Principles of Fracture Management for Primary Care Physicians Ed Schwartzenberger PGY 3 Orthopaedics

Objective Pictures taken from images.google.com

Function of Bones? Locomotion Scapholding to allow body to work Mechanical Functioning of limbs Protect soft tissues Pictures taken from images.google.com

Mechanical Characteristics of Bone Stiff (Deforms very little under load) Strength (high load before failure) Brittleness(breaks with very little deformation) Pictures taken from images.google.com

Bones Resistance To Forces (Browner, Jupiter, Levine, Trafton, & Krettek, 2009)

Different parts of the bone Pictures taken from images.google.com

How Bones Break Large force in normal bone Small force in pathologic bone Repetitive regular forces in normal bone Pictures taken from images.google.com

Forces and Bone Fracture Patterns (Browner et al., 2009)

What type of force Pictures taken from images.google.com

What type of force Pictures taken from images.google.com

What type of force Pictures taken from images.google.com

What type of force

Who Cares? Understanding the composition of different parts of the bone will help us to understand healing potential Understanding the forces can help in reversing those forces – Reduction – Fixation If we understand why a bone breaks it can help us treat the underlying cause – Osteoporosis, cancer, child abuse etc

Bone Healing What are the two types of bone healing – Primary Healing without callus – Secondary Callus formation Pictures taken from images.google.com

Secondary Fracture Healing Stages of Fracture healing Picture from tube.medchrome.comtube.medchrome.com

Primary Bone Healing Only occurs under conditions of absolute stability Compression Healing by direct haversian remodelling Cutting cones of the osteoclasts Minimal visible callus visible afterwards as fracture line disappears (Ruedi, Buckley, & Moran, 2007)

Advantages of Primary Bone Healing 0 callus Maintained reduction Pictures taken from images.google.com

Different Methods of Fracture Stabilization Relative Stability-2 O healing – Cast – Splint – External fixator – Nail – Bridging plate Absolute Stability-1 O healing – Compression – Screw – Compression plate – Tension band

Relative Stability Pictures taken from images.google.com

Absolute Stability

Goals of Fracture Care Save lives Save limbs Save joints Restore function Pictures taken from images.google.com

Two principles to attain those goals Obtain a reduction Maintain the reduction while it heals Pictures taken from images.google.com

Reduce or not to reduce... Advantages of reduction – Protect soft tissues Neurovascular Skin Peri-bone tissues – Provide comfort to patient – Almost always attempt reduction- even if going for a surgery Disadvantages of reduction – Expose patient to risk of sedation – Pain

How Good is good enough Diaphyseal Fractures Purpose of this part of the bone – Overall alignment and support Goal of reduction – Length, alignment and rotation – Individual specifics are Bone specific Pictures taken from images.google.com

How Good is Good enough Articular Fractures Purpose of this part of bone – Sliding surface to allow for smooth articulation – Remember that cartilage cannot be regenerated Goal – Anatomic reduction and fixation – Ideally primary bone healing Pictures taken from images.google.com

Problems with Prolonged Immobilization Disadvantages: Muscle atrophy Joint stiffness Disuse osteoporosis Persistent edema Pictures taken from images.google.com

Advantages of Internal Fixation Reduction and fixation of fractures that would be impossible closed Early mobilization – Prevents immobilization co- morbidities DVT Pressure sores Aids in patient care Primary bone healing possibility Pictures taken from images.google.com

Special Cases

Open Fractures Pictures taken from images.google.com

Why Care about Open Fractures Infection Morbidity Pictures taken from images.google.com

Indirect Signs of Open Fractures or Impending Open Fractures Persistently bleeding wound Fat in the blood Tenting/Blanching skin Pictures taken from images.google.com

Goals of Open Fracture Treatment – Prevent Infection – Fracture stabilization and healing – Soft-tissue coverage

Approach to Open Fractures – ATLS principles ABCs – Emergency Room Management Washout – Then cover with a sterile dressing – Take a picture to prevent multiple examinations-see infection prevention above Reduction – Neurovascular exam before and after Antibiotics – Time to antibiotics correlated with decreased mortality in sepsis » Ancef » Aminoglycoside » Penicillin Farm yard contamination Tetanus – Refer and Ship

Pediatric Fractures Pictures taken from images.google.com

Peds bones vs adult bones What makes pediatric bone different from adult bone? – Physis – Thicker periosteum – Higher water content and lower mineral content Less brittle Higher strain to failure – Greater ability to remodel Except rotation – Don’t tend to get stiff Can tolerate longer periods of immobilization

What do differences mean clinically? Different fracture types not seen in adults Pictures taken from images.google.com

Physeal Fracture Classification Salter Harris – Side – Above – Lower – Through – E Really Hard Crush Pictures taken from images.google.com

Why do we care about physeal injuries? Pictures taken from images.google.com

Review Characteristics of bone How bones break and patterns of fractures How bones heal Tools to guide healing Reduction and Immobilization Tools of Conservative management Advantages of Surgical Treatment Special Cases – Open Fractures – Pediatric Fractures

Questions