cpc orthopaedics

CPC OrthopaedicsWITH PROF. RAZIF ALI

Thye Chee Keong

Hurul AiniOon Li Keat

Nur Nadiatul Asyikin

Nanthini S

Lynette Lee

Nursheila Izrin

History

• Mr. M• 25 year old

motorcyclist• Thrown off in a

collision with a lorry• Brought to A&E unit

in a hospital

On examination

• No head and spinal injury• Stabilized• Vital signs stable• Initial assessment:

– closed fracture of his left femur– closed distal extraarticular fracture of his right radius– soft tissue injury of his right shoulder

• Decision was made for:– internal fixation of his left femur– closed reduction and POP of his right radial fracture as a semi

emergency.

Question 1:

In the Accident & Emergency Room while waiting to be admitted to the ward, describe FIVE (5) other procedures /

actions you would do as part of treatment or investigation not mentioned above?

(10 marks)

Continuation of the primary survey

• Disability (D) of the central nervous system– Basic neurologic assessment with AVPU score:

• A – Alert• V – Responds to verbal stimuli• P – Responding to painful stimuli• U – Unconscious

– Pupil size, inequality and reactivity to light– GCS score

Continuation of the primary survey

• Exposure/Environmental control/X-Rays (E)– Full exposure of the patient– Assess from head to toe for injuries not

recognized and managed– Keep patient warm

IMAGING

• X-rays:– Cervical spine: lateral view of C1-T1– Chest : Anteroposterior view– Pelvis : Anteroposterior view

• Focused abdominal sonography for trauma (FAST) scan on ‘5Ps’:– Perihepatic – liver lacerations– Perisplenic – splenic lacerations and rupture– Pelvic – free fluid e.g. haematoma– Pleural – haemothorax, pneumothorax– Pericardial – pericardial effusion

Adjunct to primary survey

• Vital signs • Oxygen saturation e.g. pulse oxymetry, blood

gases• Electrocardiography• Urine catheterization – hourly urine output• Nasogastric aspiration output

Secondary survey

• Complete history and physical examination• Each region of the body to be fully examined:

– Chest– Abdomen– Pelvis– Limbs

• Reassessment of all vital signs

Head

• Check for bruising, swellings

• Look for signs of basal skull fracture:– Battle’s sign– Racoon’s eyes

• Examine nose and ears for CSF leakage

• Pupil size and responsiveness

Chest

• Respiratory distress - Grunting, stridor

• Bruising and skin imprinting• Mediastinal shift• Penetrating injuries

Abdomen and pelvis

• External injuries• Abdominal distension by gas or fluid• Tenderness and guarding• Bleeding from urethral meatus• Presence of palpable bladder• PR exam: blood, high-riding prostate, anal

tone

Limbs

• Check the neurovascular status of each limb• Analgesia – orthopaedic injuries are extremely

painful• Correct obvious deformity by temporary

splinting

Name of procedure and Purpose

Skeletal traction of left proximal tibia

Purpose: To reduce a fracture or dislocation To prevent or reduce muscle spasm

To immobilize a joint or part of the body To treat joint pathology

PRIOR TO APPLICATION

• Ensure adequate analgesia / sedation• Place patient in supine position• Record baseline neurovascular observations:

– Pulses– Skin colour and temperature– Capillary refill time– Movement of joints– Swelling and sensation

• Observe affected limb for any:– Wounds– Swelling– Infection– Soft tissue damage

Principles of Skeletal Traction

• Align the distal to the proximal fragment• Remain constant• Allow for adequate exercise and diversion• Allow for optimum nursing care

Introduce the pin through the incision horizontally and at right angles to the long axis of the limb. Proceed until the point of the pin strikes the underlying bone and through the opposite skin.

Dress the skin wounds with sterile gauze

Attach a stirrup to the pin

Cover the ends of the pin with guards and apply traction

A rope/cord is attached to the stirrup and passed over a pulley and fixed to a weight.

Daily wound dressing done at the pin insertion site.

Inject local anaesthetic into the skin, subcutaneous tissue, and periosteum of both sides, making sure it goes under the periosteum.

LOCAL ANAESTHESIA

Bohler’s Stirrup

• Cord/ Rope is then attached to the pin’s holder and passed over a pulley, and fixed to a weight.

• The weight may pull the patient out of the bed, thus need to exert countertraction by raising the foot off his bed.

Complications

• Due to procedure itself– Infection of the pin tract– Injury to common peroneal

nerve– Excessive traction

• Due to prolonged bed rest– Thromboembolism– Decubiti– Pneumonia– Atelectasis

Compartment Syndrome

9) The problem you suspected in QXN (8), describe 4 other symptoms and/or signs would you look for ?

• 6 “P”s?• use them as criteria is Not reliable• Only pain & paraesthesia useful• The rest are uncommon or late signs

– Eg. Paralysis or even muscle weakness indicate irreversible muscle damage

Symptoms

• Pain out of proportion to apparent injury (early and common finding)

• Persistent deep ache or burning pain• Paresthesias (onset within approximately 30

minutes to 2 hours of ACS; suggests ischemic nerve dysfunction)

Signs

• Pain with passive stretch of muscles in the affected compartment (early finding)

• Tense compartment with a firm "wood-like" feeling

• Diminished sensation (two point discrimination found to be earliest)

Late signs

• Pallor from vascular insufficiency (uncommon)• Muscle weakness (onset within approximately

two to four hours of ACS)• Paralysis (late finding)

10) What first aid in the ward can you immediately give after you suspect the problem in QXN 8?

• relieving all external pressure on the compartment. Any dressing, splint, cast, or other restrictive covering should be removed

• Maintain perfusion: – Hypotension reduces perfusion, exacerbating tissue injury,

and should be treated with intravenous isotonic saline.– The limb should not be elevated. Elevation can diminish

arterial inflow and exacerbate ischemia [62].• Analgesics should be given and supplementary

oxygen provided. Further research

• Capillary blood flow becomes compromised at 20 mmHg.• • Pain develops at pressures between 20 and 30 mmHg.• • Ischemia occurs at pressures above 30 mmHg.• Traditional recommendations for decompression include

absolute pressure readings above 30 mmHg [49], or above 45 mmHg [1].

• • The delta pressure is found by subtracting the compartment

pressure from the diastolic pressure. Many clinicians use a delta pressure of 30 mmHg to determine the need for fasciotomy. Others use a difference of 20 mmHg [15].

•11) Describe the pathophysiology of the problem you suspected in QXN 8?

Compartment Syndrome

Compartment SyndromeAnatomy

• Muscle groups -including the nerves and blood vessels that flow through them- are covered by•a tough membrane (fascia) that does not readily expand-this area is called a “compartment”

PATHOPHYSIOLOGY

• complex pathophysiology• the final common pathway is cellular anoxia [15]• prerequisite for the development of increased

compartment pressure is a fascial structure (prevents adequate expansion )

• widely believed hypothesis : arteriovenous pressure gradient theory [2]

• [2] Elliott, KG, Johnstone, AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003; 85:625.

[15] Olson, SA, Glasgow, RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005; 13:436.

↑ Compartmental volume (↑ fluid content)

↓ Compartment volume (constriction of the compartment)

↑ INTRACOMPARTMENTAL PRESSURE

Due to inelasticity of fascia

venous outflow is reduced (obstruction)

Vascular congestion

Further ↑ intracompartmental pressure (venous pressure )

( arteriovenous pressure gradient)↓ capillary perfusion

Muscle and nerve ischaemia,necrosis

oedema

Compromise arterial circulation (late)

PATHOPHYSIOLOGY

Inadequate venous drainageBut early-Lymphatic Drainage

compensate

Compartment Syndrome:Sequela After Initial Injury

• Tissue damage- irreversible tissue death within 4-12 hours

• permanent disabilities can develop from undiagnosed compartment syndrome

• Amputation- sometimes tissue beyond repair and only measure to prevent gangrene and death is amputation

Vicious circle that Ends after

~12 hours

Necrosis of the nerve and muscle

within the compartment

Muscle infarctedReplaced by

inelastic fibrous tissue

( Volkmann’s ischaemic

contracture)

Nerve-capable to regenerate

• 12) If the problem still continues despite first aid in QXN 10, elaborate what would you do?

Fasciotomy

• Fasciotomy -definitive and only treatment for acute compartment syndrome (ACS)

• If intra-compartment pressure > 40mmHg• Immediate open fasciotomy

• Morbidity from delay is significant, so the operation should be performed immediately.

• The wound should not be stitched until a post-surgical assessment has been done at 48 hours.

• subsequent skin grafts may be needed for successful healing

Forearm •3 compartments: dorsal, superficial and deep volar, mobile wad•interconnected•hence fasciotomy of 1 compartment may decompress the other 2

Leg •4 compartments: anterior, lateral, superficial and deep posterior•NOT interconnected

Cross section of a forearm.Palm up.

• the thick, fibrous bands that line the muscles are filleted open,

• allowing the muscles to swell and relieve the pressure within the compartment

• Depending upon the amount of swelling (edema), a second operation may be required later to close the skin after the swelling has resolved.

• If muscle necrosis, do debridement

• Hyperbaric oxygen -considered as an adjunct treatment after surgery to promote healing and reducing repetitive surgery

• Treatment will also be directed to the underlying cause of the compartment syndrome

• try to prevent other associated complications including kidney failure due to rhabdomyolysis

13) You did a secondary survey, he complained of pain in left hip; you found he was tender in the left iliac region.What investigation will you order ? ( 1 mark )

ANTEROPOSTERIOR RADIOGRAPH OF PELVIS

VITAL SIGNS

Anatomy of the pelvic bone

14) What did the investigation in Figure 2 show ? ( 1 mark )

ISOLATED FRACTURE OF LEFT ILIUM WITH INTACT PELVIC RING

15) IN THE SAME NIGHT after admission to A&E ( 10 HOURS after admission ), his pulse rate became 140 beats a minute and blood pressure became 70 / 40 mm Hg. He looked pale, there is pallor of conjunctivae and sweaty palms and forearms but he is still conscious. Explain briefly what pathophysiology may be happening here.(2 marks)

TachycardiaHypotensiveAnaemicSweaty palms* HYPOVOLAEMIC SHOCK(CLASS III)

PELVIC FRACTUREBLOOD VESSEL INJURYBLEEDINGHYPO VOLAEMIC SHOCK

16) Name 3 investigations / actions / procedures you would do to stabilize the above situation.( 3 marks)

Resuscitation:

a)Vascular access:Insert TWO large bore cannula,Arterial line?b)Blood investigationc)Fluid therapy,oxygen

Stabilization of the fracture:-pelvic binder/external fixator

Repeat FAST scan

Refer to orthopaedic team for further management of the fracture

17) Name 3 investigations / monitoring procedures to help you know that you really stabilized the above problem adequately.( 3 marks)

a)Vital signs,Pulse oxymetry and CVP monitoring if available

b)ABG

C)CBD-urine output monitoring

The intended operation on the femur was delayed…

On DAY 3 after the accident, the patient was noted to have ↓ level of

consciousness in the ward round

Name 1 diagnosis you suspect & what other 4 symptoms and/or

signs would you look for

Fat Embolism

• Presence of fat globules obstructing arteries in the lung parenchyma & peripheral circulation after long bone or other major trauma

• More frequent in closed than in open #• Incidence ↑ with no. of # involved• Can occur in relation to other trauma • Pathogenesis: mechanical & biochemical

theory

GURD’s Criteria for Diagnosis

• Major– Axillary or subconjunctival petechiae– Hypoxaemia PaO2 <60mmHg– CNS depression disproportionate to hypoxaemia

• Minor– Tachycardia >110bpm– Pyrexia >38.5– Retinal emboli on fundoscopy– Fat globules in urine and sputum– Increased ESR, decreased haematocrit and platelet

• For diagnosis, at least 1 MAJOR and 4 MINOR criteria must be present

4 Symptoms and/or Signs

• Respiratory distress: SOB• CNS abnormalities: Confusion, restlessness,

coma• Changes in V/S: ↑ temperature, ↑ PR• Petechiae: neck, chest, axilla, subconjunctiva

Elaborate what investigations would you do?

• Clinically: -tachycardia>110bpm, tachypnea>30bpm, pyrexia>38.5◦

_ confused / restless- petechiae

• Lab Ix:- ABG (PaO2<60mmHg)- FBC: ↓ hematocrit, thrombocytopenia- LFT, RP, serum electrolytes, ↑ ESR- Urine & sputum for fat globules

IMAGING

• Chest radiograph: may be normal / snow-storm appearance / diffuse, ground glass appearance

• Head CT-evidence of microvascular injury• Spiral CT• Others:

-ECG, TEE -D-dimers-ventilation/perfusion scan

What further treatment would this patient receive?

Supportive Mx

1. Maintenance of adequate oxygenation & ventilation

2. Maintain stable hemodynamics3. Fluids & blood products as clinically

indicated4. Prophylaxis of DVT & stress-related GI

bleeding5. Nutrition

The right shoulder

When En. M recovered from the operation and ICU, he began to ambulate. He complained of a right shoulder problem when examined as shown in Figure 3A and 3B

Figure 3AFigure 3B

Question 21

Name ONE clinical test which describe the method of examination shown in the figures

Shoulder impingement test

Question 22

Name TWO diagnoses possible for the above problem

1. Rotator cuff impingement2. Rotator cuff tear

The rotator cuff muscles

Rotator cuff impingement

“Mechanical impingement of rotator cuff tendon beneath the anteroinferior portion of the acromion, especially when the shoulder is placed in the forward-flex and internally rotated position.”

Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. Jan 1972;54(1):41-50.

Neer’s classification

• Stage I: oedema and haemorrhage• Stage II: fibrosis and tendinopathy• Stage III: partial or complete tear

Clinical features

• Pain– Gradual onset– In the anterolateral part of shoulder– On overhead movement– Worse at night– Associated with weakness and stiffness

• Clicking or creaking sounds during movement• Joint instability• Positive Impingement test• Normal range of movement and strength

Rotator cuff tear

• Partial tears frequently occur with supraspinatus tendinitis

• Complete tear may result from sudden shoulder strain or as complication of tendinitis or partial rupture

Clinical features

• History of trauma to the shoulder• Pain

– Sudden onset– In anterolateral part of shoulder– Associated with gross weakness of abduction– Joint instability

• Persistent painful arc of abduction• Decreased strength on involved muscle group• Decreased range of movement

Conservative Treatment

• NSAIDS• Rest, activity modification (avoid irritating

activities)• Ice on affected area• Physical therapy for stretching/ ROM• Rotator cuff strengthening and scapular

stabilization

Physical therapy

• Strengthening the rotator cuff tendons• Stretching and regaining lost motion caused

by pain and inflammation• Allowing the humerus to be better positioned

under the acromion, thus reducing compression of the bursa

Examples of physical therapy

External rotation on elastic resistance cord Cross arm push

Surgical treatment

• Arthroscopic subacromial decompression to expand the space between acromion and rotator cuff tendons

• Rotator cuff repair in rotator cuff tears

THANK YOU

QUESTIONS?

HAPPY CHINESE NEW YEARAND

HAPPY HOLIDAY!!