Surgery: Lower Limb (orthopedics) Flashcards
1
Q
According to which principles orthopaedic management should be started with?
A
ATLS = ABCDE
Orthopaedic injuries management should not come before the management of life-threatening injuries
2
Q
Types of fractures that can be considered as ‘open fractures’ (2)
A
- 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]
3
Q
Which bone (1) a compartment syndrome most commonly occur at?
A
Tibial bone
4
Q
What to assess during the assessment of an injured limb? (3)
A
- 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)
5
Q
Initial management of a fracture/injury (5)
A
- 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
6
Q
Principle of fracture management
A
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
7
Q
What’s an open reduction technique?
A
Open reduction
Involves a formal surgical exposure →the fracture is reduced under direct vision
8
Q
What’s a closed reduction technique in the management of the fracture?
A
Closed reduction
- involves a manipulation without a surgical opening (direct visualisation)
9
Q
What does intermediate technique involve?
A
Intermediate techniques
Fracture fragments are reduced indirectly through very small incisions (e.g. MIPO techniques - ‘Minimally invasive percutaneous osteosynthesis’).
10
Q
(3) possible techniques of reduction in fracture management
A
- open
- closed
- intermediate
11
Q
How to ‘hold’ the fracture? (stabilise)
A
- 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)
12
Q
What’s that technique?
A
Plate and screws
13
Q
What’s the name of this technique?
A
Fine wire circular fixator
14
Q
Name the technique of fixation
A
Monolateral external fixator
15
Q
Name that technique
A
Plaster of Paris cast
16
Q
Name this fixation technique
A
K-wire fixation
17
Q
Name this fixation technique
A
Intramedullary nail
18
Q
Is there only one single appropriate method to treat the fracture?
A
- 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
19
Q
Pros and cons of different methods of fracture stabilisation
- back-slab
- POP cast
A
- 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.
20
Q
Pros and cons of different methods of fracture stabilisation
- splint
- traction
A
- 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
21
Q
Name that method of fracture stabilisation
A
POP cast
(Plaster of Paris)
22
Q
What’s the difference between slab and cast?
A
- slab → only a part of circumference of a limb is covered
- cast → the whole circumference of a limb is covered
23
Q
Name that method of fracture stabilisation
A
Back slab
24
Q
Name that method of fracture stabilisation
A
Splint
25
Name that method of fracture stabilisation
Traction
26
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
27
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
28
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
29
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
30
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
31
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)
32
Blood supply to femoral head
33
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)
34
What to do in a displaced femoral head fracture in a **higher demand patient**?
higher demand patient → highly mobile patient
Total hip replacement
35
How to treat **high energy comminuted** fracture of femur in a **young patient**?
36
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
37
How to treat extracapsular fractures that extend more down the femur?
Intra-medullary device
38
Treatment of **extracapsular** hip fracture:
* inter-trochanteric
* fractures extending down the femur
* inter-trochanteric → Dynamic Hip Screw
* extending down the femur → intramedullary device
39
How are **femoral shaft** fractures usually treated?
40
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
41
What's the **most common method** of fixation in **tibial shaft** fractures?
IM nails
42
When do we use **external fixation** as a method of management of **tibial shaft fracture**?
43
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**
44
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
45
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
46
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
47
What type of fracture is it?
A displaced intra-capsular fracture
48
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
49
Difference between **hemiarthroplasty** and **total hip replacement**
* **Hemiarthroplasty** → replacing half of the hip joint
* **Total Hip Replacement** → replacing the entire hip joint
50
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?
51
What's the injury?
* a **fracture of the ankle involving the lateral and the posterior malleolus and possible the medial malleolus** too
## Footnote
(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**
52
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
53
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
54
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
55
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
