lecture notes for 260713

8/12/2019 Lecture Notes for 260713

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Lecture 26/7/13

Scenario: Clinical charts, read BP, temp, case notes

Name the vertebrae parts

-

Pars is adjacent to the lamina which is adjacent to the inferior articular facet

STIR image

- vascular structures light up

- Short T1 Inversion Recovery

- Intramedullary vs extramedullary lesion (whether coming from spinal cord or not)

- Extramedullary but interosseous (in spinal cord but coming from bone)

Scoliosis

- Look from back whether shoulders and pelvis is level

- Need to perform Adam’s forward bending test to see the hump’

-

Boston brace: any coronal deformity that apex is pointing to the right side- Precaution: wrist is cut into arm, front parts cutting into abdomen: check if patient can sit

properly, run properly, food may cause early satiety

Kyphosis

- brace used

- often in patients with thoracolumbar spine

- with fractures, not going for surgery

Ivory spine

- Mets (from osteoblastic tumours) e.g. prostate, breast (can be osteoblastic or osteolytic)

- Hormonal tumours (paraneoplastic syndromes) secrete factors that cause osteolysis or

osteogenesis

BMD

- Definition: Amount of mineralized bone per unit area

- look at patient’s age, weight, height

- T-score and Z-score

- T-score for old, Z-score for young

- Lumbar not really considered due to osteophytes inflating the score to be artificially high

- T-score is same sex, age, race at 30 years old (peak bone mass)

Cause of pathological fractures?

Aneurysm

- Look for calcification of aorta and shift in the midline

Low-energy #

- Fall from standing height

Osteoporosis

- MUST EXCLUDE RED FLAGS!!

- As patient might have a secondary carcinoma

- FRAX- Calculate 10 year probability to getting a fracture for high risk patients

Singh index



- Principal tensile band

o Supports neck of femur

- Principal compressile band

- Grades 1-6

- Grade 6 is normal

o Grade by looking for the bands on X-ray

X-ray

- Compression #

- Codfish bone appearance

Osteoporosis vs osteomalacia

- in OP, the mineral-to-collagen ratio is within the reference range

- To ddx osteomalacia: measure vitamin D levels, should be done for all with osteoporotic #

Renal dystrophy

-

Renal involved in production of vitamin D- Get secondary & tertiary hyper-PTH, which causes loss of bone mass

Indications for DEXA

- Females 65 and above

- Hx of fragility #

- Radiological evidence of osteopenia/vertebral deformity

- Presence of risk factors and/or OSTA value

- FRAX

- Freq: according to individual risk

Bisphosphonates- Contraindication: Pts who cannot sit up for more than ½ hour

SERMs

- Indications

o Cannot tolerate bisphosphonates

o At risk of invasive breast CA/ vertebral fractures

- MOA

o Induces osteoclast apoptosis decrease rate of bone resorption

- SE

o Hot flushes, sweating, leg cramps, chest pain, DVT, PE, teratogenic (CI in pregnant

and lactating)

Calcitonin (nasal spray)

Indications

- postmenopausal women (>5 years)

- Cheaper and more convenient

MOA

- Binds membrane receptors on osteoclasts inhibit activity

SE

- nausea, vomiting, abd pain, diarrhoea

- Caution with prior use of bisphosphonates



HRT

- only when other symptoms are unbearable (hot flushes etc)

- MOA

o Inhibit osteoclast

- SE

o Dyspepsia, bloating, fluid retention, headache, diarrhoea, vision problems, DVT,o Increase risk of endometrial CA

Vertebral compression #

- Usually managed conservatively (90% can be treated conservatively) as surgery rarely works

o Observation

o Bracing

o Medical management

- Surgical (only these two!!)

o Vertebroplasty

Inject cement into vertebral bodies

Indications are for persistent pain

o Kyphoplasty

Restore height of vertebral body

o Surgical decompression is RARELY DONE!

Bipolar hip replacement for NOF fractures

- Research has shown that it is more effective

o Less pain, patient can walk earlier generally more effective

IT fractures

- 1 & 2: use DHS

-

3, 4, RO: use PFNA



Hip & pelvic injuries

Dashboard injuries

- PCL injury (and examine knee for abrasions on anterior tibia)

- Acetabular fracture

- Posterior dislocation- Post-traumatic OA (due to cartilage being shaved off)

- Remember that AVN is a known complication of posterior dislocation of hip and would

follow up for five years following the injury

Reduction of post. dislocation of hip

- Allis manoeuvre

o Stabilize pelvis, stand on bed, flex hip and knee to 90 degrees, abducting and apply

axial force

Anatomy of the proximal femur

-

neck shaft angle is 130 deg +/- 7- anterverted 10 deg (rotated to front)

Extracapsular arterial ring

- MFCA, LFCA

Ascending cervical arteries

Artery of lig teres

Metaphyseal vessels

Majority of head supplied by lateral epiphyseal arteries

Trabecular anatomy

-

the calcar femorale (compressive) transfers the majority of the force to the femur duringweightbearing: needs to be reconstituted during surgery

- its integrity affects outcome following fixation

In Garden I, head is rotated

Garden III, head is tilted

Garden IV, no contact with head thus falls into its normal resting posture

Pauwel’s can also be used to see if patient can walk after a fracture. In Pauwel’s I, can see where the

force displaces thus can see that patient can walk

Basal fractures can be treated like IT fractures

Diagnosis of NOF

- Ext. rotated, shortening

- Pain on axial loading, rotation

- Inability to perform active SLR

Imaging

- AP pelvis

- AP & adequate lateral views of hip

- negative x-rays in 6-8%

- Diagnosis of occult fractures

o Bone scan- highest S and S 3 days after fracture



o MRI- more useful in acute period

Treatment aims

- return patient to pre-morbid ambulatory status

- relief of pain

- retain original femoral head whenever possible- minimal/single surgical procedure

Treatment options

- Traction until pain free

- CRIF

- ORIF

- Hemiarthroplasty

o unipolar

Moore’s, Thompson’s

o bipolar

-

Young patient (<60)o Garden I and II- cannulated screw fixation within 12 hours

o Garden III IV- closed/open reduction and cannulated screw fixation within 12 hours

- Elderly patient (>60)

o Gardens I , II- cannulated screw fixation as soon as possible electively

o Garden III, IV- hemiarthroplasty next elective list after medical problems evaluated

and controlled

Community ambulatory- bipolar

Household ambulatory- unipolar

- Complications of recumbency

o DVT, pneumonia, urolithiasis, atelectasis

Complications

- AVN

- Non-union 10-30%

- Medical complications (UTI, bed sores etc) up to 60%

- Mortality 40% at 1 year

AVN

Undisplaced fractures is 11%

Incidence >80% in displaced fractures

Bipolar hemiarthroplasty

- 2 bearing surfaces

- theoretically leads to less acetabular erosion

- easier conversion to THA (as only need to remove outer head and replace the acetabulum)

Neck # in young

- emergency!

- -fixation within 12 h

- anatomical reduction through OR

- stabilized with multiple screws

- 12 hours 25%, 1 week 100%

PFNA



- for E-J 3,4, RO

- as the nail to the head and neck prevents ROTATION which will happen if either the greater

troc or lesser troc is gone and opposing muscles PULL on the femur

ST #

- remember that often occurs in a polytraumatic patient

Treatment

- traction alone

o Not done as need to be hospital close to 3 months

- provisional stabilization with external fixation- DCO (damage control orthopaedics)

- GOLD STANDARD: IM nailing- antegrade, retrograde

- Internal fixation with plate/screws- open/ MIPO (minimally invasive plate osteosynthesis)

Intra-articular knee #

usually represents extreme violence to knee jt

- neurovascular injury

- soft tissue: blistering, can get infected and disrupted, makes op more difficult/treacherous

Goals in reduction of any intraarticular #

- stability, restore satisfactory ROM, pain free

- stable fixation, early motion (to prevent stiffness, no need for aesthetic beauty), anatomical

reduction

- many pts end up with post traumatic knee joint

- Failure

o Stiffness, deformity, pain, post-traumatic OA

Tibia

- warning: commonly compartment syndrome!

- surgical stripping of tibia during ORIF

- Wound infection, OM, cannot obtain anatomical reduction, ass. with valgus varus deformity,

Ilizarov fixator for tibial plateau

- due to soft tissue injury cannot go in to put implant

- wires around bone without creating too many incisions

- minimally invasive

- minimal soft tissue complications

- minimal blood loss

- usually results from bumper injury: lateral condyle of tibia affected and lateral collateral

ligament injured

C clamp/pelvic binder

- IV lines

- even if hemodynamically stable

- increase space- tamponade effect

Urological, bowel, marel levelle lesion: denerving lesion of the buttocks

Pelvic sling

- send for therapeutic embolization

- pelvic packing if cannot control: put linen and pressure to stop tamponade effect



Acetublar fracture

- Juda view- 2 oblique views to see obdurator foramen &iiac

Hemodynamic and anatomical stable

lecture notes for 260713

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