Introduction

Orthopaedics is concerned with bones, joints, muscles, tendons and nerves the skeletal system and all that makes it move

Introduction
Scope : Congenital & developmental abnormalities Infection & inflammation Arthritis & rheumatic disorders Metabolic & endocrine disorders Tumours Sensory disturbance & muscle weakness Injury & mechanical derangement

Subdivision : Traumatology Orthopaedi : 1. Adult Reconstruction 2. Oncology Orthopaedic 3. Pediatric Orthopaedic 4. Spine 5. Hand & Microsurgery

Introduction
Steps in orthopaedic diagnosis: 1. History taking 2. Physical Examination * Posture * Gait 1. Inspection 2. Palpation 3. Examination of movements 4. Conduction of special tests 3. Further investigations 1. Examination of radiographs 2. Examination of blood, sinovial fluid, etc

Inspection
Is there swelling? Is there bruising? Is there any discoloration, or edema? Is there muscle wasting? Is there any alteration in shape or posture, or is there evidence of shortening?

Inspection

Palpation
Is the joint warm? Is there tenderness? How is the artery pulse?

Movements
Active ROM Passive ROM Fixed deformities Restriction of ROM Movements in abnormal plane Crepitus Strength of muscle contraction Gait

Movements

Conduction of Special Test

Integrity of certain joint ligaments Examination of structures associated with the joint Appropriate neurological examination

Examination of Radiographs
Soft tissue Bone : shape, size, contour Alignment

Examination of Radiographs
Comparison films Oblique projections Localized views Stress films

Arranging Further Investigations

ESR, CRP Full blood count with differential Estimation of RF Serum calcium, phosphate & AP Serum Uric Acid Chest X-Ray

Equipment Requirements
A tape measure A goniometer A tendon hammer A disposable sharp point

WHAT IS POLYTRAUMA ?

Objectives
Establish the principles for assessing the patient with musculoskeletal injuries. Establish treatment priorities. Identify the importance of musculoskeletal injuries in the multiply injured patient.

Emergency in Orthopaedic
Emergency : trauma cases - Life threatening - Limb treatening 85 % of blunt trauma affect musculoskeletal system Life saving before limb saving

Key Questions
How do musculoskeletal injuries impact on the primary survey? What are my priorities? What are my management principles?

Assessment of the Polytrauma Patient

Primary Survey A irway with cervical spine control B reathing C irculation with control of hemorrage D isability (neurological state) E xposure (take the patient clothes off)

Primary survey management

The 3 Ss Stop the bleeding! Splint the extremity Stabilize the pelvis

Primary Survey & Resuscitation

Recognize and control hemorrhage Direct pressure Splint fractures Fluid resuscitation BE AWARE OF REPERFUSION INJURY!

Primary Survey & Resuscitation

Adjuncts : Fracture immobilization Goals Hemorrhage control Pain relief Prevent further soft tissue injury Apply splint early, but avoid delay in resuscitation. Be careful in dislocation

Primary Survey & Resuscitation

Adjuncts : X-Rays Determinited by patients condition Obtain AP pelvis early if hemodynamically abnormal and no obvious source of bleeding

Secondary Survey
History

AMPLE

From Head to toe examination Every orifice must be examined Dont forget the back!

Secondary Survey
Look Feel Listen For What?

For What?
Look Deformity Pain Tenderness Wound(s) Listen
Doppler signals Bruit

Feel Crepitus Skin flaps Neurologic deficit Pulses

Life- Threatening Injuries

Major pelvic disruption with hemorrhage Major arterial hemorrhage Crush syndrome (rhabdomyolysis)

Life Threatening Musculoskeletal Trauma

Pelvic Trauma with Massive Bleeding Posterior pelvic structures disrupted Pelvis open : vessels, nerves,rectum, skin Mechanism of injury
Motorcycle Pedestrian Crush Falls > 12 feet (3.6 meters)

Life Threatening Musculoskeletal Trauma

Pelvic Trauma with Massive Bleeding

Life Threatening Musculoskeletal Trauma

Pelvic Trauma with Massive Bleeding

Pelvic Wrapping

Life Threatening Musculoskeletal Trauma

Main Arterial Rupture
1.
2

3.

Trauma - sharp, blunt Examination - Artery pulse, Doppler - Ankle / brachial index Management - Pneumatic tourniquet - Vascular clamp? - Traction, Splint

Life Threatening Musculoskeletal Trauma

Crush Syndrome

Myoglobinuria Metabolic acidosis, K, Ca and coagulopathy Compartment syndrome IV fluids, alkalization of urine

Limb- Threatening Injuries

Open fracture and joint injuries Vascular injuries Compartment syndrome Neurologic injury

What are my early concerns?

Vascular compromise Open fractures

Limb Threatening Musculoskeletal Trauma

Open Fractures

Apply appropriate splint Cleanse / debride (now or later) Consider time factor Obtain orthopaedic consult

Limb Threatening Musculoskeletal Trauma

Open Fractures
Classifying the injury Gustilos classification (Gustilo et al, 1990)

Open Fracture grade 1

Open Fracture grade 2

Open Fracture grade 3A

Open Fracture grade 3B

Open Fracture grade 3C

Limb Threatening Musculoskeletal Trauma

Open Fractures
Principles of treatment Objectives : - Prevention of infection (sepsis/osteomyelitis) - Promote bone healing - Restoration of function

Limb Threatening Musculoskeletal Trauma

Open Fractures
Principles of treatment 4 essentials are : 1. Wound irrigation & debridement 2. Antibiotic prophylaxis 3. Stabilization of the fractures 4. Early wound coverage

Open Fracture Complicated case

Not proper initial management

Limb Threatening Musculoskeletal Trauma

Vascular Trauma & Traumatic Amputation Reduce fracture(s) Splint fracture(s) Assess by Doppler Obtain consult (time is critical) Consider angiography

Limb Threatening Musculoskeletal Trauma Vascular Trauma & Traumatic Amputation

Limb Threatening Musculoskeletal Trauma Vascular Trauma & Traumatic Amputation

Management Muscle necrosis : 6 h Warm & Cold Ischemic Reimplatantation & Revascularization Proper amputee management!

Limb Threatening Musculoskeletal Trauma

Compartement Syndrome
Fractures of the arm or leg ischemia Infarcted muscles fibrous tissue (Volkmanns ischemic contracture)

Limb Threatening Musculoskeletal Trauma

Compartement Syndrome
Clinical features
Elbow, forearm bones, 1/3 prox. of tibiae, multiple fractures of the foot or hand, crush injuries & circumferential burns Five Ps The presence of a pulse does not exclude the diagnosis Be careful in unconscious patient !

Limb Threatening Musculoskeletal Trauma

Compartement Syndrome
Treatment Decompression Open fasciotomi

Limb Threatening Musculoskeletal Trauma

Dislocations
Displacement of bone from normal joint
Location : hip, shoulder, elbow, finger, patella, knee, ankle, acromioclavicular Sign : loss of normal shape & loss of movement

Posterior Hip Dislocation

Neurologic Injury

Due to fracture /dislocation Posterior shoulder : Axillary nerve Posterior hip : Sciatic nerve Recognize injury and immobilize Early orthopaedic consult
Careful reduction, if possible reassess and splint

Limb Threatening Musculoskeletal Trauma Massive skin avulsion

Abdominal flap following skin avulsion of the hand

Limb Threatening Musculoskeletal Trauma Massive skin avulsion

Kelirumologi in Fracture Management

Pitfalls

Occult injuries Occult blood loss Compartment syndrome

Case 1 : Male, 40 y.o

ICD 9-CM 79.63, 93.44

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Summary

Primary Survey : Identify life-threatening Injuries Secondary Survey : Identify limbthreatening injuries Mechanism of Injuries : History important Orthopaedic consult Early immobilization