1. 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. 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

5. 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

6. 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

7. 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

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 supplyAdequate blood supply Adequate mechanical stabilityAdequate mechanical stability Adequate blood supplyAdequate blood supply Adequate mechanical stabilityAdequate mechanical stability

10. Bone Healing Indirect Direct

12. ‘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

13. 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

14. Tibial Fracture

15. Intramedullary Nail

16. Plate and Screws

17. External Fixation

18. Hardware – In The Lumen Nail VS Rod 1 st, 2 nd and 3 rd 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 1. Prevention of infection 2. Fracture union 3. Restoration of function

26. QUESTIONS

28. Classification of Open Fractures

29. 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

30. 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

31. 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

32. Clinical Cases

33. Subtrochanteric Fracture LAT

34. CASECASE 28 yr old RTA motorcyclist Adonis Adonis

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

37. 3. Surgeon:- Locking Plate

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

41. Distal Femoral Fracture and Midshaft Tibial Fracture AP LAT

42. Distal Femoral Fracture AP LAT

43. Mid shaft Open Femoral Fracture LAT

44. Distal Femoral Fracture AP LAT

45. Distal Femoral Fracture LAT

46. AP LAT Ankle Fracture

47. AP LAT Ankle Fracture

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

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 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

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

57. 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)

60. 79 Degrees MPTA

61. 87 Degrees MPTA

63. 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

64. Open Tibial Fracture

67. CASE 5 32 yr RTA Open fracture 32 yr RTA Open fracture

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

73. What would you do??

74. MIPO plating