1. Trauma & Orthopaedic Surgery
for the Intercollegiate MRCS
Edward Gardner
SpR Trauma and Orthopaedics
1

2. What is the structure of bone?
2

3. Microscopy
• Cortical bone
– also “compact” and
“lamellar” bone
• Cancellous bone
– spongy bone, woven
bone.
3

4. Bone Cells
• Osteoblasts
make bone
• Osteoclasts
multinucleated giant cells, resorb bone
• Osteocytes
are osteoblasts in bone
4

5. Blood supply
• Blood vessels-
nutrient artery
• Endosteal
• Periosteal
• Venous drainage
5

6. 6

7. How do fractures heal?
7

8. Healing cascade: indirect healing
• Inflammation 0 – 5 days
– Haematoma
– Necrotic material
– Phagocytosis
• Repair: 5 – 42 days
– Granulation tissue
– Acid environment
– Periosteum – osteogenic cells
– Cortical osteoclasis
• Remodelling
– years
8

9. How do you treat a fracture?
9

10. TREATING A FRACTURE
• Reduce
• Hold
• Rehabilitate
10

11. TREATING A FRACTURE
• Reduce
– Open
– Closed
11

12. TREATING THE FRACTURE
• Hold
• Operative / Non Operative
• Internal / External
• Intra / Extra medullary
12

13. TREATING THE FRACTURE
• Rehabilitate
• Physio
13

14. FACTORS AFFECTING
FRACTURE HEALING
• Injury Factors
– Energy
– Associated injuries
• Bone factors
– Reduction, fixation
– Blood Supply (scaphoid, talus, femoral and humeral head)
– Infection
• Patient factors
– Smoking
– Diabetes
14

15. ATLS
A - Airway and cervical spine immobilisation
B - Breathing
C - Circulation
D - Disability
E - Exposure
15

16. Pelvis Fracture and Ex-Fix
16

17. Soft Tissue Injuries
Open
I Clean, <1cm
Simple #
II Clean, >1cm
Simple #
III Extensive
High energy #
17
Gustilo & Anderson, 1976

18. Soft Tissue Injuries
Open
I Clean, <1cm
Simple #
II Clean, >1cm
Simple #
III Extensive
High energy #
18
Gustilo & Anderson, 1976

19. Soft Tissue Injuries
Open
I Clean, <1cm
Simple #
II Clean, >1cm
Simple #
III Extensive
High energy #
19
Gustilo & Anderson, 1976

20. Soft Tissue Injuries
Open
IIIa Soft tissue cover
IIIb Soft tissue loss
periosteal strip
IIIc Vascular injury
-repair
20
Gustilo, Mendoza & Williams, 1984

21. Soft Tissue Injuries
Open
IIIa Soft tissue cover
IIIb No soft tissue cover
IIIc Vascular injury
-repair
21
Gustilo, Mendoza & Williams, 1984

22. Soft Tissue Injuries
Open
IIIa Soft tissue cover
IIIb Soft tissue loss
periosteal strip
IIIc Vascular injury
-repair
22
Gustilo, Mendoza & Williams, 1984

23. Diagnosis
• Clinical assessment
– History - Co-morbidities
– Exposure/systematic examination
• “First-aid” reduction
• Splintage and analgesia
• Radiographs
– Two planes including joints above and below area of
injury
23

24. Describe the Fracture
• Anatomical site
• Configuration Displacement
– angulation
– translation
– shortening
• Articular involvement/epiphyseal injuries
– fracture involving joint
– dislocation
– ligamentous avulsion
• Soft tissue injury
24

25. 25

26. 26

27. 27

28. What are the complications of
fractures?
28

29. Complications of Fractures
Early Late
General Other injuries Chest infection
PE UTI
FES/ARDS Bed sores
Bone Infection Non-union
Malunion
AVN
Soft-tissues Plaster sores/WI Tendon rupture
N/V injury Nerve compression
Compartment syn. Volkmann contracture
29

30. What is the definition of
compartment syndrome?
30

31. Compartment Syndrome
Increased Pressure
in a
closed tissue compartment
resulting in
local ischaemia
31

32. Pain & spasm
Tissue Compartment
Muscle swelling pressure
Ischaemia
Ischaemia
Venous
Arteriolar
Nerve
stasis
stasis
Paraesthesia 32

33. Fasciotomy
33

34. 34

35. How do you classify hip
fractures?
35

36. Fracture types
• Intracapsular
Femoral neck
• Extracapsular
Intertrochanteric
• Subtrochanteric
Below lesser troch
36

37. Gardens Classification
INTRACAPSULAR
FRACTURES
Undisplaced
Displaced
37

38. 38

39. 39

40. 40

41. Shoulder Dislocations
41

42. What is carpal tunnel
syndrome?
42

43. Carpal Tunnel Syndrome
The entrapment of the median nerve at the
fibro osseous tunnel of the carpus
43

44. CTS signs
• wasting of thener
eminence
• numbness
• weakness
• Tinel sign
• Phalen sign
44

45. CTS Treatment
• non operative
– Splint
– Steroid injection?
• surgical
decompression
– open
45

46. What is trigger finger?
46

47. Trigger Finger
Stenosing tenovaginosis of the
flexor tendon sheath (A1 pulley)
47

48. What is Dupuytren’s Disease
48

49. Dupuytren’s Contracture
nodular hypertrophy
and contracture
of the palmar fascia
49

50. What is the pathology of
rheumatoid arthritis?
50

51. Rheumatoid Arthritis
Synovitis

chronic infltrates, synovial hypertrophy, effusion
Destruction

proteolytic enzymes, pannus
Deformity

articular destruction, capsular stretching, tendon
rupture
51

52. Rheumatoid Arthritis
early joint changes
52

53. Rheumatoid Arthritis
Late Symptoms
joint destruction

pain

deformity

instability

53

54. Rheumatoid Arthritis
advanced joint changes
54

55. 55

56. 56

57. What is osteoarthritis?
57

58. Osteoarthritis
A chronic joint disorder in which there is
progressive softening and disintegration of
articular cartilage accompanied by new
growth of cartilage and bone at the joint
margins (osteophytes) and capsular
fibrosis
58

59. Osteoarthritis classification
Primary or idiopathic

Secondary - infection

- dysplasia
- Perthes’
- SUFE
- trauma
- AVN
59

60. 60

61. Osteoarthritis X-ray changes
61

62. What is the treatment of
osteoarthritis?
62

63. Non-surgical treatment
analgesia

altered activity

walking aids

physiotherapy

63

64. 64

65. 65

66. Joint Replacement
Hip Complications
dislocation - 1%

loosening >90% 10y survival

DVT / PE

infection - 1%

Death

66

67. Joint Replacement
Knee complications
limited ROM

patellar instability 3-5%

loosening > 90% 10y survival

DVT / PE

infection - 2%

67

68. What are the common bone
tumours?
68

69. Metastatic bone tumours
• Breast
• Brostate
• Bung
• Bhyroid
• Bidney
• Multiple Myeloma
69

70. Hot topics
• # NOF
• OA
• CTS
• Principles of # management
• ATLS
• Open #
70