fracture care
TRANSCRIPT
An Overview on Fractures Care
Dr. Rashidi AhmadMD USM, MMED USM, FADUSM
Lecturer/EmergentistUSM Health Campus
POP application course18th December 2006
Objectives
• To increase an awareness the importance of appropriate care of fracture
• To increase understanding on fracture management
• To gain more knowledge & skill – to make right decision & to perform the proper action
Outline
• Understanding fractures• Describing fractures based on clinical
presentations & radiological features• Principles of fracture management
Trauma patient is an injured person who requires timely diagnosis and treatment of actual or potential injuries by a multidisciplinary team of health care professionals, supported by the appropriate resources, to diminish or eliminate the risk of death or permanent disability.
Europian Trauma Life Support
Fracture?
• A fracture is a disruption in the integrity of a living bone involving injury to bone marrow, periosteum, and adjacent soft tissues.
How fractures occur?
• Typical fractures• Pathologic fractures• Stress fractures
Pathologic #
Lytic lesion
March/stress fracture
Life threatening fractures
• Le Fort II/III fracture & bilateral mandible fracture with airway compromised
• Upper cervical fracture & flail chest with impaired ventilation
• Pelvic & open fractures with vascular injury/shock• Untreated multiple long bones fracture with fat
embolism• Depressed skull fracture with extradural bleeding
Fat embolic syndrome
Pelvic injuries with intrabdominal injury & shock
Limb threatening
• Fractures with Compartmental Syndrome @ Volkmann’s ischemia
• Fractures with neurovascular injuries/ avascular necrosis
• Open fractures with infection
Compartmental syndrome
Volkmann’s ischemic contracture
Avascular necrosis
Osteomyelitis
Factors affecting fracture healing
• The energy transfer of the injury
• The tissue response– Two bone ends in opposition or compressed– Micro-movement or no movement– BS (scaphoid, talus, femoral and humeral head)– NS– No infection
• The patient• The method of treatment
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
Prehospital care• First aid principles• Preliminary splinting/sling of the injured
extremity - reduces pain- reduces damage to nerve & vessels- reduces risk of conversion to open fracture- facilitates transportation & x-ray taking.
Principles Of Splinting
• Apply dry sterile compression dressing to all open wounds
Principles Of Splinting
• Incorporate one joint above and one joint below the fracture
Types Of Splints
• Wooden Splints• Metal Wire / Frame Splints• Air Splints• Vacuum Splints• MAST suit
Post-Splinting Care
Prehospital reduction
• Prehospital reduction of deformity – by advice of physician
• Obvious fracture along the shaft of a long bone with a neurovascular deficit –longitudinal traction
• Deformity near a joint – possibility of dislocation
Careful history
• Precise MOI• Listen carefully to the patient’s symptoms• Why?
- Pain of fracture may be referred to another area- Specific x-ray view is indicated by proper history- Some injuries may not be radiologically apparent on the 1st day
High-energy injury
Low energy injury
Dashboard fracture
Chance # @ lap seat belt #
Physical examination
• Inspection for swelling, discoloration, deformity
• Assessment of active & passive ROM of the joints proximal & distal to the injury
• Palpation for tenderness• Verification of neurovascular status
Radiologic evaluation
• X-ray is an important adjunct• Ordered based on Hx & PE• 2 views – AP & lateral• 2 joints – above & below the shaft
fracture• In children with injury near the joint –
bilateral x-rays for comparison• Repeat x-rays after 1 – 2 weeks to show
callus in doubtful fractures
Describing fractures• Open versus closed• Location of the fracture• Orientation of the fracture line• Displacement & separation• Angulation• Shortening• Rotational deformity• Fracture – dislocation/subluxation• Salter fractures• Fragmentation• Soft tissue involvement
Close #
Open #
Midshaft #
Distal third #
Intertrochanteric #
Subcapital #
Location of fracture
Subtrochanteric #
Neck #
Near the head #
Head #
Supracondylar #
Lateral condyle #
Intercondylar #
Orientation of the fracture line
Torus #
Greenstick #
Bowing #
Displaced & separation
Minimally displaced distal radius fracture
Comminuted proximal- third femoral fracture with significant displacement
Angulation – amount & direction
Shortening
Rotational deformity
Bennet’s # dislocation
Monteggia’s #
Galeazzi’s #
Fracture - dislocation
Salter Harris classification
I S = SLIPPED/separated
II A = ABOVE
III L = LOWER
IV T = THROUGH/together
V R = RAMMED/ruined
Salter Harris Type I
Salter Harris Type II
Salter Harris Type III
Salter Harris Type IV
Salter Harris Type V
Rolando #
Barton’s #
Intraarticular fracure
Fragmentation
- A multi-fragmentary fracture: several breaks (>2 fragments) in the bone
- Wedge fractures: spiral (low energy) @ bending (high energy
- The complex multi-fragmentary fracture: segmental fracture in which there is no contact between the proximal & distal fragments, no bone shortening.
- Simple fractures are spiral, oblique, or transverse.
The Muller AO Comprehensive Classification of Fractures
A multi-fragmentary fracture
Wedge fractures
Soft tissue involvement
• Minor / Grade I - small punctate wound <1 cm a/w low velocity trauma. Minimal soft tissue injury. No crushing. No comminution.
• Moderate / Grade II – extensive wounds with relatively little soft tissue damage, and only moderate crushing or comminution.
• Major / Grade III - wounds of moderate or massive size with considerable soft tissue injury and/or foreign body contamination:• III A - sufficient soft tissue to cover the fracture• III B - insufficient tissue to cover the fracture; also periosteal
stripping and severe comminution• III C - arterial damage requiring repair. Degree of soft tissue
damage not considered
Gustilo. Current Concepts: the management of open fractures. JBJS (1990); 72A; 299-304
Crush injury
Degloving injury
Bomb blast injury
Gunshot #
General management of patients with fracture
• Life saving measures - Primary & secondary survey- Emergency orthopaedic involvement
–Life saving–Complication saving
Cont…
• Emergency orthopedic management- Control of pain & swelling- Keep NBM if GA @ PCS is required- Reducing fracture deformity- Tetanus prophylaxis- Irrigation & debridement- Antibiotic prophylaxis
• Conservative vs surgical management• Monitoring of fracture• Rehabilitation & Rx of complications
Emergency orthopaedic management
• Life saving measures – Reducing a pelvic fracture in haemodynamically
unstable patient– Applying pressure to reduce haemorrhage from
open fracture
• Complication saving– Early and complete diagnosis of the extent of
injuries– Diagnosing and treating soft-tissue injuries
Diagnosing the soft tissue injury
• Skin- Open fractures, degloving injuries and ischaemic necrosis
• Muscles– Crush and compartment syndromes
• Blood vessels– Vasospasm and arterial laceration
• Nerves– Neurapraxias, axonotmesis, neurotmesis
• Ligaments– Joint instability and dislocation
Treating the soft tissue injury
• All severe soft tissue injuries………require urgent treatment
– Open fractures , Vascular injuries, Nerve injuries, Compartment syndromes, Fracture/dislocations
• After the treatment of the soft tissue injury the fracture requires rigid fixation
• A severe soft-tissue injury will delay fracture healing
Treating the fracture • Purpose: to reduce, hold & maintain the # in a suitable
alignment
• Does the fracture require reduction? Displaced?
• Methods: CMR method by ACCROCHAGE and continuous traction (skin & skeletal traction)
• What is acceptable # alignment?
• Consider: age, site, weight bearing, shortening, angulation & rotation
Risk benefit
Operative Non-operative
Rehabilitation Rapid SlowRisk of joint stiffness Low PresentRisk of malunion Low PresentRisk of non-union Present PresentSpeed of healing Slow RapidRisk of infection Present LowCost ? ?
Treating the fracture • How are we going to hold the reduction?
– Semi-rigid (Plaster)– Rigid (Internal fixation)
• What treatment plan will we follow?– When can the patient load the injured limb?– When can the patient be allowed to move the
joints?– How long will we have to immobilise the fracture
for?
Indications for operative treatment
• General trend toward operative treatment last 30 yrs
– Improved implants and antibiotic prophylaxis, use of closed and minimally invasive methods
• Current absolute indications:– Polytrauma, displaced intra-articular fractures– Open #’s, #’s with vascular injury or compartment
syndrome– Pathological #’s, Non-unions
Indications for operative treatment
• Current relative indications:-– Loss of position with closed method– Poor functional result with non-anatomical
reduction– Displaced fractures with poor blood supply– Economic and medical indications
When is the fracture healed?
• ClinicallyUpper limb Lower limb
Adult 6-8 weeks 12-16 weeksChild 3-4 weeks 6-8 weeks
• Radiologically– Bridging callus formation– Remodelling
Rehabilitation
• Restoring the patient as close to pre-injury functional level as possible
• Approach needs to be:-
–Pragmatic with realistic targets–Multidisciplinary: Physiotherapist,
Occupational therapist, District nurse, GP, Social worker
Summary
• Fractures are a/w mortality & morbidity• Fractures care starts from the onset till fully
recover• Primary survey + resuscitation are the
PRIORITY• Do not underestimate the benefit of
reassurance, pain management & splinting• Multidiscipline approach
Final message
Dr. Rashidi AhmadMD USM, MMED USM, FADUSM
Pensyarah/Pakar Perubatan kecemasan & TraumaJabatan perubatan Kecemasan
Pusat Pengajian Sains PerubatanUSM Kampus Kesihatan, Malaysia
[email protected]+609 7663244