1. Dr John Trantalis
Orthopaedic Emergencies Care of the Injured Limb Hip fractures in the elderly

2. How To Examine a Joint Look Feel Move
Scars, alignment, wasting, redness, swelling
Feel
Tenderness (Location!!!!!)
Move
Active movement
Passive movement

3. Passive vs Active Motion
Patient moves the joint on their own
For active motion to be intact:
The joint must be mobile.
The “motor” must be working
PASSIVE MOTION
The examiner moves the joint for the patient
For passive motion to be intact
The joint must be mobile
The “motor” does not need to be working.
“Motor”= tendon, muscle, nerve, plexus, roots,
spinal cord, brain

4. PASSIVE vs ACTIVE motion
Loss of active Motion
Preserved Passive Motion
Joint OK
Motor is broken
Loss of both Active and Passive Motion
Joint Stiffness

5. A White, Pulseless Limb after an Injury

6. Off-ended # distal humerus
8 yo girl
Fall from monkey bars
Off-ended # distal humerus
Pale hand
Pulseless

7. Pre-post operative assessment after an elbow injury
Arteries
Compartment syndrome
Nerve Damage
Skin etc.

8. Pulseless Fractured Limb
Management: Why?

9. The elbow joint: arteries crossing the joint
Brachial artery
If damaged:
6 hours till amputation
White hand
No pulses
Cap Ref >2 secs
Pain
Super Urgent

10. Prevent This !!

11. 25yo, cast applied yesterday after fracture radius : now severe pain
Xray OK position
Unable to move fingers
Sensation and pulses intact

12. Diagnosis and Management?

13. Compartment syndrome Only clue is PAIN Unable to move fingers
Pulses normal
Cap Refill normal
Unable to move fingers
When you move them for the patient
Severe PAIN !!!!

14. Compartment syndrome Broken arm: should still be able to move fingers
6 hours to save the arm
Otherwise: amputation

15. Missed Forearm compartment syndrome: useless arm

16. Compartment Syndrome

17. Why are the Pulses normal and the Fingers Pink?
Ischaemia to muscles
Capillaries 5mmHg- shut down with small rise in compartment pressue
Radial Artery
Pressure of 120/80mmHg.
Therefore it stays open and hand stays pink

18. Therefore….
Only need one thing to diagnose compartment syndrome…..
PAIN

19. How can we differentiate normal fracture pain from Compartment Syndrome?
Active Finger (or Toe) Movement
No compartment syndrome

20. What to do if you suspect Compartment Syndrome….
CALL FOR HELP!!!!!!!!!!!!
Speak to the orthopaedic team urgently
Do not leave messages
You must speak to somebody urgently
Then…
Remove all encircling bandages…
A tight bandage or plaster can cause compartment syndrome
But it can also occur without anything wrapped around the limb… skin & fascia

21. How Do We Surgically Treat Compartment Syndrome
Urgent Fasciotomy (less than 6 hours)
Allows muscles to bulge out of wound and blood supply to return.
If you miss the diagnosis AMPUTATION

22. Clinical case 56 yo male, 24 hour h/o right knee pain Exam: temp 37.0C
No trauma
Can’t walk
Otherwise well
Exam: temp 37.0C
Swollen Knee (patella tap)
No redness
Markedly reduced ROM active and passive

23. Provisional Diagnosis?
Septic Arthritis
Differential Diagnosis?
Gout
Pseudogout
Haemarthosis

24. Key Clinical Sign for Septic Arthritis in any Joint
Decreased active and passive motion
The joint is very inflamed and painful.
Patient’s muscles spasm when movement is attempted.

25. The Work-Up Bloods: ECG, MSU, fast NBM XRAY Joint Aspirate
FBC, EUC, CRP, ESR, UA, Cultures
ECG, MSU, fast NBM
XRAY
Usually normal
Joint Aspirate

26. Inflammatory Markers CRP ESR C Reactive Protein
Very Sensitive for inflammation or infection
Indicative of what was happening in the body 1 day ago
ESR
Erythrocyte Sedimentation Rate
Indicative of what was happening in the body 3 days ago.

27. Joint Aspirate Before any antibiotics are given.
Never through red skin (can introduce skin infection into the joint)
Send off for MCS, crystals, cell count.

28. Septic Arthritis: Treatment
Joint Washout (arthroscopic)
Removes the enzymes from white cells which otherwise destroy the articular cartilage
IV antibiotics
Empirical: cover Staph Aureus

29. Fractured Hips in The Elderly

30. Risk Factors: Elderly, Female, Osteoporosis

31. One Year Mortality Rate for a Fractured NOF
30%
Within 1 year, 30% or patients who sustain a fractured NOF will pass away.
Due to comorbidities usually

32. Presentation Fall Can’t walk Pain in Groin Exam: Leg Shortened
Externally rotated

33. The Work-up Xrays Pre-op Pelvis and hip FBC. EUC, G&H ECG CXR
Fast Patient
Analgesia, Fluids, Pressure care, IDC

34. XRAYS
Trochanteric Fracture
Subcapital Fracture

35. Hip Anatomy
Acetabulum
Femoral head
Neck of femur
Trochanters

36. 2 common types of Hip Fractures
Subcapital fracture
Intertrochanteric or Pertrochanteric fractures
We Treat these differently

37. Why treat these fractures differently?
Blood Supply to the head of femur
Disrupted with a Displaced Subcapital Fracture
Intact with a displaced trochanteric fracture

38. Hip Joint Capsule The blood vessels run up through the capsule
Hence the terms:
Intracapsular # (subcapital)
Extracapsular #
(trochanteric)

39. What are the aims of Surgical Treatment
Relieve Pain
Every time patient moves in bed- pain
Regain Mobility
Patient should be able to Fully weight bear after surgery
Improve Quality of Life
Before the 1970’s
3 months Traction for everybody
50% mortality
Pneumonia, pressure sores etc

40. The Surgery Relieves Pain
Patient with # NOF in bed…The fracture ends grind and cause pain with every movement
Even with very ill patients, we still try to complete their surgery asap to relieve their pain and improve their quality of life (nursing etc)
The faster the patient gets to surgery the less chance of pneumonia / pressure sores developing.

41. Subcapital Fractures: 2 types
Non-Displaced
Screws
Displaced
Hip replacement
Half (hemiarthroplasty)
Total Hip Replacement

42. Non Displaced Subcapital Fractures
Blood supply not likely to be affected
Fix with screws and hope that it heals

43. Displaced Subcapital Fracture
Hemiarthroplasty
Blood supply is disrupted to femoral head
# won’t heal
Avascular Necrosis likely
Therefore: replace the head
Half replacement (hemiarthroplasty)
Total Hip Replacement for the more mobile patients
Total Hip Replacement

44. Intertrochanteric Fractures
Internally Fixed to allow early weight bearing
Plate
Nail
Dynamic Hip Screw (DHS)
Short femoral Nail
Intertroch #

45. Post-Op Care NV Obs Analgesia DVT prophylaxis Bloods Mobilise FWB
Pressure area care

46. Dr John Trantalis Orthopaedic Surgeon
The injured Limb
Dr John Trantalis
Orthopaedic Surgeon

47. Dislocated Joints Should all be reduced ASAP Pain XRAY 2 views always
Pressure off NV structures
Pain XRAY 2 views always
CT if you are unsure
Beware  LOC
Trauma, Head injury  Secondary survey
You will detect decreased ROM
Seizures, electrocution

48. The Open Fracture

49. Painful swollen leg after tackle.
43 yo F soccer player
Painful swollen leg after tackle.
?Management
Why?

50. Managing The Injured Limb in ED

51. Managing The Injured Limb in ED

52. Managing the Injured Limb in ED
Analgesia / Sedation
Reduce the deformity, splint the limb
Backslabs only- NEVER apply a full POP in ED.

53. Managing the Injured Limb in ED
Dress the wounds
THEN… get Xrays.
Tet tox, IV antib, Fast patient
Pre-op work-up.

54. How do we reduce the deformity?
It’s very complicated……..

55. JUST PULL!!

56. How to describe a fracture

57. Principles of fractures and joint injuries
Questions to ask…
Open or closed?
Which bone?
Location in bone?
Pattern of Fracture
Joint involvement?
Displaced or non-displaced?
Type of displacement?

58. Principles of fractures and joint injuries
How fractures are displaced

59. Principles of fractures and joint injuries
Direct healing - If fracture absolutely immobile, eg. Fixed with metal fracture healing occurs directly between fragments.

60. Principles of fractures and joint injuries
How Long Does It Take To for a Fracture to Heal?
Depends on……
Patient Factors: Age, Comorbidities etc
Fracture Factors: which bone, type of fracture etc
Can take up to 6 months for a tibia versus 2 weeks for a phalanx.
Healing seen on XRAY always takes longer than clinical union

61. Clinical signs of fracture Union
No tenderness, movement or crepitus at a fracture site.

62. The injured limb – Clinical features

63. LOOK FEEL MOVE Clinical Features
If you remember nothing else about examining a limb…
LOOK
FEEL
MOVE

64. Clinical Features Look Any Swelling? Any Bruising?
Any obvious Deformity?
Is the skin intact?
Where is the wound?
And, what size is the wound?
What colour is the skin?

65. Clinical Features Feel Tenderness Swelling Crepitus
Vascular and neurological examination before and after treatment

66. Clinical Features Move
Active and passive movement distal to the injury
Absolutely critical
Know your anatomy

67. The injured limb - Imaging

68. Clinical Features Xrays Remember the rule of 2’s!!!
2 views – a fracture or dislocation may not be evident on a single film, at least 2 views mandatory – usually AP and lateral
2 joints – joints above and below the fracture, eg. Monteggia/Galeazzi #’s
2 limbs – in children, appearance of immature physis may confuse diagnosis of fracture
2 injuries – severe force often causes trauma at more than one level, eg. Calcaneal or femur #, important to xray pelvis and spine.
2 occasions – some lesions notoriously difficult to detect immediately after injury, eg. Scaphoid #

69. Beware Ipsilateral injuries
For any # or dislocation
- always image to joint above and below

70. Clinical Features Special Imaging
Can’t see a # on XRAY but suspiscious eg scaphoid
MRI, CT, or bone scan.
CT scans useful in complex or intra-articular fractures (eg. Calcaneal, Tibial plateau)

71. The injured limb – Management principles

72. Treatment of Closed Fractures
Reduction
Putting the bone into an acceptable position
Two methods – open or closed

73. Treatment of closed fractures
Closed reduction
Sedation / Anaesthesia
Pull the limb into alignment
Splint the limb

74. Treatment of closed fractures
Closed reduction
In general, closed reduction is used for…
For most fractures in children
For fractures that are stable after reduction and can be held in a splint or cast

75. Treatment of closed fractures
Open reduction
Articular fractures – want anatomical reduction
Need bone to heal in perfect position; eg. Adult forearm shaft fractures

76. Fracture Immobilisation
Following reduction, the available methods of holding are…
cast splintage
Internal Fixation (plates, screws, nails)
external fixation
Traction

77. Fracture Immobilisation
Continuous traction
Can be applied by
Gravity, eg. Hanging cast
Skin
Skeletal, ie. Via pin inserted into bone

78. Cast splintage Plaster of Paris commonly used
Speed of union similar to traction, but allows patient to go home sooner
Generally need to immobilise joint above and below to provide stability
However, joints can become stiff – leading to “fracture disease”
Functional bracing is an alternative in some situations, allows joint movement

79. Internal Fixation Types… Pins Wires Plate/screws Intramedullary nails
Holds fracture securely, so that movement can be introduced early and “fracture disease” abolished
** Even though fixation provides mechanical stability, biological union can in fact be slower

80. External Fixation External fixation particularly useful for:
Fractures associated with severe soft tissue damage
Fractures with associated nerve/vessel injury
Severely comminuted/unstable fractures
Non-unions – can be excised and compressed, sometimes combined with elongation
Pelvis fractures
Infected fractures
Severe multiple injuries:
Provides rapid stabilisation
with minimal surgery
= “damage control orthopaedics”

81. Complications of fractures
Early Complications, including:
Vascular injury
Nerve injury
Compartment syndrome
Infection
Fracture blisters (elevation of superficial layers of skin by oedema)
Late Complications, including:
Delayed/Non-union
Malunion
Avascular necrosis
Growth disturbance
Stiffness, CRPS, post traumatic osteoarthritis, etc

82. Complications of fractures
Common nerve injuries
Shoulder dislocation = axillary nerve
Humerus shaft fracture = radial nerve
Humerus supracondylar fracture = radial or median nerves
Hip dislocation = sciatic nerve
Knee dislocation = peroneal nerve

83. Injuries of the growth plate
Childrens bones grow longer at either end via Growth Plates.
If a Growth plate is damaged, it can result in abnormal (crooked) growth.

84. Complications of fractures
Delayed Union and Non Union
Delayed union = prolonged time to fracture union
Non Union = failure of bone to unite
Factors – multiple: Smoking increases risk 30%

85. Complications of fractures
Types of Non Union
Hypertrophic Atrophic

86. Complications of fracture healing
Malunion = when fragments heal in unsatisfactory position, ie. unacceptable angulation, rotation or shortening.
Due to either…
poor reduction of fracture
failure to hold reduction
gradual collapse of comminuted or osteoporotic bone

87. Complications of fracture healing
Avascular Necrosis (AVN)
Certain fractures/injuries are notorious for their propensity to develop ischemia and subsequent bone necrosis…
1) Femoral head - #femoral neck (#NOF) or hip dislocation
2) Scaphoid – particularly with more proximal fractures, as blood supply is from distal to proximal
3) Talus – similar to scaphoid, blood supplies bone from distal to proximal, therefore body talus at risk AVN

88. Common Upper Limb Injuries

89. Common Fractures and Joint injuries
Clavicle Fractures

90. Common Fractures and Joint injuries
Shoulder Dislocation
most common direction = anteroinferior
Don’t forget xray rule of 2’s
Eg. Posterior dislocation
If unsure on AP and lateral views, then demand an axillary view!!!
Don’t forget to check axillary n.

91. Common Fractures and Joint injuries
Distal radius fractures
not all are Colles fractures!!
“Colles” = low energy osteoporotic fracture
“Smith’s” = reversed Colles
Radial styloid
Comminuted intra-articular fracture in young adults
Numerous different management options!!

92. Common Lower Limb Injuries

93. Common Fractures and Joint injuries
Hip fractures – “# NOFs”
generally used term to describe proximal femur fractures
Strictly = Neck of Femur (versus Intertrochanteric #)
Risk of AVN with #NOF, not intertrochanteric #
Clinically leg is shortened and externally rotated in both
Managed with either fixation or arthroplasty
Neck of femur
Intertrochanteric

94. Common Fractures and Joint injuries
Common fractures around the knee
Supracondylar femur fracture
Patella fracture
Tibial plateau fracture

95. Common Fractures and Joint injuries
Common foot/ankle fractures
“Jones” fracture
Simple ankle fracture
Calcaneus fracture
“Lisfranc” fracture/dislocation
Neck of talus fracture
Complex “Pilon” fracture

96. Common Paediatric Injuries

97. Common Fractures and Joint injuries
Common Paediatric Upper Limb Fractures
Monteggia #/dislocation
Supracondylar humerus
Galeazzi #/dislocation
Lateral condyle fracture
Fat pad sign

98. Common Fractures and Joint injuries
Common Paediatric Lower Limb Fractures
Physeal fractures around the knee and ankle
Femur # in children under 2 years – think child abuse!!!
Avulsion fractures - tibial tuberosity and ACL

99. Thank You