Orthopaedic anatomy

Fractures of bones of upper extremity

 

Clavicle

Lateral shaft

Fall on outstretched hand

 Fall on the point of the shoulder

Blunt injury to shoulder  

 

Midshaft

 

Scapula

Coracoid process

Scapula fractures are uncommon

Blunt direct injury to shoulder or fall on shoulder

Acromion

Body

Glenoid cavity

Glenohumeral joint dislocation

Acromioclavicular joint dislocation

Humerus

Anatomical neck

Fall on outstretched hand.

Commoner at midshaft.

Surgical neck

Shaft of humerus

Supracondylar

Intercondylar

Medial epicondylar

Lateral epicondylar

Elbow dislocation

Radius

Head

Injuries to radius may occur as a result of fall on outstretched hand

Common in young adults

May occur with fracture of shaft of ulna.

 

Neck

Shaft

Colles’

Smith’s

Distal end

Galeazzi

Ulna

Olecranon

Fall on outstretched hand can cause injuries to ulna

Common in young adults

May occur with fracture of shaft of radius.

Coronoid process

Shaft

Monteggia

Carpus

Scaphoid

Fall from outstretched hand with the wrist in forced extension.

Affects the young adult.

Lunate

Perilunar dislocation

Wrist joint dislocation

Miscellaneous

Metacarpus

Metacarpus I

Injury to metacarpal bones can be caused by blow on dorsum of hand

Punching

May affect one or more bones.

May be shaft or neck fracture

Fractures of metacarpal I and V are not very stable

Fractures of neck of metacarpal V are the commonest and the most stable.

 

Metacarpus II

Metacarpus III

Metacarpus IV

Metacarpus V

Metacarpophalangeal dislocation

Phalanges of Hand

Middle phalanges

Crushing injuries (comminution)

Direct blow (Comminution)

Proximal phalanges

Distal phalanges

Interphalangeal joint dislocation

Surgical exposure of bones of upper extremity

 

Anterolateral approach to shaft of humerus

 

  • Make skin incision along the distal half of deltopectoral groove to reach the lateral side of biceps brachii at its junction with its tendon. Open deep fascia, and ligate cephalic vein proximally and distally.

  • Expose the shaft between the deltoid and biceps brachii proximally. Distally split the brachialis longitudinally into two and retract the halves to expose the bone.

  • Further exposure at its most distal aspect is done at the interval between brachialis and brachioradialis with the radial nerve reflected laterally together with the brachialis.

Anterior approach to shoulder 

Lateral approach to elbow

Anterior approach to shaft of radius

 

Exposure of the bones of lower extremity

Medial approach to ankle joint

 

Anterior exposure of iliac crest

  • Place in supine position with sandbag under hip.

  • Make curved incision below the prominence of iliac tubercle and pull abdominal muscles upwards (external oblique etc) to expose the interval between abdominal oblique and the gluteal muscles.

  • Strip oblique muscles subperiosteally.

Remove bone from iliac crest either as thick block of cancellous bone or corticocancellous strips

 

Exposure of shaft of tibia 

  • Approach using the subcutaneous border is clear cut and simple.

  • But this approach has limited use in extensive loss of skin and subcutaneous tissue, in which case a posterolateral approach between the lateral peroneal muscles and the gastrocnemius,is desirable.

Medial parapatellar approach to knee joint

  • Make a close to vertical skin incision extending from the prominence of medial femoral condyle to more than 2cm below the superior aspect of tibial plateau, avoiding the inferiorly placed infrapatellar branches of saphenous nerve.

  • Increase incision through all layers of the synovial membrane. Then incise the synovial membrane to gain access to knee joint cavity.

  • Use hook to draw the inner edge of medial meniscus forward to allow a wider inspection of the knee.

  • For wider exposure especially at the proximal part, extend incision upward to the medial edge of quadriceps tendon and push patella laterally.

Anterior approach to shaft of femur

Posterior approach to hip joint

  • Place patient in mid-lateral position. Start your skin incision on the upper 5 cm of the femur until it reaches the tip of greater trochanter. Then turn the incision posteriorly over the buttock towards the posterior superior iliac spine to reach about 9cm.

  • Divide the fascia lata over the upper end of femur. Incise the fibrous layer on the gluteus maximus. Separate the horizontal fibers of gluteus maximus to expose the gluteal pad of fat and the sciatic nerve. Open the gluteal bursa.

  • Incise the floor of gluteal bursa immediately posterior to the greater trochanter

  • Divide the short lateral rotators muscles (piriformis, obturator internus, obturator externus, quadratus femoris) to expose the hip joint.

Repair of ruptured tendo calcaneus

 

 

 

 Fractures of lower extremity

Hip bone

Anterior dislocation

Direct blow to the hip through the long axis of the femur.

This is common in road traffic accident and causes posterior dislocation, which occurs with the hip in flexion and adduction.

Anterior dislocation is uncommon

Central dislocation is caused by fall from height when the hip is extended and abducted.

Central dislocation occurs with fracture of acetabulum.

Fracture of acetabulum may also be a complication of anterior and posterior dislocations.

Sciatic nerve injury is a common complication of all dislocations

 

 

Posterior dislocation

Central dislocation

Femur

Neck

Direct blow to the femur

Osteoporosis

and causes posterior dislocation, which occurs with the hip in flexion and adduction.

Road traffic accident

Trochanter

Subtrochanter

Shaft

Supracondylar

Condylar

Knee

 

Direct injuries

Indirect injuries caused by twisting the flexed (cartilages) and extended (ligaments) knee.

Occurs mostly in athletes and sports persons.

 

 

Patella

 

Direct blow to the knee.

Indirect blow to the quadriceps as in stumbling and falling.

Road traffic accident

 

Tibia

Condyles

Fracture of tibia is the most common in the body

Compound fractures are commonest at the shin.

Direct blow to the tibia.

Road traffic accident

 

Shaft

Medial malleolus

Tibial tuberosity

Fibula

Shaft

Uncommon

Direct blow to the lateral side of leg- abduction injuries. This is very uncommon because the shaft of fibula is protected by peroneal muscles (longus, brevis, tertius).

Common fibular fracture includes lateral malleolar.

It is commoner to have tibia and fibula fractures together than fibula alone.

Road traffic accident

Lateral malleolar

Ankle

Pott’s fractures

Pott's fractures involves bones of the ankle joint. It may occur from fall from height.

It includes some measure of twisting of the ankle at time of injury

It also includes the rupture of collateral ligaments of ankle (medial and lateral)together with tendo calcaneus

Affects the young adult.

Tarsus

 

Common with fall from height landing in the standing position can cause fracture of calcaneus.

Accompanied by thoracolumbar injuries

Fractures may involve or avoid the subtalar joint.

Metatarsus

Fractures of metatarsal V

March fractures

Common with heavy objects falling on foot.

Causes fractures to shafts of metatarsal bone mainly.

Usually includes bruising, crushing, contusion and other injuries to soft tissues.

Phalanges of foot

 

Crushing injuries (comminution) can cause injuries to phalanges of foot

Direct blow (comminution)

Run over by vehicles or trucks

Uncommon and almost always associated with more soft tissue injuries than fractures.

There is very little distinctions between different phalangeal injuries as in the hand.

 

 

 

 

 

 

 

Fractures of thorax

 

Ribs

 

Crushing injuries especially due to war can cause injuries to ribs and thoracic cage.

May also be due to road traffic accidents, (RTA).

Often associated with injuries in other parts of the body.

Sternum

 

Injuries to sternum is very uncommon

Crushing injuries especially due to war.

May also be due to road traffic accidents, (RTA).

Often associated with injuries in other parts of the body.

 

Fracture of pelvis

 

Pelvis

 

Isolated injuries to the pelvic cavity or girdle causing displaced or undisplaced single fractures.

Severe violence to pelvis as in fall from height or being run over by vehicle

Severe violence to pelvis is accompanied by multiple soft tissue injuries and multiple fractures.

Avulsion fractures include hamstrings, iliopsoas and adductors

 

Fractures of head and neck and vertebrae

Skull

Vault

Injuries of skull include, compression, local indentation and tangential injuries affecting vault and base of skull.

Accompanied by brain affection which may be either concussion, contusion or cerebral laceration.

Linear fractures indicate severity of fracture and soft tissue damage based on its site.

Comminuted fractures are usually compound in adults and depressed.

Depressed fractures in the young child is circular and called ponds fracture.

 

Base

Facial

Vertebrae

Cervical spine

Injuries to the vertebrae or spine can be caused by road traffic accident, which is common for cervical spine.

Head injuries are often complicated by injuries to spine.

Thoracolumbar spines usually cause fracture- dislocation- through forcible flexion and rotation injuries.

Thoracolumbar spine

Sacrum

Coccyx

 

Fracture of anterior cranial fossa

Causes and features 

Diagnosis

Treatment

  • Prop patient up to lower pressure and reduce escape of cerebrospinal fluid.

  • Give antibiotics copiously

  • If escape of CSF still occurs after 10 days dural repair is indicated

  • Rule our aerocele by X-ray.

Fracture of middle cranial fossa

Causes and features

Diagnosis

  • History:

  • General examination: Look out for CSF otorrhea. It may mix with blood if there is also damage to the branch of middle meningeal artery.

  • Blood which does not clot is suggestive of CSF admixture.

  • Test cranial nerves VII and sometimes VIII.

  • X-ray

Treatment

  • Prop patient up to lower pressure and reduce escape of cerebrospinal fluid.

  • Give antibiotics copiously

  • If escape of CSF still occurs after 10 days dural repair is indicated

  • If VII is damaged,it may lead to permanent facial palsy.

Fracture of posterior cranial fossa

Causes and features

It does not damage the XII because of protection at its hypoglossal canal.

Diagnosis

  • History:

  • General examination: Look out for extravasation of blood at the suboccipital region.

  • Test cranial nerves IX, X and XI. Cranial nerve I is often involved causing partial anosmia. It may involve other cranial nerves such as V, VI, at sphenoidal fissure.

  • X-ray

Treatment

  • Prop patient up to lower pressure and reduce escape of cerebrospinal fluid.

  • Give antibiotics copiously

  • If escape of CSF still occurs after 10 days dural repair is indicated

  • Rule our aerocele by X-ray.

Whiplash

Causes and features

  • This is caused by rupture of anterior longitudinal ligament of cervical spine.

  • This might be due to osteophytes on vertebral bodies.

  • It may follow fall on face or forehead especially in the elderly.

  • It follows 'whiplash' injury when a person in a car hits a stationary object without head rest, but using seat belt.

Diagnosis

Treatment

  • Clear the airways

  • Cervical patient must be carried in prone position, especially if there is association with head injury.

  • If stable fracture, immobilize with cervical collar

  • If unstable use skull traction with calipers and apply at pull of 4-5kg.

  • After initial recovery place in Minerva jacket for 3months or 'halo' splint for 2 months.  

 

 

 

 

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