ORTHOPAEDIC TRAUMA :ORTHOPAEDIC TRAUMA :FROM BASIC TO CLINICFROM BASIC TO CLINIC

BONE HISTOLOGYBONE HISTOLOGY

a/. Cortical bone : 80% of skeletal systema/. Cortical bone : 80% of skeletal systemb/. Cancellous bone : less compactb/. Cancellous bone : less compact

Cells : - OsteoblastCells : - Osteoblast- Osteocyst- Osteocyst- Osteoclast- Osteoclast- Osteoprogenator- Osteoprogenator

Matrix : - 40% organicMatrix : - 40% organic - 60% inorganic (mineral)- 60% inorganic (mineral)

CORTICAL BONE DETAILCORTICAL BONE DETAIL

BONE REMODELING BONE REMODELING

Osteoblast from new BoneOsteoblast from new Bone

Bone resorbed by Bone resorbed by osteoclasticosteoclastic

Osteoblast becomeOsteoblast becomeincorporate into boneincorporate into bone

as osteocytesas osteocytes

MATRIX MATRIX

Organic ComponentOrganic ComponentCollagenCollagenProteoglycanProteoglycanMatrix proteinMatrix proteinCalcium hydroxyapatiteCalcium hydroxyapatiteCalcium phosphateCalcium phosphate

Bone is formed in two waysBone is formed in two ways

a/. By endochondral ossificationa/. By endochondral ossification

b/. By intra membrane ossification b/. By intra membrane ossification

Growth and Ossification of Long Bones (humerus, midfrontal sections)Growth and Ossification of Long Bones (humerus, midfrontal sections)

Zonal structure and pathologic defects of cellular metabolismZonal structure and pathologic defects of cellular metabolism

INTRA MEMBRANS OSSIFICATIONINTRA MEMBRANS OSSIFICATION

➣➣ Without a cartilage modelWithout a cartilage model➣➣ Undifferentiated mesenchymal Undifferentiated mesenchymal cell aggregate into layer (or membrane)cell aggregate into layer (or membrane)➣➣ This cell differentiated into osteoblastThis cell differentiated into osteoblast and deposit organic matrixand deposit organic matrix➣➣ Examples of intramembranes bone formationExamples of intramembranes bone formation pelvis, clavicula and skullpelvis, clavicula and skull

➣➣ Proliferasi zone is weakest pointProliferasi zone is weakest point

by trauma by trauma epiphysiolysis occur epiphysiolysis occur

➣➣ Classification on radiology divided Classification on radiology divided

in 5 type by Salter Harrisin 5 type by Salter Harris

Salter-Harris Classification of injuriesSalter-Harris Classification of injuries

Distal Femoral Distal Femoral Salter-Harris Salter-Harris III FractureIII Fracture

Distal Femoral Physeal FractureDistal Femoral Physeal Fracture

FRACTURE HEALINGFRACTURE HEALING

Consists several phasesConsists several phases - Phase of Hematom- Phase of Hematom - Phase of Proliferation- Phase of Proliferation - Phase of Callus formation- Phase of Callus formation - Phase of Remodeling - Phase of Remodeling

Fracture HealingFracture Healing

Fracture RepairFracture Repair

Fracture Repair : a). Fractures; b). Union; c). Consolidation; Fracture Repair : a). Fractures; b). Union; c). Consolidation; d). Bone remodelingd). Bone remodeling The fracture must be protected until consolidatedThe fracture must be protected until consolidated

The stages of fracture healing in cortical boneThe stages of fracture healing in cortical bone

DEFINITION FRACTURE – DEFINITION FRACTURE – DISCONTINUITY OF BONEDISCONTINUITY OF BONE

Classification fracture line :Classification fracture line :- Complete- Complete- Incomplete- Incomplete

Incomplete usually happen in childrenIncomplete usually happen in children- Periosteum in children- Periosteum in children- More thickness and strength than adult- More thickness and strength than adult

On radiology On radiology manifestation like manifestation like greenstick fracture, torus fracture, greenstick fracture, torus fracture, hairline fracturehairline fracture

Greenstick Fracture Greenstick Fracture of the radius and ulnaof the radius and ulna

in a childin a child

Buckle Fracture in the metaphysisBuckle Fracture in the metaphysis

Hairline FractureHairline Fracture

Incomplete FracturesIncomplete Fractures

➣➣ In adult fracture line In adult fracture line

complete fracturecomplete fracture

➣➣ Trauma in adult produce fracture lineTrauma in adult produce fracture line

such as transverse, oblique, spiralsuch as transverse, oblique, spiral

comminution or segmentalcomminution or segmental

Transverse FractureTransverse Fracture Oblique FractureOblique Fracture

Spiral Fracture of the femoral shaft

Comminuted FracturesComminuted Fractures

Complete FracturesComplete Fractures

➣➣ Direct or indirectDirect or indirect

➣➣ Low or Height energyLow or Height energy

According of mechanism of injuryAccording of mechanism of injury

A Direct blow causes a transverse fractureA Direct blow causes a transverse fracture

An IndirectAn Indirect : Twisting force causes a spiral fracture : Twisting force causes a spiral fracture

Bone Fragment Displacement :Bone Fragment Displacement :

Apposition : Sifted side way back ward Apposition : Sifted side way back ward or to ward in relation or to ward in relation Alignment : AngulatedAlignment : AngulatedRotational : TwistRotational : TwistLength : - DistractedLength : - Distracted - Contracted- Contracted

Fracture DisplacementsFracture Displacements

Dislocation of the HipDislocation of the Hip

The open-book InjuryThe open-book Injury

Unilateral Injury

Unilateral Unstable FractureUnilateral Unstable Fracture

Fracture Classification : Fracture Classification :

- Closed- Closed

- Open- Open

Closed : - No wound around the fracture areaClosed : - No wound around the fracture area

Open : - Any wound around the fracture area Open : - Any wound around the fracture area

Open Fracture classified by Gustillo Open Fracture classified by Gustillo In 3 grades :In 3 grades :

Grade IGrade I : Wound 1 cm or less clean, fracture line transversal : Wound 1 cm or less clean, fracture line transversal or obliqueor obliqueGrade II : Wound > 1 cm lacerate, fracture line transversalGrade II : Wound > 1 cm lacerate, fracture line transversal short oblique, minimal comminutive short oblique, minimal comminutive Grade III : Extensive soft tissue damage of muscle or skinGrade III : Extensive soft tissue damage of muscle or skin IIIA : Extensive soft tissue damage laceration adequate IIIA : Extensive soft tissue damage laceration adequate bone coverage, segmental fracturebone coverage, segmental fracture IIIB : Extensive soft tissue injury with poriosteal stripingIIIB : Extensive soft tissue injury with poriosteal striping bone expose – associated with invasive comminutivebone expose – associated with invasive comminutive IIIC : Vascular injury requiring repair IIIC : Vascular injury requiring repair

Clinical Diagnosis Clinical Diagnosis

History : History : - Chief complaint- Chief complaint - Pain, Swelling, Breathing - Pain, Swelling, Breathing

- Mechanism- Mechanism - System associated injury- System associated injury - Abdominal- Abdominal - Urology- Urology - Thoraks- Thoraks - Brain- Brain

- GCS- GCS

General SignGeneral Sign :: - Shock, Haemorrhage- Shock, Haemorrhage- Damage brain- Damage brain- Predisposition cause- Predisposition cause

Local Sign :Local Sign :- Look : Swelling, deformity, wound- Look : Swelling, deformity, wound- Feel - Feel : Tenderness, sensation, pulse: Tenderness, sensation, pulse- Move : Abnormal movement - Move : Abnormal movement - Measurement : - apparent length - Measurement : - apparent length

- True length- True length

Investigation :Investigation :LaboratoryLaboratory : :

- Hemoglobin- Hemoglobin- Hematocrit- Hematocrit- Bleeding time- Bleeding time- Clothing time- Clothing time- Thrombocyte - Thrombocyte

RadiologyRadiology : :- Plain photo : - AP / Lateral / Oblique- Plain photo : - AP / Lateral / Oblique

- AP / Outlet / Inlet- AP / Outlet / Inlet - AP / Obutarator / Allow- AP / Obutarator / Allow

- CT-Scan- CT-Scan- MRI- MRI

Polytrauma management should followPolytrauma management should followAdvanced Trauma Life Support (ATLS) Protocol :Advanced Trauma Life Support (ATLS) Protocol :

Primary survey – evaluation Primary survey – evaluation ➣➣ AirwayAirway ➣➣ BreathingBreathing ➣➣ CirculationCirculation

Management Polytrauma need a team :Management Polytrauma need a team :(specially to treat multi trauma involving multi organ) :(specially to treat multi trauma involving multi organ) :

➣➣ Orthopaedic SurgeonOrthopaedic Surgeon➣➣ Digestive SurgeonDigestive Surgeon➣➣ UrologistUrologist➣➣ Neuro SurgeonNeuro Surgeon➣➣ Plastic SurgeonPlastic Surgeon➣➣ Vascular SurgeonVascular Surgeon➣➣ Gynecologist Gynecologist

Principle treatment in closed fracturePrinciple treatment in closed fracture

➣➣ SupportSupport : - Sling: - Sling - 8 type bandage (ransel)- 8 type bandage (ransel) - Crutch - Crutch

➣➣ Immobilization with splint or traction Immobilization with splint or traction (to treat undisplaced fracture, fracture femur)(to treat undisplaced fracture, fracture femur)

➣➣ Closed reposition and immobilization :Closed reposition and immobilization : to treat : - Fracture dislocationto treat : - Fracture dislocation

- Joint dislocation - Joint dislocation

Simple sling for an upper limb injury and Crutches Simple sling for an upper limb injury and Crutches with non-weightbearing on an injured lower limbwith non-weightbearing on an injured lower limb

Immobilization by external splinting (without reduction)Immobilization by external splinting (without reduction)Plaster-of-Paris casts of varying designPlaster-of-Paris casts of varying design

Closed reduction of a fracture by manipulationClosed reduction of a fracture by manipulation

Indication open reduction Indication open reduction and internal fixationand internal fixation

1). Fracture cannot reduce 1). Fracture cannot reduce

2). Unstable fracture2). Unstable fracture

3). Fractures can not unite 3). Fractures can not unite

(column femur)(column femur)

4). Pathology fracture4). Pathology fracture

5). Multiple fracture5). Multiple fracture

Fractures that are bestFractures that are besttreated by open reductiontreated by open reduction

and internal fixationand internal fixation

Metallic devices usedMetallic devices usedfor internal fixationfor internal fixation

of fractureof fracture

Management Open FractureManagement Open Fracture immediately after accident (golden period)immediately after accident (golden period)

Debridement :Debridement :- Wound cleaning by irrigation- Wound cleaning by irrigation- Surgery : excite the dirty soft tissue - Surgery : excite the dirty soft tissue

and remove the necrotic tissueand remove the necrotic tissue

The GoalThe Goal of treatment of an open fracture are of treatment of an open fracture are prevention of infection, healing of the fracture prevention of infection, healing of the fracture and restoration of the function in the extremity and restoration of the function in the extremity

Grade I – II after debridementGrade I – II after debridement the bone can be fixed by internal fixationthe bone can be fixed by internal fixation

Grade III after debridementGrade III after debridement the bone can be fixed by external fixationthe bone can be fixed by external fixation ( - Monolateral external fixation( - Monolateral external fixation - Circular external fixation- Circular external fixation - Quadrilateral external fixation) - Quadrilateral external fixation)

➣➣ Soft tissue closed may carried out immediately Soft tissue closed may carried out immediately with skin graft or flap (primary repair)with skin graft or flap (primary repair) if impossible to close the soft tissue if impossible to close the soft tissue should be performed by delayed repairshould be performed by delayed repair

The reach a maximal function The reach a maximal function

it needs Rehabilitation it needs Rehabilitation

either active or passiveeither active or passive