INTRODUCTION1741 –Nicolas Andry, french professor

publish a book – Orthopaedia or the art of Preventing and Correcting Deformities in Children.

Orthos – straight or free from deformitiesPais – childHe expressed the view that most deformities

in adults have their origin in children.

ORTHOPEDIC SURGERYIs the art and science of the prevention,

investigation, diagnosis, treatment and restoration of disorders and injuries of the musculoskeletal system by medical, surgical and physical means.

Musculoskeletal system – includes Bones,Cartilage, tendons, ligaments, joints and muscles.

BONESMain division – axial & appendicularMain Bone Types – long bones , short bones,

flat bones, irrgular bonesStructure – long bones - diaphysis,

metaphysis, epiphysis, epihyseal plate, periosteum

Blood supply – nutrient artery, periosteal vessels, metaphyseal and epiphyseal vessels

BIOCHEMICAL COMPOSITION OF BONEOrganic substances – 35% - bone cells –

osteoblast, osteoclast, osteocytes, collagenInorganic substance – 45% - calcium,

phosphorus, magnesium, sodium, hydroxyl, carbonate and flouride.

Water – 20%

Bone TypesCortical or compact bones - diaphyseal areaCancellous bones – metaphyseal and

epiphyseal.

Cartilage, Ligaments, Tendon Types – Fibrocartilage – intervertebral discs

and symphysis pubisElastic cartilage – external ear and noseHyaline cartilage – most jointsLIGAMENTSFibrous tissue primary connection between

bonesTendons – connect muscle to bones

MUSCLESkeletal muscle contracts to controls persons

posture, help maintain body temperatue and initiate movement,

Muscle ContractionsIsotonic – shorten muscle, movementIsometric – tighten , no movementOthers – twitch, tetanus, fasciculation,

fibrillation and convulsion

JOINTS1. Fibrous – sutures2. Cartilagenous – pubic bone3. Synovial –a. ball & socket, hinge, gliding pivot,

saddleJoint Motion – ReviewFlexion / extensionAbduction / adductionRotation – external / internalPronation / SupinationInversion / EversionProtraction / RetractionCircumduction

MUSCULOSKELETAL DISORDERS1. TRAUMA – FRACTURES2. CONGENITAL ANOMALIES3. INFECTIONS – OSTEOMYLITIS4. TUMORS5. ARTHRITIDIS – A. RHEUMATOID ARTHRITIS B. OSTEOARTHRITIS OR

DEGENERATIVE JOINT DISEASE C. METABOLIC – GOUTHY ARTHRITIS

FRACTURESIs a break in the continuity of the bone.Classification:According to side affected1. Complete Fracture – pereosteum and

cortical bone severed on both side2. Incomplete – one side is broken

CAUSES OF FRACTURES1. Direct force or crushing force2. Twisting forces torsion3. powerful muscle contraction4. Fatigue and stress fractures5. Pathologic

Classifications1. Broad classification - a. Closed or simple – no communication

with the outside b. Open or Compound – with

communication with the outside2 as to patternA. Transverse , oblique. Spiral3. as to appearance comminuted, impacted, compression,

depressed, longitudinal4. as to location – proximal, middle, distal

SIGN S & SYMPTOMS1. PAIN2. TENDERNESS3. SWELLING4. LOSS OF FUNCTION5. DEFORMITY6. DISCOLORATION7. CREPITUS8. BLEEDING FROM AN OPEN WOUND

Complication of Fracture 1. Immediate complications A. loss of bone fragments B. soft tissue injury – blood vessel and muscle C. bleeding D. infection 2. Away from the fracture A. pulmunary embolism B. fat embolism C. gas ganrene D. tetanus 3. On the bone itself a. avascular necrosis b. delayed union c. malunion d. non-union

PRINCIPLES OF TREATMENT 1. REDUCTION OR REALIGNEMENT OF

BONE FRAGMENT2. MAINTENANCE OF REDUCTION BY

IMMOBILIZATION3. RESTORATION OF FUNCTION

REDUCTION IS ACCOMPLISH BY:1. Closed manipulation2. Traction3, Internal fixation4. External fixation

MANIPULATIONIs done by pulling on the distal part of

fracture ends with anesthesia.Types of Anesthesia1. Vocal2. Local3. Regional4. General

MANIPULATIONCommonly done on Acute Fractures1. Closed, incomplete or complete, Fractures2. Fractures in children3. Fractures of phalanges4. Fractures without displacement

MAINTENANCE OF REDUCTION(IMMOBILIZATION)1. APPLICATION OF PLASTER CAST – is a

temporary immobilization device which is made up of gypsum sulfate anhydrous by calcination when mixed with water.

Materials in applying castPlaster of Paris (POP)Wadding sheet, stockinet, elastic bandageOther substitute – fiberglass, thermoplast

Complication of Casting1. Neurovascular compromise2. incorrect fracture alignment3. blister formation4. allergy5. swelling or edema6. blister formation

Plaster cast for upper extremity1. short arm circular cast – for wrist &

fingers2. long arm circular cast – for affection of

radius / ulna / distal humerus3. munster cast for radius/ulna with callus4. long arm posterior cast radius/ulna/

humerus5. sugar tong cast - humerus6. abduction splint –airplane splint –

proximal humerus

Casting for Lower Extremity1. Boot cast / short leg cast – for ankles

and toes2. walking cast – for ankle with callus 3. PTB-patellar tendon bearing cast – for

shaft of tibia/fibula with callus4. long leg cast – for frscture tibia/fibula5. Ischial weight bearung cast – fracture

of fmur with callus6. cylindrical cast – for fracture patella7. short leg posterior mold8. long leg posterior mold

Other Casting 1. Spica cast – shoulder spica single or

double. Hip spica single, double, one & one half

2. Collar cast – for cervical spine3. Minerva cast – upper cervical, scoliosis

potts disease4. Body cast – for lower thoracic & lumbar

spine5. Pantalon cast – pelvic injury6. Frog cast for congenital hip dislocation

TRACTIONIs the act of pulling or drawing which is

associated with counter traction Means apulling force is pllied to a part of the

body or an extremity while a countertraction pulls in the opposite direction.

Types of Traction1. Skin2. skeletal

Traction – purpose1. to lessen muscle spasm2. to redcuce fracture3. to provide immobilization4. to maintain alignmentPrincipleA. have an opposite pull or countertractionB. be free from frictionC. follow and established line of pull that is line

of pull must in line with the deformityD. be continuous tractionE. be applied to a patient in a supine position

SKIN TRACTION1. Bryant traction – fractures of femur, hip

dislocation for children below 3 years old2. bucks traction – for femur and hip3. Russels – femur4. Dunlop – supracondylar humerus5. Pelvic traction – lumbar spine6. Hammocks suspension traction - pelvic

SKELETAL TRACTIONInsertion of a steinman pin, kirstcher wire,

crutchfield tong or similar devices into the bone, enabling direct, longitudinal pull be applied directly to the bone.

Equipments : Thomas splint, pearsons attachment, pulley, cord, wire holder, balkan frame

Skeletal TractionHalo-femoral, halo-pelvic – for severe

scoliosisCrutchfield tong – cervical fractureCOMPLICATIONS:1. Vascular and nerve injury2. pin tract infection3. over traction4. muscle atropy

INTERNAL FIXATIONIs accomplish by doing surgical operation on

the fracture by directly reducing the fractured bone fragment and immobilize by applying metal implants.

a. screwing, pinning and nailingb. Plating with screw fixationc. Replacement of prosthesis

III. RehabilitationRestoration of function – by:a. Occupational Therapyb. Physical therapy Aim 1. for relief of pain 2. for increase circulation 3. for correction and prevention of

disabilties 4. for maximun return of strength,

mobility, coordination 5. teach patient whatever capacities he

possesses to fully realize his potentialities for living

CONGENITAL DEFORMITIESETIOLOGY1. Genetic Influences2. Intrauterine environmental influences3. combine genetic and environmental

influencesGeneticChromosomes anomalies- 0.5% of live

birth. Variations in chromosome number or structure. – ex. Down syndrome

Single Gene disorders – mutation, sex linked inhiretance – 10 %

Intrauterine Environmental InfluencesHeavy irradiation, thalidomide, rubella,

androgenic hormones.Deficient diets, x-rays, hypothermia, hypoxia,

virus infectionSmoking, diabeticsTreatment:1. Improved prenatal care2. should be started early

Congenital Anomalies1. Congenital Hip Dislocation2. Clubfoot3. torticollis4. Congenital abnormalities of finger and toes

– Syndactyly, Macrodactly, Polydactyly. Cleft hand, cleft foot

CONGENITAL HIP DISLOCATIONIncidence – 1-2/1000 births, 5x in boysFrequent in breech delivery Unilateral dislocation is frequentEtiology:Exact cause is unknownBoth genetic and environmentMore in twins, first bornPostnatal – common in northern Italy,

Navajo Indians, Japanese

CHD – PathologyVary with ageAt birth – capsule is lax. Elongated

ligamentum teres. Increase anteversion of the neck femur

If untreated – acetabulum is shallow and sloping, femoral head displaced upward and backward, increase anteversion of the neck, a shallow secondary acetabulum develop

CHD – Clinical FeaturesVary with age Neonatal – birth to 1 month – can be

determine by doing the following test:1. Ortolanis Test - positive – hip abducted,

pressure on the greater throchanter will cause the dislocated hip to click back.

2. Barlows Test - positive – hip adducted, pressure on the medial thigh will cause the unstable hip to click out.

CHD – Clinical Features3. Abduction test – 4. Knee level test5. Trendelenburg test negative test – child bears weight on the

normal hip, the opposite side of the pelvis is elevated, to maintain balance

positve test- child bears weight on the dislocated hip, the opposite side of the pelvis cannot be elevated

Other symptomsDuck waddling gaitScoliotic Lordotic

TREATMENTManipulation or tractionMaintain by applying frog leg casting

Talipes Equinovarus( Congenital Clubfoot)Cause is unknown1.Arrested or anomalous development of the

foot of the embryo in the first trimester2. 3rd month of uterine life – inward rotation

of the foot takes place but on the 7th month should have been outward

3. abnormalities in the maturity and lenght of muscles and tendons

CLUBFOOTIncidence- 1/1000 live birth2x in boys50% unilateral, 50% bilateralPATHOLOGYAt the talocalcaneonavicular joint1. navicular bone is displaced medially2. subtalar surface are tilted into varus

and equinus and medially3. achilles tendon is shortened

TREATMENTStart at early age as soon as possibleAt one day oldDifficulty in treatment Serial casting – application of cast every

two to three weeks – long leg circular cast.Up to two to three monthsMaintenance of correction is done by:A. dennis brown shoesB. dennis brown splint

METHODS OF CORRECTION

Correct deformity one by oneA. InversionB. VarusC. EquinusIf corrected at the same time will lead to Rocker bottom foot.

TREATMENTLate cases1. Soft tissue release a. tendon lengthening3. Osteotomy – a. triple arthrodesis