lost, pollicizing the index to replace the thumb is an option

Postoperative Care and Planning

A variety of methods are available, including rigid dressings, soft dressings, controlled environment chambers, air
splints, and skin traction.
The use of a rigid dressing controls edema, protects the limb from trauma, decreases postoperative pain, and allows
early mobilization and rehabilitation.
Splinting the hand: splint covers the forearm, wrist, and fingers. Holding the wrist in dorsiflexion, and the fingers in
plantar flexion by having an object like shape that require a gripping position of the hand
Preferred immobilization technique depends on the injury and the involved part. But in most cases, mobilization of the
muscle/joint is essential ASAP, to avoid bad outcomes of treatment
B/19. Serious injuries of the hand: replantation, revascularization. Revascularization
syndrome.

Replantation of amputated hand/finger:

First, the neuronal and vascular structures are identified on both sides and tagged (for quicker identification later)
Bone shortening (5-10mm) is required to reduce stretching of the reconnected structures
The order of correction is not important. But commonly: extensors veins dorsal skin arteries nerves
flexors plantar skin
For bone fixation K-wires are useful
In finger replantation
Extensors lateral slips (the connection at proximal phalanges) need to be secured/reattached
At least 2 veins and 1 digital artery need to be repaired
After artery repair, release the tourniquet to check for proper anastomosis

Nerve & Vessels repair: Topic A8

Revascularization syndrome
A post operative complication when a large tissue is amputated (with large muscle mass and significant muscle
ischemia), followed by late revascularization, later than 12-24 hours. Myoglobin-nephrosis occurs leading to renal
failure and death.
B/20. Possibilities for the treatment of ligament injuries in the hand.

Wrist injuries are common. If it causes significant damage to the ligaments, it may ,if not corrected, cause continuous
problems to the patient
Causes: Fall on an outstretched hand, car crash. Whether the wrist is broken or ligaments are injured usually depends
on many things, such as how strong your bones are, how the wrist is positioned during the injury, and how much
force is involved.
Symptoms: Pain and swelling are the main symptoms. There may be discoloration and bruise (ecchymosis). May
remain painful for several weeks. No specific symptoms to check whether a ligament injury has occurred.
Diagnosis: Medical history. History of wrist injuries. Physical examination of movement alignment and tenderness
X-rays can also help determine whether certain types of ligament injuries have occurred by looking at how the
bones of the wrist line up.
Arthrogram of the wrist.This test requires dye be injected into one of the small joints of the wrist. Special X-rays
are then taken to look for leakage of the dye out of the joint. This may help confirm that the ligaments are torn.
MRI can help look at the wrists.

Nonsurgical Treatment
A wrist sprain (ligament twist), may be treated with a cast or splint for three to six weeks
Surgery
In cases where the ligaments are completely torn and the joints are no longer lined up, surgery may be
suggested to either repair the ligaments or pin the bones together in the proper alignment to hold them in place
while the ligaments heal.
Percutaneous Pinning and Repair of the Ligaments
If the ligament damage is recognized within a few weeks after the injury, the surgeon may be able to insert
metal pins to hold the bones in place while the ligaments heal. This procedure is called a percutaneous
pinning. In some cases, getting the bones lined up properly is not possible, and an incision must be made to
repair the ligaments. The longer the surgery is done after the initial injury, the less likely it is that the bones
can be aligned properly. It is also less likely that torn ligaments will heal once scar tissue has developed over
the ends. The pins are usually removed four to six weeks after the procedure.
Ligament Reconstruction
When the ligament damage is discovered six months or more after the initial injury, the ligament may need
to be reconstructed. This procedure involves making an incision over the wrist joint and locating the torn
ligament. Then, a tendon graft is used to replace the ligaments that have been torn. The tendon graft is usually
borrowed from the palmaris longus tendon of the same wrist. This tendon doesn't do much and is
commonly used as a tendon graft for surgical procedures around the hand and wrist. . Again, metal pins are
used to hold the bones stationary while the tendon graft heals. The pins are removed six to eight weeks
after the surgery.
Fusion arthrodesis: When the ligament instability is discovered long after the injury and arthritis is present in the
joints between the unstable bones, a fusion may be suggested. Two or more bones are fused by removing the
cartilage surface between the bones. When the raw bone surfaces are placed together, the bone treats them as
it would a fracture. The surfaces heal together and fuse. This stabilizes the motion between the bones and
reduces the pain that occurs when the arthritic joint surfaces rub together. If the entire wrist has become
arthritic from longstanding instability, a complete wrist fusion may be required.
A/11. Possibilities of skin grafting in traumatology.

When skin loss is present, one cannot simply close the wound. But has to replace the missing skin instead

Relaxing incisions: when closure is not possible, due to large area and unextendability of the skin, a relaxing incision at
the edge might increase that, and make it possible to close the wound
Skin graft
Split skin graft: partial thickness of the skin is taken from an intact area
Whole thickness graft: better result, but leave a scar at the donor area
Skin flap
Flap of skin, muscle or fascia or a combination, can be moved to cover large exposed regions. Preferably with intact
blood supply. This will help keep the underlying tissue vital
Can be Local (adjacent), Regional (same region), or Distant graft
Xenografts: Foreign skin (pig) can be used as a temporary dressing, and removed after 1-2 weeks
Free flaps: skin and its vascular component is taken from one area, and anastomosed at the new location with the local
blood supply.
A/14. Use of metals and plastics in traumatology. Corrosion, metallosis.

Screws
Lag screws rely on compression.
There are 2 types of bone screws: the cortex and the cancellous bone screws.
The cancellous bone screws have a larger outer diameter, a deeper thread and are used for metaphyseal or
epiphyseal bone.
The cortex screws are designed for diaphysis.
Generally, a screw should not be tightened to the limits of strength, but to about 2/3 of these limits, to allow
resistance to any additional functional loading.
Best efficiency is when the screw is perpendicularly oriented in relation to the fracture surface.
Usually made from Titanium. Bone screws are made from non-reactive materials which can be safely used inside a
patient's body.
Plates
Lag screws are usually combined with plates acting as splints that bridge the fracture site.
Indications for plate include: Transverse and short oblique fractures of the shaft of long bones if IM nailing is not
adequate.
Disadvantage: A plate placed in direct contact with and pressed to the bone surface can lead to long standing
disturbance to blood flow to the underlying cortex.
Bridge plates
Bridge plating uses the plate as an extra medullary splint fixed to the two main fragments, in which the complex
fracture zone is virtually left untouched
Applicable to all long bone fractures where complex fragmentation is present and which are not suitable for IM
nailing.
External fixators
An external fixator is a device placed outside the skin which stabilizes the bone fragments through wires or pins
connected to one or more longitudinal bars/tubes.
Advantages: less damage to blood supply of bone; useful for stabilizing open fractures; requires less experience and
surgical skill than standard ORIF; quite safe to use in cases of bone infection.
Disadvantages include restricted joint motion; pin-track complications in long-standing external fixators; heavy and
not always well-tolerated.
Hip prosthesis
stainless steel one piece femoral stem and head
polyethylene (teflon), acetabular component, both of which were fixed to the bone using PMMA (acrylic) bone
cement
A titanium hip prosthesis, with a ceramic head and polyethylene acetabular cup.
Metals
Iron and steel were the most used metals
They dissolved rapidly and provoked erosion of adjacent bone. However, it still may have applications in elderly
patients, in whom physical demands and life expectancy are limited, especially when cost is a major determinant.
Stainless steels are suitable to use only in temporary implant devices.
Copper and nickel discolored bone in which they were embedded.
Gold, silver, and pure aluminum do not produce discoloration but are too weak and soft for this application.
Chromium nickel stainless steel was more corrosion resistant in body fluids than other metals.
Titanium: Its lightness and good mechano-chemical properties are important features for this application.
The strength of the titanium alloys is lower to equal to that of stainless steel, but its specific strength (strength
per density) is far greater than other alloys.
Titanium has poor shear strength, making it less desirable for bone screws, plates and similar applications.
One disadvantage of metallic implants is that a second surgery is required to remove the implant.
Certain ceramic and polymeric materials are bioresorbably and some even help to promote bone growth. But they are
generally less strong than metals.
 Hydroxyapatite
A form of calcium phosphate. This ceramic material is used for bone implants.
Hydroxyapatite is also the mineral component of natural hard tissues. When it is added to or coated on any
candidate implant material, hydroxyapatite forms a composite which is inherently biocompatible and stimulates
bone growth at the interface between the hydroxyapatite and the bone.
Polylactic acid (PLA)
Considered to have the best overall properties of the known bioresorbable polymers. Its degradation time is the
longest, ensuring that a PLA implant will support a bone for the duration of healing. The exact degradation times
vary greatly, from 6 weeks to several years. PLA is also the only polymeric material that allows osseous ingrowth
(i.e. new bone formation) to occur while the implant is degrading.
Corrosion
Caused by oxidation of metal (rusting, avoided with titanium), it can severely limit the fatigue life and ultimate
strength of the material, leading to the mechanical failure of implant. The release of corrosion products may elicit an
adverse biological reaction in the host, and increased concentrations of trace metals.
Corrosion products can cause local pain and swelling. And may result in a cascade of events leading to periprosthetic
bone loss.
Excretion of excess metal ions (especially chromium, cobalt and nickel) and their suspected role in induction of
tumors.
Metallosis
Large amounts of particles are liberated from the orthopedic implants, often so much is liberated that there will be
discoloration and it will affect the tissue around, this is metallosis.
The particles contain polyethylene and other metals (chromium, cobalt, titanium, nickel). Phagocytosis of these
particles can lead to a cascade of events that can lead to loss of bone tissue around the implant (osteolysis). This can
in worst case lead to loosening of the implant and destruction of the artificial joint.
C/1. Fractures of the pelvis and accompanying injuries.

Pelvic fractures complications include, Bladder/Urethra/Rectum injuries. Call a urologist! :). & Ant/Post hip dislocation.
Avulsion
Seen in young athletes, occurs due
to a violent stretch of the muscle
Usually at the origin of the
adductor muscles. (rectus femoris
and sartorius M. At ASIS & iliac
crest)
Treatment: based on the severity.
Large fractures need reduction,
and severe cases might require internal fixation
Single bone
common in elderly with porotic bone, after a direct localized injury.
Common locations: pubic rami (sup./inf.), and wing of the ilium.
Possible complication by injury to the bladder or urethra
Treatment: due to high muscle tissue surrounding the area and attachment
to the locations, good blood supply and holding is present. Thus early
mobilization is all that is needed (after a week). Intially the injury is very
painful, but decrease with time.
Complex (multiple site)
Anterior/Posterior compression - open book
Result in an pubic diastasis (pubic symphisis separation), fractures at the
pubic rami and/or sacroiliac joints, ilium or sacral body
Such injury may cause a catastrophic blood loss! By tearing of the iliac
vessels
Treatment
Minor injuries: bed rest and gradual mobilization
Major: close the book by pelvic sling or internal/
external fixation! (also true for blood loss)
External compression
Caused by a hit to the side of the pelvis, or greater
trochanter (of femur)
The side of injury is rotated inward, by fracture of the pubis
or ilium, disruption of sacroiliac joint or fracture of the
sacrum
Treatment: conservative if minor (>6weeks rest and gradual
mobilization, use of crutches). Internal/external fixation in major injuries
Vertical compression
By fall from a height.
Disruption of pubis, sacroiliac joint, sacrum and ilium. With possible neurological damage by sacral plexus
injury
Treatment: reduction by traction, internal/external fixation
Acetabulum
This disrupts the hip joint. And may lead to osteoarthretic degeneration later! . This can be avoided by early
mobilization ASAP
Treatment
Undisplaced: rest, and early rapid mobilization (>6 weeks non-weight-bearing mobilization)
Displaced: open reduction, internal fixation, traction. And early mobilization
Coccyx fractures: very painful. Treat with analgesics
C/2. Fractures and dislocations of the hip.

Posterior hip dislocation

Common in road traffics when the hip and knee joints are both flexed
Impact at patella patellofemoral joint femur hip joint acetabulum posterior lip
(weak point that fractures)
Thus its often associated with patellar & femular shaft fractures
The femoral head is behind the pelvis
The patient presents with a shortened, and internally rotated leg
Possible segmental / slice fracture of the femoral head, where the fracture might prevent the reduction, or damage
the sciatic nerve when reduction is done
Complications: Sciatic N. Damage, Aseptic necrosis of the femoral head (comes later >2years after), Osteoarthritis
of the femoral head & Ectopic ossification
Treatment
Reduction within 4-6 hours. Closed / Open. Record neurological function before & after.
Open reduction is better to avoid sciatic N. Damage
If hip is stable and acetabular fragment is small: bed rest for 2-3 weeks with early mobilization
If fracture is unstable: 6-8 weeks
If large fragment / or bad fragment position: consider fragmented part replacement and internal fixation
Anterior hip dislocation
Rare, might be caused by forceful abduction
Complications: aseptic necrosis of femoral head
Treatment: closed reduction
C/6. Fractures of the shaft and condyles of the femur.

Femural shaft fracture

By direct trauma, or elbow twisting
Clinically presents as shortened and fattened than normal thigh with external rotation of the foreleg.
Adductors are attached to the distal fragment and abductors to the proximal, witch give the presenting shape
Edges of the fracture can damage the surrounding muscle which contributes to the fattening (filled with blood)
Complications
Hemorrhage, typically 2-4 units (1-2 liters), true for open & closed!
Infection (if with contaminated wound)
Malunion (from the pulling of adductors and abductors)
Arterial & Nerve injury
Treatment
Immediate care: deal with the Hemorrhage and Possible contamination (if open. Debridment and cleaning)
Treat fracture: Immobilize the fracture by:
Traction: rarely used. Only in surgery contraindication or in children
Internal fixation: with intramedullary nailing, preferably with locking nails. Inserted proximally or distally. This
method enables the patient early mobilization, and to leave the hospital within days
Open reduction and fixation with plates is not often used, due to the further extensive damage done
External fixation: used for contaminated and open fractures
Cast bracing (2 pieces cast connected by metal moving part at the knee, to enable bending): used after
traction treatment

Condylar fractures
When the fracture line enters the intercondylar notch it can cause one (oblique line) or both (Y shaped line)
condyles break. Fracture can also be Comminuted (the lower femur and its condyles are fragmented to pieces)
Precise reduction is critical (millimeters) for proper function of the knee joint
Treatment
Undisplaced: aspiration of the joint from blood 4 weeks traction casting
Displaced: accurate reduction. Usually involves open reduction and internal fixation
Complications:
Aseptic necrosis: If blood supply is lost (often) collapse gross & functional deformity
Imperfect reduction/repositioning: result in valgus or varus derformity predispose to osteoarthritis
C/7. Fractures of the patella. Stable and unstable fractures of the tibial condyles. Fractures of
the intercondylar eminence.

Fractures of Patella
Comminuted
Patella is easily fractured by injury to the flexed knee, often in car accidents
Treatment: shear stress on the patella is huge. And any abnormality of its surface can cause
osteoarthritis later. So unless the fragments can be reassembled accurately, its best to
remove the patella!, and knee early mobilization
Stellate (undisplaced)
When a blow to the patella cracks it, without displacement
Treatment: conservative, blood aspiration from the knee, and a long leg cast for 3 weeks
Transverse
Indirect violence, by forced flexion of the knee, or falling with flexed knee, might result in
transverse split of the patella
The split includes not only the patella, but also the quadriceps tendon, which eventually result in further
separation of the fragments, and loss of quadriceps function
Treatment: Internal fixation, with wiring, to reconnect the 2 fragments of patella (tension band wire).

Fractures of Tibial condyles

Upon forceful hit to the lateral side of the knee 2 things can happen: medial ligament
tear, or lateral tibial condyle fracture (because of femur pressing on the lateral tibia).
these may be:
Vertical split of the lateral condyle
Depressed condyle fracture (the condyle is pressed down)
Impaction fracture of the lateral condyle
Crush fracture
Medial condyle fracture?
Type I medial
Type II medial and depression
Type III medial depression
Type IV lateral
Type V medial & lateral (bicondylar)
Type VI medial & tibial neck
Treatment:
If large fragment is present, it must be screwed back
In large depressed fragments, the fragment must be elevated,
the chondral surface should be reconstructed, and the cavity
underneath (from the crushing force) should be filled with
cancellous bone graft
If mild depression is that has happened, conservative treatment and early mobilization is all
thats needed. But in younger patient its better to choose reconstruction
C/8. Haemarthrosis. Meniscus injuries. Post-traumatic osteochondritis.

Haemarthrosis of the knee

Bleeding into the knee usually indicated a serious injury: 80% major ligament injury (mainly anterior arcuate
ligament), 15% patellar dislocation, 5% other
Blood must be removed (aspiration with/without arthroscopy), first thing!, because it acts as a glue, limiting
movement, and irritating the synovial surfaces. In addition the potential for clotting inside the joint/capsule
Aspirate must be checked for fat globules. Fat can only enter the knee from a bone fracture, and usually
indicated a serious injury
THEN, you can make the diagnosis of the cause

Meniscus injuries
The menisci serve an important role in absorbing downward pressure
from the convex femoral condyles
Often menisci injury or meniscectomies predispose to later
osteoarthritis development!
When a meniscus tears, a mobile fragment will pop in and out of the
joint, which will block the movement
Symptoms include: recurrent locking and unlocking of the joint, with
possible severe pain in locking state
Meniscal tears
Knee locking is most often associated with bucket handle tear
Others include: flap tears, torn horn, transverse
Discoid menisci: the menisci are congenitally disc, half moon, or circular shaped
Cystic menisci: myxoid degeneration causing the menisci to become soft!, causing dull pain, mostly on the lateral side
Meniscal cyst
Diagnosis: Arthroscopy or MRI
Treatment
Tears: arthroscopically (rarely open meniscectomy), the loose fragment is excised, leaving as much health
meniscal tissue as possible. Light work is allowed after 1 week, and heavy work after 2 weeks
Discoid menisci

Post-traumatic osteochondritis
Aka Osteochondritis dissecans
A gradual dissection or separation of a block of bone from its normal site. Might occure after a mild injury, that
initiates the process
Most commonly seen in medial femoral condyle
Usually in kids 8-12 years, boys 6:1 girls
Pain in walking and hyperextension, tenderness
X-ray rarely show any abnormality, especially at early stage
Treatment:
Conservative: natural union, even without a cast
Operative: indicated only if pain last >6months, with no sign of radiological union. Achieved by drilling holes
through the articular surface in the medial condyle!. In more advanced separation, screws may be applied to
connect the fragments
C/9. Tendon injuries of the knee. (Tendons? Ligaments?)

Ligament injuries at the knee

Ligaments never heal properly or regain their strength as bone does, thus, ligament
injuries have more serious long-term implications than bone fractures
In addition, ligaments dont appear on radiographs, which might lead to false diagnosis
in knee injury
Normal knee joint movement is 0-150 degrees, anterio-posterior flexion-extension
Anterior cruciate rupture (ACL)
This ligament limits forward movement of tibia
Occur in sport injuries, by sharp twisting movement, or a push from behind to the
tibia (push it forward from behind)
80% of acute haemarthroses is caused by this lesion
The patient often feels something go in the knee at the time of injury, and hears a snapping sound!. The patient
wont be able to carry one, and will feel the knee is very weak
Outcome
of patients will achieve good result without operation, and have a normal life, including sports, without
problems
of patients, the instability is very severe, and patient have a big difficulty in even walking properly without
falling. These patients need reconstruction of ligaments
of patients will experience instability, to a limited extent. Which could limit sports and some other
activities. Here, the reconstruction is optional
Treatment
Conservative: blood aspiration, followed by physiotherapy to strengthen the muscles. Especially the
hamstrings (which prevent excessive forward movement)
Operative: effective repair is impossible!, the only way is full reconstruction
Treatment of choice is intra-articular reconstruction using the middle third of the patellar tendon, or a
four-stranded hamstring graft
Best results when done ASAP
Avulsion of anterior cruciate
Tibial insertion can be avulsed in young patients
Treatment: manipulation or reduction and fixation, then immobilization for 6 weeks
Medial collateral ligament (MCL)
Complete tears are usually associated with anterior arcuate rupture
Isolated tears are caused by pure valgus strain, due to blow to the side of the knee
Isolated tears usually heal well without operation. Though tenderness and radiological signs can last for years
Treatment:
Isolated: long leg cast-brace for 6 weeks from groin to ankle (the one with the metal at the knee)
MCL & ACL: cast immobilization for 6 weeks with/without immediate ACL reconstruction that may be
combined with MCL repair
Posterior cruciate ligament
By blow to upper end of tibia when knee is flexed
By hyper extension
Or combined with other ligament injuries / dislocations
Haemarthroses follows
Excellent recovery from isolated injury. Without treatment!
Treatment:
Conservative: blood aspiration, immobilization, followed by physiotherapy to strengthen the Quadriceps.
Operative: only when there is other associated ligamentous/capsular damage
Lateral collateral ligament: uncommon, and not so important. But early operative repair is recommended
Knee dislocation: when at least 2/4 main ligaments are ruptured
C/10. Fractures of the lower leg.

Fractures of fibula
How
By direct trauma to the outer side of the leg transverse / comminuted fracture
By twisting injury spiral. usually associated with tibia or ankle fracture. The combination is called Maisonneuve
fracture
Repeated stress stress fracture. In long distance runners. Usually distally, above the tibiofibular ligament
Tenderness & Bruising at fracture site. Painful dosriflexion of the ankle
When the Tibia is intact, the patient can bear weight on his leg (walk..)
Treatment
If undisplaced, and not painful, no immobilization is required!
If displaced/painful/fatigue fractures, reduce, and cast

Fractures of tibia
How
Direct trauma
Twisting injury (rare)
Fatigue/Stress fractures. Usually between the upper and middle third
Treatment
Same as when both bones are broken

Tibia & Fibula fractures

By road traffic, twisting injuries and sport injuries
Complications
Non-union/Delayed union: common in open fractures
Malunion: common, increases wear (damage by friction/stress) on the knee, causing osteoarthritis
Vascular damage: causing gangrene in foot or ankle. Check for proper circulation and neurological damage
Soft tissue damage:
Skin loss
Compartment syndrome: closed fractures that accumulated blood an edema in closed fascial spaces, causing
ischemic fibrosis of the muscle. Patient presents with tense calf, and loss of passive extension, with diminished
sensibility
Treat by decompression of all 4 compartments of the leg. With fasciotomy
Hemorrhage: if open wound, usually between 1-3 units. Might require transfusion
Treatment
Immediate care: deal with urgent complications
Reduce (with general anesthesia) the fracture and hold in good position for 10-16 weeks by
Stable: Cast immobilization (from the groin to till the toe)
Unstable: Internal fixation (plates and screws / screws alone / wires / intramedullary nailing - all are options)
Contaminated and Unstable: External fixation
Choosing treatment
Transverse fractures of tibia: usually stable
Spiral fractures: always unstable, worse if the ends are broken off (butterfly fragment) IM nail fixation
Segmental: tibia and fibula are broken in 2 places with 2 mobile central pieces: very unstable Locking IM nail
Boot-top fractures: ski boots immobilizes the ankle, so when sudden stop happens, the leg breaks: stable
Contaminated: usually comminuted, and unstable
C/11. Fractures of the ankle.
C/12. Injuries of the ankle ligaments. Injuries of the Achilles tendon.

Ankle bones may be broken at

1. Tibia medial malleolus
2. Lower of of fibula, including lateral malleolus
3. Posterior margin of tibia posterior malleolus
Ligament tears
1. Inferior tibiofibular
2. Medial
3. Lateral collateral
Forces causing the injury
1. Abduction
2. Adduction
3. External rotation
4. Vertical compression
Grades of severity
1. Ligament injury, alone
2. Ligament injury + 1 malleolus fracture
3. Ligament injury + 2 malleoli
4. Ligament injury + 3 malleoli
5. Ligament injury + seperation at inferior tibiofibular joint + fracture
Management
Basically should reverse the movement that caused the fracture. Then hold the
ankle in good position.
Can be done only by manipulation, or internal fixation if the fracture is
unstable. The choice is based on the severity of injury, stability, and patient age
Conservative: cast for 4-8 weeks followed by physiotherapy
Internal fixation: with purpose to reconstitute the joint surface and create a stable joint
Complications: malunion, and secondary osteoarthritis

Webber classification
Type A: transverse fracture of the lateral malleolus, or below the level of the
ankle joint
Type B: the fracture involves the joint line
Type C: the fracture above the joint line

Abduction injuries
Tear in the Deltoid ligament, or avulsion of the medial malleolus
Severe swelling occurs
Treatment: casts are not good because of swelling (will loosen up later), internal fixation is preffered
Adduction injuries
Sprained ankle
Commonest ankle injury.
A partial tear of the anterior inferior talofibular ligament
Tenderness over the ligament, with possible haemarthroses
Treatment: firm elastic support. If severe, then below-knee cast.
Lateral collateral ligament rupture
Can occur without rupture
Treatment: protected mobilization for 4-6 weeks
Complications: recurrent instability. May require reconstructive procedure
 Avulsion of lateral malleolus
by the strong lateral collateral ligament when it doesnt tear.
Fracture of both malleoli: also possible
External rotation injuries
The movement pushes the talus against the lateral malleolus
Deltoid ligament rupture, medial malleolus avulsion, and fibula fracture (at/above the ankle) are all possible
Treatment: these are very unstable. Internal fixation is needed
Vertical compression / Hyperextension
Can cause a comminuted crush fracture at the tibia
Treatment: internal fixation with plate.

Achilles tendon rupture

By forward lunge movement (sport injury)
The patient feels a kick on the achilles tendon from behind
Swelling around the tendon, and the defect can be felt
The squeeze test is positive: squeeze the calf, and the leg wont move if the tendon is ruptured
Treatment: operative is usually the preferred method. Conservative treatment is possible.
After either, cast immobilization for 4 weeks (below the knee cast) in full flexion . Then changed to bring the the
foot half way up for 2 weeks. Then a walking cast for 2 weeks
After that, intensive physiotherapy
C/13. Fractures of the talus and calcaneus.

Fracture of talus
Occurs by twisting injury to the foot, violent dorsiflexion, or an impact from below
The ankle, subtalar and midtarsal joints are all affected by talus fracture
Types by site of fracture
1. Talus body
2. Talus Neck
3. Osteochondral fractures
Complications associated with Talus neck fractures
1. Skin necrosis. When the fragment stretches the skin severly
2. Non-union
3. Aseptic necrosis. By interruption to the blood supply
4. Late osteoarthrosis of subtalar and talonavicular joints
Treatment
Fractures of the neck should be reduced to good position open/closed reduction. Possible need for internal
fixation. Followed by protection from stress until union happens
Fractures of the body cannot be reduced to good position! . Treated by early mobilization

Fractures of the calcaneum

Occurs by a hit to the heel, often by landing from a hight
The calcaneum is made of cancellous bone, thus, its crushed at the moment of impact, and anatomical restoration is
difficult. And if done, a cavity inside will remain, and must be filled by a bone graft
Other types include avulsion of the posterior segment by achilles tendon. And fracture of
the sustenaculum tali
Diagnosis: on X-ray, theres loss of Bohlers angle, widening of the body, and clinically,
horseshoe bruise around the heel with tenderness
Complications: stiffness at the subtalar and midtalar joints
Treatment
Conservative: rest and protection from weight bearing for 6 weeks
Operative: open reduction with bone grafting. Preferred in crush injuries. And have better results
C/14. Fractures and dislocations of the foot.

Fracture of the tarsus

Tarsal bones are hard, and resistant to fractures. But dislocations and fracture
dislocations are common at midtarsal and tarso-metatarsal joints
Injury by twisting movement
Treatment: if not recognized at reduced accurately, a disabling deformity result and the
dislocation become permanent. Open reduction and internal fixation is often needed

Fractures of the forefoot

5th metatarsal
By twisting injury. Often the styloid process can be avulsed. But the shaft can also
be fractured
Treatment: below-knee cast, or firm crepe bandage is enough
Multiple-spiral fractures
By twisting movement
Treatment: reduce as much as possible. Immobilization with percutaneous pins might be possible
Fatigue fractures
Fracture of phalanges
By falling objects. Often a crushing fracture
Treatment: in distal phalanges, elevate the foot until swelling decrease. Proximal phalanges rarely need treatment
Crushed foot
Treatment: elevate the foot, until swelling decrease, followed by supporting bandage