Surgery: Lower Limb (orthopedics)

Question 1

According to which principles orthopaedic management should be started with?

Answer 1

ATLS = ABCDE

Orthopaedic injuries management should not come before the management of life-threatening injuries

Question 2

Types of fractures that can be considered as ‘open fractures’ (2)

Answer 2

• fractures that communicate with the outside world via a wound
• fractures that communicate with any other unclean environment [e.g. a pelvic fracture that has penetrated the bowel]

Question 3

Which bone (1) a compartment syndrome most commonly occur at?

Answer 3

Tibial bone

Question 4

What to assess during the assessment of an injured limb? (3)

Answer 4

• ATLS guidelines (i.e. treat all life-threatening injuries first)
• neurovascular assessment of the injured limb
• Take a photograph of any wounds (close up and also from a distance, so that the location of the wound relative to the limb is clear)

Question 5

Initial management of a fracture/injury (5)

Answer 5

• Gently reduce displaced fractures (ask for help unless experienced). Nerves and vessels are at risk if the limb is anatomically distorted
• Stabilise the fracture (with a splint or back-slab) and then re-assess the neurovascular status
• Radiographs should be taken after any orthopaedic intervention (e.g. reduction attempts)
• Management of open wounds (e.g. dressed, antibiotics, anti-tetanus cover etc.)
• A general work-up for theatre should be completed, where appropriate

Question 6

Principle of fracture management

Answer 6

Ask yourself: Is the position of the fracture ok?

• Yes - hold it until healed
• No - reduce it (with an open reduction or closed reduction technique) and then hold it until healed

Question 7

What’s an open reduction technique?

Answer 7

Open reduction

Involves a formal surgical exposure →the fracture is reduced under direct vision

Question 8

What’s a closed reduction technique in the management of the fracture?

Answer 8

Closed reduction

• involves a manipulation without a surgical opening (direct visualisation)

Question 9

What does intermediate technique involve?

Answer 9

Intermediate techniques

Fracture fragments are reduced indirectly through very small incisions (e.g. MIPO techniques - ‘Minimally invasive percutaneous osteosynthesis’).

Question 10

(3) possible techniques of reduction in fracture management

Answer 10

• open
• closed
• intermediate

Question 11

How to ‘hold’ the fracture? (stabilise)

Answer 11

• Back-slab
• POP
• Splint
• Traction
• K-wires
• External fixation (monolateral or ring)
• Plates and screws
• IM nails
• (Arthroplasty - in cases where it is not appropriate to reconstruct a damaged joint, it is removed and replaced instead of being fixed, e.g. in intra-capsular hip fractures)

Question 12

What’s that technique?

Answer 12

Plate and screws

Question 13

What’s the name of this technique?

Answer 13

Fine wire circular fixator

Question 14

Name the technique of fixation

Answer 14

Monolateral external fixator

Question 15

Name that technique

Answer 15

Plaster of Paris cast

Question 16

Name this fixation technique

Answer 16

K-wire fixation

Question 17

Name this fixation technique

Answer 17

Intramedullary nail

Question 18

Is there only one single appropriate method to treat the fracture?

Answer 18

• There are many appropriate ways to treat the same fracture and the method used should be tailored to the patient
• Consider the fracture pattern and the patient’s needs when deciding which option is best

Question 19

Pros and cons of different methods of fracture stabilisation

- back-slab

- POP cast

Answer 19

• Back-slab: cheap and easy but minimally supportive. Used as first aid.
• POP cast: cheap and more supportive than a back-slab but limited to relatively stable fractures.

Question 20

Pros and cons of different methods of fracture stabilisation

- splint

- traction

Answer 20

• Splint: easy to apply and can be removed. Only appropriate for stable fractures
• Traction: non-invasive and effective but requires prolonged best rest. Used most often in young children because fractures in this age group heal quickly

Question 21

Name that method of fracture stabilisation

Answer 21

POP cast

(Plaster of Paris)

Question 22

What’s the difference between slab and cast?

Answer 22

• slab → only a part of circumference of a limb is covered
• cast → the whole circumference of a limb is covered

Question 23

Name that method of fracture stabilisation

Answer 23

Back slab

Question 24

Name that method of fracture stabilisation

Answer 24

Splint

Question 25

Name that method of fracture stabilisation

Answer 25

Traction

Question 26

Pros and cons of **K-wires**

Answer 26

* minimally invasive method of ‘skewering’ bone fragments * useful in good quality bone (usually in the wrist) * rarely used in lower limb except for some paediatric fractures

Question 27

Use of **external fixators**

Answer 27

**External fixators**: * useful for complex fracture patterns or where the soft tissues are too compromised to permit a safe surgical exposure

Question 28

Pros and cons of **plates** and **screws**

Answer 28

**Plates and screws**: * formal plating techniques allow accurate fracture positioning and fixation but often require a large surgical approach * usually used where anatomical (i.e. highly accurate) reduction is required - eg. articular fractures

Question 29

Pros, cons and use of **intramedullary nails**

Answer 29

**Intra-medullary nails** * Internal splintage of long bones * Require relatively small incisions away from the fracture site * Most effective when the **fracture is around the** **mid-shaft** * Very useful **to stabilise pathological** (e.g. metastatic) bone * The inevitable intra-medullary pressure rise can compromise injured lungs in polytrauma patients

Question 30

What does fixation method of a hip fracture depend on?

Answer 30

The method of fixation depends on **whether the blood supply is likely to have been injured** by the fracture

Question 31

Method of fixation of **undisplaced** femoral fractures

Answer 31

If undisplaced → the blood supply can be assumed to be uninjured * The fracture simply needs to be fixed * Traditionally this has been done with **3 screws** (but other methods - e.g. modern **plate and screw designs** are gaining popularity)

Question 32

Blood supply to femoral head

Answer 32

Question 33

Methods of fixation of **displaced femoral fracture**

Answer 33

**Displaced →** the blood supply can be assumed to have been disrupted. This will pre-dispose the femoral head to **avascular necrosis** * The head is removed and replaced (except in young patients, where the head is given every chance of survival and fixed even when the bloods supply is likely to have been injured - because joint replacements have a limited life span)

Question 34

What to do in a displaced femoral head fracture in a **higher demand patient**?

Answer 34

higher demand patient → highly mobile patient Total hip replacement

Question 35

How to treat **high energy comminuted** fracture of femur in a **young patient**?

Answer 35

Question 36

How to treat **extra-capsular** femoral fractures?

Answer 36

There is no threat to the blood supply to the femoral head → the fracture is fixed rather than replaced * age isn’t a consideration (in contrast with deciding on the best type of hip replacement for a patient). The best device for the job is chosen, regardless of age

Question 37

How to treat extracapsular fractures that extend more down the femur?

Answer 37

Intra-medullary device

Question 38

Treatment of **extracapsular** hip fracture: * inter-trochanteric * fractures extending down the femur

Answer 38

* inter-trochanteric → Dynamic Hip Screw * extending down the femur → intramedullary device

Question 39

How are **femoral shaft** fractures usually treated?

Answer 39

Question 40

How are **intra-articular** fractures **around the knee** usually treated?

Answer 40

Because of the importance of accurately restoring the joint surface (to minimise the risk of post-traumatic arthritis) → **formal open reduction and internal fixation with plates and screws** is usually employed

Question 41

What's the **most common method** of fixation in **tibial shaft** fractures?

Answer 41

IM nails

Question 42

When do we use **external fixation** as a method of management of **tibial shaft fracture**?

Answer 42

Question 43

What's a dangerous thing about **ankle fractures**?

Answer 43

* These fractures, even if the fracture line itself doesn’t involve the joint, can have a serious effect on the ankle joint * This is because of the risk of not addressing (or of allowing the development of), **‘talar shift’** - where the talus bone fails to sit centrally between the tibial and fibula * This decreases the joint congruity /zgodnosc/ and can lead to **post-traumatic arthritis**

Question 44

What further information about the patient would you like to know?

Answer 44

* a full medical history * more detail re his bowel cancer * his pre-injury mobility status * his mental state * his home / care environment circumstances

Question 45

What medical issues may affect his management?

Answer 45

* AF → warfarin use * venous ulcers → may predispose to surgical infection) * previous bowel cancer → this may be a pathological fracture if he has developed metastatic disease – and if so, then there could also be pulmonary and thromboembolic features of metastatic disease

Question 46

What other investigations would you like to do prior to the surgery?

Answer 46

* FBC * U&Es * clotting (INR will be raised if on warfarin and will need to be reversed) * further imaging of the femur to exclude metastatic disease * ECG

Question 47

What type of fracture is it?

Answer 47

A displaced intra-capsular fracture

Question 48

What treatment options are there and which do you think is the best option in this case?

Answer 48

* In this age group, unless very active → **hemi-arthroplasty** * If he was very active → **THR** **​\*** But the medical details given above suggest that a hemi-arthroplasty would be the best option here

Question 49

Difference between **hemiarthroplasty** and **total hip replacement**

Answer 49

* **Hemiarthroplasty** → replacing half of the hip joint * **Total Hip Replacement** → replacing the entire hip joint

Question 50

What further information would you like?

Answer 50

* full medical history * her usual mobility status * occupation * Full details of the injury - how did it happen? Was it high energy or a low energy injury * Are there any other associated injuries? * Is there an associated wound (i.e. is it an open fracture?) * What is the neurovascular status of this limb? * How swollen are the soft tissues?

Question 51

What's the injury?

Answer 51

* a **fracture of the ankle involving the lateral and the posterior malleolus and possible the medial malleolus** too ## Footnote (it is difficult to be certain of the exact fracture pattern and that further imaging would be helpful - e.g. CT ) * the ankle is **dislocated**

Question 52

What's **immediate** management?

Answer 52

* the fracture should be quickly and accurately reduced and held in a supportive back and side slab * the N/V status should be re-assessed * X-Ray be performed * strict elevation to help settle the swelling

Question 53

What are the definitive treatment options?

Answer 53

**Open reduction and internal fixation →** best option (but only when the swelling has settled enough to allow a safe surgical exposure) \*POP casts are often used in ankle fractures, but in unstable types such as this, then they are rarely used for definitive treatment because of the difficulty in maintaining an accurate reduction

Question 54

What is the **initial** management?

Answer 54

* **ATLS principles** (although this is low energy trauma and so other injuries are unlikely) * **N/V assessment** of the limb * **First aid stabilisation** of the fracture with a splint (e.g. Thomas splint) followed by a repeat x-ray * **Pain relief** * **Discussion** with seniors

Question 55

What are the **definitive treatment** options?

Answer 55

* **IM nailing** (retrograde will get a better hold than anterograde) will be tricky with a total knee replacement (TKR) in situ * **Plate fixation** (probably the most straightforward option) but will require a long incision * **Traction** - possible (and in trained hands could provide a reasonable result) but would require prolonged bed rest