treatment of fracture
TRANSCRIPT
Diagnosis of Fractures
BY : 1- Clinical features ( History & Physical examination )
2 -investigation
HISTORYThere is usually a history of injury , followed by inability to use the injured limb.
But beware! The fracture is not always at the site of the injury.
and . The patient’s ageand mechanism of injury are important.
The common symptoms are :Pain, bruising and swelling ,but they do not distinguish a fracture from asoft-tissue injury.
Deformity is much more suggestive
HISTORY
Always enquire about symptoms of associatedinjuries: pain and swelling elsewhere (it is a
common mistake to get distracted by the main injury, particularly if it is severe), numbness or
loss of movement,skin pallor or cyanosis, blood in the urine,
abdominal pain , difficulty with breathing or transient loss of consciousness
PHYSICAL EXAMINATIONThe examination actually begins from the moment we set eyes on
patient. We observe his or her general appearance, posture and gait. When we proceed to the structured examination, the patient must
be suitably undressed, if one limb is affected both limbs must be exposed so that thy can be compared
1-Swelling,
2- bruising and
3- deformity may be obvious, but
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’). Note also
the posture of the distal extremity and the colour of
the skin (for signs of nerve or vessel damage).
Inspection or look
Palpation OR felllocalized tenderness. Some fractures would be missed if not specifically looked for, e.g. the classical sign (indeed the only
clinical sign!) of a fractured scaphoid is tenderness on
pressure precisely in the anatomical snuffbox . .
The common and characteristic associated injuries should
also be felt for, even if the patient does not complain
of them. For example, an isolated fracture of the proximal fibula should always alert to the likelihood of an
associated fracture or ligament injury of the ankle, and In high-energy injuries always examine the spine and
pelvis. Vascular and peripheral nerve abnormalities
•should be tested for both before and after treatment
PHYSICAL EXAMINATION
MOVE
Crepitus and abnormal movement should be tested for only in unconscious patients . Usually it is more important to ask if the patient can move the joint distal to the
injury
PHYSICAL EXAMINATION
INVESTIGATIONX-RAY
X-ray examination is mandatory. Remember the rule of twos:•Two views– (anteroposterior and lateral) must be taken ..
•Two joints–. Because it may be fractured or dislocated , •Two limbs–; x-rays of the uninjured limb are needed for
comparison .•Two injuries– Severe force often causes injuries atmore than one level. Thus, with fractures of the calcaneum or femur it is important to also x-ray thepelvis and spine.
•Two occasions– Some fractures are notoriously difficult to detect soon after injury, but another x-rayexamination a week or two later may show the
lesion.
INVESTIGATIONComputed tomography (CT) and Magnetic
resonance imaging (MRI) are useful for displaying fractures patterns in difficult sites such as vertebral
column , the acetabulum and the calcaneum .MRI may be the only way of showing whether a
fractured vertebra is threatining to compress the spinal cord.
Radioistope scanning is helpful in diagnosing a suspected stress fracture or other occult fracture..
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.
GENERALFollow the guidelines of trauma life support..
The following are of special importance with treatment of fractures :
1-Pain. Relived by Immobilization , local splinting , analgesics 2-
Blood loss
3-Attension to associated injuries N.B : the management of the internal hemorrhage and visceral
injury takes priority over a limb fracture ..
4-Tetanus toxoid & AntibioticsIn compound fractures
Local 1-Reduction 2-fixation 3-Rehablitation
Reduction : is restoration of normal anatomy To achieve a Reduction
The following steps usually are advised: 1) Apply traction in the long axis of the limb.2) Reverse the mechanism that produced the
fracture; 3) Align the fragment that can be controlled with
the one that cannot.
Reduction is not necessary when the displacement is trivial e.g… .Or when the displacement is of a nature that will leave no functional or cosmetics disability e.g…
,But is urgent when the fracture is complicated by vascular or nerve injury
Types are : closed and open Closed reduction by :1- gravity ,2- closed manipulation
,3- tractionContraindication to closed reduction when:. 1.There is no significant displacement2. The displacement is of little concern (e.g., humeral shaft).3. No reduction is possible (e.g., comminuted fracture of the head and neck of humorous).4. The reduction, if gained, cannot be held (e.g., compression fracture of the vertebral body).5. The fracture has been produced by a traction force (e.g., displaced fracture of the patella).
6-Pathologic Fractures7-Associated Vascular Injury8-Multiple Injuries9-Mobilization10-Reconstruction
Open (surgical reduction)
ImmobilizationOnce a satisfactory reduction has been
achieved, it must then be maintained until primary union has taken place.
Plaster-of-Paris Casts†
Complications of Plaster
Casts and Traction1) Plaster Sores.2) The Tight Cast3) Thermal Effects of Plaster.4) Thrombophlebitis and Equinus Position5) The Cast Syndrome6) Infection Secondary to Cast
Application.7) Allergic Reactions8) Traction Hazards
External Fixation of Fractures
Hoffman External fixator misdirection by Wegner leg-
lengthening
Othofix external fixator
Complications of External Fixation
Pin Tract Infection
Pin tract infections may be classified, in ascending order of severity, as:
Grade I-Serous drainageGrade II-Superficial cellulitis
Grade III-Deep infectionGrade IV-Osteomyelitis.
1 -wires 2- screws
3- plate and screws4-intramedullary nail
5- compression screw and plate for a fractured neck of femur
3-Plates
Plate fixation
Type of plates 1-Dynamic Compression Plates.2-Limited Contact-Dynamic
Compression Plates.3-Curved Plate4-Angled Plates5-Buttress Plates6-Reconstruction Plates7 -Wave Plate
4-Staples