PROFESSOR PROFESSOR

Fishchenko Vladimir AlexandrovichFishchenko Vladimir Alexandrovich

BASHINSKIY GENNADIY BASHINSKIY GENNADIY PETROVICHPETROVICH

Traumatology: •acute injuries, •polytrauma.

Orthopedics :•post-traumatic conditions, •axial deformities, •congenital and inherited systemic bone diseases,•limb developmental defciencies,•infammatory diseases of bones and joints, •musculoskeletal tumors.

QUESTIONINGQUESTIONINGGENERAL GENERAL APPEARANCEAPPEARANCE

LOCAL LOCAL EXAMINATION OF EXAMINATION OF THE AFFECTED AREATHE AFFECTED AREA

Patient’s complaints (pain, Patient’s complaints (pain, limitation of function, deformity)limitation of function, deformity)

History (type of injury, cause, History (type of injury, cause, time, first aid)time, first aid)

Life history (occupation, habits, Life history (occupation, habits, family history, social history, family history, social history, genetic history, previous injury or genetic history, previous injury or orthopedic disease)orthopedic disease)

WeightWeightConstitutionConstitutionPositionPositionBody buildBody buildPosture (attitude)Posture (attitude)GaitGait

For the degree of For the degree of abnormality aabnormality aссessment,essment,

simultaneous simultaneous examination of the examination of the

opposite limb requiredopposite limb required

Skin state (ecchymosis, inflamation Skin state (ecchymosis, inflamation signs, tumors bruising, swelling, signs, tumors bruising, swelling, hematoma, lacerations, or puncture hematoma, lacerations, or puncture wounds. Note scars that indicate previous wounds. Note scars that indicate previous trauma or surgeries to the limb)trauma or surgeries to the limb)

Deformities (valgus, varus, Deformities (valgus, varus, antecurvation, recurvation)antecurvation, recurvation)

Extremity lengthExtremity length Limb circumference measurementLimb circumference measurement Muscle strength measurementMuscle strength measurement The motion range measurementThe motion range measurement

Axis of Axis of extremityextremityAxis of upper extremity Axis of upper extremity

– conditionally passes – conditionally passes through the middle of through the middle of shoulder, radial and shoulder, radial and

ulnaulnar headsr heads..

Axis of lower Axis of lower extremityextremityAxis of lower extremity – Axis of lower extremity –

from the front upper from the front upper iliac horn through the iliac horn through the

middle of patella to the middle of patella to the gap between 1st and gap between 1st and 2nd fingers on feet.2nd fingers on feet.

DEFORMATION OF DEFORMATION OF EXTREMITYEXTREMITY

–Impairments of the axis Impairments of the axis are: outside – valgusare: outside – valgus

–Impairments of the Impairments of the axis are:axis are: inside – inside –

vavarrusus

Impairments of the axis Impairments of the axis are: when the angle is are: when the angle is open forward – open forward – recurvatumrecurvatum

Impairments of the Impairments of the axis are: when the axis are: when the angle is open angle is open backwards – backwards – antecurvatum.antecurvatum.

Measuring of length Measuring of length of limbsof limbs

Common lent of upper Common lent of upper extremity measure from extremity measure from akromial process of akromial process of scapula to styloid process scapula to styloid process of ulnaof ulna

TheThe common length of common length of lower extremity is lower extremity is

measured from the front measured from the front upper iliac horn to the upper iliac horn to the top of the inner ankletop of the inner ankle

The shoulder length The shoulder length is measured from is measured from the akromion to the akromion to

olecranon;olecranon;

The length of forearm is The length of forearm is measured from measured from

olecranon to styloid olecranon to styloid process of ulna process of ulna

The length of the hip is The length of the hip is measured from greater measured from greater trohanter to the head of trohanter to the head of

fibulafibula

the length of the crus is the length of the crus is measured from the head measured from the head

of fibula to the top of of fibula to the top of the lateral anklethe lateral ankle

There are following types There are following types of shorteningof shortening

11) Anatomic shortening. ) Anatomic shortening. 2) Relative shortening2) Relative shortening 3)projecting shortening3)projecting shortening 4) Functional shortening 4) Functional shortening

The patient or limb position (attitude)The patient or limb position (attitude) – – active, passive, involuntary (forced).active, passive, involuntary (forced).

- Active position indicates on absence of severe - Active position indicates on absence of severe functional disorders in case of trauma, functional disorders in case of trauma, compensatory adjustments (adaptation) in compensatory adjustments (adaptation) in orthopedic patients.orthopedic patients.

- Passive position indicates on the severity of - Passive position indicates on the severity of trauma, shock. It may be caused by fractured trauma, shock. It may be caused by fractured bones or paralysis.bones or paralysis.

- Forced extremity or trunk attitude may be result - Forced extremity or trunk attitude may be result of dislocation, inflammation, etc. After reposition of dislocation, inflammation, etc. After reposition of dislocation, reduction of the inflammatory of dislocation, reduction of the inflammatory process the forced position disappears.process the forced position disappears.

ContractureContracture is a restriction of passive movements is a restriction of passive movements in the joint.in the joint.

1. Antalgic (1. Antalgic (ффprotective, analgetic)protective, analgetic) 2. Miogenic (due to one or group of muscles 2. Miogenic (due to one or group of muscles

shortening)shortening) 3. Arthrogenic (due to posttraumatic, inflammatory 3. Arthrogenic (due to posttraumatic, inflammatory

or degenerative-dystrophic changes in the joints).or degenerative-dystrophic changes in the joints). 4. Desmogenic (scarring of fasciae, ligaments after 4. Desmogenic (scarring of fasciae, ligaments after

trauma and operations)trauma and operations) 5. Dermatogenic (after extensive burns)5. Dermatogenic (after extensive burns) 6. Neurogenic (in cases of flaccid, spastic 6. Neurogenic (in cases of flaccid, spastic

paralyses)paralyses) 7. Tenogenic (reducing of a tendon or its fusion 7. Tenogenic (reducing of a tendon or its fusion

with its vagina)with its vagina) Contracture according to the limit of movements Contracture according to the limit of movements

are divided into: flexional, extensional, abductory, are divided into: flexional, extensional, abductory, adductory, rotatory.adductory, rotatory.

Joint stiffnessJoint stiffness is a state insignificant is a state insignificant (that does not exceed 3-5°) oscillatory (that does not exceed 3-5°) oscillatory motions are saved in a joint.motions are saved in a joint.

AnkylosisAnkylosis is a complete absence of is a complete absence of movements. Ankyloses may be fibrous movements. Ankyloses may be fibrous and bony (true), intra-articular and extra-and bony (true), intra-articular and extra-articular, concordant (in functionally articular, concordant (in functionally advantageous position) and and advantageous position) and and discordant (in functionally discordant (in functionally disadvantageous position).disadvantageous position).

Absolute signs of fracture:Absolute signs of fracture: - Visible deformation (axis - Visible deformation (axis

violation)violation) - Crepitation- Crepitation - Pathological mobility- Pathological mobility - True shortening- True shortening - Pain during axis loading- Pain during axis loading

Absolute signs of dislocation Absolute signs of dislocation (luxatio):(luxatio):

- Forced limb position- Forced limb position - Violation of the joint lines- Violation of the joint lines - Palpation of the head outside the joint - Palpation of the head outside the joint

cavitycavity - Relative (dislocational) shortening or - Relative (dislocational) shortening or

lengtheninglengthening - Active movement is impossible, but - Active movement is impossible, but

passive - elasticpassive - elastic

Rozer-Nelaton’sRozer-Nelaton’s

Rozer-Nelaton’sRozer-Nelaton’s line connects line connects tuber of iscium and the front tuber of iscium and the front upper iliac horn. It is used to upper iliac horn. It is used to determine pathological states in determine pathological states in the hip joint. Normally, hip is the hip joint. Normally, hip is bent at an angle of 130°, the bent at an angle of 130°, the greater trochanter is palpated greater trochanter is palpated on this lineon this line..

Shemaker’s lineShemaker’s line

Shemaker’s lineShemaker’s line connects connects the tip of the greater the tip of the greater

trochanter and the front trochanter and the front upper iliac horn. Conditional upper iliac horn. Conditional continue of the line usually continue of the line usually

passes above the navel.passes above the navel.

Brian’s triangleBrian’s triangle

Brian’s triangleBrian’s triangle is formed by is formed by a line drawn along the axis of a line drawn along the axis of the aligned hip up to the the aligned hip up to the crossing with the perpendicular, crossing with the perpendicular, which starts from the front which starts from the front upper iliac horn. It connects it upper iliac horn. It connects it with a greater trochanter.with a greater trochanter.

Marx’s lineMarx’s line

Marx’s lineMarx’s line connects connects both epicondyles of the both epicondyles of the shoulder bone and shoulder bone and normally is perpendicular normally is perpendicular to the longitudinal axis of to the longitudinal axis of the bone.the bone.

Huter’s triangleHuter’s triangle

Huter’s triangleHuter’s triangle is is formed during forearm formed during forearm flexion at 90° by three flexion at 90° by three bone shelves: both of bone shelves: both of

epicondyles and the tip epicondyles and the tip of olecranon.of olecranon.

Huter’s lineHuter’s line

Huter’s lineHuter’s line in the in the unbent position unbent position connects two connects two

epicondyles and the epicondyles and the tip of olecranon.tip of olecranon.

LookLook SwellingSwelling BruisingBruising DeformityDeformity Overlying skinOverlying skin Adjacent jointAdjacent joint Limb shorteningLimb shortening

Local examination

FeelFeel TemperatureTemperature TendernessTenderness SwellingSwelling Peripheral sensationPeripheral sensation Peripheral pulsesPeripheral pulses

Local examination

MoveMove

No attempt should be made to No attempt should be made to elicit abnormal mobility or elicit abnormal mobility or

crepitus in a fractured bone.crepitus in a fractured bone. Joint movements should only be Joint movements should only be tested if patients can perform tested if patients can perform them actively without much them actively without much

discomfort.discomfort.

Local examination

POSTUREPOSTURE

Pt’s neck appears short and broad. Pt’s hairline is low and an associated Sprengel deformity is present, the left scapula being hypoplastic and high riding. As a result, the patient is unable to

fully raise his left arm.

CTCT

Stages of fracture healing Stages of fracture healing (Frost 1989)(Frost 1989)

1. Stage of haematoma1. Stage of haematoma Approximate timeApproximate time: : Less than 7 daysLess than 7 days

Essential features: Fracture- end necrosis Essential features: Fracture- end necrosis occurs. Sensitisation of precursor cells.occurs. Sensitisation of precursor cells.

2. Stage of granulation 2. Stage of granulation tissuetissue

Approximate time: Up to 2 – 3 weeks;Approximate time: Up to 2 – 3 weeks;

Essential features: Prolifiration and Essential features: Prolifiration and differentiation of daughter cells into differentiation of daughter cells into vessels, fibroblasts, osteoblasts etc.vessels, fibroblasts, osteoblasts etc.

3.3. Stage of callusStage of callusApproximate time: 4 – 12 weeks;Approximate time: 4 – 12 weeks;

Essential festures: Mineralisation of Essential festures: Mineralisation of granulation tissue. Callus radiologically granulation tissue. Callus radiologically visible. Fracture clinically united, no visible. Fracture clinically united, no more mobile.more mobile.

4. Stage of remodelling4. Stage of remodellingApproximate time: 1 – 2 years;Approximate time: 1 – 2 years;

Essential features: Lamellar boneformation Essential features: Lamellar boneformation by multicellular unit based remodelling by multicellular unit based remodelling of callus. Outline of callus becomes of callus. Outline of callus becomes dense and sharply defined.dense and sharply defined.

5. Stage of modelling5. Stage of modelling

Approximate time: Many years;Approximate time: Many years;

Essential features: Modelling of Essential features: Modelling of endosteal and periosteal surface so endosteal and periosteal surface so that the fracture-site becomes that the fracture-site becomes indistinguishable from the parent indistinguishable from the parent bone.bone.

Consilidation of bone tissue Consilidation of bone tissue may be due to next bone may be due to next bone callus:callus:

EndostealEndosteal PeriostealPeriosteal ParaosseousParaosseous IntermediaryIntermediary

Consolidation of bone tissue devides Consolidation of bone tissue devides to primary consolidation and to primary consolidation and secondary consolidationsecondary consolidation

Primary consolidation as rool due to Primary consolidation as rool due to intermedial callus. It’s much more intermedial callus. It’s much more complete;complete;

And secondary as rool due to periostal And secondary as rool due to periostal callus.callus.