general principles of fractures ii. clinical features history there is usually a history of 1....
TRANSCRIPT
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GENERAL PRINCIPLES OF FRACTURES II
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CLINICAL FEATURES
•History
•There is usually a history of
1. injury,
2. followed by inability to use the injured limb.
3. But beware the fracture is not always at the site of the injury a
blow to the knee may fracture the patella, the femoral condyles,
the shaft of the femur or even the acetabulum.
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4. The patient's age and the mechanism of injury are important. If
a fracture occurs with trivial trauma, suspect a pathological lesion
5. Pain, bruising and swelling are common symptoms, but they
do not distinguish a fracture from a soft-tissue injury.
6. Deformity is much more suggestive.
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•Always ask about symptoms of associate injuries;
1. numbness or loss of movement
2.skin pallor or cyanosis, blood in the urine.
3. Abdominal pain,
4. transient loss of consciousness.
5. Finally a general medical history is important, in preparation for
anesthesia or operation.
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GENERAL SIGNS
•A broken bone is part of a patient. It is important to look for
evidence of:
•(1) Shock or hemorrhage.
•(2) Associated damage to brain, spinal cord or viscera.
• (3) A predisposing cause (such as tumour or malignancy).
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LOCAL SIGN
•Injured tissue must handled gently. To elicit crepitus or
abnormal movement is unnecessarily painful; x-ray diagnosis is
more reliable. The familiar headings of clinical examination
should always considered and damage to arteries and nerves may
be overlooked.
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LOOK
1.Swelling.
2.Bruising.
3.deformity may be obvious.
4. the important point is whether the skin is intact; if the skin is
broken and the wound communicates with the fracture, the
injury is 'open' ('compound').
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FEEL
•There is localized tenderness, but it is necessary also to examine
distal to the fracture in order to feel the pulse and to test
sensation. A vascular injury is a surgical emergency.
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MOVE
•Crepitus and abnormal movement may be present, but it is more
important to ask if the patient can move the joints distal to the
injury.
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X-RAY
•X-ray exanimation is mandatory. Certain pitfalls must be
avoided by using role of twos:
1. Two views: fracture or a dislocation may not be seen on a
single x-ray film, and at least two views (anteroposterior and
lateral) must be taken.
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2. Two joints in the forearm or leg, one bone may be fractured
and angulated. Angulation, however, is impossible unless the
other bone also is broken, or a joint dislocated. The joints above
and below the fracture must both be included on the x-ray films.
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3. Two limbs in x-ray of children's bones, normal epiphysis may
confuse the diagnosis of a fracture and films of uninjured limb
are helpful.
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4. Two injuries severe force often causes injuries at more than
one level. Thus, with fractures of the calcaneum or femur it is
important also to x-ray the pelvis and spine.
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5. Two occasions Soon after injury, a fracture (e.g. of the carpal
scaphoid) may be difficult to see. If doubt exists, further
examination 10-14 days later may as a result of bone resorption,
make diagnosis easier.
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•Special imaging
•Sometimes the fracture - or the full details of the fracture is not apparent on
the plain x-ray.
• Tomography may be helpful in lesions of the spine or fractures of the tibial
condyles; CT or MRI may be the only way of showing whether a fractured
vertebra is threatening to compress the spinal cord; indeed, transectional
images are essential for accurate visualization of fractures in 'difficult' sites
such as the calcaneum or acetabulum, and three dimensional reconstructed
images are even better.
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•Radioisotope scanning is helpful in diagnosing a suspected
stress fracture or other undisplaced fractures.
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•Description
•Diagnosing a fracture is not enough; the surgeon should picture it
(and describe it) in all it complexity.
• (1) Is it open or closed?
•(2) Which bone is broken, and where?
• (3) Has it involved a joint surface?
• (4) What is the shape of the break?
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•How to read x-ray of fracture
1.Define the image e.g. plain x-ray or C-T scan.
2.Label for the name of the patient, the date and the side.
3.The region and the view.
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4. The word fracture should be followed by the questions
a. Which bone?
b. Which site in the bone?
c. What is the type and the shape of fracture?
d. Does it displaced?
e. Which type of displacement?
f. Does the fracture recent or old?
g. Does it treated or not?
h. Does it pathological?
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SECONDARY INJURIES
•Certain fractures may cause secondary injuries and these should
always be assumed to have occurred until proved otherwise.
1.Spinal cord and nerve root injury may associate with fracture
of the spine.
2.Urethral, bladder, rectal, vaginal and neurovascular injuries
may associate with fracture pelvis.
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3. Lung and heart injuries may associate with fracture of the
sternum and the ribs.
4. Brachial plexus injuries may associate with fracture and
dislocation of the pectoral girdle.
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•Treatment of closed fractures
•General treatment is the first consideration: to treat the patient,
not simply the part. The sequence is:
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•(1) First aid.
•(2) Transport.
• (3) The treatment of shock, hemorrhage and associated injuries.
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•In principle the treatment of fractures consists of manipulation
to improve the position of the fragments, followed by splintage to
hold them together until they unite; meanwhile, joint movement
and function must be preserved
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• . Fracture healing is promoted by physiological loading of the bone. So muscle action and early weight bearing are encouraged. These objectives are covered by three simple actions: REDUCE, HOLD, and EXERCISE.
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REDUCE
•Although general treatment and resuscitation must always take
the priority, treatment of fracture should not be delayed because
the soft tissue swelling associated with the fracture within first 12
hours make the reduction difficult.
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•There are certain situations in which reduction is not necessary
like
1.When there is little or no displacement.
2.When displacement does not matter like in fracture clavicle.
3.When reduction is unlikely to succeed like in compression
fracture of the spine.
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• Methods of reduction
1. Closed reduction
a.Manipulation under anesthesia ( GA, RA, or LA)
b.Traction (skin, skeletal, or gravity).
2. Open reduction.
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MANIPULATION
•Under proper anesthesia and muscle relaxation, fracture reduced
by three fold manoeuver:
1)The distal part of the limb is pulled in the line of the bone.
2)As the fragments disengage, they are repositioned by
reversing the original direction of the force.
3)Alignment is adjusted in each plane.
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•Generally manipulation is used for all minimally displaced
fractures, for most of fractures in children and for stable fractures
after reduction.
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OPEN REDUCTION
•Opened reduction of the fracture under direct vision is indicated:
• (1) When closed reduction fails, either because of difficulty in
controlling the fragments or because soft tissues are interposed between
them.
•(2) When there is a large articular fragment that needs accurate
positioning.
• (3) For traction fractures in which the fragments are held apart.
• As a rule, open reduction is merely the first step to internal fixation.
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