Principles of Orthopaedics

Mr Suheal A KhanSenior Orthopaedic Consultant &

Visiting Professor KTPH

Singapore

Orthopaedic Elective Orthopaedic Elective ProceduresProcedures

OsteotomyArthrodesisArthroplasty:

ExcisionInterposition

Amputation

Orthopaedic Trauma ProceduresOrthopaedic Trauma Procedures

ConservativeOperative: Nail

PlateExternal Fixator:

MonolateralMultiplaner

Amputation

1. Protective1. Protective

2. Locomotion2. Locomotion

3. Muscle attachments3. Muscle attachments

4. Metabolic4. Metabolic

5. Haematopoetic5. Haematopoetic

1. Protective1. Protective

2. Locomotion2. Locomotion

3. Muscle attachments3. Muscle attachments

4. Metabolic4. Metabolic

5. Haematopoetic5. Haematopoetic

Functions of the SkeletonFunctions of the Skeleton

What is Bone?What is Bone?What is Bone?What is Bone?• A protein scaffold (collagen) or A protein scaffold (collagen) or Osteoid (35%)Osteoid (35%)• Impregnated with Calcium Salts to Impregnated with Calcium Salts to give it give it stiffness stiffness (65%)(65%)• ‘‘Impregnated’ with ‘latent’ Growths Impregnated’ with ‘latent’ Growths factorsfactors

• A protein scaffold (collagen) or A protein scaffold (collagen) or Osteoid (35%)Osteoid (35%)• Impregnated with Calcium Salts to Impregnated with Calcium Salts to give it give it stiffness stiffness (65%)(65%)• ‘‘Impregnated’ with ‘latent’ Growths Impregnated’ with ‘latent’ Growths factorsfactors

Normal Osteoporosis Osteomalacia

Osteoid

Minerals

Types of BoneTypes of BoneTypes of BoneTypes of Bone

• Cortical Bone (compact bone):Cortical Bone (compact bone): • 80% of Skeletal System80% of Skeletal System

– Thick in the bone’s shaft (diaphysis) Thick in the bone’s shaft (diaphysis) areasareas

– Thinner at the ends of bone (epiphysis)Thinner at the ends of bone (epiphysis)

• Cancellous Bone (trabecular or spongy bone):Cancellous Bone (trabecular or spongy bone): • 20% of Skeletal System20% of Skeletal System

– Inner surface of boneInner surface of bone– Most of the bony structure at the end of Most of the bony structure at the end of bonesbones

• Cortical Bone (compact bone):Cortical Bone (compact bone): • 80% of Skeletal System80% of Skeletal System

– Thick in the bone’s shaft (diaphysis) Thick in the bone’s shaft (diaphysis) areasareas

– Thinner at the ends of bone (epiphysis)Thinner at the ends of bone (epiphysis)

• Cancellous Bone (trabecular or spongy bone):Cancellous Bone (trabecular or spongy bone): • 20% of Skeletal System20% of Skeletal System

– Inner surface of boneInner surface of bone– Most of the bony structure at the end of Most of the bony structure at the end of bonesbones

Bone HealingBone HealingBone HealingBone Healing

• The skeleton is the ONLY human organ The skeleton is the ONLY human organ to heal without scarringto heal without scarring

TISSUE REGENERATIONTISSUE REGENERATION

• The skeleton is the ONLY human organ The skeleton is the ONLY human organ to heal without scarringto heal without scarring

TISSUE REGENERATIONTISSUE REGENERATION

Stages of Fracture Stages of Fracture HealingHealingStages of Fracture Stages of Fracture HealingHealing

Initial Trauma

Inflammatory Response

Formation of New Soft Tissue: Callus

Formation of Bone Matrix & Cartilage Ossification of Cartilage to Bone

Remodeling

Healing with NO scar!

Prerequisites for Bone Prerequisites for Bone HealingHealing

Prerequisites for Bone Prerequisites for Bone HealingHealing

•Adequate blood supplyAdequate blood supply•Adequate mechanical Adequate mechanical stabilitystability

•Adequate blood supplyAdequate blood supply•Adequate mechanical Adequate mechanical stabilitystability

Bone HealingBone HealingBone HealingBone Healing

Indirect

Direct

‘‘a fracture is a a fracture is a severe soft tissue severe soft tissue injury with a broken injury with a broken bone in its midst’bone in its midst’

Astley Astley CooperCooper

‘‘a fracture is a a fracture is a severe soft tissue severe soft tissue injury with a broken injury with a broken bone in its midst’bone in its midst’

Astley Astley CooperCooper

Management of FracturesManagement of FracturesManagement of FracturesManagement of Fractures

• Conservative

• Operative

Internal fixation:

Intramedullary nail

Plates and screws

External fixation

• Conservative

• Operative

Internal fixation:

Intramedullary nail

Plates and screws

External fixation

Tibial FractureTibial FractureTibial FractureTibial Fracture

Intramedullary Intramedullary NailNail

Intramedullary Intramedullary NailNail

Plate and Plate and ScrewsScrews

Plate and Plate and ScrewsScrews

External External FixationFixationExternal External FixationFixation

Hardware – In The LumenHardware – In The LumenHardware – In The LumenHardware – In The Lumen

Nail VS Rod

1st, 2nd and 3rd Generation Nails

Antegrade & Retrograde

Hardware – In The WallHardware – In The WallHardware – In The WallHardware – In The Wall

Rigid Fixation

Angle Blade plate

DHS & DCS

Bridge Plating

Locking Plate

Hardware – Outside WallHardware – Outside WallHardware – Outside WallHardware – Outside Wall

Temporary VS Permanent

Uni planer VS Multiplaner

What determines choice of What determines choice of hardware?hardware?

What determines choice of What determines choice of hardware?hardware?

The Three P’s (Personalities)The Three P’s (Personalities)The Three P’s (Personalities)The Three P’s (Personalities)

The FractureThe FractureThe FractureThe Fracture

The PatientThe PatientThe PatientThe Patient

The SurgeonThe SurgeonThe SurgeonThe Surgeon

Goals of TreatmentGoals of TreatmentGoals of TreatmentGoals of Treatment

1. 1. Prevention of infectionPrevention of infection

2. 2. Fracture unionFracture union

3. 3. Restoration of functionRestoration of function

1. 1. Prevention of infectionPrevention of infection

2. 2. Fracture unionFracture union

3. 3. Restoration of functionRestoration of function

QUESTIONS

Classification of Open Classification of Open FracturesFractures

WoundWoundSizeSize

I < I < 1cm1cm

II II > 1cm> 1cm

WoundWoundSizeSize

I < I < 1cm1cm

II II > 1cm> 1cm

Soft Soft TissueTissue

CrushingCrushing

NoneNone

Slight orSlight orModerateModerate

Soft Soft TissueTissue

CrushingCrushing

NoneNone

Slight orSlight orModerateModerate

FractureFractureTypeType

SimpleSimple

ComminutedComminuted

SegmentalSegmental

FractureFractureTypeType

SimpleSimple

ComminutedComminuted

SegmentalSegmental

ContaminatiContaminationon

LittleLittle

ModerateModerate

HighHigh

ContaminatiContaminationon

LittleLittle

ModerateModerate

HighHighIIIIII Extensive damage Extensive damage

to softto soft tissue, muscle, tissue, muscle,

skin skin

IIIIII Extensive damage Extensive damage to softto soft

tissue, muscle, tissue, muscle, skin skin

Gustilo and AndersonGustilo and Anderson

ClassificationClassificationClassificationClassification

Grade IIIGrade III

AA Soft tissue cover.Soft tissue cover. Any Any

segmental #segmental #

BB Periosteal stripping +/- Periosteal stripping +/-

contaminationcontamination

CC Neurovascular injury requiring Neurovascular injury requiring

repairrepair

Grade IIIGrade III

AA Soft tissue cover.Soft tissue cover. Any Any

segmental #segmental #

BB Periosteal stripping +/- Periosteal stripping +/-

contaminationcontamination

CC Neurovascular injury requiring Neurovascular injury requiring

repairrepair

SummarySummarySummarySummary

3 ways to fix a bone: 3 ways to fix a bone: Within the boneWithin the bone

On the surface of the On the surface of the

bonebone

Outside the boneOutside the bone

The 3 Personalities:The 3 Personalities: FractureFracture

PatientPatient

SurgeonSurgeon

3 ways to fix a bone: 3 ways to fix a bone: Within the boneWithin the bone

On the surface of the On the surface of the

bonebone

Outside the boneOutside the bone

The 3 Personalities:The 3 Personalities: FractureFracture

PatientPatient

SurgeonSurgeon

Clinical Clinical CasesCases

Clinical Clinical CasesCases

Subtrochanteric FractureSubtrochanteric FractureSubtrochanteric FractureSubtrochanteric Fracture

LAT

CASE CASE CASE CASE

28 yr old RTA motorcyclist28 yr old RTA motorcyclist

AdonisAdonis

28 yr old RTA motorcyclist28 yr old RTA motorcyclist

AdonisAdonis

1. Fracture:- Closed Pilon

2. Patient:- Alcoholic

3. Surgeon:- Locking Plate

Open Tibial Open Tibial FractureFracture

15cm by 5cm wound 15cm by 5cm wound over posterior aspect over posterior aspect

of calfof calf

Open Tibial Open Tibial FractureFracture

15cm by 5cm wound 15cm by 5cm wound over posterior aspect over posterior aspect

of calfof calf

AP

LAT

Distal Femoral FractureDistal Femoral Fractureand Midshaft Tibial and Midshaft Tibial

FractureFracture

Distal Femoral FractureDistal Femoral Fractureand Midshaft Tibial and Midshaft Tibial

FractureFractureAP

LAT

Distal Femoral FractureDistal Femoral FractureDistal Femoral FractureDistal Femoral FractureAP

LAT

Mid shaft Open Femoral Mid shaft Open Femoral FractureFracture

Mid shaft Open Femoral Mid shaft Open Femoral FractureFracture

LAT

Distal Femoral FractureDistal Femoral FractureDistal Femoral FractureDistal Femoral FractureAP

LAT

Distal Femoral FractureDistal Femoral FractureDistal Femoral FractureDistal Femoral Fracture

LAT

AP

LAT

Ankle FractureAnkle FractureAnkle FractureAnkle Fracture

AP

LAT

Ankle FractureAnkle FractureAnkle FractureAnkle Fracture

AP

LAT

Too Low!Too Low! Too Medial!Too Medial!

Procurvatum

Valgus

CASE 1CASE 1CASE 1CASE 1

47 yr Old47 yr OldFell off a back of a lorry 1.5 m highFell off a back of a lorry 1.5 m highGrade 1 Open Distal Tibial FractureGrade 1 Open Distal Tibial Fracture

Wounds over posterior aspect of calf, a Wounds over posterior aspect of calf, a transvere woundtransvere wound

47 yr Old47 yr OldFell off a back of a lorry 1.5 m highFell off a back of a lorry 1.5 m highGrade 1 Open Distal Tibial FractureGrade 1 Open Distal Tibial Fracture

Wounds over posterior aspect of calf, a Wounds over posterior aspect of calf, a transvere woundtransvere wound

17/11/20122

17/11/20122

20/11/20122

4/3/20132Plate exposed over medial malleolus and dorsal pedis island flap performed.Foot in 25 degrees of equinus

13/5/2013

Flap died and metal work removed with Vac

Pump applied.

Ankle movement improved!

30/5/20132Ilizaove frame with bone grafting of non union siteCross ankle fixtor to correct equinus deformity

30/5/20132 26/6/20132

Equinus corrected after 21 days of correctionAwaiting union of fracture site

CASE 2CASE 2CASE 2CASE 2

32 yr old RTA motorcyclist32 yr old RTA motorcyclist

Soft tissue injury anterior Soft tissue injury anterior aspect of knee (Tscherne aspect of knee (Tscherne

grade 3)grade 3)

32 yr old RTA motorcyclist32 yr old RTA motorcyclist

Soft tissue injury anterior Soft tissue injury anterior aspect of knee (Tscherne aspect of knee (Tscherne

grade 3)grade 3)

79 Degrees MPTA

87 Degrees MPTA

CASE 4CASE 4CASE 4CASE 4

52 yr old low energy fall52 yr old low energy fall

Open fracture 10cm Open fracture 10cm longitudinal laceration longitudinal laceration posterior aspect of calfposterior aspect of calf

52 yr old low energy fall52 yr old low energy fall

Open fracture 10cm Open fracture 10cm longitudinal laceration longitudinal laceration posterior aspect of calfposterior aspect of calf

Open Tibial Open Tibial FractureFracture

Open Tibial Open Tibial FractureFracture

CASE 5CASE 5CASE 5CASE 5

32 yr RTA32 yr RTA

Open fractureOpen fracture

32 yr RTA32 yr RTA

Open fractureOpen fracture

CASE 6CASE 6CASE 6CASE 6

50 yr old low energy fall50 yr old low energy fall

Closed fractureClosed fracture

Known alcoholicKnown alcoholic

50 yr old low energy fall50 yr old low energy fall

Closed fractureClosed fracture

Known alcoholicKnown alcoholic

What would you do??

MIPO plating