1. Basic Management of Fractures, Sprains and Strains Phillip de Lange Walk-a-Mile Centre for Advanced Orthopaedics June 2016

2. Sprains Ankle Sprains Knee sprains and soft tissue injuries Shoulder sprains

3. Ankle Ligament injuries Lateral Ligament injuries General treatment conservative Initial immobilization <10 days Review < 2 weeks –Referral if abnormal xray Active physiotherapy Weightbearing acc to pain

4. Ankle Ligament injuries Syndesmosis injuries Tender just superior to ankle External rotation test Surgical treatment

5. Knee sprains and soft tissue injuries Mechanism of injury –Direct trauma –Twisting injury Swelling/Effusion –Immediate –Delayed Locking or clicking Instability

6. Knee sprains and soft tissue injuries Initial management –Xray : Any immediate swelling/effusion –Robert Jones Bandage –RICE Principles –Review in 1/52 unless danger signs –Beware of knee dislocations and vascular injuries

7. Knee sprains and soft tissue injuries Common injuries –Patella dislocation Patellar apprehension Need patellar strapping and physiotherapy –Meniscus tears Initial conservative management Joint line tenderness Locking symptoms require referral –Collateral ligament injuries Can generally be treated conservatively –Cruciate ligament injury Referral ASAP

8. Shoulder injuries Mechanism –Direct trauma –FOOSH –Heavy object lifting Examination essentials –Muscle girdle/C-spine –Rotator cuff attachment –Biceps tendon area –Subscapularis –AC Joint

9. Shoulder injuries Rotator cuff injuries –Complete tears –Incomplete tears Danger signs –Ability to lift arm… –Biceps deformity –AC Joint deformity Long term – Shoulder impingement

10. Hand and Fingertip injuries Most common occupational injury Fingertips –Nailbed lacerations –Tuft fractures

11. Hand and Fingertip injuries Hand Fractures –Distal phalanx Conservative –Middle and proximal phalanx Depending on displacement –Metacarpal More prone to surgical management Immobilization leads to stiffness and prolonged return to function

12. Hand and Fingertip injuries Hand lacerations –Structure dense area –High risk for vital structure injury –Low tolerance for surgical exploration

13. Open fractures Basic principles –Early IV Antibiotics/Tetanus –Sterile dressings –Splintage –Elevation Any breakage in skin in same region Small wound – Tip of iceberg

14. Open fractures Antibiotic choice –Cefazolin 2g STAT, 1g 8hrly –Add Gentamycin and Flagyl in Agricultural injuries Severe contamination Foot injuries Animal bites –Human bites Augmentin 1,2g 8hrly IVI

15. Fractures Upper Limb –Clavicle –Proximal humerus –Humerus –Elbow –Forearm –Distal Radius –Wrist fracture/dislocations

16. Clavicle fractures Indications for surgery –Shortening 2 cm –Translation >100% –Z fragment –Open injury –Threatening of the skin

17. Clavicle fractures

19. Proximal Humerus Treatment by displacement and patient age Conservative treatment often better in elderly Splint in Barford Jones sling. No use for POP Slab

20. Humerus Humeral shaft Radial nerve injury Splint: Modified shoulder splint

21. Humerus Distal Humerus Supracondylar/intracondylar High risk of ulnar nerve injury Splint in high above elbow slab

22. Elbow Olecranon Fractures

23. Elbow Olecranon Fractures

24. Forearm fractures Generally treated operatively in the adult patient

25. Forearm fractures

27. Distal Radius

29. Wrist injuries

32. Reduction should be attempted in emergency department. Examine carefully for Median nerve symptoms.

33. Scaphoid fractures If visible of pain xray – Displaced Should be fixated Tender like fracture but not visible Volar slab/Scaphoid slab Repeat x-ray 7 to 10 days ? CT – Scan in high demand wrist

34. Fractures Lower Limb and Pelvis –Pelvis/Acetabulum fractures –Femur neck fractures –Femur fractures –Tibial Plateau fractures –Tibia Fractures –Ankle Fractures –Ankle Ligament injuries

35. Pelvis/Acetabulum fractures Lateral Compression fracture –Risk of hollow viscus injury –Traction if hip displaced

36. Pelvis/Acetabulum fractures Open book fractures –Bleeding –Close book/ Pelvic binder

37. Pelvis/Acetabulum fractures

38. Femur neck fractures Young patient –Emergency –Risk for AVN

39. Femur neck fractures Old patient >65 –Undisplaced/Valgus Emergency –Displaced Hip replacement surgery –No traction –Emergency management Fluids Oxygen

40. Femur fractures

41. Tibial plateau fractures Beware – Vascular injuries

42. Tibial fractures Often massive soft tissue injury Simple fractures –Compartment syndrome

43. Ankle fractures

44. Not all ankle fracture the same ORIF for all ankle fractures except undisplaced lateral maleolus fracture with no medial tenderness

45. Ankle fractures Emergent reduction in casualty Talus in line under tibia Placed in slab/ankle in neutral to stabilize reduction Surgery – Early before swelling or elevate numerous days

46. Pilon fractures

47. The End