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Tips for orthopedics exam
1. Tips for Orthopedics Exam
(Unit 9)
By Kareem Hamimy
6th year medical student
Unit 9 – Kasr Al Ainy Medical School
2. Fracture Humerus
• Fracture Shaft
– Injury to Radial Nerve is common
• So you Must Document this Injury before reduction
(Medicolegally)
• Will lead to Finger Drop, Wrist Drop
– Management
• U shaped Cast
• Collar and cuff sling
• N.B. Edge of cast have to be 2 cm above fracture
3. • Plain X-
ray, Antero
posterior view of
a humerus of an
adult, showing
Mid shaft Spiral
Fracture, With
angulation varus
( Apex is lateral )
4. Open Reduction
• Indications :
– Associated with vascular injury
– Bilateral
– Multiple
– Compound Fracture (Haematoma communicating to
outside)
– Floating Elbow ( Fracture in humerus + Fracture radius
and ulna )
– Pathological (due to tumour/osteoporosis)
– Comminuted
5. • Supracondylar Fracture
– Types ( Flexion, Extension 90%in children)
– Risk of injury to brachial Artery very high
• Why ? After its bifurcation, its branches become
attached by fibrous tissue, being fixed makes it more
liable to injury
– Median nerve injury
– Radial nerve is least prone to injury because it is
protected between the brachialis and
brachioradialis
6. • Supracondylar fracture
– Management :
– First : Check The pulse
pulse –
– If no pulse, Document, then reduce it ( to
decrease compression on artery
– If no pulse after reduction, Do open exploration
and Vascular Surgery
7. • Plain X-
ray, Lateral
view, of and
adult elbow
joint, Showing
Supracondylar
Fracture, with
posterior
displacement of
distal segment
8. Compartment Syndrome
• Bleeding and edema inside fascial
Compartments, Increases the
pressure, leading to compression of veins then
arteries, and lately Nerves leading to a limb
threatening condition
• Treatment: By Fasciotomy
• N.B. it is not only due to fracture but also
maybe due to soft tissue injury inside a
compartment
9.
10. Complications Of Fractures
• General
– Shock
– DVT
– Pulmonary Embolism
– Fat Embolism
– Tetanus
– Psycological depression
– Constipation
– Renal Infection
– Bed sores
11. Complications Of Fractures
• Local
– Early
• Vascular Injury
• Nerve Injury
• Infection
• Tendon Injury
• Avascular necrosis of bones
– Late
• Delayed Union
• Malunion
• Nonunion
• Volkman’s Ischemic Contracture
• Myositis ossificans
12. Shock (Tissue Hypoperfusion)
• Hypovolemic
– Fracture Femur 500cc blood loss
– Fracture Pelvis 1000cc
– C.P.
• Pulse Rapid due to sympathetic response, Temp low, Respiratory rate
Rapid
• B.P. According to Severity of blood loss ( Mild decreased
systolic, Moderate Decreased Pulse pressure, Severe Decreased
Diastolic)
– Management
– 2 cannulas, Urinary catheterization (to asses perfusion)
– Crystalloid infusion increasing volume
– or Colloid (Contains Protein) infusion increase blood pressure by
keeping fluid inside vessels
– >1000 cc lost Blood transfusion
13. Shock (Tissue Hypoperfusion)
• Neurogenic
– Females, Old
– How to differentiate from Hypovolemic ?
Bradycardia, and skin flushed
– Why bradycardia ? Due to parasympathetic response
– Ttt: by analgesics
• Septic
– As in compound fracture
– Antibiotics, Antitetanus
15. Fat Embolism
• Due to yellow Bone marrow in Medulla of
Bones
• Difference between Fat Embolism and
Pulmonary embolism ( Onset )
– Fat onset is acute, immediately after trauma
– Pulmonary, 1 week after trauma
16. Bed Sores
• How to Prevent ?
– Early Mobilization (by early reduction and fixation)
– Frequent Mobilization (by changing his position in
bed )
– Proper Hydration
17.
18. Local complications
• Vascular injury
– Causes :
• Direct Injury by the blow
• Fractured (serrated) end of bone
• Compartment Syndrome
• Nerve Injury
– N.B. Sites
• Ulnar Nerve : Behind Medial Epicondyle
• Median Nerve : Cubital fossa
• Radial Nerve between brachialis and brachioradialis
• Sciatic Nerve : Behind hip Joint
19. Compound fracture
• Fracture Hematoma Connected with the
External
• Significance :
– potentially Infected
– Delayed Union ( Because the first step of healing is
the organization of the hematoma and its
resolution )
20. Union
• Malunited ( abnormal positioned)
• Delayed ( more than expected time)
• Ununited ( Not united at all)
• Causes
– Improper reduction
– Poor Blood Supply
– Gapping
– Infection
– Soft tissue between fractured bone
21. Internal Fixators
• Humerus and radius ( forearm) Plates and
Screws
• Spine Pedicular Screws
• Tibia ( Shaft ) Intramedullary Nail
• Tibia ( Pott’s) K wire or Plate and Screws
• Colles Fracture Closed reducation + K wires
• Fracture Shaft femur Tomas Tractor till
open reduction and internal fixation
29. N.B.
• In a displaced fracture, Shortening occurs
because the muscle is shorter than the
distance between the origin and
insertion, pulling the bone with it
30. N.B.
• Any poly trauma pt
• ABC
• Immobilization of back
• Inspection
• Palpation of bones and checking if there is any
fracture
• X-ray at site of fracture
• Routine X-ray on Cervical
spine, Lumbosacral, Pelvis
31. X-ray
• One joint above and one joint below the
fracture site
• Anteroposterior view and lateral view
• In children, X-ray the other limb for
comparison ( Epiphyseal lines )
32. Emergencies in Orthopedics
1. Fracture Neck Femur
– Avascular Necrosis of head can occur
– We fix by Dynamic head Screw
2. Fracture Neck talus
3. Compound Fracture
4. Dislocation ( May cause Arthritis Forever)
5. Slipped Physis (Epiphyseal Plate) in Children
– Arrest of Growth, Growth Deformities may occur
6. Fracture with Vascular Injury
33. • N.B.
• Infection in Bone is very Serious ( if
osteomyelitis occurred, we excise it as
tumour)
34. N.B
• Range of Acceptance ( range at which fracture
can be left not reduced and heals well )
• Range of Angulation “According to each bone”
• Range of Overriding “According to each bone”
• But Rotation is not accepted at all, No range
of acceptance, reduction must be done
• Range of acceptance increases in pediatrics
due to their remodelling ability
35. Comment On X-ray
• X-ray
• Anteroposterior or lateral view
• Of (Anatomy)
• Adult or child ( By Checking Epiphyseal plates)
• Showing Fracture with
– Angulation (Varus or vulgus) /
– Shortening ….. Cm (With anterior or posterior or
medial or lateral displacement, of the distal segment )
– Rotation
36. • Epiphysis means Part of bone connected to
Joint
• Arterial supply of neck of femur is very
important
• Why Fracture Neck femur occur ?
– Junction between cancellous and cortical bone
• Subcapital and midcervical Intracapsular
• BasiCervical - Extracapsular
37. Management of fracture neck femur
• Depends on Physiological activity And Age
• Extracapsular DHS
• Intracapsular
• If Young, with high activity urgent fixation DHS
• If old >60-70 years old Hemiarthroplasty
• Complications of hemiarthroplasty
– Infection
– Dislocation
– Periprosthetic Fracture
– Loosening which is painful
38.
39. Dynamic head Screw
• Used in fracture neck femur
• It uses body weigt, leading to compression
and rapid healing
• 135 degrees
• And also used in trochanteric fracture
• In Subtrochanteric fracture we use dynamic
condylar screw DCS, which is 95 degrees
40. N.B.
• How to know the bone is osteoporotic
• By comparison to the color of the cortex of
shaft
• What is the difference between Intracapsular
and Extracapsular Neck femur fracture ?
• Intracapsular Is an Emergency due to
avasucalr necrosis and high mortality rate
41. Thank you
And if there is anything wrong in the
ppt. check with Unit professor,
then Send me
Kareemhamimy89@yahoo.co.uk
