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By Jingjing Wang, Crystal Limjap, and Anan Ahmed (Y5, Edinburgh Medical School)Housekeeping Please: • Use the chat to ask any questions. • Note that the session is recorded. • Slides will be available via MedAll after the event. • Be aware that slides do contain sensitive content. • Fill out our short questionnaire - the data will be used to conduct a study about the efficacy of our teaching approach but will be completely anonymous. • Attend 6/8 sessions to get free RCSEd student affiliate membership (worth £15) • Follow ESSS’ MedAll & social media to see our future events Disclaimers: • Whilst we have strived to use resources from reputable sites, this is a peer tutoring session and therefore may contain mistakes. • All media shown is not owned by us and will be credited on each slide they feature on.Lesson Objectives + Agenda Following this tutorial: ● Attendees should be able to recognise the following surgical cases seen in Trauma and Orthopaedics 1. Total Hip Replacement 2. Open reduction and internal fixation (ORIF) 3. Fasciotomy ● Attendees will understand the role of Trauma and Orthopaedic surgeons. ● Attendees should be able to recall the following in said cases: ○ Pathophysiology ○ Anatomy ○ Clinical features ○ Investigations ○ Management ○ Complications ● Attendees should be able to apply their understanding of the above to justify choices in surgical management through a ‘choose-your-own-adventure’ simulated surgical case. ● Attendees should be able to apply their understanding of the above to surgical and anatomy context MCQs.Intro to specialty ● Trauma and orthopaedic (T&O) surgeons diagnose and treat conditions of the musculoskeletal system including bones and joints and structures that enable movement such as ligaments, tendons, muscles and nerves. ● Subspecialties include: ○ Joint reconstruction ○ Particular anatomical region (eg arm) ○ Spine (alongside neurosurgeons) ○ Bone tumour surgery ○ Rheumatoid surgery ○ Sport surgery ○ Complex trauma surgery ○ Paediatric orthopaedics ● 8 year specialty training pathway https://roadtouk.com/training-in-uk/training-in-surgical-specialties/specialty-training-in-surgical-specialties/Common Procedures • Joint arthroscopy – a minimally invasive technique which involves inserting probes into the joint to diagnose and repair damaged joint tissue (eg to torn ligaments or floating cartilage). • Fracture repair – a whole series of techniques are used depending on type, severity and location of fracture to ensure that bones are stable, heal correctly and patient retains function. This can include permanent pins and plates, immobilization, use of external pinning and frames. • Arthroplasty – the replacement of whole joints, usually due to osteo- and rheumatoid arthritis. Hip and knee replacements are the most common operations. • General repair procedures on damaged muscle or tendon. • Corrective surgery – procedures aimed at correcting problems of anatomical alignment which either limit function or would cause long-term problems if left. https://www.rcseng.ac.uk/news-and-events/media-centre/media-background-briefings-and-statistics/orthopedic-surgery/Learning Objectives ● Hip Anatomy ○ The hip joint ○ Acetabulum ○ Ligaments ○ Neurovasculature ○ Movements and muscles ● Hip fractures ○ Types and management ● Total Hip Replacements ● Interactive patient case ● Summary https://www.pinterest.co.uk/somersetortho/orthopedic-humor/The hip joint ● Articulation between trunk and lower limb ● Primary joint of locomotion ● Designed for stability and weightbearing - responsible for weight transfer between trunk and lower limb ● Synovial ball-and-socket joint between acetabulum and femoral head - articular surfaces covered by hyaline cartilage ● Movements include: ○ Flexion / Extension ○ Abduction / Adduction ○ Medial / Lateral Rotation ○ Circumduction https://geekymedics.com/hip-joint/The Acetabulum The acetabulum is divided into two surfaces: ● Lunate surface: articulates with femur ○ Crescent shaped and open at the inferior aspect ○ acetabular notch which is spanned by the transverse acetabular ligament ● Acetabular fossa: non-articular floor ○ ligamentum teres (ligament of the head of the femur) attaches, connecting the fossa to the head of femur at the fovea - this ligament contains a branch of the obturator artery, which supplies the head of the femur. The acetabular labrum (fibrocartilaginous, bound to https://www.orthobullets.com/recon/12769/hip-anatomy acetabular rim) deepens the acetabulum - stabilityLigaments The ligaments of the hip joint act to increase stability. ● Intracapsular - ligamentum teres ● Extracapsular A) Iliofemoral ligament (strongest) ■ arises from the anterior inferior iliac spine and then bifurcates before inserting into the intertrochanteric line of https://teachmeanatomy.info/lower-limb/joints/hip-joint/ the femur B) Pubofemoral Anterior ■ between the superior pubic rami and the A intertrochanteric line of the femur C) Ischiofemoral B C ■ between the body of the ischium and the greater trochanter of the femur PosteriorThe proximal femur https://teachmeanatomy.info/lower-limb/bones/femur/ Anterior View Posterior ViewNeurovascular supply Arterial supply ● Mainly via medial and lateral circumflex femoral arteries ○ Branches of the profunda femoris artery ○ Anastomose at the base of the femoral neck to form a ring, from which smaller arteries arise to supply the hip joint ○ Medial circumflex femoral artery is responsible for the majority of the arterial supply of the femoral head. Damage can result in AVN. ● Artery to head of femur ● Superior/inferior gluteal arteries https://teachmeanatomy.info/lower-limb/joints/hip-joint/ Innervation ● Sciatic, Femoral and Obturator nerves ● Same nerves innervate the knee, so pain can be referredMovements and muscles • Flexion – iliopsoas, rectus femoris, sartorius, pectineus • Extension – gluteus maximus; semimembranosus, semitendinosus and biceps femoris (the hamstrings) • Abduction – gluteus medius, gluteus minimus, piriformis and tensor fascia latae • Adduction – adductors longus, brevis and magnus, pectineus and gracilis • Lateral rotation – biceps femoris, gluteus Extension at the hip joint is limited by the joint maximus, piriformis, assisted by the capsule and the iliofemoral ligament. These obturators, gemilli and quadratus femoris. structures become taut during extension to • Medial rotation – anterior fibres of gluteus limit further movement. medius and minimus, tensor fascia latae https://geekymedics.com/hip-joint/Neck of Femur # (NOF) ● Very common - 3F :1M ● Associated with frailty, increasing frequency due to increase in aging population. ● Risk factors: age, history and risk factors of osteoporosis, previous fragility fracture, history of falls, poor nutrition, low BMI, dementia, visual impairment, cancer ● Causes: trauma (low energy or high energy) ● Poor outcomes ○ 1/3 die within 1 year ○ 1/3 have a decline in their independence ○ 1/3 return to previous baseline function ● Clinical presentation ○ Short, externally rotated leg ○ Pain on pin rolling and in the hip, groin or knee ○ Unable to weight-bearNeck of Femur # (NOF) DDx: Alternative fractures, Slipped capital femoral epiphysis, Dislocated hip, avascular necrosis, Tendonitis, Hip bursitis, Osteomyelitis Ix: ● X-ray is the first-line imaging investigation ● Baseline blood tests: FBC, U&E, coagulation screen, Group & save ● Creatine kinase - rhabdomyolysis ● A urine dip, chest radiograph (CXR), and ECG Classifications: ● Intracapsular: Garden classification (1-4) ● Extra-capsular: Intertrochanteric/Subtrochanteric Management: ● A to E, Analgesia + Intravenous access ● Early surgery ● Extensive MDT involvement for rehabilitation ● Non-operative conservative management - poor prognosis https://geekymedics.com/fractured-neck-of-femur/What type of surgery for NOF#? Surgical options ● Cannulated screws ● Dynamic hip screw ● Intramedullary nail ● Total hip arthroplasty ● Hemi hip arthroplasty Intracapsular NOF# ● Displaced - blood supply to femoral head very likely affected → total or hemi hip arthroplasty ● Un-displaced - blood supply may have been maintained! Fix the native femoral head using DHS or cannulated screws Extracapsular NOF# ● Fix it using a dynamic hip screw or intramedullary nail https://www.cuh.nhs.uk/patient-information/fractured-neck-of-femur/Patient Vignette Arthur Itis (75, ♂) PC: tripped over his dog 3 hrs ago and found by his neighbour who had gone over to complain about the barking. In excellent health, keen hiker. PMHx: Nil DHx: Nil X-ray: https://radiopaedia.org/cases/subcapital-femoral-neck-fracture-3?lang=gbWhat is a total hip replacement? acetabulum with a surgical prosthesisad and Indications • End stage arthritis • Avascular necrosis of the femoral head • Femoral neck fracture in patients with good mobility Contraindication: severe dementia or psychiatric disease, systemic infection Complications: bleeding and haematoma, nerve damage, fracturing of the femoral shaft, dislocation, prosthetic joint infection, loosening, periprosthetic fracture, leg length discrepancy, surgical site infection, VTEThe Team Consultant Surgeon Anaesthetist Scrub Nurse Specialty Trainee Theatre NurseContent Warning! Before the procedure starts, the scrub nurse lets you know that you might see some things you haven’t seen before. It’s ok to feel woozy! But if you do, feel free to pop out of theatre and grab a drink/snack if you are able or, if the faint is imminent, take a seat on the floor (better than falling into the patient!)Lead aprons ● Lead aprons protect you from radiation exposure during intraoperative x-rays ● Occupational radiation exposure has been associated with increased prevalence of female breast cancer ● For maximal protection, please ensure that all surgical team members: ○ Stand as far back from the source as possible ○ Keep arms by side where able ○ Stand square to the source to avoid exposing the axilla ○ Reduce the use of direct lateral views ○ Female orthopaedic surgeons should not be using tabard gowns ○ Vests should be fitted to the size of the individual and as close to the axilla as possible https://www.boa.ac.uk/standards-guidance/radiation-exposure-inn-hangers-3780#attr=er-risk.htms-ha172s-mobile-rail-apron-hanger-plus-10-woodeYou’re called over to assist with transferring the patient from the bed to the operating table. Which direction do we transfer patients? > Laterally > Vertically > ObliquelyLaterally The appropriate direction to shift patients from bed to operating table!Vertically Can be used to reposition patients already on the operating table.Obliquely Please don’t do that.How to transfer a patient Tools needed: a sliding board, a slide sheet, and enough team members to safely support the patient! 1. Line up the bed with the target surface 2. Slip the slide sheet underneath the patient 3. Slip the sliding board underneath the patient 4. Together as a team, slide the patient 5. Remove sliding board and slide sheet Important notes: • Must ensure you have enough team members to support the whole patient • Be careful of any attached cables or tubing that may catch • When the patient is unconsciousness they cannot cry out if they’re in an uncomfortable position, be mindful of potential pressure points and positioning https://hainesmedical.com.au/collections/transfer-mats-boards-from-bed-to-stretcher-gurney-staff-ed Posterior Anterior https://youtu.be/Po42cbJLqnM?si=2WAgf6-gdQlCwlni https://youtu.be/Po42cbJLqnM?si=2WAgf6-gdQlCwlni The consultant makes the first incision down the lateral side of the thigh. As she dissects down through the skin and subcutaneous tissue she asks, what muscle are we going to see next? > Gluteus Medius > Piriformis > Tensor Fascia LataTensor Fascia Lata The consultant smiles and nods her head. ‘Great job! The tensor fascia latae is a muscle located in the proximal anterolateral thigh, situated between the superficial and deep fibres of the iliotibial band’ +5 points for knowledgeGluteus Medius/Piriformis The SpR looks at you questioningly. school? These muscles do assist in hip abduction, however they’re deep to the tensor fascia lata’ -5 points for upsetting the regAbductor muscles The primary hip abductor muscles include the gluteus medius, gluteus minimus, and tensor fasciae latae. The secondary hip abductors include the piriformis, sartorius, and superior fibers of the gluteus maximus. https://www.physio-pedia.com/Hip_Abductors https://www.sydneyphysioclinic.com.au/tendinopathy-2/gluteus-mini mus-the-muscle-of-the-week/ Retractor Monopolar diathermy Femoral head https://youtu.be/Po42cbJLqnM?si=2WAgf6-gdQlCwlnihttps://youtu.be/Po42cbJLqnM?si=2WAgf6-gdQlCwlni Saw Femoral head Corkscrew An osteotomy is performed using a saw to separate the femoral head from the neck of the femur. A cork screw is then used to remove the femoral head. The reg asks what ligament connected the femoral head to the acetabular fossa? > Iliofemoral ligament > Ligamentum teres > Ischiofemoral ligamentLigamentum Teres The consultant smiles and nods her head. ‘Correct! The ligamentum teres connects the femoral head to the acetabular fossa! It’s the only intracapsular ligament and it also contains a branch of the obturator artery, which supplies the head of the femur.’ +5 points for knowledgeIliofemoral/Ischiofemoral ligament The SpR looks at you disappointedly. ‘These are extracapsular ligaments, not intracapsular!’ -5 points for disappointing the regLigaments ● Intracapsular - ligamentum teres connects the head of femur at the fovea to the acetabular fossa ● Extracapsular ○ Iliofemoral ligament (strongest) ■ arises from the anterior inferior iliac spine and then bifurcates before inserting into the intertrochanteric line https://teachmeanatomy.info/lower-limb/joints/hip-joint/ of the femur ○ Pubofemoral ■ between the superior pubic rami and the intertrochanteric line of the femur ○ Ischiofemoral ■ between the body of the ischium and the greater trochanter of the femurhttps://youtu.be/MzXe6mR4UeY?si=5ap-VkX3GC3W_abL The acetabulum is prepared with clearance of soft tissue and reaming of the bone. The acetabular metal component is inserted followed by a liner.The femur is prepared by creating an entry point in the posterolateral aspect of the femoral canal. The femur is then sequentially reamed and the canal rasped to fit the shape of the implant. https://youtu.be/Po42cbJLqnM?si=2WAgf6-gdQlCwlniA trial is performed with a dummy acetabular and stem prosthesis to assess stability, range of movement and leg length. The appropriate size implant is then cemented in.The wound is washed and the layers are closed. Which of the following may result if the abductor muscles aren’t repaired properly before closing the wound? > Scissors gait > Trendelenburg gait > Antalgic gaitTrendelenburg's gait The consultant smiles and nods her head proudly. ‘Spot on! The Trendelenburg gait is caused by unilateral weakness in the hip abductors’ +5 points for knowledge, you’re invited for coffee!Scissors Gait The SpR looks at you annoyed. ‘Scissors gait refers to a walking pattern where the legs cross over each other as they walk, indicating cerebral palsy, muscle weakness, or spasticity.’ -5 points for annoying the regAntalgic gait The SpR looks at you annoyed. ‘An antalgic gait is an abnormal gait secondary to pain. My headachewrong answer’ to your -5 points for annoying the regTrendelenburg's gait The Trendelenburg gait is caused by unilateral weakness in the hip abductors, primarily affecting the gluteal musculature. The pelvis tilts downwards on the non-weight bearing extremity. To compensate for this, the individual engages in a lateral tilt of the trunk away from the affected hip. https://www.physio-pedia.com/Trendelenburg_Gait#/media/F ile:Trendelenburg_gait.jpgPost-op The aims of post-operative management are to enhance recovery, promote early mobilisation and prevent future fractures and complications. • Analgesia • Physiotherapy - most patients should be mobilising and full weight-bearing from day 1 postoperatively • Thromboprophylaxis for 1 month postoperatively • Falls risk assessment • Axial bone densitometry https://geekymedics.com/fractured-neck-of-femur/● Total Hip Replacement ● 2-Common indication = intracapsular hip fracture ● Know how to identify an intracapsular vs extracapsular NOF# Mr Itis is successfully transferred to the ICU for recovery. You check the theatre list and see that an ORIF is happening in 20 minutes. What do you do? >> Hit the books and let’s learn about ORIF! << >> Hit the books and let’s learn about Open reduction and internal fixation! <<Learning Objectives ● List and differentiate the types of distal radius fractures ● Describe the key clinical features, investigations, management and complications of distal radius fractures ● Describe the principles of fracture management ● Explain the fundamental ideas of the ORIF procedure ● Identify key gross anatomy of the forearmDistal radius fractures Pathophysiology & Aetiology • Commonly a FOOSH injury • 80% of axial load is taken by the radius • Forced supination/pronation load on radius -> fractureact • Bimodal distribution; young (5-15y/o) and old (fragility fractures) Reference: MOTUS physical therapyDistal radius fractures - Types Colle’s Smith’s (AKA ‘reverse - Direct blow to an Colle’s) (FOOSH)d wrist - Direct blow to flexed - Transverse wrist (dorsal aspect) extra-articular fracture - Transverse - Dorsal displacement extra-articular - Hand-shake cast fracture of the radius - Volar displacement Barton’s - Intra-articular fracture Reference: with dislocation of the Radiopaedia radiocarpal joint - Can displace either volar (common) or dorsal (less common)Distal radius fractures Risk factors • Think Osteoporosis! • Age • Menopause • Smoking • Chronic steroids Clinical features • Trauma -> Immediate pain (+/- deformity) and swelling • +/- neurological involvement (paraesthesia / weakness) Investigations • Plain X-Ray • CT/MRI if complex Reference: orthopaedic trauma associationDistal radius fractures Complications if untreated… - Malunion - Reduced wrist - Reduced forearm rotation - Median nerve compression - Osteoarthritis Reference: C Jean-Michel et al. (2021)Principles of fracture management Reduce-Hold-Rehabilitate Reduce - Restore anatomical alignment - Correct the deforming forces Hold - Need for traction? (consider muscular pull across fracture site) - Simple splints or Plaster casts Rehabilitate - Think holistically Forearm Anatomy Reference: completeanatomy, Kenhub Reference: Complete anatomy, KenHub Forearm Anatomy Reference: Complete anatomy Reference: Complete anatomy Forearm Anatomy Forearm muscles (20 in total) Anterior compartment (8) - Intermediate layer (1) - Deep layer (3) Posterior compartment (12) - Superficial (7) - Deep (5) Reference: OrthobulletsAnterior Compartment General function: - Wrist and/or finger flexion - Located anterior to interosseous membrane - Supplied by either median or ulnar nerves - Blood supply: - Proximal: Brachial or ulnar arteries - Distal: Radial or ulnar arteries Reference: Complete anatomyAnterior Compartment (Superficial) Muscles: Reference: Teachmeanatomy, Geekymedics, Completeanatomy - Pronator teres - Flexor carpi radialis - Palmaris longus - Flexor carpi ulnarisAnterior Compartment (Intermediate) Muscles: - Flexor Digitorum Superficialis Reference: Complete anatomy, Geekymedics, KenHubAnterior Compartment (Deep) Muscles: - Flexor digitorum profundus - Flexor pollicis longus - Pronator quadratus Reference: Geekymedics, Complete anatomyPosterior compartment General: - Wrist and finger extension - Thumb adduction - Posterior to interosseus membrane - Supplied by interoessus branch of radial nerve - Blood supply - Radial recurrent and several interosseus arteries Reference: Complete anatomyPosterior compartment (Superficial) Muscles: ● Brachioradialis ● Extensor carpi radialis longus ● Extensor carpi radialis brevis ● Extensor digitorum ● Extensor digiti minimi ● Extensor carpi ulnaris ● Anconeus Reference: GeekymedicsPosterior compartment (Deep) Muscles: - Supinator - Abductor pollicus longus - Extensor pollicus longus - Extensor pollicus brevis - Extensor indicis Reference: Complete anatomy, GeekymedicsForearm Vasculature Radial artery - Supplies posterolateral aspect of the forearm Ulnar artery - Supplies anteromedial aspect of the forearm Reference: TeachmeanatomyForearm Anatomy Reference: Complete anatomyORIF procedure outline Break it down: - Open reduction - reposition bones intra-operatively to visualisethem fracture - Internal fixation - a method of physically reconnecting bones using screws, wires or nails for proper alignment and normal healing. Indication: - Treat conservatively (analgesia, splints/slings) UNLESS risk of abnormal healing of fracture (misalignment, open fracture etc.) Recovery: generally 3-12 monthsORIF - Instrumentation • K-wire (kirschner • wire) • Temporarily used to hold reductions in place while plates are screwed in • Screws • Aiming guides • Plates Reference: ‘What’s new in Orthopaedics’Content Warning! Before the procedure starts, the scrub nurse lets you know that you might see some things you haven’t seen before. It’s ok to feel woozy! But if you do, feel free to pop out of theatre and grab a drink/snack if you are able or, if the faint is imminent, take a seat on the floor (better than falling into the patient!)Patient Vignette Brocken Reece (16, Female) PC: Went rollerblading without any arm safety. High velocity fall onto pavement with outstretched arms (FOOSH) PMHx: Nil DHx: COCPRadiology Reference: NewYorkOrtho Based on the patient’s X-ray what classic sign (deformity) is the wrist exhibiting? > Garden spade > Dinner fork > Wave form Reference: NewYorkOrthoDinner fork The consultant smiles and nods her head. ‘Great job, you see it once it’s hard to forget’Garden spade The SpR looks at you questioningly. differentiate your utensils from gardening tools’’Wave form The SpR looks at you questioningly. ‘It’s wavy but we don’t call it that, we’re not mathematicians or surfers ’’The patient is put under General Anaesthesia and the right arm is prepped and draped, the limb is then exsanguinated and tourniquet is inflated to 250mmHg. Reference: NewYorkOrthoThe surgeon grabs their scalpel and starts to make the first incision, what tendon is this over? > Flexor digitorum superficialis > Flexor carpi ulnaris > Flexor carpi radialis Reference: NewYorkOrthoFlexor carpi radialis The consultant smiles and nods her head. ‘That’s right, good job differentiating it’FDP/ FCU The SpR looks at you questioningly. topsy turvy. There’s only 20 muscles in the forearm how hard could this be’The FCR sheath is incised and the FCR is mobilised to expose the floor of the FCR tendon sheath. This is sharply excised and the FPL tendon is retracted ulnarly to expose the pronator quadratus. The PQ is cut to expose the fracture site. Reference: NewYorkOrthoTime to irrigate and then to perform open reduction. What’s the first step of reduction in this case? > Traction and flex the wrist > Traction and extend the wrist > Extended traction only Reference: NewYorkOrthoTraction and extension The consultant smiles and nods her head. ‘Great answer, it’s the opposite of what you would think that helps’Traction and flexion The SpR looks at you questioningly. ‘We’re bones into each other’ot jam theExtended traction The SpR looks at you questioningly. reduction to tire out the soft tissue if it’s too stiff to reduce’Reference: NewYorkOrthoPlate is applied to the volar surface of the radius and K-wires hold the plate in place while a screw is placed in the proximal shaft through an oval hole. What’s the next step? > Repeat X-ray > Repair the Pronator teres > Align screws for distal plate implantation Reference: NewYorkOrthoRepeat X-ray The consultant smiles and nods her head. ‘That’s right. We want radiographs to assess the provision plate application first before any distal fixation’Repair Pronator teres The SpR looks at you questioningly. ‘It’s a bit early to close the patient up don’t you think’Distal plate implantation The SpR looks at you questioningly. screwing in the distal plates before we know the proximal places are in the right place??’Reference: NewYorkOrthoReference: NewYorkOrthoMs Reece is transferred over to the recovery room and you catch your breath. But don’t wait around too long, better get reading up because a SpR told you there’s an emergency fasciotomy coming! >> Hit the books and let’s learn about fasciotomy! << ● Distal radius fractures are common in young and in old, often due to FOOSH injuries ● Colle’s is the most common (dorsal displacement) - causing Dinner fork deformity ● Reduce, Hold, Rehabilitate fractures Credits: https://images.app.goo.gl/2VEA7bu7PLAegxA58Learning Objectives By the end of the teaching lesson, you should be able to: 1. Identify the anatomy of the lower limb (relevant to fasciotomy) 2. Understand the pathophysiology, clinical features and investigations of compartment syndrome 3. Explain fasciotomy in the management of compartment syndrome, including its possible complications 4. Apply knowledge of the above to relevant MCQs Anatomy of the Lower Limb https://www.mediastorehouse.co.uk/science-photo-library/lower-leg-anatomy-artwork-9217809.htmlAnatomy - Bones and Compartments 2 bones: tibia and fibula 4 muscle compartments in lower leg: ● Anterior ● Lateral ● Superficial posterior ● Deep posterior These compartments are encased in thin but tough membrane called a ‘fascia’. https://mass4d.com/blogs/clinicians-blog/compartment-syndrome-of-the-lower-limbs Image credit: https://teachmeanatomy.info/ Anatomy - Anterior Muscular: ● Extensor hallucis longus ● Extensor digitorum longus Neurovascular: ● Deep peroneal nerve ● Anterior tibial vessels Image credit: https://teachmeanatomy.info/ Anatomy - Lateral Muscular: ● Peroneal brevis ● Peroneal longus Neurovascular: ● nerveficial peroneal Image credit: https://teachmeanatomy.info/ Anatomy - Superficial Muscular: Posterior ● Gastrocnemius ● Soleusris Neurovascular: ● Sural nerve (formed and medianf lateral cutaneous nerve) Image credit: https://teachmeanatomy.info/ Anatomy - Deep Posterior Muscular: ● Tibialis posterior ● Flexor digitorum longus ● Popliteusllucis longus Neurovascular: ● Tibial nerve ● Posterior tibial vessels Compartment Syndrome Image credit: https://www.abdn.ac.uk/medical/elf/courses/view/146779/acute-compartment-syndrome/1/page10 Image credit: https://tees/compartment-syndrome/edic/principl Pathophysiology What is it? When the pressure inside a compartment increases beyond the ability of the fascia to stretch. As a result, blood flow and function of tissues within that area may be compromised. Acute vs Chronic Often follows ● Develops with muscular overuse ● fractures,y trauma, ● Commonly occurs circumferential in the leg of runner burns, crush injuries or military personnel ● a tight plaster/cast ● use of anabolic ● sudden return of blood flowClinical Features Symptoms tend to present within hours, although it can develop up to 48 hours post-insult. Pain Paraesthesia Acute limb ischaemia (5Ps) If disease progresses…● Pain ● Pallor ● Perishingly cold ● Paralysis Tense ● Pulselessness https://www.acepnow.com/article/tips-for-quickly-d Investigations iagnosing-compartment-syndrome/?singlepage=1 Creatine Kinase Clinical diagnosis Most reliable diagnostic (based on history and test: (elevated) examination) intra-compartmental Clinicians should pressure monitor Differentials: therefore have a high ● Used when there is degree of clinical clinical uncertainty ● Medial tibial stress suspicion for ● Stress fractures ● Vascular compartment syndrome abnormalities e.g. popliteal artery aneurysm, peripheral artery dissectionsFasciotomy of the legFasciotomy What is it? A procedure in which the fascia is cut to relieve pressure in the muscle compartment. Different types of techniques: - Single incision - Double incision Image credit: https://link.springer.com/chapter/10.1007/978-3-030-26871-8_12Preoperative Preparation General or local anaesthesia Preoperative antibiotics WHO surgical safety checklist Patient is positioned supine Leg should pressed and draped to above the kneesEquipment Needed Forceps Scalpel Antiseptic solution for skin preparation Diathermy device Simple hand-held retractor (Langenbeck) DressingPost-operative Complications ● Long hospital stay ● Wound infection ● Osteomyelitis ● Need for further surgery for delayed wound closure or skin grafting ● Scarring ● Delayed bone healing ● Pain and nerve injury ● Permanent muscle weakness ● Chronic venous insufficiency ● Cosmetic problem ImageCredit:https://www.ncbi.nlm.nih.gov/books/NBK553899/#:~:text=Nonetheless%2C %20fasciotomy%20carries%20sufficiency%2C%20cosmetichronic%20venous%20inPatient Vignette Name: Tibby Alex, 28 year old man match, immediate severe pain, tried to ‘walk it off’ but struggled, pain worsened 30 mins after injury and was admitted to the emergency department soon after PMHx: None DHx: NKDAThe consultant on the ward ushers you to come with them to observe a fasciotomy. On the way to the theatre, they give you a brief run through of the patient’s case. The consultant stops you before you enter the room and jokingly (half-jokingly) tells you that you can only come in if you answer their question correctly. After hearing the patient’s history, which compartment is most likely affected? a. Anterior compartment b. Superficial posterior compartmentCORRECT! Answer: A (anterior compartment) The consultant smiles. ‘Off to a great start! Hoorah!’WRONG! Answer: B (superficial posterior compartment) The SpR scoffs. “It was a 50/50 chance… and you still got it wrong” Trauma is the commonest cause of fracture). Since the anterior compartment is directly adjacent to the tibia, it is the most vulnerable to compartment syndrome.After scrubbing in, the surgeon starts the procedure. They make a single incision through a lateral approach, dissecting through fatty tissue and fascia. When they reach the layer of muscle, they point out the anterior and lateral compartment to you. Before they continue on with the surgery, they ask you a question…. ? What is this structure? a. Superficial peroneal nerve b. Great saphenous veinCORRECT! Answer: A (superficial peroneal nerve) The consultant grins widely. ‘It looks like someone knows their anatomy really well.’WRONG! Answer: B (great saphenous vein) The SpR sighs and shakes his head. ‘What are they teaching you in medical school these days?’ The superficial peroneal nerve is the most commonly injured nerve during fasciotomy of the leg compartment adjacent to the intermuscular septum ofteral the anterior and lateral compartments. The great saphenous vein runs up the medial side of the leg.Upon seeing your enthusiasm for the procedure, the surgeon fires another question at you. What device can we use to test out muscle viability? a. Diathermy b. ForcepsCORRECT! Answer: A and B (diathermy and forceps) The consultant giggles cheekily. ‘That was a trick question. Both of the answers are correct…’ Following fasciotomy, the viability of the muscles is ensured with diathermy or forceps-induced muscle contractions. Non-viable muscle mass is debrided and hemostasis is ensuredThe surgeon is finishing up with the fasciotomy. They look up at you and see you staring keenly at what they are doing. They grin mischievously, “I’ve got one last question for you.” Should the fasciotomy skin incisions be left open? a. Yes b. NoCORRECT! Answer: A (yes) The consultant nods at you approvingly. ‘I’m so impressed!’WRONG! Answer: B (no) The SpR rolls his eyes. ‘What would the point of doing the fasciotomy be if you do this?’ After fasciotomy, the wound is usually managed open and dressed sterilely with moist dressings to protect the tissue from drying and retraction. Early primary wound closure is not recommended as it may lead to increased muscle pressure and recurrent compartment syndromeLearning Objectives By the end of the teaching lesson, you should be able to: 1. Identify the anatomy of the lower limb (relevant to fasciotomy) 2. Understand the pathophysiology, clinical features and investigations of compartment syndrome 3. Understand fasciotomy in the management of compartment syndrome, including its possible complications 4. Apply knowledge of the above to relevant MCQsMCQ 1 head?e to what artery results in avascular necrosis of the femoral > Lateral femoral circumflex artery > Medial femoral circumflex artery > Profunda femoris artery > Deep femoris artery > Popliteal arteryMCQ 1 ANSWER Damage to what artery results in avascular necrosis of the femoral head? > Lateral femoral circumflex artery > Medial femoral circumflex artery > Profunda femoris artery > Deep femoris artery > Popliteal artery https://www.orthobullets.com/knee-and-sports/3110/femoral-neck-stress-fracturesMCQ 2 Which of these muscles is a part of the deep anterior compartment of the forearm? > Pronator Teres > Flexor digitorum superficialis > Palmaris Longus > Pronator Quadratus > Palmaris LongusMCQ 2 ANSWER Which of these muscles is a part of the deep anterior compartment of the forearm? > Pronator Teres > Flexor digitorum superficialis > Palmaris Longus > Pronator Quadratus > Palmaris LongusMCQ 3 What are the ranges for compartment pressure and perfusion pressure to prompt an emergency fasciotomy? A - >30 mmHg and <30 mmHg, respectively B - <10 mmHg and >10 mmHg, respectively C - <30 mmHg and >30 mmHg, respectively D - >10 mmHg and <10 mmHg, respectively E - >50 mmHg and <50 mmHg, respectivelyMCQ 3 ANSWER What are the ranges for compartment pressure and perfusion pressure to prompt an emergency fasciotomy? A - >30 mmHg and <30 mmHg, respectively B - <10 mmHg and >10 mmHg, respectively C - <30 mmHg and >30 mmHg, respectively D - >10 mmHg and <10 mmHg, respectively E - >50 mmHg and <50 mmHg, respectivelySummary ● Total Hip Replacement ○ Involves replacing the acetabulum and femoral head with a prosthetic ○ Common indication = displaced intracapsular neck of femur fracture ○ Know how to identify an intracapsular vs extracapsular NOF# ● Op○n Use of plates, K-wires and screws to internally fix fracture site post intraoperative reduction. ○ Can be at multiple sites e.g ankles, however common in complicated distal radius fractures ● Fasciotomy ○ Involves cutting fascia to relieve pressure in a muscle compartment ○ For the lower leg, there are two types: single-incision and double-incision ○ Incision left open after surgery to prevent recurrent compartment syndrome and to enable assessment for any dead tissueReferences Intro • https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/surgery/trauma-and-orthopaedic-surgery • https://roadtouk.com/training-in-uk/training-in-surgical-specialties/specialty-training-in-surgical-specialties/ Case 1: https://www.rcseng.ac.uk/news-and-events/media-centre/media-background-briefings-and-statistics/orthopedic-surgery/ • https://geekymedics.com/hip-joint/ • https://www.orthobullets.com/recon/12769/hip-anatomy • https://teachmeanatomy.info/lower-limb/joints/hip-joint/ • https://geekymedics.com/fractured-neck-of-femur/ur/ • https://www.cuh.nhs.uk/patient-information/fractured-neck-of-femur/ • https://radiopaedia.org/cases/subcapital-femoral-neck-fracture-3?lang=gb • https://www.boa.ac.uk/standards-guidance/radiation-exposure-in-theatre/breast-cancer-risk.htm • https://www.physio-pedia.com/Hip_AbductorslCwlni • https://www.sydneyphysioclinic.com.au/tendinopathy-2/gluteus-minimus-the-muscle-of-the-week/ • https://www.physio-pedia.com/Trendelenburg_Gait#/media/File:Trendelenburg_gait.jpg Case 2: • https://www.youtube.com/watch?v=wtZikbuiyyA • https://teachmesurgery.com/orthopaedic/principles/fracture-management/ • https://teachmesurgery.com/orthopaedic/wrist-and-hand/distal-radius-fracture/ • https://motusspt.com/foosh-fallen-onto-an-outstretched-hand/ • https://www.kenhub.com/en/library/anatomy/elbow-and-forearm • Jean-Michel Cognet, Olivier Mares,Distal radius malunion in adults,Orthopaedics & Traumatology: Surgery & Research,Volume 107, Issue 1, Supplement,2021,102755,ISSN 1877-0568, https://doi.org/10.1016/j.otsr.2020.102755. • https://geekymedics.com/muscles-of-the-posterior-forearm/ • Case•3: https://www.youtube.com/watch?v=YjuCN9PWK6k • https://teachmesurgery.com/orthopaedic/principles/compartment-syndrome/#:~:text=Introduction,%2C%20foot%2C%20hand%20and%20buttock. • Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448124/ • 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556153/StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; • Donaldson J, Haddad B, Khan WS. The pathophysiology, diagnosis and current management of acute compartment syndrome. Open Orthop J. 2014 Jun 27;8:185-93. doi: 10.2174/1874325001408010185. PMID: 25067973; PMCID: PMC4110398.Any Questions? Please leave feedback here!