Cagayan State University

Tuguegarao City
ORTHOPEDICS

Angel A. Cayetano, M.D., DPBO,

FPOA, FPCS, FPSMS, MHA, MPA
 Orthopedics
◼ Orthopedics/ orthopedic surgery?
◼ medical specialty concerned with the
preservation and restoration of function of the
skeletal system and its associated structures, i.e.,
spinal and other bones, joints, and muscles.
 Branches of
Orthopedics
◼ Trauma:
◼ Adult Orthopedics
◼ 18 years old and above

◼ Neglected Trauma > 1month

◼ Child Orthopedics
◼ Neglected trauma > 2 weeks

◼ 17 years old and below

◼ Hand Surgery
◼ Spine
 Topics

Trauma
◼ Fracture Diagnosis
◼ Open Fractures

◼ Fractures of the Upper Extremity

◼ Radius-Ulnar Fracture
◼ Fractures and dislocation around the elbow
Orthopaedic Basics
- History and Physical Exam -
- How to Read an X-Ray -
- Principles of Casting/Splinting –
- Fracture Fixation -
 Orthopaedic History
◼ A good general orthopaedic history contains:
◼ Onset, Duration, and Location of a problem
◼ Limitations and debilitation attributed to the
problem
◼ Good surgical history, especially with regards to
orthopaedic surgeries and prior anesthesia
◼ Co-morbid conditions that contribute to the
problem or will preclude healing in some manner
 Physical Exam Basics
◼ Inspect and Palpate everything- start with
normal structures and move to abnormal
◼ Range of motion in all planes
◼ Strength
◼ Sensation
◼ Reflexes
◼ Gait
◼ Stability
 Physical Exam Basics
◼ NVI What does this mean?
1. Neurologic exam- Always document the
neurologic status. Some fractures are
associated with nerve injuries and knowing the
status of the nerve is critical
2. Vascular exam- Always check for pulses distal
to the fracture sight. Missed vascular injuries
can be devastating
 Physical Exam
◼ NEVER trust someone else’s exam. ALWAYS
put your hands on the patient and see for
yourself
◼ Always trust your exam- you WILL pick up
something that someone else has missed at some
point
Imaging
 Intro to Reading X-rays
◼ Reading a radiograph is essentially describing the
anatomy of a certain structure
◼ In order for it to be universal and
understandable for others, clarity and precision
are essential
◼ A fracture is described based on the findings of
the physical exam and a review of radiographs
 Reading X-rays
1. Say what it is- what anatomic structure are you
looking at and how many different views are
there
2. Condition of the soft tissue- Open vs Closed
3. Regional Location- Diaphysis (rule of 1/3),
Metaphysis, Epiphysis including intra and
extra-articular, and Physis (pedi)
4. Direction of the fracture line- Transverse,
Oblique, Spiral
 Reading X-rays
5. Condition of the bone- comminution (3 or
more parts), Segmental (middle fragment),
Butterfly segment, incomplete, avulsion, stress,
impacted
6. Deformity-Displacemtent (distal with respect
to proximal), angulation (varus, valgus),
rotation, shortening (in cm’s), distraction
 Fracture Pattern
◼ Transverse
◼ Produced by a distracting
or tensile force
 Fracture Pattern
◼ Spiral
◼ Produced by a torsional
force
 Fracture Pattern
◼ Butterfly
◼ Produced by pure
bending force
 Fracture Pattern
◼ Comminuted
◼ Broken into many
pieces- high energy with
combined forces
 Displacement
◼ Characterized by % of bone
contact on either view
 Angulation
◼ Distal fragment relative to
proximal
◼ Varus, Valgus, Anterior, Posterior
◼ Apex of angle formed by
fragments
◼ E.g., Apex Anterior, Apex Medial,
Apex Ulnar
 Location
◼ Commonly described in thirds of affected bone
◼ ie distal third of tibia
◼ ie junction of proximal and middle third of femur

◼ If fractured at two levels describe as segmental

 Location-Diaphysis
◼ Shaft portion of bone
 Location-Metaphysis
◼ The ends of the bone (if
the fracture goes into a
joint it is described as
intra- articular)
 Now All Together
◼ Transverse fracture of
the femur at the middle
third- distal third
junction with 100%
displacement and varus
(or apex lateral)
angulation
 Fracture
◼ Deformation or discontinuity of bone produced
by forces that exceed the ultimate strength of
the bone
Fracture Diagnosis

◼ Fracture close complete transverse

displaced junction middle-distal
3rd femur, right
 Fracture Diagnosis

◼ Close / open ?
 Fracture Diagnosis

◼ Complete/ incomplete ?
 Fracture Diagnosis

◼ Transverse/ oblique/ spiral

comminuted
 Transverse
◼ planeof fx is perpendicular to
the long axis of the bone
 Oblique
◼ The fracture forms an angle with the axis of the
shaft (30”)
 Spiral
◼ Produced by a torsional force
◼ Pencil tip deformity
 Comminuted
◼ Multiple fracture
fragments
◼ Non-displaced/ minimally displaced/
displaced?
 Fracture Diagnosis

◼ Anatomic location (P/M/D)

◼ Laterality (R/L)
Fracture Diagnosis
 Casting, Splinting, and
Definitive Fracture Fixaiton
 Definitive Fracture Fixation
Options
◼ Casts and Splints
◼ Appropriate for many
fractures especially hand
and foot fractures
◼ Adults typically will get
plaster splints initially
transitioned to fiberglass
casts as swelling decreases
◼ Kids typically will get
fiberglass casts
 Definitive Fracture Fixation
◼ Delayed until patient is stable
(may be days or weeks)
◼ Femur Fracture has priority as
delay in fixation has negative
impact on pulmonary status by
shower of fat emboli to the lungs
◼ Goals is to stabilize skeleton to
allow patient to rapidly mobilize
from bed
 Definitive Fracture Fixation
Options
◼ Traction
◼ Useful in patients who are
too sick for surgery
◼ Useful to maintain
alignment until definitive
fixation
 Definitive Fracture Fixation
Options
◼ External Fixation
◼ Used primarily in the
treatment of open
fractures and pelvis
fractures
◼ Also useful as temporary
stabilization prior to
definitive fixation
Indications- Emergent
Stabilization
 Definitive Fracture Fixation
Options
◼ Open Reduction and
Internal fixation with
Plates and screws
◼ Used for many fractures
especially those involving
joints
 Definitive Fracture Fixation
Options
◼ Intramedullary Nails
◼ Treatment of choice for
most tibia and femur
fractures
◼ Used in selected humerus
and forearm fractures
 Definitive Fracture Fixation
Options
◼ Joint Replacement
◼ Used in displaced femoral
neck fractures in geriatric
patients
◼ Allows for early
ambulation
◼ Occasionally used in
geriatric pts with
comminuted shoulder or
elbow fractures
Stages of Fracture Healing
◼ Stage of Impact
◼ Stage of Inflammation

◼ Early reparative stage ( stage of soft

callus formation)
◼ Late reparative ( Hard Callus)

◼ Remodeling stage
 Stage of Impact

◼ Seconds

◼ Energy absorbed until failure

 Stage of Inflammation
◼ 1-2weeks
◼ Hematoma attracts inflammatory cells

◼ Cytokines are released which stimulate

mesenchymal cells
 Early reparative stage ( stage
of soft callus formation)
◼ Weeks to Months
◼ Granulation tissue forms in fracture gaps

◼ Dead bone is resorbed

◼ Osteoblastic proliferation at the periphery

◼ Cartilage forms in the central area (hyaline)

Late reparative ( Hard Callus)
◼ Weeks to months
◼ Cartilage calcifies

◼ Gradually replaced by osteoblastic

bone formation
◼ Clinical union occurs
 Remodeling stage
◼ Months to years
◼ Woven bone -→ lamellar bone
through coupled resorption and
formation