Fractuture management.ppt8

8/7/2019 Fractuture management.ppt8

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Dr. Chowdhury Iqbal Mahmud

MBBS, FRCS (UK), MCh ( Ortho, UK)


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Fractures occur when there is more force applied

to the bone than the bone can absorb. Bones are

weakest when they are twisted.

Fractures results from:

A single traumatic incident. Breaks in bones canoccur from falls, trauma, or as a result of a directblow or kick to the body.

Repetitive stress

Abnormal weakening of the bone (Pathologicalfracture).


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Open fracture (compoundfracture.)

The bone exits and is visible

through the skin, or a deepwound that exposes the bonethrough the skin or one ofthe body cavities breached.

Closed fracture (simple

fracture.) The bone is broken, but the

skin is intact.


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According to fracture line:Transverse: the break is in astraight line across the bone.Spiral: the break spirals around

the bone; common in a twistinginjury.Oblique: diagonal break acrossthe bone.

According to number of fracture

fragments:Comminuted : there are morethan two bony fragments.Simple: two fracture fragments


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Blood vessels- nutrientartery

Endosteal

Periosteal

Venous drainage

Blood supply


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Inflammation 0 5 days

Haematoma

Necrotic material

Phagocytosis

Repair: 5 42 days

Granulation tissue

Acid environment

Periosteum osteogenic

cells Cortical osteoclasis

Remodelling

years

FRACTURE HEALING


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INDIRECT BONE HEALING

Unstable situation

As in nature External Fixator / Cast

Callus stabilises #

Direct healing betweencortices

Periosteal New BoneFormation

DIRECT BONE HEALING

The response to rigidfixation

Plates Fixation

Temporary acceleration of

Haversian remodelling

Only occurs in absolute

stability of the fracture

Does not involve callus

formation

Requires good blood

supply

FRACTURE HEALING


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The energy transfer of the injury

The tissue response

Blood Supply (scaphoid, talus, femoral and humeral head)

Infection

Nerve Supply

Two bone ends in opposition or compression

Micro-movement or no movement

The patient

Smoking

Nutrition

Co-morbidity

The method of treatment

NSAID

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FRACTURE HEALING


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ClinicallyUpper limb Lower limb

Adult 6-8 weeks 12-16 weeks

Child 3-4 weeks 6-8 weeks

Radiologically Bridging callus formation

Remodelling

FRACTURE HEALING

Gener l rinci les of ealingThe following points shoul e taken into account:Average ti e taken for ones to unite is 8 weeksLower li fractures take approxi atel twice as long to uniteas the upper li fractures ractures in adults take an average twice as long to heal incomparison to those in childrenTransverse fractures take longer to heal than obli ue or spiralfractures

Compound and comminuted fractures are particularl slow touniteNo fracture heals in less than 3 weeks.


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Evaluate patient for: Age

Occupation

Activity Quality of bone

General medical

condition

Neurovascular damage

Mechanism of injury

Low energy

High energy

High energy fractures areassociated with considerablesoft tissue injuries.

In high energy fracturecompartment syndromeand arterial injury mustbe ruled out.

In open fracture with soft tissueloss or severe closed fracturesoft tissue injury must beprotected.After soft tissue recovery,

secondary procedure.


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History

Type of trauma

Mechanism of trauma

Time since trauma

Risk factors

Co- morbidities

Physical Examination Look

Feel

Move

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Common S/S of Fracture

Pain

Deformity Shortening

Swelling

Ecchymosed

Loss of function Open injury


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At least, 2 different planes

Of Fracture site

Includes joint above andbelow

Some types of Fx, specialviews

Sometimes, 2 different

times Sometimes, calls second

opinion


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Two views: A fracture or a dislocation may not be seen on a single x-rayfilm and at least two views (AP and Lateral) must be taken.

Two joints: In the forearm or leg, one bone may be fractured and

angulated. Angulation, however, is impossible unless the other bonealso broken or a joint dislocated.

Two limbs: In children appearances of epiphyses may confuse thediagnosis. Thats why x-ray of two limbs is taken for comparison.

Two injuries: Severe force often causes injuries at more than one level.

Thus with fractures of the calcaneum or femur it is important also to x-ray the pelvis and spine.

Two occasions: Some fractures are difficult to detect soon after injury,but another x-ray a week or two later may show the fracture, e.g.stress fracture, un-displaced fracture of the scaphoid, femoral neck, etc.

Rule of Two


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Aim of Treatment

Restore the patient to optimalfunctional state

Prevent fracture and soft-tissuecomplications

Get the fracture to heal, and in a

position which will produceoptimal functional recovery

Rehabilitate the patient as early

as possible


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If a patient comes with multiple injury, high

energy trauma and open fracture then follow the

ATLS (advanced trauma life support) protocol.

Which include:

Primary survey and

resuscitation

Secondary survey Definitive care.


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Primary survey

The aim of the primary survey is toidentify and treat any life threateningproblems.

A - Airway & Cervical Spine Control

B - Breathing & Oxygenation

C - Circulation & Haemorrhage Control

D - Dysfunction & Disability of the CNS

E - Exposure & Environmental Control


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Treat the patient, not only the fracturePriorities oftreatmentare:

First aid.

Transport of the patient.

Treatment of the shock & hemorrhage.

Treatment of associated injuries and then

Treatment of the fracture itself.


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General Management of Fractures Pain control with analgesics

Assessment of blood loss

Management of associatedinjuries

In case of open fracture Tetanus prophylaxis

Judicious use of antibiotics

Wound debridement wound extension

wound excision

irrigation of wound

Do not forget to asses and treat thesoft tissue


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Treatment of fracture (3 R)

Reduction Closed reduction

Open reduction

Retention

(Immobilization or hold reduction) Cast splintage (Plaster of Paris or synthetic plaster)

Functional bracing

Continuous traction (Skeletal or skin traction)

Internal fixation- plates, screws, IM nail, wire, etc

External fixation

Rehabilitation and exercise

Aims of ImmobilisationPain reliefLimit movement at the fracture sitePrevent angulation and /or

displacement.


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Manipulation to improve the position of thefragments.

Splintage to hold them together until they unite.

Joint movement & function must be preserved.

Fracture healing is promoted by muscle activityand bone loading, so exercise and early weightbearing are encouraged

Treatment


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Reduction

There should be no delay in attending to the fracture,because swelling of the soft parts during the first 12hours makes reduction more difficult.

Aim: adequate positioning and alignment of bonefragments.

Reduction is unnecessary in:

1- little or no displacement.

2- Displacement doesnt matter (e.g. some fracturesof clavicle )

3- Reduction is unlikely to succeed (e.g. compressionfractures of the vertebrae)


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Methods of Reduction:

1) Manipulation

2) Mechanical traction

3) Open operation


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Manipulation Suitable for:

- All minimally displaced fractures

- Most fractures in children

- Fractures likely to be stable after reduction

Under anesthesia and muscle relaxation, thefracture is reduced by 3 fold maneuver:

1- The distal part of the limb is pulled in theline of the bone.

2- As the fragments disengage, they arerepositioned.

3- Alignment is adjusted in each plane.


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TractionTraction is applied to the limb distal to the fracture, so toexert continues pull in the long axis of the bone.

Particularly useful for spiral fracture of long bone shaft,which are easily displaced by muscle contraction

Sustained lower limb traction keeps the patient in bed forlong time, thus increasing the risk of complications such as

thromboembolism, respiratory problem and generalweakness.

-Sustained traction is best avoided in elderly patients.


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Types of Traction

Traction by gravity

Balanced traction:

Skin traction

Skeletal traction

Fixed traction


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Cast splintagePlaster of Paris is still widely used as a splint specially for distallimb fracture and for most children's fractures.

Its safe, and the speed of union is the same as traction but thepatient can go home sooner.

The main drawback is joint stiffness from adhesions after swellingand hematoma resolution.

This is minimized by delayed splintage or starting withconventional cast but after a few weeks replace the cast by aconventional brace which permits joint movement.


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Cast SplintagePolymer resin casts:

Advantages:

1- Light

2- Rapid setting3- Water resistance

4- Radiolucent

Disadvantages:

Expensive


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Cast splintage


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Complications of castCompartment Syndrome:

-Soft tissue swelling and hematoma will cause compression ofthe vessels and nerves with signs of ischemia.

-Pain, Pallor, Pulselessness, Paralysis and Parasthesia.

Pressure sore:

- Esp. over bony prominence.

- Prevented by padding all prominent bony points beforeapplying the cast.

Skin abrasion and laceration:

- Esp. with removing plasters (when an electrical saw is used).

Cast splintage


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Indication for Operative treatmentOpen (compound) fractures

If closed manipulation is unsuccessful inreducing the fracture

Intra-articular fracture

Multiple fracture

If the fracture is unstableSoft tissue management

Management of complications e.g. vascularor head injuries.


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Indication for Operative treatment


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Internal Fixation

Bone fragments may

be fixed with screws,pins or nails, a metalplate held by screws, along intramedullarynail, circumferentialbands,

or combination ofthese.


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Types of internal fixation:

1) Screws: useful for fixingsmall fragments into the mainbone.

2) Wires: used when fracturehealing is predictably quick.

3) Plates & Screws: useful fortreating metaphyseal fracturesof long bone and diaphysealfracture of the radius and theulna.

4)Intramedullary Nails: suitablefor long bones, locking screwsare introduced to resist anyrotational force.


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Advantages of Internal fixation:

Movements can begin early.

The patient can leave hospital as soon as the wound is healed.

Full weight bearing is unsafe .

Complications:Infection: The metal doesnt predispose to infection but thequality of the patients tissue and the open operation do.

Nonunion:

- Stripping of the soft-tissue

- Unnecessary damage to the blood supply in theoperative fixation.

- Rigid fixation with a gap between the fragments.

Implant failure.

Refracture: Its important not to remove metal implants until oneyear and 18-24 months safer.

The greatest danger is sepsis, if infectionsupervenes.The risk of infection depends upon:

1- The patient

2- The surgeon3- The facilities


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Interfragmentary compression


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Tension Band Wiring


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External Fixation

The bone is transfixed above & below thefracture with screws or pins or tensioned wires

& these are clamped to a frame, or connected toeach other by rigid bars.


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Indications of External Fixator:1- Fracture associated with severe soft-tissue damagewhere the wound can be left open for inspection, dressingor coverage.

2- Severely comminuted & unstable fractures.

3- Fracture of the pelvis, which can't be controlled be anyother methods.

4- Infected fractures, which internal fixation might not besuitable.

5- Un-united fractures, where dead fragments can be

removed and the remaining ends brought together in theexternal fixator.


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Complications of external Fixator:

1- Damage to soft-tissue structures:

(pins or wires may cause damage to nerves, vessels,ligaments..)

2- Over distraction:

If there is no contact between the fragments, union may bedelayed or prevented.

3- Pin-track infection:

This is one of the most dangerous complication.


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Exercise and RehabilitationReduce edema

(edema is important cause of joint stiffness)

Stimulates the circulation so promotes fracture healing &prevents soft-tissue adhesion

Preserve joint movement

Restore muscle power

Guide the patient back to normal activity


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Early Late

General Other injuries Chest infection

Pulmonary embolism UTI

Fat embolism syndrome

Adult respiratory

distress

syndrome(ARDS)

Bone Infection Non-union

Mal-union

Delayed-union

AVN

Soft tissue Nero-vascular injury Tendon injury

Compartment syndrome Volkmans ischaemic

contracture

Nerve compression


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Increased Pressure

in a closed tissue

compartment resulting

in local ischaemia.

Needs urgent Fasciotomy

Compartment Syndrome


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Fat Embolism Common in Fx of long bone

and pelvis

Multiple Fracture >> single Fx.

Respiratory insufficiency

Usually manifests within 48 hr

Clinical

Fever

Tachepnoea

Tachycardia

Alters consciousness

Treatment

Respiratory support

Early Fx. stabilization


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Fractuture management.ppt8

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