Approach to Fracture Bone
Transcript of Approach to Fracture Bone
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APPROACH TO FRACTURE BONEAPPROACH TO FRACTURE BONE
ININ
EMERGENCY DEPARTMENTEMERGENCY DEPARTMENT
DR. RASHDAN RAHMATDR. RASHDAN RAHMAT
HUSMHUSM
20062006
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OUTLINESOUTLINES
IntroductionIntroduction
Types of fractureTypes of fracture
Management of fractureManagement of fracture-- in generalin general
-- specific types of fracturespecific types of fracture
ComplicationsComplications
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INTRODUCTIONINTRODUCTION
- Bone has its own mechanism to ward off the unnatural
forces and keep itself intact.
- but, if the force is :
-too large and occurs suddenly(as in MVA, fall etc), OR
- chronic and repetitive (eg prolonged standing/used);
OR
- when the natural resistance of the bone is eroded by
a disease process (eg tumor, infection etc),
that a bone succumbs to the insult and breaks.
- When it breaks, it is bound to injure the surrounding soft
tissue like muscles, ligaments etc.
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Severity ranges from trivial sprains to lifeSeverity ranges from trivial sprains to life-- or limbor limb--
threatening trauma.threatening trauma.
Often acute trauma is the cause of the presentation.Often acute trauma is the cause of the presentation.
Pain and decreased ROMPain and decreased ROMare the main symptomsare the main symptoms
Life threatening injuriesLife threatening injuries Limb threatening injuriesLimb threatening injuries
multiple trauma patientmultiple trauma patient
severe crush injurysevere crush injury
amputationamputation
pelvic injurypelvic injury
severe vascular injurysevere vascular injury
compound fracturescompound fractures
compartment syndromecompartment syndrome
vascular injuryvascular injury
dislocation of major jointsdislocation of major joints
nerve injurynerve injury
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FRACTURE :
FRACTURE :
a break in the surface of a bone, either across its cortexa break in the surface of a bone, either across its cortex
or through its articular surface.or through its articular surface.
Ds in fracture :Ds in fracture : Deformity is seen often in displaced fracturesDeformity is seen often in displaced fractures
Displacement could be anterior, posterior, medial orDisplacement could be anterior, posterior, medial or
laterallateral
Distal fragment is the reference point to suggest the typeDistal fragment is the reference point to suggest the typeof displacementof displacement
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TYPES OFFRACTURE :TYPES OFFRACTURE :
1.1. Simple / closed vs Compound / openSimple / closed vs Compound / open
2.2. Based on the patterns of fractureBased on the patterns of fracture
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1. Simple / Closed Fracture :1. Simple / Closed Fracture :
The bone breaks within its soft tissue envelope and notThe bone breaks within its soft tissue envelope and not
communicate to the exterior.communicate to the exterior.
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2. Compound / Open Fracture :2. Compound / Open Fracture :
The bone breaks / rip through its soft tissues or the softThe bone breaks / rip through its soft tissues or the soft
tissue itself may be damaged by the external forces,tissue itself may be damaged by the external forces,
exposing the bone to the external atmosphereexposing the bone to the external atmosphere
(communicate to the exterior)(communicate to the exterior)
Eg. open elbow fracture
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II. BASED ON THEFRACTUREPATTERNS :II. BASED ON THEFRACTUREPATTERNS :
1. Linear fracture :1. Linear fracture : Transverse, oblique orTransverse, oblique or
spiralspiral
-- # angle < 30 with the# angle < 30 with the
horizontal line :horizontal line : transversetransverse-- angleangle >> 30 :30 : obliqueoblique
2. Comminuted fracture :2. Comminuted fracture :
The fracture fragments >2 inThe fracture fragments >2 innumbernumber
3. Segmental fracture :3. Segmental fracture :
Breaks into segmentsBreaks into segments
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OTHER TYPES OFFRACTURES :OTHERTYPES OFFRACTURES :
a. Green stick fracture :a. Green stick fracture :Seen in childrenSeen in children
The bone is elastic, usually bends due to buckling orThe bone is elastic, usually bends due to buckling orbreaking of one cortex when a force is applied.breaking of one cortex when a force is applied.
b. Stress / fatigue fracture :b. Stress / fatigue fracture :As a result of being subject to uncustomary repetitiveAs a result of being subject to uncustomary repetitiveforces before the bone and its supporting tissues haveforces before the bone and its supporting tissues havehad adequate time to accommodate to such forces.had adequate time to accommodate to such forces.
Eg.Eg. March fractureMarch fracture in soldiersin soldiers
c. Pathological fracture :c. Pathological fracture :Occurs in diseased bone, from a relatively minor traumaOccurs in diseased bone, from a relatively minor trauma
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SALTERSALTER -- HARRISFRACTUREHARRISFRACTURE
Type IType I fracture is when there isfracture is when there is
a fracture across the physisa fracture across the physiswith no metaphysial orwith no metaphysial or
epiphysial injuryepiphysial injury
Type II fracture is when there is
a fracture across the physiswhich extends into the
metaphysis
# involving the physis, the cartilaginous epiphyseal plate near the ends# involving the physis, the cartilaginous epiphyseal plate near the endsof the long bones ofof the long bones ofgrowing childrengrowing children
The damage may destroy part or all of its ability to produce new boneThe damage may destroy part or all of its ability to produce new bone
substance, resulting in aborted or deformed growth of the bone thereafter.substance, resulting in aborted or deformed growth of the bone thereafter.
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SALTERSALTER -- HARRISFRACTUREHARRISFRACTURE
Type IIIType III fracture isfracture is
when there is awhen there is afracture across thefracture across thephysis which extendsphysis which extendsinto the epiphysisinto the epiphysis
Type IVType IV fracture isfracture iswhen there is awhen there is afracture throughfracture throughmetaphysis, physis,metaphysis, physis,and epiphysisand epiphysis
Type VType V fracture isfracture is
when there is awhen there is a
crush injury to thecrush injury to the
physisphysis
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MANAGEMENT :MANAGEMENT :
GOAL :
- to restore the anatomy back to its normal or as near to
normal as possible.
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MANAGEMENT IN ED :MANAGEMENT IN ED :
Primary survey :Primary survey :
Identify the life threatening injuries
ABCDE must be observed in all injuries be it serious ortrivial
E exposure :- completely undress the patient for total
assessment of the limbs
Secondary survey :
Give greater attention to the extremities
Look for perfusion, alignment, function of the involvedlimbs / extremities
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MANAGEMENT IN EDMANAGEMENT IN ED --Clinical features :Clinical features :
oo Pain, tenderness on palpationPain, tenderness on palpation
oo Loss of functionLoss of function unable to moveunable to move
oo DeformityDeformity angulation, shortening, rotatedangulation, shortening, rotated
oo SwellingSwelling
oo Abnormal postureAbnormal posture
oo CrepitusCrepitus gritty feeling at fracture sitegritty feeling at fracture site
* exam of the* exam of the pulsepulse andand neurological statusneurological status isismandatory in all fracturesmandatory in all fractures
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MANAGEMENT IN EDMANAGEMENT IN ED --Closed fracturesClosed fractures ::
3 aspects of exam. :3 aspects of exam. :
1.1. LOOKLOOK for deformity, wounds, swelling, colour andfor deformity, wounds, swelling, colour and
general appearance of the limbsgeneral appearance of the limbs
2.2. FEELFEEL for the distal pulses and detect loss offor the distal pulses and detect loss of
sensationsensation
3.3. MOVEMOVE the joints above and below the fracturethe joints above and below the fracture
Splinting :Splinting :
Prevents further STIPrevents further STI
Reduces painReduces pain
Facilitates transportationFacilitates transportation
Reduction :Reduction :
reduces compromise of skin,
nerve and vascular structures
facilitates splinting
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MANAGEMENT IN EDMANAGEMENT IN ED Open / Compound #Open / Compound #::
Aims of treatment :Aims of treatment :To convert a contaminated wound into a clean woundTo convert a contaminated wound into a clean woundand thus help to convert an open fracture into a closedand thus help to convert an open fracture into a closedoneone
To establish a union in a good positionTo establish a union in a good position
To prevent pyogenic and clostridial infectionsTo prevent pyogenic and clostridial infections
Methods :Methods :
1.1. Careful and detailed examinationCareful and detailed examination
2.2. Removal of any gross contamination (by thoroughRemoval of any gross contamination (by thoroughirrigation), application of sterile dressing and splintingirrigation), application of sterile dressing and splintingof fractureof fracture
3.3. Tetanus prophylaxisTetanus prophylaxis
4.4. Admin. of IV antibioticsAdmin. of IV antibiotics
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For muscle, non viable tissue has to be removedFor muscle, non viable tissue has to be removed 5Cs :5Cs :
** ImmobilizationImmobilization key in the Rx of MSK traumakey in the Rx of MSK trauma
Prevent furtherSTIPrevent furtherSTIRelieves painRelieves pain
Possibly decreases the incidence of fat embolism andPossibly decreases the incidence of fat embolism and
shockshock
Facilitates transportationFacilitates transportation
FeaturesFeatures ViableViable Non viableNon viable
ColourColour
ConsistencyConsistency
Capacity to bleedCapacity to bleed
CirculationCirculation
ContractilityContractility
PinkPink
FirmFirm
PreservedPreserved
PresentPresent
PresentPresent
PalePale
FlabbyFlabby
LostLost
AbsentAbsent
AbsentAbsent
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PELVICFRACTUREPELVICFRACTURE
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PelvicFracturePelvicFracture
Least common fractureLeast common fracture (3%)(3%)
Most are result of MVA (60%)Most are result of MVA (60%)
Commonly associated with other injuriesCommonly associated with other injuries
-- 50% have intraabd. Injuries50% have intraabd. Injuries
-- 15% have urethral injuries15% have urethral injuries
-- 10% have bladder injuries10% have bladder injuries
Pelvis contains many important structures :Pelvis contains many important structures :
-- Iliac vesselsIliac vessels
-- dense presacral venous plexusdense presacral venous plexus
-- urogenital organsurogenital organsMajor ligaments :
- sacroiliac, sacrospinatus, sacrotuberous
Patients can sustain large volume blood lossPatients can sustain large volume blood loss
(up to 4 L)(up to 4 L)
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ANATOMY OFPELVIS :ANATOMY OFPELVIS :
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PelvicFracturePelvicFracture --Clinical Evaluation :Clinical Evaluation :
Any patient assessment begins with the ABCDEsAny patient assessment begins with the ABCDEs
Complete neurologic and vascular examComplete neurologic and vascular exam
Have high suspicion of intraHave high suspicion of intra--abdominal injuriesabdominal injuries (50%)(50%)
Physical exam :Physical exam : Ecchymosis or contusion around hips, perineumEcchymosis or contusion around hips, perineum
Pelvic instability with stressingPelvic instability with stressing
Suspect if signs of urologic findings : blood atSuspect if signs of urologic findings : blood at
urethral meatus, highurethral meatus, high--riding prostateriding prostate High force mechanisms also associated (MVA,High force mechanisms also associated (MVA,
femur #)femur #)
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PelvicFracturePelvicFracture Management :Management :
1. Control of bleeding vessels1. Control of bleeding vessels
Hemorrhage / hypovolemic shockHemorrhage / hypovolemic shock -- the most significantthe most significantcomplication of pelvic #complication of pelvic #
-- require blood transfusion (maintain HCT > 20%)require blood transfusion (maintain HCT > 20%)
2. Pelvis stabilization :2. Pelvis stabilization :
External fixation techniquesExternal fixation techniques pelvic clamp, hammockpelvic clamp, hammockapplicationapplication
These can help in controlling ongoing bleedingThese can help in controlling ongoing bleeding
33. Surgical management of the broken bone can proceed. Surgical management of the broken bone can proceedLATER after lifeLATER after life--threatening conditions are controlled.threatening conditions are controlled.
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Long Bone Fractures :Long Bone Fractures :
Fractures of the femur, humerus, tibia / fibulaFractures of the femur, humerus, tibia / fibula
Blunt and penetrating traumaBlunt and penetrating trauma
RequiresRequires high energyhigh energy to break bone, thereforeto break bone, therefore
look for other injuries.look for other injuries.# cause localized bleeding and this can be# cause localized bleeding and this can besubstantial resulting in hypovolemic shock.substantial resulting in hypovolemic shock.
Humerus # : 0.5Humerus # : 0.5 1.5 L1.5 L
Unilateral tibia / fibula # : 0.5Unilateral tibia / fibula # : 0.5 1.5 L1.5 L
Femur # : 1.0Femur # : 1.0 2.5 L2.5 L
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Long Bone FracturesLong Bone Fractures Management :Management :
ABCDEsABCDEs
Neurovascular exam (vascular +/Neurovascular exam (vascular +/-- nerve injury)nerve injury)
Splint involved extremitySplint involved extremity
Reduction decreases pain, bleedingReduction decreases pain, bleeding
Orthopedic consultation for definitiveOrthopedic consultation for definitivemanagementmanagement
Complications :Complications :
FatFat--emboli syndromeemboli syndrome
Blood lossBlood loss
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COMPLICATIONSCOMPLICATIONS
ACUTEACUTE CHRONICCHRONIC COMP. PECULIARTOCOMP. PECULIARTO
OPEN FRACTURESOPEN FRACTURES
1. SHOCK(hypovolemic or1. SHOCK(hypovolemic or
neurogenic)neurogenic)
2. ARDS2. ARDS
3.3. THROMBOEMBOLISMTHROMBOEMBOLISM
4.4. NEUROVASCULARNEUROVASCULAR
INJURYINJURY
radial N palsy in # shaftradial N palsy in # shaft
humerushumerus
Sciatic N palsy in post. disl.Sciatic N palsy in post. disl.of hipof hip
brachial A injury inbrachial A injury in
supracondylar #supracondylar #
5.5. COMPARTMENTALCOMPARTMENTAL
SYNDROMESSYNDROMES
DELAYEDUNIONDELAYEDUNION
NONUNIONNONUNION
MALUNIONMALUNION
SHORTENINGSHORTENING
GROWTHGROWTH
DISTURBANCESDISTURBANCES
AVASCULARAVASCULAR
NECROSISNECROSIS
JOINTSTIFFNESSJOINTSTIFFNESS
POSTTRAUMATICPOSTTRAUMATIC
ARTHRITISARTHRITIS
MYOSSITISMYOSSITIS
OSSIFICANSOSSIFICANS
INFECTIONSINFECTIONS
CHRONICCHRONIC
OSTEOMYELITISOSTEOMYELITIS
GASGANGRENEGASGANGRENE
TETANUSTETANUS
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Fracture Complications :Fracture Complications :
1. Vascular Injuries1. Vascular Injuries Most commonly occur inMost commonly occur in open #, #open #, #--dislocationsdislocations, or, or
widely displaced #widely displaced # andandat sites where the vessels lieat sites where the vessels liein close proximity to the bonein close proximity to the bone ororat sites where theat sites where thevessels are held in a relatively fixed position.vessels are held in a relatively fixed position.
Classic signs:Classic signs:The 5 Ps:The 5 Ps:
PainPain
PallorPallor
Pulselessness (or diminished pulse)Pulselessness (or diminished pulse) ParesthesiaParesthesia
ParalysisParalysis..
Location of # and MOI dictate need to assess forLocation of # and MOI dictate need to assess for
potential vascular injury in asymptomatic patient.potential vascular injury in asymptomatic patient.
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Fracture Complications :Fracture Complications :
2. Nerve Injuries2. Nerve Injuries
OccurOccurmore frequentlymore frequently than vascular injuries inthan vascular injuries in
assoc. with #.assoc. with #.
Can occur due to blunt trauma, along path ofCan occur due to blunt trauma, along path ofpenetrating trauma, or be caused by the # fragmentspenetrating trauma, or be caused by the # fragments
themselves.themselves.
Nerves are at increased risk of injury when they are :Nerves are at increased risk of injury when they are :
superficial to the skin,superficial to the skin, lie close to the bone, orlie close to the bone, or
over a joint, making them susceptible to stretchover a joint, making them susceptible to stretch
injury.injury.
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Fracture Complications :Fracture Complications :
3. Fat Emboli Syndrome (FES)3. Fat Emboli Syndrome (FES)
Most common form of nonMost common form of non--thrombotic embolism.thrombotic embolism.
Single or multiple long bone fractures in young or pelvic / hip fracturesSingle or multiple long bone fractures in young or pelvic / hip fracturesin elderly predispose to FES.in elderly predispose to FES.
20%20% of patients with pelvic or long bone fractures have detectable fatof patients with pelvic or long bone fractures have detectable fatdroplets in their blood. Vast majority remain asymptomatic.droplets in their blood. Vast majority remain asymptomatic.
HasHas characteristic clinical courses :
1. Fracture sustained.1. Fracture sustained.
2. Other than fracture2. Other than fracture--associated pain, patient is asymptomatic forassociated pain, patient is asymptomatic for1
21
2--36 hours.36 hours.3. Sudden onset of life3. Sudden onset of life--threatening syndrome characterized by rapidthreatening syndrome characterized by rapid
cardiopulmonary and neurologic deterioration, agitation,cardiopulmonary and neurologic deterioration, agitation,hallucinations, delirium, coma, hypoxia, dyspnea, tachypnea, andhallucinations, delirium, coma, hypoxia, dyspnea, tachypnea, andtachycardia leading totachycardia leading to DIVC and ARDS.
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4. Compartment Syndrome4. Compartment Syndrome
Occurs whenOccurs when pressurepressure within soft tissues in awithin soft tissues in a fixed bodyfixed bodycompartmentcompartment increasesincreases to level that exceedsto level that exceeds venousvenouspressure, compromising venous blood flow, and limitingpressure, compromising venous blood flow, and limitingcapillary perfusion.capillary perfusion.
Leads toLeads to muscle ischemia and necrosis.
TRUE ORTHOPEDIC EMERGENCYTRUE ORTHOPEDIC EMERGENCYContributingFactors :ContributingFactors :
External :
Conditions thatConditions that reduced size of muscle compartmentreduced size of muscle compartment --tight casts / splints, occlusive dressing, burn scartight casts / splints, occlusive dressing, burn scar
Internal :Conditions thatConditions that increase compartment volumeincrease compartment volume ::
bleedingbleeding
swellingswelling
fluid extravasation into tissuefluid extravasation into tissue
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CS - Common in crush injuries or # with marked swelling.
- much more often in lower (rather than upper) extremities.
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Compartment Syndrome :Compartment Syndrome :
Recognition :Recognition :Suspect with long bone #, crush injuriesSuspect with long bone #, crush injuries
Presents as pain out of proportion to physicalPresents as pain out of proportion to physical
findings, +/findings, +/-- hypoesthesia, pulselessness (late).hypoesthesia, pulselessness (late).
Management :Management :
Remove compressive dressings or casts
Apply ice to the affected extremity, do no
elevate- keeping the area dependant will
increase the perfusion pressure
Treatment emergent fasciotomy
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THANK YOUTHANK YOU
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GUSTILLOS CLASSIFICATION OFOPENGUSTILLOS CLASSIFICATION OFOPEN
FRACTURE :FRACTURE :
Grade I :Grade I : -- woundwound < 1 cm,< 1 cm, minimal STI & comminution-- wound bed is clean ; bone injury is simplewound bed is clean ; bone injury is simple-- with IM nailing, average time to union is 21with IM nailing, average time to union is 21--28 weeks;28 weeks;
Grade II :Grade II : -- wound iswound is 11 10 cm,10 cm, moderate STI & contaminationmoderate STI & contamination ,,comminutioncomminution
-- with IM nailing, average time to union is 26with IM nailing, average time to union is 26--28 weeks;28 weeks;
Grade III :Grade III :-- segmental # with displacement, # with diaphyseal segmental loss, # withsegmental # with displacement, # with diaphyseal segmental loss, # withassociated vascular injury requiring repair;associated vascular injury requiring repair;-- highly contaminated woundshighly contaminated wounds
Grade IIIA # :Grade IIIA # :-- woundwound > 10 cm,> 10 cm, crushed tissue and contamination;crushed tissue and contamination;
-- soft tissue coverage of bone is usually possible;soft tissue coverage of bone is usually possible;-- with IM nailing, average time to union is 30with IM nailing, average time to union is 30--35 weeks;35 weeks;Grade IIIB # :Grade IIIB # :
-- wound > 10 cm, crushed tissue and contamination;wound > 10 cm, crushed tissue and contamination;-- soft tissue issoft tissue is inadequateinadequate and requires regional or free flapand requires regional or free flap-- with IM nailing, average time to union is 30with IM nailing, average time to union is 30--35 weeks;35 weeks;
Grade IIIC # :Grade IIIC # :
-- involvinginvolving major vascular injurymajor vascular injury requiring repair for limb salvagerequiring repair for limb salvage
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FOREARMFOREARM
COMPARTMENTSCOMPARTMENTS