1 2 fracture-classification & management
DESCRIPTION
Basic Orthopedic for M.B.B.S. studentsTRANSCRIPT
FRACTURE
DR SHRIKANT J. GORE M.S.(ORTHO)
PROFESSORDEPT. OF ORTHO.
GMC , LATUR
FRACTURE
Breach in continuity of boneBroken bone
Types
Age Growing age Adult
Covering soft tissue Simple Closed
Compound- Fractured bone exposed to atmosphereComplicated- Fracture associated with injury to vital body parts
Etiological Trauma Pathology Stress
Morphological
Pathological Fracture
Epi-physial injury
Bending - Greenstick
Morphological
Transverse Oblique Spiral Segmental Comminuted Crushed- Compressed Depressed Burst Bone loss Greenstick Buckled
Displacement
Un displaced - Incomplete, complete Displaced (Deformed)
- Bent- Angulated-Translated - Shifted-Rotated
-Overriding - Depressed-Compressed-Burst
Undisplaced
BUCKLING COMPLETE
Transverse -Oblique
Comminuted - Segmental
Compressed -Burst
Depressed- Butterfly
Rotation - Spiral
Translation - Rotation
Overriding - Angulation
Compound-Fractures
Fracture Communicating with atmosphere
Type-1 -Punctured wound (less than 1 cm.)
Type- 2 - Wound more than 1 cm but less than 10 cm
Compound-Fractures Type- 3
a) With soft tissue loss, periosteal stripping, communition , wound size >10 cm but soft tissue coverage possible
b) With severe soft tissue injury ,contamination, bone exposed & soft tissue coverage not possible
c) With arterial injury
Complicated Fractures
Fractures associated with injury to vital structures
Brain Lungs Intra-abdominal : Liver, Spleen, Bladder Neurovascular injury
Management Goal
Union in Anatomical position
for maximum functional recovery
Must realize The healing is biological process-Union can not be imposed but to
be encouraged-Vascular supply of bone is the basis
of fracture healing-You need to be a gardener rather
than a carpenter as healing is natural response of the body
Treatment plan Needs to be tailored to the needs of
particular patient considering Patient, Doctor, paramedical staff
Medical Facilities-Patient Age, Sex, occupation, G. C, Type of fracture, Extent of soft tissue injury, Associated diseases like DM,HT, renal etc & Socioeconomic status.
Treatment plan
Infrastructure facilities available,
Training & Experience of -Treating doctors(surgeons-anesthesiologists),- paramedical staff (sisters, physiotherapists, occupational therapists)
Principle of treatment
Reduction in anatomical position & maintaining reduction till fracture unites
Anatomical Reduction
Manipulative reduction
Manipulation under anesthesia Continuous traction (Pin/Skin)I/T/#, S/C
## dislocation cervical spine
*Proper understanding of - Mechanism of injury is essential- Reduction is reversal of the deforming mechanism
External immobilization
Plaster immobilization –Slab, Cast strapping- fingers, Chest, arm
splinting- Mallet splint, Ball bandage, Fixed traction in splint-
Thomas’s Continuous traction-
Skin Traction - Gallow’s Nail- Fracture phalanges Skeletal traction- Bohlar’s
complications of Immobilization
Generalized-Hypostatic pneumonia - Deep vein
thrombosis-Bed sores - Muscle wasting - Osteoporosis-Prolong hospital stay - PsychosisLocalized -Stiffness , contractures , wasting , Sudek’s plaster sore, Tight plaster – constricting band
neurovascular compression, Compartment syndrome & VIC pin tract infection.
Plaster Immobilization Done when proper & stable closed
reduction can be achieved Every joint which dose not need to be
immobilized must be exercised actively from the first day of injury to prevent stiffness
The plaster should extend one joint above & one joint below the fractured bone for its immobilization.
No joint to be immobilized unless it is a must
Post-Immobilizations Stiffness
1) Functional inactivity-lymphatic stasis, water logging –fibrosis
2) Joint injury- sero-fibrinous exudates-capsular fibrosis
3) Recurrent edema –gravitational, reactionary 4) Skeletal traction- Stretching of ligaments-
reactionary effusion pin track infection 5) Sudek’s osteodystrophy- muscular inactivity
Loss of control over vascular musculature
Skin TractionGallow’s
Thomas’s Splint Traction
Skeletal Traction When reduction & /or maintenance of
reduction is not possible due to muscle forces at Fracture site
-Conservative treat. of I/T # femur -Conservative Treat. of # shaft Femur-Post – reduction immo of dislocated hip Complications-Pin tract infection-Excessive traction- Nonunion
Skeletal Traction
Pin Tract infection
Advantages of closed reduction
Simple procedure No surgical trauma Minimum soft tissue injury Maintaince of fracture hematoma
Advantages of CR
Hence Earlier healing No chance of infection Less chances for fibrosis due to tissue
trauma Minimum anesthesia Minimum use of drugs Less expensive
Disadvantages of CR
Not possible when Soft tissue interposition - # med
malleolus Small fragments - # Muscle attachment to fracture fragments
(active force) - # patella Depressed fracture -# tibial platue Combination injuries – gallezia #
dislocation Non accessible fragments - # neck femur
Complications of immobilization
Immobilization stiffness Muscle wasting Sudek's osteodystrophy Prolonged bed rest (lower limb) Hypostatic pneumonia Bed sore Deep vein thrombosis
Advantages of surgery & internal fixation
Reduction can be achieved Rigid fixation Early mobilization – to reduce stiffness
Disadvantages of OR
Soft tissue injury Periosteal stripping Damage to blood supply – bone & soft
tissue Delayed union Infection Post surgical fibrosis
Surgical reduction & internal fixation
No surgery is possible without adding injury to the body
Minimally invasive technique should be preferred .
Every form of fixation is splinting device
Healing is biological process.
Failure of closed reduction
Soft tissue interposition -# medial malleolus Muscle attachments pulling a fragment
# lat condyle Humerus Lack of control over fragment -T/C # Femur,
# upper end Tibia , Small fragments avulsion Depressed # (elevation & Support)
Combination injuries- Monttaggia Fracture, Gallessia Fracture, Fracture shaft femur with Fracture neck Femur
Failure of maintenance of reduction
Unstable Fracture -Transverse # R/U Fracture site difficult to immobilize
# around hip, shoulder, shaft femur Intra-Articular # (tibial condyle) Collapse or compression at Fracture
site Dynamic forces - Muscle pull (#
Patella)
Surgery as treatment option
Better choice – Complications of immobilization more than surgical complications Lower limb # in old age
Fracture shaft Femur ,Tibia shaft, Humerus shaft, I/T #, R/U shaft #
Surgical complications
Soft tissue injury , Periosteal striping
Damage to blood supply – delayed union, Infection, Implant failure, Growth disturbance
Anesthesia - Antibiotics
Indications Failure of closed reduction Failure of maintenance of
reduction for internal fixation
Nonunion- to freshen the bone end
- to put bone grafts
Surgical Reduction
Study principles rather than methods
A mind that grasps principles will device its own methods
Surgical planning -general
Assessment of -patient’s general health – Hemogram, Urine, BSL,
BUN, S.Creatinin, ECG, X-Ray Chest, HIV, Hbsag, LFT, Blood grouping, & As needed
-Local condition Skin –abrasion, infection, circulation,
-Socioeconomic status, Age, Profession, etc.-Treating Doctor’s Training & experience-Paramedics Training & experience-Infrastructural & Paramedical Facilities at the hospital
-cost of the treatment
Surgical planning -general
The O.T. -Equipment Surgical & Anesthesia
-Surgical instruments & implants of proper design & size -Preparation of part one day prior & in OT-Minimally invasive, soft tissue respect(least
traumatic), short duration, anatomical closure-Use of Antibiotics, care of wound
Post op
-Early mobilization (physiotherapy) & rehabilitation
Surgical planning – The part
Skin condition – abrasion, wound, infection, circulation.
Cleaning –Painting with antiseptic solution to form film –covering the part with sterile towel
After proper anesthesia – judicious use of tourniquet
scrubbing with detergent- painting with antiseptic ( Iodine) – Removal of iodine paint using volatile antiseptic spirit -isolating the part by sterile DRAPES
Surgical procedure
Minimally invasive (small) Least injurious (Tissue planes- proper
handling of tissues -least dead tissue –less inflammation)
Minimal surgical time (to minimize the chances of infection)
Anatomical closure in layers (minimizes adhesions)
Management of compound fracture
Cleaning , debridement of wound Stabilization of # fragments with external
fixator Avoid Internal fixation – chances of
vascular damage – infection Advantages of external fixator – less
vascular damage - # fragment stability – wound care possible
External fixator