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ORTHOPEDICS I. FUNDAMENTALS OF ORTHOPEDICS PIONEERS IN ORTHOPEDICS Hippocrates – first described splinting of fracture Nicholas Andry - coined the term Orthopedia Galen – traction in orthopedics Sarmiento – functional cast brace. Malgaigne – technique of internal fixation HO Thomas – Thomas splint. Lambotte – external fixator. Gerhardt kuntscher – intramedullary nail. Robert Denis – father of modern osteosynthesis. llizarov – circular external fixator. Sir John Charnley in 1960 first developed the procedure of total joint replacement. First metallic hip replacement: Austin T Moore John Hunter: described fracture healing William Hey: described meniscal injuries & loose bodies Antonius Mathysen: invented plaster of Paris Macewen: first to perform osteotomy & bone grafting Bone histology Trabecular bone (cancellous or spongy bone) Lamellae do not form haversian systems Epiphyses consist mainly trabecular bone Compact bone Basic unit - osteon Osteon or Haversian system - composed of lamellae arranged around Haversian canals. Central Haversian canal: neurovascular canal containing 1 or 2 capillaries. Haversian canals communicate with each other via Volkman's canal (nutrient/vascular perforating channels) Compact bone forms the diaphysis Rich in glycoproteins & proteoglycans highly basophilic Biomechanically, the cement line is the weakest link in the microstructure of bone. Parts of a bone Epiphysis: ends & tips of bone, ossifies from secondary centres. Epiphyseal growth plate (physis): part b/w epiphysis & metaphysis, zone of maximum growth. Diaphysis: ossifies from primary centres, strongest part of the bone. Diaphyseal nutrient arteries are directed away from the dominant growing epiphysis. Metaphysis: o Zone of active growth o Highly vascularized zone o Hair pin arrangement of blood vessels. o More prone for injury. o Most common site of osteomyelitis in children. Bones receive 5% to 10% of the cardiac output. Long bones receive blood flow from three sources 1. The nutrient blood vessel that enters the diaphysis through the nutrient foramen 2. The metaphyseal complex, and 3. The periosteal capillaries. COMPOSITION OF BONE Made of both organic and inorganic components. Bone matrix Organic The cells and the osteoid (organic part of the matrix). The osteoid makes up 1/3 of the matrix & contributes to the bone's structure, flexibility and tensile strength Collagen (-30%) of Non collagenous dry bone weight) Type I collagen Attachment / signaling proteins eg thrombospondin, (90% of osteoponin & fibronectin demineralized Calcium binding proteins eg matrix gla protein & osteocalcin bone, & is (bone gla protein) produced by Proteoglycans eg biglycan & decorin osteoblast) Osteonectin, alpha-2 glycoprotein, sialoproteins (osteopontin) Type VI collagen Alkaline phosphatase, TGF-beta, Bone morphogenetic protein (BMP), albumin. OSTEOCALCIN Produced by osteoblasts Most abundant noncollagenous protein content(10% to 20%). Associated with mineralization of the bone matrix. Synthesis of osteocalcin is increased by 1, 25-dihydroxyvitamin D and inhibited by PTH & steroids OSTEONECTIN Produced by osteoblasts and platelets Regulate the calcium concentration within the bone matrix and potentiate mineralization Inorganic – Bone minerals (60-70% of dry weight) Poorly crystalline hydroxyapatite i.e. Ca10 (PO4)6 (OH)2 is major mineral Calcium phosphate (small amount) BONE MARKERS: Markers of bone formation Markers of bone resorption Serum bone specific alkaline Urine & Serum cross linked N telopeptide & C phosphatase telopeptide Serum osteocalcin Urine deoxypyridinoline Serum peptide of type-I collagen Urine hydroxyproline Urine hydroxylysine glycosides Serum tartrate resistant acid phosphatase Serum bone sialoprotein Zones of Growth Plate Zone of resting cartilage of growth plate Zone of proliferation – rapid synthesis of collagen requiring vitamin C. It is affected in scurvy. Zone of hypertrophy–thickest and weakest zone involved in fracture or epiphyseal slip (Slipped Capital Femoral Epiphysis) Zone of maturing cartilage of growth plate (Vitamin D Dependant, affected in Rickets) Zone of provisional calcification OSTEOGENESIS Always occur by replacing the pre existing connective tissue. In the embryo, two types os osteogenesis occur: o Intra membranous ossification: Occurs in the embryo when the mesoderm condenses into sheets of highly vascular connective tissue, which then forms a primary ossification center. Bones that are fomed via intra membranous ossification are flat bone sof the skull. o Endochondral ossification: Occurs in the embryo when the mesoderm initially forms a hyaline cartialge model, which then develops a primary ossification center at the diaphysis. Later secondary ossificaiton centers form at the epiphysis at each end of the bone. Bones that are fomed via endochondral ossification are humerus, femur, tibia and the other long bones. Growth in the diameter of long bones occurs at the diaphysis by deposition of bone at the periphery (appositional growth) as osteoprogenitor cells within the periosteum differentiate into osteoblasts. Bone growth is appositional. New layers are added only to pre-existing surfaces and, unlike chondrocytes, osteocytes enclosed in lacunae do not divide or secrete new matrix. The rigidity of mineralized bone matrix prevents internal expansion, which means that interstitial growth, which is characteristic of most tissues, is absent in bone. During endochondral ossification, five distinct zones can be seen at the light-microscope level. Collagen: Type I collagen is the most abundant form. Type II is mainly seen in cartilage and vitreous humor. Type Ill is seen in skin, lung andvascular tissues Type IV is seen in thebasement membranes. XVII-Skin hemi-desmosomes XVIII-Many tissues (eg, liver, kidney) XIX-Rhabdomyosarcoma cells. II. PRINCIPLES OF FRACTURE HEALING & ITS COMPLICATIONS General Principles of Fractures and Dislocations Based on fracture patterns (Orthopedic Trauma Association [OTA] classification) Linear fracture: These could be transverse, oblique or spiral. o Angle < 30° with the horizontal - transverse. o Angle 30° > oblique. Comminuted fractures: Fracture fragments are more than two in number Segmental fractures: A fracture can break into segments and the segment could be two –level, three – level, and a longitudinal split or comminuted. Bone loss: This could be a < 50 percent bone loss, more than 50 percent bone loss, or a complete bone loss. Atypical Fractures Greenstick fractures o Seen exclusively in children o Bone is elastic o Usually bends due to buckling or breaking of one cortex when a force is applied Impacted fractures: Fracture fragments are impacted into each other and are not separated and displaced. Stress or fatigue fractures o Usually an incomplete fracture o Commonly seen in athletes and in bones subjected to chronic and repetitive stress (e.g. third metatarsal fracture, fracture tibia, etc) Pathological fractures o Occurs in a diseased bone o Usually spontaneous Hairline or crack fracture: It is a very fine break in the bone that is difficult to diagnose clinically. Torus fracture: compression fracture of the metaphyseal region with cortical buckling in a child GUSTILO AND ANDERSON CLASSIFICATION OF OPEN FRACTURES Includes the degree of open or closed soft-tissue injury. Initially designed for open tibial fractures; however, now include all types of long bone fractures. Grad Low-energy injury Wound less than 1 Simple transverse or short e cm in oblique fractures length, often from an inside-out injury Grad High energy injury Wound more than 1 Usually display some e cm comminution and have a II long minimal to moderate crushing component Grad High-velocity gunshots, close Extensive wounds Significant fracture e range more fragment comminution, and III shotgun blasts, motorcycle than 10 cm in length a great deal accidents, of soft-tissue damage or injuries with contamination from outdoor sites such as with tornado disasters or farming accidents. Grade IIIA: Extensive soft-tissue laceration with minimal periosteal stripping and have adequate bone coverage. These injuries include some gunshot injuries and segmental fractures and do not require major reconstructive surgery to provide skin coverage. Grade IIIB: Extensive soft-tissue injury with periosteal stripping and require a flap for coverage. Grade IIIC: involve vascular compromise requiring surgical repair or reconstruction to allow reperfusion of limb. Fracture types based on nature of injury Transverse fracture: d/t direct impact on bone. Comminuted fracture: d/t crushing Spiral fracture: d/t twisting Oblique fracture: d/t compression EPIPHYSEAL INJURIES More common in children. May lead to shortening because of premature epiphyseal fusion Salter and Harris classification: Typ Definition Outcome Ie Through and parallel to physis Excellent II Through the physis with a metaphyseal Excellent III Throughfragment the physis and epiphysis Good, but may require ORIF because of potential intraarticular deformity IV Vertical fracture perpendicular to the physis Good, but unstable fracture requires (through epiphysis and metaphysis) ORIF V Physeal crush Poor (growth arrest) VI Perichondrial ring injury Good (possible angular deformities) A Tillaux fracture of the ankle is a Salter-Harris III fracture. Type II is the most common Salter-Harris fracture Type Example Treatment Prognosis I Radial neck epiphysis Closed reduction
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