Transcript The injured Limb - Shoulder and Elbow

Dr John Trantalis
How To Examine a Joint

Look
 Scars, alignment, wasting, redness, swelling

Feel
 Tenderness (Location!!!!!)

Move
 Active movement
 Passive movement
Passive vs Active Motion

ACTIVE MOTION

 The examiner moves
 Patient moves the
the joint for the
patient
joint on their own

For active motion
to be intact:
 The joint must be
mobile.
 The “motor” must
be working
PASSIVE MOTION

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
PASSIVE vs ACTIVE motion
Loss of active Motion
Preserved Passive Motion
Loss of both Active and
Passive Motion
Joint OK
Motor is broken
Joint Stiffness
8 yo girl
 Fall from monkey bars
 Off-ended # distal humerus

Pale hand
Pulseless
Pre-post operative assessment
after an elbow injury

Arteries

Compartment
syndrome

Nerve Damage

Skin etc.
Pulseless Fractured Limb
Management: Why?
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
Prevent This !!
25yo, cast applied yesterday after
fracture radius : now severe pain

Xray OK position

Unable to move
fingers

Sensation and pulses
intact
Compartment syndrome

Only clue is PAIN
 Pulses normal
 Cap Refill normal

Unable to move
fingers

When you move
them for the patient
 Severe PAIN !!!!
Compartment syndrome

Broken arm: should
still be able to move
fingers

6 hours to save the
arm

Otherwise:
amputation
Missed Forearm compartment
syndrome: useless arm
Compartment Syndrome
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
Therefore….

Only need one thing to diagnose
compartment syndrome…..
PAIN
How can we differentiate normal fracture
pain from Compartment Syndrome?

Active Finger (or Toe) Movement
 No compartment syndrome
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
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
Clinical case

56 yo male, 24 hour h/o
right knee pain
 No trauma
 Can’t walk
 Otherwise well
Exam: temp 37.0C
 Swollen Knee (patella tap)
 No redness
 Markedly reduced ROM
active and passive


Provisional Diagnosis?
 Septic Arthritis

Differential Diagnosis?
 Gout
 Pseudogout
 Haemarthosis
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.
The Work-Up

Bloods:
 FBC, EUC, CRP, ESR, UA,
Cultures

ECG, MSU, fast NBM

XRAY
 Usually normal

Joint Aspirate
Inflammatory Markers

CRP
 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.
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.
Septic Arthritis: Treatment

Joint Washout (arthroscopic)
 Removes the enzymes from white cells
which otherwise destroy the articular
cartilage

IV antibiotics
 Empirical: cover Staph Aureus
Risk Factors:
Elderly, Female, Osteoporosis
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
Presentation

Fall
Can’t walk
Pain in Groin

Exam: Leg


 Shortened
 Externally rotated
The Work-up

Xrays
 Pelvis and hip

Pre-op
 FBC. EUC, G&H
 ECG
 CXR
 Fast Patient
 Analgesia, Fluids,
Pressure care, IDC
XRAYS
Subcapital Fracture
Trochanteric Fracture
Hip Anatomy

Acetabulum

Femoral head

Neck of femur

Trochanters
2 common types of Hip
Fractures

Subcapital fracture

Intertrochanteric or
Pertrochanteric
fractures

We Treat these
differently
Why treat these fractures
differently?

Blood Supply to the head of
femur
 Disrupted with a Displaced
Subcapital Fracture
 Intact with a displaced
trochanteric fracture
Hip Joint Capsule

The blood vessels
run up through the
capsule

Hence the terms:
 Intracapsular #
(subcapital)
 Extracapsular #
(trochanteric)
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
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.
Subcapital Fractures: 2 types

Non-Displaced
 Screws

Displaced
 Hip replacement
○ Half (hemiarthroplasty)
○ Total Hip Replacement
Non Displaced Subcapital
Fractures

Blood supply not
likely to be affected

Fix with screws and
hope that it heals
Displaced Subcapital
Fracture

Blood supply is disrupted
to femoral head
Hemiarthroplasty
 # won’t heal
 Avascular Necrosis likely

Therefore: replace the
head
 Half replacement
(hemiarthroplasty)
 Total Hip Replacement for the
more mobile patients
Total Hip Replacement
Intertrochanteric Fractures
• Internally Fixed to allow early
weight bearing
• Plate
• Nail
Intertroch #
Dynamic Hip
Screw
Short femoral
Nail
Post-Op Care






NV Obs
Analgesia
DVT prophylaxis
Bloods
Mobilise FWB
Pressure area care
Dr John Trantalis
Orthopaedic Surgeon
Dislocated Joints

Should all be reduced ASAP
 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
43 yo F soccer player
 Painful swollen leg after tackle.

?Management
Why?
Managing The Injured Limb in ED
Managing The Injured Limb in ED
Managing the Injured Limb in ED

Analgesia /
Sedation

Reduce the
deformity, splint the
limb

Backslabs onlyNEVER apply a full
POP in ED.
Managing the Injured Limb in ED

Dress the wounds

THEN… get Xrays.
Tet tox, IV antib,
Fast patient
 Pre-op work-up.

How do we reduce the deformity?

It’s very complicated……..
JUST PULL!!
How to describe a
fracture
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?
-
Principles of fractures and joint injuries
How fractures are displaced
Principles of fractures and joint injuries
Direct healing - If
fracture absolutely
immobile, eg. Fixed with
metal fracture healing
occurs directly between
fragments.
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
Clinical signs of fracture Union

No tenderness, movement or crepitus
at a fracture site.
The injured limb –
Clinical features
Clinical Features
If you remember nothing else about
examining a limb…
 LOOK
 FEEL
 MOVE
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?
Clinical Features
 Feel
 Tenderness
 Swelling
 Crepitus
 Vascular and neurological
examination before and after
treatment
Clinical Features
 Move
 Active and passive movement distal to
the injury
 Absolutely critical
 Know your anatomy
The injured limb Imaging
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 #
Beware Ipsilateral injuries
For any # or dislocation
- always image to joint above and below
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)
The injured limb –
Management principles
Treatment of Closed
Fractures

Reduction
 Putting the bone into an acceptable position
 Two methods – open or closed
Treatment of closed
fractures
 Closed
reduction
 Sedation / Anaesthesia
 Pull the limb into alignment
 Splint the limb
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
Treatment of closed
fractures
 Open
reduction
○ Articular fractures – want anatomical
reduction
○ Need bone to heal in perfect position;
eg. Adult forearm shaft fractures
Fracture Immobilisation

Following reduction, the available
methods of holding are…
1) cast splintage
2) Internal Fixation (plates, screws, nails)
3) external fixation
4) Traction
Fracture Immobilisation

Continuous traction
 Can be applied by
○ Gravity, eg. Hanging cast
○ Skin
○ Skeletal, ie. Via pin inserted into bone
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
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
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”
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
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
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.
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%
Complications of fractures
Types of Non Union
Hypertrophic
Atrophic
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
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
Common Upper Limb
Injuries
Common Fractures and Joint injuries
Clavicle Fractures
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.
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!!
Common Lower Limb
Injuries
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
Common Fractures and Joint injuries
Common fractures around the knee
Supracondylar
femur fracture
Patella fracture
Tibial plateau fracture
Common Fractures and Joint injuries
Common foot/ankle fractures
Simple ankle fracture
Calcaneus fracture
Complex “Pilon” fracture
Neck of talus fracture
“Jones” fracture
“Lisfranc”
fracture/dislocation
Common Paediatric
Injuries
Common Fractures and Joint injuries
Common Paediatric Upper Limb Fractures
Supracondylar humerus
Monteggia #/dislocation
Galeazzi #/dislocation
Lateral condyle fracture
Fat pad sign
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