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

2. Orthopaedic Elective Procedures
Osteotomy
Arthrodesis
Arthroplasty:
Excision
Interposition
Amputation

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

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

5. 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

6. 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

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

8. 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!

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

10. Bone Healing
Indirect
Direct

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

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

14. Tibial Fracture

15. Intramedullary Nail

16. Plate and Screws

17. External Fixation

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

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

20. Hardware – Outside Wall
Temporary VS Permanent
Uni planer VS Multiplaner

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

22. The Fracture

23. The Patient

24. The Surgeon

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

26. QUESTIONS

28. Classification of Open Fractures

29. 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

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

31. 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

32. Clinical Cases

33. Subtrochanteric Fracture
LAT

34. 28 yr old RTA motorcyclist Adonis
CASE
28 yr old RTA motorcyclist
Adonis

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

37. 3. Surgeon:- Locking Plate

38. Open Tibial Fracture 15cm by 5cm wound over posterior aspect of calfAP
Open Tibial Fracture 15cm by 5cm wound over posterior aspect of calf
LAT

41. Distal Femoral Fracture and Midshaft Tibial FractureAP
Distal Femoral Fracture and Midshaft Tibial Fracture
LAT

42. Distal Femoral FractureAP
LAT

43. Mid shaft Open Femoral Fracture
LAT

44. Distal Femoral FractureAP
LAT

45. Distal Femoral Fracture
LAT

46. Ankle Fracture AP
LAT

47. Ankle Fracture AP
LAT

48. Too Low! Too Medial! AP
Valgus
Procurvatum
LAT

49. 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

50. 17/11/20122

51. 17/11/20122

52. 20/11/20122

53. 4/3/20132
Plate exposed over medial malleolus and dorsal pedis island flap performed.
Foot in 25 degrees of equinus

54. 13/5/2013 Flap died and metal work removed with Vac Pump applied.
Ankle movement improved!

55. 30/5/20132
Ilizaove frame with bone grafting of non union site
Cross ankle fixtor to correct equinus deformity

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

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

60. 79 Degrees MPTA

61. 87 Degrees MPTA

63. 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

64. Open Tibial Fracture

67. CASE 5
32 yr RTA
Open fracture

72. 50 yr old low energy fall Closed fracture Known alcoholic
CASE 6
50 yr old low energy fall
Closed fracture
Known alcoholic

73. What would you do??

74. MIPO plating