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General Principles of Fracture Care

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1 General Principles of Fracture Care
Presented By: Fadel Naim M.D. Orthopedic Surgeon Faculty of Medicine IUG

2 Fracture The problem is not the damage to the bone
The problem is the damage the bone does to the surrounding soft tissues. Evaluate Neurovascular Function Distally

3 Fracture A disruption in the integrity of a living bone involving injury to: Bone Bone marrow Periosteum Adjacent soft tissues

4 Mechanisms of Musculoskeletal Injury
Direct force Indirect force Twisting (rotational) force Point to Emphasize: There are three types of mechanisms that cause musculoskeletal injuries: direct force, indirect force, and twisting force. Talking Points: Direct force is a person being struck by an automobile. Twisting or rotational force can cause stretching or tearing of muscles and ligaments. Indirect force causes injuries to the body away from the actual impact and can be more serious than the original injury. Discussion Topic: Describe the three mechanisms that cause musculoskeletal injuries. Knowledge Application: Have students work in small groups. Hand out sticks and have each group present an example of a specific force that causes musculoskeletal injury. Have groups discuss their examples.

5 Direct trauma: Consists of direct force applied to the bone
Tapping fractures (eg, bumper injury) Penetrating fractures (eg, gunshot wound) Crush fractures

6 Indirect trauma Involves forces acting at a distance from the fracture site Tension (traction) Compressive forces Rotational forces

7 Indirect Trauma Rotation Tension Compression Combination Angulation

8 Classification of Fractures
Evidence based medicine Communication Treatment plan (personality of the fracture...)

9 Fracture Discription Anatomical location - ? joint Direct / indirect
Fracture configuration Simple or comminuted Open or closed Pathological Stress fracture Greenstick fracture

10 The Rule of A's Radiographs should be described as follows:
Anatomy (eg, proximal tibia) Articular (eg, extra-articular) Alignment (eg, first plane) Angulation (eg, second plane) Apex (eg, apex pointing medially) Apposition (eg, 75% or 0%)

11 Anatomical and Clinical Discreption
Which bone? Thirds (long bones) Proximal, middle, distal third Anatomic orientation E.g. proximal, distal, medial, lateral, anterior, posterior Anatomic landmarks E.g. head, neck, body / shaft, base, condyle Segment (long bones) Epiphysis, physis, metaphysis, diaphysis Epiphysis Physis Metaphysis Diaphysis (Shaft) Articular Surface

12 Articular Extension / Involvement
Anatomical and Clinical Discreption Articular Extension / Involvement Intra-articular fractures “Involves the articular surface” Dislocation Loss of joint surface / articular congruity Fracture-dislocation

13 Comminution / Pattern Transverse (Simple) Oblique (Simple)
Spiral (Simple) Linear / longitudinal Segmental Comminuted Compression / impacted “Buckle / Torus” Distraction / avulsion

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15 Displacement, Angulation, Rotation
Extent to which Fx fragments are not axially aligned Fragments shifted in various directions relative to each other describe displacement of distal fragment relative to proximal Oblique tibial shaft Fx b/w distal & middle thirds; laterally displaced

16 Displacement, Angulation, Rotation
Extent to which Fx fragments are not anatomically aligned In a angular fashion describe angulation as the direction the apex is pointing relative to anatomical long axis of the bone (e.g. apex medial, apex valgus) R Tibial shaft Fx b/w prox & middle thirds, angulated apex lateral (apex varus)

17 Displacement, Angulation, Rotation
Valgus Apex medial Parallel No angulation Varus Apex lateral

18 Displacement, Angulation, Rotation
Extent to which Fx fragments are rotated relative to each other Convention: describe which direction the distal fragment is rotated relative to the proximal portion of the bone

19 Displacement, Angulation, Rotation
PA view of rotated hip Fx Greater trochanter perpendicular to film Normal PA view of hip Greater trochanter in profile

20 Displacement, Angulation, Rotation
Shortening Has the fracture caused shortening of the bone involved? To what extent has shortening occurred?

21

22 Intrinsic Bone Quality
Normal Osteopenia Decr’d density

23 Intrinsic Bone Quality
Osteopetrosis Incr’d density Normal

24 Intrinsic Bone Quality
Osteopoikilosis Focal areas of incr’d density Normal

25 Soft tissue involvement
Is the fracture open or closed? Is associated neurological and or vascular injury present? Is there muscle damage or compartment syndrome evident?

26 Open fracture implies communication between external environment and the fracture.
A soft tissue injury complicated by a broken bone.

27 Components of open fracture
Soft-tissue damage Neurovascular compromise Contamination Extent of each component must be assessed individually in order to achieve a comprehensive understanding of the injury, upon which the treatment plan can be based.

28 Gustilo and Anderson Classification
Model is tibia, however applied to all types of open fractures Emphasis on wound size Crush injury assoc with small wounds Sharp injury assoc with large wounds Better to emphasize Degree of soft tissue injury Degree of contamination Most widely used today

29 Why use this classification?
Grades of soft tissue injury correlates with infection and fracture healing Grade 1 2 3A 3B 3C Infection Rates 0-2% 2-7% 10-25% 10-50% 25-50% Fracture Healing (weeks) 21-28 28-28 30-35 Amputation Rate 50%

30 Cover the wounds quickly
Nocosomial infection?!!!! Cover the wounds quickly Only 8% of infections were caused by the same organism initially isolated in the perioperative cultures 92% of open fracture infections were caused by bacteria acquired while the patient was in the hospital

31 Gustilo Classification of Open Fracture
Type I: Wound is shorter than 1 cm. It is clean and generally is caused by a fracture fragment piercing the skin (ie, inside-out injury). This is a low-energy injury.

32 Gustilo Classification of Open Fracture
Type II: The wound is longer than 1 cm. It is not contaminated and without major soft tissue damage or defect. This is also a low-energy injury.

33 Gustilo Classification of Open Fracture
Type III: Wound longer than 1 cm, with significant soft tissue disruption High-energy trauma resulting in a severely unstable fracture with varying degrees of fragmentation IIIa: Sufficient soft tissue to cover the bone without the need for local or distant flap coverage

34 Gustilo Classification of Open Fracture
Type III: IIIb: Extensive soft tissue disruption Local or distant flap coverage is necessary to cover the bone The wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound

35 Gustilo Classification of Open Fracture
Type III: IIIc: Any open fracture associated with an arterial injury, which requires repair is considered type IIIC Involvement of vascular surgeons is generally required

36 Gustilo Classification of Open Fracture
Type I: Wound is shorter than 1 cm. It is clean and generally is caused by a fracture fragment piercing the skin (ie, inside-out injury). This is a low-energy injury. Type II: The wound is longer than 1 cm. It is not contaminated and without major soft tissue damage or defect. This is also a low-energy injury. Type III: Wound longer than 1 cm, with significant soft tissue disruption High-energy trauma resulting in a severely unstable fracture with varying degrees of fragmentation IIIa: Sufficient soft tissue to cover the bone without the need for local or distant flap coverage IIIb: Extensive soft tissue disruption Local or distant flap coverage is necessary to cover the bone The wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound IIIc: Any open fracture associated with an arterial injury, which requires repair is considered type IIIC Involvement of vascular surgeons is generally required

37 IIIA I II IIIB IIIC

38 Clinical Manifestations of fracture
Edema Pain and Tenderness Muscle spasm Deformity Ecchymosis Loss of Function Crepitation

39 The six “P”s of musculoskeletal assessment
Pain on palpation on movement constant Pallor - pale skin or poor cap refill Paresthesia - “pins and needles” sensation Pulses - diminished or absent Paralysis Pressure

40 Pre-reading Musculoskeletal Radiographs
1: Name, date, old films for comparison 2: What type of view(s) 3: Identify bone(s) & joint(s) demonstrated 4: Skeletal maturity (physes: growth plates) 5: Soft tissue swelling 6: Bones & joints (fractures & dislocations)

41 Reading X-rays Say what it is- Regional Location-
what anatomic structure are you looking at how many different views are there Regional Location- Diaphysis (rule of 1/3) Metaphysis Epiphysis including intra and extra-articular Direction of the fracture line- Transverse, Oblique, Spiral

42 Reading X-rays Condition of the bone- Deformity
comminution (3 or more parts) Segmental (middle fragment) Butterfly segment Incomplete Avulsion Stress impacted Deformity Displacemtent (distal with respect to proximal) angulation (varus, valgus) Rotation shortening (in cm’s) distraction

43 Diagnosis of Fracture X-Ray The Rule of 2s
Two views: Anteroposterior (AP) and lateral views of the injured limb (2 views 90° orthogonal to each other) Two joints: The joint above and the joint below the injury Two limbs: Radiographs of both the injured and noninjured limbs especially in children with epiphyseal-plate injuries Two times: 1 prereduction image and 1 postreduction or postfixation image

44 What do you see?

45 What do you see?

46 What do you see?

47 CT Scanning Not indicated for routine evaluation of common fractures
Preoperative planning for complicated fractures Provide information about the architecture of fracture lines especially about intra-articular fractures Evaluate severely fragmented fractures and those involving the epiphyseal segment Is indicated in assessing the spinal column for injury

48 Fracture Healing Primary healing
Non displaced fractures, fractures with compressive fixation across the fracture site Osteoblasts traverse the fracture site and lay down lamellar bone without forming immature bone when there is direct contact between cortical bone ends

49 Fracture Healing Secondary healing
No compression across fracture site, motion can occur Fracture callus forms to stop motion, stage of consolidation and remodeling

50 Patient Factors Influencing Fracture Healing
Ideal Problematic Age Youth Advanced age (>40 y) Trauma Single limb Multiple traumatic injuries Comorbidities None Multiple medical comorbidities (eg, diabetes) Medications Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids Social factors Nonsmoking Smoking Local factors No infection Local infection Type Closed fracture, neurovascularly intact Open fracture with poor blood supply Nutrition Well nourished Poor nutrition

51 Fracture Management Don’t treat the X-rays of the fracture, but treat the patient Life saving measures Diagnose and treat life threatening injuries (head injuries, Chest & abdominal injuries) Emergency orthopaedic involvement Life saving Complication saving Emergency orthopaedic management (day 1) Monitoring of fracture (days to weeks) Rehabilitation and treatment of complications (weeks to months)

52 GOALS OF FRACTURE TREATMENT
Restore the patient to optimal functional state Prevent fracture and soft-tissue complications Get the fracture to heal, and in a position which will produce optimal functional recovery Rehabilitate the patient as early as possible

53 LIFE SAVING MEASURES A Airway and cervical spine immobilisation
B Breathing C Circulation (treatment and diagnosis of cause) D Disability (head injury) E Exposure (musculo-skeletal injury)

54 EMERGENCY ORTHOPAEDIC MANAGEMENT
Life saving measures Reducing a pelvic fracture in haemodynamically unstable patient Applying pressure to reduce haemorrhage from open fracture Complication saving Early and complete diagnosis of the extent of injuries Diagnosing and treating soft-tissue injuries

55

56 Fracture management Either
The ideal goal of fracture management is anatomical reduction and function restoration compatible with the severity of injury, age, occupation and activity of daily living of injured patient. Either Operative Non operative (Conservative) Traction Splint (Cast / Slab)

57 Nonoperative Fracture Management
Nonoperative technique consists A closed reduction if required Followed by a period of immobilization with casting or splinting Closed reduction is needed if the fracture is significant displaced or angulated

58 Closed Reduction Contraindicated under the following conditions:
For any fracture that is Displaced Shortened Angulated Applying traction to the long axis of the injured limb and then reversing the mechanism of injury Contraindicated under the following conditions: If significant displacement is unappreciable If displacement exists but is not relevant (eg, humeral shaft fracture) If reduction is impossible (severely comminuted fracture) If the reduction, when achieved, cannot be maintained If the fracture has been produced by traction forces (eg, displaced patellar fracture)

59

60 Common Casts Used in Treatment of Disorders of the Musculoskeletal System

61 Traction Traction is the application of a pulling force to a part of the body Purpose: to reduce, align, and immobilize fractures; Unstable and unfixable When reduction and/or proper length cannot be maintained by static immobilization to minimize muscle spasm to prevent or reduce skeletal deformities or muscle contractures.

62 Classification of Traction
Skin Traction : is maintained by direct application of a pulling force on the patient’s skin . Generally temporary measure. To reduce muscle spasms To maintain immobilization before surgery In children

63 Classification of Traction
Skeletal Traction : applied to bone by means of a pin or wire surgically inserted into the bone, providing a strong steady, continuous pull, and can be used for prolonged periods .

64

65 Complications of traction
Neurovascular compromise. Inadequate fracture alignment.. Skin breakdown . Soft tissue injury Pin tract infection . Osteomyelitis can occur with skeletal traction.

66 Surgical Therapy Treatment goals
Anatomic reduction of the fracture fragments: For the diaphysis, assuring that length, angulation, and rotation are corrected For intra-articular fractures anatomic reduction of all fragments required Stable internal fixation to fulfill biomechanical demands Preservation of blood supply Active pain-free early mobilization to prevent the development of fracture disease

67 Indications for ORIF of Fractures:
Absolute: Unable to obtain an adequate reduction Displaced intra-articular fractures Certain types of displaced epiphyseal fractures Major avulsion fractures where there is loss of function of a joint or muscle group Non-unions Re- implantations of limbs or extremities

68 Indications for ORIF of Fractures:
Relative: Delayed unions Multiple fractures to assist in care and general management Unable to maintain a reduction Pathological fractures To assist in nursing care To reduce morbidity due to prolonged immobilisation For fractures in which closed methods are known to be ineffective

69 Contraindications to Surgical Reconstruction
Active infection (local or systemic) or osteomyelitis Osteoporotic bone that is too weak to sustain internal or external fixation Soft tissues overlying the fracture or surgical approach that are poor in quality due to burns, surgical scars, or infection (in such scenarios, soft tissue coverage is recommended.) Medical conditions that contraindicate surgery or anesthesia (eg, recent myocardial infarction) Cases in which amputation would better serve the limb and the patient

70 Kirschner Wires Commonly used for temporary and definitive treatment of fractures They do not resist rotation and have poor resistance to torque and bending forces Usually casting or splinting is used in conjunction Be placed percutaneously or through a mini-open mechanism

71

72 Plates Buttress plates Compression plates Neutralizing plates
Counteract compression and shear forces Commonly used around joints to support intra-articular fractures Compression plates Counteract bending, shear, and torsion forces Eccentrically loaded holes in the plate Commonly used in long bones Neutralizing plates Used in combination with interfragmentary screw fixation Commonly used for fractures involving the fibula, radius and ulna, and humerus Bridge plates Useful in the management of multifragmented diaphyseal and metaphyseal fractures

73 Intramedullary Nailing
Operate like an internal splint that shares the load with the bone Flexible or rigid, locked or unlocked, and the intramedullary canal can be reamed or unreamed Allows for compressive forces at the fracture site, which stimulates bone healing Advantages : Minimally invasive procedures Early postoperative ambulation Early ROM

74 Hybrid Fixation

75 External Fixation Provides stabilization of a fracture at a distance from the fracture site without interfering with the soft tissue near the fracture. Provides stability for the extremity and maintains length, alignment, and rotation without requiring casting. It also allows for inspection of the soft tissue structures vital for fracture healing.

76

77 External Fixation Indications for external fixation are as follows:
Open fractures that have significant soft tissue disruption (eg, type II or III open fractures) Soft tissue injury (eg, burns) Acetabular and pelvic fractures Severely comminuted and unstable fractures Fractures that are associated with bony deficits Limb-lengthening procedures Fractures associated with infection or nonunion

78 Management of Open Fractures
The goals of treatment of open fractures: To prevent infection To allow the fracture to heal To restore function in the injured limb

79 Stages of care for open fractures

80 Antibiotic Therapy Cefazolin is adequate for type I and type II injuries If the wound is severely contaminated (type III), an aminoglycoside can be added (eg, gentamycin or tobramycin) If the injury is a “barnyard injury” and if clostridium perfringens prophylaxis is required, penicillin is added Tetanus prophylaxis and immunization should be administered to patients who have not been previously immunized

81 Urgent irrigation and debridement (I&D) of the wound in the operating room is mandatory.
For type II and type III injuries, serial I&D is recommended every hours after the initial debridement. The wound is closed when it is clean. Antibiotics are generally given for 2 days after final I&D. Management of the fracture depends on the site of injury and type of open fracture. If soft tissue coverage is inadequate, soft tissue transfers or free flaps are performed when the wound is clean and the fracture reduced and stabilized definitively.

82

83 vfdsawrerty

84 Complications of fractures
General complications Shock ARDS Fat embolism Head, chest, abdomen and pelvic injuries Crush syndrome Tetanus Gas gangrene Infections – UTI, Chest DVT/PE Bed sores Depression/PTSD

85 Complications of fractures
Early Visceral injury Vascular injury Compartment syndrome (later Volkmann conctracture) Nerve injury Haemarthrosis Infection Late Delayed union Non-union Mal-union Tendon rupture Myositis ossificans Osteonecrosis Algodystrophy Osteoarthritis and joint stiffness

86 Bleeding After Long Bone Fractures
Fx’s cause localized bleeding and this can be substantial resulting in hypovolemic shock Humerus: cc Unilateral tibia/fibula: cc Femur fx: cc

87 Fractures in Children Not just small adults

88 Children’s bones are different

89 Anatomy Unique to Skeletally Immature Bones
Periosteum Thicker More osteogenic Attached firmly at periphery of physes Bone More porous More ductile

90 Salter Harris Classification
N I II III IV V S A L T E R: The fracture line is I -Same as the growth plate, II -Above the growth plate, III -Lower than the growth plate, IV -Through the growth plate, V -Epiphyseal crush

91

92 The power of remodeling
Tremendous power of remodeling Can accept more angulation and displacement Rotational mal-alignment ?does not remodel

93 The power of remodeling
Factors affecting remodeling potential Years of remaining growth – most important factor Position in the bone – the nearer to physis the better Plane of motion – greatest in sagittal, the frontal, and least for transverse plane Physeal status – if damaged, less potential for correction Growth potential of adjacent physis e.g. upper humerus better than lower humerus

94 Indications for operative fixation
Open fractures Displaced intra articular fractures ( Salter-Harris III-IV ) fractures with vascular injury ? Compartment syndrome Fractures not reduced by closed reduction ( soft tissue interposition, button-holing of periosteum ) If reduction could be only maintained in an abnormal position

95 Methods of fixation Casting - still the commonest K-wires
most commonly used Metaphyseal fractures Intramedullary wires, elastic nails Very useful Diaphyseal fractures Screws Plates – multiple trauma IMN - adolescents Ex-fix Combination

96 Complications Ma-lunion is not usually a problem
( except cubitus varus ) Non-union is hardly seen ( except in the lateral condyle ) Growth disturbance – epiphyseal damage Vascular – volkmann’s ischemia Infection - rare

97 Pathological Fractures
1. Stress fractures Patient usually healthy Fracture site often tender and pain May present with a lump which turns out to be fracture callus May not be evident on x-ray, only becoming evident as callus begins to form Most need only avoidance of the aggravating activity

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99 Pathological Fractures
2. Abnormal bone 54% are secondary to metastatic disease 5% are due to primary bone tumours 41% are secondary to benign bone conditions Breast ca leading cause 41% of pathological fracture Other tumours 43% (kidney, lung, prostate, bowel and thyroid) Myeloma or lymphoma account for 16% More than half of the secondary deposits are in the femur

100 Pathologic fracture

101 Thank You


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