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

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

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

Types of Bone Cortical Bone (compact bone):Cortical Bone (compact bone): 80% of Skeletal System80% of Skeletal System –Thick in the bone’s shaft (diaphysis) areas –Thinner at the ends of bone (epiphysis) Cancellous Bone (trabecular or spongy bone):Cancellous Bone (trabecular or spongy bone): 20% of Skeletal System20% of Skeletal System –Inner surface of bone –Most of the bony structure at the end of bones Cortical Bone (compact bone):Cortical Bone (compact bone): 80% of Skeletal System80% of Skeletal System –Thick in the bone’s shaft (diaphysis) areas –Thinner at the ends of bone (epiphysis) Cancellous Bone (trabecular or spongy bone):Cancellous Bone (trabecular or spongy bone): 20% of Skeletal System20% 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 The skeleton is the ONLY human organ to heal without scarring TISSUE REGENERATION The skeleton is the ONLY human organ to heal without scarring 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 supplyAdequate blood supply Adequate mechanical stabilityAdequate mechanical stability Adequate blood supplyAdequate blood supply Adequate mechanical stabilityAdequate mechanical stability

Bone Healing Indirect Direct

‘a fracture is a severe soft tissue injury with a broken bone in its midst’ Astley Cooper ‘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 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 1 st, 2 nd and 3 rd 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 1. Prevention of infection 2. Fracture union 3. Restoration of function

QUESTIONS

Classification of Open Fractures

WoundSize I < 1cm II > 1cm WoundSize I < 1cm II > 1cm Soft Tissue CrushingNone Slight or Moderate Soft Tissue CrushingNone Slight or ModerateFractureTypeSimpleComminutedSegmentalFractureTypeSimpleComminutedSegmentalContaminationLittleModerateHighContaminationLittleModerateHigh III Extensive damage to soft tissue, muscle, skin tissue, muscle, skin III Extensive damage to soft tissue, muscle, skin tissue, muscle, skin Gustilo and Anderson

ClassificationClassification Grade III ASoft tissue cover.Any segmental # BPeriosteal stripping +/- contamination CNeurovascular injury requiring repair Grade III ASoft tissue cover.Any segmental # BPeriosteal stripping +/- contamination CNeurovascular injury requiring repair

SummarySummary 3 ways to fix a bone: Within the bone On the surface of the bone Outside the bone The 3 Personalities:Fracture PatientSurgeon 3 ways to fix a bone: Within the bone On the surface of the bone Outside the bone The 3 Personalities:Fracture PatientSurgeon

Clinical Cases

Subtrochanteric Fracture LAT

CASECASE 28 yr old RTA motorcyclist Adonis Adonis

1. Fracture:- Closed Pilon 2. Patient:- Alcoholic

3. Surgeon:- Locking Plate

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

Distal Femoral Fracture and Midshaft Tibial Fracture AP LAT

Distal Femoral Fracture AP LAT

Mid shaft Open Femoral Fracture LAT

Distal Femoral Fracture AP LAT

Distal Femoral Fracture LAT

AP LAT Ankle Fracture

AP LAT Ankle Fracture

AP LAT Too Low!Too Medial! Procurvatum Valgus

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 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

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

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

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

79 Degrees MPTA

87 Degrees MPTA

CASE 4 52 yr old low energy fall Open fracture 10cm longitudinal laceration posterior aspect of calf 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 32 yr RTA Open fracture

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

What would you do??

MIPO plating