The injured Limb - Shoulder and Elbow

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 Cant 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. Patients 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 Cant 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 1970s

3 months Traction for everybody 50% mortality Pneumonia, pressure sores etc The Surgery Relieves Pain Patient with # NOF in bedThe 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 # wont 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 (DHS) 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? Its 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 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 2s!!! 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 Cant 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 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 Dont forget xray rule of 2s Eg. Posterior dislocation If unsure on AP and lateral views, then demand an axillary view!!! Dont forget to check axillary n.

Common Fractures and Joint injuries Distal radius fractures not all are Colles fractures!! Colles = low energy osteoporotic fracture Smiths = 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

Complex Pilon fracture Calcaneus 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

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