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Orthopaedics
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WHAT IS OCCUPATIONAL
THERAPY?
Occupational therapy is a profession concernedwith promoting health and well being through
occupation. The primary goal of occupational therapy is to
enable people to participate in the activities ofeveryday life.
Occupational therapists achieve this outcome byenabling people to do things that will enhancetheir ability to participate or by modifying theenvironment to better support participation.
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What is physical therapy? It is defined as a system for assessing
problems of function of musculoskeletal
and neurophysiological origin includingthose of pain and of psychosomatic natureof dealing with and of preventing them orby natural methods based on manual
therapy, movements and physical agencies.
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Introduction Orthopaedics surgery is made up of
physicians and other healthcare
professionals who provide comprehensiveorthopaedics services.
Their expertise provides treatment andcare of diseases, injuries, fractures, and
pain. Orthopaedists also design rehabilitationprograms for the physically disabled andparticipate in ongoing musculoskeletalresearch.
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Definition of Orthopaedics
It is the branch of medicine concerned
with diseases, injuries, and conditions of
the musculoskeletal system - relating tothe body's muscles and skeleton, and
including the joints, ligaments, tendons,
and nerves.
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Common Orthopaedic
Disorders Arthritis
OA
Rheumatoid Arthritis Osteoporosis
Anklosing spondylitis
Puget's disease of the bone
Bursitis
Elbow Pain and Problems
Cubital Tunnel Syndrome
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Tennis Elbow (Lateral Epicondylitis)
Golfers or Baseball Elbow (Medical
Epicondylitis)
Fibromyalgia
Foot Pain and Problems
Fractures Low back pain
Common Orthopaedic
Disorders
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Hand pain and problems
Carpal Tunnel Syndrome
Knee Pain and problems Ligament Injuries to the knee
Torn Meniscus
Neck Pain and problems
Scoliosis
Shoulder pain and problem
Soft tissue injuries
Common Orthopaedic
Disorders
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What is arthritis?
Arthritis is inflammation of a joint - the pointwhere two or more bones meet.
In arthritis, inflammation occurs in the
damaged area of a joint.
Damage may be caused by any number of
conditions, including trauma, infection,
neurogenic disturbances, degenerative joint
disease, metabolic disturbances, or for
unknown reasons.
Arthritis is usually chronic, which means
that it rarely changes, or it progresses
slowly.
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Causes of Arthritis Specific causes for most forms of
arthritis are not yet known.
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Clinical feature of arthritis Pain
Swelling
Limited movement in joints and
connective tissues in the body.
Redness
warmth.
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What are the parts of a joint?
Joints are the areas where two bonesmeet.
Most joints are mobile, allowing thebones to move.
Joints consist of the following:
Cartilage
Synovial membrane
Ligaments Tendons, Bursas and Meniscus.
Synovial fluid
Femur - tibia - patella.
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Cartilage Cartilage, is a smooth protective layer
which allows the bones to glide
smoothly upon each other, lines thebones inside the joint. In arthritis, this
smooth lining becomes damaged.
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Synovial membrane It is a tissue called the synovial
membrane lines the joint and seals
it into a joint capsule.
The synovial membrane secretessynovial fluid (a clear, sticky fluid)
around the joint to lubricate it.
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Ligaments, tendons and bursas Ligaments - strong ligaments (tough,
elastic bands of connective tissue)
surround the joint to give support andlimit the joint's movement.
Tendons - tendons (another type oftough connective tissue) on each sideof a joint attach to muscles thatcontrol movement of the joint.
Bursas - fluid-filled sacs, called bursas,between bones, ligaments, or otheradjacent structures help cushion thefriction in a joint.
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Synovial fluid - a clear, sticky fluid
secreted by the synovialmembrane.
Femur - the thighbone.
Tibia - the shin bone.
Patella - the kneecap.
Meniscus - a curved part ofcartilage in the knees and other
joints.
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What are the most common types of arthritis?
The three most prevalent forms ofarthritis include the following:
OA
fibromyalgia
rheumatoid arthritis - an
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Other forms of arthritis
o gout - a result of a defect in body chemistry(such as uric acid in the joint fluid), this painfulcondition most often attacks small joints,especially the big toe. It can usually be
controlled with medication and changes in diet.o systemic lupus erythematosus (lupus) - a
very serious, chronic, autoimmune disordercharacterized by periodic episodes of
inflammation of and damage to the joints,tendons, other connective tissues, and organs,including the heart, lungs, blood vessels, brain,kidneys, and skin.
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H
ow is arthritis diagnosed? In addition to a complete medical history
and physical examination, diagnosticprocedures for arthritis may include the
following: X-rays or other imaging procedures (to show
the extent of damage to the joint)
Blood tests and other laboratory tests,including the following:
1. Antinuclear antibody (ANA) test - to checklevels of antibodies in the blood.
2. Arthrocentesis or joint aspiration (to removea sample of the synovial fluid to determine if
crystals, bacteria, or viruses are present)
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1. Complete blood count (to determine ifwhite blood cell, red blood cell, and platelet
levels are normal)2. Creatinine (to monitor for underlying
kidney disease)
3. Erythrocyte sedimentation rate (to detect
inflammation).4. Hematocrit (to measure the number of red
blood cells)
5. Rheumatoid factor test (to determine if
rheumatoid factor is present in the blood)6. Urinalysis (to determine levels of protein,
red blood cells, white blood cells, andcasts)
7. White blood cell count (to determine levelof white blood cells in the blood).
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What is OA?
It is the most common form of arthritis inelderly people.
It represent a major cause of morbidity, chronic
pain and increases health care usage.
It is a chronic, degenerative, joint disease thataffects mostly middle-aged and older adults.
It is characterized by the breakdown of joint
cartilage and adjacent bone in the neck, lower
back, knees, hips, and/or fingers.
The disease is also known as degenerative
arthritis or degenerative joint disease.
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Causes of OA
It can be classified as primary orsecondary.
Primary OA has an unknown cause secondary OA is caused by another
disease, infection, injury, or deformity.
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Several risk factors are associated with OA,including the following:
Age.
Heredity- slight joint defects or laxity of the
joint and genetic defects may contribute to thedevelopment of OA.
Obesity- excessive weight can put unduestress on such joints as the knees over time.
Injury/overuse- significant injury to a joint,such as the knee, can later result in OA.
Injury may also result from repeated overuseor misuse over a period of time.
Causes of OA
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Diagnoses of OA
In addition to a complete medical historyand physical examination, diagnostic
procedures for OA may include thefollowing:
X-ray - a diagnostic test which usesinvisible electromagnetic energy beams toproduce images of internal tissues, bones,and organs onto film.
Joint aspiration - involves a removal offluid from the swollen bursa to excludeinfection or gout as possible causes.
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The goals of treatment
The goals of treatment for OA are to
reduce joint pain and stiffness, and
improve joint movement.
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Treatment for OATreatment may include: Specific treatment for OA will be determined by
your physician based on:
The age, overall health, and medical history. Exercise- aerobic exercise, and stretching and
strengthening exercises may help reduce the
symptoms of and pain associated with OA.
Heat treatment help to reduce pain.
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Physical and occupational therapy may help to
reduce joint pain, improve joint flexibility when
performing daily activities, and reduce jointstrain.
Weight maintenance may help to prevent or
reduce the symptoms of OA.
Medication for specific symptoms may include
pain relievers (in pill form or topical cream) and
anti-inflammatory medications, if inflammation is
present. Injections of thick liquids into the joints to
maintain normal joint fluid.
Joint surgery may be necessary to repair or
replace a severely damaged joint.
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Rheumatoid Arthritis
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What is rheumatoid
arthritis? It is a chronic, autoimmune disease, is the most
crippling form of arthritis and affects approximately 2.1million Americans.
It is characterized by painful and stiff joints on bothsides of the body that may become enlarged anddeformed.
It is affects more women than men (75 percent ofpersons with rheumatoid arthritis are women).
The disease most often occurs between the ages of 20and 45.
Patients with rheumatoid arthritis often also haveosteoporosis, a progressive deterioration of bone
density.
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Juvenile rheumatoid arthritis
Juvenile rheumatoid arthritis (JRA) is a
form of arthritis in children ages 16 or
younger that causes inflammation andstiffness of joints for more than six weeks.
Unlike adult rheumatoid arthritis, which is
chronic and lasts a lifetime, children often
outgrow juvenile rheumatoid arthritis.
However, the disease can affect bone
development in the growing child.
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Causes of rheumatoid
arthritis? The exact cause of rheumatoid arthritis is not known.
It is an autoimmune disorder, which means the body'simmune system attacks its own healthy cells and
tissues.
The response of the body causes inflammation in andaround the joints, which then may lead to adestruction of the skeletal system.
It is also may have devastating effects to otherorgans, such as the heart and lungs.
Researchers believe certain factors, includingheredity, may contribute to the onset of the disease.
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Symptoms of rheumatoid arthritis
The joints most commonly affected byrheumatoid arthritis are in the hands,
wrists, feet, ankles, knees, shoulders, andelbows.
The disease typically causes inflammationsymmetrically in the body, meaning thesame joints are affected on both sides ofthe body.
Symptoms of rheumatoid arthritis maybegin suddenly or gradually.
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Common symptoms of
rheumatoid arthritis. inflamed, painful joints
stiff joints
enlarged and/or deformed joints (such asfingers bent toward the little finger and/orswollen wrists)
frozen joints (joints that freeze in one
position) cysts behind the knees that may rupture,
causing lower leg swelling and pain
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Hard nodules (bumps) under the skin near
affected joints.
low-grade fever. Inflamed blood vessels (vasculitis) may occur
occasionally, leading to nerve damage and leg
sores.
Inflamed membranes around the lungs (pleurisy),
the sac around the heart (pericarditis), or
inflammation and scarring of the lungs
themselves, that may lead to chest pain, difficulty
breathing, and abnormal heart function.
Common symptoms of
rheumatoid arthritis.
C t f
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Swollen lymph nodes.
Sjgren's syndrome (dry eyes and mouth).
Eye inflammation.
Morning stiffness that lasts longer than one hour for at
least six weeks.
Three or more joints that are inflamed for at least sixweeks.
Presence of arthritis in the hand, wrist, or finger joints
for at least six weeks. The symptoms of rheumatoid arthritis may resemble
other medical conditions or problems, including acuterheumatic fever, Lymph disease, psoriatic arthritis, gout,osteoarthritis and ankylosing spondylitis.
Common symptoms of
rheumatoid arthritis.
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Diagnosis of rheumatoid arthritis
Diagnosis of rheumatoid arthritis may be difficult in
the early stages, because symptoms may be very
subtle and go undetected on x-rays or blood tests.
In addition to a complete medical history and physical
examination, diagnostic procedures for rheumatoid
arthritis may include the following: x-ray - a diagnostic test which uses invisible
electromagnetic energy beams to produce images of
internal tissues, bones, and organs onto film.
joint aspiration - involves a removal of fluid from theswollen bursa to exclude infection or gout as possible
causes.
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Biopsy (of nodules tissue) - a procedure in
which tissue samples are removed (with a
needle or during surgery) from the bodyfor examination under a microscope; to
determine if cancer or other abnormal
cells are present.
Blood tests (to detect certain antibodies,called rheumatoid factor, and other
indicators for rheumatoid arthritis)
Diagnosis of rheumatoid arthritis
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Introduction
Theanterior cruciate ligament) ACL) is probablythe most commonly injured ligament of the knee.
In most cases, the ligament is injured by peopleparticipating in athletic activity.
As sports have become an increasingly importantpart of day-to-day life over the past few decades,the number ofACL injuries has steadily increased.
This injury has received a great deal of attentionfrom orthopedic surgeons over the past 15 years,
and very successful operations to reconstruct thetorn ACL have been invented.
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ACL
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Introduction
Theposterior cruciate ligament) PCL) is
one of the less commonly injured ligaments
of the knee. Understanding this injury anddeveloping new treatments for it have
lagged behind the other cruciate ligament in
the knee, theanterior cruciateligament) ACL), probably because there are
far fewerPCL injuries than ACL injuries.
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Anterior and PosteriorCruciate
Ligament
Thenormal posterior cruciate
ligament (PCL (is easily
viewed as a dark wavy line
running from the femur to the
tibia .
Torn anterior cruciate ligament
(ACL)
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PCL tear (right slide(
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The case:
A 57-year-old woman presented with left
knee pain after falling off of a stool.
A R di l i C S d
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Answer to Radiologic Case Study
Knee Dislocation
Figure 1 :Consecutive sagittal proton density MRI of the left knee
shows a torn PCL (A,B) andACL (C).Anterior translation of the tibia
(D)Figure 2 :Consecutive coronal T2 MRI of the left knee shows an
intact lateral collateral ligament (A).
Tears of the MCL and lateral meniscus can be seen, as well as lateral
translation of the tibia (B-D )
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Foot Pain and Problems
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Anatomy of the foot
The foot is one of the most complex partsof the body, consisting of 38 bones
connected by numerous joints, muscles,tendons, and ligaments.
The foot is susceptible to many stresses.
Foot pain and problems can cause pain,inflammation, or injury, resulting inlimited movement and mobility.
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What are the different types of foot
problems? Foot pain is often caused by improper foot function.
Improperly fitted shoes can worsen and, in some cases,
cause foot problems.
Shoes that fit properly and give good arch support can
prevent irritation to the foot joints and skin.
There are many types of foot problems that affect the
heels, toes, nerves, tendons, ligaments, and joints of the
foot. The symptoms of foot problems may resemble other
medical conditions and problems.
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What are heel spurs?
A heel spur is a bone growth on the heel bone,particularly on the underside forepart of the heelbone where the bone connects to the plantar fascia.
If the plantar fascia, a long band of connectingtissue running from the heel to the ball of the foot,is over-stretched, it can cause a bone growth, orspur, to develop.
This connective tissue holds the arch together andacts as a shock absorber during activity.
The pain results from the stress and inflammationof the plantar fascia pulling on the bone.
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Ankle joint fractures
These fractures may be serious and
require immediate medical attention.
Ankle fractures usually require a cast,and some may require surgery if the
bones are too separated or misaligned.
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metatarsal bone
fractures Fractures of the metatarsal bones, located
in the middle of the foot, often do not
require a cast. A stiff-soled shoe may be all that is
needed for support as the foot heals.
Surgery sometimes is needed to correct
misaligned bones or fractured segments.
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Sesamoid bone
fractures
The Sesamoid bones are two small, round bones
at the end of the metatarsal bone of the big toe.
Usually, padded soles can help relieve pain.
However, sometimes, the Sesamoid bone may
have to be surgically removed.
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Toe fractures
Fractures of the middle toes can heal without a
cast.
Fractures of the big toe or little toe may requirea cast and/or surgery.
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What is foot pain?
Foot pain can be debilitating to an active
lifestyle.
Foot pain can have many sources, fromfractures and sprains to nerve damage.
Listed below are three common areas of pain in
the foot and their causes:
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pain in the ball of the
foot Pain in the ball of the foot, located on the
bottom of the foot behind the toes, may be
caused by nerve or joint damage in that area. In addition, a benign (non-cancerous) growth,
such as Morton's neuroma, may cause the pain.
Corticosteroid injections and wearing
supportive shoe inserts may help relieve thepain. Sometimes, surgery is necessary.
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plantar fasciitis Plantar fasciitis is characterized by severe pain in the
heel of the foot, especially when standing up after resting.
The condition is due to an overuse injury of the solesurface (plantar) of the foot and results in inflammation
of the fascia, a tough, fibrous band of tissue that connectsthe heel bone to the base of the toes.
Plantar fasciitis is more common in women, people whoare overweight, people with occupations that require alot of walking or standing on hard surfaces, people with
flat feet, and people with high arches. Walking orrunning, especially with tight calf muscles, may alsocause the condition.
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Treatment
Treatment may include:
o rest
o ice pack applications
o nonsteroidal anti-inflammatory medications
o stretching exercises of the Achilles tendons
and plantar fascia
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Achilles tendon injury
The Achilles tendon is the largest tendonin the human body. However, this tendonis also the most common site of rupture
or tendonitis, an inflammation of thetendon due to overuse.
Achilles tendonitis is caused by overuseof the tendon and calf muscles.Symptoms may include mild pain after
exercise that worsens gradually, stiffnessthat disappears after the tendon warmsup, and swelling.
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Treatment
o rest
o nonsteroidal anti-inflammatorymedications
o supportive devices and/or bandages forthe muscle and tendon
o stretching
o massage
o ultrasoundo strengthening exercises
surgery
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What is a fracture?
A fracture is a partial or complete break in the
bone. When a fracture occurs, it is classified as
either open or closed: Open fracture (Also called simple fracture) - the
bone exits and is visible through the skin, or a
deep wound that exposes the bone through the
skin. Closed fracture (Also called compound fracture)
- the bone is broken, but the skin is intact.
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Types of Fractures
transverse - the break is in a straight line across the bone.
spiral - the break spirals around the bone; common in atwisting injury.
oblique - diagonal break across the bone.
compression - the bone is crushed, causing the brokenbone to be wider or flatter in appearance.
comminuted - the break is in three or more pieces and
fragments are present at the fracture site. segmental - the same bone is fractured in two places, so
there is a "floating" segment of bone.
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What causes a
fracture? Fractures occur when there is more force
applied to the bone than the bone can
absorb.
Bones are weakest when they are twisted.
Breaks in bones can occur from falls,
trauma, or as a result of a direct blow orkick to the body.
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What are the symptoms
of a fracture? pain in the injured area.
swelling in the injured area.
obvious deformity in the injured area.
difficulty using or moving the injured
area in a normal manner.
warmth, bruising, or redness in the
injured area.
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Diagnosed OF fracture
In addition to a complete medical history
(including asking how the injury occurred) and
physical examination, diagnostic procedures fora fracture may include the following:
X-ray
Magnetic resonance imaging (MRI)
Computed tomography scan (Also called a CT or
CAT scan.
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Complication related to the
fracture itself Infection
Delayed union
Non-union
A vascular necrosis
Mal-union
Shortening
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Causes of Non-union
Infection of the bone.
Inadequate blood supply to one or both fragments.
Excessive shearing movement between the fragments.
Interposition of soft tissue between the fragments. Loss of apposition between the fragments (including over-
distraction by traction apparatus.
Dissolution of the fracture hematoma by synovial fluid (in
fractures within joints). The presence of corroding metal in the immediate vicinity of
the fracture.
Destruction of the bone by a tumor (in pathological fracture).
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Types of bone grafts
Autogenous grafts- obtained from another
part of the patients body.
Allograft; homogenous graft- obtained fromanother human subject.
Heterogeneous grafts- obtained from animals
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Complications attributable to
associated injury Injury to major blood vessels
Injury to nerves
Injury to viscera
Injury to tendons
Injuries and post-traumatic affections of joints
Fat embolism
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Treatment for a
fracture Specific treatment for a fracture will be
determined by your physician based on:
your age, overall health, and medical history
The goal of treatment is to control the pain,
promote healing, prevent complications, and
restore normal use of the fractured area.
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Types of fractures
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Fracture ulna and radius
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Four fracture of the wrist
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Rolando Fracture
Comminuted
Intra-articular
Fracture through base ofthumb
Prognosis: worse than
Bennett's fracture
(difficult to reduce)
Bennett's Fracture
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Bennett's Fracture
Intra-articular
fracture/dislocation of base
of 1st metacarpal
Small fragment of 1st
metacarpal continues to
articulate with trapezium
Lateral retraction of 1st
metacarpal shaft byabductor pollicis longus
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Barton's Fracture
Intra-articular fracture
of the dorsal margin
of the distal radius Extends into radio-
carpal joint
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Colles' Fracture
Extra-articular fracture of the
distal radius
Does not extend into joint
space
Dorsal angulations with radial
and dorsal displacement of
distal fragment
Frequently associated withfracture of ulnar styloid
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Colles fracture
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Tibia fractures
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Fracture Femur
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Conversion of arthrodesis to THR
Arthrodesed hip 30 years previously
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Typical Hip Fracture: Adult
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Fracture Reconstruction and Hip
Replacement
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Surgical treatment
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Revision hip replacement with
bulk allografting
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Profix Total Knee Replacement
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Compression fracture
Normal vertebra Compression fracture
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Fracture Humorous
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Anatomy of the carpal bone
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Fracture of metacarpal bone
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Fracture cervical vertebral
Left clavicle fracture
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Left clavicle fracture
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Fracture styloid
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Fracture dislocation
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Fracture skull
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Fracture scaphoid
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Fracture ankle
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Shoulder Pain and Problems