ORTHOPEDIC SURGERY

The branch of medical science concerned with disorders or

deformities of the spine and joints.

Orthopedic Terminology“Position and Movement”

Abduction move a part away from body Adduction move a part toward the body Dorsiflexion bend or flex foot toward leg Plantar flexion extend foot with toes pointed down (as

when depressing the gas pedal) Flexion to bend a part Extension make a limb straight Eversion turn outward Inversion turn inward Distal farthest away from point of origin Proximal closest to point of origin Medial nearest mid-line Lateral away from the midline

Orthopedic Terminology“Position and Movement”

Valgus -abnormal displacement of part of a limb away from the midline of the body – distal from the affected joint – knees together

Varus - a deformity in which part of a limb is turned inward to an abnormal degree – distal from the affected joint – knees apart

Orthopedic Terminology Acetabulum hollowed area of pelvis that receives head of femur Acromioclavicular (AC) joint where clavicle joins acromion process

of scapula Arthritis inflammation of a joint Arthrodesis surgical fusing or fixation of a joint Arthroplasty surgical reconstruction of a joint Arthroscopy visualization of a joint through an endoscope (diagnostic

or operative) Arthrotomy surgical incision into a joint Articulation joint movement Atrophy muscle wasting from lack of use Bone marrow found in medullary canal of long bones and porosites of

cancellous bone Cartilage elastic, strong, dense connective tissue Compact bone hard outer covering of bone Cortical bone hard bone that forms shell of bones/acts as supporting

structure Condyle rounded part of a bone where ligaments articulate with

adjacent bones Curvature normal or abnormal bending

Orthopedic Terminology Diaphysis shaft of a long bone Dislocation displacement of a joint Dysplasia abnormal tissue growth Endosteum inside lining of bones where new bone forms

(marrow) Epiphysis two ends of a long bone Exostosis bony growth arising from a bone’s surface Fibroma tumor composed of fibrous or connective tissue Foramen normal bone opening through which nerves,

vessels, etc. pass Foramen magnum occipital bone opening where spinal

cord passes to vertebral column Fossa shallow depression of a bone Fracture break or crack of a bone Hallux big toe Implant implantation of graft (synthetic or tissue)

Orthopedic Terminology Lamina flat layer or plate of a bone Ligament connective tissue that joins bone

surfaces Malleolus rounded bone process (ankle) Malunion faulty union of a fractured bone Nonunion failure of fractured bone to unite Osteogenesis origination/development of bone

(ossification) Osteomyelitis inflammation of bone tissue Osteoporosis diminished calcium in a bone Osteotomy surgical cutting of bone

Orthopedic Terminology Pelvic Girdle bony structure that supports the

trunk and provides attachment for the legs Periosteum membrane surrounding bone

(contains blood vessels) Polydactylism more than normal number of

digits Scoliosis abnormal curvature of spine Syndactylism webbing between digits Synovial membrane lining of a joint capsule Tendon fibrous tissue that connects muscle to

bone Traction force placed on bones or muscles to

align or immobilize parts

Primary purposes of orthopedic surgery

1. Repair, revision, reconstruction, reattachment or removal any of the 206 bones of the skeletal structure and surrounding tissue

Bones, joints and affected muscle tissue Tendons, ligaments or cartilage

2. Accurately classify treatment Axial skeletal procedures Upper extremity procedures Lower extremity procedures Limb reattachment procedures Amputation procedures

Purposes (continued)3. Investigate, preserve and restore form and function to the

musculoskeletal structures and associated tissues of the extremities and also the spine. Treatment depends on the type of injury and the duration of necessary immobility.

Stages of treatment Investigation – diagnosis of structural issues

External Internal

Preservation Restoration

Types of treatment Fracture management

Reduction Immobilization Rehabilitation

Corrective surgeries Bone grafts Implants Internal and external fixation

The Skeleton

Function of Skeletal System

Support Protection Movement Storage Hematopoiesis -

the formation of blood cells in the living body (especially in the bone marrow)

Bone Histology Bone is a type of

connective tissue 2 Types of Bone: Dense/Compact

Bone/ Corticalhard on outside/canal on insidecomposed of Haversian Units or Osteon

Spongy/Cancellous Bone

Bone Formation Osteogenesis is bone formation Two Types: Intramembranous Endochondral More Terms:

Osteoblast :a cell from which bone develops Osteocytes: a star-shaped cell, is the most abundant

cell found in bone. They are osteoblasts that have completed their bone-forming function and have become trapped in new bone tissue, evolving into structural bone cells and is involved in the maintenance of that bone. A mature bone cell.

Osteoclasts: cells break down and assimilate bone. They are located in minute, bony chambers called lacuna.

Intramembranous Ossification Sheets of primitive connective tissue form at site of

future bone Primitive connective cells collect around blood

vessels in these layers Connective tissue cells differentiate into osteoblasts,

which deposit spongy bone Osteoblasts become osteocytes when bony matrix

surrounds them (lacunae) Connective tissue on surface of each developing

structure forms a periosteum Osteoblasts on the inside of periosteum deposit

compact bone

Endochondral Ossification Masses of hyalin cartilage form models of future

bones Cartilage tissue breaks down/Periosteum

develops Blood vessels and differentiating osteoblasts

from the periosteum invade the disintegrating tissue

Osteoblasts form spongy bone in space occupied by cartilage

Osteoblasts become osteocytes when bone matrix completely surrounds them

Osteoblasts beneath periosteum deposit compact bone around spongy bone

Relevant anatomy1. Skeletal system – articulated skeleton

comprised of 206 bones Axial skeleton – skull, spine and ribs

Skull – includes cranial and maxillofacial bones Cranial bones – 8 cranial bones Facial bones – 13 facial bones Middle ear bones – 6 middle ear bones Mandible – one jaw bone

Hyoid bone Vertebral column – 26 backbones

Verebral – 24 backbones: 7 cervical, 12 thoracic, and 5 lumbar

Sacrum – one sacrum bone Coccyx – one tailbone

Thoracic cage – 25 thoracic bones Sternum one cartilaginous bone that supports most ribs Rib cage – 24 rib bones; 12 pair posteriorly attached to the

spine

Relevant anatomy - Cervical C-1 : a.k.a. Atlas:

like Atlas man (Greek mythology), the bone supporting the skull.

C-2 Axis: bone that

allows the head to pivot.

Axial Skeleton

Appendicular Skeleton The appendicular skeleton

consists of 126 bones in the human body which make motion possible and protects the organs of digestion, excretion, and reproduction.

The word appendicular refers to an appendage or anything attached to a major part of the body, such as the upper and lower extremities.

The appendicular skeleton has four major regions:

Pectoral Girdles(4 bones) Upper Limbs (60 bones) Pelvic Girdle(2 bones) Lower Limbs(60 bones)

Anatomy (continued) Appendicular Skeleton Upper extremities –shoulder,

arm and hand bones of the appendicular skeletal system Pectoral girdle – four pectoral or

collar bonesScapula – two posterior collar

bonesGlenoid fossaCoracoid processAcromion process

Clavicle – two anterior collar bones

Upper limbs –arm, wrist and hand bonesHumerusRadiusulna

Anatomy (continued) Lower extremities –hip

and leg bones of the appendicular skeletal system Pelvic girdle

IliumPubisIschium

Lower limbs – leg and foot bonesFemurPatellaTibiaFibulaTarsalsMetatarsalsphalanges

Anatomy of a Bone

Bone Marrow Within the long

bones are two types of bone marrow: red marrow and yellow marrow.

The yellow marrow is fatty tissue.

During starvation, the body uses the fat in yellow marrow for energy.

Bone Marrow The red marrow of some

bones is an important site for blood cell production.

Here all red blood cells, platelets, and white blood cells form in adults. Red blood cells carry

oxygen and nutrients to the body tissues.

Platelets help in blood clotting.

White blood cells help fight disease and infection.

Muscles

Anatomy (continued)2. Muscular anatomy

Neck muscles – sternocleidomastoid, platysma and trapezius

Torso muscles – deltoid, pectoralis, serratus anterior, latissimus dorsi, transverse abdominus, rectus abdominus and levator ani

Arm muscles – biceps brachii, triceps brachii, brachialis, brachioradialis, carpi, digitorium and pollicis

Leg muscles – gluteus, sartorius, quadriceps femoris, adductor, hamstring, gastrocnemius, tibialis anterior and digitorium, both flexor and extensor

Muscles Functional unit of a muscle is the sarcomere 3 Types:

Skeletalvoluntary/conscious movementstriated in appearancefound along-side skeletal system

Cardiac involuntary/unconscious movementfound only in myocardium of heart

Smoothinvoluntary/unconscious movementfound in the viscera

4 muscles of the Rotator Cuff

Knee anatomyANTERIOR POSTERIOR

Knee Anatomy

FootExtensor digitorum longus (EDL) – MUSCLE -The EDL extends or lift the toes

Hand

Bone composition types1. Membranous bone – highly specialized

connective osseous tissue that originally is membrane, then ossifies to bone

Cranial Facial – maxilla (upper jaw), mandible (lower),

nasal and lacrimal bones2. Cartilaginous bone

Long bones Flat bones

Irregular bones Short bones Sesamoid bones

Bone Types

Types of Joints

Joint Classification1. Functionally

based on degree of movement*synarthroses-no movement*amphiarthroses-slight movement*diarthroses-freely moveable

2. Structurallybased on type of connective tissue and type of joint cavity*fibrous-no movement, no joint cavity, dense fibrous connective tissue, synarthoses*cartiligenous-slight to no movement, can be synarthroses or amphiarthroses*synovial-joint cavity, diarthroses

Diarthroses Joints The 6 types of diarthroses joints:

• Ball-and-Socket• Condyloid• Saddle• Pivot• Hinge• Gliding

Ball-and-Socket Joint The ball-shaped end of

one bone fits into a cup shaped socket on the other bone allowing the widest range of motion including rotation.

Examples include the shoulder and hip.

Condyloid Joint Oval shaped condyle fits into

elliptical cavity of another allowing angular motion but not rotation.

Saddle Joint This type of joint occurs

when the touching surfaces of two bones have both concave and convex regions with the shapes of the two bones complementing one other and allowing a wide range of movement.

The only saddle joint in the body is in the thumb.

Pivot Joint Rounded surfaces of

one bone fit into a ring of one or tendon allowing rotation.

An example is the joint between the axis and atlas in the neck.

Hinge Joint A hinge joint allows

backward and forward movement in only one direction, much like a door opening and closing.

Examples Knee joint Elbow joint

Gliding Joint Flat surfaces move

against each other allowing sliding or twisting without any circular movement

Joints and surrounding tissue

1. Joints – points of articulation where movement between bones can occur

Axial skeleton Skull

Cranial and facial sutures Temporomandibular

Vertebral column Atlanto-occipital Intervertebral

Ribs and sternum Sternoclavicular sternocostal

Joints and surrounding tissue (continued)

Upper extremities Pectoral girdle

AcromioclavicularShoulder (glenohumeral or humeroscapular)

Elbow Hand

Wrist (radiocarpal)Digit

Lower extremities Pelvic girdle

SacroiliacPubic symphysisHip

Knee (tibiofemoral and femoropatellar)

Joints and surrounding tissue (continued)

Tibiofibular (proximal and distal) Ankle Foot

Intertarsal Metatarsophalangeal Toe (interphalangeal)

2. Joint structure Articular hyaline cartilage Fibrous capsule

Fat pad Articular joint disc Ligaments – connecting bone to bone Tendons – connect muscle to the bone

Synovial membrane and fluid

Joints and surrounding tissue (continued)3. Joint articulation types

Synovial – allow free movement/have a joint cavity

Cartilaginous – allow little movement/no joint cavity

Fibrous – allow no movement/No joint cavity4. Surrounding soft tissue

Circulatory – blood vessels Peripheral nerves Foramen muscles

Pathology1. Pathologic

Congenital Dysplasia – abnormal tissue growth Hip dislocation Polydactylism Scoliosis, kyphosis and lordosis – abnormal

curvature of the vertebral column Syndactylism – webbing between digits

Acquired disease Arthritis – inflammation of a joint

Osteoarthritis (OA) Rheumatoid arthritis (RA)

Bursitis – inflammation of the synovial fluid herniation

Pathology (continued)• Infection

Osteomyelitis – inflammation of bone tissue• Calcium disorders

Rickets – vitamin D and calcium deficiency Osteomalacia – soft bones Osteoporosis – fragile and porous bones

• Tumors Osteochondroma – generally benign Osteoma – benign tumor of the bone Fibroma – composed of fibrous tissue Osteosarcoma – malignant tumor of the bone Myeloma – cancer in the bone marrow Chondrosarcoma – tumors of the hyaline cartilage, often

malignant• Volkmann’s contracture

Strain – stretching of joint tendons

Pathology (continued)2. Traumatic

Damaged or dislocated joints Fracture

Closed (simple) – bon does not protrude the skin

Open (compound) Complete or incomplete Multiple

fragmentation

Bone fracture pathology1. Fractured bones

Simple (closed) Compound (open) Compression – bone is crushed Comminuted – bone breaks into more than 2

pieces Depressed – bone forced inward Greenstick – partially bent or broken Impacted – driven into another bone

fragment2. Fracture geometry

Longitudinal (linear) – fracture line runs along the length of the bone

Bone fracture pathology (continued)

Oblique – fracture line lies at an angle Spiral Transverse

3. Stages of bone healing after fracture Hematoma or hemorrhage (stage 1) Granulation (stage 2) Bony callus formation (stage 3) Consolidation, calcification and bone remodeling

(stage 4)4. Osteogenesis – bone growth stimulated by use

of electrical impulses5. Complications in bone healing

Delayed union of bone Mal-union of bone Non-union of bone

Fracture management methods

1. Closed reduction (CR) procedures Closed reduction via external fixation (CREF)

– manipulation of fracture of bone using external devices such as casts or traction

Closed reduction via internal fixation (CRIF) externally manipulated fracture of bone using internal devices such as pins or rods

2. Open reduction (OR) procedures Open reduction with external fixation (OREF) Open reduction with internal fixation (ORIF)

External Fixation

External Fixation

External ManipulationTraction Techniques

Closed Reduction Via External Fixation

Fracture management stabilization devices

1. External fixation Casts

Plaster (fast, medium, slow-setting) Fiberglass Types

Shoulder spica Minerva jacket Body cast Short arm/leg Long arm/leg Hip spica Cylinder cast

Hip Stabilization

Goals of Casting/Splinting Relieve pain Augment healing Stabilize fracture Prevent further injury

Splinting is better if practical because it is easier to manage swelling considering the entire limb is not isolated by a circumferential cast

Casting Considerations Casts

– Proper placement of cast brings patient safety issues• Patient’s limb should be elevated• Webril should be placed so no wrinkles are in cotton to

cause pressure sores• As plaster or fiberglass is placed, assistant must not

make marks in plaster as it dries—these may cause pressure sores

• Reflective materials will reflect heat given off by casting material if fiberglass and may burn patient’s limb

• Tip of limb should be cleaned of all prepping solution so patient may be monitored for signs of circulatory disruption: increasing pain, pain that progresses into numbness, cyanotic skin, cold skin, poor capillary refill

Casting Differences Plaster

webril first

wet casting with warm water before application

primarily used on children or where a lot of swelling is anticipated because can split if necessary (poor circulation due to swelling)

Fiberglass

webril first

can wet with warm or cold water

cannot split if needed/must be removed and reapplied

Combo Casting “Orthoglass” Outer soft sleeve (sock-like on outside) Inside composed of moldable fiberglass Wet, apply, wrap with ace

Fracture management (continued)

Splints Abduction splint

Braces Frames and external fixation devices Traction

Buck’s traction – skin traction Skeletal traction

Fracture management (continued)

Grafts – human material used to stabilize bone Bone grafts

Autogenous graft – bone from own bodyCotrical graft – “matchsticks” or small narrow slices of cortical

boneCancellous graft – spongy boneHomogenous graft – donor bone from another human

Fracture management (continued)

Orthopedic implants Metal, ceramic, silicone or high-density molecular plastic

prostheticsHumeral endoprosthesis for shoulderUlnar prosthesis for elbowSilastic implant for finger jointsFemoral endoprosthesis for hipKnee arthroplasty implants – total kneePress-fit implants – secured to area without cement

Fixation options – cemented or non-cemented

Common diagnostics performed prior to surgery

1. Lab studies – blood cultures, urine samples, spinal fluid or synovial fluid tests

Biopsy, bone marrow Erythrocyte sedimentation rate (ESR) –

measures rate of RBC fall, since inflammations cause them to fall faster than normal

Serum alkaline phosphates (SAP) – check for increased levels of SAP, which indicated multiple kinds of bone disease

Diagnostics (continued)2. Diagnostics

Arthrocentesis - procedure of using a syringe to collect synovial fluid from a joint capsule. It is also known as joint aspiration. Arthrocentesis is used in the diagnosis of gout, arthritis, and synovial infections.

Arthrography – injection of gas or contrast media for inspection of cartilage and ligaments surrounding joints

Arthroscopy Bone densitometers – measuring bone density Computerized tomography (CT) Magnetic resonance imaging (MRI) X-rays

The Operating Room

OR Beds and PositionersCHIC TABLE BLUE ALLEN

OR Beds and PositionersJACKSON FLAT TOP JACKSON FX TABLE

OR Beds and PositionersANDREWS TABLE CLOWARD

OR Beds and PositionersBEACH CHAIR MCCONNEL HEAD REST

OR Beds and PositionersJACKSON SLING VAC PAC OR BEAN BAG

OR Beds and PositionersWILSON FRAME HANA TABLE FOR ANTERIOR

APPROACH TOTAL HIPS

OR Beds and PositionersMAYFIELD HEAD REST PEG BOARD POSITIONER

Special considerations1. General considerations

Preoperative considerations Aseptic technique Full 10 minute scrub (varies per institution/surgeon) Additional scrub attire Protective attire Extra drapes Laminar air flow Ultraviolet irradiation Cast rooms are separated from operating rooms to

reduce plaster dust contamination. If a cast room is not available, preoperatively bivalve the cast in patient’s room or holding area, then remove in OR

Special considerations (continued)

Intraoperative considerations Use antibiotic irrigation solution Magnetic mat may be used for placement of

instruments Postoperative considerations

Elevate the extremity Cooling apparatus

Special considerations (continued)

2. Surgery-specific considerations Implants – require proper selection, handling

and application Methyl methacrylate Handling of implant

Casts Tourniquets Endoscopic equipment Powered equipment Compressed gas cylinders or wall units

Basic orthopedic supplies1. Beanbags, sandbags and pillows2. Sutures

Surgical steel Ethibond, Prolene and Nurolon – used in attaching

tendons, ligaments, bones Vicryl – used for work with periosteum and closure

3. Drapes4. Fixative (bone cement) – Methyl methacrylate or

polymethyl methacrylate (PMMA) 5. Agents

Anti-inflammatory agents – Cortisone steriods Hemostatic agents

Avitene – applied dry directly to bone surface Bone wax Gelfoam thrombin

Basic orthopedic equipment1. Arthroscopic support equipment2. Bone stimulator3. Braces, casts and other immobilizers4. Coblation – a new cauterization method that is non-heat

driven5. Fluoroscope (C-arm)

Mandatory lead apron6. Irrigation7. Specialty positioning devices

Fracture table Andrews frame – maintains patient in modified knee-

chest position Wilson frame – prone position

8. Tourniquet9. Traction devices

Basic orthopedic instrumentation

1. Basic sets Bone sets

Small bone set – used on extremities such as hands and feet

Large bone – long bones and joints Hip set Knee set Shoulder set Bone graft set

2. Minimally invasive surgery Arthroscope Support instrumentation

Basic instruments (continued)3. Bone cutting

Curettes, bone Cutters, bone

Single or double-action Chisels

Hibbs Elevators, periosteal Files, bone Drills Gouges Hooks, bone mallets

Basic instruments (continued)

Knives, orthopedic Amputating knife Smillie meniscus knives

Osteotomes Rasps Reamers Rongeurs

Single or double action

Basic instruments (continued)4. Bone manipulation tools

Bone clamps Lowman Lane

Bone hooks Retractors

Bennett Hohmann

Saws Gigli saw Amputation saw

Tendon pulling forceps Tendon strippers Powered instruments – includes power drills, reamers,

and oscillating and reciprocating saws

Basic instruments (continued)5. Bone piercing tools – generally used to

insert fixation devices Cutters Kirschner wires, Rush rods, Steinman pins,

screws, plates Plates Pins (pin cutter must be available)

Steinman pins are smooth or threaded Sizes 1/32”, 1/16”, 3/32”, 1/8”, 5/32”, 3/16” and

¼”

Basic instruments (continued)

ScrewsCortical screwsCancellous screws – common diametes are 32 mm and 64

mmMalleolar screws

Rods or intermedullary nailsKirschner rod or intermedullary nailRush rodVertebral column rod (Harrington)

WiresKirschner wires (K-wires) – available smooth or threadedSizes – 0.032, 0.045, 0.062

Rush awl reamer Screwdrivers Traction bow

Basic instruments (continued)6. Bone measuring devices

Screw gauges Bone screw gauge Depth gauge – used to determined length of

screw needed Calipers rulers

Relevant positions, skin prep and draping

1. General information Position – varies greatly, depending on

surgical area Skin prep – generally one joint above and one

joint below operative site. Shaving may be required. 10-minute skin prep with Betadine scrub and paint is most commonly used

Draping – while still holding the extremity in a raised position, place the “down” sheet, an impervious flat sheet, under the extremity. Apply the impervious stockinette, covering the entire extremity. A variety of large incision sheet may be used (extremity sheet, U-drape, split sheet or laparotomy sheet)

Relevant positions, skin prep and draping (continued)

2. Upper extremities Shoulder and upper arm surgeries

Position Supine or modified supine Fowler’s or “Beach-chair”

Skin prep – prep entire arm and shoulder, requires additional person

Draping – apply impervious “down sheet” tucked under shoulder and axillary area. Follow with sterile stockinette from the fingers to the shoulder. Coban may be used to secure the stockinette. Place split-sheet around the shoulder. Drape the arm free

Elbow, forearm and hand surgeries Position – supine with armboard Skin prep – elevate and prep entire hand and arm to

tourniquet Draping – apply impervious “down sheet” over armboard.

Follow with stockinette and extremity sheet.

Relevant positions, skin prep and draping (continued)3. Lower extremities

Hip surgeries Positions – varies according to procedure

Supine with a rolled towel-covered sand bag placed under the thigh

Full lateral with bean bag Supine or lateral on fracture table

Skin prep – elevate affected leg, enlisting additional personnel if needed. Prep entire leg and foot, prepping toes and groin areas separately and last. When fracture table is used, prep affected side of hip from umbilical line to knee

Draping – isolate perineum with adhesive sterile plastic U-drape. Tuck impervious “down sheet” under hip joint and extend the length of OR table, then apply laparotomy sheet or U-drape

Relevant positions, skin prep and draping (continued)

Knee and lower leg surgeries Position – modified supine with knees at table break,

which is lowered to 90- degrees Skin prep – support affected leg by the foot for entire

prep. Prep from tourniquet on upper thigh to foot and toes

Draping – place impervious “down sheet” under affected leg, covering opposing leg. Apply stockinette over leg and foot to tourniquet, then place extremity sheet or split sheet

Ankle, foot and toe surgeries Position – supine Skin prep – support affected leg using leg holder or

personnel. Prep from knee, including the foot and toes

Draping – apply impervious “down sheet”. Apply stockinette over foot to tourniquet, then place extremity sheet

Common axial skeletal procedures

1. Craniofacial – maxillofacial or Le Fort fractures (usually performed by plastic surgeon)

2. Vertebral column Laminectomy Disectomy Spinal fusion Trauma scoliosis

Common joint reconstruction procedures

1. Arthrodesis – surgical fixation or fusion of a joint.

2. Arthrotomy – incision into a joint3. Arthroscopy – direct visualization into a

joint4. Arthroplasty – surgical repair of a joint5. Repair of joint dislocations

Common upper extremity procedures

1. Clavicle surgery Acrominoclavicular (AC) separation repair – reattach the

ligaments at the joint between the clavicle and the acromion

Acromioplasty – relieve the impingement of soft tissue in the joint

2. Shoulder joint Glenohumeral dislocation repair

Bristow procedure – the coracoid process (a long, curved projection from the scapula) with its muscle attachments is transferred to the neck of the scapula and creates a muscle sling at the front of the glenohumeral joint

Rotator cuff repair Bankart procedure performed for recurrent dislocation of the

shoulder Putti-Platt procedure – detachment of the subscapularis tendon

and the capsule Arthroplasty of the total shoulder – total replacement of the

shoulder

Common upper extremity procedures (continued)3. Humerus (supracondylar, epicondylar,

intercondylar) and elbow – for all procedures distally of the humerus, a tourniquet is usually applied high on the affected arm. The entire hand and arm to the tourniquet will be prepped and draped

ORIF of the humeral head Arthroplasty of the humeral head Fractured humerus Supracondylar, epicondylar, intercondylar

fracture Arthroplasty of the total elbow Fracture olecranon

Common upper extremity procedures (continued)4. Radius and ulna

Excision of the radial head Fractures of the radius and ulna Ulnar nerve transposition – anterior ulnar

nerve is brought to the posterior position after damage from elbow trauma

Colles fracture of the distal radius near the wrist joint

Excision of ganglionic cyst5. Wrist

Fractures of the carpals Arthroplasty of the wrist

Common upper extremity procedures (continued)6. Hand – involves metacarpals and

phalanges Fractures of the metacarpal and/or phalange Arthroplasty of the metacarpal phalangeal

joint (MPJ) Arthroplasty of the phalangeal joints – similar

to MPJ procedure with silicone implants Palmar fasciectomy (Dupuytren’s release) –

prevents full extension of finger, usually ring and little fingers

Syndactyly release – requires a split-thickness skin graft

Common lower extremity procedures

1. Hip and femur procedures Congenital hip dislocation reduction, open

and closed Fractured hip

Intertrochanteric fracture – very common fracture; located in the area between the greater and lesser trochanteres

Femoral head fractures Subcapital fracture or near the proximal area of the

femoral neck Arthroplasty of the total hip Fractured femoral shaft

Closed ORIF of femur

Common lower extremity procedures (continued)2. Knee procedures

Arthroscopic procedures Diagnositc Shaving of articular cartilage fragments Synovectomy Medial or lateral meniscectomy Removal of loose bodies

Repair of the anterior (ACL) and posterior cruciate ligaments (PCL) with autogenous or homogenous grafts

Open knee surgery Arthroplasty of the total knee Baker’s cyst excision – located in the posterior popliteal

fossa Patellectomy – removal of entire patella

Common lower extremity procedures (continued)3. Tibia and fibual procedures – this area is

prone to open fractures Fractured tibia Ligament repairs connecting the femur Tibial osteotomy – performed to re-align the

tibia Fractured fibula Fractured ankle joint

Common lower extremity procedures (continued)4. Ankle and/or foot procedures

Arthrodesis Arthrodesis, ankle Arthrodesis, triple – fusion of the talocalcaneal,

talonavicular and calcaneocuboid joints Arthroplasty of the total ankle Arthroplasty of the tarsals Fractured metatarsals and phalanges Bunionectomy – excision of exostosis of the

metatarsal-phalangeal joint of the great toe Hammer toe deformity correction

Common tendon and ligament repairs

1. Tendon repairs (Tenorrhaphy) Achilles tendon – most powerful tendon in the foot Tibial tendon Extensor tendon of the forearm Flexor tendon of the forearm

2. Ligament repairs – reconstruction of ligaments may require non-absorbable sutures, wires, staples, and grafts. Grafts may be autographs, allografts, or synthetic

Gamekeeper’s thumb Release of trigger finger

Limb reattachment procedures

1. General background Involves reattachment of severed extremity; every

case is different Extremely delicate and lengthy procedure; often 12 to

24 hours Involves many specialists Exchange in personnel to avoid extensive fatigue May involve two teams Requires extensive, detailed positioning of patient and

affected areas2. Basic sequence of events

Bones – anatomically aligned and stabilized Vasculature and nerves Restructuring – plastic surgeon completes

restructuring process

Amputation procedures1. Disarticulation – amputation through a

joint2. Above-elbow (AE) amputation3. Below-elbow (BE) amputation4. Above-knee (AK) amputation5. Below-knee (BK) amputation6. Transmetatarsal amputation – dissection

through the metatarsals7. Single toe amputation

Any questions Bone Heads?