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Fracture & Dislocation



fractures

A fracture is a structural breech in the normal

continuity of bone.



Mechanism of injury

1-Tubular bone:

- Direct violence to the bone

- Indirectly due to twisting or angulations 2- Cancellous bone:

- may be fractured by compression



FRACTURE DESCRIPTION

Name of the injured bone

Location of the injury (eg, dorsal or volar;

metaphysis, diaphysis, or epiphysis) Orientation of the fracture (eg, transverse,

oblique, spiral, Greenstick)

Condition of the overlying tissues (eg, openor closed fracture).



Fracture healing

Bone healing is usually divided into three

slightly overlapping stages:

1. inflammatory phase 2. reparative phase

3. remodeling phase



inflammatory phase

The initial inflammatory phase is dominated

by vascular events.

Following a fracture, a hematoma forms. Subsequently, reabsorption occurs of the 1 to

2 mm of bone at the fracture edges that have

lost their blood supply

Next, multipotent cells are transformed intoosteoprogenitor cells, which begin to form

new bone.



reparative phase

new blood vessels develop from outside thebone that supply nutrients to the cartilage,

which begins to form across the fracture site Callus typically forms as a collar of new,

endochondral bone around the fractured area.

Callus is progressively replaced-from 3 weeks

onwards in a child and 4 weeks onwards in anadult long bone-by mature (lamellar) bone with aHaversian structure strong enough to immobilisethe fracture site and produce union.



Clinical union Absence of tenderness on direct pressure over the

fracture site

Little or no pain when the fracture site is stressedby angulation or rotation

Absence of movement at the fracture site

As a general rule

adult

4-8

weeks for fractures in cancellous bones 6-12 weeks for fractures in long bones

children approx half these times



Diagnosis

Clinical:

- History of trauma

- Pain, swelling, inability to use the injured body part-Tenderness, swelling and bruising

- Deformity, abnormal movement (sure signs of fracture)



X -ray: A suspected fractured bone should be x-rayed.

- X-ray should be taken in at least two planes (AP andlateral)

- Should always include the joints proximal and distalto the fracture

- Look in theX-ray for:

Presence of fracture

The part of bone fracturedThe pattern of the fracture

Presence and type of displacement



Principles of fracture

management A) GENERAL TREATMENT

- follow theATLS system.

- Always assess the status of distal circulationand neurological function.

- Administer anti pain and splint all fracturesbefore sending the patient for x-ray or

referring.



B ) Local treatment of the fracture:-

I-Reduction

manipulation of the fractured bone to restorenormal or near normal anatomic position.

needed only for displaced fractures



Techniques of Reduction

1. Using gravity

2.Closed reduction

Manipulation

Traction

3. Open (Operative) reduction

closed reduction fails

very accurate reduction is required, e.g. a fracture

which involves a joint surface the fracture has caused a vascular or (sometimes) a

nerve injury.



II- Immobilization

The purpose of immobilization is to:

prevent redisplacement of a reduced fracture decrease movement at the site of fracture and

prevent further soft tissue injury

relieve pain



Methods of Immobilization

1. External splints e.g plaster of Paris (POP) cast

- Is the safest and cheapest method of immobilization

- Immobilization should always include the twoadjacent joints

- Joints should be immobilized in a functional

position- Complications include joint stiffness and

compartment syndrome.



2.Continuous traction

Using gravity: e.g. U-slab for humeral shaftfracture

Skin traction:A method of applying traction

using bandage, usually used in children andtemporarily in adults.The maximum weightthat can be applied is 2kg.

Skeletal traction:Traction applied via a pin

inserted into the bone distal to the fracture.



3. External fixation

a rigid bridging device held in place by bone pins

proximal and distal to the fracture mainly used in the management of open or

infected fractures



4. Internal fixation

a method of operative fixation of fractures by

plates, nails, screws, pins and wires

strongly indicated in patients with:

multiple injuries

pathological fractures

associated neurovascular injury

fractures where accurate reduction is required (e.g.those involving joints)

the need to avoid a long period of immobilisation inbed, e.g. an elderly patient with a fracture of theneck of the femur.



III - Active movement and rehabilitation

Rehabilitation starts immediately after treatment. The patient is asked to move the injured part as

much as the method of fixation allows.

The slight movement produced at the fracture site

helps to: stimulate union

decrease disuse osteoporosis

prevent muscle atrophy

minimise joint stiffness.



Complications of Fractures

I. Soft tissue Injuries

- Arteries,Nerves andViscera may be injured



II. Compartment syndrome

Is a dangerously increased pressure within theenclosed fascial compartments of extremities,especially forearm and leg.

The high compartmental pressure causes Ischemiaand necrosis of soft tissues in the compartment.

It may be aggravated by application of tight bandagesor circular POP casts on a freshly injured limb.

Severe pain, especially with passive flexion of fingersis the earliest indicator.

Paresthesia, Paralysis, Pallor or Pulselessness maydevelop later

Early diagnosis and complete splitting of a tightbandage or circular POP cast may resolve thesituation.

Fasciotomy is done if the above measures have failed.



III. Infection

-Usually complicates open fractures

- Chronic osteomyelitis may be the result.- Adequate debridement is the most critical factor in

preventing infection.



IV. Bone healing abnormalities Delayed Union

Failure of a fracture to heal in the expected timeperiod.

Non union

Total failure of the fracture to heal with formation of a false joint between the fractured ends(pseudoarthrosis)

Malunion

Healing occurs with deformity

Avascular necrosis

Necrosis of part of the fractured bone occurs due todisruption of its vascular supply. E.g. Femoral head.



V. Joint complications

Joint stiffness

Secondary Hemarthrosis osteoarthritis

VI. Systemic complications

Usually follow polytrauma and major long bone

fracture

IncludeARDS and fat embolism syndrome



DISLOCATIONS

A dislocation is a total disruption of joint with

no remaining contact between the articular

surfaces. A subluxation is partial joint disruption with

partial remaining but abnormal contact of

articular surfaces.



Ty pes of Dislocation

1-Traumatic dislocations

This is a type of dislocation caused by trauma.

A force strong enough to disrupt the joint capsuleand other supporting ligamentous structuresdislocates a previously normal joint.



2- Pathological /Spontaneous dislocation

This is a type of dislocation which occurs when a

pathological condition in the joint causesabnormality in the structural integrity of the joint.E.g. Septic hip dislocation



Diagnosis

The limb assumes an abnormally fixed

position with loss of normal range of

movement in the affected joint. Associated soft tissue injuries should be

looked for:

E.g. Popliteal artery in knee dislocation

Sciatic nerve in posterior hip dislocation

X-ray in various planes and views confirms

diagnosis



M anagement

Early reduction of the dislocation

Immobilizing the joint to allow time for the

supporting structures of the joint to heal Rehabilitation of the joint



AMPUTATIONS

An amputation is removal or excision of part

or whole of a limb.



I ndications

1- Dead limb (Gangrene) Atherosclerosis Embolism Major arterial injury Diabetic gangrene

2- Deadly limb Life threatening infection (e.g. Gas gangrene) or

malignancies which cant be controlled by other localmeasures

3- Dead loss Severe soft tissue injury especially associated with

major nerve injury, which may occur in compoundfractures.



Level of amputation

The choice for the level of amputation

depends on:

Age

The nature and extent of the pathology e.g.Neoplasm, trauma

The vascularity of tissues

Presence of infection Status of the joints

Access to the various types of prostheses



In the upper limb, attempt should be made toconserve every possible inch.

In the lower limb, the most important factoris to try and conserve the knee joint

whenever possible.



C omplications of amputation

Edema

Hematoma

Secondary and reactionary hemorrhage Infection

Ischemic necrosis

Flexion contracture Chronic pain-psychogenic, neuromas, etc.

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