fractures and dislocations

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Overview of Fractures and dislocations

Wherever the art of medicine is loved,there is also a love of humanity. HippocratesOverview of Fractures and dislocationsYahyia Khalfan Mohammed Al-Abri 90440Junior Definitions Causes of fracturesfracture classificationClinical features of fracturesPain control in fracturesFractures treatmentDislocation Clinical features of dislocations

Outline

What is fracture?Is a break in the structural continuity of bone.

What is dislocation?The joint surface is completely displaced and are no longer in contact.Definitions 4Sudden trauma.Most common Direct vs indirect Stress and fatigue fractures.Most in tibia , fibula , and metatarsal.Pathological fractures osteoporosis , osteogenesis imperfecta ,Paget's disease ,bone cyst and metastasis.Causes of fracturesMost fractures are caused by sudden and excessive force, which may be direct or indirect. With direct forcethe bone breaks at the point of impact and the surrounding soft tissues are also damaged. With indirect force the bone breaks at a distance from where the force is applied: a common example is a fracture of the femoral neck due to a blow on the bended knee; soft-tissue damage at the fracture site is not inevitable.

5fracture classificationDisplacement Pattern LocationIntegrity of Skin and Soft Tissue

Closed (simple) skin/soft tissue over and near fracture is intact open (compound )skin/soft tissue over and near fracture is lacerated or abraded, fracture exposed to outside environment

Integrity of Skin and Soft Tissue

Name of bone?Right or left ?Where in the bone?Epiphyseal end of bone, forming part of the adjacent jointMetaphyseal the flared portion of the bone at the ends of the shaftDiaphyseal the shaft of a long bone (proximal, middle, distal)Physis growth plateLocation

Picture for questions 8Pattern Complete TransverseObliqueButterflySegmentalSpiralComminutedAvulsionCompression/impacted

Incomplete GreenstickTorusStress fractureCompression Fractures

Orientation/Fracture Pattern

TransverseOblique

Butterfly

Segmental

Spiral

Comminuted/multi-fragmentary

Avulsion

Compression/impacted

Green-stick

TorusOrientation/Fracture Pattern (Figure 6) transverse: fracture line perpendicular to long axis of bone; direct high energy force oblique: angular fracture line; angular or rotational force butterfly: fracture site fragment which looks like a butterfly segmental: a separate segment of bone bordered by fracture lines; high energy spiral: complex, multi-planar fracture line; rotational force, low energy comminuted/multi-fragmentary: more than 2 fracture fragments intra-articular: fracture line crosses articular cartilage and enters joint avulsion: tendon or ligament tears/pulls fragment off bone; often in children, high energy compression/impacted: impaction of bone, e.g. vertebrae, proximal tibia torus: a buckle fracture of one cortex, often in children (Figure 51, OR38) green-stick: an incomplete fracture of one cortex, often in children (Figure 51, OR38) pathologic: fracture through bone weakened by disease/tumour10

Questions

1- transvers Tibial shaft stress fractures Spiral fracture with butterfly fragments 11Non-displacedDisplaced Angulated Rotated DistractedTranslated Displacement Non-displaced : fracture fragments are in anatomic alignmentDisplaced: fracture fragments are not in anatomic alignment

Displacement

Displacement (Figure 6) nondisplaced: fracture fragments are in anatomic alignment displaced: fracture fragments are not in anatomic alignment angulated: direction of fracture apex, e.g. varus/valgus translated: percentage of overlapping bone at fracture site rotated: fracture fragment rotated about long axis of bone13DisplacementAngulated: direction of fracture apex, e.g. varus /valgus

Rotated: fracture fragment rotated about long axis of bone

Distracted : fracture fragments are separated by a gap

Translated percentage of overlapping bone at fracture site

DisplacementSign and symptoms

pain and tenderness

Swelling or bruising

Deformity Loss of function bone protruding Numbness and tingling.

Crepitus

.in the injured area.In open fractures, from the skin.

Severe pain and tenderness , but the bone is not sensitive to pain !!? The bone tissue itself not contains nociceptors, however bone fracture is painful for several reasons:Breaking of theperiosteum, with or without endosteum, as both contain multiplenociceptors.Edemaof nearbysoft tissuescaused by bleeding of torn periosteal blood vessels evokes pressure pain.Muscle spasmstrying to hold bone fragments in place

16History History of injury followed by inability to use the injured limb.Age and mechanism of injury.If fracture occurs with trivial trauma suspect pathological lesion.Pain, swelling and bruising are common symptoms but they do not distinguish a fracture form soft tissue injury. Deformity more suggestiveSymptoms of associated injury( numbness or loss of movement , skin pallor or cyanosis, blood in the urine, difficulty with breathing or transit lose of consciousness) get distract by the main injury. Pervious injury or musculoskeletal problems( confusion with the x-ray)General medical history (preparation for anesthesia or operation) Clinical features( history) Beaware the fracture maybe a way from the site of injury. Note on page 329 17Clinical features( Examination)

lookfeelMove 18Look:Swelling, bruising and deformityskin is intact?posture of the distal extremity and the color of the skin (for tell-tale signs of nerve or vessel damage).Feel: Palpate for tendernessTest for vascular and peripheral nerve abnormalitiesMove:Crepitus and abnormal movement

Examination Crepitus and abnormal movement should be tested for only in unconscious patient. Usually it is more important to ask if the patient can move the joint distal to the injury.Move X-Ray is mandatory (rule of two) Two viewsTwo joints Two limbs Two injuriesTwo occasion

Imaging

Perarticular fractures 21Pain control in fracturesPharmacological:systemic analgesia (e.g morphine, NSAIDS)Nerve blockneuraxial anesthesia(spinal and epidural anesthesia)

22Non-pharmacological:Transcutaneous Electrical Nerve Stimulation (TENS)stabilization of the fracture using traction

TENSuses electrodes to apply electrical energy to peripheral nerves to treat acute and chronic musculoskeletal pain. Electrical stimulation can be administered at varying amplitudes and frequencies, depending on the indication23The general aim of early fracture management is to control hemorrhage, provide pain relief, prevent ischemia-reperfusion injury, and remove potential sources of contamination (foreign body and nonviable tissues)Fracture treatment24Fractures treatmentReduce Hold Exercise The treatment of the fractures consist of manipulation to improve the positon of the fragment followed by splintage to hold them together , joint movemnt 25Reduce (Closed reduction )

1-Pull the distal of the limp2-Reposition (reverse the original direction)3- Alignment is adjust in each plane.Open reductionOperative reductionWhen to use it??When closed reduction failedWhen there is large articular fragment that needs accurate positioningAvulsion fractureWhen an operation needed for associated injuriesArterial damage

Reduce (open reduction ) The aim is to Splint the fracture, not necessarily entire limp.

Hold

Sustained traction

Cast splintage

Functional bracing

Internal fixationexternal fixation

MethodsFunctional bracingexternal fixation

28More correctly restore function not only to the injured part but also to the patient as whole.The objective are to Reduce edema Preserve joint movement Restore muscles power Guide patient to normal activity Exercise

The aim is to try to prevent them from becoming infected : the four essentials are:

Open fracture

Early definitive wound coverStabilisation of the fractureDebridementAntibiotic prophylaxis / gentamicin

Early definitive wound cover

30Common site of dislocations The most commonly dislocated is the shoulder joint.[13]Elbow: Posterior dislocation, 90% of all elbow dislocations[14]Wrist: Lunate and Perilunate dislocation most common[15]Finger: Interphalangeal (IP) or metacarpophalangeal (MCP) joint dislocations[16]Hip: Posterior and anterior dislocation of hip

A dislocated joint may be:Accompanied by numbness or tingling at the joint or beyond itIntensely painful, especially if you try to use the joint orput weight on itLimited in movementSwollen or bruisedVisibly out of place, discolored, or misshapen

Acutely dislocated joint clinicallyhttp://www.nlm.nih.gov/medlineplus/ency/article/000014.htm

32Diagnosis History:pain, swelling, characteristic posturing, and the inability to movePhysical examination:Shoulder dislocation:Arm in a characteristic position of external rotation and slight abductionFullness anteroinferior to the coracoid process is palpable

Elbow dislocation:elbow held in flexionsignificant amount of soft tissue swelling around the elbow

Finger dislocation:oedema and ecchymosis (bruising)

Patellar dislocationswollen knee held in flexion and no obvious lateral prominenceoften associated with haemarthrosis (bleeding into joint spaces)

Hip dislocation:

Posterior hip dislocation is with the hip in a position of flexion, internal rotation, and adduction

Anterior hip dislocations, the hip is classically held in external rotation, with mild flexion and abduction.

Imaging

Anteroposterior x-ray view of a shoulder showing an anteroinferior dislocation

Anteroposterior x-ray view of an elbow dislocation

Shoulder dislocationIn standard AP views, the humeral head rests anteroinferiorly to the coracoid in anterior shoulder dislocations.(see image)--------------------------------Elbow dislocationDislocations are posterior in more than 90% of casesIn a posterior dislocation, these show the radius and ulna lying posterior to the distal humerus.(see image)

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38Comprehensive medical reference and review for the Medical Council of Canada.Apley's concise system of orthopaedics and fractureMedscaperadiologymasterclass.co.ukPain Management Interventions for Hip Fracture(http://www.ncbi.nlm.nih.gov/books/NBK56661/)

References