1 https://sites.google.com/a/kasralainy.edu.eg/ibrahimgalal/

2 BY DR. IBRAHIM GALAL PROFESSOR OF SURGERY CAIRO UNIVERSITYORTHOPEDIC SURGERY BY DR. IBRAHIM GALAL PROFESSOR OF SURGERY CAIRO UNIVERSITY

3 ANIMATION BY MOHAMMAD IBRAHIM

4 FRACTURES FRACTURES : STRUCTURAL BREAK

5 ETIOLOGY TRAUMA. PATHOLOGICAL. STRESS.

6 PATHOLOGY SITE. EXTENT. LINE. DISPLACEMENT. STABILITY. SKIN.

7 1. SITE EPIPHYSEAL. METAPHYSEAL. DIAPHYSEAL.

8 COMPLETE INCOMPLETE 2. EXTENT Predominantly in children

9 COMPLETE INCOMPLETE 2. EXTENT Predominantly in children

10 3. LINE TRANSVERSE

11 3. LINE TRANSVERSE OBLIQUE

12 3. LINE TRANSVERSE OBLIQUE SPIRAL

13 3. LINE TRANSVERSE OBLIQUE SPIRAL COMMINUTED

14 SPIRAL FRACTURE

15 4. DISPLACEMENT LATERAL. ANGULATION. DISTRACTION. IMPACTION.OVERRIDING. ROTATION. DEPRESSION.

16 LATERAL DISPLACEMENT (PRESERVED ALIGNMENT+ LOSS OF APPOSITION)

17 ANGULATION DISPLACEMENT (LOSS OF ALIGNMENT + LOSS OF APPOSITION)

18 DISTRACTION DISPLACEMENT

19 IMPACTION DISPLACEMENT

20 OVERRIDING DISPLACEMENT

21 ROTATION DISPLACEMENT

22 DEPRESSION DISPLACEMENT

23 5. STABILITY STABLE FRACTURE IS THAT ONE WHICH TENDS TO STAY IN PLACE AFTER REDUCTION WITHOUT ANY FURTHER REDISPLACEMENT. INSTABILITY MAY BE PRODUCED BY: -UNFAVORABLE FRACTURE LINE (OBLIQUE ,SPIRAL , COMMINUTED). -LIGAMENTOUS DYSFUNCTION (TEAR ,ELONGATION , WEAKNESS). -MUSCLE PULL.

24 UNSTABLE OBLIQUE FRACTURE LINE

25 6. SKIN CONDITION NORMAL : CLOSED FRACTURE.ABNORMAL : OPEN FRACTURE (RISK OF INFECTION) - DISRUPTION (IMMEDIATE CONTAMINATION ) ISCHEMIA (LATE CONTAMINATION ).

26 HEALING (UNION) PHASE 1 : GRANULATION (3 WEEKS). PHASE 2 :CALLUS FORMATION (3 MONTHS). (HYALINE CARTILAGE) PHASE 3 : OSSIFICATION (6 MONTHS).

27 FACTORS AFFECTING UNIONAGE. INFECTION. IMMOBILIZATION. VASCULARITY. LINE (LONGER IS BETTER e.g. OBLIQUE ). DISPLACEMENT (IMPACTED IS BETTER).

28 MANAGEMENT GENERAL . LOCAL : 1- PAIN. 2- BLOOD LOSS.3- SOFT TISSUE INJURY. 4- FRACTURE MANAGEMENT: REDUCTION FIXATION REHABILITATION

29 REDUCTION - AIM : RESTORE ACCEPTABLE ANATOMY.NOT NECESSARY IF # DOES NOT AFFECT FUNCTION &/OR COSMESIS. -TIMING : EARLY : BEFORE EDEMA & INFLAMMATION ESPECIALLY WITH INJURY OF NEUROVASCULAR BUNDLE. -METHODS : 1- CLOSED: -GRAVITY( IN WEAK MUSCLES). -MANIPULATION UNDER ANESTHESIA. -TRACTION (SKIN OR SKELETAL). 2- OPEN : -FAILED CLOSED. -INACCESSIBLE FRAGMENT(SHORT OR INTRAARTICULAR). -DELAYED REDUCTION.

30 REDUCTION MANIPULATION TRACTION

31 FIXATION EXTERNAL: 1-PLASTER OF PARIS (SLAB/CAST).2-TRACTION (SKIN OR SKELETAL). 3-EXTERNAL FIXATOR. INTERNAL : 1-WIRE. 2-PIN. 3-NAIL (TRANFIXATION /INTRAMEDULLARY). 4-SCREW (REGULAR /DYNAMIC). 5-PLATE.

32 PLASTER OF PARIS

33

34 EXTERNAL FIXATOR

35 ILIZAROV TECHNIQUE

36 INTRAMEDULLARY NAIL REGULAR

37 INTRAMEDULLARY NAIL REGULAR

38 INTRAMEDULLARY NAIL REGULAR INTERLOCKING

39 PIN

40 SCREW REGULAR

41 SCREW REGULAR DYNAMIC

42 SCREW REGULAR DYNAMIC

43 PLATE & SCREW

44 INDICATIONS OF INTERNAL FIXATIONNONUNION (NECK FEMUR). MALUNION (AROUND ANKLE & WRIST). PATHOLOGICAL. MULTIPLE. UNSTABLE. DISTRACTION (OLECRANON &PATELLA). NEUROVASCULAR INJURY. DIFFICULT NURSING (ELDER & PARAPLEGIC)

45 ADVANTAGES OF INTERNAL FIXATIONACCURATE REDUCTION RIGID FIXATION. EARLY AMBULATION.

46 COMPLICATIONS OF FRACTURESGENERAL : -SHOCK , FAT EMBOLISM , RECUMBENCY. LOCAL : 1-EARLY: INFECTION, AVASCULAR NECROSIS , SOFT TISSUE INJURY. 2-LATE : MALUNION , DELAYED UNION ,SUDEK’S ATROPHY , STIFFNESS, OSTEOPOROSIS, MYOSITIS OSSIFICANS , GROWTH DISTURBANCE.

47 DELAYED (NON)UNION ISCHEMIA. INFECTION. DISTRACTION. INTERPOSITION.BAD FIXATION.

48 UPPER LIMB INJURIES 1-CLAVICLE. 2-SHOULDER DISLOCATION. 3-HUMERUS. 4-FOREARM : -MONTEGGIA & GALEAZZI. -COLLES’. 5-HAND : -SCAPHOID. -BENNET’S. -MALLET.

49 # CLAVICLE COMMONEST # IN THE BODY. 80% MIDDLE THIRD.MAY PRODUCE INJURY OF THE SUBCLAVIAN VS. & BRACHIAL PLEXUS. MALUNION IS COMMON. TT: -SLING 3 WEEKS . -INTERNAL FIX. IN N-V INJURY.

50 # MID THIRD CLAVICLE

51 SHOULDER DISLOCATION COMMON DUE TO WIDE RANGE OF MOBILITY.PREDISPOSING FACTORS: SHALLOW GLENOID . LARGE ARTICULAR SURFACE OF HUMERAL HEAD. LAX CAPSULE. WEAK LIGAMENTS & MUSCLES.

52 MECHANISM OF SHOULDER DISLOCATIONTHE DISPLACED HEAD OF HUMERUS TEARS EITHER THE CAPSULE OR THE GLENOID LABRUM. WHILE DOING SO , THE HEAD USUALLY SUFFERS A COMPRESSION FRACTURE. TYPES: 1-ANTERIOR (MORE THAN 95 %): -SUBCORACOID (80%). -SUBGLENOID. -SUBCLAVICULAR. 2-POSTERIOR (3%). 3-INFERIOR (0.5%): -ADDUCTION. -ABDUCTION((LUXATIO ERECTA) ASSOCITED AXILLARY N/V INJURY.

53 ANTERIOR SHOULDER DISLOCATIONCL CR G subclavicular

54 SUBCORACOID (80%)

55 POSTERIOR SHOULDER DISLOCATIONNORMAL POSTERIOR DISLOCATION

56 INFERIOR SHOULDER DISLOCATIONABDUCTION (LUXATIO ERECTA) ADDUCTION

57 MANAGEMENT -REDUCTION BY KOCHER’S TECHNIQUE: -ARM IS SUBMITTED TO: (TRACTION  L. ROTATION ADDUCTION  M. ROTATION). -FIXATION (3 WEEKS): -BANDAGE OF THE ARM TO THE SIDE. -ARM SLING. -PHYSIOTHERAPY (AVOID L. ROTATION) 3 WEEKS.

58 REC.& DELAYED CASES OPERATIVE INTERVENTION ONLY IN GREAT DISABILITY.EITHER: 1- PUTTI PLATT : ANT. CAPSULORRAPHY. 2- BANKART : ANATOMICAL REPAIR

59 HUMERUS UPPER END . SHAFT. LOWER END.

60 UPPER END HUMERUS ANATOMICAL NECK. GREATER TUBEROSITY.LESSER TUBEROSITY. SURGICAL NECK. TREATMENT: SLING TILL NO PAIN. A A SN A A RD

61 SHAFT HUMERUS TREATMENT: U- SLAB OR CAST. IMN (N/V INJURY). WRIST DROP(RADIAL NERVE MAY BE INJURED IN THE SPIRAL GROOVE)

62 LOWER END HUMERUS SUPRACONDYLAR. INTER CONDYLAR. CONDYLAR.ARTICULAR (CAPITULUM&TROCHLEA). EPICONDYLAR.

63 SUPRACONDYLAR # TT: ANGLE LESS THAN 20  ONLY FIX.ANGLE MORE THAN 20  REDUCE & FIX (IN EITHER FLEXION OR EXTENSION). INJURY OF THE BRACHIAL ART./MEDIAN N  INT. FIX.

64 CUBITUS VARUS

65 # DIAPHYSIS BOTH BONES

66 MONTEGGIA & GALEAZZI DISLOCATION RADIUS FRACTURE ULNA DISLOCATION

67 COLLES’ # DISTAL 1 INCH RADIUS. IMPACTED , DORSAL, LATERAL.+ DISLOCATED INF. R/U JOINT + # ULNAR STYLOID. TT: RED.& BEC 6W .

68 COLLES’ #

69 HAND SCAPHOID. BENNET’S. MALLET.

70 SCAPHOID C/P:PAIN (MAY BE MISSED FOR SPRAIN).TT: BEC INCLUDING THE PROXIMAL PHALANX OF THE THUMB. COMPLICATION: AVASCULAR NECROSIS OF DISTAL POLE

71

72 BENNET’S #/DISLOCATIONOBLIQUE # OF THE BASE OF 1 ST. METACARPAL INVOLVING THE ARTICULAR SURFACE RESULTING IN #/DISLOCATION. IT IS UNSTABLE & USUALLY REQUIRES INTERNAL FIXATION.

73 MALLET FINGER MALLET = HAMMER WITH A LARGE WOODEN HEAD.IT IS NOT A FRACTURE , IT IS A FLEXION DEFORMITY OF THE DISTAL PHALANX DUE TO AVULSION OF THE EXTENSOR EXPANSION FROM ITS BASE.

74

75 PELVIC # TYPES: - NOT INVOLVING THE RING .- INVOLVING THE RING : -SINGLE. -MULTIPLE (OPEN BOOK). TT : -TT OF SOFT TISSUE INJURIES (COMMON). -BINDER & TRACTION. -INTERNAL FIXATION.

76 PELVIC #

77 LOWER LIMB INJURIES (# & DISLOCATION)HIP DISLOCATION. FEMUR : - NECK. - SHAFT. - DISTAL. EXTENSOR APPARATUS (PATELLA). TIBIA. ANKLE.

78 HIP DISLOCATION TYPES : - ANTERIOR (DOWNWARDS ELONGATION). - CENTRAL.- POSTERIOR (UPWARDS  SHORTENING) (COMMON). C/P : - PAIN. - DEFORMITY. - LIMITATION.

79 NORMAL HIP

80 POSTERIOR HIP DISLOCATION (COMMONEST)1-HEAD: OUTSIDE ACETABULUM. 1

81 POSTERIOR HIP DISLOCATION (COMMONEST)1-HEAD: OUTSIDE ACETABULUM. 2-SHENTON’S LINE: INTERRUPTED. 1 2

82 POSTERIOR HIP DISLOCATION (COMMONEST)1-HEAD: OUTSIDE ACETABULUM. 2-SHENTON’S LINE: INTERRUPTED. 3-LESSER TROCHANTER: LESS APPARENT(ROTATION). 1 2 3

83 POSTERIOR HIP DISLOCATION (COMMONEST)1-HEAD: OUTSIDE ACETABULUM. 2-SHENTON’S LINE: INTERRUPTED. 3-LESSER TROCHANTER: LESS APPARENT(ROTATION). 4-ACETABULUM: # POST. MARGIN. 1 2 4 3

84 POSTERIOR HIP DISLOCATION (COMMONEST)TT : 1- REDUCTION : -FLEXION. -ADDUCTION. -TRACTION. -EXTENSION. 2- FIXATION: -SKIN TRACTION.

85 CENTRAL HIP DISLOCATION

86 NECK FEMUR HEAD FEMUR NECK 8 cm BELOW LESSER TROCHANTER

87 # NECK FEMUR BLOOD SUPPLYLIGAMENTUM. TERES

88 # NECK FEMUR BLOOD SUPPLYLIGAMENTUM. TERES NUTRIENT

89 # NECK FEMUR BLOOD SUPPLYRETINACULAR LIGAMENTUM. TERES NUTRIENT

90 # NECK FEMUR TYPES: 1-INTRACAPSULAR: (TORN RETINACULAE)-HIGH CERVICAL (SUBCAPITAL). -MIDCERVICAL. 2-EXTRACAPSULAR: (INTACT RETINACULAE) -PERTROCHANTERIC (BASE TO L.TROCH.) -SUBTROCHANTERIC (L.TROCH. TO 8cm BELOW )

91 # NECK FEMUR SUBCAPITAL PERTROCHANTERIC MIDCERVICAL SUBTROCHANTERICINTRACAPSULAR EXTRACAPSULAR

92 PERTROCHANTERIC FRACTURE

93 TREATMENT 0F # NECK FEMUR INTRACAPSULAR (TORN RETINACULAE)ALWAYS OPERATIVE CAUSE THE PROXIMAL SEGMENT: -VASCULARITY IS COMPROMISED (25%). -MANIPULATION IS IMPOSSIBLE. -FIXATION IS IMPOSSIBLE. TT: -IMPACTED  ONLY I.F. (SCREW). -DISIMPACTED(R.&I.F.) . -ABOVE 65ys  HEMIARTHROPLASTY.

94 SCREW

95 HEMIARTHROPLASTY

96 TREATMENT 0F # NECK FEMUR EXTRACAPSULAR (INTACT RETINACULAE)IN EXTRACAPSULAR # THE PROXIMAL SEGMENT IS: -WELL VASCULARISED. -ACCESSIBLE (FOR R. & F.). TT : -TROCHANTERIC  DHS. -SUBTROCHANTERIC  PLATE & SCREW

97 DYNAMIC HIP SCREW (DHS)

98 DYNAMIC HIP SCREW (DHS)

99 DYNAMIC HIP SCREW (DHS)

100 DYNAMIC HIP SCREW (DHS)

101 SHAFT FEMUR TT: 1-TRACTION: A-SLIDING -SKIN (GALLOWS SPLINT) .-SKELETAL. B-FIXED (THOMAS SPLINT) . 2-(OR & IF): ( I M NAIL OR PLATE & SCREWS). TRACTION ALONE IS USUALLY INSUFFICIENT CAUSE : -THIGH MUSCLES ARE STRONG & INSTABILITY IS COMMON. -IMMOBILIZATION IS PROLONGED (COMPLICATIONS). -SOFT TISSUE INTERPOSITION IS COMMON. -DELAYED UNION. -LATERAL POPLITEAL NERVE CAN BE INJURED.

102 TRACTION GALLOWS

103 INTERNAL FIXATION

104 ANKLE # ANKLE JOINT IS FORMED OF: -SUPERIORLY: TIBIA.-INFERIORLY : TALUS. -MEDIALLY : MEDIAL MALLEOLUS. -LATERALLY : LATERAL MALLEOLUS. -POSTERIORLY : THIRD MALLEOLUS. THE JOINT IS STABILIZED BY : -ANTERIORLY : ANTERIOR TIBIOFIBULAR LIGAMENT. -POSTERIORLY : POSTERIOR TIBIOFIBULAR LIGAMENT. -MEDIALLY : TALO - TIBIAL LIGAMENT (DELTOID). -LATERALLY : TALO - FIBULAR LIGAMENT.

105 MECHANISM OF INJURY: INDIRECT VIOLENCE PRODUCING EXCESSIVE :1- EXTERNAL ROTATION (POTT’S #) COMMONEST. 2- INTERNAL ROTATION. 3- ADDUCTION (INVERSION. 4- ABDUCTION (EVERSION). 5- VERTICAL COMPRESSION.

106 POTT’S FRACTURE EXCESSIVE EXTERNAL ROTATION OF THE FOOT MAY LEAD TO:1- INJURY THE LATERAL STRUCTURES OF THE ANKLE. 2- INJURY THE MEDIAL STRUCTURES OF THE ANKLE. 3- INJURY THE POSTERIOR STRUCTURES OF THE ANKLE.

107 INJURY OF THE MEDIAL & LATERAL STRUCTURES

108 FIXATION OF THE MEDIAL & LATERAL STRUCTURES

109 INJURY THE POSTERIOR STRUCTURES

110 If you have questions I am more than willing to answer