Academic Courses
FACULTY OF CLINICAL MEDICINE AND SURGERY
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Topic One: Introduction to surgery: Definitions; types of surgery; surgical divisions
Topic Objectives
By end of this topic, you should be able to:-
·
Define surgery
· Classify types of surgery
· Classify surgical conditions
· Define surgical terminologies
. Identify the main surgical divisionsClick here to access Unit one Content..
Topic 1: Definition, types of surgery, surgical conditions
Definition
· Surgery is a medical specialty that uses operative, manual and instrumental techniques on a patient to investigate and / or treat a pathological condition such as disease or injury, to help improve bodily
function or appearance.
· An act of performing surgery may be called a surgical procedure, operation, or simply surgery.
· To operate means to perform surgery
· Surgical means pertaining to surgery
· As a general rule, a procedure is considered surgical if it involves cutting of a patient’s tissues or closure of a previously sustained wound.
· Surgery can be used to repair broken bones, stop uncontrolled bleeding, remove injured or diseased tissue and organs, and reattach severed limbs.
· Surgeons are doctors who do operations – cutting tissue to treat disease.
· Surgery is an art or craft as well as a science.
· It involves making judgment, coping under pressure, taking decisive action when necessary, and teaching & training skills
.
Types of surgery
Based on timing:
- Elective surgery – done to correct a non-life-threatening
condition. It is subject to the surgeon’s and surgical facility’s availability.
- Emergency surgery – surgery which must be done promptly to
save life, limb, or functional capacity.
Based
on purpose:
- Exploratory
surgery – performed to aid or confirm a diagnosis.
- Therapeutic
surgery – treats a previously diagnosed condition.
- Cosmetic
surgery – done to improve the appearance of an otherwise normal structure.
Classification
of surgical conditions
Surgery
is classified according to whether it is vital to life, necessary for continued
health, or desirable for medical or personal reasons.
Surgical conditions can be classified into:
·
Emergency
surgical conditions
·
Urgent
surgical conditions
·
Elective
surgical conditions
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Topic 1: Surgical conditions ...
Emergency surgical conditions
Unpredictable events that result in the need for immediate surgical attention are termed emergency surgeries. E.g.: -
Injury from:
- • An automobile accident
- • A fire
- • A violent assault
A sudden change in a chronic medical problem such as a perforated peptic ulcer or a strangulated hernia.
Emergency cases typically involve treatment of:
- Gunshot and stab wounds
- Fractures of the skull and other major bones
- Head injury with intracranial hematoma and lateralizing signs
- Severe eye injuries
- Acute airway obstruction e.g. choking
- Multiple injuries
- Acute abdomen: presenting as acute onset severe pain in the abdominal area for which immediate surgery might be the remedy.
- Acute appendicitis
- Intestinal obstruction
- Intussusception
- Testicular torsion, etc.
Urgent surgical conditions
Cases in which an operation is vital but can be postponed for a few days. E.g.
Injury with minor bone fracture
Acute cholecystitis, acute diverticulitis
Kidney stones
Cancer of a vital organ
Elective surgical conditions
Elective surgery can be: required, selective, or optional.
1. Required surgery cases include physical ailments that are serious enough to need corrective surgery but that can be scheduled weeks or months in advance.
2. Selective surgery covers a broad range of conditions that are of no real threat to the immediate physical health of the patient, but nevertheless should be corrected by surgery in order to improve comfort and emotional health. E.g. cleft lip and cleft palate, removal of certain cysts and benign fatty or fibrous tumors.
3. Optional surgery includes operations that are primarily of cosmetic benefit. E.g. removal of warts and other non-malignant growths on the skin, blemishes on the skin, plastic surgery undertaken for cosmetic reasons.
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Topic 1: Terminology
Terminology
-ectomy: Excision - starts with the name of the organ to be excised and ends in –ectomy. E.g. colectomy, gastrectomy, lumpectomy.
-otomy: procedures involving cutting into an organ or tissue end in –otomy. E.g. laparotomy = cutting through the abdominal wall to gain access into the abdominal cavity.
-ostomy: procedures for formation of a permanent or semi-permanent opening (stoma) in a body, end in –ostomy. E.g. colostomy, ileostomy.
-oplasty: reconstruction, plastic or cosmetic surgery of a body part starts with the name of the body part to be reconstructed and ends in –oplasty. E.g. rhinoplasty.
-rraphy: repair of damaged or congenital abnormal structure ends in – rraphy. E.g. herniorraphy.
-oscopy: minimally invasive procedures involving small incisions through which an endoscope is inserted. End in –oscopy). E.g. laparoscopy.
Amputation: surgical removal of a limb or body part
A fistula
- • Implies a tunnel connecting two epithelial surfaces.
A sinus
- • Is a blind track opening on to the skin or a mucous surface
- • A fluid may discharge from a sinus or fistula.
- • The discharge should be examined and noted: is it blood, blood-stained, clear, bile-like, serous, faecal or purulent?
- • The type of fluid may give a clue to the possible diagnosis.
Lymphangitis
- • Is inflammation within a lymphatic vessel and appears as a red line often leading to an inflamed regional lymph node.
Thrombophlebitis
- • Is a thrombosed and inflamed vein – it is more usual in superficial veins often associated with varicose veins, which are tender and hard.
Cellulitis
- • Is a spreading inflammation of tissues, usually superficial or subcutaneous tissue due to bacterial infection, usually beta haemolytic streptococci or staphylococci
- • The part affected is swollen, tense and tender.
- • Later it becomes red, shiny and boggy.
- • It may progress to an abscess, which is the presence of pus in the tissue concerned.
Inflammation
- • Is the presence of redness, swelling, heat and tenderness, often associated with the loss of function
Translucency
- • There are occasions when swellings containing clear fluid lie adjacent to the skin.
- • When a torch is shone through the swelling it lightens the area, confirming translucency.
Crepitus
- • Is a term used in a variety of conditions but in each having a fundamental diagnostic importance
- • Bone crepitus is noted as coarse grating on movement of a bone – it is very painful to the patient, and an unmistakable diagnosis of a fracture of a bone.
- • Joint crepitus is elucidated by one hand on a joint and passively moving the joint with the other hand: fine, evenly spaced crepitations are present in many subacute and chronic joint conditions.
- • Coarse, irregular crepitations signify osteoarthritis.
- • The crepitus of tenosynovitis is found over an inflamed tendon sheath when effusion has occurred into the sheath.
- • The crepitus of subcutaneous emphysema is due to gas in the tissues; a peculiar crackling sensation is imparted to the examining fingers.
Ballottement
- • Is when a swelling can be tapped away from the examining finger, often due to fluid adjacent to the swelling
- • The term also describes the ability to palpate bimanually a renal swelling and to tap the kidney forward from the loin to the examining fingers of the other hand on the abdomen.
- • A swelling may be balloted from the pelvis, by a finger in the vagina, to the examining abdominal hand.
Fluctuation
- • Is a specific term to elucidate the presence of fluid
- • Two watching fingers are placed on either side of a swelling and a central displacing finger presses momentarily.
- • An impulse is felt by the watching finger confirming the presence of fluid, provided the sign is elicited in more than one place.
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Topic One: Surgical divisions
Surgical Divisions
1. General surgery:
- Is the broadest surgical division.
- Focuses on surgery of the abdomen, the breast, and the endocrine organs.
- General surgeons operate on the appendix, colon, small intestine, gallbladder, stomach, pancreas, spleen, and liver.
2. Neurosurgery:
- Involves operations on the brain & spinal column.
- These procedures include excising, or cutting out, brain tumours and removing ruptured discs in the spine, an operation known as laminectomy.
3. Orthopaedic surgery:
- Entails operations on bones, muscles, and joints.
- Orthopaedic surgery allows for the replacement of hip and knee joints with artificial joints made of special metals and plastics.
- Fractures in bones are repaired with the implantation of pins, metal plates, and screws.
- These techniques greatly reduce the time needed for healing and recuperation.
4. Plastic surgery:
- Encompasses cosmetic procedures to improve appearance and reconstruct damaged parts of the body such as skin and underlying muscle.
- Cosmetic procedures include enlarging or reducing the size of the breasts; rhinoplasty (cosmetic surgery of the nose); face lift (cosmetic surgery to tighten facial tissues); and blepharoplasty (cosmetic surgery on the eyelids).
5. Cardiothoracic surgery:
- Deals with surgery of the lungs, chest wall, heart, and large blood vessels of the chest.
- Typical procedures include the removal of malignant cancers and correction of structural birth defects in the heart, lungs and chest.
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Topic One: Further Reading
Reference Material
Atingà, J. E., Mutiso, V. M., & Otsyeno, F. M. (2014). AORF Text Book of Orthopaedics. Nairobi: Acrodile Publishing.
Burkitt, H. G., Quick, C. R., & Reed, J. B. (2014). Essential Surgery - Problems, Diagnosis and Management. London: Churchill Livingstone, ELSEVIER.
Dandy, D. J., & Edwards, D. J. (2009). Essential Orthopaedics and Trauma. London: Churchill Livingstone, ELSEVIER.
Ebnezar, J. R. (2016). Textbook of Orthopedics. New Delhi: Ansari.
Garden, O. J., & Parks, R. W. (2018). Principles and Practice of Surgery. London: ELSEVIER.
Hamblen, D. J., & Simpson, A. H. (2013). Adams`s Outline of Fractures. London: Churchill Livingstone, ELSEVIER.
Hamblen, D. S. (2010). Outline of orthopaedics. London: Elsevier Churchill Livingstone.
Kenneth, A., et al (2010). Handbook of Fractures, 4th Ed. Wolters Kluwer, Philadelphia
McRae, R. (2010). Clinical Orthopaedic Examination. London: Churchill livingstone Elsevier.
Solomon, L. W. (2009). Apley's System of Orthopaedics and Fractures. London: CRC Press.
Solomon, L., Warwick, D., & Nayagam, S. (2014). Apley and Solomon`s Concise System of Orthopaedics and Trauma. London: CRC Press.
Williams, N. S., Bulstrode, C. J., & O`Connell, P. R. (2008). Bailey & Love`s Short Practice of Surgery. London: Hodder ARNOLD.
Further Reading Resources
Terminologies related to organs; e.g. arthro is related to joint, osteo is related to bone. Search for more.
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Topic Two: Surgical Clerkship
Steps in surgical clerkship
1. Assemble all the available facts gathered from particulars (Bio data), chief complaints, history of presenting illness and relevant history
2. Analyze and interpret the examination details to reach the provisional diagnosis (impression)
3. Make differential diagnoses
4. Order for appropriate investigations
5. Select a closest possible diagnosis
6. Come up with an effective treatment plan
Components
1. Personal particulars (bio data)
2. Chief complaint(s)
3. History of presenting illness
4. Review of systems
5. Past medical and surgical history
6. Family history
7. Personal, social and economic history
8. General examination
9. Vital signs
10. Local examination
11. Other systems examination
12. Provisional diagnosis
13. Investigations
14. Final diagnosis
15. Treatment plan
Self-introduction
1. Greet the patient by name
2. Introduce yourself
3. Shake the patient`s hand
4. Ensure the patient is comfortable
Personal Particulars
They include:
1. Patient’s name:
To communicate with the patient
To establish a rapport with the patient
Record maintenance
Psychological benefits
2. Age:
Age related diseases
For diagnosis
Treatment planning
3. Sex:
Certain diseases are gender specific
Record maintenance
Treatment planning
4. Residence/ address:
For future correspondence
View of socio-economic status
Prevalence and geographical distribution
5. Occupation:
To assess socio-economic status
Prediction of different diseases in different occupations
6. Religion:
Beliefs and customs that might impact on treatment modalities
To identify festive periods when religious people are reluctant to undergo treatment
7. Patients registration number:
Maintain records
Billing purposes
Medico-legal aspects
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Topic Two: Surgical clerkship
Chief complaints
Chief complaint is usually the reason for the patient’s visit. It is stated in patient’s own words (no medical terms) in chronological order of their appearance (Brief & duration). Chief complaint aids in diagnosis and treatment hence should be given utmost priority.
Common chief complaints:
- Pain
- Swelling
- Ulcer
- Vomiting
- Abdominal distension
- Bleeding
- Discharge
- Deformity
History of presenting illness
Elaborate on chief complaints in detail. Symptoms can be elaborated in terms of:
- Mode and cause of onset
- Course and duration of disease
- Symptoms related and relation to constitutional factors
- Special character and effects- nearby structures
- Treatment taken
- Leading questions- to help the patient
- Negative answers- more valuable to exclude the disease
Review of systems
- Review all the systems that are not affected and thus not covered in the history of presenting illness.
- Helps to discover any other problems the patient could be having.
- Ask specific questions in relation to each system
Past medical & surgical history
- Note the past history in chronological order
- All diseases-previous to present noted: pay attention to diseases like diabetes, systemic hypertension, heart diseases, bleeding disorders, tuberculosis, asthma, epilepsy etc.
- Previous operations or accidents
- Previous blood transfusions or fluid infusions
- Drug allergies and intolerances
Treatment or drug history
- Ask about the drugs the patient was on
- Special enquiry on steroids, antihypertensive drugs, contraceptives, antidiuretic drugs, ARVS etc.
- Treatment for current illness
Gynaecological and obstetric history
- For females
- Gynecological and obstetric history is important in determining pregnancy status
- Rules out or confirms certain conditions associated with pregnancy e.g. ectopic pregnancy.
Personal, social and economic history
- Marital status
- Occupation
- Education level
- Diet
- Habits of smoking and drinking alcohol
- Hobbies
Family history
- Family members share genes as well as their environment, lifestyle and habits
- Certain diseases run in families- diabetes, hypertension, piles, peptic ulcers, cancer (such as breast, thyroid) etc. should be noted
- Enquire about family members- alive or dead/current illnesses among family members
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Topic Two: Surgical clerkship
- Examination
- General survey or examination
- Analyze the patient entering the clinic for gait, built & nutrition, attitude and mental status
- Check for pallor, jaundice, cyanosis, finger clubbing, oedema, dehydration, lymphadenopathy and any skin eruptions
- Record the vital signs- blood pressure, pulse, respiration rate and temperature
- Local examination
- It is the most important part- definite clue to arrive at a diagnosis.
- It entails:
- Inspection- looking at affected part
- Palpation- feeling of affected part
- Percussion- listening to notes produced by tapping the affected part
- Auscultation- listening to the sounds produced
- Movements and measurements
- Lymph node examination
- Inspection
- Make sure there is good lighting
- Position and expose body parts so that all surfaces can be viewed
- Inspect each area for size, shape, colour, symmetry, position and abnormalities
- If possible compare each area inspected with the same area on the opposite side of the body
- Palpation
- Use the pulp (palmar surface) of the fingers to palpate for:
- 1. Texture- smooth, rough, moist or dry
- 2. Masses- size, surface, edges, mobility, tenderness
- 3. Fluid- fluctuancy
- Use the dorsum of hand to assess for local warmth or temperature
- Client should be relaxed and positioned comfortably
- Types of palpations
- 1. Light palpation
- 2. Deep palpation
- 3. Bimanual palpation
- Percussion
- Used to evaluate for presence of air or fluid in body tissues
- Sound waves are heard as percussion notes
- Percussion notes can be: -
- 1. Dull
- 2. Stony-dull
- 3. Resonant (chest)
- 4. Hyper-resonant (chest)
- 5. Tympanic (abdomen)
- Types of percussion
- Direct percussion- by tapping the affected area directly using flexed finger
- Indirect percussion- by placing the left middle finger over the area and its middle phalanx is tapped with the tip of the right middle or index finger
- Fist percussion- placing one hand flat against the body and striking the back of the hand with a clenched fist of the other hand
- Auscultation
- Done using a stethoscope
- Note the following characteristics of sounds:
- • Pitch
- • Loud or soft
- • Duration
- • Quality
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Topic Two: Surgical clerkship
Examination of systems
1. Head and neck
- • Cranial nerves- iii,iv,v,vi,vii,ix,xi and xii examined
- • Eyes – visual field, pupil, movement
- • Mouth and pharynx- teeth and gum, tongue, and tonsils
- • Movement of neck, neck veins, lymph nodes, carotid pulse and thyroid gland
2. Musculoskeletal system
Upper limbs
- • Arms and hands- power, tone, reflexes and sensations
- • Axillae and lymph nodes
- • Joints
- • Finger nails
Lower limbs
- • Legs and feet- power, tone, reflexes and sensations
- • Varicose veins
- • Joints
- • Oedema
Spine
- • Curvature – lordosis, kyphosis and scoliosis
- • Swellings
- • Pain and tenderness
- • Movements
3. Thorax – RS, CVS, Breasts
Examine the respiratory and cardiovascular systems using the format of inspection, palpation, percussion, and auscultation.
- • Chest symmetry
- • Dilated vessels and pulsations
- • Position of trachea
- • Apex beat
- • Lungs - percussion notes, breath sounds, air entry, ...
- • Heart - sounds, murmurs, ...
- • Breasts
4. Abdomen
Follow the formats of inspection, auscultation, palpation, and percussion.
- • Abdominal wall- umbilicus, scars, dilated vessels
- • Symmetry and movement with respiration
- • Masses, tenderness, percussion
- • Hernias
- • Inguinal lymph nodes
- • Bowel sounds
- • Rectal examination
- • Gynecological examination- if required
Provisional diagnosis
- • Also referred to as tentative or working diagnosis
- • It is formed after evaluating the case history and performing the physical examination
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Topic Two: Surgical Clerkship
- Investigations
- Investigations are requested/ performed to:
- 1. Confirm the diagnosis
- 2. Rule out differential diagnosis
- 3. Aid in management of the patient
- 4. To monitor success of treatment
- Types of investigations:
- Laboratory investigations:
- • Full blood count (complete blood count)
- • Erythrocyte sedimentation rate (ESR)
- • Renal function tests- electrolytes, urea & createnine levels
- • Liver function tests- bilirubin, liver enzyme (alanine transaminase, aspartate transaminase) serum proteins, alkaline phosphatase
- • Blood for grouping and cross matching
- • Random blood sugar
- • C-reactive proteins- elevated acute infections/inflammatory conditions
- • Coagulation tests- prothrombin test, thrombin time etc
Fine needle aspirate cytology (FNAC) for cytology
Open biopsy for histology
Urinalysis
- 2. Radiological investigations
- • Plain radiographs (X-rays)
- • Computerized tomographic scans (CT Scans)
- • Magnetic resonance imaging (MRI)
- • Ultrasound
- • Doppler ultrasound
- 3. Endoscopies
- Differential diagnosis
- • The process of listing two or more diseases having similar signs and symptoms with the provisional diagnosis
- Treatment plan
- • Formulation of treatment plan depends on knowledge & experience of a competent clinician and nature and extent of treatment facilities available
- • Medical assessment is needed to identify the need of medical consultation and to recognize significant deviation from normal health that may affect management
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Topic Two: Summary
In summary, surgical clerkship consists of:
- Components of a surgical history
- Chief complaints
- History of presenting illness; expounding on symptoms
- General examination
- Local examination
- Examination of systems
- Investigations
- Provisional diagnosis
- Treatment plan
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Topic Two: Further Reading
Reference Material
Atingà, J. E., Mutiso, V. M., & Otsyeno, F. M. (2014). AORF Text Book of Orthopaedics. Nairobi: Acrodile Publishing.
Burkitt, H. G., Quick, C. R., & Reed, J. B. (2014). Essential Surgery - Problems, Diagnosis and Management. London: Churchill Livingstone, ELSEVIER.
Dandy, D. J., & Edwards, D. J. (2009). Essential Orthopaedics and Trauma. London: Churchill Livingstone, ELSEVIER.
Ebnezar, J. R. (2016). Textbook of Orthopedics. New Delhi: Ansari.
Garden, O. J., & Parks, R. W. (2018). Principles and Practice of Surgery. London: ELSEVIER.
Hamblen, D. J., & Simpson, A. H. (2013). Adams`s Outline of Fractures. London: Churchill Livingstone, ELSEVIER.
Hamblen, D. S. (2010). Outline of orthopaedics. London: Elsevier Churchill Livingstone.
Kenneth, A., et al (2010). Handbook of Fractures, 4th Ed. Wolters Kluwer, Philadelphia
McRae, R. (2010). Clinical Orthopaedic Examination. London: Churchill livingstone Elsevier.
Solomon, L. W. (2009). Apley's System of Orthopaedics and Fractures. London: CRC Press.
Solomon, L., Warwick, D., & Nayagam, S. (2014). Apley and Solomon`s Concise System of Orthopaedics and Trauma. London: CRC Press.
Williams, N. S., Bulstrode, C. J., & O`Connell, P. R. (2008). Bailey & Love`s Short Practice of Surgery. London: Hodder ARNOLD.
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Topic 3: Medical Conditions that Affect Surgical Treatment
Introduction
A number of medical conditions can affect the outcome of surgical treatment. These are discussed below:
Diabetes mellitus
- Blood sugar levels must be under control before surgery.
- Uncontrolled diabetes can slow the healing of surgical wound
- It also makes one to be more susceptible to post-operative infection
- Surgery can cause increased stress to the body and higher blood sugar.
- Insulin dose may need to be adjusted.
- 1. Certain complications of diabetes are associated with a higher post-operative risk
- 2. Stress (e.g. surgery, trauma & infection) causes increased production of catabolic hormones which oppose the action of insulin. This makes diabetic control more difficult.
- 3. General anaesthesia, surgery, deprivation of oral intake and post-operative vomiting disrupt the delicate balance between dietary intake, exercise (energy utilization) and diabetic therapy.
- 4. Diabetic ketoacidosis may cause an elevated leucocyte count and raised amylase level, which may confuse the diagnosis of acute abdomen. DKA may sometimes present with abdominal pain.
- 5. Diabetic patients are at greater risk of hospital-acquired infection.
Perioperative management of insulin dependent diabetics:
- 1) Establish good diabetic control before operation
- 2) Give soluble insulin as a continuous intravenous infusion during the operative period
- 3) Give an infusion of dextrose throughout the operative period to balance the insulin given and to make up for lack of dietary intake
- 4) Add potassium to the dextrose infusion
- 5) Monitor blood glucose and electrolytes frequently throughout the operative and early post-operative period.
Diabetics controlled on oral hypoglycaemic drugs:
- 1. Maintain on short-acting sulphonylureas such as glipizide [omit dose on the morning of the operation]
- 2. Patients on long-acting drugs such as metformin should be changed to a short acting sulphonylurea several days before the operation
- 3. If this fails to provide adequate control, an insulin regimen can be used
Diabetics controlled by diet alone:
- These do not require special preoperative measures as they do not become hypoglycemic and blood glucose rarely drifts above acceptable levels.
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Topic 3: Medical conditions that affect surgical treatment
Anaemia
- Anaemia increases the risk of cardiac and wound complications during surgery.
- Full blood count should be done before surgery. Haemoglobin level must be checked.
Haemoglobinopathies
- Patients with sickle-cell disease and beta thalassaemia have a high operative morbidity and mortality.
- They require intensive perioperative management with particular attention to avoiding hypoxia, infection, acidosis, dehydration and hypothermia.
Bleeding disorders
1. Thrombocytopenia
2. Haemophilia
3. Von-Willebrands disease
- Can cause uncontrolled bleeding intra-operatively
Most surgical bleeding problems are caused by:
- Poorly controlled anticoagulant therapy
- Liver disease
- Aspirin therapy
- Vitamin K malabsorption such as in obstructive jaundice
Varicose veins, leg swelling, DVT
- Surgery and post-operative immobility increases the risk of DVT.
- Blood clots can be dislodged leading to embolism to the lungs.
Hypertension
- Blood pressure control is necessary before surgery.
- High blood pressure can lead to excessive haemorrhage during surgery.
Jaundice
- Jaundice delays post-operative wound healing.
- Vitamin K malabsorption in obstructive jaundice can lead to excessive bleeding.
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Topic 3: Medical conditions that affect surgical treatment
Obesity
Overweight and obese patients are at increased risk of medical and surgical complications, including wound infections, pneumonia, blood clots and heart attack. Losing weight before surgery would improve the outcome of surgery.Surgical complications of obesity:
Cardiopulmonary complications such as cardiac failure and chest infections
Wound complications such as infection, wound dehiscence and burst abdomen
Venous thromboembolism – increased risk of deep venous thrombosis and pulmonary embolism
General anaesthesia complications:
- • Anatomical problems, e.g. intravenous canulae are difficult to insert and intubation is more difficult. Clinical signs of dehydration and hypovolaemia are more difficult to elicit.
- • Physiological problems: metabolic problems, e.g. altered distribution of drugs
- • Hypertension
- • Ischaemic heart disease
- • Type 2 diabetes
- • Gallstones
- • Gout
- • Operations take longer to perform because of difficult access and vital structures obscured by fat.
- • This leads to a higher incidence of anaesthetic and surgical complications, particularly involving the wound.
- • Weight and size limitations of standard equipment, e.g. CT scanners, operating tables, beds.
- • Risks to staff involved in lifting and handling
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Topic 3: Medical conditions that affect surgical treatment
Thyrotoxicosis
- Thyroid or non-thyroid surgery for a patient with uncontrolled thyrotoxicosis carries a risk of thyrotoxic crisis with attendant high mortality.
- It can increase the risk of cardiac complications.
- Hyperthyroidism must be controlled before surgery.
- The patient should be rendered euthyroid before operation using antithyroid drugs and beta-blocking drugs
- Non-selective beta-blocking drugs rapidly control the cardiovascular effects of thyrotoxicosis and can be used for urgent perioperative preparation.
Hypothyroidism
- Have moderate risk when undergoing surgery
- They are more sensitive to CNS depressants, have a decreased cardiovascular reserve, and are also susceptible to electrolyte disorders e.g. water retention.
- If clinical suspicion of hypothyroidism, operation should be delayed or postponed until oral replacement is commenced.
Arrhythmias
- A problem with the rate or rhythm of the heartbeat.
- o Tachycardia
- o Bradycardia
- o Irregular heart beat
- Can lead to operative and post-operative cardiac complications.
Adrenal insufficiency
- Patients with potential adrenal insufficiency must be given steroid cover during the perioperative period. I.V. hydrocortisone 25-50mg prior to operation and 50mg daily until recovery.
- Lack of additional adrenal response to the stresses of surgery or trauma may cause acute postoperative cardiovascular collapse with hypotension and shock (Addisonian crisis)
Cushing’s syndrome
- Results from excess secretion of cortisol.
- Long term steroid therapy for conditions such as rheumatoid arthritis or asthma is the most common cause of cushingoid features.
- The main surgical problems in cushingoid patients are hypertension, hyperglycemia, poor wound healing, infection and peptic ulceration.
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Topic 3: Summary
You have learnt how some medical conditions can affect surgical treatment. The conditions could complicate the surgery intra-operatively, could make surgery technically difficult, could lead to anaesthesia complications, and also post-operative complications, among others. You have also learnt how to manage some of these conditions in preparation for surgery.
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Topic 3: Further Reading
Reference Material
Atingà, J. E., Mutiso, V. M., & Otsyeno, F. M. (2014). AORF Text Book of Orthopaedics. Nairobi: Acrodile Publishing.
Burkitt, H. G., Quick, C. R., & Reed, J. B. (2014). Essential Surgery - Problems, Diagnosis and Management. London: Churchill Livingstone, ELSEVIER.
Dandy, D. J., & Edwards, D. J. (2009). Essential Orthopaedics and Trauma. London: Churchill Livingstone, ELSEVIER.
Ebnezar, J. R. (2016). Textbook of Orthopedics. New Delhi: Ansari.
Garden, O. J., & Parks, R. W. (2018). Principles and Practice of Surgery. London: ELSEVIER.
Hamblen, D. J., & Simpson, A. H. (2013). Adams`s Outline of Fractures. London: Churchill Livingstone, ELSEVIER.
Hamblen, D. S. (2010). Outline of orthopaedics. London: Elsevier Churchill Livingstone.
Kenneth, A., et al (2010). Handbook of Fractures, 4th Ed. Wolters Kluwer, Philadelphia
McRae, R. (2010). Clinical Orthopaedic Examination. London: Churchill livingstone Elsevier.
Solomon, L. W. (2009). Apley's System of Orthopaedics and Fractures. London: CRC Press.
Solomon, L., Warwick, D., & Nayagam, S. (2014). Apley and Solomon`s Concise System of Orthopaedics and Trauma. London: CRC Press.
Williams, N. S., Bulstrode, C. J., & O`Connell, P. R. (2008). Bailey & Love`s Short Practice of Surgery. London: Hodder ARNOLD.
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Topic 1: Diagnosis of orthopaedic disorders
Introduction
Orthopaedics is the branch of surgery that deals with diseases and injuries of the trunk and limbs. It deals with conditions affecting bones, joints, muscles, tendons, ligaments, bursae, nerves, and blood vessels. The term “Orthopaedic” is derived from Greek words meaning ‘straight child’. Orthopaedics originally dealt with the art of correcting deformities in children.
DIAGNOSIS OF ORTHOPAEDIC DISORDERS
Depends first upon an accurate determination of all the abnormal features from
- 1. History
- 2. Clinical examination
- 3. Radiographic examination/ imaging
- 4. Special investigations
Secondly, upon a correct interpretation of the findings.
HISTORY
Except in the most obvious conditions, a detailed history is always required, the exact nature of the patient’s complaint being determined. The development of symptoms is traced step by step from their earliest beginning up to the present. It is important to take into consideration the patient’s own views on the cause of the symptoms. They are often correct.
Pay attention to the following:
- • Relieving and aggravating factors/activities
- • Effect of any previous treatment
- • Presence or absence of symptoms in other parts of the body
- • Whether the general health of patient affected
- • History of previous illnesses
Facts that often have an important bearing on the condition/problem are:
- 1. Age
- 2. Present occupation
- 3. Previous occupation
- 4. Hobbies and recreational activities
- 5. Previous injuries.
In cases that seem trivial, inquire tactfully as to why patient decided to seek advice, and to what extent he is worried by his disability.
CLINICAL EXAMINATION
The clinical examination should include:
- 1. Examination of the part complained of
- 2. Investigation of possible sources of referred symptoms
- 3. General examination of the body as a whole
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Topic 1: Examination of the part complained of
Examination of the part complained of
Exposure for examination
The part to be examined should be adequately exposed and in good light, and when a limb is being examined, the sound limb should always be exposed for comparison.
Inspection
- The bones – general alignment and position of the parts to detect any deformity, shortening, or unusual posture.
- The soft tissues – observe soft tissue contours. Compare the two sides. Note swelling and muscle wasting.
- Color and texture of the skin – look for redness, cyanosis, pigmentation, shininess and loss of hair.
- Scars or sinuses – if a scar is present, determine from its appearance whether it was caused by:
- 1. Operation (linear scar with suture marks)
- 2. Injury (irregular scar), or
- 3. Suppuration (broad, adherent, puckered skin).
Palpation
- Four points should be considered:
- 1. Skin temperature
- 2. The bones – general shape and outline.
- • Feel for thickening, abnormal prominence, and disturbed relationship of the normal landmarks.
- 3. The soft tissues
- • Muscles
- • Joint tissues: thickened synovial membrane; effusion
- • Local swelling: ? Cyst; ? Tumor; General swelling of the part.
- 4. Local tenderness.
- • The exact site of any local tenderness should be mapped out and an attempt made to relate it to a particular structure.
Measurements
- Measurement of limb length is often necessary especially in the lower limbs, where discrepancy between the two sides is important.
- Measurement of limb circumference (compare two sides at the same site) provides an index of: muscle wasting, soft tissue wasting, and bony thickening.
Estimation of fixed deformity
Fixed deformity exists when a joint cannot be placed in the neutral (anatomical) position. The degree of fixed deformity at a joint is determined by bringing the joint as near as it will come to the neutral (anatomical) position and then measuring the angle by which it falls short.
Movements
The following should be sought in the examination of joint movement:
- • What is the range of active movement?
- • Is passive movement greater than active?
- • Is movement painful?
- • Is movement accompanied by crepitation?
- • Is there any spasticity (stiff resistance of free movement)?
It is wise always to use the unaffected limb for comparison. Limitation of movement in all directions suggests some form of arthritis. Selective limitation of movements in some directions with free movement in others is more suggestive of a mechanical derangement.
The passive range will exceed the active range only in the following circumstances: -
- 1. When the muscles responsible for the movements are paralyzed.
- 2. When the muscles or their tendons are torn, severed or unduly slack.
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Topic 1: Examination ...
Stability
The stability of a joint depends partly upon the integrity of its articulating surfaces and partly upon intact ligaments, and to some extent upon healthy muscles. When a joint is unstable, there is abnormal mobility; for instance, lateral mobility in a hinge joint.
Power
The power of the muscles responsible for each movement of a joint is determined by instructing the patient to move the joint against the resistance of the examiner. Compare the two sides.
- Power 0 - no contraction
- Power 1 - a flicker of contraction
- Power 2 - slight power, sufficient to move the joint only with gravity eliminated.
- Power 3 - power sufficient to move the joint against gravity.
- Power 4 - power to move the joint against gravity plus added resistance.
- Power 5 - normal power.
Sensation
- Test for sensibility to light touch and to pin prick throughout the affected area.
- In unilateral affection the opposite side should be similarly tested.
- Any blunting or loss of sensibility should be carefully mapped out.
- Identify the nerves affected (dermatomes).
Peripheral circulation
Examine for the following: -
- 1. The color of the skin – normal pink or pale, cyanosed.
- 2. The temperature of the skin – cold in impaired arterial supply
- 3. The texture of the skin and nails – ischaemia causes loss of hair, thin & inelastic skin, coarse, thickened, irregular nails
- 4. The arterial pulses – lower limb (dorsalis pedis, posterior tibial, popliteal, femoral)
- 5. Capillary return
Reflexes
Deep reflexes: Determine the integrity of central nervous system or peripheral nervous system. They are exaggerated in CNS problem and depressed in PNS problem.
Superficial reflexes: motor responses to scraping of the skin, e.g. abdominal reflex; Cremasteric reflex; plantar reflex.
Tests of function
Assess how much the disorder affects the part in its fulfillment of everyday activities. E.g. observe the patient standing, walking, running, jumping, ascending and descending stairs.
INVESTIGATION OF THE POSSIBLE SOURCES OF REFERRED SYMPTOMS
Think of possible extrinsic disorders with referred symptoms. E.g.:
- 1. For shoulder pain, examine the neck (Brachial plexus), thorax, abdomen (diaphragmatic irritation).
- 2. For hip pain, examine the back (spine) and sacro-iliac joints.
- 3. Pain in the thigh – examine the spine, abdomen, pelvis, genito-urinary system, or hip
GENERAL EXAMINATION
- 1. Examine the patient as a whole.
- 2. Assess the general physical condition and psychological outlook of the patient.
- 3. Do systemic examination.
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Topic 1: Diagnostic Imaging & Special Investigations
DIAGNOSTIC IMAGING
You can carry out the following investigations: -
- 1. Radiography
- 2. Ultrasound scanning
- 3. Computerized tomography (CT) scanning
- 4. Magnetic resonance imaging (MRI)
- 5. Radioisotope scanning
- 6. Positron emission tomography (PET CT)
Radiography
Plain radiography – X-rays
- At least two projections in planes at right angles to one another – usually AP & Lateral views
- The films should always include a good length of bone above and below the site of the injury or lesion, including the adjacent joints.
Contrast radiography
- • Myelography – in which the spinal theca is outlined with an oily non-absorbable contrast medium (fluid).
- • Radiculography – in which water-soluble absorbable contrast medium allows visualization of the nerve sleeves, as well as the spinal theca itself. (Especially used for lumbar spine).
- • Arthrography – outlines the cavity of a joint.
- • Arteriography or angiography- to show the arterial tree.
- • Venography – shows network of veins.
- • Lymphangiography – shows lymphatic network
- • Sinography – defines the course and ramifications of a sinus.
SPECIAL INVESTIGATIONS
Depend on the condition you are dealing with.
- • Haematological – e.g. haemogram, ESR
- • Serological – e.g. Widal test, V.D.R.L
- • Bacteriological – E.g. Gram stain, Culture and sensitivity
- • Biochemical – upon urine, plasma, cerebrospinal fluid
- • Histological - biopsy
Assignment
Outline the steps taken in reading and correctly interpreting a plain radiograph in orthopaedics.
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Topic One: Summary
In this topic we have seen that:
Diagnosis of orthopaedic disorders depends:
- First, upon an accurate determination of all the abnormal features from
- History
- Clinical examination
- Radiographic examination/ imaging
- Special investigations
- Secondly, upon a correct interpretation of the findings.
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Topic One: Further Reading
Reference Material
Atingà, J. E., Mutiso, V. M., & Otsyeno, F. M. (2014). AORF Text Book of Orthopaedics. Nairobi: Acrodile Publishing.
Burkitt, H. G., Quick, C. R., & Reed, J. B. (2014). Essential Surgery - Problems, Diagnosis and Management. London: Churchill Livingstone, ELSEVIER.
Dandy, D. J., & Edwards, D. J. (2009). Essential Orthopaedics and Trauma. London: Churchill Livingstone, ELSEVIER.
Ebnezar, J. R. (2016). Textbook of Orthopedics. New Delhi: Ansari.
Garden, O. J., & Parks, R. W. (2018). Principles and Practice of Surgery. London: ELSEVIER.
Hamblen, D. J., & Simpson, A. H. (2013). Adams`s Outline of Fractures. London: Churchill Livingstone, ELSEVIER.
Hamblen, D. S. (2010). Outline of orthopaedics. London: Elsevier Churchill Livingstone.
Kenneth, A., et al (2010). Handbook of Fractures, 4th Ed. Wolters Kluwer, Philadelphia
McRae, R. (2010). Clinical Orthopaedic Examination. London: Churchill livingstone Elsevier.
Solomon, L. W. (2009). Apley's System of Orthopaedics and Fractures. London: CRC Press.
Solomon, L., Warwick, D., & Nayagam, S. (2014). Apley and Solomon`s Concise System of Orthopaedics and Trauma. London: CRC Press.
Williams, N. S., Bulstrode, C. J., & O`Connell, P. R. (2008). Bailey & Love`s Short Practice of Surgery. London: Hodder ARNOLD.
Further Reading Resources
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Topic Two: TREATMENT OF ORTHOPAEDIC DISORDERS
Orthopaedic treatment falls into three categories: -
1. No treatment – simply reassurance and advice
2. Non-operative treatment
3. Operative treatment
NON-OPERATIVE TREATMENT METHODS
REST
- • Is one of the mainstays of orthopaedic treatment
- • This may be in the form of bed rest or immobilization of the diseased part
SUPPORT
• Rest and support often go together
• Support can be used to:
- 1. Stabilize a joint rendered insecure by muscle paralysis
- 2. Prevent the development of deformity
- 3. Support can be provided by cast, splint or orthosis
• Examples of orthoses include:
- 1. Spinal braces or corsets
- 2. Cervical collars
- 3. Wrist supports
- 4. Walking calipers
- 5. Knee and ankle orthoses, and devices to control foot drop.
PHYSIOTHERAPY
Is very useful in non-operative and post-operative management of orthopaedic conditions.
Physiotherapy can be:
- 1. Active
- 2. Passive
- 3. A combination of active and passive
Passive approaches are carried out on the patient by the physiotherapist
Active approaches require active involvement by the patient, either by exercising or changing behaviour.
Active interventions include: Exercises and Physical fitness.
Exercises aim to: Strengthen specific muscles; Stretch soft tissues; Mobilize joints; and Improve co-ordination of muscles.
Physical fitness programmes include aerobic exercise with an aim to improve overall cardiovascular fitness, as well as specific exercises.
Hydrotherapy is a way of allowing active pain-free movements of all joints in warm water.
Passive interventions
Are carried out by the therapist and do not require any active participation by the patient.
The chief use of passive movements or mobilization is to preserve full mobility when the patient is unable to move the joint actively, e.g. when muscles are paralyzed or severed.
Passive interventions include: Manual therapy; Soft tissue techniques; Traction; Electrotherapy; and Ultrasound.
LOCAL INJECTIONS
Indicated in two scenarios:
- 1. In joint affections that require intra-articular injection of drugs
- E.g. injection of hydrocortisone or other steroid into the joint in osteoarthritis or rheumatoid arthritis
- 2. In extra-articular lesions ascribed to chronic strain such as tennis elbow, tendonitis about the shoulder, and certain types of back pain.
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Topic Two: Treatment of Orthopaedic conditions - Drugs
DRUGS
Categories of drugs used include:
• Antibacterial agents
• Analgesics
• Sedatives
• Anti-inflammatory drugs
• Hormone-like drugs
• Anti-osteoporosis drugs
• Specific drugs
• Cytotoxic drugs
Antibacterial agents
Are used in infective lesions such as: Acute osteomyelitis; acute pyogenic arthritis; and Tuberculosis.
Treatment must be started early for best outcomes.
Analgesics and sedatives
Analgesics should be used as sparingly as possible
It is undesirable to prescribe analgesics continuously for prolonged periods
Sedatives may be given if needed to promote sleep, but should not be overprescribed.
Anti-inflammatory drugs
These are drugs that dampen excessive inflammatory response by inhibiting the cyclooxygenase enzymes responsible for prostaglandin formation. Non-steroidal anti-inflammatory drugs are to be preferred. Many of these drugs also have analgesic action.
Steroids such as cortisone, prednisolone, and their analogues should be used with extreme caution due to possible adverse effects.
Hormone-like drugs
These include:
- i. Corticosteroids
- ii. Sex hormones or analogues used for prevention of osteoporosis in post-menopausal women, and for the control of certain metastatic tumours such as hormone-dependent breast and prostatic tumours.
- iii. Biphosphonates – drugs which block the resorption of bone mineral.
Specific drugs
• Vitamin C for scurvy
• Vitamin D for rickets
• Salicylates for arthritis of rheumatic fever
Cytotoxic drugs
Form the basis of chemotherapy for malignant tumours. These anticancer drugs include: Cyclophosphamide, Melphalan, Vincristine, Doxorubicin, and Methotrexate. They have serious side effects and are used only under expert supervision.
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Topic Two: Treatment of orthopaedic disorders
MANIPULATION
This is the passive movements of joints, bones, or soft tissues carried out by the surgeon – with or without anaesthesia, and often forcefully – as a deliberate step in treatment. This method has three main uses:
- i. Manipulation for correction of deformity – e.g. reduction of fractures and dislocations; correction of deformity from contracted or short soft tissues e.g. CTEV.
- ii. Manipulation to improve the range of movements at a stiff joint
- iii. Manipulation for relief of chronic pain in or about a joint, especially in the neck or spine.
RADIOTHERAPY
Radiotherapy by X-rays or by the gamma rays of radio-active substances may be used for certain benign conditions or for malignant disease.
OPERATIVE TREATMENT
Includes:
- 1. Synovectomy
- 2. Osteotomy
- 3. Arthrodesis
- 4. Arthroplasty
- 5. Bone grafting operations
- 6. Tendon transfer operations
- 7. Tendon grafting operations
- 8. Equalization of leg length
- 9. Amputation
Synovectomy
Is the operation for removal of the inflamed lining of a joint (synovial membrane), while leaving the capsule intact.
Useful in early rheumatoid arthritis and in some types of chronic infective arthritis.
Osteotomy
Is the operation of cutting bone or creating a surgical fracture
Indications include: -
- 1. Correction of excessive angulation, bowing or rotation of a long bone.
- 2. To permit angulation of a bone so as to compensate for mal-alignment at a joint
- 3. To allow for lengthening or shortening of a bone in the lower limb in order to correct length discrepancy.
- 4. To improve stability of the hip by altering the line of weight transmission (abduction osteotomy)
- 5. To improve containment in transient avascular necrosis of the epiphysis of a long bone
- 6. To relieve the pain of an osteoarthritic hip.
Arthrodesis
This is an operation to fuse a joint
Indications:
- 1. Advanced osteoarthritis or rheumatoid arthritis with disabling pain, especially when confined to a single joint
- 2. Quiescent tuberculous arthritis with destruction of the joint surfaces, to eliminate risk of recrudescence and to prevent deformity
- 3. Instability from muscle paralysis, as after poliomyelitis
- 4. For permanent correction of deformity, as in hammer toe.
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Topic Two: Treatment of orthopaedic disorders
Arthroplasty
Arthroplasty is the operation for the reconstruction of a new movable joint. It can be carried out in the following joints: Hip, Knee, Ankle, Shoulder, Elbow, Hand joints, First metatarso-phalangeal joint.
Indications of Arthroplasty include:
- 1. Advanced osteoarthritis or rheumatoid arthritis with disabling pain, especially in the hip, knee, ankle, shoulder, elbow, hand and metatarso-phalangeal joints.
- 2. Quiescent destructive tuberculous arthritis especially of the elbow or hip
- 3. For the correction of certain types of deformity, especially hallux valgus
- 4. Certain ununited fractures of the neck of the femur
Methods of arthroplasty:
- • Excision arthroplasty: Excision of one end or both of the articular ends so that a gap is created between them, creating a false joint or pseudoarthrosis.
- • Hemiarthroplasty or half-joint replacement: Only one of the articulating surfaces is removed and replaced with a prosthesis of similar shape.
- • Total replacement arthroplasty: Both of the articular ends are excised and replaced by prosthetic components.
Bone grafting operations
Types of bone grafts:
- • Autogenous grafts or autografts: are bone grafts obtained from another part of the patient`s own body
- • Allografts or homogenous grafts or homografts: are bone graft obtained from another human subject
- • Xenografts or hetrogenous grafts or heterografts: are grafts obtained from animals
Indications
- • In non-union of fractures to promote union
- • In arthrodesis of joints, either to supplement an intra-articular arthrodesis or to promote extra-articular fusion
- • To fill a defect or cavity in a bone
Techniques / Methods
Strut grafts
Are obtained from strong cortical bone such as the subcutaneous part of the tibia. The graft is fixed to the recipient bone by internal fixation or by inlaying. It serves as an internal splint as well as providing a framework for the growth of new bone.
Strip grafts
Sliver or strip grafts are obtained from spongy cancellous bone – especially from the iliac crest. Commonly used for ununited fractures. They are laid about the fracture, deep to the periosteum.
Chip grafts
Are obtained from cancellous bone; are smaller pieces than sliver grafts. They are used for non-united fractures; the chips are packed firmly into or around the recipient bone and held in place by suture of the soft tissues over them.
Vascularised grafts
Require a suitable donor site such as the fibula, rib, or iliac crest. Anastomosis of nutrient vessels is meticulously done at the new site.
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Topic Two: Summary
In this topic we have learned that;
Orthopaedic treatment falls into three categories: -
- 1. No treatment – simply reassurance and advice
- 2. Non-operative treatment
- 3. Operative treatment
We have also discussed the various non-operative methods of treatment and the operative methods of treatment.
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Topic 3: Pathology of Fractures and Fracture Healing
PATHOLOGY OF FRACTURES AND FRACTURE HEALING
Definition of fracture
A bone fracture (#) is a break in the continuity of the bone. It may be a complete break or an incomplete break of the bone.
A bone fracture can be the result of:
- • High force impact or stress, or
- • Trivial injury as a result of certain medical conditions that weaken the bones, where the fracture is then properly termed a pathological fracture.
Classification of fractures
Fractures can be classified according to:
- 1. Aetiology
- 2. Whether open or closed
- 3. Fracture pattern
CLASSIFICATION BY AETIOLOGY
Fractures may be classified, according to their aetiology, into four groups:
- 1) Traumatic fractures
- 2) Fragility fractures
- 3) Fatigue or stress fractures
- 4) Pathological fractures
Traumatic fracture - This is a fracture due to sudden injury or trauma. e.g. - Fractures caused by a fall, road traffic accident, fight etc. They occur through bone that was previously free from disease. May occur by direct violence or by indirect violence.
Fragility fractures – these are fractures associated with generalized bone weakness due to osteoporosis. Seen most commonly in elderly patients
Fatigue or stress fractures – occur from oft-repeated stress and not from a single violent injury. Commonly occur in athletes or new military recruits. They occur when the rate of microdamage exceeds the rate of repair. The microdamage accumulates and progresses to a complete fracture across the full width of the bone. Mostly occur in the metatarsals (mostly 2nd and 3rd). May also occur in the shaft of fibula, tibia and neck of femur.
Pathological fractures – fractures through bone already weakened by disease. Occur following trivial violence, or even spontaneously. Usually occur in conditions that weaken the bones, such as bone cancer, osteogenesis imperfecta, bone cysts, chronic bone infection.
CLOSED AND OPEN FRACTURES
All fractures can be broadly described as:
- 1. Closed (simple) fractures: Are those in which the skin is intact, and therefore no communication between the site of fracture and the exterior of the body.
- 2. Open (compound) fractures: There is a wound on the skin surface that communicates with the fracture. May thus expose bone to contamination. Open injuries carry a higher risk of infection.
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Topic 3: Pathology of Fractures and Fracture Healing
PATTERNS OF FRACTURE
Fractures can be designated by descriptive terms denoting the shape or pattern of the fracture. 
The following are the terms in common use:
1. Transverse fracture: A fracture that is at a right angle to the bone's long axis.
2. Oblique fracture: A fracture that is diagonal to a bone's long axis. 
3. Spiral fracture: A fracture where at least one part of the bone has been twisted.
4. Comminuted fracture: A fracture in which the bone has broken into several pieces (more than 2).
5. Compression or crush fracture: usually occurs in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis
6. Greenstick fractures – A greenstick fracture occurs when a bone bends and cracks, instead of breaking completely into separate pieces. They are peculiar to children below 10 years. Their bones are springy and resilient like branches of a young tree (a green stick) 
7. Impacted fractures – the bone fragments are driven so firmly together that they become interlocked and there is no movement between them.
8. Segmental fracture - is a fracture composed of at least two fracture lines that together isolate a segment of bone, 
usually a portion of the diaphysis of a long bone. It is a comminuted fracture with middle fragment having the full circumference intact.
9. Avulsion fracture: A fracture where a fragment of bone is separated from the main mass as a result of a tendon or ligament pulling off a piece of the bone.
10. Linear fracture: A fracture that is parallel to the bone's long axis.
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Topic 3: Healing of Fractures
HEALING OF FRACTURES
A fracture begins to heal as soon as the bone is broken. Healing proceeds through several stages until the bone is consolidated. Fracture healing, is a proliferative physiological process in which the body facilitates the repair of a bone fracture.
REPAIR OF TUBULAR BONE
Occurs in five stages:
- 1. Stage of haematoma
- 2. Stage of subperiosteal and endosteal cellular proliferation
- 3. Stage of callus
- 4. Stage of consolidation
- 5. Remodeling
Stage of haematoma
- • Bleeding torn vessels form a haematoma between and around the fracture surfaces
- • Haematoma is contained by the periosteum, which may be stripped up
- • Where the periosteum is torn, the haematoma extravasates into soft tissues and is contained by muscles, fascia and skin.
- • Deprived of blood supply, about 1or 2 millimeters of bone at the fracture surfaces dies.
Stage of subperiosteal and endosteal cellular proliferation
- • Within 8 hours of the fracture there is an acute inflammatory reaction with migration of inflammatory cells and the initiation of proliferation and differentiation of mesenchymal stem cells.
- • Cells proliferate from the deep surface of the periosteum and the breeched medullary canal [in the endosteum and marrow tissue].
- • The cells are precursors of osteoblasts, which later lay down the intercellular substance.
- • The cellular tissue form a collar of active tissue around each fragment, which grows out towards the other fragment and this creates a scaffold across the fracture site.
- • The clotted haematoma is gradually absorbed and fine new capillaries grow into the area.
Stage of callus
- • The differentiating stem cells give rise to osteoblasts and chondroblasts.
- • The osteoblasts lay down an intercellular matrix of collagen and polysaccharide, which soon becomes impregnated with calcium salts to form the immature bone or osteoid of fracture callus.
- • Osteoclasts also begin to mop up dead bone.
- • As the immature fibre bone [woven bone] becomes more densely mineralized, movement at the fracture site decreases progressively and the fracture becomes rigid.
- • At about 4 weeks after injury the fracture fragments unite and the fracture is said to be ‘sticky’.
- • The callus may be felt as a hard mass surrounding the fracture.
- • The mass of callus is also visible in radiographs and gives the first indication of union.
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Topic 3: Healing of Fractures
Stage of consolidation
- •With continuing osteoclastic and osteoblastic activity, the woven bone is transformed into lamellar bone [a more mature bone with a typical lamellar structure]
Stage of remodeling
- • Newly formed bone often forms a bulbous collar which surrounds the bone and obliterates the medullary canal.
- • The mass of callus tends to be large when:
- There is marked periosteal stripping
- The fracture haematoma has been large
- There is marked displacement of the fragments.
- • The mass tends to be small when:
- Bone fragments are in exact anatomical apposition
- The fragments are rigidly fixed in close apposition by a metal plate with screws or by an intramedullary nail.
- • Callus is usually profuse in children because the periosteum is easily stripped from the bone by extravasated blood, allowing bone to form beneath it.
- • In the months that follow, the bone is gradually strengthened along the lines of stress, and surplus bone outside the line of stress is slowly removed. The medullary cavity is gradually reformed, and eventually the bone assumes a shape as close to normal as possible.
- • In children, remodeling is usually so perfect that eventually the site of the fracture becomes indistinguishable on radiographs.
- • In adults the site of fracture is usually permanently marked by an area of thickening or sclerosis.
REPAIR OF CANCELLOUS BONE
- • Healing of cancellous bone follows a different pattern from that of tubular bone.
- • Because the bone is of uniform spongy texture and has no medullary canal, there is a relatively much broader area of contact between the fragments, and the open meshwork of trabeculae allows easier penetration by bone forming tissue.
- • Union can occur directly between the bone surfaces and it does not have to take place through the medium of external callus.
- • The first stage of healing is the formation of a haematoma, into which new blood vessels and proliferating osteogenic cells from the fracture surfaces penetrate until they meet and fuse with similar tissue growing out from the opposing fragment.
- • Osteoblasts then lay down the intercellular matrix, which becomes calcified to form woven bone.
Assignment
- 1. Discuss the rate of union of fractures, outlining factors that influence the speed of union.
- 2. Classify the common causes of pathological fractures.
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Topic 3: Summary
In this topic you have learnt that:
Fractures can be classified according to:
- 1. Aetiology
- 2. Whether open or closed
- 3. Fracture pattern
Healing of tubular bone occurs in five stages:
- 1. Stage of haematoma
- 2. Stage of subperiosteal and endosteal cellular proliferation
- 3. Stage of callus
- 4. Stage of consolidation
- 5. Remodeling
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Topic Four: PRINCIPLES OF FRACTURE MANAGEMENT
PRINCIPLES OF FRACTURE MANAGEMENT
Learning objectives
- • Outline the steps in the initial management of a patient with fracture.
- • Outline the priorities of management of a patient with multiple injuries
- • Discuss the three fundamental principles of fracture treatment: Reduction; Immobilization; and Rehabilitation
Initial management
First Aid and Clinical Assessment
First Aid
At accident site:
- • Clear the airway
- • Control any external bleeding
- • Cover wounds with clean dressing
- • Immobilize fractured limbs
- • Make patient comfortable
Moving the patient:
- • If fracture of long bone, apply traction while the limb is being moved
- • If spinal column fracture/dislocation is suspected, avoid flexion of the spine. In some cases also avoid extension. Patient should be lifted bodily (straight) on to a firm surface, and the neck protected with a cervical collar.
Temporary immobilization of limbs:
- • Bandage the two lower limbs together (sound limb acts as a splint)
- • Bandage arm to chest
- • Apply a sling for forearm
Control haemorrhage:
- • Apply firm bandage over a pad
- • Application of tourniquet (if profuse pulsatile bleeding despite pressure). Time of application must be indicated
- • Apply firm manual pressure over the main artery at the root of the limb
Clinical assessment
- • Follow the priorities of management of a multiple injury patient.
- • Primary survey – ABC
- • Secondary survey
- 1. Re-examine ABC
- 2. Investigate as per injury
- 3. Physical examination of all systems
- 4. Drug treatment (analgesics, antibiotics, tetanus toxoid)
Examination of the limb should determine:
- • Whether there is a wound communicating with the fracture
- • Evidence of vascular injury
- • Evidence of nerve injury
- • Evidence of visceral injury
Resuscitation
Is done during primary survey
- • Airway
- • Breathing
- • Circulation
- Many of the severe trauma patients (multiple fractures with visceral injury) have problem with circulation. They are usually in shock.
Correction of shock:
- Immediate replenishment of circulating blood volume
- Infuse electrolyte fluids to establish intravenous infusion: Normal saline; Ringer’s lactate.
- Plasma expanders (colloids) to replace the lost volume: Dextran – a high molecular weight polysaccharide; Hemacel – a gelatin solution.
- Transfusion only for severe haemorrhage > 1 liter
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Topic Four: Priorities of management of multiple injury patient
Priorities of management of a patient with multiple injuries
Advanced trauma life support (ATLS)
Steps in the ATLS philosophy:
- 1. Primary survey with simultaneous resuscitation – identify and treat what is killing the patient.
- 2. Secondary survey – proceed to identify all other injuries.
- 3. Definitive care – develop a definitive management plan.
On arrival:
- • Take a brief history
- • Do Primary survey – ABC
• Airway:
- 1. The airway must be evaluated first
- 2. Check verbal response. If present, the airway is not immediately at risk.
- 3. Ensure the airway is clear. Clear the mouth and airway with a large-bore sucker. Inspect for any FBs.
- 4. Stabilize the neck to protect the cervical spine.
• Breathing:
- 1. Make sure the patient is ventilating and if not, assist (Ambu bag, oxygen)
- 2. Give 100% oxygen at high flow
- 3. Check for tension pneumothorax
- 4. Decompress at once if tension pneumothorax is suspected (needle in the second intercostal space mid-clavicular line)
• Circulation:
- 1. Assess consciousness level – compromised cerebral perfusion; Assess skin colour for pallor; Asses the pulse; BP
- 2. Secure an intravenous line
- 3. Give I.V. fluids to restore blood volume
- 4. Stop obvious bleeding
- 5. Blood for GXM, Hb, haematocrit, blood gases
Secondary survey
Secondary survey involves:
- 1. Re-examine ABC
- 2. Investigate as per suspected injuries
- • Skull x-ray
- • Chest x-ray
- • Spinal x-ray
- • Pelvic x-ray
- 3. Perform a physical examination of body systems even if you think they are not injured
- 4. Give analgesics
- 5. Administer tetanus toxoid in case of open wounds
- 6. Give antibiotics in case of open wounds
- 7. Splint the fractures
- 8. Admit or refer the patient
Definitive care
There should be as little delay as possible in reaching this stage. A definitive management of the injuries identified is carefully planned and carried out.
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Topic Four: Fundamental principles of fracture treatment
Fundamental principles of fracture treatment
Are three:
- 1. Reduction
- 2. Immobilization
- 3. Rehabilitation – preservation of function
Reduction
Reduction is done if necessary. In some cases there is no displacement, or displacement may be immaterial to the final result. Imperfect apposition of the fragments can be accepted, e.g. a loss of contact of half the diameter in fracture femur. Imperfect alignment may not be accepted, e.g. angulation (angular deformity of more than 20 degrees in fracture femur). Fractures involving joint surfaces must be reduced as accurately as possible. The articular fragments must always be restored as nearly as possible to normal to lessen the risk of osteoarthritis.
Methods of reduction
Three methods:
- 1. Closed manipulation
- • Manipulative reduction usually under anaesthesia or sedation and strong analgesia.
- 2. Mechanical traction (with or without manipulation)
- • To overcome contraction of large muscles that exert a strong displacing force.
- 3. Operative reduction (open reduction)
Immobilization
If necessary
Indications for immobilization:
- • To prevent displacement or angulation of the fragments – in order to maintain correct alignment
- • To prevent movement that might interfere with union
- • To relieve pain
Prevention of displacement or angulation:
- • Immobilize to prevent displacement or angulation of the fragments – in order to maintain correct alignment
Prevention of movement:
- • Movement is undesirable when it might shear the delicate capillaries bridging the fracture, e.g. rotation movements.
- 1. Fracture of the neck of femur
- 2. Fracture of the scaphoid bone
- 3. Fracture of the shaft of ulna
- 1. Fracture of the ribs
- 2. Fracture of the clavicle
- 3. Fractures of the scapula
- 4. Stable fractures of the pelvic ring
• Injured fingers poorly tolerate prolonged immobilization. Leads to stiffness.
Relief of pain:
- • Relief of pain is an important reason for immobilization
- • The limb is made comfortable
- • It is possible to use the limb without causing movement at the fracture site, therefore causing no pain.
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Topic Four: Methods of Immobilization
Methods of immobilization
Four methods:
- 1. Plaster of Paris cast (P.O.P), Dyna cast or other external splint, e.g. cervical collar, malleable strips of aluminium.
- 2. Continuous traction
- 3. External fixation
- 4. Internal fixation
Immobilization by plaster /cast
- Assignment:
- 1. Write down the requirements and procedure of application of plaster of Paris.
- 2. Describe the use of:
- a) Plaster-cutting shears
- b) Powered oscillating plaster saw
- c) Plaster spreader
- 3. What complications may follow application of P.O.P, and how do you prevent/manage them?
Immobilization by sustained traction
• Used mainly for fractures that are difficult or impossible to hold in proper position by plaster or external splint alone. E.g. fractures of shaft of femur.
• Also used when the fragments are difficult to hold in position particularly when the fracture is oblique or spiral because the elastic pull of muscles tends to draw the distal fragment proximally so that it overlaps the proximal fragment.
• The pull of muscles must be balanced by sustained traction upon the distal fragment, by a weight or other mechanical device.
• Angular deformity is prevented by use of a splint e.g. Thomas’s splint for femur and Braun’s splint/frame for tibia.
Skeletal traction
Traction is applied to pins passed through the bone. They allow substantial loads to be applied accurately to the bone itself. Common sites for application are:
- 1. Upper end of the tibia (tibial tuberosity)
- 2. Distal femur
- 3. Calcaneum
- 4. Olecranon
- 5. The skull
- 6. Pelvis
- 7. Greater trochanter
Types of pin used in skeletal traction
Two types of pin are in common use:
- 1) Steinmann pin
- • Has a trocar and smooth sides
- • Easy to insert, but it can slip sideways after being in position for some time
- 2) Threaded pins, e.g. Denham pin
- • Have threads which grip the bone and prevent lateral slippage
- • Are harder to insert
Skin traction
- • Is applied by means of adhesive strapping stuck directly onto the skin.
- • They pull the bone indirectly through the overlying skin and muscles (soft tissues)
- • The soft tissues can be disrupted if too much weight is applied.
- • The usual upper limit is 5 kg (12 lb)
- • Skin traction is suitable for children and the elderly, and as a temporary measure in adults until definitive treatment is instituted.
Types of traction
- 1. Skeletal or skin traction
- 2. Fixed or sliding
- 3. Fixed traction with a splint e.g. fixed to a Thomas's splint.
- 4. Fixed traction using gravity e.g. gallows traction.
- 5. Sliding traction uses a system of pulleys and weights. E.g. Hamilton-Russell traction.
- 6. Sliding traction can be balanced or not balanced.
- 7. In a balanced traction, one weight applies longitudinal traction and others are applied to the upper and lower ends of the limb so that it ‘floats’ in a gravity-free field.
Complications of traction
1. Over-distraction with resultant: -
• Circulatory embarrassment
• Stretched or damaged nerves
• Non-union or delayed union as fragments are held apart and do not join
2. Loss of position
• Slipped, angulated or overlapped
3. Pressure sores
4. Pin track infection
5. Allergy to adhesive strapping
Assignment:
- 1) Describe the procedure of application of skin traction
- 2) State the indications, contraindications, and complications of skin traction
- 3) Describe the procedure of application of skeletal traction for fractures of the femur
- 4) State the indications, contraindications, and complications of skeletal traction
- 5) Name the various traction arrangements (e.g. Russell's traction) and their indications
- 6) Name the various parts of an orthopaedic bed and traction apparatus.
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Topic Four: Immobilization by External Fixation
Immobilization by external fixation
• External fixation implies anchorage of the bone fragments to an external device such as a metal bar through the medium of pins inserted into the proximal and distal fragments of a long bone fracture. 
• Threaded pins are inserted into the bone from one side.
• Two or three pins are inserted into each fragment and the protruding ends of the pins are clamped to the rigid body of the fixator, which lies just clear of the skin surface parallel with the fractured bone.
Indications of External Fixation
1. Stabilization of severe open fractures 
2. Stabilization of fractures associated with infection or nonunion
3. Severely comminuted diaphyseal and peri-articular fractures
4. Closed fracture with associated severe soft tissue injuries
5. Severely comminuted and unstable fractures
6. Pelvic ring disruptions 
7. Arthrodesis
8. Fractures that are associated with bony deficits
9. Limb-lengthening procedures
10. Osteotomies
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Topic Four: Immobilization by Internal Fixation
Immobilization by internal fixation
Indications:
1. To provide early control of limb fractures when conservative methods would interfere with the management of other severe injuries, for instance of the head, thorax or abdomen.
2. As a method of choice in certain fractures, to secure immobilization of the fracture and to allow early mobility of the patient, e.g. in the elderly patient with trochanteric hip fracture
3. When it has been necessary to operate upon a fracture to secure adequate reduction
4. If it is impossible in a closed fracture to maintain an acceptable position by splintage alone.
5. Fractures that cannot be controlled in any other way
6. Patients with fractures in more than one bone
7. Fractures in which the blood supply to the limb is jeopardized and the vessels must be protected
8. Intra-articular, displaced fractures
Methods of internal fixation 
1) Metal plate held by screws or locking plate (with screws fixed to the plate by threaded holes)
2) Intramedullary nail – plain [e.g. K-nail] or interlocking i.e. with locking screws [e.g. Sign nail] 
3) Dynamic compression screw-plate [dynamic hip screw] 
4) Condylar screw-plate
5) Tension band wiring
6) Transfixion screws
7) Kirschner wire fixation
Metals for internal fixation
- • Must be resistant to corrosion in the tissues.
- • A special stainless steel containing chromium, nickel and molybdenum is widely used.
- • A non-ferrous alloy containing chromium, cobalt and molybdenum has even better resistance to corrosion in the body and is used for all types of internal appliance except wire.
- • Titanium and its alloys are also resistant to corrosion and are used for the manufacture of prostheses and internal fixation devices.
The place of operative fixation
Operative fixation is accepted as the best routine method of treating fractures of the neck and trochanteric region of the femur in the elderly. Intramedullary nailing is used for most fractures of the shaft of femur or tibia, and many fractures of the upper limb are also now routinely operated on.
Advantages of internal fixation
1. Substantial reduction in hospital stay and time away from work
2. Function of the limb, and particularly of the joints, may be restored earlier
3. By providing rigid fixation of the fracture, complications such as delayed union and non-union will be reduced.
Rehabilitation
Rehabilitation is always essential, and should begin as soon as the fracture is under definitive treatment. The purpose of rehabilitation is to: -
- Preserve function while the fracture is uniting;
- Restore function to normal when the fracture is united.
This is achieved by encouraging the patient to help himself by active use and active exercises. Supervision of a physiotherapist is required.
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Topic Four: Summary
In this topic you have learnt steps in the initial management of a patient with fracture (First aid); Priorities of management of a patient with multiple injuries (Primary survey, Secondary survey); and Fundamental principles of fracture treatment, which are three:
- 1) Reduction
- 2) Immobilization
- 3) Rehabilitation – preservation of function
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Topic Five: OPEN FRACTURES
OPEN FRACTURES
Definition:
A fracture is open or compound when there is a wound of the skin surface leading down to the site of fracture. A fracture is classed as open only when a direct communication exists between the body surface and the fractured bone ends.
Gustilo-Anderson Classification of open fractures
The Gustilo–Anderson classification divides open fractures into three types – I, II & III. 
Type I:
Clean wound smaller than 1 cm in diameter, Appears clean, Simple fracture pattern, No skin crushing.
Type II:
A laceration larger than 1 cm but without significant soft tissue crushing: No flaps, No degloving, No contusion [a bruise]. Simple fracture pattern
Type III:
High-energy injury with extensive soft tissue damage; or an open segmental fracture or multifragmentary fracture, or bone loss irrespective of the size of skin wound; or Severe crush injuries; or vascular injury requiring repair. Also included are injuries older than 8 hours or severe contamination.
Type III injuries are subdivided into three types: 
- Type III A: Adequate soft tissue coverage of the fracture despite high energy trauma or extensive laceration or skin flaps.
- Type III B: Inadequate soft tissue coverage with periosteal stripping. Soft tissue reconstruction is necessary.
- Type III C: Any open fracture that is associated with vascular injury that requires repair.
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Topic Five: Treatment of open fractures
Treatment of open fractures
An open fracture requires urgent attention. The sooner the wound can be dealt with, the smaller is the risk of infection arising from contaminating organisms. Initial management at the emergency department includes carrying out a primary survey – ABC: -1. AIRWAY: Ensure airway is clear
2. BREATHING: Make sure the patient is ventilating and if not assist (Ambu bag, oxygen)
3. CIRCULATION:
- • Assess for bleeding – inspect, pulse, BP
- • Start an IV line
- • Give IV fluids to restore volume
- • Stop obvious bleeding
- • Blood for grouping and cross-match, Hb, haematocrit, blood gases.
Principles of treatment
1) Clean the wound by performing a thorough surgical toilet.
- • Remove all dead and devitalized tissue
- • Remove all extraneous material
- • Aim at leaving healthy, well-vascularized tissues that are able to fight infection from any remaining contaminating organisms.
2) The wound should not be subjected to repeated examination, but should be covered with sterile dressing.
3) Avoid immediate skin closure.
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Topic Five: Treatment of open fractures ...
Technique of operation for major wounds
- 1. Enlarge the skin wound to display clearly the extent of the underlying damage
- 2. Flush the wound with copious quantities of water or saline to remove all contaminating dirt.
- 3. Pick out with forceps any foreign matter e.g. shreds (pieces) of clothing.
- 4. Excise any tissues that are obviously dead
- 5. Remove dead or devascularized muscle in order to reduce the risk of gas gangrene.
- 6. Remove bone fragments that are small and completely detached.
- 7. Large bone fragments, which usually retain some soft tissue attachments, should be preserved.
- 8. The bone ends must be inspected.
- 9. When debriding bone, the fracture edges are curetted and all dirt and non-viable bone are removed.
- 10. Damage to major blood vessels is dealt with by:
- • Ligation
- • Suture
- • Or vein grafting
- 11. The ends of severed nerve trunks may be tucked lightly together with one or two sutures to facilitate later definitive repair.
- 12. Tourniquets should be avoided when possible to prevent additional ischemic injury to the soft tissues.
- 13. Necrotic tissue is removed and only viable tissue is left behind. The exception is skin, where none is removed unless obviously necrotic.
- 14. The quality of the muscle tissue is assessed using the classic 4 C’s:
- • Color (red or brown)
- • Consistency (how does the muscle feel)
- • Capillary Circulation (does it bleed?)
- • Contractility (responds to pinch or electro-cautery)
Skin closure
The wound should be left unsutured after surgical toilet and dressed with sterile covering. Delayed closure should be done as soon as infection has been aborted or overcome (delayed primary suture).
Methods of skin closure
Direct suture of the skin edges if feasible, depending upon the amount of skin destroyed and lost in the injury. If the skin loss is negligible and the skin edges can be brought together without tension, direct suture should be done. A free split-skin graft is used if the skin edges will not come together easily (full-thickness skin graft). Soft-tissue flaps can also be done.
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Topic Five: Treatment of open fractures ...
Treatment of the fracture
Once the wound has been dealt with, the fracture itself should be treated following the general principles of managing closed fractures.
There should be greater reluctance to resort to operative methods of fixation, due to increased risk of infection.
If the fracture is unstable and unsuitable for treatment by traction or by simple splintage, external fixation should be done. This provides temporary stabilization and minimizes additional soft-tissue injury. This fixation facilitates access to the wound for inspection between debridements.
Once the wound has healed, the fracture can be immobilized in plaster for the remaining duration of treatment.
Other treatment
1. Antibiotics:
- • A course of treatment with a broad-spectrum antibiotic, such as a third generation cephalosporin, should be begun immediately and continued until the danger of infection is past.
- • Antibiotics should be given intravenously.
2. Prophylaxis against tetanus:
- • Tetanus toxoid should be given and repeated 6 weeks later or a booster should be given if the patient was already immunized previously.
3. Analgesics
4. Monitor vital signs
The end!
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Topic Six: COMPLICATIONS OF FRACTURES
COMPLICATIONS OF FRACTURES
Complications of fractures can be classified into three broad groups depending upon their time of occurrence. These are as follows -
- 1. Immediate complications - occurs at the time of the fracture.
- 2. Early complications - occurring in the initial few days after the fracture.
- 3. Late complications - occurring a long time after the fracture.
Immediate complications
Systemic
- • Hypovolaemic shock due to haemorrhage
Local
- • Injury to major blood vessels
- • Injury to nerves
- • Injury to muscles and tendons
- • Injury to joints
- • Injury to viscera
Early complications
Systemic
- • Fat embolism syndrome
- • Deep vein thrombosis
- • Disseminated intravascular coagulation [DIC]
- • Septicemia (in open fracture)
- • ARDS - Adult respiratory distress syndrome [shock lung or wet lung]
Local
- • Infection
- • Compartment syndrome
Late complications
Imperfect union of the fracture
- • Delayed union
- • Non union
- • Mal union
- • Cross union
Others
- • Avascular necrosis
- • Shortening
- • Joint stiffness
- • Sudeck's dystrophy
- • Osteomyelitis
- • Ischaemic contracture
- • Myositis ossificans
- • Osteoarthritis
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Topic Six: Complications of fractures
Complications of fractures can also be classified as follows:
Related to the # itself
- • Infection
- • Delayed union
- • Non-union
- • Avascular necrosis
- • Mal-union
- • Shortening
Due to associated injury
- • Injury to major blood vessels
- • Injury to nerves
- • Injury to viscera
- • Injury to tendons
- • Injuries and post-traumatic affections of joints
- • Fat embolism
- • Compartment syndrome
Infection
- • Is common in open fractures contaminated by organisms carried in from outside.
- • Could also follow operative treatment of a closed fracture
- • Very rarely occurs in some closed fractures due to bacteraemia
- • Infection often leads to osteomyelitis
- • The infection of bone tends to become chronic.
Treatment:
- • Acute infection is treated by:
- Establishing free drainage
- Antibacterial medication – choice depends on sensitivity of the organisms.
- • Chronic infection:
- Sequestrectomy and saucerization and chiseling away bone with small pus containing cavities
Mal-union
- • Refers to a fractured bone that has united soundly but in the wrong position (imperfect position).
- • Results from improper or imperfect reduction
- • Commonly presents as angulation, rotation, loss of end-to-end apposition, or overlap and consequent shortening.
- • Treatment of clinically significant mal-union is by dividing the bone, correcting the deformity, and fixing the fragments by the appropriate means.
Shortening
Shortening of a bone after a fracture may occur from the following causes:
- • Mal-union with overlap
- • Mal-union with marked angulation
- • Crushing of bone as in severely comminuted compression fractures
- • Loss of bone as in gunshot wound with a piece of bone shot away
- • Interference with epiphyseal growth plate in children
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Topic Six: Delayed union; Non-union
Delayed union
- • A fracture with delayed union takes longer than expected to unite, but eventually does so.
- • Union is usually deemed to be delayed if the fracture is still mobile 3 or 4 months after the injury.
- • In delayed union, there is nothing in the condition of the bones to indicate that union will fail altogether.
Non-union
- • Healing process fails
- • Bone ends do not unite and remain separate
- • The bone ends at the site of the fracture become dense and rounded.
- • The fracture line becomes increasingly clear-cut.
- • Two types of non-union are seen:
- 1. Hypertrophic non-union
- 2. Atrophic non-union
Hypertrophic non-union:
- • Occurs due to excessive movement at the fracture site, with abundant callus formation but failure to unite due to instability.
- • Characterized by a massive cuff of bone around the ends of the fractures that looks like an elephant’s foot.
- • These fractures are trying desperately to heal.
- • Healing can be enhanced by realigning the limb and preventing movement between the bone ends.
- • Prevention of movement can be done by rigid internal fixation
Atrophic non-union:
- • The fracture gap is filled by fibrous tissue and the bone fragments remain mobile.
- • Shows rounding of the bone ends, sometimes so marked that the tips of the bone ends resemble pencils, and the medullary cavity may be closed.
- • This is indicative of a poor blood supply to the bone ends.
- • A pseudoarthrosis forms in some patients.
- • Treatment aims to ‘kick start’ osteogenesis by bone grafting with fresh cancellous bone or marrow.
Causes of non-union include:
- 1. Infection of the bone
- 2. Incomplete reduction
- 3. Excessive shearing movements between the fragments
- 4. Interposition of soft tissues between the fragments
- 5. Loss of the fracture haematoma in an open fracture
- 6. Dissolution of fracture haematoma by synovial fluid (#s within joints)
- 7. Destruction of bone as by a tumour
Treatment:
- • Bone grafting operation
- • Joint replacement operation e.g. Austin-Moore prosthesis in fracture of the neck of femur
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Topic Six: Avascular necrosis; Post-traumatic ossification; Osteoarthritis
Avascular necrosis
This is death of bone from a deficient blood supply. It occurs when the blood supply to a bone or part of a bone is interrupted by injury. It usually occurs as a complication of a fracture near the articular end of a bone, especially where the terminal fragment is devoid of vascular soft tissue attachments and depends for its nutrition almost entirely upon the intra-osseous vessels which may be torn by the injury. It often leads to non-union and osteoarthritis. The avascular bone gradually loses its rigid trabecular structure and becomes granular or gritty. The bone crumbles easily and may eventually collapse from pressure imposed by muscle tone or body weight.
Sites of avascular necrosis:
• Head of the femur after # neck of femur or hip dislocation
• Proximal half of the scaphoid bone after a fracture through the waist of the scaphoid
• Body of the talus after a fracture through the neck of the talus
• Lunate bone may undergo avascular necrosis after its dislocation.
Diagnosis:
• May be recognized from radiographs about 1-3 months after injury
• The avascular fragment appears denser due to its not taking part in the osteoporosis of disuse affecting surrounding bones.
• Fragment may have reduced height, with a shrunken crumbled appearance.
Treatment:
• Early operation to prevent joint disorganization
• Promote revascularization by drilling the avascular fragment, with or without bone grafting.
• Excision of the avascular fragment and replacing it with a prosthesis, (arthroplasty) or perform arthrodesis.
Post-traumatic ossification
Is a rare cause of joint stiffness after fracture or dislocation. It is Sometimes called myositis ossificans. It occurs in severe injury to a joint, especially when the capsule and periosteum have been stripped from the bones by violent displacement of the fragments. Blood colllects under the stripped soft tissues, forming a large haematoma about the joint. Instead of being absorbed, the haematoma is invaded by osteoblasts and becomes ossified. This leads to restriction of joint movement. It is encountered most commonly in the elbow after fracture-dislocation. It also occurs in the hip after dislocation. There is greater risk of occurrence in children than in adults because the periosteum is only loosely
Treatment
1) Gentle active exercises
2) Excise a mass of bone that is blocking movement.
Osteoarthritis
• Occurs due to roughening or irregularity of joint surface
• Is likely to develop sooner or later after any displaced fracture which involves an articular surface
• Even a slight step between the fragments may lead to serious subsequent disability from arthritis, esp. in a weight bearing joint.
• Avascular necrosis is also an important cause of osteoarthritis.
• There is risk of osteoarthritis if fracture fragments unite with angular deformity because mal-alignment of joint surfaces causes excessive stress at one part of the joint and accelerates wear-and-tear changes.
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Topic Six: Compartment Syndrome
Compartment syndrome
This is a rise in hydrostatic pressure within a fascial compartment leading to compromised circulation within the compartment, with resultant tissue ischaemia and eventually, necrosis.Pathophysiology:
Muscles are contained within fascial compartments. If swelling occurs within a compartment as a consequence of injury, the fascia resists the swelling, and pressure within the compartment rises greatly. Increased pressure occludes the veins and small arteries supplying the muscles causing ischaemia. Muscle ischaemia in turn promotes further swelling worsening the situation. Within a few hours, irreversible changes may occur:
- The muscles may become necrotic
- The nerves within the affected compartment lose their conductivity because of ischaemia
- The muscles are eventually replaced by fibrous tissue, which contracts causing Volkmann’s ischaemic contracture.
Clinical features
• Severe pain in the limb
• Pain worsened by attempted passive extension of the digits
• Pallor of the limb
• Coldness of the limb
• Pulses may be absent if the relevant artery is contained within the affected compartment.
- A lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often well below arterial pressures. Therefore, in compartment syndrome the peripheral arterial pulses may still be present, and this could cause confusion as to the true diagnosis.
• Congestion of the digits with prolonged capillary refill time.
• Paraesthesia (altered sensation e.g., "pins & needles") in the cutaneous nerves of the affected compartment.
• Paralysis of the limb is usually a late finding.
Treatment
• Immediate operation to decompress the whole length of the affected compartment or compartments by fasciotomy.• The fascial compartments and the skin must be divided so that the muscle can swell.
• The wound is left open until swelling has subsided, after which it may be closed or grafted.
Compartments
Forearm
There are two compartments in the forearm:1) Ventral (flexor) compartment
- • Includes the median and ulnar nerves, and the radial and ulnar arteries.
- • Is less often damaged than the ventral
- • It includes the posterior interosseous nerve but no major vessels.
- • Consequences are less serious.
Lower limb
In the leg there are four compartments:1) Anterior tibial compartment
- • Contains the anterior tibial artery and deep peroneal nerve
- • Composed of gastrocnemius and soleus only
- • Has no important vessels or nerves
- • Contains the posterior tibial vessels and nerves and the peroneal artery
- • Consequences are serious
- • Contains the superficial peroneal nerve, but it is seldom affected by compression.
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Topic Six: Fat Embolism Syndrome
Fat embolism syndrome
Is one of the most serious complications of fractures
The essential feature is occlusion of small blood vessels by fat globules.
Pathology
Fat embolism syndrome mainly affects the lungs and brain. Occlusion of blood vessels leads to oedema and haemorrhages in the alveoli of the lungs. Transfer of oxygen from the alveoli to arterioles is thus impaired. This leads to hypoxaemia, which may be severe. In the brain there may be multiple petechial haemorrhages. Petechial haemorrhages occur also in other organs and in the skin.
Clinical features
1. Occurs mainly after severe fractures in the lower limbs particularly those of the femur and tibia.
2. The onset is usually within two days of the injury
3. There is a symptom-free period between injury and onset. This distinguishes fat embolism from cerebral contusion.
4. Breathlessness
5. Cerebral disturbance
6. Marked restlessness
7. Confusion
8. Drowsiness or coma
9. Cerebral symptoms may be caused partly by petechial haemorrhages in the brain, but in large measure they are probably secondary to hypoxia from occlusion of small blood vessels in the lungs.
10. Tachypnoea
11. Dyspnoea
12. Petechial rash
- • On the front of the neck
- • On the anterior axillary folds or chest
- • In the conjunctiva
- The finding of such a rash strongly supports a diagnosis of fat embolism syndrome.
Diagnosis
1) Characteristic clinical features
2) Arterial blood gas analysis may show reduction of the partial pressure of oxygen in the blood well below 100mmHg and often below the critical level of 60mmHg at which respiratory failure is likely.
3) Chest radiographs show patchy consolidation
4) Platelet count is low
5) Serum lipase is low
6) Fat globules may be present in the urine
Treatment
Fat embolism is spontaneously reversible if the patient can be tided over the dangerous period of hypoxia.
• This may be achieved by administration of 100% oxygen with positive pressure ventilation if necessary. Control oxygen requirement by repeated blood gas analysis
• Patient needs to be managed in the intensive care unit.
• The administration of methylprednisolone in patients with severe multiple injuries may help to prevent and correct the adverse effects of fat embolism by maintaining blood oxygen tension and stabilizing the free fatty acids.
• Heparin or Dextran 40 may also be administered intravenously to improve capillary flow.
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Topic Six: Reflex sympathetic dystrophy; Articular adhesions
Reflex sympathetic dystrophy
Also known as: Sudeck’s atrophy, Sudeck’s post-traumatic osteodystrophy, Post-traumatic painful osteoporosis, Complex regional pain syndrome.
• It is characterized by pain, swelling and marked joint stiffness in the hand or foot of the injured limb.
• The cause and exact nature of the condition are unknown.
• Probably due to a disturbance of centrally mediated autonomic regulation with consequent increased stimulation of sympathetic and motor efferent fibres.
Clinical features
• Symptoms are noticed about 2 months after the injury, or when the plaster is removed.
• The function of the limb is not regained as it should be with active use and exercises.
• Instead, the patient complains of severe pain in the affected hand or foot when attempting to use it.
• On examination:
1) The limb is swollen and may be hyperaemic.
2) The skin creases are obliterated, giving the surface a glossy appearance
3) The nails and hair of the hand or foot are atrophic.
4) The palmar aponeurosis may be thickened
5) Joint movements are severely impaired, esp. the metacarpophalangeal and interphalangeal joints (‘frozen hand’)
6) Radiographs show spotty osteoporosis, often of severe degree.
Treatment
• Most cases respond slowly but surely to efficient conservative treatment.
• Mainstay of treatment is active exercise, with active use of the limb so far as the pain will allow.
• Periods of elevation and local heat (warm baths)
• Adequate recovery is usually gained in 2-4 months.
Intra-articular and peri-articular adhesions
• Joint stiffness after adhesions is common after fractures, esp. those that are near a joint.
• The knee, shoulder, elbow and finger joints stiffen easily and often suffer permanent impairment.
• The hip and wrist usually regain their full mobility without difficulty.
• Adhesions occur chiefly after a fracture that has involved the articular surface of a bone. Blood escapes into the joint (haemarthrosis) and may leave residual strands of fibrin which later become organized into fibrous adhesions between opposing folds of synovial membrane.
• Peri-articular changes are a more frequent cause of joint stiffness than intra-articular adhesions. Due to the injury and possibly prolonged immobilization, oedema fluid collects in the tissues, binding together the connective tissue fibers. This leads to loss of resilience of the peri-articular tissues such as joint capsule and ligaments, and also impairs the free gliding of muscle fibres one upon another.
• Direct adhesion of muscle to the underlying bone at the site of fracture is another cause of stiffness.
Treatment
1) Active exercises preferably under supervision of physiotherapist
2) Manipulation:
- • Manipulation under anaesthesia may be considered if active exercises and use are not achieving steady improvement.
- • Manipulation is more likely to be successful in overcoming stiffness from intra-articular adhesions.
The end.
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Topic Seven: SPECIAL FEATURES OF FRACTURES IN CHILDREN
Special features of fractures in children
Injuries involving the growth plate
• Also known as epiphyseal injuries
• Each end of the long bones has a cartilaginous growth plate.
• Most growth occurs away from the elbow and towards the knee.
• The growth plate is a potentially weak point in the bone and is commonly injured in children.
• Epiphyseal injuries can be classified radiologically into five types as described by Salter and Harris.
• Designated as Salter-Harris classification. 
Salter-Harris classification
• Type I injury: complete separation of epiphysis at the growth plate without damage to the metaphysis or epiphysis.
• Type II injury: the most common type, with a characteristic triangular fragment of the metaphysis attached to the displaced epiphysis.
• Type III injury: involves the articular surface with separation of an epiphyseal fragment.
• Type IV injury: fracture of the articular surface with extension across the growth plate into the metaphysis.
• Type V injury: compression fracture involving part or all of the growth plate.
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Topic Seven: Special features of fractures in children
Bone resilience
Bones in children are more resilient and springy, withstanding greater deflection without fracture. This explains the predominance of incomplete fractures of the greenstick type in children.
Periosteum
The periosteum in children’s bones is attached only loosely to the diaphysis and is therefore easily stripped from the bone over a considerable part of its length by blood collecting beneath it. This leads to abundance of callus following injury, even with little displacement of the fragments.
Site of fracture
Certain fractures that are common in adults are uncommon in children; e.g. Fractures of: Scaphoid bone, Neck of femur, Trochanteric region of femur. Some fractures are quite common in childhood: - Supracondylar fractures of humerus, Fractures of the capitulum of the humerus
Healing
Healing of childhood fractures is usually rapid, the younger the child the more rapid the healing. In infancy a fracture may be soundly united in 2 or 3 weeks; in later childhood the average time required for union gradually increases. Remodeling is very active and complete in early childhood; so much so that all evidence of a past fracture may be obliterated within a matter of months.
Effect on growth
After a fracture of a long bone in a child, growth is often accelerated for a time, perhaps from hyperaemia of the neighbouring epiphyseal cartilage. Growth may be seriously disturbed if the growth plate is damaged. If the whole area of the growth plate is fused, all growth ceases at that site.
The degree of consequent shortening will depend on the age at which premature fusion occurred; the younger the patient at the time of fusion, the greater the eventual shortening.
If premature fusion occurs in only a part of the epiphyseal plate, further growth will be prevented at that point but will continue in the undamaged part of the plate, leading to angulation deformity. Angulation will also occur if there is premature arrest in one bone of a pair, as in the forearm or leg.
The end.
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Topic Eight: JOINT INJURIES
JOINT INJURIES
A Joint injury is dysfunction of a joint as a result of an injury, following either acute trauma or chronic overuse. A joint injury can involve damage to the bones, ligaments or other tissues of the joint. The larger limb joints tend to be the most utilized and are hence more prone to injuries. Severity of symptoms varies depending on the type and location of injury and often the primary symptom is pain.
Symptoms of joint injury
- 1. Joint pain
- 2. Joint swelling
- 3. Joint redness
- 4. Joint discoloration
- 5. Inability to move joint
- 6. Movement problems
- 7. Bruising around joint
- 8. Broken bone in joint
- 9. Deformed joint
- 10. Joint tenderness
- 11. Reduced range of joint motion
- 12. Joint weakness
- 13. Joint numbness
- 14. Joint warmth
Mechanisms of injury
Joints are usually injured by twisting or tilting forces that stretch the ligaments and capsule. If the force is great enough the ligaments may tear, or the bone to which they are attached may be pulled apart. The articular cartilage may also be damaged if the joint surface is compressed or if there is a fracture into the joint. Forceful angulation usually tears ligaments rather than crush the bone. However, in older people with osteoporosis, the ligaments may hold and the bone on the opposite side of the joint is crushed. In children there may be a fracture-separation of the epiphysis.
Common joint injuries
A joint injury can be:
- 1. A sprain of the joint
- 2. A strain of the ligaments
- 3. A rupture of the ligaments
- 4. A subluxation of the joint
- 5. A dislocation of the joint
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Topic Eight: Sprain; Strain; Rupture
Sprain/ Strain / Rupture
A sprain is any painful wrenching (twisting or pulling) movement of a joint that does not cause tearing of the capsule or ligaments.
A strain is a physical effect of tensile stress associated with stretching of the ligaments, which involves tearing of some fibers.
If the stretching or twisting force is severe enough, the ligament may be strained to the point of complete rupture.
Strained ligament
• Only some of the fibers in the ligament are torn and the joint remains stable.
• The injury occurs when a joint is momentarily twisted or bent into an abnormal position.
• The joint is painful and swollen and the tissues may be bruised.
• Tenderness is localized to the injured ligament and tensing the tissues on that side causes a sharp increase in pain.
Treatment of a strained ligament
1. The joint should be firmly strapped and rested until the pain subsides.
2. Ice packs can be applied locally
3. Non-steroidal anti-inflammatory medication
4. Thereafter active movements are encouraged.
5. Muscle strengthening exercises are carried out.
Ruptured ligament
The ligament is completely torn and the joint is unstable. Sometimes avulsion of the bone to which the ligament is attached occurs if the ligament holds and fails to rupture. Treatment is easier in the case of avulsion because the bone fragment can be securely reattached.
The mechanism of injury is a sudden forceful twist or bending of the joint into an abnormal position. The patient might hear a snap sound during the injury.
Rupture most likely affects joints that are insecure by virtue of their shape or their being least well protected by the surrounding muscles. They include: the knee; the ankle; and finger joints.
Clinical features
1) Severe pain
2) Bleeding under the skin (ecchymosis)
3) Swollen joint, probably due to a haemarthrosis
4) Very tender joint, patient does not want the joint to be disturbed
5) Examination under anaesthesia by stressing the joint demonstrates joint instability. This distinguishes the lesion from a strain.
6) X-ray may show a detached flake of bone in the case of avulsion.
Treatment of Ruptured ligament
Torn ligaments heal by fibrous scarring.
1. Non-operative treatment is encouraged in the first instance.
- •The joint is splinted for 1-2 weeks and local measures taken to reduce swelling [elevation, cold compress]
- •Thereafter the splint is replaced with a functional brace that allows joint movement but prevents repeat injury to the ligament.
- •Physiotherapy – muscle strengthening exercises.
2. In the case of an avulsion of bone with the ligament, reattachment of the ligament is indicated if the piece of bone is large enough.
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Topic Eight: Dislocation and Subluxation
Dislocation and subluxation
• Dislocation means that the joint surfaces are completely displaced and are no longer in contact.
• Subluxation implies a lesser degree of displacement, such that the articular surfaces are still partly apposed.
Clinical features
1. Severe joint pain
2. Patient avoids moving the joint
3. The shape of the joint is abnormal 
4. Bony landmarks may be displaced
5. The limb is held in a characteristic position depending on the joint affected
6. Movement is painful and restricted
X-ray findings
Radiographs will clinch the diagnosis and will also show if there is any associated bony injury (fracture-dislocation)
Apprehension test
If the dislocation is reduced by the time the patient is seen, the joint can be tested by stressing it as if almost to reproduce the suspected dislocation: the patient develops a sense of impending disaster and violently resists further manipulation.
Recurrent dislocation
If the ligaments and joint margins are damaged, repeated dislocation may occur. This is termed recurrent dislocation. This is especially common in the shoulder and the patella-femoral joint.
Treatment of dislocation/subluxation
1. The dislocation must be reduced as soon as possible by manipulation. 
2. A general anaesthetic is usually required or an opioid analgesic [e.g. pethidine or morphine]
3. A muscle relaxant may also be required [e.g. diazepam]
4. The joint is then rested or immobilized until soft tissue swelling reduces – usually after 2 weeks.
5. Physiotherapy
Complications of dislocation/subluxation
1) Vascular injury
2) Nerve injury
3) Avascular necrosis of bone
4) Heterotopic ossification (post-traumatic ossification)
5) Joint stiffness
6) Secondary osteoarthritis
The end - Thank you.