fracture care
TRANSCRIPT
![Page 1: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/1.jpg)
An Overview on Fractures Care
Dr. Rashidi AhmadMD USM, MMED USM, FADUSM
Lecturer/EmergentistUSM Health Campus
POP application course18th December 2006
![Page 2: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/2.jpg)
Objectives
• To increase an awareness the importance of appropriate care of fracture
• To increase understanding on fracture management
• To gain more knowledge & skill – to make right decision & to perform the proper action
![Page 3: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/3.jpg)
Outline
• Understanding fractures• Describing fractures based on clinical
presentations & radiological features• Principles of fracture management
![Page 4: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/4.jpg)
Trauma patient is an injured person who requires timely diagnosis and treatment of actual or potential injuries by a multidisciplinary team of health care professionals, supported by the appropriate resources, to diminish or eliminate the risk of death or permanent disability.
Europian Trauma Life Support
![Page 5: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/5.jpg)
![Page 6: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/6.jpg)
Fracture?
• A fracture is a disruption in the integrity of a living bone involving injury to bone marrow, periosteum, and adjacent soft tissues.
![Page 7: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/7.jpg)
How fractures occur?
• Typical fractures• Pathologic fractures• Stress fractures
![Page 8: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/8.jpg)
Pathologic #
Lytic lesion
![Page 9: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/9.jpg)
March/stress fracture
![Page 10: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/10.jpg)
Life threatening fractures
• Le Fort II/III fracture & bilateral mandible fracture with airway compromised
• Upper cervical fracture & flail chest with impaired ventilation
• Pelvic & open fractures with vascular injury/shock• Untreated multiple long bones fracture with fat
embolism• Depressed skull fracture with extradural bleeding
![Page 11: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/11.jpg)
Fat embolic syndrome
![Page 12: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/12.jpg)
Pelvic injuries with intrabdominal injury & shock
![Page 13: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/13.jpg)
Limb threatening
• Fractures with Compartmental Syndrome @ Volkmann’s ischemia
• Fractures with neurovascular injuries/ avascular necrosis
• Open fractures with infection
![Page 14: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/14.jpg)
Compartmental syndrome
Volkmann’s ischemic contracture
![Page 15: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/15.jpg)
Avascular necrosis
![Page 16: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/16.jpg)
Osteomyelitis
![Page 17: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/17.jpg)
Factors affecting fracture healing
• The energy transfer of the injury
• The tissue response– Two bone ends in opposition or compressed– Micro-movement or no movement– BS (scaphoid, talus, femoral and humeral head)– NS– No infection
• The patient• The method of treatment
![Page 18: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/18.jpg)
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
![Page 19: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/19.jpg)
Prehospital care• First aid principles• Preliminary splinting/sling of the injured
extremity - reduces pain- reduces damage to nerve & vessels- reduces risk of conversion to open fracture- facilitates transportation & x-ray taking.
![Page 20: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/20.jpg)
Principles Of Splinting
• Apply dry sterile compression dressing to all open wounds
![Page 21: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/21.jpg)
Principles Of Splinting
• Incorporate one joint above and one joint below the fracture
![Page 22: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/22.jpg)
Types Of Splints
• Wooden Splints• Metal Wire / Frame Splints• Air Splints• Vacuum Splints• MAST suit
![Page 23: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/23.jpg)
Post-Splinting Care
![Page 24: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/24.jpg)
Prehospital reduction
• Prehospital reduction of deformity – by advice of physician
• Obvious fracture along the shaft of a long bone with a neurovascular deficit –longitudinal traction
• Deformity near a joint – possibility of dislocation
![Page 25: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/25.jpg)
Careful history
• Precise MOI• Listen carefully to the patient’s symptoms• Why?
- Pain of fracture may be referred to another area- Specific x-ray view is indicated by proper history- Some injuries may not be radiologically apparent on the 1st day
![Page 26: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/26.jpg)
High-energy injury
![Page 27: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/27.jpg)
Low energy injury
![Page 28: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/28.jpg)
![Page 29: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/29.jpg)
![Page 30: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/30.jpg)
![Page 31: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/31.jpg)
Dashboard fracture
![Page 32: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/32.jpg)
Chance # @ lap seat belt #
![Page 33: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/33.jpg)
Physical examination
• Inspection for swelling, discoloration, deformity
• Assessment of active & passive ROM of the joints proximal & distal to the injury
• Palpation for tenderness• Verification of neurovascular status
![Page 34: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/34.jpg)
Radiologic evaluation
• X-ray is an important adjunct• Ordered based on Hx & PE• 2 views – AP & lateral• 2 joints – above & below the shaft
fracture• In children with injury near the joint –
bilateral x-rays for comparison• Repeat x-rays after 1 – 2 weeks to show
callus in doubtful fractures
![Page 35: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/35.jpg)
Describing fractures• Open versus closed• Location of the fracture• Orientation of the fracture line• Displacement & separation• Angulation• Shortening• Rotational deformity• Fracture – dislocation/subluxation• Salter fractures• Fragmentation• Soft tissue involvement
![Page 36: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/36.jpg)
Close #
Open #
![Page 37: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/37.jpg)
Midshaft #
Distal third #
Intertrochanteric #
Subcapital #
Location of fracture
![Page 38: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/38.jpg)
Subtrochanteric #
Neck #
Near the head #
Head #
![Page 39: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/39.jpg)
Supracondylar #
Lateral condyle #
Intercondylar #
![Page 40: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/40.jpg)
Orientation of the fracture line
![Page 41: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/41.jpg)
Torus #
Greenstick #
![Page 42: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/42.jpg)
Bowing #
![Page 43: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/43.jpg)
Displaced & separation
![Page 44: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/44.jpg)
Minimally displaced distal radius fracture
Comminuted proximal- third femoral fracture with significant displacement
![Page 45: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/45.jpg)
Angulation – amount & direction
![Page 46: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/46.jpg)
Shortening
![Page 47: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/47.jpg)
Rotational deformity
![Page 48: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/48.jpg)
Bennet’s # dislocation
Monteggia’s #
Galeazzi’s #
Fracture - dislocation
![Page 49: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/49.jpg)
Salter Harris classification
I S = SLIPPED/separated
II A = ABOVE
III L = LOWER
IV T = THROUGH/together
V R = RAMMED/ruined
![Page 50: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/50.jpg)
Salter Harris Type I
![Page 51: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/51.jpg)
Salter Harris Type II
![Page 52: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/52.jpg)
Salter Harris Type III
![Page 53: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/53.jpg)
Salter Harris Type IV
![Page 54: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/54.jpg)
Salter Harris Type V
![Page 55: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/55.jpg)
Rolando #
Barton’s #
Intraarticular fracure
![Page 56: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/56.jpg)
Fragmentation
- A multi-fragmentary fracture: several breaks (>2 fragments) in the bone
- Wedge fractures: spiral (low energy) @ bending (high energy
- The complex multi-fragmentary fracture: segmental fracture in which there is no contact between the proximal & distal fragments, no bone shortening.
- Simple fractures are spiral, oblique, or transverse.
The Muller AO Comprehensive Classification of Fractures
![Page 57: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/57.jpg)
A multi-fragmentary fracture
Wedge fractures
![Page 58: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/58.jpg)
Soft tissue involvement
• Minor / Grade I - small punctate wound <1 cm a/w low velocity trauma. Minimal soft tissue injury. No crushing. No comminution.
• Moderate / Grade II – extensive wounds with relatively little soft tissue damage, and only moderate crushing or comminution.
• Major / Grade III - wounds of moderate or massive size with considerable soft tissue injury and/or foreign body contamination:• III A - sufficient soft tissue to cover the fracture• III B - insufficient tissue to cover the fracture; also periosteal
stripping and severe comminution• III C - arterial damage requiring repair. Degree of soft tissue
damage not considered
Gustilo. Current Concepts: the management of open fractures. JBJS (1990); 72A; 299-304
![Page 59: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/59.jpg)
Crush injury
Degloving injury
![Page 60: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/60.jpg)
Bomb blast injury
Gunshot #
![Page 61: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/61.jpg)
General management of patients with fracture
• Life saving measures - Primary & secondary survey- Emergency orthopaedic involvement
–Life saving–Complication saving
![Page 62: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/62.jpg)
Cont…
• Emergency orthopedic management- Control of pain & swelling- Keep NBM if GA @ PCS is required- Reducing fracture deformity- Tetanus prophylaxis- Irrigation & debridement- Antibiotic prophylaxis
• Conservative vs surgical management• Monitoring of fracture• Rehabilitation & Rx of complications
![Page 63: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/63.jpg)
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
![Page 64: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/64.jpg)
Diagnosing the soft tissue injury
• Skin- Open fractures, degloving injuries and ischaemic necrosis
• Muscles– Crush and compartment syndromes
• Blood vessels– Vasospasm and arterial laceration
• Nerves– Neurapraxias, axonotmesis, neurotmesis
• Ligaments– Joint instability and dislocation
![Page 65: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/65.jpg)
Treating the soft tissue injury
• All severe soft tissue injuries………require urgent treatment
– Open fractures , Vascular injuries, Nerve injuries, Compartment syndromes, Fracture/dislocations
• After the treatment of the soft tissue injury the fracture requires rigid fixation
• A severe soft-tissue injury will delay fracture healing
![Page 66: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/66.jpg)
Treating the fracture • Purpose: to reduce, hold & maintain the # in a suitable
alignment
• Does the fracture require reduction? Displaced?
• Methods: CMR method by ACCROCHAGE and continuous traction (skin & skeletal traction)
• What is acceptable # alignment?
• Consider: age, site, weight bearing, shortening, angulation & rotation
![Page 67: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/67.jpg)
Risk benefit
Operative Non-operative
Rehabilitation Rapid SlowRisk of joint stiffness Low PresentRisk of malunion Low PresentRisk of non-union Present PresentSpeed of healing Slow RapidRisk of infection Present LowCost ? ?
![Page 68: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/68.jpg)
Treating the fracture • How are we going to hold the reduction?
– Semi-rigid (Plaster)– Rigid (Internal fixation)
• What treatment plan will we follow?– When can the patient load the injured limb?– When can the patient be allowed to move the
joints?– How long will we have to immobilise the fracture
for?
![Page 69: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/69.jpg)
![Page 70: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/70.jpg)
![Page 71: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/71.jpg)
Indications for operative treatment
• General trend toward operative treatment last 30 yrs
– Improved implants and antibiotic prophylaxis, use of closed and minimally invasive methods
• Current absolute indications:– Polytrauma, displaced intra-articular fractures– Open #’s, #’s with vascular injury or compartment
syndrome– Pathological #’s, Non-unions
![Page 72: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/72.jpg)
Indications for operative treatment
• Current relative indications:-– Loss of position with closed method– Poor functional result with non-anatomical
reduction– Displaced fractures with poor blood supply– Economic and medical indications
![Page 73: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/73.jpg)
When is the fracture healed?
• ClinicallyUpper limb Lower limb
Adult 6-8 weeks 12-16 weeksChild 3-4 weeks 6-8 weeks
• Radiologically– Bridging callus formation– Remodelling
![Page 74: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/74.jpg)
Rehabilitation
• Restoring the patient as close to pre-injury functional level as possible
• Approach needs to be:-
–Pragmatic with realistic targets–Multidisciplinary: Physiotherapist,
Occupational therapist, District nurse, GP, Social worker
![Page 75: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/75.jpg)
Summary
• Fractures are a/w mortality & morbidity• Fractures care starts from the onset till fully
recover• Primary survey + resuscitation are the
PRIORITY• Do not underestimate the benefit of
reassurance, pain management & splinting• Multidiscipline approach
![Page 76: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/76.jpg)
Final message
![Page 77: Fracture care](https://reader034.vdocuments.us/reader034/viewer/2022042614/556e5b89d8b42a6a248b4637/html5/thumbnails/77.jpg)
Dr. Rashidi AhmadMD USM, MMED USM, FADUSM
Pensyarah/Pakar Perubatan kecemasan & TraumaJabatan perubatan Kecemasan
Pusat Pengajian Sains PerubatanUSM Kampus Kesihatan, Malaysia
[email protected]+609 7663244