Given the signs and symptoms, what other information are necessary in arriving to the correct

diagnosis?

Relevance of clinical signs

Unfailing signs  Abnormal mobility

 Crepitus
Reliable signs  Tenderness
 Shortening
Important signs  Bruise
 Swelling
Other signs  Loss of function
 Deformity
Late or inconstant signs  Blisters
 Ecchymosis
 Swelling due to callus

Five Ps (In detecting impending vascular damage in musculo-skeletal trauma)

• Pain
• Pallor
• Paresthesia
• Pulselessness
• Paralysis

“D” in fracture:
• Deformity is seen often in displaced fractures.
• Displacement could be anterior, posterior, medial or lateral.
• Distal fragment is the reference point to suggest the type of displacement.
• Dislocation of joints usually presents a deformity.

What are the goals of the initial evaluation of trauma patients?

Aims of the initial evaluation of trauma patients
 Stabilize the patient.
 Identify life-threatening conditions in order of risk and initiate supportive treatment.
 Organize definitive treatments or organize transfer for definitive treatments.

Physical examination on trauma patient. Primary Survey

A = Airway maintenance cervical spine protection
 Are there signs of airway obstruction, foreign bodies, facial, mandibular or laryngeal
fractures? Management may involve secretion control, intubation or surgical airway
(eg, cricothyroidotomy, emergency tracheostomy).
 Establish a clear airway (chin lift or jaw thrust) but protect the cervical spine at all
times.[9]If the patient can talk, the airway is likely to be safe; however, remain vigilant
and recheck. A nasopharyngeal airway should be used in a conscious patient; or, as a
temporary measure, an oropharyngeal airway in an unconscious patient with no gag
reflex. Definitive airway should be established if the patient is unable to maintain
integrity of airway; mandatory if Glasgow Coma Scale (GCS) is less than 8 or 9.
 Cervical spine protection is critical throughout the airway management process.
Movement of the cervical spine could cause spinal injury so movement of the cervical
spine should be avoided unless absolutely necessary for maintaining an airway. The
trauma mechanism or history may suggest the likelihood of a cervical spine injury, but
 always assume there is a spinal injury until proven otherwise, especially in any
multisystem trauma or if there is an altered level of consciousness. Inline
immobilization and protection of the spine should be maintained and X-rays can be
taken once immediately life-threatening conditions have been dealt with.
B = Breathing and ventilation
 Provide high-flow oxygen through a rebreather mask if not intubated and ventilated.
Evaluate breathing: lungs, chest wall, diaphragm.
 Chest examination with adequate exposure: watch chest movement, auscultate, percuss
to detect lesions acutely impairing ventilation:
Tension pneumothorax - requires needle thoracostomy followed by drainage.
Flail chest - management involves ventilation.
Hemothorax - will usually require intercostal drain insertion.
Pneumothorax - may require intercostal drain insertion.
Note: it can be difficult to tell whether the problem is an airway or ventilation problem. What
appears to be an airway problem, leading to intubation and ventilation, may turn out to be a
pneumothorax or tension pneumothorax which will be exacerbated by intubation and
ventilation.
C = Circulation with hemorrhage control
 Blood loss is the main preventable cause of death after trauma. To assess blood
loss rapidly observe: Level of consciousness.
 Skin colour.
 Pulse.
 Bleeding - this should be assessed and controlled:
 IV access should be achieved with two large cannulae (size and length of cannula
is determinant of flow not vein size) in an upper limb. Access by cut down or
central venous catheterization may be done according to skills available. At
cannula insertion, blood should be taken for crossmatch and baseline
investigations.
 IV fluids will need to be given rapidly, usually as 250 ml to 500 ml warmed boluses
(10-20 ml/kg in children). Often a total of 2-3 L of IV fluids is necessary (40 ml/kg in
children), which will then need to be followed by blood transfusion (O negative to
begin with, if typed blood is not available). Ringer's lactate is the preferred initial
crystalloid solution.[11]
 Direct manual pressure should be used to stem visible bleeding (not
tourniquets, except for traumatic amputation, as these cause distal ischemia).
 Transparent pneumatic splinting devices may control bleeding and allow visual
monitoring; surgery may be necessary if these measures fail to control
hemorrhage.
 Occult bleeding into the abdominal cavity and around long-bone or pelvic
fractures is problematic but should be suspected in a patient not responding to
fluid resuscitation.
Note: response to blood loss differs in:
o Elderly - limited ability to increase heart rate; poor correlation between
blood loss and blood pressure.
o Children - tolerate proportionately large volume loss but then rapidly
deteriorate.
o Athletes - do not show the same heart rate response to blood loss.
o Chronic conditions and medication may affect response and early on in trauma
management will not be known about.
D = Disability: neurological status
 After A, B and C above, rapid neurological assessment is made to establish:
 Level of consciousness, using GCS.
 Pupils: size, symmetry and reaction.
 Any lateralizing signs.
  Level of any spinal cord injury (limb movements, spontaneous respiratory effort).
 Oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycemia may all also affect
the level of consciousness.
 Patients should be re-evaluated frequently at regular intervals, as deterioration can
occur rapidly and often patients can be lucid following a significant head injury before
worsening. Signs such as pupil asymmetry or dilation, impaired or absent light reflexes,
and hemiplegia/weakness all suggest an expanding intracranial mass or diffuse edema.
This requires IV mannitol, ventilation and urgent neurosurgical opinion. Hypertonic
saline can be used as an alternative to mannitol especially in hypovolemic patients.
E = Exposure/environmental control
 Undress the patient, but prevent hypothermia. Clothes may need to be cut off but, after
examination, attend to prevention of heat loss with warming devices, warmed blankets,
etc. Also check blood glucose levels.
Additional considerations to primary survey and resuscitation
 ECG monitoring
 Urinary/gastric catheters
 Other monitoring: Pulse rate, blood pressure, ventilatory rate, arterial blood gases, body
temperature and urinary output, Pulse oximetry measures oxygenation of hemoglobin
colorimetrically
 Diagnostic procedures: e.g. CXR, Pelvic X-ray, CT scans, Lateral cervical spine X-
ray(If needed)
Secondary survey
History
A = Allergies.
M = Medication currently used.
P = Past illnesses/Pregnancy.
L = Last meal.
E = Events/Environment related to injury

 Additional considerations to secondary survey

A range of further diagnostic tests and procedures may be required after the secondary survey.
These include CT scans, ultrasound investigations, contrast X-rays, angiography, bronchoscopy,
esophageal ultrasound, etc.

What is the relevance of doing a complete PE in regards to a medico-legal case?

A medico-legal case can be defined as a case of injury or ailment, etc., in which
investigations by the law-enforcing agencies are essential to fix the responsibility regarding the
causation of the injury or ailment. In simple language, it is a medical case with legal implications
for the attending physician where the attending physician, after eliciting history and examining
the patient, thinks that some investigation by law enforcement agencies is essential or a legal
case requiring medical expertise when brought by the police for examination.
All patients presenting to the emergency department (ED) due to crushing, traffic
accidents, firearms and explosive injuries, assault, burns, electric shock, asphyxia, torture, child
abuse, falls and other injuries, poisoning, and suicide attempt are considered traumatic medico-
legal cases [1,2]. Traumatic medico-legal cases occur frequently in the EDs, which are seen as
the entrance to health institutions. The ED examinations often constitute the first step of
forensic examination. Emergency physicians have a duty to evaluate cases of medico-legal
 trauma and to transmit judicial findings to the appropriate judicial authorities in accordance
with accepted procedures [1].
Emergency physician's medical records and official reports are very important in the
cases of legal problem. Forensic reports created by the EDs represent critical evidence for the
judicial process. Inaccurate reports cause delays in judicial proceedings and result in misleading
decisions that may lead to the loss of patient rights. Identification of mistakes and deficiencies in
forensic reports will help prevent accusations such as "neglect of judicial responsibility" and
"untruthful expertise"[5]. The identification of common patterns in traumatic medico-legal cases
can be used to help minimize such incidents.

Relevant Anatomy and Physiology

Remember the functions of bone:

• Protection of vital organs

• Support to the body
• Hematopoiesis
• Movement and locomotion
• Mineral storage

Bone Development
Bone development begins with the condensation of the mesenchyme in the embryo.
There are certain exceptions like the vault of the skull (membranous ossification), the clavicle
(mixed ossification) and the mandible (Meckel’s cartilage). From this condensation, the bone
rapidly form a cartilaginous model. Between the cartilaginous bone and plates, it forms small
clefts for the future joints. During this period of 12 weeks, it is particularly vulnerable to
teratogenic influences. As early as the fifth week of intrauterine life, it develops a primary center
of ossification, which gradually replaces this cartilage model to bone by a process of
endochondral ossification. During the late fetal stages or early few years of life, it develops
secondary centers of ossification. Growth plate, which keeps the primary and secondary centers
of ossification separated from each other until skeletal maturity, helps it grow longitudinally and
increases its width from the growth of the thickened periosteum. In addition, it keeps
remodeling itself from the fetal stage to the adult stage. Only the rate varies (50% during the
first two years of life and 5% per year thereafter until adulthood).

General Structures of the Bone

Epiphysis is an expanded portion at the end develops usually under pressure and forms
a support for the joint surface. It is easily affected by developmental problems like epiphyseal
dysplasias, trauma, overuse, degeneration and damaged blood supply. The result is distorted
joints due to avascular necrosis and degenerative changes.
Growth plate (physis) though mechanically weak it helps longitudinal growth. It
responds to growth and sex hormones. It is affected by conditions like osteomyelitis, tumor,
slipped epiphysis resulting in short stature or deformed growth or growth arrest.
Metaphysis is concerned with remodeling of bone. It is the cancellous portion and heals
readily. It gives attachment to ligament and tendons. It is vulnerable to develop osteomyelitis,
dysplasias and tumors resulting in distorted growth and altered bone shapes.
 Diaphysis is a significant compact cortical bone which is strong in compression and
which gives origin to muscles. It forms the shafts of the bones. Healing is slow when compared
to metaphysis. In remodeling, it can remodel angulations but not rotation. It may develop
fractures, dysplasias, infection and rarely tumors.

Anatomy to Review:

Muscles insertion for: pectoralis major, deltoid, coracobrachialis

Pectoralis major
Origin Clavicular head: anterior surface of medial half of clavicle; Sternocostal head:
anterior surface of sternum, superior six costal cartilages, and aponeurosis of
external oblique muscle
Insertion Lateral lip of intertubercular groove of humerus

Action Adducts and medially rotates humerus; draws scapula anteriorly and inferiorly;
Acting alone: clavicular head flexes humerus and sternocostal head extends it
Innervation Lateral and medial pectoral nerves; clavicular head (C5 and C6, sternocostal
head (C7, C8, and T1) (C5, C6, C7, C8, T1)
Arterial pectoral branch of the thoracoacromial trunk
Supply

Deltoid
Origin Lateral third of clavicle, acromion, and spine of scapula

Insertion Deltoid tuberosity of humerus

Anterior part: flexes and medially rotates arm; Middle part: abducts arm;
Action
Posterior part: extends and laterally rotates arm

Innervation Axillary nerve (C5 and C6) (C5, C6)

Arterial
Deltoid branch of thoracoacromial artery
Supply

Coracobrachialis
Origin Tip of coracoid process of scapula

Insertion Middle third of medial surface of humerus

Action Helps to flex and adduct arm

Innervation Musculocutaneous nerve (C5, C6 and C7) (C5, C6, C7)

Arterial
Muscular branches of brachial artery
Supply

Origin: for brachialis, triceps, brachioradialis

Brachialis
Origin Distal half of anterior surface of humerus

Insertion Coronoid process and tuberosity of ulna

Action Major flexor of forearm -- flexes forearm in all positions

Innervation Musculocutaneous nerve (C5,C6) & Radial nerve

Arterial
Muscular branches of brachial artery, recurrent radial artery
Supply

Triceps
Origin Long head: infraglenoid tubercle of scapula; Lateral head: posterior surface of
humerus, superior to radial groove; Medial head: posterior surface of humerus,
inferior to radial groove

Insertion Proximal end of olecranon process of ulna and fascia of forearm

Action Chief extensor of forearm; long head steadies head of abducted humerus

Innervation Radial nerve (C6, C7 and C8) (C6, C7, C8)

Arterial
Branches of deep brachial artery
Supply

Brachioradialis
Origin Proximal 2/3 of lateral supracondyle ridge of humerus

Insertion Lateral surface of distal end of radius

Action Flexes forearm

Innervation Radial nerve (C5, C6, C7)

Arterial
Radial recurrent artery
Supply

Nerve: radial nerve (courses along spiral groove, 14cm proximal to the lateral epicondyle, 20cm
proximal to the medial epicondyle);
 From posterior cord of brachial plexus C5-C6-C7-C8-T1,
 Descends behind axillary and brachial arteries,
 Enters posterior compartment of forearm
 Winds at back of humerus (spiral groove w/ profunda artery)
 Pierces lateral intermuscular septum above elbow
 Descends in front of lateral epicondyle
 Divides into superficial and deep terminal branches
 Radiological clues one should look for on plain X-rays for diagnosis of fractures:
• Where is the fracture?
• Situations: Whether it is in the diaphysis, metaphysis, epiphysis and the articular surface.
• Anatomy: Look for the fracture line, whether it is transverse, oblique, spiral,
segmental, comminuted, etc.
• Also look for the alignment, angulation, displacement, rotation, etc.
• Number: How many fragments are seen?
• Bone condition: Identify whether the bone is normal or pathological.
• Joint involvement: Look for the extension of the fracture line into the joint, joint
swelling and for evidence of dislocation.
• Soft tissue swelling: The extent of the soft tissue swelling indicates the severity of the
injury.
Pitfalls of X-ray
 Presence of a fracture line on an X-ray helps confirm the diagnosis but its absence
does not rule out a fracture.
 Hairline fractures tend to be missed (e.g. scaphoid).
 Some dislocations, if associated with fractures could be missed (e.g. Monteggia
fracture).
 In comminuted fractures the number of fragments could be misleading.
 Beware of artifacts they could mislead you.
 Be careful in interpreting fracture-like appearances, e.g.apophysis.
 Avoid interpreting a low quality X-ray.

What other diagnostic tests that can be ordered in this case?

 Transthoracic lateral view - may give better appreciation of sagittal plane deformity
rotating the patient prevents rotation of the distal fragment avoiding further nerve or
soft tissue injury
 Traction views - may be necessary for fractures with significant shortening, proximal or
distal extension but not routinely indicated

Types and Classifications of Fractures.

Definition of terms:
Fracture is a break in the surface of a bone, either across its cortex or through its articular
surface.
Dislocation is a complete and persistent displacement of a joint.
Subluxation is partial dislocation of a joint.
Sprain is a temporary subluxation of a joint due to ligament injury and the articular surfaces
return to normal alignment.
Strain is a tear in the muscle.

Types of Fractures
Simple/Closed - the bone can break within its soft tissue envelope and may not communicate to
the exterior
Compound/Open – may rip through its soft tissues or the soft tissue itself may be damaged by
the external forces, exposing the bone to the external atmosphere

Figs 3.1A and B: Simple and compound fractures

Based on the extent of fracture line:

A. Incomplete fractures—it involves only one surface or cortex of the bone.
B. Complete fracture—here the fracture involves both the cortices and the entire bone.
A complete fracture could be undisplaced or displaced.
Based on fracture patterns (orthopedic trauma association classification—Figs 3.2A to E)
A. Linear fractures: These could be transverse, oblique or spiral. Any fracture that forms
an angle less than 30° with the horizontal line is called transverse. Angle equal to or
more than 30° is termed oblique.
B. Comminuted fractures: Here the fracture fragments are more than two in number.
They are further subclassified into ≥ 50 percent comminution or more than 50 percent
comminution. Butterfly-shaped fractures are also included in this group and could be
less than 50 percent or equal to or more than 50 percent.
C. Segmental fractures: A fracture can break into segments and the segment could be
two- level, three-level, and a longitudinal split or comminuted.
D. Bone loss: This could be a < 50 percent bone loss, more than 50 percent bone loss, or
a complete bone loss.
 Figs 3.2A to E: Types of fractures based on fracture patterns:
(A) Transverse, (B) Spiral, (C) Oblique, (D) Comminuted, and
(E) Segmental fractures

CLASSIFICATION (GUSTILLO AND ANDERSON’S) for OPEN FRACTUREs

Type I: Wound is less than 1 cm in size. It is usually due to a low-velocity trauma.
Type II: Wound is more than 1 cm and less than 10 cm but there is no devitalization of soft
tissue and is associated with very little contamination. These are due to high-energy trauma.
Type III: Wounds moderate and severe in size (> 10 cm) and the soft tissues are devitalized and
contaminated.
Type IIIA: Extensive soft tissue injury but with adequate soft tissue to cover the fractured bone.
Type IIIB: Extensive soft tissue damage and loss. Bone cannot be covered and is exposed to the
atmosphere.
TypeIIIC: Compound fractures with arterial injuries.

No classification invites so much of debate as for open fractures with only 60 percent of the
surgeons across the globe accepting it. Hence, newer modifications are now being suggested
like:
a. The modified Gustillo Anderson’s classification.
b. The Trafton classification (this combines the Gustillo Anderson’s and Tscherne classification).
c. AO classification of soft tissue injury with alphanumeric classification of fractures.

Holstein-Lewis fracture
 A spiral fracture of the distal one-third of the humeral shaft commonly associated with
neuropraxia of the radial nerve
Fig: X-ray of a Holstein-Lewis fracture

Discuss the conservative vs. surgical treatment options? What are the indications for a
conservative or surgical treatment?

Isolated humeral shaft fractures are usually treated conservatively. The radial nerve
spirals around the humeral shaft and is at risk for injury; therefore, a careful neurovascular exam
is important. The patient should be checked for wrist drop. The majority of humeral shaft
fractures can heal with nonsurgical management if they are within an acceptable degree of
angulation. They are treated with a coaptation splint or functional bracing, which consists of a
plastic clamshell brace with Velcro straps. Close follow-up with serial radiographs is important to
verify healing of the fracture, and gentle motion exercises are begun within 1 to 2 weeks.
Fractures with significant angulation are most commonly treated with open reduction and plate
fixation, with care to protect the radial nerve as it often lies close to the fracture site.
Intramedullary nailing can also be performed, though it carries the risk of shoulder pain from
the nail insertion.
A. Non-operative/Conservative
 Coaptation splint followed by functional brace
 Indications
 indicated in vast majority of humeral shaft fractures
 criteria for acceptable alignment include:
 < 20° anterior angulation
 < 30° varus/valgus angulation
 < 3 cm shortening
 Absolute contraindications
 severe soft tissue injury or bone loss
 vascular injury requiring repair
 brachial plexus injury
 Relative contraindications
 see relative operative indications section
 radial nerve palsy is NOT a contraindication to functional bracing
 Outcomes
 90% union rate
 increased risk with proximal third oblique or spiral fracture
 varus angulation is common but rarely has functional or cosmetic
sequelae
 Techniques
 coaptation splint
 applied until swelling resolves
 adequately applied splint will extend up to axilla and over
shoulder
 common deformities include varus and extension
- valgus mold to counter varus displacement
 functional bracing
 extends from 2.5 cm distal to axilla to 2.5 cm proximal to
humeral condyles
 sling should not be used to allow for gravity-assisted fracture
reduction
 shoulder extension used for more proximal fractures
 weekly radiographs for first 3 weeks to ensure maintenance of
reduction then every 3-4 weeks after that

 Damage control orthopedics (DCO)

 closed humerus fractures, including low velocity GSW, should be initially
managed with a splint or sling
 type of fixation after trauma should be directed by acceptable fracture
alignment parameters, fracture pattern and associated injuries

B. Operative
 Open reduction and internal fixation (ORIF)
 Absolute indications
 open fracture
  vascular injury requiring repair
 brachial plexus injury
 ipsilateral forearm fracture (floating elbow)
 compartment syndrome
 periprosthetic humeral shaft fractures at the tip of the stem
 Relative indications
 bilateral humerus fracture
 polytrauma or associated lower extremity fracture
 allows early weight bearing through humerus
 pathologic fractures
 burns or soft tissue injury that precludes bracing
 fracture characteristics
- distraction at fracture site
- short oblique or transverse fracture pattern
- intraarticular extension
 Approaches
 Anterolateral approach to humerus
 used for proximal third to middle third shaft fractures
 distal extension of the deltopectoral approach
 radial nerve identified between the brachialis and
brachioradialis distally
 Posterior approach to humerus
 used for distal to middle third shaft fractures although can be
extensile
 triceps may either be split or elevated with a lateral
paratricipital exposure
 radial nerve is found medial to the long and lateral heads and
2cm proximal to the deep head of the triceps
 radial nerve exits the posterior compartment through lateral
intramuscular septum 10 cm proximal to radiocapitellar joint
 lateral brachial cutaneous/posterior antebrachial cutaneous
nerve serves as an anatomic landmark leading to the radial
nerve during a paratricipital approach
 Techniques
 plate osteosynthesis commonly with 4.5mm plate (narrow or broad)
 3.5mm plates may function adequately
 absolute stability with lag screw or compression plating in simple
patterns
 apply plate in bridging mode in the presence of significant comminution
 Postoperative
 full crutch weight bearing shown to have no effect on union

 Intramedullary nailing (IMN)

 Relative indications
 pathologic fractures
 segmental fractures
 severe osteoporotic bone
 overlying skin compromise limits open approach
  polytrauma
 Techniques
 can be done antegrade or retrograde
 Complication
 nonunion
 nonunion rates not shown to be different between IMN and
plating in recent meta-analyses
 IM nailing associated with higher total complication rates
 shoulder pain
 increased rate when compared to plating (16-37%)
 functional shoulder outcome scores (ASES scores) not shown to
be different between IMN and ORIF

What are the differences between Open reduction and fixation vs. Closed reduction and fixation?

 Closed: no skin incision; methods include casts (e.g. Plaster of Paris), brace or splint
 Open: treatment of choice for unstable fractures; methods include: ORIF (Open
Reduction and Internal Fixation) using surgical implants like titanium plates, screws,
wires and intramedullary nails.

Pathologic fractures

 It occurs in a diseased bone and is usually spontaneous. The force required to bring
about a pathological fracture is trivial. It is common among elderly people and
possible causes include osteoporosis, osteomalacia, Paget's disease, osteitis,
osteogenesis imperfecta, benign bone tumors and cysts, secondary malignant bone
tumors and primary malignant bone tumors.

Roles of Antibiotics and ATS in open fracture

 Role of antibiotics: It will not replace the wound debridement. Topical antibiotics have
very little role. Parenteral administration is recommended. The choice of antibiotics is
usually a broad spectrum, bactericidal hypoallergenic agent with adequate serum
concentration. The patient has to be protected against tetanus by effective
immunization against them.

 ATLS Protocol on Antibiotics for Muskuloskeletal Trauma

 The table above is for open fractures but in our case, it is a closed fracture. According to the
Clinical practice guidelines for perioperative antibiotic prophylaxis developed jointly by the American
Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Surgical
Infection Society, and the Society for Healthcare Epidemiology of America recommend routine use of
cefazolin unless contraindicated for “clean” orthopedic procedures involving internal fixation such as
the treatment of closed long bone fractures. In the current study, 96% of surgeons used cefazolin as
their preferred preoperative antibiotic prophylaxis. This shows a high rate of compliance with
recommendations. In the current study, 85% of respondents reported they re-administer antibiotics
every 3 to 4 h, and 96% of respondents reported using cefazolin, indicating high compliance with the
CDC recommendation to maintain therapeutic levels of antibiotics throughout the procedure.

What is the drug of choice for surgical prophylaxis against surgical site infections?

Cefazolin is the drug of choice for surgical prophylaxis against surgical site infections for many
surgical procedures because of its activity against staphylococci; can usually be administered as a
single preoperative dose.

Mechanism of action, pharmacodynamics and pharmacokinetics of Cefazolin

Antimicrobial Spectrum:
Gram-positive bacteria: methicillin-susceptible Staphylococcus aureus (MSSA), coagulase – negative
Staphylococci, penicillin-susceptible Streptococcus pneumoniae, Streptococci spp. Gram-negative
bacteria: Moraxella catarrhalis, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis
Mechanism of Action:
Cephalosporins exert bactericidal activity by interfering with the later stages of bacterial cell wall
synthesis through inactivation of one or more penicillin-binding proteins and inhibiting cross-linking of
the peptidoglycan structure. The cephalosporins are also thought to play a role in the activation of
bacterial cell autolysins which may contribute to bacterial cell lysis.
Pharmacodynamics:
Cephalosporins produce time-dependent killing
Pharmacokinetics:
Cmax: 188mcg/ml Half-life: 1.8hours
Volume of distribution: 10L

What are the microorganisms involved in the surgical site infections of orthopedic surgical
implants?

The trend of the offending organisms in SSI has changed over time. Historically,
Staphylococcus aureus has been the most commonly isolated microorganism in SSI. However, other
studies, most of them recent, have demonstrated Escherichia coli as the most predominant bacterium
in SSI. Also, emerging organisms like Vancomycin-resistant Enterococci and gram-negative bacilli with
unusual patterns of resistance have been isolated more frequently. In orthopedic SSIs, gram-positive
organisms predominate, with both methicillin-resistant and susceptible Staphylococcus aureus being
the most common microorganism.

4 stages of bone healing

1. Inflammation formation (Days 1 to 7 post-fracture)

The fracture results in:
 Soft-tissue damage
 Disruption of blood vessels in bone
 Separation of small bony fragments
 Hematoma forms and the periosteum ruptures partly.
 Cells migrate into the fracture hematoma.
 Coagulation starts.
 Fibrin fibers are formed and stabilize the hematoma (hematoma callus).
2. Fibrocartilaginous callus formation (2-3 weeks)
 Once injury occurs, the natural process of bone healing begins with the creation of soft
callus—a cascade of cellular differentiation occurs.
Phase 1:
· New blood vessels invade the organizing hematoma
· Decrease of pain and swelling
Phase 2:
· Fibroblasts, derived from periosteum, invade and colonize the hematoma.
Phase 3:
· Fibroblasts produce collagen fibers (granulation tissue).
Phase 4:
· Collagen fibers are loosely linked to the bone fragments.
Phase 5:
 · The cells of the granulation tissue gradually differentiate to form fibrous tissue and
subsequently fibrocartilage (replacing hematoma).
3. Bony callus formation (3-12 weeks)
 Endochondral ossification converts the soft callus to woven bone starting at the
periphery and moving towards the center, further stiffening the healing tissue.
 This continues until there is no more interfragmentary movement.
4. Bone Remodelling (Months to years)
 The remodeling stage: conversion of woven bone into lamellar bone through
surface erosion and osteonal remodeling once interfragmentary movement ceases.
 Fracture healing becomes complete with remodeling of the medullary canal
and removal of parts of the external callus.

Differences between Primary bone healing and Secondary Bone Healing

 Primary bone healing is the reestablishment of the cortex without the formation of a
callus. It occurs if a fracture is adequately "fixed" through reduction, immobilization, and
rehabilitation.
 Secondary bone healing occurs through the formation of a callus and subsequent
remodeling.

What are the general complications of fracture? What are the possible post-operative
complications and the management?

Table 4.1: Complications of fractures

Acute Chronic Complications peculiar open fractures
to
• Shock (Hypovolemic or neurogenic) • Delayed union • Infection
• Nonunion • Chronic
• ARDS • Malunion osteomyelitis
• Thromboembolism • Shortening • Gas gangrene
• Neurovascular injuries • Growth disturbances • Tetanus
• Hypovolemic shock
1. Radial nerve palsy in • Avascular necrosis • Miscellaneous
fracture shaft humerus • Joint stiffness • Implant failure
2. Sciatic nerve palsy in posterior • Post-traumatic arthritis • Reflex
dislocation of hip sympathic
3. Supracondylar fractures causing dystrophy, etc.
brachial artery injury • VIC
• Acute Volkmann’s ischemia • Myositis ossificans
• Crush syndrome
• Deep vein thrombosis

What are the possible post-operative complications and the management?

Post-operative Complications
A. Humeral shaft fx nonunion
 no callous on radiograph and gross motion at the fracture site at 6 weeks from
injury has a 90-100% PPV of going on to nonunion in closed humeral shaft
fractures
B. Malunion
 varus angulation is common but rarely has functional or cosmetic sequelae
 risk factors
 transverse fracture patterns
C. Radial nerve palsy
 Incidence
  seen in 8-15% of closed fractures
 increased incidence distal one-third fractures (22%)
 neuropraxia most common injury in closed fractures and neurotomesis
in open fractures
 iatrogenic radial nerve palsy is most common following ORIF via a lateral
approach (20%) or posterior approach (11%)
 85-90% of improve with observation over 3 months
 spontaneous recovery found at an average of 7 weeks, with full
recovery at an average of 6 months
 Treatment
 observation
 indicated as initial treatment in closed humerus fractures
 obtain EMG at 3-4 months
 wrist extension in radial deviation is expected to be regained first
 brachioradialis first to recover, extensor indicis is the last
 surgical exploration
 indications
o open fracture with radial nerve palsy (likely neurotomesis injury
to the radial nerve)
o closed fracture that fails to improve over ~ 3-6 months
o fibrillations (denervation) seen at 3-4 months on EMG

What will be the post-operative care upon discharge of this patient?

Post operative management

 postop: 2-3 week postoperative visit
 wound check
 check range of motion
 diagnose and management of early complications
 postop: ~ 6 week postoperative visit
 diagnosis and management of late complications
 check radiographs for healing of the tuberosities
 check range of motion
 the elbow motion should be near normal range
 start shoulder strengthening
 3 month postoperative visit
 check that callus is present on the x-rays
 if callus is not present, then repeat x-rays every 6 weeks until radiographic
evidence of healing.