principles of fractures (adults) sultan aldosari; md; frcsc
TRANSCRIPT
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PRINCIPLES OF FRACTURES (ADULTS)
SULTAN ALDOSARI; MD; FRCSC.
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OBJECTIVES
• Introduction.• Basic science of fracture healing.• Principles of evaluating patients with
fractures.• Principles of management.• Common fractures in adults
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introduction
• Fracture means literally broken bone.• This can be described in different ways:• Extent • Location• Morphology• Mechanism • Associated soft tissue injuries
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• Extent:• Complete: fracture
extends 360° of bone circumference (all around)
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• Extent:• Complete: fracture
extends 360° of bone circumference (all around).
• Incomplete: seen almost only in children: • Greensick
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• Extent:• Complete: fracture
extends 360° of bone circumference (all around).
• Incomplete: seen almost only in children: • Greensick• Buckle fracture
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• Location:• Name of bone• Side• Diaphysis, metaphysis or epiphysis• Long bones (diaphysis): divide them in thirds
(proximal, middle or distal third)• Metaphysis: intra-articular v.s extra-articular
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• Morphology:• Transverse: loading
mode resulting in fracture is tension
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• Morphology:• Oblique: loading mode is
compression.
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• Morphology:• Spiral: loading mode is
torsion.
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• Morphology:• Fracture with Butterfly
fragment: loading mode is bending.
• It also called a wedge fracture.
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• Morphology:• Comminuted fracture: 3
or more fragments• Segmental fracture
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• Mechanism:• High energy vs. low energy.• Multiple injuries vs. isolated injury.• Pathological fracture: normal load in presences of
weakened bone (tumor, osteoporosis, infection)• Stress fracture: normal bone subjected to
repeated load (military recruits).
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• Associated soft tissue injuries:• Close fracture: skin integrity is maintained.• Open fracture: fracture is exposed to external
environment . Any skin breach in proximity of a fracture is an
open fracture until proven otherwise.
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QUESTIONS ?
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FRACTURE HEALING
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Natural Bone Healing
• Indirect bone healing (endochondral ossification) occurs in nature with untreated fracture.
• It is called indirect because of formation of cartilage at intermediate stage.
• It runs in 4 stages:– Hematoma formation– Soft callus formation– Hard Callus formation– Remodeling
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PRINCIPLES OF EVALUATION
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Diagnosis: HistoryPatients complain of pain and inability to use the limb (if they are conscious and able to communicate)
What information can help you make the diagnosis?
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Diagnosis: History
Onset:When and how did the symptoms begin?Specific traumatic incident vs. gradual onset?
If there was a specific trauma, the details of the event are essential information:
Mechanism of injury?Circumstances of the event? Work-related?Severity of symptoms at the time of injury and progression after?
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Diagnosis: Physical exam
Inspection
Swelling
Ecchymosis
Deformity
If fracture is open:
Bleeding
Protruding bone
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Diagnosis: Physical exam
Palpation
Bony tenderness
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Diagnosis: Physical exam
If a fracture is suspected what should we rule out?
Neurovascular injury (N/V exam)
Compartment syndrome
Associated MSK injuries (examine joint above and below at minimum)
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Diagnosis: ImagingX-rays are 2D: get minimum two orthogonal views!
Include joint above and below injury
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Diagnosis: Imaging
NB: Fractures hurt, immobilization helps.
Immobilizing a patient in a backslab is the most effective way to relieve pain from a fracture and may be done BEFORE getting x-rays
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Diagnosis: ImagingFractures may be obvious on x-ray
Undisplaced or stress fractures are sometimes not immediately apparent
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Secondary signs of fracture on x-ray:
Soft tissue swelling
Fat pad signs
Periosteal reaction
Joint effusion
Cortical buckle
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Secondary signs of fracture on x-ray:
Soft tissue swelling
Fat pad signs
Periosteal reaction
Joint effusion
Cortical buckle
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Secondary signs of fracture on x-ray:
Soft tissue swelling
Fat pad signs
Periosteal reaction
Joint effusion
Cortical buckle
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Secondary signs of fracture on x-ray:
Soft tissue swelling
Fat pad signs
Periosteal reaction
Joint effusion
Cortical buckle
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Secondary signs of fracture on x-ray:
Soft tissue swelling
Fat pad signs
Periosteal reaction
Joint effusion
Cortical buckle
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How to describe a fracture
Clinical parameters
Radiographic parameters
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Clinical Parameters
Open vs. closedANY break in the skin in proximity to the fracture site is OPEN until proven otherwise
Neurovascular status
Presence of clinical deformity
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LocationWhich bone?
Which part of the bone?
Epiphysis -intraarticular?
Metaphysis
Diaphysis -divide into 1/3s
Use anatomic landmarks when possible
e.g. medial malleolus, ulnar styloid, etc
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PatternSimple vs. comminuted
Complete vs. incomplete
Orientation of fracture line
Transverse
Oblique
Spiral
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Displacement
Displacement is the opposite of apposition
Position of distal fragment relative to proximal
Expressed as a percentage
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Angulation
Deviation from normal alignment
Direction of angulation defined by apex of
Expressed in degrees
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Fracture description: Summary
Clinical parametersOpen vs. ClosedNeurovascular statusClinical deformity
Radiographic parametersLocationPatternDisplacementAngulationShortening
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Treatment Principles
1. Reduction if necessary.2. Immobilization (definitive or
temporary).3. Definitive treatment 4. Rehabilitation.
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Initial (Reduction)
• IF fracture is displaced.• Meant to re-align
fracture fragments.• To minimize soft tissue
injury.• Can be consider
definitive if fragments’ position is accepted.
• Should be followed by immobilization.
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Initial (Immobilization)
• To hold reduction in position.
• To provide support to broken limb
• To prevent further damage.
• Control the Pain
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Initial (Immobilization)
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Definitive
• If satisfactory reduction can not be achieved or held at initial stage.
• Reduction can be attempted close or open (surgery)
• Immobilization can be achieved with:– Plate and screws.– IM nail– EX-fix
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Treatment: Principles
• Rehabilitation Motion as early as possible without
jeopardizing maintenance of reduction. Wt bearing restriction for short period. Move unaffected areas immediately
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Treatment: Principles
Reduce (if necessary)to maximize healing potential
to insure good function after healing
Immobilizeto relieve pain
to prevent motion that may interfere with union
to prevent displacement or angulation of fracture
Rehabilitateto insure return to function
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Multiple Trauma • Multi-disciplinary approach.• Run by Trauma Team Leader (TTL) at ER.
Orthopedic is part of the team.• Follow trauma Protocol as per your
institution.• Treatment is prioritized toward life
threatening conditions then to limb threatening conditions.
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Take home pointsFractures hurt –immobilization relieves pain.
R/o open fracture, Compartment syndrome and N/V injuries.
Principles of fracture treatment:
Reduce (if necessary)
Immobilize
Rehabilitate
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QUESTIONS?
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THANKS