displacement described as: distal in relation to proximal un-displaced shift sideways shortening...
TRANSCRIPT
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Displacement
Described as: Distal in relation to proximal
Un-displaced
ShiftSidewaysShorteningDistraction
Angulation In all planes
Rotation
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Fracture Diagnosis
Clinical features
Imaging: Radiology (x-Ray)
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Clinical Features
History of Trauma
Symptoms and signs:1. Pain
2. Swelling
3. Deformity
4. Bony tenderness
5. Abnormal movement
6. Crepitus
7. Loss of function
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Approach - history
Details of injuryMechanism, force, bleeding, consciousness, …
Details of factureDeformity, pain, loss of function, ..
Other medical problems
Anti-tetanus status if open injuries
Careful:Fractures are not always at the site of impactSome fractures do not need severe force
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Approach – clinical exam
General medical conditionshould be evaluated to exclude
shockbrain injuryother problems
Vital signsshould be observed and followed up
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Approach – clinical exam
Look:Adequate exposureGeneral on patientLocal:
Swelling, deformity, bruises, color, …Special attention is to be paid to wounds
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Approach – clinical exam
Feel:Tenderness, distal pulses, temperature and crepitus
on movementSensory and motor deficitsPulse distal to injuryCompartment syndrome
Move:With care
make sure not to cause more pain or injuryCrepitus & abnormal movement indicates a fractureJoints distal to the affected area
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Approach – clinical exam
Examination of the visceraLiver and spleen in rib fracturesUrinary bladder and urethra in pelvic fracturesNeurological examination in head and spinal injury
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Investigations - Imaging
X-rays:Low of 2s
Two views: AP and LateralTwo joints: Above and BelowTwo sides: Right and LeftTwo occasionsTwo Doctors !
Special views:Obliques, Tunnel view, skyline, functional flexion /
extensionArthrography:
Shows intra-articular structuresFunctional in hip
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Imaging
Plain x-ray: (law of twos)Two views:AP and Lateral
Apley’s System of Orthopedics & Fractures
AP
AP
Lat
Lat
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Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint below
Apley’s System of Orthopedics & Fractures
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Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison
more in children to
compare epiphysis
Apley’s System of Orthopedics & Fractures
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Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison
more in children to
compare epiphysisTwo occasions
e.g. stress fracturese.g. scaphoid fracture
Apley’s System of Orthopedics & Fractures
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Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison
more in children to
compare epiphysisTwo occasions
e.g. stress fracturese.g. scaphoid fracture
Two injuriese.g. patellar fracture and hip injurye.g. calcaneal fractures & spine injuries
www.jumpintheair.com
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Imaging
Plain x-ray: (law of twos)Two views: AP and LateralTwo joints: joint above and joint belowTwo limbs: for comparison
more in children to
compare epiphysisTwo occasions
e.g. stress fracturese.g. scaphoid fracture
Two injuriese.g. calcaneal fractures & spine injuries
.....and two Doctors!
www.123rf.com/
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Imaging
Plain x-ray: (law of twos)
Special views:Calcaneal viewShoulder dislocation: axial viewScaphoid viewsAcetabular fractures: 45o tilt views
http://osuemed.wordpress.com/
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Imaging
CT Scan:In complex and ntra-articular fracturesIn spineIn pelvic and acetabular fracturesIn calcaneal fractures
www.learningradiology.com
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Imaging
MRIShow associated injuries in spinal fracturesAssociated soft tissue injuries – e.g. kneeHidden fractures:
Subtrochanteric (ST) disruptionStress (fatigue) fracturesScaphoid fracture
Suspected avascular
necrosis
www.highperformancesports.blogspot.comwww.bjj.boneandjoint.org.uk
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Fracture healing
A broken bone heels because …..it is broken !
Alan Apley
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Natural bone healing
Movement at the fracture site initiates a healing process—callus formation
Vascular and cellular response leads to tissue differentiation and mineralization resulting in restoration of mechanical integrity
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Natural bone healing
http://classes.midlandstech.edu/
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Cascade of tissue differentiation
Following a Fracture:
1. Hematoma
2. Granulation tissue
3. Connective tissue
4. Fibrocartilage
5. Mineral deposition
6. Bone
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Fracture healing1. Inflammation
Hematoma Mesenchymal cells
2. Soft callus Granualation tissue
3. Hard callus Intramembranous bone
formation Enchondral ossification
4. Remodeling bony bridging
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Cellular and Vascular Reaction
cells haematoma granulation tissue
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Tissue Differentiation
connective tissue
granulation tissue
Giemsa
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Tissue Differentiation Cascade
Cartilage formation
BoneMineral deposition
Masson-Goldner
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Healing time & strength
Process Timing Strength
Hematoma 2 hrs 1%
Inflammation 2 days 5%
Soft callus 2 weeks 25%
Hard callus 2 months 74%
Re-modelling 2 years 100%
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Fracture Healing
Conditions necessary for bone healing:Good blood supplyControlled motionNo infection
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Fracture Healing
Unfavorable factorsImpairment of blood supplyInfectionExcessive movementPresence of tumorInterposition of soft tissueAny form of Nicotine (smoking)Bad nutrition
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Average healing time
Children: Upper limb: 3-4 weeksLower limb: 2X upper limb (6-8 weeks)
Adults:Upper limb: 2X children (6-8 weeks)Lower limb: 2X upper limb (12-16 weeks)
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Fracture Treatment
Aim of fracture treatmentaid healing,in normal position,avoiding complications
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Fracture treatment
Treat the patient, not only the fracture
Reduce the fracture
Immobilize the fracturePrevents displacementAlleviates painPromotes soft tissue healing
Mobilize the patient
Avoid complications