General OrthopedicsCHAPTER 1

The term orthopedics was coined by ^?'Nicholas Andrey’—A French physician.

There are total 206 bones in the human body.

These can be divided into two groups:

On the basis of shape and size, these can be of following types:

The long bone can be divided into:

There are four main sources of blood supply:

A joint exists between two or more bones or cartilaginous components. These may be of following types:

^? It is a structural break in the normal continuity of bone

Repair of bone injury differs from soft tissue repair insofar as formation of the specialized calcified tissue of bone involving the activity of osteoblasts and osteoclasts. There are five stages of healing:

Time taken to unite the fractures:

Complete fractures—The fracture involves the entire bone.

Incomplete fractures—The bone is incompletely divided and the periosteum remains in continuity. It may be of following types:

Due to trauma:

Due to some underlying disease:

Cracks can occur in the bone due to repetitive stress. This is usually seen in tibia, fibula or metatarsals, especially in athletes, dancers, and army recruits.

It results in an alpha-numeric code which is suitable for computer sorting and which allows for research purposes but is not suitable for conveying information about the nature of an individual fracture, (e.g. over the telephone).

Example: AO classification 12-A 1.2 means humeral shaft # (12), which is simple (A), spiral (1) and of middle part (2).

Type I : An open fracture with a wound <1 cm and clean.

Type II : An open fracture with a wound >1 cm with extensive soft tissue damage and avulsion of flaps.

Type IIIa : An open fracture with adequate soft tissue coverage of bone in spite of extensive soft tissue lacerations or flaps or high energy trauma irrespective of the size of wound.

Type IIIb : An open fracture with extensive soft tissue loss, periosteal stripping and exposure of bone.

Type IIIc : An open fracture associated with an arterial injury which requires repair.

There is usually a history of trauma followed by inability to use the injured limb. The trauma may be severe, trivial or repetitive.

Monteggia fracture dislocation—Fracture of the proximal third of the ulna with dislocation of the superior radioulnar joint.

Galeazzi fracture dislocation—Fracture of the distal third of the radius with dislocation of inferior radioulnar joint.

Nightstick fracture—Isolated fracture of the shaft of the ulna, sustained while trying to protect from a stick blow.

Essex-Lopresti fracture dislocation—It is a fracture of the head radius associated with dislocation of inferior radioulnar joint.

Colles fracture—A # of distal end of radius at corticocancellous junction within 2.5 cm of wrist with typical dorsolateral displacement, it is usually seen in elderly women.

Smith’ s fracture—A fracture of distal end of radius at corticocancellous junction with ventral tilt and displacements (reverse Colles #)

^? Barton's fracture—A vertical, marginal intra-articular fracture of the distal end of radius occurring in coronal plane with volar or dorsal displacement.

Chauffeur fracture—An intra-articular oblique fracture of the styloid process of the radius.

^? Bennett's fracture-dislocation—An oblique intra-articular fracture and dislocation of the base of the first metacarpal.

13 Boxer's fracture—A fracture through the neck of the 5th metacarpal, usually occurs in boxers. Side-swipe fracture (baby car #\traffic elbow)—An elbow injury occurs when one's elbow projecting out of a car, is side swept by another vehicle. It shows a combination fractures of the distal end of the humerus with fractures of upper ends of radius and/or ulna.

^? Bumper fracture—A comminuted depressed fracture of the lateral condyle of the tibia.

Pott's fracture—It is the fracture around ankle joint which results from a deforming force (usually twisting force).

Cotton's fracture—Trimalleolar ankle fracture.

^? Maisonneuve's fracture—An ankle fracture associated with spiral fracture of neck of the fibula.

^? Dupuytren's fracture dislocation—Pott's fracture with diastesis due to avulsion or tear of inferior tibiofibular ligament.

Tillaux fracture—A tibial avulsion fracture at anterior tibiofibular ligament attachment.

Pilon fracture (Explosion fracture)—A comminuted intra-articular fracture of the distal end of the tibia and fibula.

Aviators fracture—Fracture of neck of the talus.

Lisfranc's fracture dislocation—A fracture dislocation through tarsometatarsal joints.

Chopart fracture dislocation—A fracture dislocation through intertarsal joints.

Jones fracture—An avulsion fracture of the base of the 5th metatarsal caused by the pull exerted by the peroneus brevis tendon.

^? March fracture—A fatigue fracture usually of the 2nd metatarsal neck or shaft, caused by repeated stress.

Burst fracture—A comminuted fracture of the vertebral body, caused by axial compression injury.

Chance fracture (Car seat belt injury)—A horizontal # of the vertebra extending from body to the posterior element, caused by a strong distraction force.

^? Clay shoveler fracture—An avulsion fracture of spinous process of the lower cervical or upper thoracic vertebrae.

Hangman's fracture—A fracture through the pedicle and lamina of C2 vertebra, with subluxation of C2 over C3-caused by hanging.

^? Jefferson fracture—Burst fracture of Atlus vertebra.

Straddle fracture—Bilateral superior and inferior pubic rami fractures of the pelvis.

Malgaigne's fracture—A fracture of pelvis having a combination of ipsilateral fracture of pubic rami anteriorly and sacroiliac joint disruption posteriorly.

^?LeFort's fracture—Faciomaxillary fracture.

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Trauma is commonest cause of death in people under 40. The management of a road traffic accident (RTA) fracture can be divided into three phases:

We should examine the patient as a whole:

First of all stabilize the general condition of the patient and then concentrate over the injured limb.

Any material which is used to support a fracture is called as splint. It can be either unconventional type as folded newspaper, foot rule, pillow, bamboo, or conventional type as wooden, crammer wire, Thomas splint, Bohler brawn and plaster of peris splint.

Functions of splintage:

Types—Wooden splint:

Long Liston splint (LL)—It is a long wooden splint having a notch at lower end and two holes perineal (upper) and malleolar (lower). It extends from lower boundary of axilla to 2–3 inches beyond the sole of foot and this is used for first aid in fractures around hip joint, dislocation hip, # shaft femur. It can also be combined with PL splint in #s around knee. During application of this splint, bony prominences (as greater trochanter, head of fibula and, lateral malleolus) should be padded adequately.

Posterior leg splint (PL)—It extends from junction of upper and middle third of thigh to the toes of the foot. This is used for first aid in fractures both bone leg, # pott's and # patella, it can also be combind with LL splint in #s around knee. The adequate padding should be done below the tendo-Achilles so that the heel remains free and does not rest on the splint with pressure.

Short posterior leg splint (Short PL)—It extends from 1–2 inches below the head of fibula to the toes of the foot. This is used for first aid in fractures calcaneum, tarsals and metatarsals.

Lateral elbow splint—It extends from just above the insertion of deltoid upto metacarpophalangeal joints. This is used for first aid in fractures supracondylar humerus, #s around elbow joint, dislocation elbow, # radius and ulna. It can also be applied for fracture shaft humerus by reversing it, i.e. by applying the long arm of splint to the arm of the patient and short arm to the forearm. The adequate padding should be done over lateral epicondyle and styloid process.

High LE splint—When both the arms of LE splint are equal and long enough so that it extends from acromion process to the elbow joint. This is ideal for # shaft humerus.

17 Cramer wire splint—This is made-up of galvanized iron and appears like a ladder. This can be manually molded to fit easily and snugly in all shape and sizes of the body parts. It can be autoclaved therefore can be used in operation theater. It does not provide rigid immobilization and its radiopaque shadow can mask the fracture line in X-ray.

Thomas knee splint—This was devised by Sir Hugh Oven Thomas (father of orthopedic surgery) and initially used for tuberculosis knee therefore called as Thomas knee splint. It consist of a circular ring, parallel bars and a notched end. It can be applied in # shaft femur, intertrochanteric femur and after reduction of dislocated hip. The possible complications are lateral popliteal nerve palsy, pressure sores and leucoplast reaction.

Traction is applied to the limb distal to the # in the long axis of bone, used to reduce fracture or dislocation or to achieve immobilisation.

On the basis of method of application—It is of three types:

On the basis of effect of traction

Gypsum salt 2CaSO₄.1/2 H₂O + H₂O → CaSO₄.2H₂O + Heat

Plaster of Paris can be applied in two forms:

The brace works by supporting the soft tissues in a tight compartment. As the whole leg is enclosed in a confined space, it develops a sort of hydraulic pressure within the brace, which helps in maintaining the # alignment.

In this method, after reduction of fracture, it is fixed internally with the help of some metallic or nonmetallic device such as screws, plates, K-wire, SS wire, pins, nails, etc.23

Bridge plate (biological fixation): Bridge plates are used to stabilized a comminuted unstable fracture or bony defect of the long bone in which an anatomic reduction and rigit stability of the fracture can not be restored by fracture reduction. It is done without exploration of the fracture site. Biologic plating has a high rate of union with minimal complications.

Pin fixator—The schanz pins are inserted into the bone. Each pin is attached to a clamp which are tightened over a tubular rod. It is applied for compound fractures, unstable #, multiple trauma and # pelvis.24

Ilizarov's ring fixator—Developed by Gavril Abramovich Ilizarov (A Russian Scientist), who described the law of tension stress, i.e. the principle of a new tissue develops between the distracted bone ends, in 1950. Indications are limb lengthening, arthrodesis, infected nonunion, deformity correction, etc.

JESS—(Joshi's external stabilization system). It was designed by an Indian orthopedic surgeon Dr BB Joshi. It can be applied for deformity correction and trauma of hand and foot.

Orthofix fixator/Rail fixator—This is monolateral fixator available in the form of a rail or a telescoping multijoint assembly. In this, 6 mm pins are inserted into the bone. These pins are attached to the different blocks which can move over a tract. According to need, the bone can be compressed or distracted as in Ilizarov's ring fixator. However, it is less versatile as compared to the ilizarov fixator and it cannot be used at all in osteoporotic bone. It can be applied in compound fracture, limb lengthening, infected nonunion, etc.25