HTHSCI 2F03 Lecture Notes - Lecture 14: Hydroxylapatite, Clavulanic Acid, Hip Fracture

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26 Dec 2020

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Orthopaedics

Contents

Bone and Fracture Physiology .................................................................................................................................................. 110

Fracture Classification ............................................................................................................................................................... 110

Fracture Management: 4Rs ....................................................................................................................................................... 111

Fracture Complications ............................................................................................................................................................. 112

Hip Fracture ............................................................................................................................................................................... 114

Distal Forearm Fractures ........................................................................................................................................................... 115

Scaphoid Fractures ................................................................................................................................................................... 115

Radial and Ulna Shaft Fractures ............................................................................................................................................... 115

The Shoulder ............................................................................................................................................................................. 116

Supracondylar Fractures of the Humerus ................................................................................................................................. 117

Femoral and Tibial Fractures .................................................................................................................................................... 118

Ankle Injuries ............................................................................................................................................................................. 118

Knee Injuries .............................................................................................................................................................................. 119

Osteoarthritis ............................................................................................................................................................................. 120

Back Pain .................................................................................................................................................................................. 121

Osteochondritis .......................................................................................................................................................................... 122

Traction Apophysitis .................................................................................................................................................................. 122

Osteochondritis Dissecans ........................................................................................................................................................ 122

Avascular Necrosis .................................................................................................................................................................... 122

The Limping Child ...................................................................................................................................................................... 123

Acute Osteomyelitis ................................................................................................................................................................... 124

Septic Arthritis ........................................................................................................................................................................... 124

Bone Tumours ........................................................................................................................................................................... 125

Brachial Plexus Injuries ............................................................................................................................................................. 127

Other Nerve Injuries .................................................................................................................................................................. 127

Carpal Tunnel Syndrome .......................................................................................................................................................... 128

Minor Hand Conditions .............................................................................................................................................................. 129

Minor Leg and Foot Conditions ................................................................................................................................................. 130

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Bone and Fracture Physiology

Composition

Cells: osteoblasts, osteoclasts, osteocytes, OPCs

Matrix

 Organic = osteoid (40%)

 Collagen Type I

 Resists tension, twisting and bending

 Inorganic (60%)

 Calcium hydroxyapatite

 Resists compressive forces

Classification

Woven Bone

 Disorganised bone that forms the embryonic skeleton

and fracture callus.

Lamellar Bone

 Mature bone that can be of two types:

 Cortical/compact: dense outer layer

 Cancellous/trabecular: porous central layer

Formation

Intramembranous Ossification

 Direct ossification of mesenchymal bone models

formed during embryonic development.

 Skull bones, mandible and clavicle.

Endochondral Ossification

 Mesenchyme → cartilage → bone

 Most bones ossify this way

Fracture Healing

Reactive Phase (injury – 48hrs)

1. Bleeding into # site → haematoma

2. Inflammation → cytokine, GF and vasoactive

mediator release → recruitment of leukos and

fibroblasts → granulation tissue

Reparative Phase (2 days – 2 wks)

3. Proliferation of osteoblasts and fibroblasts →

cartilage and woven bone production → callus

formation.

4. Consolidation (endochondral ossification) of woven

bone → lamellar bone

Remodelling Phase (1wk – 7yrs)

5. Remodelling of lamellar bone to cope c

¯ mechanical

forces applied to it (Wolff’s Law: “form follows

function”)

Healing Time

 Closed, paediatric, metaphyseal, upper limb: 3wks

 “Complicating factor” doubles healing time

 Adult

 Lower limb

 Diaphyseal

 Open

Fracture Classification

Classification

 Traumatic #

 Direct: e.g. assault c

¯ metal bar

 Indirect: e.g. FOOSH → clavicle #

 Avulsion

 Stress #

 Bone fatigue due to repetitive strain

 E.g. foot #s in marathon runners

 Pathological #

 Normal forces but diseased bone

 Local: tumours

 General: osteoporosis, Cushing’s, Paget’s

Describing a fracture: PAID

 Radiographs must be orthogonal: request AP and lat. films.

 Need images of joint above and joint below #.

1. Demographics

 Pt. details

 Date radiograph taken

 Orientation and content of image

2. Pattern

 Transverse

 Oblique

 Spiral

 Multifragmentary

 Crush

 Greenstick

 Avulsion

3. Anatomical Location

4. Intra- / extra-articular

 Dislocation or subluxation

5. Deformity (distal relative to proximal)

 Translation

 Angulation or tilt

 Rotation

 Impaction (→shortening)

6. Soft Tissues

 Open or closed

 Neurovascular status

 Compartment syndrome

7. ? Specific # classification/type

 Salter-Harris

 Garden

 Colles’, Smith’s, Galeazzi, Monteggia

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Fracture Management: 4Rs

1: Resuscitation

Principles

 Follow ATLS guidelines

 Trauma series in 1O survey: C-spine, chest and pelvis

 # usually assessed in 2O survey

 Assess neurovascular status and look for dislocations

 Consider reduction and splinting before imaging

 ↓ pain

 ↓ bleeding

 ↓ risk of neurovascular injury

 X-ray once stable

Open fractures require urgent attention: 6As

 Analgesia: M+M

 Assess: NV status, soft tissues, photograph

 Antisepsis: wound swab, copious irrigation, cover with

betadine-soaked dressing.

 Alignment: align # and splint

 Anti-tetanus: check status (booster lasts 10yrs)

 Abx

 Fluclox 500mg IV/IM + benpen 600mg IV/IM

 Or, augmentin 1.2g IV

Mx: debridement and fixation in theatre

Gustillo Classification of Open #s

1. Wound <1cm in length

2. Wound ≥1cm c

¯ minimal soft tissue damage

3. Extensive soft tissue damage

Clostridium perfringes

 Most dangerous complication of open #

 Wound infections and gas gangrene

 ± shock and renal failure

 Rx: debride, benpen + clindamycin

2: Reduction

Principles

 Displaced #s should be reduced

 Unless no effect on outcome, e.g. ribs

 Aim for anatomical reduction (esp. if articular surfaces

involved)

 Alignment is more important than opposition

Methods

 Manipulation / Closed reduction

 Under local, regional or general anaesthetic

 Traction to disimpact

 Manipulation to align

 Traction

 Not typically used now.

 Employed to overcome contraction of large

muscles: e.g. femoral #s

 Skeletal traction vs. skin traction

 Open reduction (and internal fixation)

 Accurate reduction vs. risks of surgery

 Intra-articular #s

 Open #s

 2 #s in 1 limb

 Failed conservative Rx

 Bilat identical #s

3: Restriction

Principles

 Interfragmentary strain hypothesis dictates that tissue

formed @ # site depends on strain it experiences.

 Fixation → ↓ strain → bone formation

 Fixation also → ↓ pain, ↑ stability, ↑ ability to function.

Methods

 Non-rigid

 Slings

 Elastic supports

 Plaster

 POP

 In first 24-48h use back-slab or split cast due to

risk of compartment syndrome

 Functional bracing

 Joints free to move but bone shafts supported in

cast segments.

 Continuous traction

 e.g. collar-and-cuff

 Ex-Fix

 Fragments held in position by pins/wires which

are then connected to an external frame.

 Intervention is away from field of injury.

 Useful in open #s, burns, tissue loss to allow

wound access and ↓ infection risk.

 Risk of pin-site infections

 Internal fixation

 Pins, plates, screws, IM nails

 Usually perfect anatomical alignment

 ↑ stability

 Aid early mobilisation

4: Rehabilitation

Principles

 Immobility → ↓ muscle and bone mass, joint stiffness

 Need to maximise mobility of uninjured limbs

 Quick return to function ↓s later morbidity

Methods

 Physiotherapy: exercises to improve mobility

 OT: splints, mobility aids, home modification

 Social services: meals on wheels, home help

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Document Summary

Disorganised bone that forms the embryonic skeleton and fracture callus. Mature bone that can be of two types: Direct ossification of mesenchymal bone models formed during embryonic development. Reactive phase (injury 48hrs: bleeding into # site haematoma, inflammation cytokine, gf and vasoactive mediator release recruitment of leukos and fibroblasts granulation tissue. Reparative phase (2 days 2 wks: proliferation of osteoblasts and fibroblasts cartilage and woven bone production callus formation. Radiographs must be orthogonal: request ap and lat. films. Need images of joint above and joint below #: demographics. Orientation and content of image: pattern. Avulsion: anatomical location, intra- / extra-articular. Dislocation or subluxation: deformity (distal relative to proximal) Colles", smith"s, galeazzi, monteggia: consolidation (endochondral ossification) of woven bone lamellar bone. Remodelling phase (1wk 7yrs: remodelling of lamellar bone to cope c mechanical forces applied to it (wolff"s law: form follows function ) Trauma series in 1o survey: c-spine, chest and pelvis. Assess neurovascular status and look for dislocations.

HTHSCI 2F03 Lecture Notes - Lecture 14: Hydroxylapatite, Clavulanic Acid, Hip Fracture

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