Displacement Described as: Distal in relation to proximal Un-displaced Shift Sideways Shortening Distraction Angulation In all planes Rotation

Fracture Diagnosis Clinical features Imaging: Radiology (x-Ray)

Clinical Features History of Trauma Symptoms and signs: 1. Pain 2. Swelling 3. Deformity 4. Bony tenderness 5. Abnormal movement 6. Crepitus 7. Loss of function

Approach - history Details of injury Mechanism, force, bleeding, consciousness, … Details of facture Deformity, pain, loss of function,.. Other medical problems Anti-tetanus status if open injuries Careful: Fractures are not always at the site of impact Some fractures do not need severe force

Approach – clinical exam General medical condition should be evaluated to exclude shock brain injury other problems Vital signs should be observed and followed up

Approach – clinical exam Look: Adequate exposure General on patient Local: Swelling, deformity, bruises, color, … Special attention is to be paid to wounds

Approach – clinical exam Feel: Tenderness, distal pulses, temperature and crepitus on movement Sensory and motor deficits Pulse distal to injury Compartment syndrome Move: With care make sure not to cause more pain or injury Crepitus & abnormal movement indicates a fracture Joints distal to the affected area

Approach – clinical exam Examination of the viscera Liver and spleen in rib fractures Urinary bladder and urethra in pelvic fractures Neurological examination in head and spinal injury

Investigations - Imaging X-rays: Low of 2s Two views: AP and Lateral Two joints: Above and Below Two sides: Right and Left Two occasions Two Doctors ! Special views: Obliques, Tunnel view, skyline, functional flexion / extension Arthrography: Shows intra-articular structures Functional in hip

Imaging Plain x-ray: (law of two s ) Two views:AP and Lateral Apley’s System of Orthopedics & Fractures AP Lat

Imaging Plain x-ray: (law of two s ) Two views: AP and Lateral Two joints: joint above and joint below Apley’s System of Orthopedics & Fractures

Imaging Plain x-ray: (law of two s ) Two views: AP and Lateral Two joints: joint above and joint below Two limbs: for comparison more in children to compare epiphysis Apley’s System of Orthopedics & Fractures

Imaging Plain x-ray: (law of two s ) Two views: AP and Lateral Two joints: joint above and joint below Two limbs: for comparison more in children to compare epiphysis Two occasions e.g. stress fractures e.g. scaphoid fracture Apley’s System of Orthopedics & Fractures

Imaging Plain x-ray: (law of two s ) Two views: AP and Lateral Two joints: joint above and joint below Two limbs: for comparison more in children to compare epiphysis Two occasions e.g. stress fractures e.g. scaphoid fracture Two injuries e.g. patellar fracture and hip injury e.g. calcaneal fractures & spine injuries

Imaging Plain x-ray: (law of two s ) Two views: AP and Lateral Two joints: joint above and joint below Two limbs: for comparison more in children to compare epiphysis Two occasions e.g. stress fractures e.g. scaphoid fracture Two injuries e.g. patellar fracture and hip injury e.g. calcaneal fractures & spine injuries

Imaging Plain x-ray: (law of two s ) Two views: AP and Lateral Two joints: joint above and joint below Two limbs: for comparison more in children to compare epiphysis Two occasions e.g. stress fractures e.g. scaphoid fracture Two injuries e.g. calcaneal fractures & spine injuries.....and two Doctors!

Imaging Plain x-ray: (law of two s ) Special views: Calcaneal view Shoulder dislocation: axial view Scaphoid views Acetabular fractures: 45 o tilt views

Imaging CT Scan: In complex and ntra-articular fractures In spine In pelvic and acetabular fractures In calcaneal fractures

Imaging MRI Show associated injuries in spinal fractures Associated soft tissue injuries – e.g. knee Hidden fractures: Subtrochanteric (ST) disruption Stress (fatigue) fractures Scaphoid fracture Suspected avascular necrosis

Fracture healing A broken bone heels because …..it is broken ! Alan Apley

Natural bone healing Movement at the fracture site initiates a healing process—callus formation Vascular and cellular response leads to tissue differentiation and mineralization resulting in restoration of mechanical integrity

Natural bone healing

Cascade of tissue differentiation Following a Fracture: 1. Hematoma 2. Granulation tissue 3. Connective tissue 4. Fibrocartilage 5. Mineral deposition 6. Bone

Fracture healing 1. Inflammation Hematoma Mesenchymal cells 2. Soft callus Granualation tissue 3. Hard callus Intramembranous bone formation Enchondral ossification 4. Remodeling bony bridging

Cellular and Vascular Reaction cells haematoma granulation tissue

Tissue Differentiation connective tissue granulation tissue Giemsa

Tissue Differentiation Cascade Cartilage formation Bone Mineral deposition Masson-Goldner

Healing time & strength ProcessTimingStrength Hematoma2 hrs1% Inflammation2 days5% Soft callus2 weeks25% Hard callus 2 months74% Re-modelling2 years100%

Fracture Healing Conditions necessary for bone healing: Good blood supply Controlled motion No infection

Fracture Healing Unfavorable factors Impairment of blood supply Infection Excessive movement Presence of tumor Interposition of soft tissue Any form of Nicotine (smoking) Bad nutrition

Average healing time Children: Upper limb: 3-4 weeks Lower limb: 2X upper limb (6-8 weeks) Adults: Upper limb: 2X children (6-8 weeks) Lower limb: 2X upper limb (12-16 weeks)

Fracture Treatment Aim of fracture treatment aid healing, in normal position, avoiding complications

Fracture treatment Treat the patient, not only the fracture Reduce the fracture Immobilize the fracture Prevents displacement Alleviates pain Promotes soft tissue healing Mobilize the patient Avoid complications