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

2. Objective Pictures taken from images.google.com

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

4. 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

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

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

7. 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

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

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

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

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

12. What type of force

13. 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

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

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

16. 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)

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

18. 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

19. Relative Stability Pictures taken from images.google.com

20. Absolute Stability

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

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

23. 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

24. 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

25. 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

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

27. 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

28. Special Cases

29. Open Fractures Pictures taken from images.google.com

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

31. 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

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

33. 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

34. Pediatric Fractures Pictures taken from images.google.com

35. 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

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

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

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

39. 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

40. Questions