Orthopedic Surgery

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1

The Skeletal System

  • Provides framework for body support
  • Serves as an attachment point for muscles
  • Protects some integral organs from injury
  • Serves as source of RBC's
  • Storage site & source of calcium
2

Osteocytes

  • Bone cells that have the ability to synthesize and reabsorb the matrix
  • Surrounding matrix composed of calcium salts & collagen
  • Calcium salts give bones strength
3

Cortical (compact) Bone

  • Hard, dense bone tissue that surrounds the marrow cavity
  • Composed of Haversian units
    • Circular rings of bone matrix with implanted osteocytes that form a canal
    • Single venule & arteriole run through each canal
4

Cancellous (spongy) Bone

  • Found at the ends of bone & lining the marrow cavity
  • Composed of columns of trabeculae with large interspersed spaces
  • Adapts to load-bearing due to formation along stress lines
5

Periosteum

  • The thin, fibrous layer of tissue that surrounds the bone
  • Composed of two layers:
    • Inner cambium layer
      • Area where new bone cells are formed
    • Collagen fibers
      • Serves as an anchor of attachment
  • Permeated with nerves and blood vessels that nourish underlying bone
  • Serves as layer of defense against infection
6

Bone Marrow

  • Semisolid tissue found in the spaces of cancellous bone
  • Red marrow
  • Yellow Marrow
    • Does not produce RBC's
    • Blood supply supplies the cortex of the bone
7

Endosteum

  • The fibrous layer of tissue that lines the medullary cavity in long bones
8

Long Bones

  • Humerus, Femur, phalanges
9

Diaphysis

  • Shaft of the long bone
    • Composed of compact bone surrounding the medullary cavity
10

Epiphyses

  • Ends of long bones
    • Composed of cancellous bone
11

Bursa

  • Small sacs containing synovial fluid (shoulder)
    • Acts as a lubricant to aid in joint movement
    • Acts as a cushion in weight-bearing & impact activities
12

Epiphyseal Plate

  • Active area of bone growth under cartilage at the epiphyses
  • When bone growth is complete, epiphyseal plate disappears (then known as a closed epiphysis
13

Endochondral Ossification

  • Process of new bone-forming at the epiphyseal plate
14

Short Bones

  • Carpals and tarsals
    • usually occur in clusters
    • Aid in movement of an extremity
15

Flat Bones

  • Sternum, ribs, scapula, cranial bones
    • Majority of RBC's manufactured & supplied to body in ribs & sternum
16

Round (sesamoid) Bones

  • Patella, "ball of foot"
17

Articulation

  • Area where two bones meet to form a joint
18

Synarthrosis

  • Immoveable
    • EX: cranial bones
    • Bones are in close contact and separated by thin layer of cartilage
19

Amphiarthrosis

  • Slightly moveable
    • Ex: Vertebrae, symphysis pubis
    • Disk of fibrous cartilage within the joint that connects the bones
    • Allows some movement due to limited flexibility or cartilage
20

Diarthrosis

  • Freely moveable
    • Referred to as a synovial joint
    • Further classified according to movements they allow
21

Ball-and-socket

  • Shoulder and hip
    • Allows for widest range of motion with possible movement in all planes
22

Condyloid

  • TMJ
    • Allows for movement in only one plane with some lateral movement
23

Saddle

  • Trapezium of wrist with metacarpal of thumb
    • Allows movement in variety of planes
24

Hinge

  • Elbow
    • Allows movement only in 1 plane
25

Pivot

  • Proximal radius
    • Allows rotational movement around the central axis
26

Gliding

  • Carpals
    • Allows side-to-side & twisting movements
27

Types of joints

  • Ball-and-socket
  • Condyloid
  • Saddle
  • Hinge
  • Pivot
28

Joint Movements

  • Muscle attached to bone produce movement of diarthrosis
  • When muscle contracts, muscle insertion is pulled toward the origin causing joints to move
29

Origin

  • One end of the muscle attached to an immovable end of one bone of a joint
30

Insertion

  • Another end of a muscle is attached to a moveable end of the other bone
31

Mineral Storage

  • Bone contains a large quantity of calcium
    • Calcium constantly removed from bone to maintain normal blood calcium levels (this accounts for bone being active tissue)
    • Osteoclasts (stimulated by parathyroid hormone) break down bone tissue and increase circulating calcium
    • Hormone calcitonin (secreted by thyroid gland) inhibits osteoclast activity and decreases calcium resorption from bones
    • Calcium in bone replaced at equal rate to its removal
32

Factors that Affect Bone Growth

  • Heredity
    • Potential for height due to genes inherited from both parents
  • Nutrition
    • Nutrients derived from food are raw materials from which bone is produced
    • Vitamin D needed for calcium and phosphorous absorption (occurs in the small intestine)
    • Calcium, phosphorous, and protein become part of the bone matrix
  • Weight-bearing exercise
    • Without weight & stress, bone lose calcium at a more rapid rate than replaced
33

Types of fractures

  • Classified according to the type of fracture and extent of damage
  • May be complete or incomplete
34

Normal Bone healing

  • Complete healing of bone expected to be 8-12 weeks
  • 5 stages of osteogenesis
    • inflammation
    • Cellular proliferation
    • Callus formation
    • ossification
    • Remodeling
35

Inflammation

  • Begins at the time of injury & lasts 2 days
  • Fracture hematoma forms at this time (blood clot is the foundation for cell proliferation)
36

Cellular Proliferation

  • Begins at approximately day 2
  • Macrophages debride area & allow formation of fibrin mesh that approximates edges of the fracture site
37

Callus Formation

  • Formation stage lasts 3-4 weeks
  • Formed on outer surface of a fractured bone
  • Bone Fragments grow inward bridging the gap
  • Fibrous tissue, cartilage and immature bone stabilize the fracture site
38

Ossification

  • Begins 2-3 weeks post-injury and can last 3-4 months
  • Osteoid is the matrix of osteoblasts, calcifies and unites the bone
39

Remodeling

  • Devitalized tissue removed
  • New bone organized for maximum support and function
  • Osteoblasts and osteoclasts resume equal activity
40

Pathological Bone Growth

  • Disruption at any stage of bone healing or maintenance resulting in an abnormal condition
41

Disruptions Include

  • Poor immobilization of the fracture
    • Movement disrupts hematoma and causes additional bleeding at the fracture site
  • Distraction of bone fragments (bone contact does not occur)
    • Gap between fragments fills with granulation tissue
    • Tension on blood vessels decreases blood supply to the fracture site
  • The interposition of soft tissue
    • Soft tissue grows over ends of fracture fragments
    • Soft tissues seals surface between the fractured bones and does not allow hematoma or callus to form
  • Deficient/nonexistent blood supply
    • Avascular necrosis occurs when capillary networks or circulation cannot be reestablished following injury
    • Maybe pharmacological, pathological, or idiopathic
  • Infection
    • Compound fracture compromises the integrity of the skin and allows possible entry of microorganisms
    • Osteomyelitis is an infection in the bone and can lead to chronic osteomyelitis
42

Delayed union

  • Increase in healing time
    • Osteoporosis, distraction, mobilization or trauma
43

Non-Union

  • Fractured bone ends do not unite
    • Usually caused by infection and movement of the fracture site
44

Malunion

Fracture heals in abnormal position

45

Compartmental Syndrome

  • Increase in pressure within a closed space (usually occurs in the forearm and tibia)
    • Fracture ends of bone cause excess pressure and neurovascular compromise
    • May also be caused by a cast that is too tight or intracompartmental bleeding
  • Compartment pressure increases bleeding and swelling of tissue
    • Fascia expands from swelling then pressure directed inward and compresses blood vessels and nerves
    • Capillary circulation to muscle stops the muscle then becomes ischemic, necrosis (begins 2-4 hrs and becomes irreversible after 12 hrs)
    • Nerve damage occurs within 30 mins and after 12 hrs, irreversible loss of muscle function
46

Casting

  • Method used to immobilize fractures (subsequent to closed reduction)
    • Avoids distraction and malalignment complications
  • Fiberglass
  • Plaster
47

Cast Cart

  • Bucket, webril and stockinette (various sizes), plaster casting (various widths and lengths), Heavy scissors
48

Types of castings

  • Short arm
  • Long arm
  • Short leg
  • Long leg
  • Cylinder
  • Hip Spica
  • Body
  • Jacket
49

The Skeleton

  • 206 bones in total
  • Axial skeleton
    • Skull, vertebral column, ribs and sternum
  • Appendicular Skeleton
    • Arms, legs, shoulders, and pelvis
50

Clavicles

  • Collarbone
    • The long, slender, curved bone that acts as a brace for scapula and keeps the shoulder in place
    • Articulates with the manubrium and acromion process of the scapula
51

Scapula

  • Shoulder blade
    • Flat, triangular-shaped bone on either side of the upper back
    • Consists of the acromion process and coracoid process separated by a spine
    • Between the processes is a fossa known as the glenoid cavity
      • Serves as a socket for the head of the humerus
52

Pectoral Girdle

  • Consists of glenohumeral, sternoclavicular and acromioclavicular (AC) joints
  • Rotator Cuff has four muscles that surround the shoulder joint
    • Infraspinatus, teres minor, subscapularis, supraspinatus
  • The main function is to provide strength and stability to the shoulder joint
53

Humerus

  • Longest and largest bone in the upper extremity
    • The head fits into the glenoid fossa of the scapula
54

Greater tubercle (humerus)

  • (Lateral side of the humeral head) insertion site for 3 tendons
55

Lesser Tubercle (humerus)

  • (anterior side) Insertion site for subscapular tendon
56

Anatomical Neck (humerus)

  • Circumferential depression that separates the head from the tubercles
57

Surgical Neck (humerus)

  • Region just below the tubercles
  • Common fracture site
58

Deltoid Tuberosity (humerus)

  • Lies near the middle of the humeral shaft
  • Provides attachment for the deltoid muscle (raises the arm horizontally and laterally)
59

Lateral Condyle (humerus)

  • (capitulum)
  • Articulates with the head of the radius
60

Medial Condyle

  • (trochlea)
  • Articulates with the ulna
61

Radius

  • Lies on the thumb side of the arm
  • Proximal end articulates with the capitulum of the humerus and radial notch of the ulna
  • The distal end divides into two surfaces
    • The lateral surface articulates with the carpal bones and contains the styloid process
    • The medial surface articulates with the ulna
62

Ulna

  • Proximal portion (trochlea) articulates with the humerus
    • The olecranon and coronoid processes are located on each side of the articulation (provides muscle attachment sites)
  • The distal head articulates with the ulnar notch on the radius
  • Also had a styloid process
63

Pelvis

  • Provides support for the trunk and attachments for the femur
  • Created from the fusion of the ileum, ischium, and pubis
    • Together called the innominate bone or ox coxae
64

Ilium (pelvis)

  • Superior
  • LArgest of the 3 bones
  • Flares outward into the ridges known as the iliac crest
    • Common site for a bone graft
65

Ischium (pelvis)

  • inferior
  • Strongest of the 3 bones
66

Pubis (pelvis)

  • Anterior
  • the 2 pubic bones join at the midline to form the symphysis pubis
    • Actual disk of cartilage that connects to the two pubic bones
67

Hip

  • Ball-and-socket joint is formed by the acetabulum (fossa) and head of the femur
68

Femur

  • Largest bone in the body
69

Greater Trochanter (femur)

  • Upper, lateral shaft of the femur (insertion site for the gluteus muscles)
70

Lateral and medial condyles (femur)

  • Articulates with the tibial condyles to form the knee joint
  • Femoral condyles separated by a depression is known as a patellar groove
71

Patella

  • Sesamoid bone contained within the quadriceps tendon
  • The anterior and posterior cruciate ligaments stabilize movement of the knee joint
72

PCL

  • Prevents the femur from sliding anteriorly on the tibia when the knee is bent
73

ACL

  • Prevents the femur from sliding posteriorly on the tibia
    • Prevents hyperextension of the knee
    • Limits the medial rotation of the femur when the leg is fixed and the foot is planted
74

Tibia

  • Shinbone
  • Larger and stronger bone of the lower leg
  • Located on the medial side of the leg
  • Distally articulates with the talus bone forming the ankle joint
  • Laterally articulates with the fibula
  • Medial prominence at the ankle joint is known as the medial malleolus
75

Fibula

  • The non-weight bearing bone that is the attachment site for the muscles and ligaments
  • The lateral malleolus articulates with the talus bone to form the other portion of the ankle joint
76

Tarsal

  • 7 bones
  • Calcaneus*, navicular, cuboid, medial cuneiform, middle cuneiform, lateral cuneiform
  • The calcaneus supports the weight of the body and is the attachment site for the foot muscles
77

Metatarsals

  • 5 bones
78

Phalanges

  • 14 bones
  • 3 bones/each toe; 2 bones in the great toe
79

Positioning devices

  • Foot holder, shoulder positioner, Vaccum beanbag, Wilson frame, Andrews table, fracture table
80

Pneumatic Tourniquet

  • Provides a bloodless operative site to aid in visualization
  • The maximum tourniquet time should not exceed:
    • 1 hr for the upper extremity
    • 1.5 hrs for the lower extremity
81

Traction

  • Used to immobilize a joint, reduce a fracture and align a body part
  • May be used pre-op, intra-op, and post-op
  • 3 types: manual, skin, and skeletal
82

Radiography

  • x-rays. fluoroscopy (c-arm)
83

Air Flow

  • Body exhaust suits
84

Continuous Passive Range-of-Motion Machines (CPM)

  • Decreases pain and swelling
  • Reduces joint stiffness
  • Inhibits the formation of adhesions
  • Provides early mobility
  • Decreases effects of immobilization, i.e muscle atrophy
85

Transcutaneous electric nerve stimulation (TENS)

  • Portable, battery-powered unit with electrodes placed on the skin
  • Suppresses pain by stimulating large sensory nerve fibers
86

Electrical Stimulation of Bone

  • Electrical stimulation influences osteogenesis
  • May be used in the presence of implants
  • Requires immobilization of an extremity for long periods
87

Saws, Drills, and Reamers

  • Powered by nitrogen, air, or electricity
  • Oscillating saw (blade moves side to side)
  • Reciprocating Saw (blade moves back and forth)
  • Arthroscopic equipment is used on the knee, ankle, shoulder, elbow and wrist
88

Implants

  • Screws, plates, wires, pins, intramedullary nails and rods, total joint components
  • FDA requires proper documentation and tracking
    • #of implants used, type, size, and serial number
  • Alloys include: titanium, stainless steel, cobalt, chromium
89

Poly-Methyl Methacrylate (PMMA)

  • Bone cement
  • Stabilizes implants in the correct anatomical position
90

Sutures

  • Absorbable: Used to close the periosteum
  • Non-absorbable: used to repair ligaments, tendons, muscles, and bones
  • Orthopedic sets
91

Self-tapping

  • Cuts its own thread holes in the bone as it is screwed into place
  • Prior to inserting a screw in cortical bone, a guide hole is first drilled that has the same diameter as the core diameter of the screw to be inserted
    • A separate tapping step is eliminated shortening the operative time
92

Non-tapping

  • Requires a drill hole to be tapped prior to the placement of the screws
  • A tap is inserted which cuts the thread holes for the screw and the screw is then inserted
93

Shoulder Arthroscopy

  • Used for the removal of loose bodies, bursectomy, rotator cuff repairs, labral tear repair, repair of impingement syndrome
  • The patient is in lateral or semi-fowlers position
    • The operative arm is placed in suspension with 5-15lbs of weight on a pulley system
94

Rotator Cuff Repair

  • Need for surgery is based on clinical findings and the degree to which injury affects the patients normal functions
  • Surgery should be performed ASAP to avoid atrophy and loss of tissue
95

Acromioplasty

  • Candidates are affected by impingement syndrome (limits the range of motion of the shoulder)
  • The anterior edge of the acromion is resected and the undersurface of the acromion is beveled
96

Colles' Fracture

  • Angulated fracture of the distal radius at the epiphysis
  • The fracture causes the hand to assume a dorsal and lateral position until the treatment
  • TX: Closed reduction with cast application, external fixation, internal fixation with Kirschner wires (comminuted fracture)
  • External Fixation: Advantages include, decreased interference with a joint, early mobilization for the patient, eliminates the need for casting
  • Features of external fixation devices
    • Steinmann pins and /or k-wires
    • Clamps and rings to connect and hold the device together
    • Long smooth rods that serve as supporting devices for clamps and rings
  • Considered a sterile procedure
97

Open Reduction-Internal Fixation of the Humerus

  • Most fractures involving the humerus are best treated with closed reduction and immobilization
  • Indications for ORIF
    • Closed reduction will not produce optimal alignment of the fracture
    • Soft tissue injuries caused by the fracture are present and requires treatment
    • Spontaneous (pathological) fracture due to osteoma
98

Open Reduction-Internal Fixation (operation)

  • Fracture is reduced and bone ends kept in place with reduction clamps
    • Lohman clamp, bone reduction forceps, or k-wires
  • Correct size of the plate is chosen and held in place over the fracture site
  • First hole is drilled through the opening in the plate and into the bone
  • Depth of the drill hole is measured
  • Tap used to prepare the drill hole for the screw, the screw is placed
99

Repair of a Hip Fracture

  • Fractures that require ORIF: Interochantric, subtrochanteric, femoral neck, and basilar neck fracture
  • Fracture can disrupt the blood supply to the femoral head resulting in bone necrosis
100

Total Hip Arthroplasty

  • Prosthesis consists of femoral and acetabular components
    • Metal acetabular cup with polyethylene cup that snaps into a metal shell (requires cement)
    • PMMA used for cementing (adheres to metal but not bone)
  • No "universal" set of hip instruments
101

Internal Fixation of Femoral Shaft Fracture

  • Usually caused by trauma or pathological diseases
  • Requires repair ASAP after injury (delay> 12hrs can lead to difficulties in reducing the fracture)
    • Traction is used if surgery is delayed
  • TX: closed reduction, skeletal traction, and surgical repair
    • External fixation and plates/screws not commonly used complications (infections, broken or bend plates/screws)
  • Standard method of treatment is intramedullary fixation nails (aka femoral nails)
  • Types of nail used depends on the fracture
    • Type and location of the fracture
    • Whether the trochanteric or condylar fractures are present
    • Whether bone fragments are present
102

Knee Arthroscopy

  • Performed for diagnostic purposes, removal of loose bodies, shaving the patella a torn meniscus, meniscectomy, or repair
  • Meniscal injury is one of the most common knee injuries
    • Most common tear= bucket handle (incomplete longitudinal tear with a displacement of the inner portion of the meniscus
  • Aim of meniscal surgery is the preservation of as much cartilage as possible
    • Rim of the meniscus is left intact to aid cushioning and stabilizing the knee joint
    • Extensive tears require a total meniscectomy (knee left unstable)
103

Arthroscopic Anterior Cruciate Ligament Repair

  • Most frequently injured ligament of the knee
  • Often occurs in young athletes (basketball, football); can occur in the older patients (skiing injuries)
  • Tear occurs from non-contact deceleration that produces a valgus twisting injury
  • Diagnostic aids: MRI, Lachman test (determines if the tear has occurred and millimeters of displacement)
  • Tx: Rehab/exercise, arthroscopic repair
  • Examination under anesthesia (EUA) before prep/drape; diagnostic arthroscopy; ACL repair
104

Above the knee amputation

  • Performed because of trauma or disease that inhibits vascular supply to the extremity
    • Diabetic patients are at most risk for amputation of the leg/foot
  • Bone resection is approx 4-6 in proximal to the knee joint
  • 2 skin flaps are created :
    • Anterior flap so the scar is posterior
    • Long adductor muscle flap used to suture across the end of resected femur
105

Total knee Arthroplasty

  • Most difficult and challenging joint for implants
    • Knee motion occurs in three planes: abduction/ adduction, extension/flexion and rotation
  • Tricompartmental implants replace the opposing femorotibial joint and patellofemoral joint but also preserves the PCL
106

Triple Arthrodesis

  • Results in fusion of subtalar, calcaneocuboid, and talonavicular joints
  • Most often performed for a patient with forefoot or hindfoot deformities
  • Post-op patient has plantar flexion and dorsiflexion only
107

Achilles Tendon Repair

  • Most often ruptured by trauma and results in avulsion or laceration of the tendon
  • Surgical repair should be performed ASAP to prevent atrophy of the tendon
  • Torn ends may be sutured together (if adequate length) or proximal end may need to be reinserted into the bone
    • Krackow whip stitch: Suture is placed along each tendon edge for approximation
  • Achilles tendon covered by the partenon (equivalent to synovial sheath)
108

Bunionectomy

  • A bunion (hallux valgus)- bony exostosis located on the medial side of the 1st metatarsal head of the great toe
  • Most common in women
  • s/s: pain and swelling of the great toe
  • Surgical procedures include asked, Austin, chevron, McKeever and Keller techniques
    • All procedures may have the same outcome: removal of exostosis and realignment of the great toe
  • Steinmann pins may be placed across the metatarsal joint
109

Abduction

  • Moving a body part away from the midline of the body
110

Adduction

  • Moving a body part toward the midline of the body
111

Circumduction

  • Moving a particular body part in a circular path without moving the entire body part (EX: moving a finger in a circular motion without moving the hand)
112

Rotation

  • Moving a body part around a central axis
113

Dorsiflexion

  • Bending the foot upward at the ankle joint
114

Plantar Flexion

  • Bending the foot downward at the ankle joint
115

Eversion

  • Turning the foot outward or inside out at the ankle joint so the sole of the foot is shown outward
116

Inversion

  • Turning the foot outward at the ankle joint so the sole of the foot is pointing inward
117

Flexion

  • Bending a joint
118

Extension

  • Straightening a joint
119

Pronation

  • Pointing a body part downward (EX: facing the palm of the hand downward)
120

Supination

  • Pointing a body part upward