Senior Orthopaedic Consultant & Principles of Orthopaedics Mr Suheal A Khan Senior Orthopaedic Consultant & Visiting Professor KTPH Singapore

Orthopaedic Elective Procedures Osteotomy Arthrodesis Arthroplasty: Excision Interposition Amputation

Orthopaedic Trauma Procedures Conservative Operative: Nail Plate External Fixator: Monolateral Multiplaner Amputation

Functions of the Skeleton 1. Protective 2. Locomotion 3. Muscle attachments 4. Metabolic 5. Haematopoetic

What is Bone? A protein scaffold (collagen) or Osteoid (35%) Impregnated with Calcium Salts to give it stiffness (65%) ‘Impregnated’ with ‘latent’ Growths factors Minerals Osteoid Normal Osteoporosis Osteomalacia

Types of Bone Cortical Bone (compact bone): 80% of Skeletal System Thick in the bone’s shaft (diaphysis) areas Thinner at the ends of bone (epiphysis) Cancellous Bone (trabecular or spongy bone): 20% of Skeletal System Inner surface of bone Most of the bony structure at the end of bones

Bone Healing The skeleton is the ONLY human organ to heal without scarring TISSUE REGENERATION

Stages of Fracture Healing Initial Trauma Inflammatory Response Formation of New Soft Tissue: Callus Formation of Bone Matrix & Cartilage Ossification of Cartilage to Bone Remodeling Healing with NO scar!

Prerequisites for Bone Healing Adequate blood supply Adequate mechanical stability OKU-6

Bone Healing Indirect Direct

‘a fracture is a severe soft tissue injury with a broken bone in its midst’ Astley Cooper

Management of Fractures Conservative Operative Internal fixation: Intramedullary nail Plates and screws External fixation

Tibial Fracture

Intramedullary Nail

Plate and Screws

External Fixation

Hardware – In The Lumen Nail VS Rod 1st, 2nd and 3rd Generation Nails Antegrade & Retrograde

Hardware – In The Wall Rigid Fixation Angle Blade plate DHS & DCS Bridge Plating Locking Plate

Hardware – Outside Wall Temporary VS Permanent Uni planer VS Multiplaner

What determines choice of hardware? The Three P’s (Personalities)

The Fracture

The Patient

The Surgeon

Goals of Treatment 1. Prevention of infection 2. Fracture union 3. Restoration of function

QUESTIONS

Classification of Open Fractures

III Extensive damage to soft Gustilo and Anderson Wound Size I < 1cm II > 1cm Soft Tissue Crushing None Slight or Moderate Fracture Type Simple Comminuted Segmental Contamination Little Moderate High III Extensive damage to soft tissue, muscle, skin

Classification Grade III A Soft tissue cover. Any segmental # B Periosteal stripping +/- contamination C Neurovascular injury requiring repair

Summary 3 ways to fix a bone: Within the bone On the surface of the bone Outside the bone The 3 Personalities: Fracture Patient Surgeon

Clinical Cases

Subtrochanteric Fracture LAT

28 yr old RTA motorcyclist Adonis CASE 28 yr old RTA motorcyclist Adonis

Fracture:- Closed Pilon 2. Patient:- Alcoholic

3. Surgeon:- Locking Plate

Open Tibial Fracture 15cm by 5cm wound over posterior aspect of calf AP Open Tibial Fracture 15cm by 5cm wound over posterior aspect of calf LAT

Distal Femoral Fracture and Midshaft Tibial Fracture AP Distal Femoral Fracture and Midshaft Tibial Fracture LAT

Distal Femoral Fracture AP LAT

Mid shaft Open Femoral Fracture LAT

Distal Femoral Fracture AP LAT

Distal Femoral Fracture LAT

Ankle Fracture AP LAT

Ankle Fracture AP LAT

Too Low! Too Medial! AP Valgus Procurvatum LAT

CASE 1 47 yr Old Fell off a back of a lorry 1.5 m high Grade 1 Open Distal Tibial Fracture Wounds over posterior aspect of calf, a transvere wound

17/11/20122

17/11/20122

20/11/20122

4/3/20132 Plate exposed over medial malleolus and dorsal pedis island flap performed. Foot in 25 degrees of equinus

13/5/2013 Flap died and metal work removed with Vac Pump applied. Ankle movement improved!

30/5/20132 Ilizaove frame with bone grafting of non union site Cross ankle fixtor to correct equinus deformity

Equinus corrected after 21 days of correction Awaiting union of fracture site 30/5/20132 26/6/20132

CASE 2 32 yr old RTA motorcyclist Soft tissue injury anterior aspect of knee (Tscherne grade 3)

79 Degrees MPTA

87 Degrees MPTA

Open fracture 10cm longitudinal laceration posterior aspect of calf CASE 4 52 yr old low energy fall Open fracture 10cm longitudinal laceration posterior aspect of calf

Open Tibial Fracture

CASE 5 32 yr RTA Open fracture

50 yr old low energy fall Closed fracture Known alcoholic CASE 6 50 yr old low energy fall Closed fracture Known alcoholic

What would you do??

MIPO plating