ORTHOPEDIC SURGERY The branch of medical science concerned

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 Valgus bent outward Varus bent inward

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 Repair, revision, reconstruction, reattachment or removal any of the 206 bones of the skeletal structure and surrounding tissue 1. § § Bones, joints and affected muscle tissue Tendons, ligaments or cartilage Accurately classify treatment 2. § § § 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 ü External ü Internal Preservation Restoration § Types of treatment Fracture management ü Reduction ü Immobilization ü Rehabilitation Corrective surgeries ü Bone grafts ü Implants ü 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/ Cortical hard on outside/canal on inside composed 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 boneforming 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 anatomy Skeletal system – articulated skeleton comprised of 206 bones 1. § Axial skeleton – skull, spine and ribs Skull – includes cranial and maxillofacial bones ü ü Hyoid bone Vertebral column – 26 backbones ü ü ü Cranial bones – 8 cranial bones Facial bones – 13 facial bones Middle ear bones – 6 middle ear bones Mandible – one jaw bone Verebral – 24 backbones: 7 cervical, 12 thoracic, and 5 lumbar Sacrum – one sacrum bone Coccyx – one tailbone Thoracic cage – 25 thoracic bones ü ü 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 bones ü Scapula – two posterior collar bones Ø Glenoid fossa Ø Coracoid process Ø Acromion process ü Clavicle – two anterior collar bones Upper limbs –arm, wrist and hand bones ü Humerus ü Radius ü ulna

Anatomy (continued) § Lower extremities –hip and leg bones of the appendicular skeletal system Pelvic girdle ü Ilium ü Pubis ü Ischium Lower limbs – leg and foot bones ü Femur ü Patella ü Tibia ü Fibula ü Tarsals ü Metatarsals ü phalanges

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) Muscular anatomy 2. § § 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: � Skeletal voluntary/conscious movement striated in appearance found along-side skeletal system � Cardiac involuntary/unconscious movement found only in myocardium of heart � Smooth involuntary/unconscious movement found in the viscera

4 muscles of the Rotator Cuff

Knee anatomy ANTERIOR POSTERIOR

Knee Anatomy

Foot Extensor digitorum longus (EDL) - The EDL extends or lift the toes

Hand

Bone composition types Membranous bone – highly specialized connective osseous tissue that originally is membrane, then ossifies to bone 1. § § Cranial Facial – maxilla (upper jaw), mandible (lower), nasal and lacrimal bones Cartilaginous bone 2. § § Long bones Flat bones ü ü ü Irregular bones Short bones Sesamoid bones

Bone Types

Types of Joints

Joint Classification 1. 2. Functionally based on degree of movement *synarthroses-no movement *amphiarthroses-slight movement *diarthroses-freely moveable Structurally based 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

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 Joints – points of articulation where movement between bones can occur 1. § Axial skeleton Skull ü Cranial and facial sutures ü Temporomandibular Vertebral column ü Atlanto-occipital ü Intervertebral Ribs and sternum ü Sternoclavicular ü sternocostal

Joints and surrounding tissue (continued) § Upper extremities Pectoral girdle üAcromioclavicular üShoulder (glenohumeral or humeroscapular) Elbow Hand üWrist (radiocarpal) üDigit § Lower extremities Pelvic girdle üSacroiliac üPubic symphysis üHip Knee (tibiofemoral and femoropatellar)

Joints and surrounding tissue (continued) Tibiofibular (proximal and distal) Ankle Foot ü Intertarsal ü Metatarsophalangeal ü Toe (interphalangeal) Joint structure 2. § § 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) Joint articulation types 3. § § § Synovial – allow free movement/have a joint cavity Cartilaginous – allow little movement/no joint cavity Fibrous – allow no movement/No joint cavity Surrounding soft tissue 4. § § Circulatory – blood vessels Peripheral nerves Foramen muscles

Pathology Pathologic 1. § 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 ü Osteoarthritis (OA) ü Rheumatoid arthritis (RA) Bursitis – inflammation of the synovial fluid herniation

Pathology (continued) • Infection ü Osteomyelitis – inflammation of bone tissue • Calcium disorders ü Rickets – vitamin D and calcium deficiency ü Osteomalacia – soft bones ü Osteoporosis – fragile and porous bones • Tumors ü Osteochondroma – generally benign ü Osteoma – benign tumor of the bone ü Fibroma – composed of fibrous tissue ü Osteosarcoma – malignant tumor of the bone ü Myeloma – cancer in the bone marrow ü Chondrosarcoma – tumors of the hyaline cartilage, often malignant • § Volkmann’s contracture Strain – stretching of joint tendons

Pathology (continued) Traumatic 2. § § Damaged or dislocated joints Fracture § Closed (simple) – bon does not protrude the skin Open (compound) Complete or incomplete Multiple fragmentation

Bone fracture pathology Fractured bones 1. § § § § 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 fragment Fracture geometry 2. § Longitudinal (linear) – fracture line runs along the length of the bone

Bone fracture pathology (continued) § § § Oblique – fracture line lies at an angle Spiral Transverse Stages of bone healing after fracture 3. § § Hematoma or hemorrhage (stage 1) Granulation (stage 2) Bony callus formation (stage 3) Consolidation, calcification and bone remodeling (stage 4) Osteogenesis – bone growth stimulated by use of electrical impulses Complications in bone healing 4. 5. § § § Delayed union of bone Mal-union of bone Non-union of bone

Fracture management methods Closed reduction (CR) procedures 1. § § 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 Open reduction (OR) procedures 2. § § Open reduction with external fixation (OREF) Open reduction with internal fixation (ORIF)

External Fixation

External Fixation

External Manipulation Traction Techniques Closed Reduction Via External Fixation

Fracture management stabilization devices External fixation 1. § Casts Plaster (fast, medium, slow-setting) Fiberglass Types ü ü ü ü 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 � Fiberglass webril first wet casting with warm water before application can wet with warm or cold water primarily used on children or where a lot of swelling is anticipated because can split if necessary (poor circulation due to swelling) 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 ü Autogenous graft – bone from own body ü Cotrical graft – “matchsticks” or small narrow slices of cortical bone ü Cancellous graft – spongy bone ü Homogenous graft – donor bone from another human

Fracture management (continued) § Orthopedic implants Metal, ceramic, silicone or high-density molecular plastic prosthetics ü Humeral endoprosthesis for shoulder ü Ulnar prosthesis for elbow ü Silastic implant for finger joints ü Femoral endoprosthesis for hip ü Knee arthroplasty implants – total knee ü Press-fit implants – secured to area without cement Fixation options – cemented or non-cemented

Common diagnostics performed prior to surgery Lab studies – blood cultures, urine samples, spinal fluid or synovial fluid tests 1. § § § 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) Diagnostics 2. § 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 Positioners CHIC TABLE BLUE ALLEN

OR Beds and Positioners JACKSON FLAT TOP JACKSON FX TABLE

OR Beds and Positioners ANDREWS TABLE CLOWARD

OR Beds and Positioners BEACH CHAIR MCCONNEL HEAD REST

OR Beds and Positioners JACKSON SLING VAC PAC OR BEAN BAG

OR Beds and Positioners WILSON FRAME HANA TABLE FOR ANTERIOR APPROACH TOTAL HIPS

OR Beds and Positioners MAYFIELD HEAD REST PEG BOARD POSITIONER

Special considerations General considerations 1. § 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) Surgery-specific considerations 2. § 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 supplies 1. 2. 3. 4. 5. Beanbags, sandbags and pillows Sutures § Surgical steel § Ethibond, Prolene and Nurolon – used in attaching tendons, ligaments, bones § Vicryl – used for work with periosteum and closure Drapes Fixative (bone cement) – Methyl methacrylate or polymethyl methacrylate (PNMA) Agents § Anti-inflammatory agents – Cortisone steriods § Hemostatic agents Avitene – applied dry directly to bone surface Bone wax Gelfoam thrombin

Basic orthopedic equipment 1. 2. 3. 4. 5. 6. 7. 8. 9. Arthroscopic support equipment Bone stimulator Braces, casts and other immobilizers Coblation – a new cauterization method that is non-heat driven Fluoroscope (C-arm) § Mandatory lead apron Irrigation Specialty positioning devices § Fracture table § Andrews frame – maintains patient in modified knee-chest position § Wilson frame – prone position Tourniquet Traction devices

Basic orthopedic instrumentation Basic sets 1. § 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 Minimally invasive surgery 2. § § Arthroscope Support instrumentation

Basic instruments (continued) Bone cutting 3. § § Curettes, bone Cutters, bone § Chisels § § § Single or double-action 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) Bone manipulation tools 4. § Bone clamps § § Bone hooks Retractors § § § Bennett Hohmann Saws § Lowman Lane Gigli saw Amputation saw Tendon pulling forceps Tendon strippers Powered instruments – includes power drills, reamers, and oscillating and reciprocating saws

Basic instruments (continued) Bone piercing tools – generally used to insert fixation devices 5. § § Cutters Kirschner wires, Rush rods, Steinman pins, screws, plates Pins (pin cutter must be available) ü Steinman pins are smooth or threaded ü Sizes 1/32”, 1/16”, 3/32”, 1/8”, 5/32”, 3/16” and ¼”

Basic instruments (continued) Screws üCortical screws üCancellous screws – common diametes are 32 mm and 64 mm üMalleolar screws Rods or intermedullary nails üKirschner rod or intermedullary nail üRush rod üVertebral column rod (Harrington) Wires üKirschner wires (K-wires) – available smooth or threaded üSizes – 0. 032, 0. 045, 0. 062 § § § Rush awl reamer Screwdrivers Traction bow

Basic instruments (continued) Bone measuring devices 6. § Screw gauges Bone screw gauge Depth gauge – used to determined length of screw needed Calipers rulers

Relevant positions, skin prep and draping General information 1. § § § 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) Upper extremities 2. § Shoulder and upper arm surgeries Position ü ü § 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 arm to tourniquet Draping – apply impervious “down sheet” over armboard. Follow with stockinette and extremity sheet.

Relevant positions, skin prep and draping (continued) Lower extremities 3. § Hip surgeries Positions – varies according to procedure ü Supine with a rolled towel-covered sand bag placed under the thigh ü Full lateral with bean bag ü 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 Udrape. 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 Craniofacial – maxillofacial or Le Fort fractures (usually performed by plastic surgeon) Vertebral column 1. 2. § § § Laminectomy Disectomy Spinal fusion Trauma scoliosis

Common joint reconstruction procedures 1. 2. 3. 4. 5. Arthrodesis – surgical fixation or fusion of a joint. Arthrotomy – incision into a joint Arthroscopy – direct visualization into a joint Arthroplasty – surgical repair of a joint Repair of joint dislocations

Common upper extremity procedures Clavicle surgery 1. § § 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 Shoulder joint 2. § 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) 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 arm to the tourniquet will be prepped and draped 3. § § § 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) Radius and ulna 4. § § § 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 cyst Wrist 5. § § Fractures of the carpals Arthroplasty of the wrist

Common upper extremity procedures (continued) Hand – involves metacarpals and phalanges 6. § § § 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 Hip and femur procedures 1. § § 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) Knee procedures 2. § 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) Tibia and fibual procedures – this area is prone to open fractures 3. § § § 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) Ankle and/or foot procedures 4. § 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 Tendon repairs (Tenorrhaphy) 1. § § Achilles tendon – most powerful tendon in the foot Tibial tendon Extensor tendon of the forearm Flexor tendon of the forearm Ligament repairs – reconstruction of ligaments may require non-absorbable sutures, wires, staples, and grafts. Grafts may be autographs, allografts, or synthetic 2. § § Gamekeeper’s thumb Release of trigger finger

Limb reattachment procedures General background 1. § § § 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 areas Basic sequence of events 2. § § § Bones – anatomically aligned and stabilized Vasculature and nerves Restructuring – plastic surgeon completes restructuring process

Amputation procedures 1. 2. 3. 4. 5. 6. 7. Disarticulation – amputation through a joint Above-elbow (AE) amputation Below-elbow (BE) amputation Above-knee (AK) amputation Below-knee (BK) amputation Transmetatarsal amputation – dissection through the metatarsals Single toe amputation

Any questions Bone Heads?