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General Principles of Orthopedic Trauma.

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General Principles of Orthopedic Trauma.

This is for the Lewis Kapp School of Medicine Physician Assistant Program.

I'm Saki Brahman.

These are my financial and related disclosures.

And some of the images were borrowed from the AO Foundation.

So these are the lecture objectives.

Number one, to understand the assessment and basic management of fractures.

to understand why some fractures do not heal,

to understand the complications and associated injuries that present with fractures,

and to understand some very basic principles of pediatric fractures and how they differ.

So, what is orthopedic trauma?

Well, it's a field that deals with the management of fractures and related injuries.

It often deals with hospitalized patients,

perhaps a little more so than some of the other orthopedic disciplines.

It includes operative and non-operative care to help patients return to function after injury.

So these are some of the topics I'd like you to know after this lecture and our live session.

extremity and pelvic fractures, associated neurovascular injury,

pathologic fractures, osteoporosis, fracture non-unions,

splinting and casting principles, and this will be reinforced in a workshop,

and basic surgical fixation principles,

just real basic simple stuff.

Now, there are some related topics that will be covered separately,

namely compartment syndrome, open fractures,

dislocations, So essentially, these will be in the emergencies.

All right, this will be in the emergencies lecture,

and then Dr. Haydell is going to cover this topic of musculoskeletal infection in a separate lecture as well.

So, well first, this is kind of going to be our outline for this first section of this.

Very basic anatomy and terminology.

We'll go through mechanisms in a little bit of detail,

and evaluation, and then some basic management and treatment.

We'll probably get into that in the next video.

So basic anatomy and terminology.

And this is perhaps going back to gross anatomy and some definitions,

perhaps covered in the radiology session of this block.

but let's just get through some basic definitions to reinforce this.

So understand proximal and distal with regard to the anatomy,

proximal being closer to the center of the body and distal the opposite.

With regard to bone, we're gonna talk a lot about cancellous versus cortical bone.

We'll get into that in the next few slides.

Should understand the diaphysis is the shaft of the bone and it has a medullary canal.

The metaphysis is sort of the trabecular end here.

And then you have the epiphysis with distal and proximal ends of the bone,

which are the articulating or articular portions of the bone.

Here it's gonna be your knee joint and up here is gonna be your hip joint in this femur.

So a few notes about bone structure

so there's essentially the easiest way to break it down it's cortical bone

and cancelus bone

so cortical bone is your compact bone it represents 80% of

the skeleton by by weight it has a very high compressive bending

and rotational strength with a relatively slow turnover of bone

so for instance

if you have a fracture of the cortical bone takes a little bit longer relative to cancelus bone

so cancelus bone is your so-called spongy bone by weight it's 20% of the skeleton it's less dense

and strong and is a high turnover rates

when you have a fracture through cancelus bone it it typically can heal much faster.

And here you can kind of see,

here's an example of a tibia in this image here.

And they're trying to show you a cross section here at the metaphyseal level where you have this

cancellous bone with a somewhat thin cortex and then a periosteum which is sort of the outer layer

of the bone which has blood supply and aids in healing

and also in young children can be very thick and protects the bone mechanically to some degree.

Inside the bone you have the bone marrow.

So you can see the cortical bone,

the end osteal surface, and then the bone marrow.

Here you can see an example of the periosteum being a tissue layer literally being kind of opened up and peeled away,

which potentially can be done surgically if needed.

Okay, and here you see some of those just basic descriptions,

epiphysis, metaphyysis, diaphysis, the medullary canal,

and then the opposite at the other end.

So if you were to look under a microscope,

and of course with some color aids here,

you can see that cortical bone is very dense,

tightly packed osteons, whereas Kensellis bone is a more loose meshwork of trabecula. So some other definitions.

This is something you'll hear a lot of patients ask.

Well, is it fractured or is it broken?

And the fact is, at least as far as medical terminology goes,

it's the same thing.

So we use the terms interchangeably.

Fracture is the same as being broken.

It's defined by a disruption of that bone cortex,

and it can occur in any type of bone or any part of the bone.

And essentially it results in pain, loss of related function.

So of course that makes it difficult to move, needless to say.

And it cannot provide its structural support for the body to stand,

up or to weight bear,

load, use the limb, fight against gravity,

etc. That's why the bone is there.

It's an insertion point for the muscles,

for instance, and that's mechanically unstable when you're fractured.

So by mechanism, fractures occur due to a mechanical failure of bone under stress.

All right, now this can occur or sort of biomechanically by multiple mechanisms.

It could be axial loading.

Bone tends to be fairly strong under compression,

but with enough compression you can get a fracture.

Rotation and torsion, bending, and when you have a bending you potentially have,

so for instance here, you may have bending where the bone is perhaps,

let's just say, hit from here,

there's sort of a bending this way and this way.

So the fracture first occurs here under a tension or bending,

100

and then with compression on the opposite side,

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then failure occurs out this way.

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Okay?

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You can also have a missile injury,

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and this could be from a gunshot,

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most typically, or some other high-energy missile penetrating trauma.

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So here's an image from the textbook, again showing the mechanism.

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So very simple again, showing a femur.

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So if this femur were to be loaded,

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let's say, so if you had this person fall from a height,

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land on their feet, their feet

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and the force is directed this way there's going to

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potentially be this tension occurring on this lateral cortex right and then you're going to get this compression on the

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medial cortex here and then that's going to lead just like I try to draw in the last image

114

to a failure of the bone right here under tension, failure under tension.

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And in this case, the compressive forces are not enough to cause any additional fracture like you saw

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that in that other image,

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that fracture line's coming out this way.

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Here you just have a complete fracture line that comes across as a transverse fracture of the femur.

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so some other terms to keep in mind regarding fracture displacement

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the fracture can be non-displaced in

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which basically what a patient may call a hairline fracture they could be displaced

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which just basically means the fractures are no longer in their

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usual alignment can be angulated as shown here there's also a term called bayonet

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meant to sort of invoke the image of a bayonet on a rifle,

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for instance, in which you have sort of the two fragments overriding each other with slight shortening,

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or you can have distraction.

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Distraction essentially means there's a large gap because of either the pawns being pulled apart or perhaps with bone loss,

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you may use the same terminology.

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But then essentially when there's a large gap,

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that can be called distracted.

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So this is a little bit of a busy slide,

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but you'll want to take a look at this.

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You may want to pause the video and sort of make sure you understand this.

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You'll be hearing these terms in this lecture

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and possibly in the next several lectures as some of the lecturers may bring up a case with a fracture

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and use some terminology.

137

So, I've already used this already.

138

So transverse fracture means that the fracture is perpendicular to the shaft of the bone,

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comes transversely across.

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Comminuted basically means that there's multiple fragments.

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Oblique means that there's an angulated fracture line in an oblique fashion.

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And I'm going to go in a little bit of a different order here.

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A spiral fracture is really when you have a...

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it's kind of like oblique,

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except it tends to spiral around a little bit more,

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typically from a rotational injury.

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And then a segmental fracture,

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shown here, is a fracture where you have essentially a segment,

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or there's two fracture lines with a floating fragment in the middle.

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So that's a prototypical segmental fracture there.

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Now, intra-articular fracture is shown here Intraarticular fracture essentially means that the fracture goes into the joint.

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So in this case, this is an intraarticular fracture of the medial femoral condyle going into the knee joint.

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So now I'm going to actually drop down here.

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We'll talk about impaction.

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So impaction fracture essentially, this is a term used to describe fractures typically that occur in the metaphyseal region

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where the bone is, again,

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a little bit more spongy or the epiphyseal region,

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and the fracture kind of collapses under,

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it sort of collapses or shortens and impacts into itself,

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similar to a compression fracture,

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except the term compression fracture is used almost exclusively in spinal vertebrae,

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vertebral bodies as a essentially type of impaction.

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A depressed fracture or fracture depression is a term used specifically for articular fragments.

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So up here you saw an intra-articular fracture that really was just a clean fracture line coming down,

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you could say, whereas here,

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and the image is small,

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So you may have to stop,

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pause, zoom, whatever, to get a better look.

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But you can see in the tibia,

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medially, the proximal tibia, there's a depression.

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Perhaps you could say it's like an impaction,

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but when it involves the articular surface,

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and there's this, you know,

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kind of like step-off, we call that a depression.

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All right?

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Then you can have a stress fracture.

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So stress fracture essentially is a phenomenon that occurs when you either have normal bone that's been overloaded and stressed,

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or you have abnormal bone that fails because it's weak, essentially.

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You can have a stress fracture with no trauma.

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And, you know, this is sort of a very similar phenomenon here.

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A pathologic fracture, and we'll talk about this in one of the other videos,

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is a fracture through bone weakened by tumor okay

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and then here's our uh our two pediatric fracture types you can have a buckle fracture

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and we'll get into this in the pediatric portion of the lecture or a green stick fracture which is

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sort of similar but you actually have a tension failure on one side

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and the other side just does not snap so to speak all right

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so i'm going to pause there and end this video

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and we'll pick up with the rest of the lecture in the next video.

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Thanks.

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