INTRODUCTION

1741 Nicolas Andry, french professor publish a book

Orthopaedia or the art of Preventing and Correcting Deformities in Children. Orthos straight or free from deformities Pais child He expressed the view that most deformities in adults have their origin in children.

ORTHOPEDIC SURGERY
Is the art and science of the prevention, investigation, diagnosis, treatment and restoration of disorders and injuries of the musculoskeletal system by medical, surgical and physical means. Musculoskeletal system includes Bones,Cartilage, tendons, ligaments, joints and muscles.

BONES
Main division axial & appendicular Main Bone Types long bones , short bones, flat

bones, irrgular bones Structure long bones - diaphysis, metaphysis, epiphysis, epihyseal plate, periosteum Blood supply nutrient artery, periosteal vessels, metaphyseal and epiphyseal vessels

BIOCHEMICAL COMPOSITION OF BONE

Organic substances 35% - bone cells osteoblast,

osteoclast, osteocytes, collagen Inorganic substance 45% - calcium, phosphorus, magnesium, sodium, hydroxyl, carbonate and flouride. Water 20%

Bone Types
Cortical or compact bones - diaphyseal area
Cancellous bones metaphyseal and epiphyseal.

Cartilage, Ligaments, Tendon

Types Fibrocartilage intervertebral discs and

symphysis pubis Elastic cartilage external ear and nose Hyaline cartilage most joints LIGAMENTS Fibrous tissue primary connection between bones Tendons connect muscle to bones

MUSCLE
Skeletal muscle contracts to controls persons posture,

help maintain body temperatue and initiate movement, Muscle Contractions Isotonic shorten muscle, movement Isometric tighten , no movement Others twitch, tetanus, fasciculation, fibrillation and convulsion

JOINTS

1. Fibrous sutures 2. Cartilagenous pubic bone 3. Synovial a. ball & socket, hinge, gliding pivot, saddle Joint Motion Review Flexion / extension Abduction / adduction Rotation external / internal Pronation / Supination Inversion / Eversion Protraction / Retraction Circumduction

MUSCULOSKELETAL DISORDERS
1. TRAUMA FRACTURES 2. CONGENITAL ANOMALIES 3. INFECTIONS OSTEOMYLITIS 4. TUMORS 5. ARTHRITIDIS A. RHEUMATOID ARTHRITIS B. OSTEOARTHRITIS OR DEGENERATIVE JOINT DISEASE C. METABOLIC GOUTHY ARTHRITIS

FRACTURES
Is a break in the continuity of the bone.
Classification: According to side affected 1. Complete Fracture pereosteum and cortical bone

severed on both side 2. Incomplete one side is broken

CAUSES OF FRACTURES
1. Direct force or crushing force
2. Twisting forces torsion 3. powerful muscle contraction 4. Fatigue and stress fractures 5. Pathologic

Classifications
1. Broad classification a. Closed or simple no communication with the outside b. Open or Compound with communication with the outside 2 as to pattern A. Transverse , oblique. Spiral 3. as to appearance comminuted, impacted, compression, depressed, longitudinal 4. as to location proximal, middle, distal

SIGN S & SYMPTOMS

1. PAIN 2. TENDERNESS 3. SWELLING 4. LOSS OF FUNCTION 5. DEFORMITY 6. DISCOLORATION 7. CREPITUS 8. BLEEDING FROM AN OPEN WOUND

Complication of Fracture

1. Immediate complications A. loss of bone fragments B. soft tissue injury blood vessel and muscle C. bleeding D. infection 2. Away from the fracture A. pulmunary embolism B. fat embolism C. gas ganrene D. tetanus 3. On the bone itself a. avascular necrosis b. delayed union c. malunion d. non-union

PRINCIPLES OF TREATMENT
1. REDUCTION OR REALIGNEMENT OF BONE

FRAGMENT 2. MAINTENANCE OF REDUCTION BY IMMOBILIZATION 3. RESTORATION OF FUNCTION

REDUCTION
IS ACCOMPLISH BY:
1. Closed manipulation 2. Traction 3, Internal fixation 4. External fixation

MANIPULATION
Is done by pulling on the distal part of fracture ends

with anesthesia. Types of Anesthesia 1. Vocal 2. Local 3. Regional 4. General

MANIPULATION
Commonly done on Acute Fractures
1. Closed, incomplete or complete, Fractures 2. Fractures in children 3. Fractures of phalanges 4. Fractures without displacement

MAINTENANCE OF REDUCTION (IMMOBILIZATION)

1. APPLICATION OF PLASTER CAST is a temporary

immobilization device which is made up of gypsum sulfate anhydrous by calcination when mixed with water. Materials in applying cast Plaster of Paris (POP) Wadding sheet, stockinet, elastic bandage Other substitute fiberglass, thermoplast

Complication of Casting
1. Neurovascular compromise
2. incorrect fracture alignment 3. blister formation 4. allergy 5. swelling or edema 6. blister formation

Plaster cast for upper extremity

1. short arm circular cast for wrist & fingers
2. long arm circular cast for affection of radius / ulna / distal humerus 3. munster cast for radius/ulna with callus 4. long arm posterior cast radius/ulna/ humerus 5. sugar tong cast - humerus

6. abduction splint airplane splint proximal humerus

Casting for Lower Extremity

1. Boot cast / short leg cast for ankles and toes 2. walking cast for ankle with callus 3. PTB-patellar tendon bearing cast for shaft of tibia/fibula with callus 4. long leg cast for frscture tibia/fibula 5. Ischial weight bearung cast fracture of fmur with callus 6. cylindrical cast for fracture patella 7. short leg posterior mold 8. long leg posterior mold

Other Casting
1. Spica cast shoulder spica single or double. Hip spica single, double, one & one half
2. Collar cast for cervical spine 3. Minerva cast upper cervical, scoliosis potts disease 4. Body cast for lower thoracic & lumbar spine 5. Pantalon cast pelvic injury 6. Frog cast for congenital hip dislocation

TRACTION
Is the act of pulling or drawing which is associated

with counter traction Means apulling force is pllied to a part of the body or an extremity while a countertraction pulls in the opposite direction. Types of Traction 1. Skin 2. skeletal

Traction purpose

1. to lessen muscle spasm 2. to redcuce fracture 3. to provide immobilization 4. to maintain alignment Principle A. have an opposite pull or countertraction B. be free from friction C. follow and established line of pull that is line of pull must in line with the deformity D. be continuous traction E. be applied to a patient in a supine position

SKIN TRACTION
1. Bryant traction fractures of femur, hip dislocation

for children below 3 years old 2. bucks traction for femur and hip 3. Russels femur 4. Dunlop supracondylar humerus 5. Pelvic traction lumbar spine 6. Hammocks suspension traction - pelvic

SKELETAL TRACTION
Insertion of a steinman pin, kirstcher wire, crutchfield

tong or similar devices into the bone, enabling direct, longitudinal pull be applied directly to the bone. Equipments : Thomas splint, pearsons attachment, pulley, cord, wire holder, balkan frame

Skeletal Traction

Halo-femoral, halo-pelvic for severe scoliosis Crutchfield tong cervical fracture COMPLICATIONS: 1. Vascular and nerve injury 2. pin tract infection 3. over traction 4. muscle atropy

INTERNAL FIXATION
Is accomplish by doing surgical operation on the fracture by directly reducing the fractured bone fragment and immobilize by applying metal implants. a. screwing, pinning and nailing b. Plating with screw fixation c. Replacement of prosthesis

III. Rehabilitation
Restoration of function by: a. Occupational Therapy b. Physical therapy Aim 1. for relief of pain 2. for increase circulation 3. for correction and prevention of disabilties 4. for maximun return of strength, mobility, coordination 5. teach patient whatever capacities he possesses to fully realize his potentialities for living

CONGENITAL DEFORMITIES
ETIOLOGY 1. Genetic Influences 2. Intrauterine environmental influences 3. combine genetic and environmental influences Genetic Chromosomes anomalies- 0.5% of live birth. Variations in chromosome number or structure. ex. Down syndrome Single Gene disorders mutation, sex linked inhiretance 10 %

Intrauterine Environmental Influences

Heavy irradiation, thalidomide, rubella, androgenic

hormones. Deficient diets, x-rays, hypothermia, hypoxia, virus infection Smoking, diabetics Treatment: 1. Improved prenatal care 2. should be started early

Congenital Anomalies
1. Congenital Hip Dislocation
2. Clubfoot 3. torticollis 4. Congenital abnormalities of finger and toes

Syndactyly, Macrodactly, Polydactyly. Cleft hand, cleft foot

CONGENITAL HIP DISLOCATION

Incidence 1-2/1000 births, 5x in boys Frequent in breech delivery Unilateral dislocation is frequent Etiology: Exact cause is unknown Both genetic and environment More in twins, first born Postnatal common in northern Italy, Navajo Indians, Japanese

CHD Pathology
Vary with age At birth capsule is lax. Elongated ligamentum teres.

Increase anteversion of the neck femur If untreated acetabulum is shallow and sloping, femoral head displaced upward and backward, increase anteversion of the neck, a shallow secondary acetabulum develop

CHD Clinical Features

Vary with age
Neonatal birth to 1 month can be determine by doing the following test: 1. Ortolanis Test - positive hip abducted, pressure on the greater throchanter will cause the dislocated hip to click back. 2. Barlows Test - positive hip adducted, pressure on the medial thigh will cause the unstable hip to click out.

CHD Clinical Features

3. Abduction test 4. Knee level test 5. Trendelenburg test negative test child bears weight on the normal hip,

the opposite side of the pelvis is elevated, to maintain balance positve test- child bears weight on the dislocated hip, the opposite side of the pelvis cannot be elevated

Other symptoms
Duck waddling gait
Scoliotic Lordotic

TREATMENT
Manipulation or traction
Maintain by applying frog leg casting

Talipes Equinovarus( Congenital Clubfoot)

Cause is unknown
1.Arrested or anomalous development of the foot of

the embryo in the first trimester 2. 3rd month of uterine life inward rotation of the foot takes place but on the 7th month should have been outward 3. abnormalities in the maturity and lenght of muscles and tendons

CLUBFOOT
Incidence- 1/1000 live birth 2x in boys 50% unilateral, 50% bilateral PATHOLOGY At the talocalcaneonavicular joint 1. navicular bone is displaced medially 2. subtalar surface are tilted into varus and equinus and medially 3. achilles tendon is shortened

TREATMENT
Start at early age as soon as possible At one day old Difficulty in treatment Serial casting application of cast every two to three weeks long leg circular cast. Up to two to three months Maintenance of correction is done by: A. dennis brown shoes B. dennis brown splint

METHODS OF CORRECTION
Correct deformity one by one
A. Inversion B. Varus C. Equinus If corrected at the same time will lead to

Rocker bottom foot.

TREATMENT
Late cases
1. Soft tissue release

a. tendon lengthening 3. Osteotomy a. triple arthrodesis