ORTHOPEDIC SURGERY

Rannie R. Rabe-Baquiran, MD, FPCS, FPALES

October 2, 2015
ORTHOPEDICS
• Medical specialty that focuses on the injuries and
diseases of the musculoskeletal system

• Bones (extremities and the spine), joints, tendons,

muscles

• Subspecialty:
▫ Trauma
▫ Sports
▫ Spine
▫ Joint
▫ Oncology
▫ Pediatric Orthopedics
ORTHOPEDIC TRAUMA
• 5th leading cause of death (US) in the first 5th
decades of life
• Injuries resulting to fracture of the bones,
damage to joints and injuries to the soft tissues

• FRACTURE
▫ Disruption of the normal architecture of the bone
ORTHOPEDIC TRAUMA
• Definition of Terms
▫ Acute Fracture
 Sharp, well defined edges of fragments
▫ Chronic Fracture
 Rounded and sclerotic appearance after resorption
of bone has occurred on fractured ends
▫ Incomplete Fracture
 Greenstick (children) or infractions (adults)
▫ Stress fractures
 Chronic repetitive trauma causing microscopic
disruptions (overuse injuries)
ORTHOPEDIC TRAUMA
• Definition of Terms
▫ Pathologic fracture
 Failure of the bone through a weakened bone by a
preexisting disease
 Bone tumors, metastatic lesions, infections
ORTHOPEDIC TRAUMA
• Goals of treatment:
▫ Restore normal anatomy
▫ Immobilize for pain relief and allow healing
▫ Repair/reconstruct to restore function
 FRACTURES
• Result from high energy
trauma

• Types of Acute
fracture:
▫ Transverse
▫ Oblique
▫ Spiral – rotational force
▫ Segmental
▫ Comminuted – multiple
fragments
FRACTURES
• Displaced fractures
▫ Reduction under anesthesia
▫ Splinting or casting

• CLOSED vs OPEN fracture

▫ Splinting
▫ Debridement with use of implants (screws, plates,
rods, external fixators
OPEN FRACTURES
• Occurs when the bone breaks
through the skin
• Often associated with damage of
the surrounding soft tissues and
contamination of the wound

• TREATMENT
▫ immediate debridement and
antibiotics
▫ Definitive treatment is delayed
(limb salvage vs amputation)
 GUSTILO-ANDERSEN
CLASSIFICATION OF OPEN
FRACTURES
FRACTURES
• How to describe a fracture
1. Open or close, grade
2. Type of fracture (transverse, oblique, etc)
3. Laterality (right or left)
4. Location in the bone (condylar, shaft, etc)

▫ Fracture, open grade III, comminuted, left

femoral shaft
FIXATION PRINCIPLES
• External fixation
▫ External frames (pins,
connectors and rods)

• Internal Fixation (ORIF)

▫ Pins and screws
▫ Tension bands
▫ Plates
▫ Intermedullary nail
REDUCTION AND IMMOBILIZATION
• Splinting
• Casting
• Skeletal traction
CLAVICULAR FRACTURES
• One of the most common fractures
• Usually in the middle 3rd

• Treatment:
▫ Sling and ROM exercises
▫ Open reduction and surgical repair only for those
with severe displacement
FOREARM FRACTURES
• Results from high energy trauma or falls onto
outstretched arm
• Types:
▫ Nightstick Fx
 Isolated ulnar shaft fracture
▫ Monteggia FX
 Ulnar shaft fx + radial head dislocation
▫ Galeazzi fx
 Radial shaft fracture with disruption of distal radioulnar
joint

• Management:
▫ Plate and screw fixation
FEMORAL NECK FRACTURE
• Occurs with the capsule of the hip joint
• Injury to the vascular supply can lead to
osteonecrosis
• Usually occurs in elderly female with history of
fall
• Management:
▫ Surgical placement of screws if low risk for
disruption of blood supply
▫ Hip replacement if vascular compromise
FEMORAL NECK FRACTURE
INTRATHROCANTERIC HIP
FRACTURE
• Fractures in between the greater and lesser
trochanters of the proximal femur
• Abundant blood supply
• Internal fixation with hip screw,
cephalomedullary nail
SUBTHROCANTERIC HIP FRACTURE
• Fractures in the proximal femoral shaft just
distal to the lesser trochanter
• Muscles attached to the lesser trochanter
displaces the bone fragments
• Long cephalomedullary nail with screws
FEMORAL SHAFT FRACTURES
• Long bone fractures are highly associated with
thromboembolic events (fat emboli syndrome)
and Acute respiratory distress syndrome (ARDS)

• Management should not be delayed beyond 24

hours

• Intermedullary nail or external fixation if

hemodynamically unstable
PELVIC FRACTURES
• Indicative of high energy trauma
• Associated with other injuries to the head, chest,
abdomen
• Life threatening hemorrhage can occur
• Bleeding is often due to injury to the venous
plexus in the posterior pelvis
• First line treatment: pelvic binder, external
fixation
SPRAIN
• Ligamentous injuries
▫ Grade I
 stretching of the ligament complex, no instability
▫ Grade II
 partial rupture of the ligaments with concommitant
instability of the joint
▫ Grade III
 Complete ruptures with significant instability to the
joint
STRAIN
• Injury to the muscle or tendon
• Usually from overuse
• Treatment: rest, cold compress and elevation of
extremity
COMPARTMENT SYNDROME
• An surgical emergency
• Caused by significant swelling within a
compartment of an injured extremity that
jeopardizes the blood supply to the limb
• Edema prevents venous outflow (congestion)
• Leads to ischemia and necrosis
• Causes:
▫ Fractures, arterial injury, gunshot wound, limb
compression, burns, constrictive dressings and
tight casts
COMPARTMENT SYNDROME
• Clinical presentation: pain, paresthesia,
pulselessness
• HIGH degree of clinical suspicion

• Surgical Management: Fasciotomy

FASCIOTOMY
DISLOCATIONS
• Orthopedic emergency
• Prolonged dislocation can lead to cartilage cell
death, posttraumatic arthritis, neurovascular
injury and avascular necrosis
• Presentation:
▫ Gross deformity (shortened limb, adducted
position, etc)
▫ Limited range of motion (muscle spasm)
DISLOCATIONS
• Shoulder dislocation
▫ Most commonly displaced joint
▫ Usually Anterior dislocations
 Associated with injuries to the labrum, impression
fractures of the humeral head and rotator cuff tear
▫ Posterior dislocations
 Associated with seizures or electrical shock

▫ Management:
 Reduction and immobilization with a sling
DISLOCATIONS
• Elbow Dislocation
▫ Also fairly common
▫ Usually Posterior dislocation
▫ Results to injury to the joint capsule and rupture
of the lateral collateral ligament
▫ Management:
 Reduction and immobilization
 Surgery is necessary if with concomitant fracture
DISLOCATIONS
• Hip dislocation
▫ Result from high energy trauma
▫ Usually posterior dislocation
▫ Can cause injury to the sciatic nerve
▫ URGENT reduction
 Within 6 hours
 Prevent necrosis of the femoral head (avascular
necrosis)
DISLOCATIONS
• Knee Dislocation
▫ Rare but devastating injury that can be limb-
threatening
▫ Injuries to the ACL, PCL, LCL, MCL
▫ Injury to the popliteal artery

▫ Management:
 Multiligamentous reconstruction
 Stiffness and instability is a common complication
SPORTS MEDICINE
• Deals with the prevention and treatment of
injuries related to sports and exercise

• Does not only treat the injury but also has to

consider return to activity (“Getting back in the
game”)

• Surgical Intervention: arthroscopic approach

SPORTS MEDICINE
• Shoulder
▫ Rotator cuff injuries
 Associated with forceful or repeatedoverhead or
pulling
▫ Shoulder instability
 Usually after shoulder dislocation
▫ Superior labrum and Biceps tendon
▫ Acromioclavicular joint
SPORTS MEDICINE
SPORTS MEDICINE
• Knee
▫ Menisci
 Contact sports, squatting and twisting the knee
 Meniscectomy
SPORTS MEDICINE
• Knee
▫ Collateral Ligaments (MCL, LCL)
 MCL is most commonly injured
 Can be managed non-operatively
 “unhappy triad”: MCL, medial meniscus, and ACL
injury
SPORTS MEDICINE
• Knee
▫ Cruciate Ligaments (ACL, PCL)
 Situated centrally within the intercondylar notch of
the knee
 ACL tears are more common (soccer, basketball)
 ACL tears will not heal without surgery
 Mainly surgical management
SPINE
• Spinal Trauma
▫ Jefferson Fracture (C1)
▫ Odontoid Fracture (C2)
▫ Hangman’s Fracture of C2
 Sudden extension forces on the neck
SPINE
• Disc Herniation
▫ Common between 20-50 years old
▫ Tear of the annulus allowing the nucleus pulposus
to extrude through the annulus and enter the
canal causing compression of the nerve roots

▫ Surgery is indicated if symptoms persist beyond 6-

8 wks

▫ Anterior Decompression and laminectomy

ORTHOPEDIC PATHOLOGY AND
ONCOLOGY
• Orthopedic Oncology
▫ Care and management of individuals with primary
and secondary neoplasms of the musculoskeletal
system

▫ Involves adequate oncologic resection and skeletal

reconstruction and restoration of function
ORTHOPEDIC PATHOLOGY AND
ONCOLOGY

• Malignant Bone tumors

▫ Presents with a history of unremitting pain
unrelated to activity or pain that interferes with
sleep suggests malignancy

▫ Age, location and gender can help in the

differential diagnosis
MALIGNANT BONE TUMORS
• OSTEOSARCOMA
▫ Most common primary
malignant bone tumor

▫ Presents during 10-20 years

of age

▫ Surgical with margins

MALIGNANT BONE TUMORS
• EWING’S SARCOMA
▫ Second most common primary
bone tumor

▫ Age under 30

▫ Usually occurs in the diaphysis

of the femur

▫ “Onion Skin” periosteal

reaction on xray

▫ Chemotherapy and surgery or

RT
CARTILAGE FORMING TUMORS
• CHONDROSARCOMA
▫ Typically occurs in male
patients over 40 years old
▫ 3rd most common primary
bone malignancy
▫ Pelvis, shoulder and ribs are
common locations
▫ “popcorn calcifications” are
seen on xray
▫ Treatment: wide excision
 Not sensitive to chemotherapy
or radiation
PEDIATRIC FRACTURES
• Unossified epiphyseal growth plate in children
is an important consideration

• Reduction and stabilization is important to

minimize permanent growth disturbances and
deformity
CLASSIFICATION OF GROWTH PLATE
INJURIES
• Salter and Harris Classification
▫ Type I
 Simple transverse fracture through the physis
▫ Type II
 Component fracture through the growth plate in continuity
with a fracture of the metaphysis
▫ Type III
 Occurs through the physis and exits through the growth plate
▫ Type IV
 Fracture line extends through from metaphysis into epiphysis
▫ Type IV
 Crushing of the physis
PEDIATRIC FRACTURES
• Treatment
▫ Anatomic reduction of fractures
▫ Internal fixation avoids placing hardware across
the growth plate to minimize premature growth
plate closure
DEVELOPMENTAL DISEASES
• Developmental Dysplasia of the Hip (DDH)
▫ Seen in firstborn females with family history and
breech birth
▫ Ortolani’s test
 Gentle elevation and abduction of the femur causing
a palpable click in the relocation of the displaced hip
▫ Barlow’s Test
 Gentle adduction and depression of the femur which
causes a palpable click as hip slips into a dislocated
position
DEVELOPMENTAL DISEASES
• Developmental Dysplasia of the Hip (DDH)
▫ Treatment
 Pavlick harness to maintain
hip in flexion and abduction
 6-12 weeks for mild DDH
 Severe DDH – adductor tenotomy
DEVELOPMENTAL DISEASES
• Congenital Talipes Equivarus
▫ “Clubfoot”
▫ Common problem
▫ Contractures of the medial tendons of the foot ,
tight achilles tendon and contractures of the ankle,
hindfoot and midfoot

▫ Treatment: sequential corrective casting

Thank You!