Surgery: Lower Limb (orthopedics) Flashcards
According to which principles orthopaedic management should be started with?
ATLS = ABCDE
Orthopaedic injuries management should not come before the management of life-threatening injuries
Types of fractures that can be considered as ‘open fractures’ (2)
- fractures that communicate with the outside world via a wound
- fractures that communicate with any other unclean environment [e.g. a pelvic fracture that has penetrated the bowel]
Which bone (1) a compartment syndrome most commonly occur at?
Tibial bone
What to assess during the assessment of an injured limb? (3)
- ATLS guidelines (i.e. treat all life-threatening injuries first)
- neurovascular assessment of the injured limb
- Take a photograph of any wounds (close up and also from a distance, so that the location of the wound relative to the limb is clear)
Initial management of a fracture/injury (5)
- Gently reduce displaced fractures (ask for help unless experienced). Nerves and vessels are at risk if the limb is anatomically distorted
- Stabilise the fracture (with a splint or back-slab) and then re-assess the neurovascular status
- Radiographs should be taken after any orthopaedic intervention (e.g. reduction attempts)
- Management of open wounds (e.g. dressed, antibiotics, anti-tetanus cover etc.)
- A general work-up for theatre should be completed, where appropriate
Principle of fracture management
Ask yourself: Is the position of the fracture ok?
- Yes - hold it until healed
- No - reduce it (with an open reduction or closed reduction technique) and then hold it until healed
What’s an open reduction technique?
Open reduction
Involves a formal surgical exposure →the fracture is reduced under direct vision
What’s a closed reduction technique in the management of the fracture?
Closed reduction
- involves a manipulation without a surgical opening (direct visualisation)
What does intermediate technique involve?
Intermediate techniques
Fracture fragments are reduced indirectly through very small incisions (e.g. MIPO techniques - ‘Minimally invasive percutaneous osteosynthesis’).
(3) possible techniques of reduction in fracture management
- open
- closed
- intermediate
How to ‘hold’ the fracture? (stabilise)
- Back-slab
- POP
- Splint
- Traction
- K-wires
- External fixation (monolateral or ring)
- Plates and screws
- IM nails
- (Arthroplasty - in cases where it is not appropriate to reconstruct a damaged joint, it is removed and replaced instead of being fixed, e.g. in intra-capsular hip fractures)
What’s that technique?
Plate and screws
What’s the name of this technique?
Fine wire circular fixator
Name the technique of fixation
Monolateral external fixator
Name that technique
Plaster of Paris cast
Name this fixation technique
K-wire fixation
Name this fixation technique
Intramedullary nail
Is there only one single appropriate method to treat the fracture?
- There are many appropriate ways to treat the same fracture and the method used should be tailored to the patient
- Consider the fracture pattern and the patient’s needs when deciding which option is best
Pros and cons of different methods of fracture stabilisation
- back-slab
- POP cast
- Back-slab: cheap and easy but minimally supportive. Used as first aid.
- POP cast: cheap and more supportive than a back-slab but limited to relatively stable fractures.
Pros and cons of different methods of fracture stabilisation
- splint
- traction
- Splint: easy to apply and can be removed. Only appropriate for stable fractures
- Traction: non-invasive and effective but requires prolonged best rest. Used most often in young children because fractures in this age group heal quickly
Name that method of fracture stabilisation
POP cast
(Plaster of Paris)
What’s the difference between slab and cast?
- slab → only a part of circumference of a limb is covered
- cast → the whole circumference of a limb is covered
Name that method of fracture stabilisation
Back slab
Name that method of fracture stabilisation
Splint
Name that method of fracture stabilisation
Traction
Pros and cons of K-wires
- minimally invasive method of ‘skewering’ bone fragments
- useful in good quality bone (usually in the wrist)
- rarely used in lower limb except for some paediatric fractures
Use of external fixators
External fixators:
- useful for complex fracture patterns or where the soft tissues are too compromised to permit a safe surgical exposure
Pros and cons of plates and screws
Plates and screws:
- formal plating techniques allow accurate fracture positioning and fixation but often require a large surgical approach
- usually used where anatomical (i.e. highly accurate) reduction is required - eg. articular fractures
Pros, cons and use of intramedullary nails
Intra-medullary nails
- Internal splintage of long bones
- Require relatively small incisions away from the fracture site
- Most effective when the fracture is around the mid-shaft
- Very useful to stabilise pathological (e.g. metastatic) bone
- The inevitable intra-medullary pressure rise can compromise injured lungs in polytrauma patients
What does fixation method of a hip fracture depend on?
The method of fixation depends on whether the blood supply is likely to have been injured by the fracture
Method of fixation of undisplaced femoral fractures
If undisplaced → the blood supply can be assumed to be uninjured
- The fracture simply needs to be fixed
- Traditionally this has been done with 3 screws (but other methods - e.g. modern plate and screw designs are gaining popularity)
Blood supply to femoral head
Methods of fixation of displaced femoral fracture
Displaced → the blood supply can be assumed to have been disrupted. This will pre-dispose the femoral head to avascular necrosis
- The head is removed and replaced (except in young patients, where the head is given every chance of survival and fixed even when the bloods supply is likely to have been injured - because joint replacements have a limited life span)
What to do in a displaced femoral head fracture in a higher demand patient?
higher demand patient → highly mobile patient
Total hip replacement
How to treat high energy comminuted fracture of femur in a young patient?
How to treat extra-capsular femoral fractures?
There is no threat to the blood supply to the femoral head → the fracture is fixed rather than replaced
- age isn’t a consideration (in contrast with deciding on the best type of hip replacement for a patient). The best device for the job is chosen, regardless of age
How to treat extracapsular fractures that extend more down the femur?
Intra-medullary device
Treatment of extracapsular hip fracture:
- inter-trochanteric
- fractures extending down the femur
- inter-trochanteric → Dynamic Hip Screw
- extending down the femur → intramedullary device
How are femoral shaft fractures usually treated?
How are intra-articular fractures around the knee usually treated?
Because of the importance of accurately restoring the joint surface (to minimise the risk of post-traumatic arthritis) → formal open reduction and internal fixation with plates and screws is usually employed
What’s the most common method of fixation in tibial shaft fractures?
IM nails
When do we use external fixation as a method of management of tibial shaft fracture?
What’s a dangerous thing about ankle fractures?
- These fractures, even if the fracture line itself doesn’t involve the joint, can have a serious effect on the ankle joint
- This is because of the risk of not addressing (or of allowing the development of), ‘talar shift’ - where the talus bone fails to sit centrally between the tibial and fibula
- This decreases the joint congruity /zgodnosc/ and can lead to post-traumatic arthritis
What further information about the patient would you like to know?
- a full medical history
- more detail re his bowel cancer
- his pre-injury mobility status
- his mental state
- his home / care environment circumstances
What medical issues may affect his management?
- AF → warfarin use
- venous ulcers → may predispose to surgical infection)
- previous bowel cancer → this may be a pathological fracture if he has developed metastatic disease – and if so, then there could also be pulmonary and thromboembolic features of metastatic disease
What other investigations would you like to do prior to the surgery?
- FBC
- U&Es
- clotting (INR will be raised if on warfarin and will need to be reversed)
- further imaging of the femur to exclude metastatic disease
- ECG
What type of fracture is it?
A displaced intra-capsular fracture
What treatment options are there and which do you think is the best option in this case?
- In this age group, unless very active → hemi-arthroplasty
- If he was very active → THR
* But the medical details given above suggest that a hemi-arthroplasty would be the best option here
Difference between hemiarthroplasty and total hip replacement
- Hemiarthroplasty → replacing half of the hip joint
- Total Hip Replacement → replacing the entire hip joint
What further information would you like?
- full medical history
- her usual mobility status
- occupation
- Full details of the injury - how did it happen? Was it high energy or a low energy injury
- Are there any other associated injuries?
- Is there an associated wound (i.e. is it an open fracture?)
- What is the neurovascular status of this limb?
- How swollen are the soft tissues?
What’s the injury?
- a fracture of the ankle involving the lateral and the posterior malleolus and possible the medial malleolus too
(it is difficult to be certain of the exact fracture pattern and that further imaging would be helpful - e.g. CT )
- the ankle is dislocated
What’s immediate management?
- the fracture should be quickly and accurately reduced and held in a supportive back and side slab
- the N/V status should be re-assessed
- X-Ray be performed
- strict elevation to help settle the swelling
What are the definitive treatment options?
Open reduction and internal fixation → best option (but only when the swelling has settled enough to allow a safe surgical exposure)
*POP casts are often used in ankle fractures, but in unstable types such as this, then they are rarely used for definitive treatment because of the difficulty in maintaining an accurate reduction
What is the initial management?
- ATLS principles (although this is low energy trauma and so other injuries are unlikely)
- N/V assessment of the limb
- First aid stabilisation of the fracture with a splint (e.g. Thomas splint) followed by a repeat x-ray
- Pain relief
- Discussion with seniors
What are the definitive treatment options?
- IM nailing (retrograde will get a better hold than anterograde) will be tricky with a total knee replacement (TKR) in situ
- Plate fixation (probably the most straightforward option) but will require a long incision
- Traction - possible (and in trained hands could provide a reasonable result) but would require prolonged bed rest
