Orthopaedics
For Physician Assistants
Dr. Allen Steele- Dadzie
Family Physician
Korle Bu Teaching Hospital
Fractures
Objectives
• At the end of this lecture, listeners are expected to:
-understand the definition of fractures
-recognize fractures in clinical practice and initiate management
-describe common fractures
-understand the management of simple fractures
-recognize features that indicate referrals
Question
• A 26 year old man was brought to your clinic having been knocked
down by a moving saloon car. He has excruciating pain in his right leg
and is unable to walk.
• Describe how you would manage his condition.
Principles of management
• Resuscitation – BLS/ ATLS
• History
• Examination
• Investigations
• Management
Pre-hospital treatment and resuscitation
ATLS- Advanced Trauma Life support
Involves
• 1. Primary survey with simultaneous resuscitation- here you identify
and treat what is killing the patient
• 2. Secondary survey- proceed to identify all other injuries
• 3. Definitive care
Primary survey and resuscitation
Airway with cervical spine
Breathing and provision of oxygen
Circulation with control of bleeding
• Look for signs of shock
• Look for bleeding- 5 common sites of bleeding:
• External bleeding
Abdomen
Chest
Retroperitoneum
Muscle compartments
Fractures and their management
• Definition
• Causes
• Classification
• Initial management
• Definitive management
• complications
Fracture description
Mnemonic – OLD ACIDS
O- open or closed
L- location
D- degree
A-articular involvement
C-comminuted or not
I-intrinsic bone quality
D-displacement
S-soft tissue injury
Fracture description
• Fracture location
• Open or closed
• Fracture type
• Fracture displacement
Classification
Classification
Describing fracture
• Site- bone involved; segment of bone involved
• Type of fracture
E.g closed, transverse,undisplaced fracture at distal third of the left
humerus
Healing of fractures
Management
Initial management
Splinting
Purpose: reduce pain; reduce bleeding and swelling; prevent further
soft tissue damage; prevent vascular constriction
What to splint
Fracture; dislocation; tendon rupture
Materials
Padding material
Cast- plaster, fibre glass
Procedure
• Apply padding-protects bony prominence; allows for swelling
• Apply cast or splint
Fracture management-cast
When to refer
• Life-threatening cases
• Open fracture
• Displaced fractures that need reduction
• Intra-articular fracture
• Arterial and nerve injuries
• Associated tendon injuries
• Compartment syndrome
Complications
• Compartment syndrome- from injury itself or management
• Abnormalities of fracture healing: mal-union, non-union
• Infections- open fractures, osteomyelitis
• Deformities and disability
Abdominal Trauma
Causes
A. Blunt trauma- most commonly RTA
• Mass & speed of the vehicle at the time of impact
• Were occupants restrained
• Was occupant ejected
• Was there interaction of occupant/ pedestrian with vehicle parts
• B. Penetrating trauma- gunshots, sharp objects
• C. Blast injury
• D. Crush injuries- crushed muscle results in rhabdomyolysis with
release of myoglobin acute renal failure
Abdominal trauma
Results in
• rupture of organs- spleen, liver
• Stomach and bowel may also rupture, usually from seat belt.
Management involves
• Resuscitation
• Abdominal CT scan
• Management
Question
• A 6 year old boy who sustained a penetrating wound to his left lower
leg 1 week ago complains of severe, worsening pain in that part of the
leg with associated swelling. His temperature is 38.5 oC. His is unable
to walk because of the pain.
• Further examination reveals swelling of the leg, severe tenderness
and inability to use that leg?
• What are the likely causes?
• What investigations would you request to help evaluate this patient?
• How would you treat him?
Osteomyelitis
• An infection of bone.
Causes
• Blood-borne infection from a septic focus.
• Following trauma.
• Open fractures
Osteomyelitis-predisposition
• Commoner in children
• Sickle cell disease
• Immunosuppression- diabetes, HIV, long term use of steroids
• Recent trauma
• Bone surgery
Causes
• Staphylococcus aureus, commonest cause
• Gram negative organisms like- E coli, Proteus, Pseudomonas
• In sickle cell disease Streptococcus and Salmonella are common
causes
Pathogenesis
• May be acute or chronic
• Children usually get acute; adults get acute and chronic.
• Acute OM develops rapidly, usually over 7-10 days.
Chronic esteomyelitis
Symptoms
• Fever
• Irritability, fatigue
• Nausea
• Unwillingness to move affected site
• Osteomyelitis of the vertebrae may cause severe back pain, especially
at night.
Signs
• Temperature > 38oC
• Local signs of inflammation- swelling, tenderness, redness, warmth,
limitation of movement at the affected site.
• There may be fluctuant abscess over the affected bone
Investigations
• FBC, ESR
• X ray of the affected part
• Bone scans
• In acute infection it may be normal. But from 10-14 days, periosteal
reaction may be visible.
• Blood culture or culture of pus from lesion may be done
Osteomyelitis-treatment
Objectives of treatment
Pain relief
Eradicate infection
Restore function
Prevent complications- chronic osteomyelitis, pathological fractures
Treatment
Pain relief with paracetamol
Splint affected limb
Treatment of infection
• Duration of treatment is 6 weeks
• Treat with IV antibiotics for 2 weeks and 4 weeks oral
• Shorter duration of treatment is inadequate and may lead treatment
failure and may result in chronic osteomyelitis
Antibiotic regimen
• Cloxacillin or
• Clindamycin
• In sickle cell disease add ciprofloxacin for Salmonella
Complications
• Acute osteomyelitis may result in chronic osteomyelitis which is more
difficult
• Pathological fractures, especially due to underlying chronic
osteomyelitis.
When to refer
• Patient not responding to antibiotics after 2 days
• Chronic osteomyelitis and pathological fracture
Septic Arthritis
• Infection of joints (usually large joints) usually by bacteria
Septic arthritis
Causes
Gonococcal and non-gonococcal
Non-gonococcal
• Staph aureus in most cases
• Streptococcus pyogenesis or Pneumococci
• Salmonella in sickle cell disease
Gonococcal
• Neisseria gonorrhoeae- common among sexually active young people
Predisposition
• Elderly
• Children
• Immunosuppression
• Joint prosthesis
• Intravenous drug abuse
Pathogenesis
Micro organisms reach the joint via
• Haematogenous spread from abscesses, wounds or unknown sources
• From osteomyelitic source
• Adjacent soft tissue infection
• Penetrating trauma
• Iatrogenic source
Diagnosis
Based on clinical presentation and joint aspiration
Symptoms
• Sudden onset of pain usually in a large joint
• Pain and limitation of use of affected joint
• Fever
Signs
Fever (temp >38oC)
Local/joint features
• Swollen with effusion
• Tender
• Warm
• Limitation of movement
Investigations
• FBC
• ESR
• Joint aspiration for microscopy and culture
• Blood culture in severe cases
• In suspected gonococcal SA, urethral swab
Treatment
• Role of physician assistant is prompt recognition and management or
referral.
• Delay in treatment results in complications/ disability and death
Treatment objectives
• To relieve pain
• Treat infection
• Prevent joint damage
Treatment
• Rest affected joint with splint
• Aspirate joint to help pain relief and for investigation
Antibiotics: non-gonococcal
• Treat for 6 weeks
• IV antibiotics for 2 weeks and oral for 4 weeks
Options
A.
• IV cloxacillin 6 hourly for 2 weeks, then oral flucloxacillin 6 hourly for
4 weeks
• B.
• Clindamycin IV 6-8 hourly for 2 weeks and orally for 4 weeks
• In sickle cell disease, add IV ciprofloxacin for 2 weeks, then oral for 4
weeks
• Pain relief and control of fever with paracetamol
gonococcal arthritis
• Sexually active young person
• Joint pain
• May involve more than one joint; usually assymetrical.
• In addition to joint problem, they may also have urethral discharges,
skin rashes, tenosynovitis
Investigation
Urethral discharge swab, skin or genital lesions swab for culture
Treatment
• Ciprofloxacin oral 500mg bd for 14-21 days;
• (Oral doxycycline for associated Chlamydia infection)
• Alternative drug is cefotaxime IV
Question
• A 45 year woman presents with painful swelling of her left lower leg
since 3 days ago. She also has fever. She was found to have diabetes
mellitus 2 years ago but has not been attending clinic and does not
take any medication. Temperature is 38.1oC.
• What is the most likely diagnosis?
• Discus how you would manage this condition.
Cellulitis
Inflammation of subcutaneous tissue.
Predisposition - anything that breaches the protective barrier of skin or
causes immunosuppression.
• Infected wound
• Penetrating wound/injury
• Insect bite
• Cracks in between toes
• Diabetes mellitus
Causes
• Commonest cause is Streptococcus pyogenes
• Staphylococcus aureus also an important cause
Symptoms
• General symptoms- fever, malaise,
• Local symptoms- pain, swelling, redness, discharge
Signs- local swelling, tenderness, warmth, wound/ ulcer, discharge,
blisters
Regional lymphadenitis
Fever
Investigation
FBC
FBS
Wound swab for C/S if ulcer or discharge present
Differentials
• DVT
• Gout
• Osteomyelitis
• Abscesses
Cellulitis-treatment
1. Pain relief with paracetamol
2. Treatment of infection with-
3. Treat underlying predisposition like wound or diabetes mellitus
Treatment
• Rest and elevate affected part if possible
• Treat wound
• If abscess present treat
• Pain relief with paracetamol
Decide whether to admit or treat as OPD depending on clinical state
OPD treatment
• A. Combination of amoxicillin and flucloxacillin for 7 days
• B. Oral amoxiclav
• C. for those with penicillin allergy erythromycin or clindamycin
• In-patient treatment
• IV Benzylpenicilin and cloxacillin for 7 days
Referral
• Severely ill/septicaemia
• Abscesses, gangrene
Question
A 6 year old boy ate at a Chinese restaurant and within 4 hours, he
began to experience an itchy rash all over his body. Soon he began to
have difficulty in breathing and collapsed. He was rushed to a clinic.
• Q. What is the most likely diagnosis?
• What is the most appropriate initial management?
Anaphylaxis
• An acute allergic systemic reaction with life-threatening conditions.
Causes
• Insect stings
• Drugs
• Vaccines
• Antisera- anti-snake, anti-tetanus
• Foods- sea foods, ground nuts, fruits
• Intravenous contrast medium in radiological tests
symptoms
• Severe itching, urticarial
• Swelling of the face and around the mouth(peri-oral)
• Difficulty in breathing and wheeze
• Collapse, syncope
Signs
• Itchy skin rashes/ urticarial
• Swollen face and mouth- angioedema
• Difficulty in breathing and wheeze due to bronchospasm laryngeal
oedema
• Cold clammy extremities
Treatment
• Resuscitate –secure ABC
• Reverse vital signs-
SPO2
BP 100mmHg systolic or more
• Reverse symptoms
• Remove or reverse underlying cause
• Prevent death
Initial steps
• Give intranasal oxygen
• Give IM adrenaline to reverse bronchospasm and improve breathing;
help restore circulation.
• Adrenaline 1:1000, 0.3-0.6 ml IM in adults, may repeat every 10
minutes as necessary
• IV hydrocortisone 100-200 mg 6 hourly
• Monitor patient critically
